A changing working life Working Life and Health A Swedish Survey Bengt Järvholm (Ed.) Production group Editor: Lars Grönkvist Cover typography: Lena Karlsson Cover illustration: © Diana Ong/Great Shots Layout: Eric Elgemyr Figures: Marit Skoglund © The Swedish National Board of Occupational Safety and Health, The National Institute for Working Life, & The Swedish Council for Work Life Research National Institute for Working Life S-171 84 Solna, Sweden Tel: (+46)-8-730 91 00 Fax: (+46)-8-730 19 67 ISBN 91-7045-386-1 Printed by AB Boktryck, Helsingborg Working life and health. A Swedish survey A changing working life Preface This review is an assessment of contemporary working life in Sweden and its effects on health. It is designed to be used by decision-makers as a basis for developing strategies and setting priorities for improvement measures, research, and supervision of work environments over the next several years. The work was done at the joint request of three Swedish authorities: the National Board of Occupational Safety and Health, the National Institute for Working Life and the Council for Work Life Research. A similar review was published in 1990 by a governmental committee, the Swedish Commission on Working Conditions, and that analysis has been used as a model. The review starts with the present situation and attempts to identify opportunities and expected problems. Work environments can be greatly changed by decisions at all levels. This report makes it clear that a good work environment is an important part of “the good job” and that working life has a great influence on health and illness. National data have been used when available. Regional data have been used when there are no national data and when the information is regarded as relevant to other regions of the country. Assessment of trends has also been attempted, but insufficient data often makes it difficult to quantify the changes over time. In these cases trends have been estimated. Quantitative differences in health and ill health between different groups are explained on the basis of present theories whenever possible. Working life and health. A Swedish survey Since July 1994, the National Board of Occupational Safety and Health has had responsibility for keeping statistics on the work environment. A further purpose of this review has been to assess the usefulness of these statistics. More than twenty different researchers collaborated in writing this review. The editor was Professor Bengt Järvholm. The researchers have also written more extensive reviews which will be published and presented elsewhere. This translation includes mainly quantitative data and conclusions. Those wishing to know more about a particular area reviewed can contact the researcher who wrote that review. A list of the contributors, including their addresses, is found at the end of the book. Chapters that have not been translated are also included in the list. Members of the steering committee for this review were Anders Englund, National Board of Occupational Safety and Health, (chairman), Carl A Asklöf, Swedish Work Environment Fund (until June 30, 1995), Gunnar Aronsson, National Institute for Working Life, Elisabet Broberg, National Board of Occupational Safety and Health, Gunnel Färm, Swedish Council for Work Life Research (as of July 1, 1995), Christer Hogstedt, National Institute for Working Life, and Folke K Larsson, National Institute for Working Life and Swedish Council for Work Life Research. National Board of Occupational Safety and Health National Institute for Working Life Swedish Council for Work Life Research A changing working life Contents 1 A changing working life............................................................7 2 Physical, chemical and biological factors............................... 15 3 Psychosocial factors................................................................ 21 4 Mortality in occupational groups........................................... 27 5 Work environment and myocardial infarction...................... 29 6 Occupation and cancer........................................................... 33 7 Respiratory diseases................................................................ 41 8 Skin diseases........................................................................... 45 9 Work-related musculoskeletal disorders................................ 49 10 Threats, violence, sexual harassment and suicide................ 57 11 Accidents at work................................................................. 63 12 Work and gender.................................................................. 67 13 Elderly persons in working life............................................ 73 14 Immigrants........................................................................... 79 15 Disability............................................................................... 83 16 Professional drivers.............................................................. 87 17 Construction workers........................................................... 91 18 Working life in the future.................................................... 97 19 Summary............................................................................. 101 List of contributors.................................................................. 107 Working life and health. A Swedish survey A changing working life 1 A changing working life Hardly any period since World War II has seen faster, larger and sometimes more surprising changes in Swedish working life than the beginning of the 1990s. The changes have affected both the labour market and the organisation of work. In 1990 a Swedish governmental committee, the Swedish Commission on Working Conditions wrote that the lack of labour would be substantial during the 1990s and that those who were employed would consequently have higher demands regarding work and working conditions. Three years later there was widespread unemployment rather than a lack of labour. Between 1990 and 1993 the number of employees decreased by more than 200,000 in the manufacturing industry and by 75,000 in the construction industry. The number of employees also decreased in the public sector, which had been growing for some decades. Change of employment The population of Sweden has increased steadily, and in the past hundred years grown from a little less than five million to nearly nine million. The proportion aged 16 to 64 has remained fairly constant, between 60 and 65 percent. The number of employed women has increased. In 1890 less than 20 percent of Swedish women had a job outside the home (excluding maids); by the 1980s the proportions of employed men and women were of similar size. The largest sectors today are manufacturing and health care. Each employs approximately 20 percent of the working population. Health care workers are predominantly women, while employees in the construction and manufacturing industries are predominantly Working life and health. A Swedish survey men (Table 1.1). In Sweden there are about 640,000 workplaces, 270,000 of which have employed persons. the other just have self-employed persons. Table 1.1. Percentages of men and women employed in 1995, by industry (Survey of Labour). Industry Women Men Total Farming, forestry and fishing 2 4 3 Construction 110 6 Manufacturing 112920 Public administration, defence 5 5 5 Communication 4 9 7 Trade 121413 Education, research11 6 8 Health care 37 521 Restaurants and hotel 32 3 Financing, insurance, business services 91211 Recreation, culture and sport222 Others 3 2 3 Numbers (in thousands)1,9272,061 3,988 Unemployment Except for the above-mentioned increase of unemployment during the 1990s, unemployment has been about one to three percent since World War II (Figure 1.1). The number of long-term unemployed increased during the 1990s. Figure 1.1. Unemployment rates in Sweden, 1945–1995. For 1985–1995 the proportion of the labour force in government programs for the unemployed is also shown. A changing working life The unemployment rate is higher among men (8.4%) than among women (6.9%) (Labour Survey, 1995). Adolescents and young adults have a higher unemployment rate: 14 percent among persons 16 to 24 years old, compared to 4 to 10 percent in other age groups. Organisation and work Three dimensions have been identified as closely related to the health and well-being of workers: psychological stress and demands, control, and social support. Some changes in the organisation of work can benefit both the worker and the employer. Flatter organisations, development of competence, and greater individual responsibility and authority, for example, are regarded as increasing competitiveness and efficiency. There are two general strategies for increasing the flexibility of an organisation. In one, permanent staff is kept to a minimum and other personnel are engaged as needed. This may be done by term employment, contracting of personnel or services, and/or use of consultants. This method makes it more difficult to transfer a worker to another job, for example in cases of prolonged illness, since the number of different jobs decreases in a company with a highly specialised production. The increased number of persons with non-permanent jobs may be a consequence of this strategy for more flexible organisation. A second trend is broader competence. Workers who have competence in several areas of production can rarely be replaced by short-term employees. This has positive consequences for the workers, since they have more control over their work and more opportunities to learn during work. One negative aspect is increased psychological stress due to higher demands. Another is that it is difficult to expand the work force quickly if the company wants to increase production. There has therefore been a lot of overtime work during the past year even though the unemployment rate has been high. Non-permanent employees The number of permanent jobs decreased from 3.7 million to about three million between 1987 and 1995. Half of the permanent jobs that disappeared were jobs for persons below the age of 25. 10 Working life and health. A Swedish survey Non-permanent employment accounted for about 50 percent of all new hires in 1990. In 1994 this had grown to 70 percent. In 1995 about 500,000 persons had jobs that were not permanent. About 180,000 were substitutes, 90,000 were project workers, 80,000 were employed on demand, 45,000 were on probation and 30,000 had seasonal employment. About 75,000 were trainees or had holiday jobs. All groups except those who work on demand, who have increased since 1987, fluctuate more or less with conditions on the market. A questionnaire was sent to a random sample of permanent and non-permanent employees in 1995. The results showed that those who do not have permanent jobs know less about occupational safety and health than those with permanent positions. Project workers had more opportunity to control their own work, even compared to those who had permanent jobs, whereas substitute workers, seasonal workers and people who work on demand have less control over their work than those with permanent positions. Further, the number of days for training on paid time was highest among those who had project employment: 15 days for men and 8 days for women; for persons with permanent positions it was 9 days for men and 7 days for women. Persons who worked on demand had the lowest number of paid days for training: 4 days for men and 2 days for women. Organisations There are several Swedish authorities and organisations concerned with working conditions and occupational health. A few are briefly reviewed here. Occupational Health Services have changed considerably during the 1990s. The causes are the recession, the terms of a collective agreement, and the end of government funding for the occupational health centres. In January of 1993, when the government funding stopped, it covered 27 percent of the cost of the occupational health centres. The number of employees in the occupational health centres decreased from 10,000 to 7,500 between 1992 and 1994. In total there are about 700 occupational health centres in Sweden. Occupational Health Services is a larger organisation than the Labour Inspectorate, National Institute for Working Life or the Departments of Occupational Medicine (Table 1.2). 11 A changing working life Table 1.2. Number of persons in some organisations in the occupational health area in 1995. Organisations N National Institute for Working Life 475 National Board of Occupational Safety and Health 320 Labour Inspectorate 600 Occupational Health Services 7,500 Swedish Council for Work Life Research 40 Departments of Occupational Medicine*250 * includes persons working in environmental medicine. The National Board of Occupational Safety and Health and the Labour Inspectorate are in the same organisation. The Labour Inspectorate is divided into eleven districts. It enforces the law and inspects the workplaces. Its main task is to see to it that employers work systematically to improve the work environment and that they make proper provisions for rehabilitation. The Labour Inspectorate is legally empowered to give notice to a company to correct observed shortcomings in the work environment. It may also issue prohibitions or injunctions. Notices were given to 23,000 companies in 1993, and injunctions or prohibitions were issued to 455. There are 113,000 safety representatives in Sweden. They are authorised to stop work if they consider it to be dangerous. In total there were 40 such stops in 1994. The National Institute for Working Life was founded in July 1995, in a merger of the National Institute of Occupational Health and the Swedish Institute for Work Life Research. The Institute conducts and promotes research, education, development and international collaboration on research and development to improve working life. The Swedish Council for Work Life Research was founded in 1995, replacing the Swedish Work Environment Fund. It supports research and development, and has a budget of approximately 265 millions SEK per year. Statistics There are several sources that can be used to evaluate the work environment and its influence on health. In a recent review Forsberg (1994) listed 17 different sources of information. The registers used in this evaluation are briefly described below. 12 Working life and health. A Swedish survey Occupational Injury Information System (ISA) All on-the-job accidents and occupational injuries or illnesses are to be reported to this register. Reports are sent by the employer to the social insurance office. Not all reported cases are evaluated by the office regarding eligibility for compensation. Because of changes in the rules for compensation, the frequency of reporting has varied over the years even though the reporting is compulsory. Most employers also have additional private insurance for accidents and occupational diseases, negotiated between the unions and the employer. The statistics from that organisation (TSI) are used in this evaluation to examine the occurrence of accidents. The Census-linked Death Register (CDR) All deaths in Sweden are reported to a central register containing the person’s national registration number, name and cause of death. The death register contains no information about occupation, but by combining the information with that given in a census the mortality in different occupations can be described. In this survey the census of 1980 has generally been used. The National Survey of the Working Environment (NWE) Since 1989, Sweden has had a national survey every second year in which a random sample of the population answers questions about their work and working conditions. The questions cover both the physical, chemical and psychosocial work environment. There is also an annual population-based survey of work-related symptoms. The Swedish Survey of Living Conditions (ULF) Since the 1970s, Statistics Sweden has interviewed a random sample of the Swedish population about their living conditions. The interviews also contain some questions on work and working conditions. The Cancer-Environment Register (CER) Sweden’s national Cancer Register was begun in 1958. The reporting of any diagnosed case of cancer is mandatory. The Cancer Register contains no information on occupation, but by linking this register with the censuses of 1960 and 1970 the incidence of cancer in different occupations can be calculated. A changing working life The Level of Living Survey (LNU) This is a register compiled and kept by the Swedish Institute for Social Research at Stockholm University (SOFI). It is based on interviews (1968, 1974, 1981, 1991) of a random sample of the population. About 3,900 persons were interviewed on each occasion. The register contains some information on occupation and working conditions. 13 14 Working life and health. A Swedish survey A changing working life . 2 Physical, chemical and biological factors This chapter deals with noise, vibration, electromagnetic fields, work at computers, chemical hazards and contagious diseases. The quantitative data are mainly from questionnaires. There is little information available on concentrations of chemicals – even for the most common substances, there are no data from sampling surveys. Noise About 50 percent of male and 20 percent of female skilled workers reported in 1993 that during at least one fourth of the workday the noise level at their workplace was so high that they could not carry on an ordinary conversation. Among professionals 6 percent reported such noise. This means that about 800,000 Swedes, during at least one fourth of their workday, are exposed to such noise that they cannot converse in a normal tone of voice. According to the law, workers should be protected against noise above 85 dBA (AFS 1986:5). A government committee suggested that the noise level in production areas should not exceed 70–75 dBA; for office work 35 dBA was recommended. There is no study of typical noise levels in Swedish workplaces, but in 1993–94 the Labour Inspectorate measured noise at 34 workplaces where they had reason to assume that levels were high. In all of them the maximum was exceeded (> 85 dBA). 