Occupational Medicine 2015;65:154–156 Advance Access publication 16 January 2015 doi:10.1093/occmed/kqu191
Health-care barriers for workers with HAVS in Ontario, Canada T. Bodley1, S. Nurmohamed1, D. L. Holness2,3,4,5, R. House2,5 and A. M. S. Thompson3,4,5 Faculty of Medicine, Undergraduate Medical Education Program, Toronto, Ontario M5S 1A8, Canada, 2Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada, 3Department of Medicine, University of Toronto, Toronto, Ontario M5G 2C4, Canada, 4Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada, 5 Department of Occupational and Environmental Health, St. Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada. 1
Background Hand–arm vibration syndrome (HAVS) becomes irreversible unless it is identified early and progression prevented. Aims
To describe the health-care-seeking behaviours of workers with HAVS and barriers to health care.
Methods
We invited all patients assessed for HAVS between 15 January and 27 March 2013 at a hospitalbased occupational health clinic (OHC) in Ontario, Canada, to complete a questionnaire asking why and from whom they sought health care, reasons they waited to seek care and barriers they encountered in accessing care. We analysed the data using descriptive statistics.
Results
Forty-one (82%) patients agreed to participate. Thirty-seven had confirmed HAVS; 30 (84%) were Stockholm workshop vascular stage 2 or greater and 35 (97%) were sensorineural stage 1 or greater. The commonest employment sectors were construction [21 (57%)] and mining [6 (17%)]. The main reasons for seeking treatment were pain [11 (30%)], finger numbness [8 (22%)] and functional limitations [5 (14%)]. The commonest initial point of health care was the family physician [23 (66%)]. The mean wait between symptom onset and seeking treatment was 3.4 years, while the mean time between onset and OHC assessment was 9 years. Reasons for delay in seeking care were ignorance of the seriousness and irreversibility of HAVS and ability to continue to work. Family physicians suspected HAVS in 17% of cases and recommended job modification in 34%.
Conclusions Workers with HAVS in Ontario delay seeking health care. Primary care physicians often fail to recognize HAVS. Barriers to health care include ignorance of HAVS and of the importance of prevention. Key words
Access to health services; hand–arm vibration syndrome; HAVS; health-seeking behaviours.
Introduction Hand–arm vibration syndrome (HAVS) refers to vascular, neurological and musculoskeletal pathology arising after sufficient exposure to hand–arm vibration. Most Canadian provinces neither have legislation to limit occupational exposure to hand–arm vibration nor require medical surveillance for vibration-exposed workers [1], hampering prevention and early identification efforts. Although HAVS may be reversible in its early stages [2–4], if allowed to progress it causes upper extremity disability [5] and decreased quality of life [6]. Unfortunately, the literature suggests workers often delay seeking care for
HAVS symptoms and usually have advanced disease at the time of initial clinical assessment [7,8]. In Ontario, Canada, workers suspected of having HAVS are referred to an occupational health clinic (OHC) by their primary care physician or through the provincial workers’ compensation board. Occupational health (OH) services in Canada are generally limited to tertiary care OHCs and employer-based OH services. Most OH issues are therefore managed by primary care physicians. Barriers to workers’ seeking medical attention, timely referral and treatment are poorly understood. This study aimed to evaluate the use of health care by workers with HAVS and to identify barriers to obtaining appropriate care.
