Occupational injury and disease among patients presenting to general practitioners in a community health centre Dick Copeman, Jill Skinner and Audrey Burgin I d a Community Health Centre, Brisbane
Abstract:A prospective survey was conducted of all patients presentingover a six-month period to the primary medical care unit of a community health centre in an urban industrial area to determine the number and types of work-related injuries and disease, the causes, and details of the injured workers and their workplaces. Two-hundred and eighty-three patients, 7.2 per cent of the total number of patients attending, were diagnosed as having a work-related injury or disease; 250 patients had occupational injuries and 33 had occupational diseases. The most common injuries were open wounds, sprains and strains, contusions and eye injuries; the most frequent diseases were musculoskeletal strain syndromes, dermatitis and respiratory conditions. Most of,those injured were skilled tradesmen or labourers from small (less than 30 employees) or medium-sized (30 to 99 employees) manufacturing workplaces. In five of the local medium-sized workplaces, more than 10 per cent of the workforce presented with occupational injury or disease in the six months. The mechanisms of injury for common injuries such as back strain and eye injuries are described. Most patients were managed totally within the primary care setting. Thirty per cent of all patients surveyed received a worker's compensation certificate. It is possible that occupational diseases were underdiagnosed and that worker's compensation was underutilised. The information obtained from the survey is being used in planning prevention. (Aust J Public Health 1992; 16: 413-8)
ccupational health was until 'recently, a 1 neglected area of health services.' Despite the recognition in recent years of the importance of occupational health,2 the roles of general Dractitioners and communitv health centres in occubational health in Australia 'have been inadequately explored. Workers' Health Centres have played an important role in supporting the efforts of workers and their unions to improve conditions in workplaces,Ybut primary health care services such as general practitioners and community health centres generally have not placed a high priority on occupational health.4 General practitioners, to whom most people with work-related injury and disease present initially, have usually received little specific training in occupational health.* There is little information available about the work-related disease and injury seen by primary health care practitioners in Australia apart from some recent information on injuries seen in hospital accident and emergency department^.^ Research from overseas suggests that occupational injury and disease are underdiagnosed in primary The diagnosis of injury and disease as work-related may be difficult.8.9Management of work-related illness can be complicated by the possible involvement of worker's compensation.10Injured or ill workers may have different understanding and expectation of worker's compensation from their doctors, who in turn may have different concerns from those of employers.
0
Correspondence to Dr Dick Copem.an, Department of Social and Preventive Medicine, University of Queensland Medical School, Herston Road. Herston Qld 4006
In a number of countries overseas, innovative primary health care approaches to occupational health have been developed, particularly for small industries. These have included locating occupational health workers in general practitioners' surgeries," employing occupational health nurses to visit groups of smaller enterprises,'*J5and legislating to oblige municipal health centres to provide occupational health services for small firms and self-employed farmers.l4 The Queensland Workplace Health and Safety Act, 1989, imposes an obligation on all employers to ensure the health and safety of their employees and provides for the appointment of health and safety officers and health and safety committees in workplaces with 30 or more employee^.'^ However, the majority of workplaces in Queensland have fewer than 30 employees and so are exempt from the requirement of having health and safety officers and committees. The Inala Community Health Centre (CHC) is located in an industrial area of Brisbane and includes a primary medical care or general practice service as well as a community health team comprising community health nurses, therapists and other health workers. Some of the staff at Inala CHC saw the implementation of the Workplace Health and Safety Act as an opportunity to become involved in occupational health and safety at the local level, particularly in smaller workplaces. Before planning preventive occupational health programs, a prospective survey of all patients presenting over a six-month period to the primary medical care unit of Inala CHC was conducted to determine the number of cases and types of workrelated injury and disease as well as the causative fac-
AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1992
VOL. 16 NO.
4
413
COPEMAN ET M.
tors and details of the injured workers and their workplaces. This paper describes that survey and its results.
Methods All patients who presented over a period of six months (March to September 1990) were screened by one of three practice nurses. The nurses identified all new problems that appeared (from the presenting statement of the patient) to be work-related. The five general practitioners in the practice were asked also to identify any work-related conditions, especially diseases, which had not been identified by the nurses. If, at the initial screening, there was any uncertainty about whether the problem was work-related, the nurses were asked to complete a form and leave the judgment about work-relatedness to the doctors. Only three patients who werejudged by the nurses to have a work-related condition were subsequently judged by one of the doctors not to have a workrelated condition. The doctors were not given formal criteria for deciding whether problems were work-related. The decisions were left to their clinical judgment but there was regular, informal discussion among the doctors about these patients and their diagnoses during the course of the survey. Agreement among the doctors was good except in the area of chronic musculoskeletal conditions in patients with a history of repetitive strain movements at work (see Results). To check the completeness of the recording of work-related conditions, the duplicates of all worker’s compensation certificates filled out by the doctors during the six-month survey period were reviewed. Six extra cases of work-related injury were identified in this way. The s t a f f member who identified the patient as having a new work-related problem obtained information about the patient’s age, sex, country of birth, fulljob title, main duties performed, type of industry, business or service, duration of employment in that type of work, name of employer,suburb of workplace and whether the person wished to claim worker’s compensation. This information was entered on a record form which was designed as a systematised version of normal written case notes. The doctor who treated the patient entered a description of how the injury or disease occurred, the clinical details, and the investigations and management arranged or perfolllled. Occupation was coded from the job title and description of duties performed, according to the Australian Standard Classification of Occupations (ASCO).16 Industry was coded according to the Australian Standard Industry Classification (ASIC).” The nature and bodily location of the injury or disease as well as the agency and mechanism of injury were coded according to the draft version of the Type of Occurrence Classification compiled by Worksafe Australia in 1990. According to that classification, ‘an injury’ is ‘the result of a single traumatic event where the harm or hurt is immediately apparent’, 414
while ‘a disease ... results from repeated or long-term exposure to an agent or event’. Cases of occupational injury were recorded only if it was a new injury. Patients with occupational disease were recorded whether their disease was new or preexisting, but they were recorded only once each during the six months of the survey. Because the routine records of the primary medical care unit included only the number of consultations but not whether these were for first consultations or return consultations, an audit was made of a random sample of all primary medical care unit consultation records in the six months to determine the average number of consultations per patient at the unit during the six months. This allowed the total number of patients seen to be calculated approximately and the presentation rate for work-related conditions to be derived. The survey data were entered and analysed on a personal computer using the statistical programme SAS. ReSUltS Of the 12 932 consultations with the 5 doctors at the Inala CHC during the six months, 283 patients were identified as having new injuries or diseases caused by work. The average number of consultations per patient in that six-month period was 3.1 so that the total number of patients seen was approximately 4 170. Thus approximately 7.2 per cent of all patients were identified as having an occupational disease or injury. Eighty-six per cent of the patients with occupational disease and injury were male and 51 per cent were aged between 20 and 39 years. Sixty-four per cent worked in Inala or in the adjacent suburbs. Twenty-one per cent were born in non-English speaking countries, including Spanish-speaking countries, Spain, Chile, El Salvador, Argentina (3.5 per cent), Vietnam (3.2 per cent), Yugoslavia (1.8 per cent), Portugal (1.4 per cent) and Germany and Italy (1.2 per cent each). Thirteen per cent were born in the United Kingdom and 67 per cent were born in Australia or New Zealand. The majority of the patients worked as labourers (40 per cent), tradespersons (39 per cent), or plant and machine operators (14 per cent) in manufacturing industries (55 per cent), in’the wholesale and retail trades (20 per cent) or in construction (6 per cent) or community services (6 per cent). More than half of the patients had been in their present jobs for more than three years (Table 1). Table 1 : Duration of employment Years at present iob
loo Total
.