15 16 Working life and health. A Swedish survey Vibrations Hand-arm vibrations may cause white fingers and nerve damage. In a Swedish study 66 percent of welders and 45 percent of platers reported numbness in their hands, versus 6 percent in controls. In the national surveys made by Statistics Sweden between 1989 and 1993, 220,000 to 300,000 men and 30,000 women reported hand vibrations for at least one fourth of the workday. Whole-body vibrations are common during the driving of heavy vehicles. The National Board of Occupational Safety and Health has estimated that about 500,000 drivers daily are exposed to whole-body vibrations. In the national survey in 1993, 12 percent of men and 1 percent of women reported whole-body vibrations for at least one fourth of the workday. Electromagnetic fields There is no threshold limit value for occupational exposure to magnetic fields. A criteria group concluded in 1995 that available knowledge provided an insufficient basis for establishing a maximum allowable level. In a survey of 1,098 Swedish men in different occupations it was found that 40 percent were exposed to an average above 0.2µT. The daily average for welders was 1.9µT. Loggers had the highest value, 2.5µT, due to the exposure from chain saws. Programmers and systems analysts who often work with computers had a daily average of 0.2µT. For a little more than 50 percent of 90 different occupational groups, average exposures exceeded 0.2µT. However, since exposures within occupational groups varied widely, job titles were usually a poor indication of exposure. Work at computers Ten years ago about one person in four worked at a computer. In 1995, 54 percent of men and 48 percent of women used computers in their work. Computers are most common in administrative and office work, where more than 90 percent worked at a computer in 1995. In farming and forestry 20 percent of the workers used computers. About 10 percent of all employed persons reported in 1995 that they used a computer at home for their work. About 20 percent of those had a modem. About 1 percent of all employed persons worked at least half time at computers in their homes in 1995. A changing Physical, chemical working andlife biological factors Chemical products Chemical products that are manufactured or imported in quantities above 100 kilograms per year must be reported to the Product Register of the National Chemicals Inspectorate. In 1995, 50,000 such products were registered, 80 percent of which were used only in workplaces. About 130,000 different substances occurred in these products. The companies have classified about 1,600 products as toxic or extremely toxic. There is no systematic register of the concentrations of individual substances in the work environment. The National Board of Occupational Safety and Health has determined maximum allowable concentrations for about 370 substances. A control of randomly selected small workplaces in Stockholm in 1994 revealed that about 30 percent of them used more than 20 kilograms of toxic products per year. The risk of dangerous exposures was high or fairly high in 11 percent of the workplaces. There has been a national register of persons occupationally exposed to lead in Sweden. The register was closed in 1990. An analysis of lead concentrations in blood between 1978 and 1989 showed that the number of persons with blood lead levels above 2.5 µmoles per litre had not decreased (Figure 2.1). Figure 2.1. Number of persons in Sweden with a blood lead concentration above 2.5 µmoles per litre, 1978–1989. (Source: Lead Register, National Board of Occupational Safety and Health.) 17 18 Working life and health. A Swedish survey Persons with a blood lead concentration above 2.5 µmoles per litre are not allowed to work with lead. For women below the age of 50 the limit is 1.5 µmoles per litre (AFS 1992:17). In the national survey a random sample of the population answered a questionnaire about exposures (NWE). It can be estimated from the answers that about 200,000 persons, mostly men, were exposed to oils or organic solvents for at least one fourth of their working time (Table 2.1). The number of exposed persons decreased by 25 percent between 1989 and 1993. A separate analysis of the engineering industry showed that the proportion exposed to chemicals changed very little between 1989 and 1993. The decrease in number of exposed persons is thus mostly due to the decreased number of persons employed in the industry. From the national surveys it can be estimated that about 450,000 persons were exposed to organic dust for at least one fourth of their working time. The numbers of exposed men and women were similar. Since this information comes from questionnaires it gives no indication of the concentrations. Table 2.1. Some representative occupational exposures, 1989–1993. Information is based on interviews in which persons have reported that they are exposed to the substance for at least one fourth of their working time. Number of exposed persons (in thousands) Oil on skin Organic dust Organic solvents Women 1989 47242 199129216 199323227 47 42 34 Men 1989252268205 1991221246198 1993193227151 To estimate the use of some chemicals, a questionnaire was sent in 1995 to chemists and occupational hygienists in each district of the Labour Inspectorate. They were asked the number of persons exposed to some substances and whether the use of these substances had increased or decreased. They responded that for most substances use was apparently decreasing, but they indicated an increased use of isocyanates. The questionnaire also showed that the average number of exposed persons per workplace was ten or fewer. 19 A changing Physical, chemical working andlife biological factors The national survey revealed that the number of persons exposed to environmental tobacco smoke (ETS) decreased by 40 percent between 1989 and 1993. In 1993, 215,000 women and 306,000 men reported that they were exposed ETS at work for at least one fourth of their working time. Table 2.2. Some hazardous substances: Number of exposed persons, number of companies where the substance is used, and the trend in use estimated by the Labour Inspectorate. The information was collected in 1995. Substance Number of exposed Number of companies Asbestos2,000–4,000 900–1,400 Quartz2,000–5,000 900–1,200 Styrene1,000–2,000200–300 Isocyanates10,000–20,0002,000–3,000 Cutting fluids15,000–30,0002,000–4,000 Lead2,000–4,000200–500 Cadmium 600–1,400 60–90 Trend declining declining declining increasing declining declining declining Infectious material and other biological risk factors Hospital personnel report most cases of infection during work to the occupational injuries information system (ISA). Reported cases of infection due to occupational exposure to hepatitis viruses (type B or C) have been below five per year since the late 1980s. In some cases it is difficult to determine whether the infection occurred at work. There is no known case in Sweden of a person being infected by HIV during work. In Sweden there are about 600 cases of tuberculosis per year. Since 1990 there have been one to four cases reported per year involving hospital workers infected by tuberculosis at work. Personnel at pre-school and day care centres often catch respira tory infections, but these cases are not reported to ISA. Another risk, for persons working at slaughterhouses for hens and chickens, is infection by Campylobacter, but there are no statistics. There are no survey data on exposure to mould, bacteria and endotoxins, or other microbiological risk factors in farming, water purification plants etc. However, there is information indicating that exposure to mould and spores in sawmills is decreasing. 20 Working life and health. A Swedish survey . A changing working life . 3 Psychosocial factors Psychological demands and the freedom to make one’s own decisions at work are important psychosocial factors (Karasek and Theorell, 1990). Negative stress arises when the demands are high and the freedom is low. Active work is defined as high psychological demands in combination with high control over the work situation. Psychological demands and control over the job differ between blue-collar and white-collar workers. High-level professionals usually have higher psychological demands and greater freedom to plan their own work. For unskilled manual workers the situation is the opposite. The nature of psychosocial factors was therefore investigated in four different groups: unskilled workers, skilled workers, low-level salaried employees and mid- or high-level salaried employees (here called “professionals”). The frequency of stressful (high demand, low control) and active (high demand, high control) jobs in different industries was determined for each group. The importance of workplace size, employment sector (private, state, municipal), shift work, supervisory responsibilities and social support were analysed. Jobs with high mental demands and good conditions for individual decisions are more common in small workplaces, in the public sector and among non-shift workers. Managers and supervisors more often have work with negative stress, but they also have more active work than other employees. The psychological demands on foremen and managers are usually rather high, so their freedom to make their own decisions largely determines whether they have an active job or 21 22 Working life and health. A Swedish survey one with negative stress. Social support generally lowers the risk of negative stress. The occurrence of negative stress and active work were analysed through the Surveys on Living Conditions (ULF) and the National Surveys of Work Environment (NWE), both conducted by Statistics Sweden. These surveys are based on interviews and/or questionnaires given to large samples representative of the Swedish population. Persons who reported high psychological demands and low control were classified as having negative stress and persons who reported high demands and high control were classified as having active work. For each of the four groups, the variation across industries in the percentages of persons reporting negative stress and active work was estimated. The reference category is “manufacturing industry excluding engineering.” Estimates above 1.0 mean that negative stress (or active work) is more common than in the reference category, and estimates below 1.0 mean that it is less common than in the reference category. Negative stress For unskilled workers, there are five industries with an elevated risk of negative stress: health services, retail trade, hotels and restaurants, transport and communications (Table 3.1). All these are in the service sector. There are five occupational groups with high risk of negative stress: assistant nurses, kitchen assistants, post office clerks, drivers and shop assistants (especially those working at the cash registers). For skilled workers, there is a higher than average risk of negative stress in health services and hotels and restaurants. The risk of negative stress is approximately three times higher in the hotel and restaurant business than in the manufacturing industry (excluding engineering). In health services the risk is two to four times higher than in the reference group. Occupational groups where negative stress is common are waiters, cooks and assistant nurses. For low-level salaried employees, negative stress is most common in health services, transport, communications, and banking and insurance. Dental nurses, salesmen, receptionists, computer opera tors, telephone operators and assistant accountants are occupational groups where negative stress is relatively common. 23 A changing working Psychosocial factors life For professionals, negative stress is more common in health services and hotels and restaurants. Occupational groups with an elevated risk of negative stress are nurses, doctors, dentists, catering supervisors and some categories of teachers. In summary, negative stress is more common in the service sector than in manufacturing. In health services and hotels and restaurants the risk of negative stress is considerably elevated for all four groups. Table 3.1. Occurence of negative stress in different industries by occupational category (unskilled workers, skilled workers, salaried employees professionals). Relative risks expressed as ratios between the proportion of stressful jobs in a given category and the proportion in the reference category “manufacturing industry excluding engineering”. Ratios above (below) 1.0 mean that the proportion of employees in the industry who have stressful jobs is higher (lower) then the corresponding proportion in the reference category. Results from both the ULF and the NWE surveys are presented in the table (*** = too few cases). Industry Workers unskilled skilled Professionals low-level high-level ULF/NWE ULF/NWE ULF/NWE ULF/NWE Engineering1.2/0,91.7/0.61.7/0.9 0.5/0.8 Construction 0.4/0.6 0.7/0.51.5/0.61.0/1.2 Wholesale trade1.1/0.6 0.8/1.0 0.8/1.3 0.6/0.9 Retail trade1.0/1.51.8/1.21.0/1.81.4/1.7 Hotels and restaurants1.6/1.52.7/3.4 0.5/2.5 5.6/4.5 Transport1.8/1.32.0/1.32.1/3.01.9/1.2 Communications1.3/1.5 0.8/0.72.1/2.6 0.8/0.7 Banking and insurance *** ***1.7/2.11.1/1.2 Public administration *** ***1.1/1.21.4/1.2 Education *** *** ***/1.7 0.9/2.3 Health services2.0/1.1 4.0/2.3 3.2/3.1 4.0/3.4 Other services 0.5/0.6 0.9/1.11.0/0.9 0.7/0.6 Active work For unskilled workers, active work is five to ten times more common in social care than in the manufacturing industry. In some industries where negative stress is relatively common, active work is also common: this is the case in health services, hotels and restaurants, retail trade, transport and communications. Active work is also relatively common in the construction industry and in wholesale trade. Occupational groups which often have active jobs are children’s nurses, home helpers and assistant occupational therapists. For skilled workers, active work is four times as common in social care as in 24 Working life and health. A Swedish survey the manufacturing industry. Active work is also common in hotels and restaurants, health services, and wholesale and retail trade. For white-collar workers, there are generally small differences across industries in the prevalence of active work. Vulnerable groups On average, psychosocial working conditions are worse for women than for men. In 1992/93, 12 percent of women had work with negative stress compared to 8 percent of men. However, if the occurrence of negative stress is compared within occupational groups there is no difference between male and female employees. Hence, the relatively large proportion of women experiencing negative stress at work is due to the fact that women tend to have other types of occupations than men. The difference in occurrence of active work is small between men and women, on average. However, there is a large difference, to the disadvantage of women, if men and women are compared within the same occupational group or industry. Compared to native Swedes, immigrants have a higher percentage of jobs with negative stress and a lower percentage of active jobs. The difference cannot be explained by differences in occupational distribution. In 1992/93, 15 percent of immigrants had stressful jobs compared to 9 percent of Swedes. Active work was reported by 18 percent of immigrants and 25 percent of native Swedes. Trends During the past decade, the proportion of unskilled workers has decreased while the proportion of professionals has increased. Manufacturing employs a decreasing percentage of the population and the social and health care sector has grown. Because of these changes, work with high psychological demands and high control has become more common, i. e. active work has increased. On top of this structural change, psychological demands have increased markedly. In 1979, 29 percent of all employees described their work as hectic and mentally demanding. This figure had increased to 35 percent by 1992/93. The trend is especially marked in social care, health services and education. This rise in psychological demands of structural change, has resulted in an increasing number A changing working Psychosocial factors life of stressful jobs. All in all, then, the 1980s and early 1990s have witnessed a polarisation of jobs with respect to their psychosocial character. Both active work and negative stress have become more common. Reference: Karasek R, Theorell T. Healthy work. Stress, productivity, and the reconstruction of working life. New York, Basic Books, 1990. 25 26 Working life and health. A Swedish survey 27 Psykisk ohälsa, våld och trakasserier . 4 Mortality in occupational groups Socioeconomic differences in age-adjusted mortality have increased in several Western countries during the past few decades. The increase is most prominent in men. In Sweden the mortality of middle-aged manual workers was virtually unchanged between 1961 and 1985, whereas it decreased considerably for other groups. The mortality in different social classes has been analysed by comparing the Cause-of-Death-Register with the censuses of 1980 and 1985. The sex-specific and age-adjusted mortality for workers aged 20 to 64 was calculated for the periods 1981–1985 and 1986–1990. Mortality had decreased in all groups of men (Table 4.1). Table 4.1. Age-adjusted mortality according to social class among occupationally acitve persons (cases per 100,000 persons and year), 1981–85 and 1986–90. Women Men 1981–85 1986–90 1981–85 1986–90 High-level non-manual employees 154 Middle level non-manual employees 142 Lower non-manual employees 164 Self-employed 150 Farmers 130 Skilled workers 171 Semi- and unskilled workers 170 142 135 157 155 145 161 162 252 264 321 310 260 325 391 205 237 285 305 236 306 350 The largest decrease was in high-level non-manual workers, who already had the lowest mortality. The previously increasing difference between manual workers and other groups slowed down 28 Working life and health. A Swedish survey during the late 1980s. Thus, mortality can decrease while the difference between classes remains. The changes for women are much smaller than for men. The difference in mortality between women and men has decreased in all groups. The cause of this is unknown. Occupation and mortality Mortality was calculated for men and women in 245 occupational groups and for two periods of time. In 66 combinations of sex and occupational group there was a statistically significant high or low mortality during both time periods. Elevated mortality was found for 31 combinations of sex and occupational group: both male and female bookbinders, joiners, cleaners, printers and toolmakers, for example, had elevated mortalities during both periods. For men, waiters, cooks and kitchen assistants had an elevated mortality during both periods, whereas there was no increase for females in these jobs. The cause of this difference between the sexes is unknown. In a previous analysis, the Swedish Commission on Working Conditions identified drivers as a group with high mortality. Relative risks were 1.5 for male drivers and 1.35 for female drivers during the period 1986–1990. Occupational groups with a low mortality during both periods were engineers, dentists, judges and teachers. Male business administrators, salesmen, buyers and shop managers had a lower than average risk. Female shop assistants, physiotherapists and nurses had low mortality. The causes of the differences in mortality between occupational groups are largely unknown. Probably both occupational and non-occupational factors are of importance. Reference Vågerö D, Lundberg O. Socioeconomic mortality differentials among adults in Sweden. In Lopez A, Caselli G, Valkonen T (eds). Adult Mortality in Developed Countries. Oxford: Clarendon Press, 1995. Psykisk ohälsa, våld och trakasserier . 