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://occmed.oxfordjournals.org/ at University of Connecticut on June 19, 2015
Correspondence to: A. M. S. Thompson, Department of Occupational and Environmental Health, St. Michael’s Hospital, 30 Bond Street, 4th Floor Shuter Wing, Toronto, Ontario M5B 1W8, Canada. Tel: +1 416 864 5074; fax: +1 416 864 5421; e-mail: [email protected]
T. BODLEY ET AL.: HEALTH CARE OF WORKERS WITH HAVS 155
Methods
Results Of 50 consecutive patients, 41 (82%) consented to participate in the study. Thirty-seven of these had confirmed HAVS by clinical assessment, plethysmography and nerve conduction studies. The 37 participants were all men. The mean (standard deviation) age was 48 (11) years. The commonest employment sectors were construction [21 (57%)], mining [6 (17%)] and manufacturing [5 (14%)]. Clinically, 30 (84%) participants were Stockholm workshop vascular stage 2 or greater and 35 (97%) were Stockholm workshop sensorineural stage 1 or greater. Sixteen (43%) had carpal tunnel syndrome. Participants indicated the main reason they pursued treatment for their symptoms was increasing pain [11 (30%)], increasing finger numbness and tingling
Discussion Workers with HAVS delayed seeking heath care for symptoms for 3 years and 6 months on average due to ignorance of the seriousness and irreversibility of HAVS and ability to continue to work. Diagnosis by primary care physicians and referral for specialist assessment and management was delayed by a mean of 9 years from symptom onset. Family physicians suspected HAVS in 17% of cases and recommended job modification in 34%. Strengths of this study include the consecutive recruitment of subjects to minimize selection bias and
Table 1. Reasons patients with HAVS symptomatology waited to seek care Patients’ reasons for waiting to seek care (n = 37)a
n (%)
I believed my symptoms were a natural consequence of work or ageing I didn’t think the symptoms were serious enough I thought the symptoms would eventually get better The symptoms were not limiting my ability to work My co-workers had similar symptoms and didn’t think it was a big deal I was worried that seeking medical attention would lead to conflict with employer The symptoms were not limiting my regular activities outside of work I was concerned about missing work for appointments I was concerned about losing my job I did not think a doctor would be able to help me I was worried about the cost of treatment (medications, medical appointments, etc.) I was anxious about my symptoms and preferred not to have them looked at
26 (70) 21 (57) 18 (49) 18 (49) 18 (49) 15 (41) 13 (35) 12 (32) 9 (24) 8 (22) 5 (14) 3 (8)
Wording reflects options as they were presented to patients on the questionnaire for yes/no selection.
a
Downloaded from http://occmed.oxfordjournals.org/ at University of Connecticut on June 19, 2015
We invited all patients assessed for HAVS at a hospitalbased OHC in Toronto, Ontario, between 15 January and 27 March 2013 to complete a self-administered questionnaire (available as Supplementary data at Occupational Medicine Online). The only exclusion criterion was inability to read or write English. We did not collect data from patients who declined consent. The questionnaire asked how long and why patients delayed seeking care for HAVS symptoms, how participants navigated the healthcare system before arriving at the OHC and personal and external barriers to obtaining care encountered throughout the process. We designed the questionnaire to ensure face and content validity for HAVS patients, but it was not otherwise validated. We abstracted demographic information, occupational history and results of clinical HAVS assessment including Stockholm workshop scale stage and nerve conduction study results from patient records. We analysed data using descriptive statistics and only included patients with confirmed HAVS in the analysis. The study was approved by the teaching hospital’s Research Ethics Board.
[8 (22%)] and functional limitation at work or home [5 (14%)]. The commonest point of first health-care contact was family physicians [23 (66%)], workplace clinics [5 (14%)], walk-in clinics [3 (9%)] and nurse practitioners [1 (3%)]. The remaining participants did not provide interpretable responses. Participants waited a mean of 3 years and 6 months from HAVS symptom onset to consulting a primary care practitioner. Participants chose from a list of potential reasons for delaying seeking health care on the questionnaire and the responses are summarized in Table 1. The results of initial assessment, which we ascertained from the questionnaire, are summarized in Table 2. Thirty-five (95%) subjects were referred to the OHC by the compensation board and two (5%) were referred by their primary care physician. No participants were referred by specialists such as rheumatologists, neurologists or hand surgeons. The mean time between symptom onset and assessment at the OHC was 9 years. Most respondents credited their physician [11 (32%)] or union [9 (26%)] with speeding up their HAVS assessment, while one respondent credited their employer. Six (25%) identified no significant obstacles to accessing care for HAVS, five (21%) reported wait times as the most significant barrier and four (17%) reported lack of awareness of HAVS as a barrier.
156 OCCUPATIONAL MEDICINE
Table 2. Family doctor assessment of patients with HAVS from self-reported questionnaire n (%)
Key points
•• Workers in Ontario significantly delay seeking health care for hand–arm vibration syndrome symptoms.