Note: lo)Fifty-nine potienh came from wohploces outside the lnolo area; the workplace size for 47 pocients wos not known or not recorded.
Sixteen per cent of the patients who worked in the Inala area worked in small workplaces (workplaces with fewer than 30 employees) and 47 per cent worked in medium-sized workplaces (30 to 99 employees)(Table 2). Two hundred and fifty patients were identified as having injuries and 33 had diseases. The most frequent forms of injury reported were open wounds, sprains and strains, contusions and eye injuries (Table 3). Musculoskeletalconditions,dermatitis and respiratory illnesses were the most common diseases recorded (Table 4). One patient had angina pectoris which had been aggravated by mental stress at work. The most common parts of the body affected were the fingers and hand (30 per cent), the eye (20 per cent), the shoulder, arm and wrist (11 per cent) and the back and neck (11 per cent). The causes of the injuries and the diseases are shown in Tables 5 and 6. Being hit by objects or hitting objects were the most common mechanisms of injury while body stressing was the most common mechanism causingdiseases. The pattern of the injuries and illnesses sustained by those patients who worked in small workplaceswas similar to that of those who came from medium-sized and larger workplaces except that workers from smaller workplaces sustained proportionally fewer open wounds. A number of subgroup analyses were performed to identify areas for possible action. Of the 24 patients with back pain, eight worked in manufacturingindustry, mainly metal and plastic manufacturing, seven worked in the service sector, four worked in the wholesale or retail trades and only one worked in the
construction industry. Eighteen sustained their injuries while handling objects or bending or twisting, and five sustained their injuries as a result of falls, trips and slips or from hitting, or being hit by, an object. Eye injuries similarly occurred predominantly in people working in manufacturing industry. Thirty of the 42 people presenting with eye injuries worked in manufacturing industry, including 16 in metal manufacturing. Analysis of the causes for the eye injuries showed that 12 of the 32 eye injuries attributed to foreign bodies were caused by falling objects, mainly dust falling from surfaces or being blown by the wind. The remainder were caused by moving objects, mainly metal fragments from grinding and welding. Five of the medium-sized workplaces (SO to 99 workers) had more than 10 per cent of their total workforce attend Inala CHC with a work-related injury or disease during the six months of the study. From one of these workplaces, a heavy engineering company, six of the total workforce of 72 suffered eye injuries and at another, a metal manufacturing company, four of 59 suffered open wounds. The clinical investigation and management received by the patients is listed in Table 8. Almost all patients were managed totally within the resources and expertise of the Community Health Centre. One fifth had an X-ray and almost one third had a minor operation. Thirty per cent received a workers’ compensation certificate and another nine percent were given a sickness certificate. This nine percent included some who asked for a sickness certificate because they felt that their employers were hostile towards worker’s compensation claims, others who said they could not afford the delay of many weeks that often ensues before workers’compensation payments are received and a few who had private accident insurance. Of the 119 patients who said that they did wish to claim workers’ compensation, only 45 (38 per cent) actually received a workers’ compensation certificate and nine (eight per cent) received a sickness certificate. Conversely, of the 110 patients who said that they did not wish to claim workers’ compensation, 14 (13 per cent) patients actually did receive a workers’ compensation certificate.
Table 3: Occupational injuries Nature of injury
Number of patients
Open wound Sprain or strain
71
Contusion Foreign body in eye
52 22
Eye injury-no
55
foreign body found
Bums
Superficial injury fracture Poisoning Internal injury Total
20 17 7 4 1
I 250
Table 4: Occupational diseases %
28 22 21 9 8 7 3 2 0 0 100
Number of patients Disorders of muscle, tendons and soft tissues
Hernia lxhoemic heart disease
17 5 3 3 2 1 1 1
Total
33
Dermatitis 01 eczema Respiratory conditions Disorders of joints Deafness Disorders of the spine
AUSTRALIAN JOURNAL Of PUBLIC HEALTH 1992 v a . 16 NO. 4
%
52 15 9 9 7 3 3 3 100
415
COPEMAN ET AL.
Table 5: Occupational injuries: causes Number of cases for each cause injury type
Hitting obiects
Hit by moving objects
48 4 17 2
18 5 18 20 12 7 5
Open wound Sprain or strain Contusion Foreign body in eye Eye injury-no
foreign body
3 2 1
Burns
Superficial injury
.