5 Work environment and myocardial infarction Approximately 1,900 Swedish men and 400 Swedish women below the age of 65 die every year of myocardial infarction. The mortality increases rapidly with increasing age. Less than 300 men and 50 women below the age of 50 die annually of myocardial infarction. Both morbidity and mortality due to myocardial infarction have varied in recent decades. There are no national statistics on morbidity. In Stockholm county morbidity increased by approximately 2 percent per year during the 1970s and then decreased at approximately the same rate. The decrease occurred among both women and men, younger and older, although it is less pronounced for younger persons. There are similar trends in mortality due to myocardial infarction, but the causes of these trends are unknown. Changes in smoking and dietary habits are often suggested as explanations, as is medical treatment of high blood pressure and high blood lipids. The occurrence of myocardial infarction in Sweden shows some geographical variation. The risk is higher in the north. There are also differences between socioeconomic groups. The risk is approximately 50 percent higher among blue-collar workers than among white-collar workers, for example (Alfredsson et al, 1995). The geographical and sociological differences in occurrence of myocardial infarction are too large to be explained by recognised 29 30 Working life and health. A Swedish survey risk factors such as tobacco smoking, high blood pressure or high blood lipids. Risk of myocardial infarction in different occupations The Cause of Death Registers for 1981–86 and 1987–92 were investigated to determine the mortality due to ischemic heart disease in different occupations. The relative risks were calculated by comparing the mortality in an occupational group with the average mortality for all gainfully employed. A relative risk of 1.0 means that the occupational group has a risk similar to that of the average Swedish worker. In the analyses of the occupational groups the differences in age were taken into account. Occupational groups with higher or lower than average risk of death due to ischemic heart disease were identified (Tables 5.1 and 5.2). Table 5.1. Occupational groups with a high risk of myocardial infarction 1987–92. Nurses’ assistants Welfare workers Forestry workers Miners Ship’s deck and engine-room workers Drivers Railways engine drivers Truck dispatchers Messengers Furnace men Hardeners Forge and foundry workers Toolmakers Metal platers and coaters Cabinetmakers and joiners Laminated wood and fibreboard workers Sawmill workers Concrete workers Plastic product makers Unskilled workers Earth-moving and other heavy equipment operators Forklift truck and conveyor operators Greasers Packers Longshoremen Warehouse workers Cooks and kitchen assistants Cleaners Other service workers Psykiskenvironment ohälsa, våldand och myocardial trakasserierinfarction Work Table 5.2. Occupational groups with a low risk of myocardial infarction, 1987–92. Graduate engineers Managers of machine shops Chemists and physicists Physicians Dentists School principals College teachers High school teachers Grade school teachers Systems analysts, programmers Legislators and administrators Business managers Advertising salesmen Sales representatives Shop managers Farmers Policemen There were 30 male occupational groups with an elevated risk. Four had a risk above 2.0: ship’s deck and engine-room workers, railway engine drivers, laminated wood and fibreboard workers and “other” service workers. Of the 30 male occupational groups with an elevated risk, 17 were in the manufacturing industry, 5 in transport, storage and communication, and 5 in the service sector. Among professional drivers there were in total 961 deaths during the studied period. One fourth of them, or 254 cases, could be attributed to the elevated risk of the occupation. There were 777 deaths among toolmakers: one fourth, or 183 cases; could be attributed to the elevated risk in this occupation. There were five female occupational groups with higher than average risk: professional drivers, toolmakers, storage and warehouse workers, kitchen assistants and cleaners. Twenty male occupational groups with a lower than average risk were identified. Physicians and dentists had the lowest risk (relative risk = 0.5). Twelve of the groups were in the sector natural sciences, technical and social sciences, humanities or arts, three in the administrative sector and three in the commercial sector. The other two were farmers and policemen. Two female occupational groups with a low risk were identified: nurses and primary education teachers. 31 32 Working life and health. A Swedish survey Analyses for 1981–86 show the same pattern for men and women, low risk in university graduates and high risk in workers in the manufacturing industry and service sector. An earlier report by the Swedish Commission on Working Conditions showed an elevated risk for drivers and supervisors in the transport sector. This is less obvious in the analyses for 1981–86 and 1987–92. For both men and women, there is a fivefold difference between the highest and the lowest risk categories. Most of the low-risk occupations require a university degree. Most of the high-risk occupations are in the manufacturing and service sectors, e.g. blue-collar workers and office workers with low education. The explanation for these differences is not known, but it is reasonable to assume that they result from a combination of lifestyle and chemical, physical and/or psychosocial factors in the work environment. References Alfredsson L, Hammar N, Gillström P. Increasing differences in myocardial infarction incidence between socio-economic groups in Stockholm. Nutr Metab Cardiovasc Dis 1995;5:99–104. Hammar N, Ahlbom A, Theorell T. Geographical differences in myocardial infarction incidence in eight Swedish counties, 1976–1981. Epidemiology 1992;3:348–355. Psykisk ohälsa, våld och trakasserier . 6 Occupation and cancer The Swedish Cancer Committee estimated at the end of the 1970s that approximately 2 percent of all cases of cancer would not have occurred if the known causes of cancer in work environments had been eliminated. Most cases that would occur would be among men, and the factor that caused most cases would be asbestos. Two percent of cancer in Sweden today is approximately 800 cases. Studies in northern and southeastern Sweden indicate that approximately every tenth case of lung cancer in men could have been prevented by work environment interventions in the 1970s. A study in Gothenburg in the mid-1980s showed that if asbestos had not been used earlier, approximately 15 percent of cases of lung cancer would have been eliminated in men below the age of 75. The IARC has evaluated the carcinogenic potential of approxi mately 1,000 substances and exposures. Substances and exposures that the IARC has classified as definitely or probably carcinogenic and which occur in Sweden in substantial amounts are listed in Table 6.1. Job-exposure matrices were used to estimate the number of persons exposed to carcinogenic substances in the work environment. A matrix shows the combinations of occupation and industry in which there is a risk of exposure to a certain carcinogenic substance. For each combination of occupation in industry the number of exposed persons is estimated. The estimates in the table are based on the census of 1990. When a maximum allowable concentration is changed, the National Board of Occupational Safety and Health estimates number of exposed persons. This 33 34 Working life and health. A Swedish survey information was compared to the numbers from the job-exposure matrix. The results in the matrix were also compared to the Finnish register of persons exposed to carcinogenic substances. There was a fair concordance between these different sources. Table 6.1. Estimates of the numbers of persons in Sweden exposed to some carcinogens. The projected numbers of cancer cases are based on some assumptions (see text). Exposure Number of exposed 1990 Men Women Cases of cancer/year at RR=1.1 Type of tumour Men Women Arsenic 200 30 lung cancer Asbestos 1,500 30 lung cancer Benzene 40,000 5,000 leukaemia Diesel exhaust 30,000 1,300 lung cancer Ethylene oxide 500 100 leukaemia/lymphoma Formaldehyde 2,000 700 Glass industry work 600 250 lung cancer stomach cancer large intestine cancer Foundry work 1,000 100 lung cancer Rubber industry work 300 30 lung cancer urinary bladder cancer Cadmium 400 100 lung cancer Chromiun (6+) 2,000 100 lung cancer Silica 12,000 400 lung cancer Painting 22,000 800 lung cancer Chlorinated organic solvents 800 1,100 liver cancer Radon 2,000 70 Leather dust (shoe manufacturing) 300 300 Soot, tar and combustion products 9,000 300 Strong acids 600 100 Wood dust 32,000 1,000 Vinyl chloride 300 30 non-Hodgkin lymphoma lung cancer nasal cancer skin cancer lung cancer urinary bladder cancer larynx cancer nasal cancer liver cancer 0.06 0.4 0.8 9 0.1 0.01 0.2 0.1 0.2 0.3 0.09 0.07 0.1 0.6 4 6 0.01 0 0.1 0.2 0.02 0 0.04 0.02 0.1 0.02 0 0 0.02 0.02 0.07 0.1 0.03 0.03 0.1 0.6 0.1 0.02 0 0 2 3 2 0.02 0.2 0.01 0.04 0.05 0.03 0 0 0 The number of cancer cases in the future Estimates were made of the number of cancer cases that could have been avoided if the known causes of cancer in the work environment had been eliminated. These estimates are based on the following assumptions: the number of new cancer cases per year is constant and the same as in 1992; the age distribution of the population is constant; and the relative risk does not increase before the age of Psykisk ohälsa, och trakasserier Occupation and våld cancer 30 but thereafter is the same for all age groups and calendar years. Two combinations of relative risk and occupational turnover were used. Occupational turnover is defined as the proportion that leave an exposed occupation/branch of industry during one year. In one combination the relative risk was set to 1.1 and the occupational turnover to 10 percent, and the results are given in Table 6.1. Comments on some exposures Some common exposures are discussed. The number of cancer cases today can be estimated rather well for some agents, such as asbestos, but for substances such as diesel exhausts the estimates are much more uncertain. Asbestos The Cancer Register shows that pleural mesothelioma has increased (Figure 6.1). Peritoneal mesothelioma is far less common (fewer than 20 cases per year) and has increased little over the past few decades. A high proportion of the cases of pleural mesothelioma are probably caused by occupational exposure to asbestos. There is no other known cause of mesothelioma in Sweden: erionite, for example, does not occur in Sweden. Figure 6.1. Swedish import of asbestos in tons and cases of pleural mesothelioma. 35 36 Working life and health. A Swedish survey The import of asbestos decreased rapidly in the mid-1970s and by the beginning of the 1990s it was below 500 tons per year. Mesothelioma rarely occurs less than 20 years after the first exposure. The risk then increases even if the exposure stops. The number of mesothelioma cases in Sweden has thus increased although exposure to asbestos virtually stopped in the 1970s. If the increase continues at the present rate approximately 150–200 men and 40–60 women per year will develop mesothelioma in 2010. It is much more difficult to estimate the number of lung cancers that could have been avoided if there has been no asbestos in the work environment. The risk is also reduced if exposed persons stop smoking. A few studies also indicate a possibility that the risk for lung cancer might decrease if exposure stops. Judging from earlier Swedish studies, it is a reasonable assumption that the number of lung cancer cases in men would have been at least 5 percent lower if asbestos had never been used in Sweden. For women the effect would hardly be detectable. Five percent of all lung cancer cases among men corresponds to about 100 cases per year in Sweden today. Present exposures to asbestos would increase the risk for lung cancer and mesothelioma by barely more than 10 percent among those approximately 1,500 persons who are still exposed to asbestos. That means less than one case per year is caused by the present exposure to asbestos in Sweden (Table 6.1). Diesel exhaust Long-term and heavy exposure to diesel exhaust probably increases the risk of lung cancer. Workers in bus garages who have been exposed to high concentrations of diesel exhaust for a long time have approximately double the average risk of developing lung cancer. An elevated incidence has also been observed in Swedish longshoremen, probably caused by exposure to diesel exhaust. If the present exposure to diesel exhaust increases the risk of lung cancer by 10 percent, that will be approximately 10 cases per year in Sweden. Benzene It is well known that benzene may cause some types of leukaemia. Benzene occurs almost exclusively in petrol for motor vehicles, Psykisk ohälsa, Occupation andvåld cancer och trakasserier which in Sweden contains 3 to 4 percent benzene. It is impossible to estimate the number of persons exposed to benzene by using a job-exposure matrix. The National Board of Occupational Safety and Health estimated that in Sweden 40,000 to 50,000 persons are exposed to benzene. According to Table 6.1, a relative risk of 1.1 is equivalent to less than one case of cancer per year. Painting Many studies have indicated that painters have a greater than average risk of lung cancer. One cause may be exposure to asbestos. Other causes may be silica, pigment, binders and solvents. There are also some data indicating that painters smoke more than the population as a whole. In a Swedish study, an elevated incidence of lung cancer was found in painters who started to work in the 1930s and earlier, but no such tendency was seen in younger cohorts. Swedish painters are no longer exposed to asbestos, and the number of cancer cases will therefore probably be lower than that indicated by a relative risk of 1.1 (Table 6.1). Silica Persons with silicosis have an increased risk of developing lung cancer. However, silicosis is now a rare disease in Sweden. It is less certain whether exposure to silica increases the risk of lung cancer. The job-exposure matrix indicates that approximately 12,000 Swedish workers are exposed to silica, but the risk of lung cancer at the present exposure level is hard to estimate. If the assumption in the model is correct, a few cases per year may occur due to present exposure to silica. Soot, tar and combustion products Soot, tar and combustion products contain carcinogenic substances such as polyaromatic hydrocarbons (PAH). The risk of skin cancer from exposure to mineral oils with a high concentration of PAH has now been almost eliminated in Sweden. Coal tar and pitch are rarely used in Sweden today. Swedish chimney sweeps have an elevated risk of lung cancer. Asphalt containing coal tar may increase the risk of lung cancer, but the asphalt now used in Sweden is based on bitumen, and it is uncertain whether such exposure increases the risk of lung cancer. Chimney sweeps, gas oven workers and workers in 37 38 Working life and health. A Swedish survey aluminium smelters have an elevated risk of bladder cancer . This is probably an effect of exposure to PAH. It is difficult to estimate the number of cancer cases caused in Sweden by present exposures to PAH in combustion products and soot. A few cases per year of lung cancer and bladder cancer would probably be prevented if all exposure to soot and combustion products stopped. The number of skin cancers prevented would probably be of the order of one case per year or lower. Other environmental factors UV radiation increases the risk of skin cancer. The Swedish Cancer-Environment Registe shows that Swedish farmers and fishermen have more than double the average risk of developing cancer of the lip (EpC, 1994), probably because of exposure to UV radiation. Hepatitis increases the risk of liver cancer. In Sweden approximately five persons per year catch hepatitis from exposure at work. Consequently, very few cases of liver cancer will result from such infections. Environmental tobacco smoke in workplaces may increase the risk of lung cancer, but there is evidence that this exposure is decreasing. If exposure to all the substances listed in Table 6.1 were eliminated, less than a hundred cases of cancer among men and less than ten cases among women would be prevented each year. The best estimate of the total is somewhere between 10 and 100 cases per year. Today there are 200 to 250 cases of cancer caused by previous asbestos exposure, and the estimate of 10 to 100 cases per year assumes that present asbestos exposure will cause very few new cases. Compared to the 1950s and 1960s, another few hundred cases of cancer have probably been prevented by elimination of asbestos. Work to decrease the risk of occupational cancer has thus been successful. Continuing research may lead to detection of new cancer risks. In the future, more exposures will probably be regarded as carcinogenic. If all substances which have been suggested as carcinogenic had been included in Table 6.1 the number of cases due to present exposures would obviously be higher. The risks of electrical and magnetic fields have been discussed in recent years. It is impossible to make a firm conclusion as to whether such fields increase the risk of cancer. Occupation andvåld cancer Psykisk ohälsa, och trakasserier There are several current studies attempting to identify genetic markers indicating if a person has a higher or lower than average risk of developing cancer. However, it is unlikely that such genetic markers will be routinely used to prevent occupational cancer during the next five years. Reference Cancer Environment Register 1960–70. EpC-rapport 1994;4, Socialstyrelsen, Stockholm, 1994. 39 40 Working life and health. A Swedish survey . Psykisk ohälsa, våld och trakasserier . 7 Respiratory diseases Asthma and hay fever (allergic rhinitis) have increased in Sweden during the past few decades. The increase is most obvious in children; the trend is less clear for adults. In the beginning of the 1990s 6 to 8 percent of adolescents living in northern Sweden had asthma. The prevalence among adults is approximately 5 percent. Chronic obstructive pulmonary diseases (COPD), including emphysema, occur mainly in smokers. In the beginning of the 1990s 8 percent of men in the age group 60-69 years had COPD, compared to 4 percent of women. In 1990-1992, 300 persons per year claimed their asthma to be occupational asthma (ISA). If the frequency of reporting had been the same in Sweden as in Finland, approximately twice that number of cases would have been reported. Among men, occupational asthma was most often reported by bakers, furnace men, welders and spray painters. Among women the most common occupations were wood workers, plastic product makers and livestock, dairy and poultry farm workers. Mortality due to asthma has been calculated for different occupations, with adjustment for smoking habits in different occupational groups, by combining information from the Census and the Cause of Death Register. There are few cases per occupation and the random variations in relative risk are large. Farmers and agricultural workers were the only male occupational groups that had a significantly higher mortality due to asthma between 1981 41 42 Working life and health. A Swedish survey and 1992. Hairdressers were the only female occupational group with an elevated mortality due to asthma (8 cases versus 1.8 expected). There were four occupational groups with elevated mortality from COPD between 1981 and 1992 (Cause of Death Register, Census data and adjustments for smoking habits). The groups were horticultural workers (16 cases versus 7 expected), postmen (13 cases versus 5.7 expected), truck drivers (22 cases versus 10.5 expected) and storage and warehouse workers (64 cases versus 30.5 expected). The only female group with elevated mortality was storage and warehouse workers (12 cases versus 5 expected). The higher risk in these occupational groups is probably due largely to occupational turnover for health reasons. COPD develops over a long period and the patients may have been transferred or applied for other jobs when they developed symptoms. Table 7.1. Occupational groups with the highest frequencies of asthma during 1990–1992 (ISA). Occupation Frequency (cases/100,000/year) Men Bakers Furnace men Welders Spray painters Chemical processing workers Foundry workers Wood processing workers Woodworking machine operators Plastic products makers Paper mill workers Women Wood workers Plastic products makers Livestock, dairy and poultry farm workers Machine shop workers Laboratory technicians Packers Dressmakers and seamstresses Cleaners Hairdressers Number of cases 78 70 65 60 59 57 46 35 35 30 16 6 54 11 6 6 14 14 9 8 100 63 6 10 60 26 25 24 22 13 13 5 6 6 10 8 35 6 In the ISA statistics of occupational injuries and diseases it is difficult to distinguish between COPD and chronic bronchitis. Psykisk ohälsa, våld och trakasserier Respiratory diseases In 1990–1992 about 50 men and 25 women per year reported those diseases. The five male occupational groups reporting the highest frequencies were workers in the steel and metal industry, non-specific production workers, chemical processing workers, rubber product makers, painters, floor layers and carpenters/ cabinetmakers. In women these diagnoses were most common in chemical processing workers and rubber product workers. Few cases of rhinitis were reported to ISA as an occupational disease during these three years: 32 male cases and 13 female cases. All but two men and one woman were bakers. During the 1990–1992 period 51 cases of allergic alveolitis were reported by men and 11 cases by women. Thirty-three cases were farmers: 30 men and 3 women. Six cases occurred among carpenters and cabinetmakers. For this group the cases reported to the register have decreased during the past decade from about 80 to 20 cases per 100,000 persons per year. New causes of respiratory disorders Changes in the work environment influence the risk of respiratory diseases. Asbestosis and silicosis have been virtually eliminated since the use of asbestosis has been prohibited, and exposure to silica has decreased considerably. Increased use of paints and lacquers containing isocyanates may increase the risk of asthma unless measures are taken to reduce exposure. Paper pulp is now bleached with ozone, which may be a new cause of occupational asthma. The shift from solvent-based to water-based paints may increase the risk of respiratory disorders, since the water-based paints contain biocides. An increased use of glues and paints based on reactive chemicals may increase the risk of respiratory diseases in the manufacturing and construction industries. A few new factors that can cause respiratory disorders have been identified during the past decade, including latex dust in hospitals, aziridrin in some paints and the environment in pig farming. 