8 (35) 4 (17) 2 (9) 1 (4) 1 (4) 1 (4) 6 (26) 12 (34) 4 (11) 17 (47) 3 (8) 10 (27) 1 (3)
WCB/WSIB, Workplace Compensation Board/Workplace Safety and Insurance Board.
a high participation rate. Limitations are the relatively small sample size and potentially limited generalizability to workers outside the construction sector and Canada. Our findings agree with previous work suggesting time from symptom onset to seeking health care is exceedingly long [7,8]. Delay may be due to workers minimizing their symptoms and waiting until they progress to the point of disability. This is reflected in our finding that 70% of workers believed their symptoms were a natural consequence of work or ageing, 57% did not think their symptoms were serious enough and 49% stated their symptoms were not limiting their ability to work. Some of the delay in seeking health care could also be due to a lack of understanding of the progressive and irreversible nature of HAVS; 49% thought their symptoms would improve and the same proportion said their co-workers had similar symptoms so they did not think it was a significant problem. Lack of HAVS awareness by primary care physicians also appears to be a barrier to care. Most primary care physicians did not seem to connect symptoms to a workplace aetiology, which is in keeping with the literature suggesting inappropriate referral and misdiagnosis are the main causes of delayed diagnosis and management of HAVS [8,9]. Future work should focus on the development and evaluation of education for employers, workers and primary care physicians to address the health-care barriers for workers with HAVS in Ontario.
•• Delayed access to health care for hand–arm vibra-
tion syndrome appears to be due to workers minimizing symptoms and their ignorance of the condition, and to primary health-care providers’ failure to diagnose and connect symptoms to work. •• Education for employers, workers and primary care physicians is needed to improve recognition, timely referral and management of hand–arm vibration syndrome.
Funding No financial support was sought or provided from any source.
Conflicts of interest None declared.
References 1. Thompson A,Turcot A,Youakim S, House R. Compensation of hand-arm vibration syndrome in Canada. Can Acoust 2010;39:112–113. 2. Bovenzi M, Franzinelli A, Scattoni L, Vannuccini L. Handarm vibration syndrome among travertine workers: a follow up study. Occup Environ Med 1994;51:361–365. 3. Heaver C, Goonetilleke KS, Ferguson H, Shiralkar S. Hand-arm vibration syndrome: a common occupational hazard in industrialized countries. J Hand Surg Eur Vol 2011;36:354–363. 4. Sauni R, Pääkkönen R, Virtema P, Toppila E, Uitti J. Doseresponse relationship between exposure to hand-arm vibration and health effects among metalworkers. Ann Occup Hyg 2009;53:55–62. 5. House R, Wills M, Liss G, Switzer-McIntyre S, Manno M, Lander L. Upper extremity disability in workers with hand-arm vibration syndrome. Occup Med (Lond) 2009;59:167–173. 6. Cederlund R, Iwarsson S, Lundborg G. Quality of life in Swedish workers exposed to hand-arm vibration. Occup Ther Int 2007;14:156–169. 7. Ayers B, Forshaw M. An interpretative phenomenological analysis of the psychological ramifications of hand-arm vibration syndrome. J Health Psychol 2010;15:533–542. 8. Voelter-Mahlknecht S, Pritsch M, Gigic B et al. Sociomedicinal aspects of vibration-induced white finger disease. Disabil Rehabil 2008;30:999–1013. 9. Sauni R, Pääkkönen R, Virtema P et al. Vibration-induced white finger syndrome and carpal tunnel syndrome among Finnish metal workers. Int Arch Occup Environ Health 2009;82:445–453.