Fracture
Body stressing
Falls, trips and slips
Heat, radiation & electricity
3 17 13
1
28
3
Chemical substances
2 4
1
3
Poisoning Internal injury
1
77 31
Totala
96
31 13
89
36
7
34 14
3
Note: (a1 Three cases had no information on mechanism of inlury
Discussion
evidence that this one doctor preferentially attracted patients with work-related conditions nor that he overdiagnosed such conditions, although he did have a special interest in the field of occupational health and may therefore have been more attuned to the diagnosis of such conditions. The patient population attending the primary medical care unit at Inala CHC is fairly representative of that of general practices in lower socioeconomic, industrial areas, except that it may include a slightly greater number of workers from local industries who come because the unit has on-site X-ray facilities and a well-appointed minor operations facility. The local population is fairly similar in age distribution to the broader population except for the very old (over 75 years) age group, which is underrepresented. The results of this survey are similar to those reported for a recent survey of all occupational injuries occurring in a mediumsized city in northern Sweden.'* In that survey, as in this one, about half of the patients worked in manufacturing industry and their injuries and the bodily locations of them were similar to those reported here. There is little published research about workrelated conditions in general practice. In Sheffield in
IdentiJication of occ&ztionul injuv and diseases This survey sought to identify all work-related conditions in patients presenting to the general practitioners at a community health centre over a six-month period. Approximately seven percent of consultations were identified as being for workrelated conditions. The accuracy of this figure in reflecting the true rate of occurrence of work-related conditions depends on whether there was any variation in diagnoses among staff members and on whether there was complete recording of workrelated conditions. The close agreement between the doctors and the nurses concerning diagnoses and the relatively small number of worker's compensation cases not picked up by the survey suggest that the sample is fairly complete in recording occupational injuries. However, the acknowledged disagreement among the doctors over the diagnosis of repetitive strain conditions and the fact that one doctor, with a special interest in work-related conditions, diagnosed most of the cases of work-related disease, suggest that cases of occupational disease may have been underdiagnosed by the other doctors. There was no
Table 6: Occupational diseases: causes Number of cases for each cause Disease type or location
Hitting objects
Hit by moving objects
Noise
Heat and radiation
Chemical substances
1
4
Joints or spine
2
2
3
Respirotory conditions
2
Deafness Hernia
1 1
lschaemic heart disease Total
1
2
19
%
3
6
58
~
416
Mental stress
16
1
Muscle, tendon, soft tissues Dermatitis or eczemo
Body stressing
~
2 6
1
3
~~~~~~
AUSTRALIAN JOURNAL OF PUBLIC HEALTH
~
1992
VOL.
16 NO. 4
7 21
1
3
OCCUPATIONAL INJURY AND DISEASE
Table 8: Investigation and management of occupational injuries and diseases
Table 7: Agency of injury Number of patients
Agency
% Management
Materials and substances Non-powered handtools, appliances and equipment Machinery and fixed plant Environmental agencies Powered equipment, tools and appliances Mobile plant and transport Chemicals and chemical products Animal, human and biological agencies Total
Number of patients
%
80
29 62
22
72
27
Pathology tests
5
2
33
12
Hospital admission
3
1
22
8
Referral to outpatients department or specialist
7 7 6
Physiotherapy
11 15
4
19 19 17 10
Return appointment
42
Dressing
a2
29
4
Minor operation
82
29
272O
100
178 26
63 9 30
X-ray
Drugls) Sickness certificate
Nore; la1 1 1 missing values
Worker's compensation certificate
the United Kingdom in 1987, ten percent of 200 patients attending two group general practices in a lower socioeconomic industrial area had a condition resulting from their work.I9 The diseases of dermatitis and noise-induced hearing loss were the most frequent work-related conditions discovered in that study in contradistinction to the present survey in which injuries were reported much more commonly than diseases. These results may reflect different types of local industries with different occupational exposures. They also may reflect different awareness among the doctors in the two surveys of the possibility of work-related diagnoses and hence the possibility t h a t work-related diseases were underdiagnosed in the present survey. It is recognised that it is more difficult to diagnose occupational disease than occupational injury.8 Accurate evaluation of occupational exposures is often difficult enough at the workplace, let alone from the vantage of the doctor's consulting room. Diseases often have multiple possible aetiologies, making it difficult to evaluate work-relatednes~.~ The common occupational diseases such as acute and chronic lung conditions, dermatitis, deafness and musculoskeletal repetitive strain syndromes are also common nonoccupational diseases,9so that unless an occupational aetiology is considered and enquired about, work-related conditions may not be identified as such. The method of classification of work-related conditions by worker's compensation boards and other authorities may also affect their diagnosis. For example, a condition such as back pain that is classified as an injury may be more likely to be identified as being of occupational origin purely because it is thought of as a 'injury' than a condition such as tendonitis which is thought of as a 'disease'. Despite these difficulties, there are some simple questions that can be asked during a medical history that will help identify work-related conditions. Asking patients whether they feel that their conditions could be work-related," whether other workers at their places of employment have similar symptoms and whether their symptoms improve on weekends and holidays and recur when they return to
86
5 15
work are simple ways of helping to identify occupational causes of diseases.'O Another approach has been tried in Sheffield where occupational health workers have been employed in general practitioners' surgeries to raise the awareness of both doctors and patients about occupational injuries and diseases." Whatever approach is used, an important first step in efforts to decrease the incidence of work-related health problems is accurate and complete identification and recording of all such problems. General practitioners have a significant role to play in this endeavour. Additional research would be required to confirm whether general practitioners are lacking in knowledge of occupational health. Any such deficits should then be addressed by improved training and experience at both undergraduate and postgraduate level.