43 44 Working life and health. A Swedish survey . Psykisk Skin diseases ohälsa, våld och trakasserier . 8 Skin diseases In 1993, 935 men and 1,423 women reported skin disorders caused by their work (ISA). These cases account for 4 percent of all reported occupational diseases. Ninety percent were eczema cases, and in nine of ten of these the skin of the hands was affected. Skin disorders are reported more often by women than by men, and are more common in young than in elderly persons (Figure 8.1). Figure 8.1. Frequency of skin disorders reported to the ISA, 1980–1992. 45 46 Working life and health. A Swedish survey Reports have declined in number during the 1990s, especially among younger persons. The decrease may be an effect of the lower number of persons employed in the manufacturing industry. It was found in previous studies that reported cases on average require 15 weeks of sick leave and that two thirds of those who were on sick leave for more than 90 days due to skin disorders had applied for compensation for occupational disease. Only a small percentage of hand eczema cases are reported to the ISA. In a cross-sectional study made in Gothenburg during the 1980s it was found that approximately 10 percent of the population had had hand eczema during the previous year (Meding, 1990). Hand eczema was twice as common among women as among men. Occupations with an elevated risk of occupational skin disease were identified by combining information from the ISA for 1990–91 and the census of 1990 (Table 8.1). The highest risks were in occupational groups having frequent skin contact with water, detergents and oils. In half of the reported cases water and detergents are considered the cause of the hand eczema. Table 8.1. Occupational groups with an elevated incidence of skin disorders, 1990–91. Occupation (gender) Number of reported cases Hairdressers (women) Machine fitters (women) Cooks (women) Dental assistants (women) Toolmakers, machine tool setters and operators (men) Cooks (men) Cleaners (women) Kitchen assistants (women) Home helpers (women) Machine assemblers (men) Assistant nurses and hospital orderlies (women) Packers (women) Machine fitters (men) Painters (men) 92 52 77 53 142 33 237 148 208 126 256 35 61 42 Female hairdressers have the highest risk. It is estimated that approximately 20 percent of them have to change their occupation due to hand eczema (Meding, 1990). The most common occupational skin disorder is irritant contact dermatitis caused by water and detergents. Jobs with this kind Psykisk Skin diseases ohälsa, våld och trakasserier of exposure are common among women: hairdressers, cleaners, kitchen assistants, home helpers, dental assistants etc. The high incidence of hand eczema among working women is probably an effect of exposures both at work and at home. The most common causes of allergic contact dermatitis are nickel, rubber chemicals, colophony (rosin), biocides, chromates, synthetic resins and perfumes. Ten percent of women and 1 percent of men in Sweden are allergic to nickel. Sensitization to nickel is often not of occupational origin but due to cheap jewellery and other metal objects in close contact with the skin-watch bands, buttons etc. The risk of sensitization from occupational exposure to nickel in tools is under investigation in Sweden. Cement used to be a common cause of contact allergy to chromates. As a preventive measure, for the past 10 or 15 years ferrous sulphate has been mixed into cement produced in Sweden to reduce the amount of sensitizing chromate. The most common cause of contact allergy to rubber is the use of rubber gloves. Rosin originates from coniferous woods. When used in soldering it may cause allergic contact dermatitis on the face. Rosin also occurs in paper, and there are a few reports of allergic contact dermatitis in pulp and paper mill workers, but the size of this problem is unknown. The rosin content is higher in mechanical pulp than in chemical pulp (Karlberg et al, 1995). Contact urticaria may be either allergic or non-specific. Since the symptoms occur within a few minutes of the exposure the association is usually obvious, and the victims rarely seek medical attention. The incidence of these symptoms is unknown, but a study now in progress indicates that a few percent of all workers have or have had work-associated contact urticaria. Allergic contact urticaria is often caused by proteins and may sometimes develop into chronic eczema, “protein dermatitis.” Common occupational causes of contact urticaria are exposure to latex rubber in gloves, handling food and working with animals. Latex allergy is a problem mostly for hospital workers who use gloves. Approximately 6 million pairs of surgical gloves and 50–60 million examination gloves of latex rubber are used every year in Sweden. At the beginning of the 1990s, three percent of workers in dental care and in operation theatres in Stockholm were allergic to latex (Wrangsjö, 1993). 47 48 Working life and health. A Swedish survey Atopy increases the risk of hand eczema. At least 25 percent of all Swedes are atopics. Several Scandinavian studies have shown that persons who had atopic dermatitis in childhood are three times as likely as non-atopics to develop hand eczema in adult life (Meding, 1990). An analysis shows that at least 40 percent of Swedes aged 16–24 who report occupation-related skin disorders had atopic dermatitis in childhood. Several international studies have revealed that atopic symptoms are increasing rapidly in most countries. Since atopic dermatitis increases the risk of hand eczema, an increased occurrence is expected. The prevalence of hand eczema in Sweden in the 1980s was double that of twenty years earlier. A patient will probably be able to continue working at the same job if exposure to the cause of the eczema is eliminated. In a survey made in Gothenburg, 8 percent of persons with hand eczema reported that they had changed jobs because of the skin disease (Meding, 1990). Those most likely to change jobs were hairdressers, bakers, dental assistants, cleaners, kitchen assistants, cooks and machine assemblers. References: Karlberg A-T, Gäfvert E, Lidén C. Environmentally friendly paper may increase risk of hand eczema in rosin-sensitive persons. J Am Acad Dermatol 1995; 33:427–432. Meding B. Epidemiology of hand eczema in an industrial city. Acta Derm Venereol 1990; suppl 153. Wrangsjö K. IgE-mediated latex allergy and contact allergy to rubber in clinical occupational dermatology. Arbete och Hälsa 1993:25. 49 Psykisk ohälsa, våld och trakasserier . 9 Work-related musculoskeletal disorders The national surveys contained questions on working positions and movements such as bending and twisting (Table 9.1). In 1993, 11 percent of men and 5 percent of women reported that they had heavy lifts during at least half the workday. Repeated twisting and bending, on the other hand, was more common among women. Heavy work and heavy lifting were most common among construction workers. Painters were the occupational group who most often worked with the hands above shoulder level. Almost 80 percent of the painters reported such work at least two hours per day. Table 9.1. Frequencies of physical risk factors for musculoskeletal disorders among employed persons in 1984, 1989 and 1993. Women 1984 1989 1993 1984 19891993 Heavy work at least half the time Twisting and bending in the same way several times per hour every day Bending forward without support from the hands or arms at least half of working time Twisted work posture at least half the time Hands at or above shoulder level at least half the time * not available. Men 15 11 11 6 5 5 28 * 22 35 * 28 20 18 17 19 19 17 16 14 15 17 15 15 12 12 13 8 8 9 50 Working life and health. A Swedish survey Low control and repetitive work increase the risk of disorders in the musculoskeletal system. In 1993, 51 percent of women and 37 percent of men reported that they could control their work tasks for at most half of their working time (Table 9.2). Repetitive work was more common among women, and the changes in frequencies between 1984 and 1993 are rather small. Table 9.2. Frequencies of psychosocial risk factors among employed persons in 1984, 1989 and 1993. Men Women 198419891993 198419891993 Can decide the work pace during at most half of working time * Repeat simple movements several times per hour for at least half of working time 34 Usually cannot decide for themselves when task should be done * Usually not in the position to decide about planning of own work * 35 37 * 48 51 34 32 45 42 39 36 36 * 48 49 24 21 * 30 28 * not available. Sick leave, disability retirement and occupational injuries Musculoskeletal disorders are the most common type of occupational injury and the primary cause of sick leaves and early disability retirements. In 1994 these disorders accounted for 40 percent of all early retirements in men and 53 percent in women. In 1990, 37 percent of all days of sick leave were due to musculo skeletal disorders. In 1994, 73 percent of all occupational diseases were musculoskeletal disorders; 37 percent occurred in the neck and shoulders, 22 percent in the arms and 19 percent in the back. In the ISA statistics, musculoskeletal disorders are divided into injuries and diseases. The number of reported diseases varies with occupational group; they are most common in occupational groups with high physical load (Table 9.3). Occupational groups with a low risk included engineers and teachers. Injuries to the musculoskeletal system have a pattern different from the diseases. About 20 percent of all reported injuries in 1993 were overloads of some part of the body. They were usually due to lifting, 51 Psykisk ohälsa,musculoskeletal våld och trakasserier Work-related disorders often in moving a patient. These injuries are most common among women, especially those working in health services (Table 9.4). Table 9.3. The five occupations with the highest frequencies of occupational disorders caused by work load. Only occupational groups with at least 1,000 workers are included. Occupation Frequency per 1,000 workers Women Glass-, pottery, tile work Butchers and meat packers Machine fitters Welders and flame cutters Metal processing workers 44 42 39 37 36 Men Butchers and meat packers Bricklayers Foundry workers Floor layers Glass formers and cutters 31 24 23 22 22 Table 9.4. The occupational groups with the highest frequencies of injuries due to overexertion, 1990–91. Occupation Frequency per 1,000 workers Due to lifting Women Home care workers Nurses’ assistants for mentally retarded Nurses’ assistants and auxiliary nurses Butchers Nurses’ assistants in psychiatric care 9 6 5 5 4 7 5 4 3 3 Men Concrete workers Dairy workers Miners Policemen Cast concrete pruduct makers 6 5 4 4 4 4 1 2 1 2 The sick leave after an occupational injury provides some information about the seriousness of the consequences. The patient’s absence depends on both the seriousness of the disorder and the work environment. The risk of sick leave due to a work-related musculoskeletal disorder (disease or injury) was highest in heavy industry (Table 9.5). Women in the construction industry had a lower frequency than men, since women in this industry usually have office work. In all other groups, the consequences are generally more serious 52 Working life and health. A Swedish survey for women than for men. This is partly an effect of the fact that women more often have repetitious manual work. Table 9.5. The industries with the highest number of days of absence due to musculoskeletal disorders (diseases or injureis). Number of days per worker Industry men women total Mining Forestry Textile Rubber and plastic manufacturing Construction Sea transport Steel/metal processing Metal products manufacturing 3.0 2.0 1.1 1.2 1.8 1.1 1.3 1.2 5.9 1.9 2.7 2.8 0.7 2.8 2.8 2.6 3.2 2.0 1.9 1.8 1.7 1.5 1.5 1.5 All industries 0.9 1.0 0.9 Occupational groups with high risk Construction workers run a high risk of work-related diseases or symptoms in the musculoskeletal system. Regardless of whether sick leaves, symptoms, early retirements or reports to the ISA are studied, the pattern is the same. The job is physically demanding. Other occupational groups with physically demanding work, such as butchers, loggers and welders, also have an elevated risk. For women, highrisk jobs include nurses’ assistant, auxiliary nurse, shop assistant, dressmaker, butcher and some machinists. High risks are usually associated with high physical demands and repetitious, monotonous work. Monotonous work at cash registers and in packing may partly explain why female shop assistants have a high risk. Drivers have an elevated risk of musculoskeletal problems, possibly due to whole-body vibration, prolonged sitting and heavy lifting during loading and unloading. Dental care workers, including dentists, are the only college-educated professional group reporting a high prevalence of symptoms that influence their ability to work. No other occupational group has such a high percentage of symptoms involving the neck, shoulders and arms. The cause is probably precision work in combination with difficult working positions. An additional problem is doing piecework. Teachers, systems analysts, programmers, engineers and office workers in banks and insurance companies are examples of occupational groups with a low frequency of symptoms, sick leave 53 Psykisk ohälsa,musculoskeletal våld och trakasserier Work-related disorders and early retirement. Their jobs are neither strenuous nor monotonous and do not require fixed or difficult working positions. These workers also usually have control over their work. The difference in risk between women and men The frequency of reported work-related diseases in musculoskeletal system in 1990–91 was 13 per 1,000 among male machine fitters, compared to 39 per 1,000 among female machine fitters. The women more often have monotonous work and less control over it. The women also have a double load, since they also do housework. Physiological differences between men and women may also have importance, e. g. for tendinitis due to repeated movements using power grips. Trends The work environment surveys from Statistics Sweden indicate that the factors that may influence the risk of musculoskeletal disorders remained about the same between 1984 and 1993 (Tables 9.1 and 9.2). A similar trend is seen in the Statistics Sweden study of work-related musculoskeletal symptoms (Table 9.6). There was a slight increase in the proportion of persons with symptoms between 1984 and 1989, but the proportion in 1989 was about the same as in 1993. Table 9.6. Symptoms reported in national surveys, 1984–1993. Percentage of all employed men and women. Symptoms every week Year Men Women Hands and wrists 1984 1989 1991 1993 8 9 9 9 11 14 14 14 Shoulders and arms 1984 1989 1991 1993 16 18 19 19 22 30 30 30 Upper back or neck 1984 1989 1991 1993 16 19 19 19 27 32 32 33 Lower back 1984 1989 1991 1993 20 20 20 20 23 24 23 22 54 Working life and health. A Swedish survey Statistics from the ISA give a different picture. The number of reported occupational diseases and injuries increased during the 1980s but than declined considerably (Figures 9.1 and 9.2). The peak in reported occupational diseases in 1993 is due to a change in the law on compensation for occupational diseases. Figure 9.1. Frequency of reported occupational accidents resulting in musculo skeletal injury since 1980. Figure 9.2. Frequency of reported occupation-related diseases in musculoskeletal systems since 1980. Psykisk Work-related ohälsa,musculoskeletal våld och trakasserier disorders It is not known whether the decline in reported occupation-related disorders of the musculoskeletal system during the 1990s is an effect of a decreased number of persons suffering from these disorders or an effect of the changed rules for compensation. Another hypothesis is that fewer persons report musculoskeletal symptoms and pain when unemployment is high, since they are afraid they may lose their jobs if they do so. There are still several physically heavy jobs, especially in the service sector. The increased number of elderly persons has increased the demand for health care. More patients and elderly people will be staying in their homes, where the options for assistance, ergonomically adjusted work and aids are limited. It is therefore probable that heavy lifting will continue to be a problem in many jobs in the health care sector. 55 56 Working life and health. A Swedish survey . Psykisk ohälsa, Accidents at work våld och trakasserier . 