Downloaded from http://occmed.oxfordjournals.org/ at University of Connecticut on June 19, 2015
Family doctor diagnosis (n = 23) Carpal tunnel syndrome HAVS possible Raynaud’s phenomenon Arthritis Lateral epicondylitis Dupuytren’s contracture None Family doctor recommendations (n = 35, 36, 36) Job modification Contacted employer Provided information regarding WCB/WSIB Family doctor referrals (n = 37) Rheumatologist Neurologist Hand surgeon No referral (n = 23)
Health-care barriers for workers with HAVS in Ontario, Canada T. Bodley1, S. Nurmohamed1, D. L. Holness2,3,4,5, R. House2,5 and A. M. S. Thompson3,4,5 Faculty of Medicine, Undergraduate Medical Education Program, Toronto, Ontario M5S 1A8, Canada, 2Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada, 3Department of Medicine, University of Toronto, Toronto, Ontario M5G 2C4, Canada, 4Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada, 5 Department of Occupational and Environmental Health, St. Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada. 1
Background Hand–arm vibration syndrome (HAVS) becomes irreversible unless it is identified early and progression prevented. Aims
To describe the health-care-seeking behaviours of workers with HAVS and barriers to health care.
Methods
We invited all patients assessed for HAVS between 15 January and 27 March 2013 at a hospitalbased occupational health clinic (OHC) in Ontario, Canada, to complete a questionnaire asking why and from whom they sought health care, reasons they waited to seek care and barriers they encountered in accessing care. We analysed the data using descriptive statistics.
Results
Forty-one (82%) patients agreed to participate. Thirty-seven had confirmed HAVS; 30 (84%) were Stockholm workshop vascular stage 2 or greater and 35 (97%) were sensorineural stage 1 or greater. The commonest employment sectors were construction [21 (57%)] and mining [6 (17%)]. The main reasons for seeking treatment were pain [11 (30%)], finger numbness [8 (22%)] and functional limitations [5 (14%)]. The commonest initial point of health care was the family physician [23 (66%)]. The mean wait between symptom onset and seeking treatment was 3.4 years, while the mean time between onset and OHC assessment was 9 years. Reasons for delay in seeking care were ignorance of the seriousness and irreversibility of HAVS and ability to continue to work. Family physicians suspected HAVS in 17% of cases and recommended job modification in 34%.
Conclusions Workers with HAVS in Ontario delay seeking health care. Primary care physicians often fail to recognize HAVS. Barriers to health care include ignorance of HAVS and of the importance of prevention. Key words
Access to health services; hand–arm vibration syndrome; HAVS; health-seeking behaviours.
Introduction Hand–arm vibration syndrome (HAVS) refers to vascular, neurological and musculoskeletal pathology arising after sufficient exposure to hand–arm vibration. Most Canadian provinces neither have legislation to limit occupational exposure to hand–arm vibration nor require medical surveillance for vibration-exposed workers [1], hampering prevention and early identification efforts. Although HAVS may be reversible in its early stages [2–4], if allowed to progress it causes upper extremity disability [5] and decreased quality of life [6]. Unfortunately, the literature suggests workers often delay seeking care for
HAVS symptoms and usually have advanced disease at the time of initial clinical assessment [7,8]. In Ontario, Canada, workers suspected of having HAVS are referred to an occupational health clinic (OHC) by their primary care physician or through the provincial workers’ compensation board. Occupational health (OH) services in Canada are generally limited to tertiary care OHCs and employer-based OH services. Most OH issues are therefore managed by primary care physicians. Barriers to workers’ seeking medical attention, timely referral and treatment are poorly understood. This study aimed to evaluate the use of health care by workers with HAVS and to identify barriers to obtaining appropriate care.