Implications for prmention The injuries most commonly reported in this survey (open and closed wounds, sprains and strains, and eye injuries) reflect the nature of the industries from which the patients came, as well as the semiskilledand unskilled nature of most of their jobs. Analysis of the profile of particular occupational problems identified by the survey should help in the planning of intervention programs to control those problems. For example, programs aimed at diminishing the problem of back pain in industry in the Inala area should be aimed at service and wholesale and retail industries as well as at manufacturing industries.'I The causes of the eye injuries seen in this group of patients is similar to those reported from a hospital survey of eye injuries in a nearby area of Brisbane.22 In that survey, 43 per cent of eye injuries were caused by grinding, drilling or welding and 31 per cent by wind or dust. The implication of both surveys is that control of eye injuries will require not only greater provision and use of well-designed protective equipmentzP but also, in some situations, more attention to keeping the workplace clean in order to miniise the significant proportion of such injuries
AUSTRALIAN JOURNAL OF PUBLIC HEALTH
1992
VOL. 16 NO. 4
41 7
COPEMAN ET AL.
caused by dust blowing or falling into workers’ eyes. The five medium-sized workplaces that had 10 per cent or more of their workforce affected by workrelated injury or disease in the six-month period are obvious targets for future preventive interventions aimed at improving occupational health and safety. The new Workplace Health and Safety Act in Q~eensland’~ provides a framework within which the staff of Inala CHC, supported by experts in occupational health, may be able to conduct such interventions in order to help improve occupational health and safety at the local level. In the larger workplaces which have workplace health and safety committees it should be possible to work with those committees to address the problems identified by this survey. In the smaller workplaces which do not have workplace health and safety committees, a more informal approach will be required. Such interventions are being planned and tested currently at Inala CHC.
disease. To realise this role they will need to establish links with local workplaces and with occupational health committees in those workplaces. Acknowledgments Our thanks to the staff and patients of the Primary Medical Care Unit of the Inala Community Health Centre for their cooperation, to the staff of the former Division of Accident Prevention, Queensland Government, for assistance and to Lyn Baxter for data entry and analysis. References 1. Rosenstock L. Occupational medicine: too long neglected. Ann Intem Med 1981; 95: 774-6. 2. Douglas D, Ferguson D, Harrison J, Stevenson M. Occupational health and sa-fdy. Canberra: Australian Medical Association, 1986. 3. Biggins D, Abrahams H. Farr T, Kempnich B. The role of the Workers’ Health Centre. J &cup Health Sa-fAust NZ 1989; 5 317-25. 4. Lennie I. Work as a variable in client problems: a survey of
fdes at three community health centres. Community Health
Worker’scompensation and sickness certificates There are a number of possible reasons why only one third of patients were given either worker’s compensation or sickness certificates. Some of the injuries were of a fairly minor nature and therefore did not require any time off work. Other patients may have been inhibited from claiming worker’s compensation by fear for the security of their jobs in a time of worsening economic environment. However, substantially more patients said that they would like to claim worker’s compensation than actually received a worker’s compensation certificate, suggesting that it may have been the doctors who were reluctant to agree to a request for worker’s compensation. This apparent reluctance by the doctors to complete a worker’s compensation certificate, despite their recording the injury or illness as being workrelated, could have been for a number of reasons. They could have been taking their gatekeeper role very seriously, feeling that they had a responsibility to help keep the worker’s compensation premiums of the local industries as low as possible.lO They may have felt that they were acting in the best interests of the patients by not encouraging them to become long-term ‘compo’ cases, or they simply could have felt that completing a worker’s compensation certificate was a tiresome chore.’O Whatever the real reasons were, the fact that such a small proportion of patients were given worker’s compensation certificates raises the possibility that too few, rather than too many, injured and ill workers may be receiving workers’ compensation. Conclusion Primary health care services do have an important role in identifying and treating work-related injury and disease. In order to fulfil this role, the issue of whether such services are identifyingall work-related disease in their patients needs to be resolved. Primary health care services could have an important role also in prevention of work-related injury and 418
Stud 1980; 4: 220-3.
5. Vimpani G, Hartley P. Informational system for the prevention of injury. Med J Aust 1989; 150 470-2. 6. Rutstein DR, Mullan RJ. Frazier TM et al. Sentinel health
7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17. 18. 19.
20. 21.
22.
events (occupational): a basis for physician recognition and public health surveillance. Am J Mlic Health 1983; 73: 1054-6 1. Capoon I. Capoon P. Occupational health and the family physician. Part 1: definition and resources. Can Fam Physicinn 1982; 28: 329-3. Mayers MR. Occupational disease diagnosis. N Y Sldc J Med 1952; 52: 2381-5. Brown TC. Evaluating work relatedness of diseases. Chest 1981; 79(Suppl): 1 2 7 ~ 9 s . Burry HC. Accident compensation: gates and gatekeepers. Med J Awl 1990; 152: 450-1. Sheffield Occupational Health Project. OEnrpational health w m h in fnimary health care. Shefield: Russell Press, 1989. Phoon WO. Primary health care for small industries. J Occ Health Saf Aust NZ 1989; 2: 45660. Glass WIG. Occupational health nursing and primary health care at work-the New Zealand experience. J Occup Health saf A w l NZ 1986; 2: 490-6. Kurppa K. Rantanen J. The utilikation of the primary health care approach to the provision of occupational health services in Finland. J Occup Health Saf Aust NZ 1986; 2: 482-9. Queensland Government. Wmhphu Health and Safety Ad, Brisbane: Queensland Government Publisher, 1989. Australian Bureau of Statistics. Australian standard chrrifi&ion ofoccupatim. Canberra: Australian Government Pub lishing Service, 1986. Cat. nos. 1229.0, 1223.0. Australian Bureau of Statistics. Australian standard industq c h f i i i o n . Canberra: Australian Government Publishing Service, 1986. Cat. nos. 1201.0, 1202.0. Larsson T, Bjornstig. The epidemiologyof occupational accidents: three ways to measure the problem in a Swedish municipality. J Occup Health Saf Aust NZ 1990; 6 39-52. Shefield Occupational Health Project. An occupational hcallh project in g m l practice. Unpublished report, 1988, available from: Birley Moor Health Centre, 1 East Glade Crescent. Shefield 12, UK. Lee WR. What do you work with? B r J Med 1985; 2 9 0 18467. Department of Employment, Vocational Education, Training and Industrial Relations Back can af wonk. Brisbane: Department of Employment. Vocational Education, Training and Industrial Relations. 1990. Kruger RA, HigginsJ, Rashford S et ‘al. Emergency eye injuries. Aust Fam Phys 1990; 19: 934-7.
AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1992 v a . 16 NO. 4
Abstract:A prospective survey was conducted of all patients presentingover a six-month period to the primary medical care unit of a community health centre in an urban industrial area to determine the number and types of work-related injuries and disease, the causes, and details of the injured workers and their workplaces. Two-hundred and eighty-three patients, 7.2 per cent of the total number of patients attending, were diagnosed as having a work-related injury or disease; 250 patients had occupational injuries and 33 had occupational diseases. The most common injuries were open wounds, sprains and strains, contusions and eye injuries; the most frequent diseases were musculoskeletal strain syndromes, dermatitis and respiratory conditions. Most of,those injured were skilled tradesmen or labourers from small (less than 30 employees) or medium-sized (30 to 99 employees) manufacturing workplaces. In five of the local medium-sized workplaces, more than 10 per cent of the workforce presented with occupational injury or disease in the six months. The mechanisms of injury for common injuries such as back strain and eye injuries are described. Most patients were managed totally within the primary care setting. Thirty per cent of all patients surveyed received a worker's compensation certificate. It is possible that occupational diseases were underdiagnosed and that worker's compensation was underutilised. The information obtained from the survey is being used in planning prevention. (Aust J Public Health 1992; 16: 413-8)
ccupational health was until 'recently, a 1 neglected area of health services.' Despite the recognition in recent years of the importance of occupational health,2 the roles of general Dractitioners and communitv health centres in occubational health in Australia 'have been inadequately explored. Workers' Health Centres have played an important role in supporting the efforts of workers and their unions to improve conditions in workplaces,Ybut primary health care services such as general practitioners and community health centres generally have not placed a high priority on occupational health.4 General practitioners, to whom most people with work-related injury and disease present initially, have usually received little specific training in occupational health.* There is little information available about the work-related disease and injury seen by primary health care practitioners in Australia apart from some recent information on injuries seen in hospital accident and emergency department^.^ Research from overseas suggests that occupational injury and disease are underdiagnosed in primary The diagnosis of injury and disease as work-related may be difficult.8.9Management of work-related illness can be complicated by the possible involvement of worker's compensation.10Injured or ill workers may have different understanding and expectation of worker's compensation from their doctors, who in turn may have different concerns from those of employers.
0
Correspondence to Dr Dick Copem.an, Department of Social and Preventive Medicine, University of Queensland Medical School, Herston Road. Herston Qld 4006
In a number of countries overseas, innovative primary health care approaches to occupational health have been developed, particularly for small industries. These have included locating occupational health workers in general practitioners' surgeries," employing occupational health nurses to visit groups of smaller enterprises,'*J5and legislating to oblige municipal health centres to provide occupational health services for small firms and self-employed farmers.l4 The Queensland Workplace Health and Safety Act, 1989, imposes an obligation on all employers to ensure the health and safety of their employees and provides for the appointment of health and safety officers and health and safety committees in workplaces with 30 or more employee^.'^ However, the majority of workplaces in Queensland have fewer than 30 employees and so are exempt from the requirement of having health and safety officers and committees. The Inala Community Health Centre (CHC) is located in an industrial area of Brisbane and includes a primary medical care or general practice service as well as a community health team comprising community health nurses, therapists and other health workers. Some of the staff at Inala CHC saw the implementation of the Workplace Health and Safety Act as an opportunity to become involved in occupational health and safety at the local level, particularly in smaller workplaces. Before planning preventive occupational health programs, a prospective survey of all patients presenting over a six-month period to the primary medical care unit of Inala CHC was conducted to determine the number of cases and types of workrelated injury and disease as well as the causative fac-
AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1992
VOL. 16 NO.
4
413
COPEMAN ET M.
tors and details of the injured workers and their workplaces. This paper describes that survey and its results.
Methods All patients who presented over a period of six months (March to September 1990) were screened by one of three practice nurses. The nurses identified all new problems that appeared (from the presenting statement of the patient) to be work-related. The five general practitioners in the practice were asked also to identify any work-related conditions, especially diseases, which had not been identified by the nurses. If, at the initial screening, there was any uncertainty about whether the problem was work-related, the nurses were asked to complete a form and leave the judgment about work-relatedness to the doctors. Only three patients who werejudged by the nurses to have a work-related condition were subsequently judged by one of the doctors not to have a workrelated condition. The doctors were not given formal criteria for deciding whether problems were work-related. The decisions were left to their clinical judgment but there was regular, informal discussion among the doctors about these patients and their diagnoses during the course of the survey. Agreement among the doctors was good except in the area of chronic musculoskeletal conditions in patients with a history of repetitive strain movements at work (see Results). To check the completeness of the recording of work-related conditions, the duplicates of all worker’s compensation certificates filled out by the doctors during the six-month survey period were reviewed. Six extra cases of work-related injury were identified in this way. The s t a f f member who identified the patient as having a new work-related problem obtained information about the patient’s age, sex, country of birth, fulljob title, main duties performed, type of industry, business or service, duration of employment in that type of work, name of employer,suburb of workplace and whether the person wished to claim worker’s compensation. This information was entered on a record form which was designed as a systematised version of normal written case notes. The doctor who treated the patient entered a description of how the injury or disease occurred, the clinical details, and the investigations and management arranged or perfolllled. Occupation was coded from the job title and description of duties performed, according to the Australian Standard Classification of Occupations (ASCO).16 Industry was coded according to the Australian Standard Industry Classification (ASIC).” The nature and bodily location of the injury or disease as well as the agency and mechanism of injury were coded according to the draft version of the Type of Occurrence Classification compiled by Worksafe Australia in 1990. According to that classification, ‘an injury’ is ‘the result of a single traumatic event where the harm or hurt is immediately apparent’, 414
while ‘a disease ... results from repeated or long-term exposure to an agent or event’. Cases of occupational injury were recorded only if it was a new injury. Patients with occupational disease were recorded whether their disease was new or preexisting, but they were recorded only once each during the six months of the survey. Because the routine records of the primary medical care unit included only the number of consultations but not whether these were for first consultations or return consultations, an audit was made of a random sample of all primary medical care unit consultation records in the six months to determine the average number of consultations per patient at the unit during the six months. This allowed the total number of patients seen to be calculated approximately and the presentation rate for work-related conditions to be derived. The survey data were entered and analysed on a personal computer using the statistical programme SAS. ReSUltS Of the 12 932 consultations with the 5 doctors at the Inala CHC during the six months, 283 patients were identified as having new injuries or diseases caused by work. The average number of consultations per patient in that six-month period was 3.1 so that the total number of patients seen was approximately 4 170. Thus approximately 7.2 per cent of all patients were identified as having an occupational disease or injury. Eighty-six per cent of the patients with occupational disease and injury were male and 51 per cent were aged between 20 and 39 years. Sixty-four per cent worked in Inala or in the adjacent suburbs. Twenty-one per cent were born in non-English speaking countries, including Spanish-speaking countries, Spain, Chile, El Salvador, Argentina (3.5 per cent), Vietnam (3.2 per cent), Yugoslavia (1.8 per cent), Portugal (1.4 per cent) and Germany and Italy (1.2 per cent each). Thirteen per cent were born in the United Kingdom and 67 per cent were born in Australia or New Zealand. The majority of the patients worked as labourers (40 per cent), tradespersons (39 per cent), or plant and machine operators (14 per cent) in manufacturing industries (55 per cent), in’the wholesale and retail trades (20 per cent) or in construction (6 per cent) or community services (6 per cent). More than half of the patients had been in their present jobs for more than three years (Table 1). Table 1 : Duration of employment Years at present iob
loo Total
.