10 Threats, violence, sexual harassment and suicide There is little knowledge or research on the association between the work environment and mental diseases. During work with this report we tried to find out about sick leave due to mental diseases in different occupational groups and industries, but found it to be impossible. In this report violence and threats at work, bullying, sexual harassment and suicide are related to the work environment. Violence and threats at the workplace During recent years violence and threats have become more widely recognised as an occupational health problem. The cases in the ISA records were usually reported because of mental illness or injuries. In 1985–94, 600 to 800 such cases were reported among women and 400 to 500 cases among men. Approximately half of the reports came from the health care sector. Other occupational groups with a high reported frequency were watchmen and policemen (Table 10.1). In the 1989–93 national surveys by Statistics Sweden (NWE), a random sample of the working population was asked whether they were threatened or physically attacked in their work. Nine percent of the women and 5 percent of the men reported that they were threatened or injured by violence at least twice per month. The difference between men and women is statistically significant. Threats were most common in the health care and social sectors, 57 58 Working life and health. A Swedish survey where 22 percent of the women and 30 percent of the men reported such problems. Men are more often employed in psychiatric care, where violence and threats are more common. Table 10.1. Occupational groups with a high frequency of reported occupational injuries due to threats or violence. Only cases with sick leave or tooth injury. Number of cases per year Men Women Attendants in psychiatric care Watchmen Hospital aides for mentally disabled Policemen Tram and underground drivers Ticket collectors Social workers 71 66 11 70 4 7 14 100 23 87 12 4 3 32 Relative frequency Men Women 9.6 8.5 3.6 4.6 4.9 13.8 2.6 6.2 7.1 5.4 4.4 7.6 10.0 1.8 Policemen are the occupational group where threats and violence are most common (Table 10.2). Half of those who report violence or threats have feelings of apprehension about going to work. This feeling is much more common among men. Those who have been threatened also report more fatigue and more sleep disorders. Table 10.2. Occupational groups where threats and violence are common. The figures give the percentages of all men and women who report that they suffer from violence or threats at least twice per month. Policemen Attendants in psychiatric care Watchmen Hospital aides for mentally disabled Social workers Bus and taxi drivers Assistant nurses Nurses Post office clerks Physicians 72 70 57 48 43 35 28 23 22 17 In 1992 the occurrence of threats and violence was surveyed in the Swedish Confederation of Professional Associations. On average 11 percent reported that they had been threatened or had suffered from violence at work during the previous two years. This was most common among occupational therapists, social workers and physicians, about 25 percent of whom had been exposed to threats or violence. In 1993, 4 percent of prosecutors reported suffering from violence at work during the previous three years and 32 Psykisk ohälsa, våld och trakasserier Threats, violence, sexual harassment and suicide percent reported being threatened. Violence directed towards the prosecutor’s family was reported by 2 percent, and threats against the family were reported by 11 percent. Bullying About 250 women and 100 men per year reported bullying as an occupational disorder in 1992–93. In a 1989–93 national survey, 5 percent of women and men reported that they suffered from personal harassment at least twice per month. This analysis indicates that differences between occupations and industries are rather small. In comparing men and women in different occupational groups, only women in the manufacturing industry and men in teaching were found to suffer a significantly higher frequency of bullying. In 1991, 75 percent of men suffering from bullying reported that they were attacked by other men and 3 percent only by women. Forty percent of women were mobbed by other women, 30 percent by men. Others were attacked by both men and women. In the national surveys in 1989 and 1993 bullied persons often reported health disorders, fatigue, headaches or stomach pains. Sexual harassment In a national survey made by Statistics Sweden in 1993, two percent of women and one percent of men reported sexual harassment. Other Swedish and international studies have reported higher frequencies for women, from 13 to 23 percent (Lagerlöf, 1993). The differences are probably due to a combination of differences in interview technique and definitions of harassment. In an analysis of the work environment survey of 1993, sexual harassment was more common for women if they worked in restaurants or hotels or drove a bus or taxi. More than half the women and men who have been harassed have feelings of apprehension when they go to work. They also more often report sleep disturbance and fatigue. Suicide About 1,500 deaths per year were registered as suicide during the 1980s. One third were women. For more than another 500 59 60 Working life and health. A Swedish survey deaths per year it is difficult to determine whether the death was accidental or suicide. Studies have shown that most of these cases are probably suicide, and they are therefore often included in suicide statistics. There are no national statistics on suicide attempts. It is estimated that there are approximately ten attempts per completed suicide. To study the occurrence of suicide in different jobs, the 1980 census-linked Death Register for two periods, 1981–86 and 1987–92, was investigated. A similar analysis was made previously for 1971–75 and 1976–79. For men, ten occupational groups show an elevated frequency of suicide during at least three of the four time periods (Table 10.3). Table 10.3. Occupational groups with an elevated risk of suicide among men, 1971–1992. Attendants in psychiatric care Hospital aides Horticultural workers Forestry workers Ship’s deck and engine room workers Machine tool setters and operators Welders Chemical process workers Unskilled workers Warehouse and storage workers For women, suicide is more common among physicians and nurses. Some occupational groups have a lower than average frequency of suicide during both 1981–86 and 1987–92 (Table 10.4). Among men, engineers and managers, and among women teachers, shop assistants and children’s nurses, have low frequencies. Table 10.4. Occupational groups with a lower than average frequency of suicide during both 1981–86 and 1987–92. The analysis includes only groups with at least ten cases. Men Engineers Electrical and electronics workers Managers in machine shops Systems analysts and programmers Managers Other business administrators Women Primary school teachers Shop assistants Children’s nurses Psykisk ohälsa, våld och trakasserier Threats, violence, sexual harassment and suicide Just why suicide is more or less common than average in certain occupations is unknown. The cause of the high risk among persons working in health care is unknown, but mental strain and knowledge of how to commit suicide have been suggested as contributing factors. In an inquiry in Stockholm, 12 percent of male physicians reported that they had considered committing suicide during the previous year, compared with 2 percent of male engineers or managers. Among women there were no obvious differences between occupational groups. Trends The number of occupation-related mental disorders reported to ISA increased between 1985 and 1993. However, it is not known whether this increase is due to changes in work environments or to a difference in willingness to report such an occupational disease. It will not be possible to use ISA records to study mental disorders in the future because they are usually not covered by the new compensation laws. Figure 10.1. Reported occupation-related mental illnesses, 1985–93 (ISA). There is no information for 1988–89. The national surveys for the 1989–93 period show a slight increase in the percentage of persons who reported that they had been 61 62 Working life and health. A Swedish survey threatened or suffered violence. The frequency had increased from 8.3 to 9.6 percent for women and from 4.7 to 5.9 percent for men. Both increases are statistically significant. The only single occupational group with a statistically significant increase was female shop assistants, where the frequency increased from 3 percent in 1989 to 9 percent in 1993. However, no corresponding increase in reported injuries due to threats or violence is indicated in the ISA records. The number of men who reported bullying in the national survey increased from 4 percent in 1989 to 5 percent in 1993. Five percent of women reported bullying in 1989 and 1993. There is not enough register data to indicate whether the number of persons who suffer from sexual harassment increased or decreased. The incidence of suicides declined between 1980 and 1993 for both men and women in all economically active ages. For male physicians there was an elevated incidence from 1971 to 1979. From 1981 to 1992 there is no statistically significant increase in risk. However, a study of different age groups showed that during this period male physicians born between 1921 and 1940 had an elevated risk. Between 1987 and 1992 the relative risk for suicide in male physicians was 1.1. For other occupational groups with a higher than average risk, there were no significant changes in relative risk between the different periods. Prevention Threats, bullying and sexual harassment have quite recently been recognised as occupational health hazards. The Work Environment Act stipulates that the employer must plan and organise the work so that both threats and bullying are prevented, and must make it clear that bullying is not acceptable at the work site. Bullying is considered to be related to shortcomings in work organisation and leadership. The equality act makes it the responsibility of the employer to prevent sexual harassment of employees. Reference Lagerlöf E. Women, work and health. Ministry of Health and Social Affairs, 1993 (Ds 1993:38), Stockholm, 1993. Psykisk ohälsa, våld och trakasserier . 11 Accidents at work Statistics on accidents at work have been kept in Sweden since 1906. There are now three national registers. The Information System on Occupational Injuries, ISA, which covers all employed persons, is based on the accident reports submitted by employers to the social insurance system. The ISA is administered by the National Board of Occupational Safety and Health. There is an additional national private insurance system (TSI) which includes those who are insured. Membership in TSI is negotiated between unions and employers. Statistics Sweden makes an annual survey of a random sample of the population aged 16 to 64. They are asked whether they have symptoms caused by their work and if these have caused absence from work. Approximately 25,000 persons have answered these questions every year since 1991. The reporting to ISA has changed since 1992, when it became a rule that employers must pay the first 14 days of sick leave. However, it seems that it is accidents in small companies and with brief absences that are not reported to ISA to the same extent as previously. As 80 percent of the labour force works in companies with at least ten employees, the statistics are not much influenced by the decreased reporting from small firms. The number of persons covered by TSI has declined during the 1990s. Fatal accidents There have been 100 to 150 fatal on-the-job accidents per year among employees and self-employed persons since 1990. The incidence is 4.9 cases per 100,000 employed men and 0.4 cases for 63 64 Working life and health. A Swedish survey employed women. Since the late 1980s the risks have decreased for men, but are unchanged for women. The largest decreases among men occurred in the oldest ages. The incidence of fatal accidents at work is low in Sweden compared to other countries, including the other Nordic countries. A little less than half of the deaths during the 1990s occurred in accidents between vehicles or aircraft. Falling caused 14 percent of the deaths, falling trees and other falling objects 14 percent, and violence against persons was the cause of two percent. The ISA statistics of deaths are reliable but the number of cases is small, which makes it difficult to relate the deaths to particular occupations or industries. During the past years pilots, fishermen, miners and ship deck and engine room workers have had the highest risks of fatal occupational accidents. During the 1990s there has been a change in the age distribution of fatal accidents. The youngest workers now have the highest frequencies, whereas in earlier years older workers always had the higher frequencies. Figure 11.1. Number of fatal occupational accidents per 100,000 employed in France, the USA and Sweden. Decline in accidents at work The decreased tendency to report accidents applies mostly to milder cases. The analysis here is therefore based on cases with Psykisk ohälsa, våld och trakasserier Accidents at work at least 30 days of sick leave. Approximately 10,000 such accidents per year have been reported to the ISA in recent years. The rates approximately halved between 1986 and 1993, with decreases among both men and women and in all age groups. The statistics from TSI show that serious accidents decreased by 22 percent between 1989 and 1992. Figure 11.2. Number of occupational accidents with at least 30 days of sick leave per 1,000 employed, 1986–93. Overloads to the musculoskeletal system are the type of accident which has shown the largest decrease. Between 1990 and 1993 the number of reported cases per 10,000 employed have halved for both men and women. For women, machine accidents were halved and falling accidents decreased by 20 percent. The largest decrease occurred among younger women. For men, machine accidents and falling accidents each decreased by one third. For both sexes, the oldest workers have the highest incidences of accidents requiring long sick leaves. There are many explanations for the decreasing frequency of occupational accidents. Safety work is constantly going on at the workplaces. The work of the Labour Inspectorate and stricter requirements regarding internal control by the employer may influence the decrease. The number of persons working in heavy industry has also declined. There are also fewer recently employed 65 66 Working life and health. A Swedish survey young men, who have a higher risk of accidents than older workers. However, it is not possible to judge the relative importance of these different factors. The decrease in the total number of on-the-job accidents does not mean that the risk for a single worker has decreased in a similar way. In hospital services, for example, the frequency of occupational accidents for assistant nurses and hospital aides was the same in 1990 as in 1980, and during this period the number of accidents among nurses increased. There is a similar pattern among home helpers and children’s nurses. Occupational accidents in heavy industry The risks for occupational accidents in 290 different occupations were compared. Among men there were 84 occupations with a statistically significant higher risk for accidents compared to all working men and women. Most of them, 57 occupations, were in the manufacturing industry; there were 9 groups in transport and communication and 7 groups in farming and fishing. Among women there were 24 occupations with higher than average risk: 14 were in the manufacturing industry and four in agriculture, forestry and fishing. The 15 occupational groups with the highest relative risks were all male. A different pattern appears if specific types of accidents are analysed; electricians, for example, have a high risk of accidents involving electric power. The highest risks were among ship deck workers, carpenters doing construction work, firemen and wood processing workers. There was no occupational group of women with a relative risk of three or higher compared to all employed persons. The study of occupational accidents during 1985–86 showed the same pattern. Disabling accidents were studied in TSI, and the pattern is similar to that in ISA. The cost of an injury can also be analysed in TSI. The occupations which had the highest payment from TSI per worker are wood processing workers, miners, farmers and forestry workers. The Work Environment Act also covers school pupils, but there is no reporting system for accidents in schools. New studies have shown that the risk of accidents is higher for school pupils than Psykisk ohälsa, våld och trakasserier . 12 Work and gender Sweden has a higher percentage of employed females than most countries. In 1995, 76 percent of women and 80 percent of men aged 16 to 64 were gainfully employed. Horizontal segregation Many occupational groups are held predominantly by either men or women (Figure 12.1). This is called horizontal segregation. In 1990 about 40 percent of women worked in occupations where the proportion of women was at least 90 percent. About 45 percent of the men had jobs where the proportion of men was at least 90 percent. Figure 12.1. The 15 largest occupational categories in percent. 67 68 Working life and health. A Swedish survey Many women work in health services and home care. In most other countries home care is part of housework and is therefore not included in the labour statistics. The Swedish labour market therefore appears to be more sex-segregated than that of other countries. Figure 12.2. Percentage of women in the five most common jobs dominated by men. Figure 12.3. Percentage of men in the five most common jobs dominated by women. 