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://occmed.oxfordjournals.org/ at University of Connecticut on June 19, 2015
Correspondence to: A. M. S. Thompson, Department of Occupational and Environmental Health, St. Michael’s Hospital, 30 Bond Street, 4th Floor Shuter Wing, Toronto, Ontario M5B 1W8, Canada. Tel: +1 416 864 5074; fax: +1 416 864 5421; e-mail: [email protected]
T. BODLEY ET AL.: HEALTH CARE OF WORKERS WITH HAVS 155
Methods
Results Of 50 consecutive patients, 41 (82%) consented to participate in the study. Thirty-seven of these had confirmed HAVS by clinical assessment, plethysmography and nerve conduction studies. The 37 participants were all men. The mean (standard deviation) age was 48 (11) years. The commonest employment sectors were construction [21 (57%)], mining [6 (17%)] and manufacturing [5 (14%)]. Clinically, 30 (84%) participants were Stockholm workshop vascular stage 2 or greater and 35 (97%) were Stockholm workshop sensorineural stage 1 or greater. Sixteen (43%) had carpal tunnel syndrome. Participants indicated the main reason they pursued treatment for their symptoms was increasing pain [11 (30%)], increasing finger numbness and tingling
Discussion Workers with HAVS delayed seeking heath care for symptoms for 3 years and 6 months on average due to ignorance of the seriousness and irreversibility of HAVS and ability to continue to work. Diagnosis by primary care physicians and referral for specialist assessment and management was delayed by a mean of 9 years from symptom onset. Family physicians suspected HAVS in 17% of cases and recommended job modification in 34%. Strengths of this study include the consecutive recruitment of subjects to minimize selection bias and
Table 1. Reasons patients with HAVS symptomatology waited to seek care Patients’ reasons for waiting to seek care (n = 37)a
n (%)
I believed my symptoms were a natural consequence of work or ageing I didn’t think the symptoms were serious enough I thought the symptoms would eventually get better The symptoms were not limiting my ability to work My co-workers had similar symptoms and didn’t think it was a big deal I was worried that seeking medical attention would lead to conflict with employer The symptoms were not limiting my regular activities outside of work I was concerned about missing work for appointments I was concerned about losing my job I did not think a doctor would be able to help me I was worried about the cost of treatment (medications, medical appointments, etc.) I was anxious about my symptoms and preferred not to have them looked at
26 (70) 21 (57) 18 (49) 18 (49) 18 (49) 15 (41) 13 (35) 12 (32) 9 (24) 8 (22) 5 (14) 3 (8)
Wording reflects options as they were presented to patients on the questionnaire for yes/no selection.
a
Downloaded from http://occmed.oxfordjournals.org/ at University of Connecticut on June 19, 2015
We invited all patients assessed for HAVS at a hospitalbased OHC in Toronto, Ontario, between 15 January and 27 March 2013 to complete a self-administered questionnaire (available as Supplementary data at Occupational Medicine Online). The only exclusion criterion was inability to read or write English. We did not collect data from patients who declined consent. The questionnaire asked how long and why patients delayed seeking care for HAVS symptoms, how participants navigated the healthcare system before arriving at the OHC and personal and external barriers to obtaining care encountered throughout the process. We designed the questionnaire to ensure face and content validity for HAVS patients, but it was not otherwise validated. We abstracted demographic information, occupational history and results of clinical HAVS assessment including Stockholm workshop scale stage and nerve conduction study results from patient records. We analysed data using descriptive statistics and only included patients with confirmed HAVS in the analysis. The study was approved by the teaching hospital’s Research Ethics Board.
[8 (22%)] and functional limitation at work or home [5 (14%)]. The commonest point of first health-care contact was family physicians [23 (66%)], workplace clinics [5 (14%)], walk-in clinics [3 (9%)] and nurse practitioners [1 (3%)]. The remaining participants did not provide interpretable responses. Participants waited a mean of 3 years and 6 months from HAVS symptom onset to consulting a primary care practitioner. Participants chose from a list of potential reasons for delaying seeking health care on the questionnaire and the responses are summarized in Table 1. The results of initial assessment, which we ascertained from the questionnaire, are summarized in Table 2. Thirty-five (95%) subjects were referred to the OHC by the compensation board and two (5%) were referred by their primary care physician. No participants were referred by specialists such as rheumatologists, neurologists or hand surgeons. The mean time between symptom onset and assessment at the OHC was 9 years. Most respondents credited their physician [11 (32%)] or union [9 (26%)] with speeding up their HAVS assessment, while one respondent credited their employer. Six (25%) identified no significant obstacles to accessing care for HAVS, five (21%) reported wait times as the most significant barrier and four (17%) reported lack of awareness of HAVS as a barrier.
156 OCCUPATIONAL MEDICINE
Table 2. Family doctor assessment of patients with HAVS from self-reported questionnaire n (%)
Key points
•• Workers in Ontario significantly delay seeking health care for hand–arm vibration syndrome symptoms.