Note: lo)Fifty-nine potienh came from wohploces outside the lnolo area; the workplace size for 47 pocients wos not known or not recorded.
Sixteen per cent of the patients who worked in the Inala area worked in small workplaces (workplaces with fewer than 30 employees) and 47 per cent worked in medium-sized workplaces (30 to 99 employees)(Table 2). Two hundred and fifty patients were identified as having injuries and 33 had diseases. The most frequent forms of injury reported were open wounds, sprains and strains, contusions and eye injuries (Table 3). Musculoskeletalconditions,dermatitis and respiratory illnesses were the most common diseases recorded (Table 4). One patient had angina pectoris which had been aggravated by mental stress at work. The most common parts of the body affected were the fingers and hand (30 per cent), the eye (20 per cent), the shoulder, arm and wrist (11 per cent) and the back and neck (11 per cent). The causes of the injuries and the diseases are shown in Tables 5 and 6. Being hit by objects or hitting objects were the most common mechanisms of injury while body stressing was the most common mechanism causingdiseases. The pattern of the injuries and illnesses sustained by those patients who worked in small workplaceswas similar to that of those who came from medium-sized and larger workplaces except that workers from smaller workplaces sustained proportionally fewer open wounds. A number of subgroup analyses were performed to identify areas for possible action. Of the 24 patients with back pain, eight worked in manufacturingindustry, mainly metal and plastic manufacturing, seven worked in the service sector, four worked in the wholesale or retail trades and only one worked in the
construction industry. Eighteen sustained their injuries while handling objects or bending or twisting, and five sustained their injuries as a result of falls, trips and slips or from hitting, or being hit by, an object. Eye injuries similarly occurred predominantly in people working in manufacturing industry. Thirty of the 42 people presenting with eye injuries worked in manufacturing industry, including 16 in metal manufacturing. Analysis of the causes for the eye injuries showed that 12 of the 32 eye injuries attributed to foreign bodies were caused by falling objects, mainly dust falling from surfaces or being blown by the wind. The remainder were caused by moving objects, mainly metal fragments from grinding and welding. Five of the medium-sized workplaces (SO to 99 workers) had more than 10 per cent of their total workforce attend Inala CHC with a work-related injury or disease during the six months of the study. From one of these workplaces, a heavy engineering company, six of the total workforce of 72 suffered eye injuries and at another, a metal manufacturing company, four of 59 suffered open wounds. The clinical investigation and management received by the patients is listed in Table 8. Almost all patients were managed totally within the resources and expertise of the Community Health Centre. One fifth had an X-ray and almost one third had a minor operation. Thirty per cent received a workers’ compensation certificate and another nine percent were given a sickness certificate. This nine percent included some who asked for a sickness certificate because they felt that their employers were hostile towards worker’s compensation claims, others who said they could not afford the delay of many weeks that often ensues before workers’compensation payments are received and a few who had private accident insurance. Of the 119 patients who said that they did wish to claim workers’ compensation, only 45 (38 per cent) actually received a workers’ compensation certificate and nine (eight per cent) received a sickness certificate. Conversely, of the 110 patients who said that they did not wish to claim workers’ compensation, 14 (13 per cent) patients actually did receive a workers’ compensation certificate.
Table 3: Occupational injuries Nature of injury
Number of patients
Open wound Sprain or strain
71
Contusion Foreign body in eye
52 22
Eye injury-no
55
foreign body found
Bums
Superficial injury fracture Poisoning Internal injury Total
20 17 7 4 1
I 250
Table 4: Occupational diseases %
28 22 21 9 8 7 3 2 0 0 100
Number of patients Disorders of muscle, tendons and soft tissues
Hernia lxhoemic heart disease
17 5 3 3 2 1 1 1
Total
33
Dermatitis 01 eczema Respiratory conditions Disorders of joints Deafness Disorders of the spine
AUSTRALIAN JOURNAL Of PUBLIC HEALTH 1992 v a . 16 NO. 4
%
52 15 9 9 7 3 3 3 100
415
COPEMAN ET AL.
Table 5: Occupational injuries: causes Number of cases for each cause injury type
Hitting obiects
Hit by moving objects
48 4 17 2
18 5 18 20 12 7 5
Open wound Sprain or strain Contusion Foreign body in eye Eye injury-no
foreign body
3 2 1
Burns
Superficial injury
.