69 Psykiskand Work ohälsa, gender våld och trakasserier The proportion of occupations with an even distribution between the sexes increased from 21 to 30 percent over the past ten years. The changes from 1975 to 1990 in proportions of men and women in the five largest occupations dominated by men or women are shown in Figures 12.2 and 12.3. The proportion of women among sales representatives increased from 12 to 25 percent, while the proportion of men working as secretaries decreased from 13 to 9 percent. The proportions of women increased most strongly in male-dominated jobs requiring a university degree: biologist, lawyer, chemist, physicist, physician, dentist, veterinarian etc. Vertical segregation It is common that within an occupation women have lower status. This is called vertical segregation. The lower status of tasks done by women also means that women’s salaries are lower than those of men. A comparison between women and men who finished high school in 1982–1985 and worked full time in 1990 showed that the median annual salary for women was approximately 30,000 SEK lower. Table 12.1. Women working as managers in the private and public sector, percent. Sector Privat sector Public sector government municipalities county councils Percentage of women Percentage of women among managers among all employees 9 29 20 16 40 35 70 49 80 83 The difference has several causes: women work in occupations with lower salaries (horizontal segregation) and women within the same occupation as men have lower income (vertical segregation). In 1968 men had on average 27 percent higher salary than women in the same sector with similar education, experience and positions. By 1981 this difference in salaries had decreased to 12 percent . During the 1980s the difference did not change, and in 1991 men had 13 percent higher salary than women with similar jobs. 70 Working life and health. A Swedish survey Paid and unpaid working time Women work part time more often than men do. Almost 40 percent of women worked part time in 1995, compared to about 10 percent of men. In 1992, 28 percent of absence for women and 3 percent for men was due to taking care of children. On average, women used 26 hours per week for paid employment and 19 hours per week for housework in 1991. Men used 40 hours per week for paid employment and only five hours per week for housework. Differences in work environment The sex-segregated labour market also means differences in working conditions. Men are more often exposed to oils, organic solvents, vibrations, noise and heat. Men work more often in the manufacturing or construction industry where such exposures are common. Women are more often exposed to violence, threats and bullying. They also more often have musculoskeletal disorders. The national surveys of the work environment in 1989–93 were analysed for information on working conditions in jobs held predominantly by either men or women. Table 12.2. Working conditions reported by white-collar workers in jobs held predominantly by women or men or with even sex distribution, percent. Working condition Predom. women women men Difficult working conditions Monotonous work Heavy lifting Can influence own work Can learn new things and improve at work Predom. men women men Even sex distribution women men 21 45 4 14 34 8 18 41 3 8 25 8 19 43 3 12 30 7 76 84 80 89 78 86 48 61 61 70 58 71 For the analysis the material was divided into blue-collar and white-collar workers, and a predominantly men’s (women’s) job was defined as a job where at least 75 percent of the workers were men (women). Other jobs were classified as jobs with even sex distribution. Female white-collar workers more often had difficult working positions and lower control over their own 71 Psykiskand Work ohälsa, gender våld och trakasserier work. They also had fewer opportunities to learn and improve at work. In blue-collar jobs held predominantly by women the frequency of difficult working positions was similar for men and women. However, also in these jobs, men had more control over their working time and their work: 56 percent of the men, compared to 44 percent of the women, could themselves decide when a job should be done. Men also reported less stress. Table 12.3. Working conditions reported by blue-collar workers in jobs held predominantly by women or men or with even sex distribution, percent. Working condition Predom. women women men Difficult working conditions Monotonous work Heavy lifting Can influence own work Can learn new things and improve at work Predom. men Even sex distribution women men women men 34 51 24 37 58 29 54 82 17 33 67 33 44 76 17 32 62 28 70 74 42 66 54 62 38 46 24 38 31 40 The result shows that working conditions for men and women are different, whether they are blue-collar or white-collar workers. The sex that is in the minority is not always discriminated against. Men in jobs held mostly by women, for example, had in general greater control over their job and workplace than women with the same jobs. The horizontal segregation is decreasing slowly. The decrease will probably be faster in male-dominated jobs that require a higher education. Women will probably obtain more well-paid jobs, while men will probably not choose jobs in occupations dominated by women because such jobs have lower salaries, less good career prospects, and fewer opportunities to improve competence. 72 Working life and health. A Swedish survey . Psykisk ohälsa, våld och trakasserier . 13 Elderly persons in working life There is no commonly accepted definition of an elderly worker. The ILO has defined an old worker as one 55 years old or more (Schneider, 1995). Some Swedish authorities use the same age limit. If both the employers’ expectations and early signs of biological ageing are considered, a limit of 45 years may be more realistic. The proportion of persons aged 45–64 is increasing in the working population. In 1985, 38 percent were in that age group; in 1995 it was 41 percent; and it is estimated to be 45 percent in 2005. The proportion of the population that is working has been weakly decreasing in elderly men while it has increased for elderly women (Figure 13.1). Figure 13.1. Proportions of employed men and women aged 55–59 and 60–64, 1976–1995. 73 74 Working life and health. A Swedish survey During the recession in the 1990s it decreased for both men and women. The decreased proportion of elderly persons that are working in Sweden is an effect of the rise in unemployment and an increase in early retirements. Early retirement is approximately five times more common among persons 60–64 years of age than among those 45–54 years of age. Monotonous work is associated with a 1.5 to two times higher than average risk for early retirement in persons aged 45 or older. The most common reasons for these early retirements are musculoskeletal disorders (approximately 30%) and cardiovascular diseases (7%). Many elderly persons neither work nor have early retirement pensions. About every third woman and every fifth man 64 years of age in 1992 was in that group. Figure 13.2. Proportions of employed men and women 60–64 years of age in different countries in 1993 (source ILO). Among business sectors, hotels and restaurants have the lowest proportion of elderly workers and farming and forestry have the highest (Table 13.1). These differences probably reflect both working conditions and cultural and temporal shifts in selection of occupation. Industries which are declining often have higher proportion of elderly workers, whereas expanding industrial sectors have a higher proportion of younger persons. The proportion of elderly men in the manufacturing industry is remarkably low, 9 75 Psykisk persons Elderly ohälsa, våld in working och trakasserier life percent, which indicates that the working conditions are poorly adjusted to the capacity and demands of this group. Table 13.1. Elderly persons (55–64 years of age) in the labour force in different industries in 1994 (percentages). Industry Men Women Farming and forestry Manufacturing and mining Engineering Construction Restaurants and hotels Wholesale and retail trade Communications Pubblic administration Health care 21 9 12 11 4 13 20 14 14 21 15 10 15 10 14 8 17 13 All 13 13 Demands in working life and the abilities of the elderly Jobs with high physical demands exist in farming, forestry, mining, construction and manufacturing, but also in the service sector – health care, cleaning, hotels and restaurants, and storage and transportation. Many elderly women have service jobs. In 1989–93, 44 percent of women 50–64 years of age who worked in health care reported that they had physically demanding work; 54 percent of women in service jobs and 67 percent of men in manufacturing and mining also reported physically demanding work. In some industries and occupations the physical demands are probably too high for elderly people to cope with. However, there are no measurements that give a representative picture of both the job demands and the employee’s abilities. In the national surveys of 1989–93 approximately equal proportions of young and elderly workers reported that they were physically tired after work at least once a week. The difference between men and women was large, indicating that the women had work that was closer to the limits of their physical capacity. Recent research indicates that psychological and mental capacity declines with age at a much slower rate than was previously believed. Moreover, the elderly can compensate for losses of cognitive capacity and psychomotor speed by more strategic ways of planning and performing their work. The productivity of the elderly has been shown in several studies to be as high as that of younger employees. 76 Working life and health. A Swedish survey Health Elderly people are more likely to have chronic diseases. Thus, cardiovascular diseases were reported in 22 percent of persons aged 55–64 in 1992/93, but in only 3 percent of persons aged 35–44. Decreased agility was reported by 28 percent of men and 20 percent of women aged 55–64, but by only 5 percent of men and 3 percent of women aged 35–44. Elderly workers thus are more likely to require adjustment of their work to compensate for chronic disease. The lower physical capacity of elderly persons will probably in the future have less importance in traditionally heavy industry as physically demanding work becomes easier through mechani sation. Some jobs, such as construction work, manual garbage collection and firefighting (especially smoke diving), have such high physical requirements that a change of work in higher ages is more the rule than the exception. If there is no other work or labour market for these groups there is a high risk that they will become unemployed. In the future, work will continue to be physically demanding in the service sector, especially home health services. Elderly women are a vulnerable group, as they make up a large proportion of health care workers and have many heavy duties. Approximately every fourth women 55–64 years of age has lost some agility, and there is consequently a need to adapt work or provide an alternative labour market for this group. Elderly persons can handle heavy work easier if they can decide for themselves when and how it should be done. Work organisation is therefore important. Moreover, simple ergonomic improvements such as introduction of lifting aids, better lighting and lower noise levels will reduce the total physical stress on the elderly employee. For persons born before 1950 the number of years in primary and secondary school is correlated to age. Older persons have fewer years of schooling. Elderly people have a vulnerable situation in the labour market due to this poor schooling. Many of them went to school 25 to 45 years ago and their knowledge is partly out of date. Moreover, the demands for education and training are increasing in working life. The proportion of men aged 55–64 who had jobs requiring at least three years of education increased Psykisk persons Elderly ohälsa, våld in working och trakasserier life from 17 percent in 1984 to 26 percent in 1993. A critical factor is the elderly person’s ability to adjust fast enough to new demands on the labour market. “Lifelong learning” is therefore necessary, especially considering the present rapid rate of change. During recent years the term “lifelong learning” has been used especially to refer to learning and development in close connection with the workplace. This type of learning is extremely important and probably extremely efficient for elderly persons. Reference Schneider G. Ageing societies: Problems and prospects for older workers. World Labour Report 1995. ILO, Geneva, 1995, pp 31-54. 77 78 Working life and health. A Swedish survey . Psykisk ohälsa, våld och trakasserier . 14 Immigrants Immigration to Sweden has been substantial since World War II, but its composition has shifted. For example, towards the end of the war the immigrant population was composed largely of refugees from Estonia, Denmark and Norway. During the boom in the 1940s, skilled male workers were recruited from Italy and Hungary. This recruitment of skilled male workers continued during the 1950s, but most of the immigrants to Sweden during that decade were women, mainly from Germany and Finland, who worked as housemaids. In the 1960s the Swedish economy enjoyed an upturn and a great many workers from abroad were recruited, mainly from Finland and southern Europe. Since the beginning of the 1970s, refugees have become the predominant immigrant group. Immigrants are not a homogeneous group. Their occupations and employment opportunities differ, depending on what nationality they have and when they arrived in Sweden. Some immigrants, such as well-educated specialists from Western European countries, have a strong position on the labour market, comparable to that of native-born Swedes. Eight percent of those who were gainfully employed in Sweden in 1994 were born abroad, and 4 percent were foreign citizens. The proportion of immigrants who are employed varies according to country of birth (Table 14.1). The differences are larger among women than among men; e.g. less than half of the women from Iran and Turkey have jobs. 79 80 Working life and health. A Swedish survey Table 14.1. Percentages of people aged 16–64 who were gainfully employed in Sweden in 1994. By country of birth. Men Women Denmark Finland Norway Germany ex-Yugoslavia Poland Iran Turkey Chile 72 78 80 83 58 70 58 70 66 70 73 71 63 51 66 44 38 54 Total foreign-born 69 61 Total including those who were born in Sweden 79 76 Immigrants more often have jobs in occupations that do not require high levels of education and training, e.g. in the manufacturing industry and the service sector, or else they work in occupations that require high educational levels but are not dependent on specific ties to Swedish culture, e.g. engineers, physicians and scientists. If job demands include fluency in the Swedish language, e.g. certain administrative positions, then the proportion of immigrants is usually low. Immigrants constitute a high proportion of the work force in certain occupations (Table 14.2.). Male immigrants work as cleaners, in the textile industry, and in hotels and restaurants more often than Swedes do. This tendency has not changed during the downturn of the economy in the 1990s: it was the same in 1994 as in 1989. Although immigrant women work in the manufacturing industry more often than Swedish women, female immigrants from the other Nordic countries and Germany are exceptions. Temporary employment became more common during the recession in the 1990s. On the average, 17 percent of the immigrants in Sweden had only temporary employment in 1994, compared to 9 percent for the total Swedish labour force. Immigrants are more often found in jobs that impose negative stress. This is the case even if the comparison is adjusted for occupation. For example, handicapped immigrants have jobs that are physically and mentally more stressful than their Swedish counterparts. 81 Psykisk ohälsa, våld och trakasserier Immigrants Table 14.2. Occupations with the highest over-representation of immigrant men and immigrant women in 1994. Parentheses enclose an index which is the ratio between the number of immigrants in that occupation and the expected number. Only occupations in which at least 5,000 men or women are employed have been included. Country of birth Men Denmark textile workers (4.3) glass workers (4.0) Finland metal workers (3.7) textile workers (3.7) Norway health care (5.2) dental care (3.4) Germany transportation (5.8) precision manu- facturing work (4.3) ex-Yugoslavia cleaners (8.1) textile workers (7.1) Poland cleaners (5.9) textile workers (5.5) Born outside Europe* cleaners (8.2) hotel and restaurant (7.0) All foreign born Women agricultural Work (3.8) systems analysts (3.1) security guards/ watchmen (2.5) machine fitters (1.5) systems analysts (3.1) road workers (3.1) wood workers (10.8) precision manu- facturing work (5.2) provision workers (9.9) electronics workers (9.0) electronics workers (4.8) graphics workers (3.8) textile workers (4.5) electronics workers (3.5) cleaners (4.3) machine fitters (2.4) hotel and restaurant (3.6) textile workers (2.3) * Except Australia, Canada, New Zealand and the USA (Source: Survey of Labour, 1994). Men who were born abroad have shift work more often than native Swedish men do, 14 percent and 6 percent respectively. The difference for women is smaller, 5 percent and 3 percent respectively. The frequency of occupational accidents per 1,000 people was approximately 20 percent higher among immigrants, and occupationrelated illness was 30 percent higher among immigrants, during the 1988–92 period. These analyses are adjusted for gender, age and occupation. The reason for the higher incidence of accidents and illnesses among immigrants is still unclear. Future trends On average, immigrants do not have less education than people who were born in Sweden, often the reverse. However, a long education does not guarantee a job that requires one. Immigrants less frequently have jobs with high educational requirements, 82 Working life and health. A Swedish survey although there are large differences between immigrants from different countries. People born in Sweden receive more training during working hours than immigrants do. The increasing wage differentials between jobs requiring high education and jobs requiring little education will probably increase the current disparities between people who were born in Sweden and those who were not. Psykisk ohälsa, våld och trakasserier . 15 Disability A disability is a restriction that makes a person unable to perform an activity in a normal way. It can be present from birth or due to disease or injury. A handicap is defined as the consequence of a disability. The handicap is always relative and occurs in the interplay between the individual and the environment. A disabled person can be handicapped in some tasks but not in others. It is estimated that about one fourth of the population of the European Community has some type of disability. The description of the situation for disabled persons is difficult in the absence of longterm statistics. The Labour Market Board has 68,000 persons registered for various measures due to disability affecting work: 46,000 had part of their salary paid by the government, 29,000 worked in a public company for disabled persons (Samhall), 17,800 worked in special government programs and 4,800 worked in the public sector with support. According to Statistics Sweden, 40 percent of all persons with impaired vision had employment in the ordinary labour market and 27 percent of all persons with impaired hearing had disability pensions. According to a Swedish study made in 1991–92, 28 percent of all persons with impaired hearing had not told their employer about their impaired hearing. There has been a disability ombudsman for disabled persons in Sweden since 1994. It is the duty of this authority to protect the rights of disabled persons and 83 84 Working life and health. A Swedish survey to follow relevant international developments, especially within EC. The disability ombudsman should also spread information, influence public opinion, give advice about rights, and monitor laws and regulations. Samhall is a publicly owned group of companies which employ 29,000 disabled persons. The objective is for them to leave Samhall and obtain employment in ordinary companies. In 1990–94 less than 4,000 persons, or 2 to 5 percent of the employees, left Samhall for other jobs. Half of those who got jobs in ordinary companies were employed in a smaller private company, and 37 percent got the same type of job they were doing in Samhall. Work environments In the national survey of living conditions (ULF), disabled persons more often report that they have monotonous work, awkward working positions, work with vibrating tools, and noisy and dirty jobs (Table 15.1). Table 15.1. Working conditions of disabled persons, 1990–93, percent (source: ULF). Group/ impairment Little opportunity to influ- ence working conditions Highly unsatisfied Proportion with type of job of population* Disabled Impaired hearing Impaired vision Heart disease Highly impaired work capacity 38 29 27 31 13 7 9 7 1,5 8,1 0,6 1,1 35 10 4,9 Total population 25 6 100 *Proportion in percent of all who answered the survey (ULF) and reported impairment. The work is described as busy and monotonous. However, there is little difference between disabled and non-disabled persons in their reports about mental strain, social relations and the occurrence of accidents (Table 15.2). A comparison between women and men shows that there is the same difference between the sexes among disabled persons as in the total working population. Men more often have noisy, dirty jobs and work more often with vibrating tools. Women more often have monotonous work. 85 Psykisk ohälsa, våld och trakasserier Disability Table 15.2. Working conditions reported by persons with impairments and by the total population 1990/93, percent (Source: ULF). Monotonous, repeated movements Awkward working positions Vibrations High noise levels Very dirty work Busy and monotonous work Mental strain Close friends at work Isolated at work Accident at work during the past 12 month Disabled Total 47 53 13 25 17 14 42 79 0,8 8,5 37 42 9 18 12 9 40 83 1 6 A comparison between disabled Swedes and disabled immigrants shows that differences in working conditions are rather small but statistically significant. Disabled immigrants, more often than disabled Swedes, have work with physical and mental strain. The trends in working conditions for disabled persons can be studied in the national surveys made between 1976 and 1990/93 (ULF) (Table 15.3). Table 15.3. Changes in working conditions between 1976 and 1990–93, percent (Source: ULF). Monotonous movements 1976 1990–93 Awkward working postures 1976 1990–93 Vibrations 1976 1990–93 High noise levels 1976 1990–93 Busy and monotonous work 1976 1990–93 Mental strain 1976 1990–93 Disabled persons Persons with impaired hearing Total employed population 48 43 46 43 39 37 45 57 46 51 36 42 11 14 18 15 9 9 22 23 35 30 21 18 16 18 11 11 12 9 43 47 37 38 38 40 86 Working life and health. A Swedish survey There is a remarkably high frequency of awkward working positions among disabled persons, and high noise levels around persons with impaired hearing. These had decreased somewhat but were still higher than for the average worker. These findings indicate that persons with these disabilities tend to stay in the environment where the disability occurred. There is no indication of a tendency for persons with a disability to seek a work environment which is as good as or better than average. The trend seen between 1976 and 1990/93 is rather the opposite. A possible explanation is that persons with impairments remain in manual work. Future trends Persons with disabilities have a weak position on the labour market. There is therefore a risk that they will work in environments which have a higher than average risk. An example is persons with hearing impairment, who work in a noisy environment more often than others. This further decreases their ability to understand speech in the workplace, and their hearing impairment may even increase more rapidly due to their exposure to noise. Technological advances have made many tasks less physically demanding. The development of aids can increase the disabled person’s possibilities of finding work in ordinary companies. On the other hand, demands on flexibility, social competence and ability to adapt to change makes it more difficult for a disabled person to find a job. References Backenroth G. Social interaction in deaf/hearing bicultural work groups. In Conference Proceedings from the XII World Congress of the World Federation of the Deaf: Towards Human Rights. Austria Vienna 6–16 July, 1995, (in press). Backenroth G. Social interaction in deaf/hearing bicultural working groups. Int J Rehabil Res (accepted). 