8 (35) 4 (17) 2 (9) 1 (4) 1 (4) 1 (4) 6 (26) 12 (34) 4 (11) 17 (47) 3 (8) 10 (27) 1 (3)
WCB/WSIB, Workplace Compensation Board/Workplace Safety and Insurance Board.
a high participation rate. Limitations are the relatively small sample size and potentially limited generalizability to workers outside the construction sector and Canada. Our findings agree with previous work suggesting time from symptom onset to seeking health care is exceedingly long [7,8]. Delay may be due to workers minimizing their symptoms and waiting until they progress to the point of disability. This is reflected in our finding that 70% of workers believed their symptoms were a natural consequence of work or ageing, 57% did not think their symptoms were serious enough and 49% stated their symptoms were not limiting their ability to work. Some of the delay in seeking health care could also be due to a lack of understanding of the progressive and irreversible nature of HAVS; 49% thought their symptoms would improve and the same proportion said their co-workers had similar symptoms so they did not think it was a significant problem. Lack of HAVS awareness by primary care physicians also appears to be a barrier to care. Most primary care physicians did not seem to connect symptoms to a workplace aetiology, which is in keeping with the literature suggesting inappropriate referral and misdiagnosis are the main causes of delayed diagnosis and management of HAVS [8,9]. Future work should focus on the development and evaluation of education for employers, workers and primary care physicians to address the health-care barriers for workers with HAVS in Ontario.
•• Delayed access to health care for hand–arm vibra-
tion syndrome appears to be due to workers minimizing symptoms and their ignorance of the condition, and to primary health-care providers’ failure to diagnose and connect symptoms to work. •• Education for employers, workers and primary care physicians is needed to improve recognition, timely referral and management of hand–arm vibration syndrome.
Funding No financial support was sought or provided from any source.
Conflicts of interest None declared.
References 1. Thompson A,Turcot A,Youakim S, House R. Compensation of hand-arm vibration syndrome in Canada. Can Acoust 2010;39:112–113. 2. Bovenzi M, Franzinelli A, Scattoni L, Vannuccini L. Handarm vibration syndrome among travertine workers: a follow up study. Occup Environ Med 1994;51:361–365. 3. Heaver C, Goonetilleke KS, Ferguson H, Shiralkar S. Hand-arm vibration syndrome: a common occupational hazard in industrialized countries. J Hand Surg Eur Vol 2011;36:354–363. 4. Sauni R, Pääkkönen R, Virtema P, Toppila E, Uitti J. Doseresponse relationship between exposure to hand-arm vibration and health effects among metalworkers. Ann Occup Hyg 2009;53:55–62. 5. House R, Wills M, Liss G, Switzer-McIntyre S, Manno M, Lander L. Upper extremity disability in workers with hand-arm vibration syndrome. Occup Med (Lond) 2009;59:167–173. 6. Cederlund R, Iwarsson S, Lundborg G. Quality of life in Swedish workers exposed to hand-arm vibration. Occup Ther Int 2007;14:156–169. 7. Ayers B, Forshaw M. An interpretative phenomenological analysis of the psychological ramifications of hand-arm vibration syndrome. J Health Psychol 2010;15:533–542. 8. Voelter-Mahlknecht S, Pritsch M, Gigic B et al. Sociomedicinal aspects of vibration-induced white finger disease. Disabil Rehabil 2008;30:999–1013. 9. Sauni R, Pääkkönen R, Virtema P et al. Vibration-induced white finger syndrome and carpal tunnel syndrome among Finnish metal workers. Int Arch Occup Environ Health 2009;82:445–453.
Downloaded from http://occmed.oxfordjournals.org/ at University of Connecticut on June 19, 2015
Family doctor diagnosis (n = 23) Carpal tunnel syndrome HAVS possible Raynaud’s phenomenon Arthritis Lateral epicondylitis Dupuytren’s contracture None Family doctor recommendations (n = 35, 36, 36) Job modification Contacted employer Provided information regarding WCB/WSIB Family doctor referrals (n = 37) Rheumatologist Neurologist Hand surgeon No referral (n = 23)