Fracture
Body stressing
Falls, trips and slips
Heat, radiation & electricity
3 17 13
1
28
3
Chemical substances
2 4
1
3
Poisoning Internal injury
1
77 31
Totala
96
31 13
89
36
7
34 14
3
Note: (a1 Three cases had no information on mechanism of inlury
Discussion
evidence that this one doctor preferentially attracted patients with work-related conditions nor that he overdiagnosed such conditions, although he did have a special interest in the field of occupational health and may therefore have been more attuned to the diagnosis of such conditions. The patient population attending the primary medical care unit at Inala CHC is fairly representative of that of general practices in lower socioeconomic, industrial areas, except that it may include a slightly greater number of workers from local industries who come because the unit has on-site X-ray facilities and a well-appointed minor operations facility. The local population is fairly similar in age distribution to the broader population except for the very old (over 75 years) age group, which is underrepresented. The results of this survey are similar to those reported for a recent survey of all occupational injuries occurring in a mediumsized city in northern Sweden.'* In that survey, as in this one, about half of the patients worked in manufacturing industry and their injuries and the bodily locations of them were similar to those reported here. There is little published research about workrelated conditions in general practice. In Sheffield in
IdentiJication of occ&ztionul injuv and diseases This survey sought to identify all work-related conditions in patients presenting to the general practitioners at a community health centre over a six-month period. Approximately seven percent of consultations were identified as being for workrelated conditions. The accuracy of this figure in reflecting the true rate of occurrence of work-related conditions depends on whether there was any variation in diagnoses among staff members and on whether there was complete recording of workrelated conditions. The close agreement between the doctors and the nurses concerning diagnoses and the relatively small number of worker's compensation cases not picked up by the survey suggest that the sample is fairly complete in recording occupational injuries. However, the acknowledged disagreement among the doctors over the diagnosis of repetitive strain conditions and the fact that one doctor, with a special interest in work-related conditions, diagnosed most of the cases of work-related disease, suggest that cases of occupational disease may have been underdiagnosed by the other doctors. There was no
Table 6: Occupational diseases: causes Number of cases for each cause Disease type or location
Hitting objects
Hit by moving objects
Noise
Heat and radiation
Chemical substances
1
4
Joints or spine
2
2
3
Respirotory conditions
2
Deafness Hernia
1 1
lschaemic heart disease Total
1
2
19
%
3
6
58
~
416
Mental stress
16
1
Muscle, tendon, soft tissues Dermatitis or eczemo
Body stressing
~
2 6
1
3
~~~~~~
AUSTRALIAN JOURNAL OF PUBLIC HEALTH
~
1992
VOL.
16 NO. 4
7 21
1
3
OCCUPATIONAL INJURY AND DISEASE
Table 8: Investigation and management of occupational injuries and diseases
Table 7: Agency of injury Number of patients
Agency
% Management
Materials and substances Non-powered handtools, appliances and equipment Machinery and fixed plant Environmental agencies Powered equipment, tools and appliances Mobile plant and transport Chemicals and chemical products Animal, human and biological agencies Total
Number of patients
%
80
29 62
22
72
27
Pathology tests
5
2
33
12
Hospital admission
3
1
22
8
Referral to outpatients department or specialist
7 7 6
Physiotherapy
11 15
4
19 19 17 10
Return appointment
42
Dressing
a2
29
4
Minor operation
82
29
272O
100
178 26
63 9 30
X-ray
Drugls) Sickness certificate
Nore; la1 1 1 missing values
Worker's compensation certificate
the United Kingdom in 1987, ten percent of 200 patients attending two group general practices in a lower socioeconomic industrial area had a condition resulting from their work.I9 The diseases of dermatitis and noise-induced hearing loss were the most frequent work-related conditions discovered in that study in contradistinction to the present survey in which injuries were reported much more commonly than diseases. These results may reflect different types of local industries with different occupational exposures. They also may reflect different awareness among the doctors in the two surveys of the possibility of work-related diagnoses and hence the possibility t h a t work-related diseases were underdiagnosed in the present survey. It is recognised that it is more difficult to diagnose occupational disease than occupational injury.8 Accurate evaluation of occupational exposures is often difficult enough at the workplace, let alone from the vantage of the doctor's consulting room. Diseases often have multiple possible aetiologies, making it difficult to evaluate work-relatednes~.~ The common occupational diseases such as acute and chronic lung conditions, dermatitis, deafness and musculoskeletal repetitive strain syndromes are also common nonoccupational diseases,9so that unless an occupational aetiology is considered and enquired about, work-related conditions may not be identified as such. The method of classification of work-related conditions by worker's compensation boards and other authorities may also affect their diagnosis. For example, a condition such as back pain that is classified as an injury may be more likely to be identified as being of occupational origin purely because it is thought of as a 'injury' than a condition such as tendonitis which is thought of as a 'disease'. Despite these difficulties, there are some simple questions that can be asked during a medical history that will help identify work-related conditions. Asking patients whether they feel that their conditions could be work-related," whether other workers at their places of employment have similar symptoms and whether their symptoms improve on weekends and holidays and recur when they return to
86
5 15
work are simple ways of helping to identify occupational causes of diseases.'O Another approach has been tried in Sheffield where occupational health workers have been employed in general practitioners' surgeries to raise the awareness of both doctors and patients about occupational injuries and diseases." Whatever approach is used, an important first step in efforts to decrease the incidence of work-related health problems is accurate and complete identification and recording of all such problems. General practitioners have a significant role to play in this endeavour. Additional research would be required to confirm whether general practitioners are lacking in knowledge of occupational health. Any such deficits should then be addressed by improved training and experience at both undergraduate and postgraduate level.