87 Construction workers 16 Professional drivers At the census of 1990, there were approximately 110,000 professional drivers in Sweden – not including drivers of forklift trucks and earth-moving equipment (Table 16.1). The driver usually works alone. The jobs have high demands but little opportunity to control the work. Many drivers have sedentary work with little chance to take a break. Heavy lifts, poor working postures, vibrations and air pollution make up the working conditions of many drivers. Table 16.1. Distribution of professional drivers in 1990, men and women (percent). Lorry and pickup drivers Bus and taxi drivers Railway engine drivers Tram and underground drivers Men (N=100,857) 67 29 3 1 Women (N=8,870) 26 68 1 5 Health effects Several studies in Sweden and elsewhere have shown that professional drivers have a higher than average risk of cardiovascular disease. A review of 19 different Nordic studies showed that bus drivers and taxi drivers have the highest risks. The findings for lorry drivers are equivocal. The high risk for cardiovascular disease is probably an effect both of lifestyle and work environment (Hedberg et al, 1993). Several studies indicate that professional drivers smoke more than the general population, but they are smoking less than they used 88 Working life and health. A Swedish survey to. A comparison between 1981 and 1990 shows that the regular smokers had decreased from 47 to 31 percent. In studies of professional drivers several of them, especially bus and taxi drivers, report that they have a poor psychosocial work environment (Figure 16.1). Tight schedules, hectic traffic and impatient passengers increase the strain on bus drivers, especially in large cities. Taxi drivers usually work on contract and have little chance to influence their incomes. The risk of violence in combination with working alone increases the feeling of poor social support. Shift work and variable working hours may also increase the risk of cardiovascular disease. Figure 16.1. Demands and control of work for professional drivers (n=352) and a control group of employed men (n=650). Shown according to the model by R Karasek. Drivers have sedentary work, and generally do not exercise much in their leisure time. This, in combination with eating habits, may be the reason why drivers tend to weigh more than the general population. A Swedish study found that professional drivers eat more fat food and less vegetables and fruits than the average Swede. The irregular work schedules also influence their eating habits. It was found in a Swedish study that drivers working for moving companies or as garbage collectors have pain in arms and hands more often than other drivers (Hedberg et al, 1988). Tank truck drivers more often have pain in arms, ankles and feet. They have Constructiondrivers Professional workers some heavy tasks, such as pulling the hose to the tank that is to be filled. Drivers of light trucks in local service more often have pain in the lower back and legs. A Swedish study of taxi, bus and lorry drivers revealed that different groups had different risk of cancer (Jakobsson et al, 1994). The risks also showed geographical differences. Drivers of taxis and lorries in large cities had a higher risk of lung cancer than the same groups in other areas. In Stockholm county the risk of cancer is highest for drivers of delivery vans. However, that study revealed no increased risk of lung cancer in bus drivers. Traffic accidents are the most common type of fatal occupational accident. In 1990 there were 4,166 on-the-job accidents involving professional drivers. On average, 4 percent of professional drivers have an accident each year. Although there has been a decrease since 1987, the incidence is still double the average for all sectors. There is a Swedish study of all occupational accidents resulting in disablement or death. It shows that professional drivers have a higher proportion of severe or disabling injuries than other occupational groups. One reason may be a low usage of safety belts. The use of drugs increases the risk of accidents. In a Swedish study it was found that 8 percent of the drivers who died in accidents during working time had alcohol in their blood (Bylund et al, 1995). Future trends Professional drivers today usually have a fairly low level of edu cation. The demands on technical competence and language skills are increasing, and this will affect the education and recruitment of drivers. New technology will change the work environment for railway engine drivers. The job will increasingly be a matter of supervising instruments. The stress will probably increase, as the work will become less independent and the new trains will travel much faster. For most professional drivers the new information technology means that their control over their work decreases. The mental strain will therefore increase. This increased stress is especially serious for bus and taxi drivers, who already have a high risk of cardiovascular disease. 89 90 Working life and health. A Swedish survey Preventive measures Measures are being taken in Sweden to change the lifestyle of the professional drivers: physical exercise, anti-smoking campaigns and information on good eating habits to decrease the risk of cardiovascular diseases. Preliminary results from a study indicate that informing the drivers about good eating habits and suggesting to the restaurants along their routes how they can provide more healthful food has had a good effect. The use of safety belts was made mandatory in Sweden in 1975, but does not apply to drivers of lorries and taxis. Approximately every third drivers of a light truck or lorry uses a safety belt. About 10 percent of taxi drivers use safety belts. The use of safety belts is even lower among drivers of heavy lorries. Buses have very poor security in collisions, since there is no impact zone around the driver. A limit on driving times and working times especially during the night will decrease the risk for accidents due to dozing at the wheel. There is a good outlook for decreasing the number of accidents among professional drivers, since the best known technology has not yet been applied. References Jakobsson R, Gustafsson P, Lundberg I. Lung cancer among male bus, taxi and truck drivers in Sweden. 10th International Symposium on Epidemiology in Occupational Health ISEOH, Como, Italy, September 20–23, 1994. Hedberg G. The period prevalence of musculoskeletal complaints among Swedish professional drivers. Scand J Soc Med 1988;16:5–11. Hedberg G; Jacobsson KA, Janlert U, Langendoen S. Risk indicators of ischemic heart disease among male professional drivers in Sweden. Scand J Work Environ Health. 1993;19:326–333. Construction workers . 17 Construction workers In 1995 there were 240,000 workers in the construction industry in Sweden, 4 percent of whom were women. This industry accounted for almost 10 percent of the GNP. The number of persons employed in the construction industry has changed substantially during the past decade. The present depression is longer and deeper than earlier depressions. Construction workers used to be employed on a defined project. In the middle of the 1980s there was a general agreement specifying permanent employment with conditional tenure. A large number of workers have been laid off during the depression, and these were mainly younger workers. The average age of construction workers is therefore higher today than it was during the 1980s. Construction work makes high mental and physical demands. Many persons therefor leave the industry before the ordinary retirement age. Less than ten percent of employed construction workers continue as construction workers until 65 years of age. In the mid-1980s the largest construction firms and local building contractors established a special company, Galaxen, for rehabilitation of construction workers. The company was supported by the government, which paid part of their salaries. One fourth of the workers in Galaxen have returned to work in ordinary construction firms. A substantial proportion have been able to continue to work in Galaxen until they reach 65, the ordinary age for retirement. In most countries there are three types of health risks in the construction industry (Ringen et al, 1995): accidental falls, musculoskeletal disorders and toxic substances, notably asbestos, silica 91 92 Working life and health. A Swedish survey and organic solvents. Hearing impairments due to noise are also common. The risks of construction workers can be assessed by comparing data from the Death Register, the Cancer Environment Register, the information system for occupational diseases and injuries and the national surveys made by Statistics Sweden. There is also a computerised register from the occupational health centre for construction workers (Bygghälsan). Accidents In 1993, 24 accidents per 1,000 construction workers were reported to the ISA. This is approximately double the average for all workers. During recent years accidents in the construction industry have decreased much like all other industrial accidents. The most common accidents are falling (28%), accidents from objects in motion (28%), hand injuries (18%), and accidents due to overexertion (15%). The highest frequencies occur among the oldest and youngest construction workers. Sick leaves for construction workers are longer than the average, 34 days versus 27 days. The frequency of fatal accidents for construction workers is approximately double the average for all workers. However, there are too few fatal accidents in the construction industry to allow a more extended analysis of single occupations or year-to-year variations. The decline in fatal accidents in the construction industry is similar to the decline in Swedish industry as a whole. The frequency in Norway and Finland was double that in Sweden (Table 17.1). Table 17.1. Average frequency of fatal accidents in the construction industry in some countries during the 1980s. (Source: ILO, 1994.) Country Number of deaths per 100,000 workers Sweden The Netherlands Denmark Norway Finland Great Britain USA* West Germany Belgium France 4 5 7 8 10 10 16 20 22 25 * Recalculated from number of cases per million working hours. Construction workers The Netherlands has a frequency similar to Sweden, whereas in Great Britain it is approximately the same as in Finland and Norway. The frequencies in West Germany, France and Belgium were several times higher than in Sweden. The differences are probably an effect of national differences in preventive measures. Musculoskeletal disorders In 1994 musculoskeletal disorders accounted for 73 percent of all reported occupational diseases among construction workers. National surveys have shown that construction workers have musculoskeletal symptoms resulting from difficult working positions about twice as often as the average worker. The frequency of heavy lifting is three times higher in the construction industry, and construction workers report double the average frequency of back and hip problems. For painters, who frequently work with their hands above shoulder level, the frequency of symptoms involving the neck, shoulders, arms and hips is double that of the average employee. Health examinations of construction workers made between 1988 and 1992 revealed a positive correlation between high physical strains and symptoms involving the musculoskeletal system: painters, for example, often work with their hands above shoulder height, which increases the risk of disorders in shoulders and neck. Chemical substances Chemical substances are the cause of one case of occupational disease per 1,000 construction workers, as reported to the ISA. In every third case asbestos was reported as the cause. An analysis of the computerised register from the occupational health service for construction workers shows that insulators, plumbers and sheet metal workers, who previously had high exposure to asbestos, have an elevated risk of pleural mesothelioma. They also have a two to three times higher incidence of lung cancer. However, the incidence of lung cancer in wood workers who were rarely exposed to asbestos is lower than the average for all Swedes. Painters who began to work during the 1930s have a higher risk of lung cancer (relative risk = 1.5), but there is no increase among painters who began in later years. 93 94 Working life and health. A Swedish survey The analysis of the computerised register also shows that concrete workers have a somewhat increased risk of lip cancer, probably due to exposure to ultraviolet radiation during outdoor work. Noise In 1994 one case of impaired hearing due to noise was reported to the ISA per 1,000 construction workers. Health examinations have shown that hearing impairments have decreased among construction workers. For concrete workers and platers, the frequency of hearing impairment due to noise dropped by half between 1970 and 1980. This is probably an effect of preventive measures. Psychosocial conditions Uncertain employment conditions used to be a characteristic of the construction industry. However, construction work has generally been regarded as good work with a fair amount of autonomy and good opportunities to develop competence and skills. During the 1990s building time was shortened, primarily to decrease credit costs. The delays in the later phases of a building project, e.g. painting, had to be reduced. Stress has therefore probably increased considerably during recent years. However, in the national survey made by Statistics Sweden in 1995 only 3 percent of workers in the construction industry reported stress and mental strain, compared to 5 percent among the total working population. Foremen in the construction industry work under heavy mental strain. Several foremen have had myocardial infarctions and reported being under high stress before they got ill. In a few cases they have applied for compensation, but the decisions have varied. Construction workers who were given medical examinations in 1971 and 1979 and followed through 1992 showed lower mortality than the average in Sweden. The relative risk of death from cardiovascular disease was 0.8. Deaths from causes usually associated with alcohol, such as cirrhosis, were also low, with a relative risk of 0.6. Future trends Experience has shown that proper planning of a building project is an important step in preventing accidents. Good planning for transport of materials can also prevent accidents. Accidental falls Construction workers may be prevented by regular safety rounds where rails, coverage of holes etc. are inspected One possible future threat is a building boom with rapid recruitment of personnel who have little experience of construction work and its health hazards. Construction workers have to plan their own work to a much greater extent than other industrial workers. They must have a basic knowledge of ergonomics if they are to avoid injuries. Extreme specialisation, e.g. that a worker only nails cornices on the roof, may increase the risk of occupational injuries. The occupational health service for construction workers, Bygghälsan, was the result of a special agreement between the employers and the unions. This comprehensive occupational health centre and the agreement behind it no longer exist. References ILO Yearbook of labour statistics 1994. ILO, Geneva, 1994. Ringen K, Englund A, Welch L, Weeks J, Seegal J (ed). Construction, Safety and Health. Occupational Medicine: State of the art reviews. 1995:10. 95 96 Working life and health. A Swedish survey . Construction workers . 18 Working life in the future Working life is continually changing. During the last ten years the number of persons in the manufacturing and construction industries has decreased by 20 to 25 percent. In the engineering industry the proportion of middle-aged men has increased and the proportions of women and young persons have decreased, i.e. segregation according to age and gender has increased. As a consequence of the reduced employment in traditional industries the proportion of workers in the service sector, public sector and business has increased. Unemployment has increased, and there are more workers with non-permanent jobs. Increasing automation in the manufacturing industry will mean that fewer persons will be exposed to physical loads and chemicals. It is more difficult to predict whether the exposure levels for those who are still exposed to chemicals will increase, decrease or be unchanged. New processes may mean that new substances will be used, or that hazardous substances will be used to a greater extent, e.g. more persons will be exposed to isocyanates due to changed production technology and restrictions on the use of organic solvents. The service sector will probably grow further, and companies will continue to seek improvements in efficiency, which often means that mental strain increases. Negative stress will increase if the demands on the workers rise and their control over their work simultaneously diminishes. On the other hand, if this control is extended the higher demands may have a positive effect. 97 98 Working life and health. A Swedish survey The difference between salaried employees and blue-collar workers will become smaller and more diffuse. The sharp distinction between industrial work and office environments will also become weaker. The consequences of these changes are difficult to predict, but they will surely influence our attitudes toward life, learning and stress. The definition of work environment will also become more diffuse when the difference between work and time off becomes less clear. A possible consequence of a high unemployment rate is an artificial decrease in labour turnover. People may stay with a job for too long, when they should change jobs in order to preserve their health and well-being. Increased economic insecurity may bring more overtime and a black market where unemployed persons are recruited for dangerous work. The present mechanism for “signals” about problems in the work environment will not work under such circumstances. The widespread concern about the environment and increased emphasis on recycling will influence the work environment primarily for those who handle garbage and recycle goods. In the late 1980s the Swedish Work Environment Commission observed that the difference in health between blue-collar workers and salaried employees seemed to be increasing. There is still a large difference in mortality between men in these two groups, but the difference does not seem to have increased during the last decade. The present risk of myocardial infarction varies between occupational groups, and it is impossible to predict whether these differences will increase or decrease. The risk of occupational accidents varies with occupational group. High risks occur mainly in heavy industry. The frequency of accidents has been decreasing for several years but there is still a great potential to reduce the risks even farther. However, lower risks are usually more difficult to detect and sometimes more difficult to prevent. The new information technology introduces both possibilities and problems. Some monotonous and repetitious work can be automated, which may lead to a decrease of musculoskeletal disorders. The new technology may also create monotonous work. Monitoring a control panel is monotonous work and may lead to negative stress Construction Working life in workers the future e.g. for railway engine drivers. Information technology can also be used for supervising workers, with the consequence that their control over their own work is decreased. For some occupational groups, e.g. bus drivers and taxi drivers, the lack of control already means an increased risk of cardiovascular disease. The Swedish labour market is divided between a male and female sector. There is a trend toward equalisation, which is most rapid in well educated groups and in occupations which are predominantly held by men. The proportion of women in the manufacturing industry has dropped even lower during the 1990s recession and there is a risk for even more segregation, since demands in the manufacturing industry will probably increase and few women have higher technical competence. Some groups have not got their fair share of the general improvements in the work environment. Disabled persons have on average more physically and mentally demanding environments than other groups, and the differences increased between 1970 and 1990. Today, the labour market requests flexibility, social competence, adaptability and willingness to work overtime. Immi grants, disabled persons and elderly with low formal education may have the less attractive jobs, which usually means the worst work environments. During the last decades asthma and allergies have become increasingly common among children. When they grow up and enter working life more workers will be sensitive to work in wet environments, exposure to irritants etc. If they are to be free to choose a job they want, there are high demands on the work environment. Otherwise, they will probably be discriminated against on the labour market. In summary, the changes in working life will increase the differences in health between different groups. Jobs with good psychosocial conditions will tend to be more common. This means that working conditions and health will be improved for some groups. On the other hand there is the risk that some vulnerable groups will have unchanged or even worse working conditions. 99 100 Working life and health. A Swedish survey . Construction workers . 19 Summary There have been large changes in Swedish working life during the last decade. The number of persons employed in farming, forestry, manufacturing and construction has decreased by 20 to 25 percent. There is a trend towards a higher proportion of persons with non-permanent employment. In Sweden today, 13 percent of the labour force, or half a million persons, have non-permanent jobs. Their working conditions vary. Persons with project work have good prospects for training and control over their own work, while workers who are employed on demand have worse than average working conditions. Approximately 50 percent of Swedes now use a computer in their work, and one percent work with a computer from home for more than half their working time. There is segregation according to gender on the Swedish labour market; more than one woman in three works in the health care sector, compared to about one man in twenty. The construction and manufacturing industries employ 10 percent of the women and 40 percent of the men. Vulnerable groups Women more often work part time. Their work has on average lower status than the men’s work and requires less education and training. Women on average also have less control of their work. They have more repetitious work and more often have work-related musculoskeletal disorders. Elderly women working in the 101 102 Working life and health. A Swedish survey health service and care sector are an especially vulnerable group. Their physical capacity decreases with increasing age, while the demands of the job include heavy lifting. Disabled persons have more monotonous, repetitious, dirty jobs, and work more often with vibrating tools than the average worker. They also work more often in noisy environments. Immigrants are not a homogeneous group and their options on the labour market depend on where they come from and when they arrived in Sweden. Men from non-European countries are seven or eight times more likely to work as cleaners or in hotels and restaurants than men born in Sweden. For women born in nonEuropean countries work in the textile and electronics industries is four times more common than for women born in Sweden. Chemical and physical factors There are about 130,000 registered chemical substances in Swedish work environments. Fewer persons are exposed to organic solvents, oils and lead than 10 years ago. However, it is unclear whether the exposure levels have decreased for those who have the highest exposures. Information from the Lead Register (which was closed in 1990) indicates that the number of persons most heavily exposed to lead did not decrease during the 1980s. If the trend is unchanged there are about 150 persons in Sweden with blood lead levels above 2.5 mmoles per litre. Noise is still a major problem at many Swedish workplaces. About 200,000 persons are exposed to hand and arm vibrations for at least one fourth of their working time. Changing psychological demands If the mental demands are high and the control over the job is low the worker is exposed to negative stress. Employees in hotels, postal services, restaurants, health care and communications have more negative stress than employees in other industries such as manufacturing. The mental demands have increased in many sectors and jobs during the past 20 to 25 years. The increase is largest in the health care and education sectors. In the manufacturing industry the changes are small. Construction workers Summary Different patterns of ill health The risk of myocardial infarction varies with occupational group. University graduates have the lowest risks. In some groups the risk is only half of the average for all employed persons. In some occupational groups in the manufacturing industry and service sector the risk for myocardial infarction is twice the average. Individual factors such as smoking or high blood pressure may explain part of these differences. It is unclear which factors in the work environment are the most important causes of the decreased or increased risk and what occupational health measures would most effectively prevent cardiovascular disease. However, the large differences between occupational groups and sectors indicate that work to prevent myocardial infarction can be very successful if the negative and positive factors can be identified. Work-related musculoskeletal disorders are the most common occupational diseases and the primary cause of early retirements: 40 percent of men who were forced to retire before age 65 have a musculoskeletal disorder. The number of work-related diseases and injuries in the musculoskeletal system reported to the ISA has decreased considerably during the 1990s, but about 20,000 cases are still reported each year. An estimated 150,000 men and 10,000 women in Sweden are exposed to known carcinogens. The most common are benzene, wood dust, diesel exhausts and other combustion products. Between 10 and 100 future cases of cancer per year could be prevented if all occupational exposures to known carcinogens were stopped. In Sweden 300 new cases of asthma are reported as work-related each year. More than 2,000 cases of skin disorders are reported as having occupational origin. The most common occupational cause of hand eczema is wet work, such as hairdresser or cleaner. About every fifth hairdresser has to change job due to hand eczema. Two of three persons with long-term sick leaves due to a skin disorder have reported it as an occupational disease. The serious occupational accidents are decreasing. The number of fatal accidents has halved during the last fifteen years. Accidents resulting in more than thirty days of sick leave also halved between 1986 and 1993. The occupations with the highest risks are the same 103 104 Working life and health. A Swedish survey today as they were ten years ago: firemen, construction worker, foundry workers, miners and wood processing workers. Mental illness Violence and threats at work have been reported more often during recent years. About 10 percent of women and 5 percent of men reported in 1993 that they suffered from violence or were threatened at work at least twice per month. It is unclear why suicide is more common in certain occupational groups. For men, seamen, forestry workers, unskilled manual workers and workers in health services have a higher risk of suicide. High-risk occupations for women are physician and nurse. New diseases and risk groups Vulnerable groups have been receiving more attention in recent years. It can be expected that more people will have allergies when they start their working life. The strong horizontal and vertical segregation between women and men is getting more attention than it did ten years ago. High unemployment and high immigration during the 1990s made it more difficult for immigrants to get jobs. The high unemployment among immigrants has therefore been addressed. The fact that immigrants seem to have worse working conditions than other groups, however, has not been given the same attention in discussions and evaluations. During the 1980s the mental demands of several jobs increased. Some groups with a high degree of control over their work, e.g. several professionals, some construction workers and workers in day care centres, have experienced positive changes. In health services the psychological pressure has increased considerably. For some this has meant an increase in negative stress, and for others – those who also obtained more control over their work – it has meant a more challenging and satisfying job. Better work environments Many work environments and working conditions are improving. Preventive measures have yielded many positive results. Many classical occupational diseases, e.g. silicosis, asbestosis and metal poisoning, have virtually disappeared in Sweden. Fewer persons are exposed to chemicals. Construction workers Summary Several cancer risks have been eliminated. Today fewer persons are exposed to known carcinogens than was the case ten years ago. Exposure to asbestos has declined since the mid-1970s and has now virtually ceased. Exposures to carcinogenic mineral oils and dyes has similarly decreased. The Swedish Cancer Committee estimated in 1984 that about two percent of all new cancer cases are caused by factors in the work environment, with exposures occurring during the 1960s and earlier. Two percent of cancers in Sweden today is equivalent to about 800 cases per year. It is estimated that the known carcinogens present in Swedish work environments today cause between 10 and 100 cases per year. The work done to prevent accidents at work has been very successful. No other European country have such a low incidence of fatal occupational accidents as Sweden. The fatal accidents among construction workers and several other groups have decreased by approximately 75 percent over the past 25 years. The psychosocial work environment has improved for several occupational groups as their control over their jobs has increased. The knowledge that good working conditions also increase productivity and efficiency has been a major driving force behind improvement work. The good job It is possible to identify circumstances and conditions that should not exist in a good job. The good job has no exposure to hazardous substances, no monotonous and repetitious movements, and a minimum of negative stress. It provides opportunities to learn and develop. It optimises benefit for both the employer and the employee. Social relations are good. All these factors are important to a worker’s well-being and health. Work is an important part of life, and it is affected by the worker’s other roles in family and society. A good job should have a positive effect on the worker’s actions in these other roles. Good social support at the workplace is a characteristic of a good job. This implies that the unions and employers will endeavour to provide job security, act with justice and otherwise exert a positive influence. Good jobs include demands and challenges and the authority and responsibility required to meet them. They offer room to 105 106 Working life and health. A Swedish survey decide when and how tasks will be done and provide opportunities to learn and grow. Such jobs are found in several occupations for college graduates. These groups have the lowest mortalities and the lowest risks of myocardial infarction. With the exception of some jobs in health services, they have also a low risk of suicide. These good psychosocial environments also exist in some other jobs – carpenters, electricians, platers and agricultural workers. This review shows that many present trends in working life are basically positive. Fewer persons are exposed to hazardous chemicals and fewer suffer from severe occupational accidents. The jobs of many workers are being expanded, with greater responsibility and authority and more opportunities to learn and develop. For others, e.g. some groups with non-permanent employment, there are no such positive trends. Construction workers . List of contributors Many researchers have contributed to this report. This list contains the main contributors who may be contacted for further information. The list also contains contributors who wrote on subjects that were not included in the English translation of the report. Professor Anders Ahlbom, Department of Environmental Medicine, Karolinska Institutet, Box 210, S-171 77 Stockholm; fax +46 8 31 39 61 (myocardial infarction). Gunnar Ahlborg, consultant, Department of Occupational and Environmental Medicine, Örebro Regional Hospital, S- 701 85 Örebro; fax +46 19 12 04 04 (teratology). Professor Gunnar Aronsson, National Institute for Working Life, S-171 84 Solna; fax +46 8 653 17 50 (organisation, future working life, non-permanent employees). Associate Professor Gunnel Backenroth-Ohsako, Department of Psychology, Stockholm University, S-106 91 Stockholm; fax +46 8 15 93 42 (disabled workers). Elisabet Broberg, Head of Division, Occupational Injury Statistics Division, Swedish National Board of Occupational Safety and Health, S-171 84 Solna; fax +46 8 730 19 67 (work-related accidents). Professor Mats Ekholm, Högskolan i Karlstad, S-650 09 Karlstad, fax +46 54 83 84 61 (teachers and school children). Göran Engholm, statistician, National Board of Health and Welfare, S-106 30 Stockholm fax +46 8 783 32 52 (construction workers). Anders Englund, Director, Medical and social department, Swedish National Board of Occupational Safety and Health, S-171 84 Solna; fax +46 8 730 19 67 (construction workers). Professor Mats Hagberg, National Institute for Working Life, S-171 84 Solna; fax +46 8 730 19 67 (musculoskeletal disorders). 107 108 Working life and health. A Swedish survey Associate Professor Anne Hammarström, Department of Family Medicine, Umeå University, S-901 85 Umeå; fax +46 90 77 66 83 (mental disorders). Associate Professor Gudrun Hedberg, National Institute for Working Life, Box 7654, S-907 13 Umeå; fax +46 90 16 50 27 (professional drivers). Lars-Gunnar Hörte, Head of sector, Forensic Medicine, Uppsala University, Dag Hammarskölds väg 17, S-752 37 Uppsala; fax +46 18 55 90 53 (suicides). Urban Janlert, lecturer, Department of Epidemiology and Public Health, Umeå University, S-901 85 Umeå; fax +46 90 13 89 77 (unemployment). Professor Bengt Järvholm, Department of Occupational and Environmental Medicine, University Hospital, S-901 85 Umeå; fax + 46 90 10 24 56 (editor, physical and chemical factors). Professor Åsa Kilbom, National Institute for Working Life, S-171 84 Solna; fax +46 8 730 19 67 (elderly workers). Hanne-lotte Kindlund, Riksförsäkringsverket, S-103 51 Stockholm; fax +46 8 786 95 80 (rehabilitation). Elisabeth Lagerlöf, National Institute for Working Life, S-171 84 Solna; fax +46 8 730 19 67 (working conditions and the EU). Associate Professor Ingvar Lundberg, Department of Occupational Health, NVSO, Karolinska Hospital, S-171 76 Stockholm; fax +46 8 33 43 33 (occupational cancer). Associate Professor Birgitta Meding, National Institute for Working Life, S-171 84 Solna; fax +46 8 730 19 67 (skin disorders). Kjell Torén, MD, Department of Occupational Medicine, Sahlgrenska University Hospital, St Sigfridsgatan 85, S-412 66 Göteborg; fax +46 31 40 97 28 (respiratory diseases). Associate Professor Michael Tåhlin, Department of Sociology, Stockholm University, S-106 91 Stockholm; fax +46 8 612 55 80 (psychosocial factors). Professor Eskil Wadensjö, Institute for Social Research, Stockholm University, S-106 91 Stockholm; fax +46 8 15 46 70 (immigrants). Professor Denny Vågerö, Department of Sociology, Stockholm University, S-106 91 Stockholm; fax +46 8 612 55 80 (mortality). Piroska Östlin, medical sociologist, National Institute of Public Health, Box 27848, S-115 93 Stockholm; fax + 46 8 783 35 05 (work and gender).
© Copyright 2018