Implications for prmention The injuries most commonly reported in this survey (open and closed wounds, sprains and strains, and eye injuries) reflect the nature of the industries from which the patients came, as well as the semiskilledand unskilled nature of most of their jobs. Analysis of the profile of particular occupational problems identified by the survey should help in the planning of intervention programs to control those problems. For example, programs aimed at diminishing the problem of back pain in industry in the Inala area should be aimed at service and wholesale and retail industries as well as at manufacturing industries.'I The causes of the eye injuries seen in this group of patients is similar to those reported from a hospital survey of eye injuries in a nearby area of Brisbane.22 In that survey, 43 per cent of eye injuries were caused by grinding, drilling or welding and 31 per cent by wind or dust. The implication of both surveys is that control of eye injuries will require not only greater provision and use of well-designed protective equipmentzP but also, in some situations, more attention to keeping the workplace clean in order to miniise the significant proportion of such injuries
AUSTRALIAN JOURNAL OF PUBLIC HEALTH
1992
VOL. 16 NO. 4
41 7
COPEMAN ET AL.
caused by dust blowing or falling into workers’ eyes. The five medium-sized workplaces that had 10 per cent or more of their workforce affected by workrelated injury or disease in the six-month period are obvious targets for future preventive interventions aimed at improving occupational health and safety. The new Workplace Health and Safety Act in Q~eensland’~ provides a framework within which the staff of Inala CHC, supported by experts in occupational health, may be able to conduct such interventions in order to help improve occupational health and safety at the local level. In the larger workplaces which have workplace health and safety committees it should be possible to work with those committees to address the problems identified by this survey. In the smaller workplaces which do not have workplace health and safety committees, a more informal approach will be required. Such interventions are being planned and tested currently at Inala CHC.
disease. To realise this role they will need to establish links with local workplaces and with occupational health committees in those workplaces. Acknowledgments Our thanks to the staff and patients of the Primary Medical Care Unit of the Inala Community Health Centre for their cooperation, to the staff of the former Division of Accident Prevention, Queensland Government, for assistance and to Lyn Baxter for data entry and analysis. References 1. Rosenstock L. Occupational medicine: too long neglected. Ann Intem Med 1981; 95: 774-6. 2. Douglas D, Ferguson D, Harrison J, Stevenson M. Occupational health and sa-fdy. Canberra: Australian Medical Association, 1986. 3. Biggins D, Abrahams H. Farr T, Kempnich B. The role of the Workers’ Health Centre. J &cup Health Sa-fAust NZ 1989; 5 317-25. 4. Lennie I. Work as a variable in client problems: a survey of
fdes at three community health centres. Community Health
Worker’scompensation and sickness certificates There are a number of possible reasons why only one third of patients were given either worker’s compensation or sickness certificates. Some of the injuries were of a fairly minor nature and therefore did not require any time off work. Other patients may have been inhibited from claiming worker’s compensation by fear for the security of their jobs in a time of worsening economic environment. However, substantially more patients said that they would like to claim worker’s compensation than actually received a worker’s compensation certificate, suggesting that it may have been the doctors who were reluctant to agree to a request for worker’s compensation. This apparent reluctance by the doctors to complete a worker’s compensation certificate, despite their recording the injury or illness as being workrelated, could have been for a number of reasons. They could have been taking their gatekeeper role very seriously, feeling that they had a responsibility to help keep the worker’s compensation premiums of the local industries as low as possible.lO They may have felt that they were acting in the best interests of the patients by not encouraging them to become long-term ‘compo’ cases, or they simply could have felt that completing a worker’s compensation certificate was a tiresome chore.’O Whatever the real reasons were, the fact that such a small proportion of patients were given worker’s compensation certificates raises the possibility that too few, rather than too many, injured and ill workers may be receiving workers’ compensation. Conclusion Primary health care services do have an important role in identifying and treating work-related injury and disease. In order to fulfil this role, the issue of whether such services are identifyingall work-related disease in their patients needs to be resolved. Primary health care services could have an important role also in prevention of work-related injury and 418
Stud 1980; 4: 220-3.
5. Vimpani G, Hartley P. Informational system for the prevention of injury. Med J Aust 1989; 150 470-2. 6. Rutstein DR, Mullan RJ. Frazier TM et al. Sentinel health
7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17. 18. 19.
20. 21.
22.
events (occupational): a basis for physician recognition and public health surveillance. Am J Mlic Health 1983; 73: 1054-6 1. Capoon I. Capoon P. Occupational health and the family physician. Part 1: definition and resources. Can Fam Physicinn 1982; 28: 329-3. Mayers MR. Occupational disease diagnosis. N Y Sldc J Med 1952; 52: 2381-5. Brown TC. Evaluating work relatedness of diseases. Chest 1981; 79(Suppl): 1 2 7 ~ 9 s . Burry HC. Accident compensation: gates and gatekeepers. Med J Awl 1990; 152: 450-1. Sheffield Occupational Health Project. OEnrpational health w m h in fnimary health care. Shefield: Russell Press, 1989. Phoon WO. Primary health care for small industries. J Occ Health Saf Aust NZ 1989; 2: 45660. Glass WIG. Occupational health nursing and primary health care at work-the New Zealand experience. J Occup Health saf A w l NZ 1986; 2: 490-6. Kurppa K. Rantanen J. The utilikation of the primary health care approach to the provision of occupational health services in Finland. J Occup Health Saf Aust NZ 1986; 2: 482-9. Queensland Government. Wmhphu Health and Safety Ad, Brisbane: Queensland Government Publisher, 1989. Australian Bureau of Statistics. Australian standard chrrifi&ion ofoccupatim. Canberra: Australian Government Pub lishing Service, 1986. Cat. nos. 1229.0, 1223.0. Australian Bureau of Statistics. Australian standard industq c h f i i i o n . Canberra: Australian Government Publishing Service, 1986. Cat. nos. 1201.0, 1202.0. Larsson T, Bjornstig. The epidemiologyof occupational accidents: three ways to measure the problem in a Swedish municipality. J Occup Health Saf Aust NZ 1990; 6 39-52. Shefield Occupational Health Project. An occupational hcallh project in g m l practice. Unpublished report, 1988, available from: Birley Moor Health Centre, 1 East Glade Crescent. Shefield 12, UK. Lee WR. What do you work with? B r J Med 1985; 2 9 0 18467. Department of Employment, Vocational Education, Training and Industrial Relations Back can af wonk. Brisbane: Department of Employment. Vocational Education, Training and Industrial Relations. 1990. Kruger RA, HigginsJ, Rashford S et ‘al. Emergency eye injuries. Aust Fam Phys 1990; 19: 934-7.
AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1992 v a . 16 NO. 4
