• Promoting a Healthier Workforce

    Health and Productivity Management

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  • Health and Productivity Management Center

    Health and Productivity: A Role for Occupational Health Professionals

    JOEM/January 2001

    Robert J. McCunney, MD, MPH

    The impressive economic gains achieved by many nations within the past decade have been attributed primarily to improvements in productivity from technological changes. The resultant low unemployment levels, however, emphasize the importance of human capital in the success of any enterprise. Concurrently, some economists have proposed an alternative economic view regarding the relationship between health and income, postulating that improvements in the health of the nation's population have a substantial effect on its economic viability. Such a view directly pertains to occupational health professionals, who are often charged with promoting the health of the worker. Although studies relating the beneficial impact of occupational health on productivity and human performance are limited, some efforts have shown impressive effects, as measured primarily by reduced absenteeism. The prompt, assertive management of occupational injuries and illnesses and their treatment have been well documented. Illnesses not considered traditional occupational ailments, such as migraine headaches, allergic disorders, infectious diseases, and depression, offer opportunities for occupational health professionals to ensure an accurate diagnosis and proper treatment for minimizing the impact on work performance. Considerable opportunities exist for occupational health professionals to demonstrate the importance of certain services to productivity.  (J. Occup Environ Med. 2001;43:30 – 35)

    Throughout the 1990s, the United States and most developed countries witnessed substantial economic gains manifested by increased per capita income and gross national product and reduced unemployment. What has been most impressive to a variety of observers, especially economists, is that the economic growth has proceeded with no appreciable inflationary effect. This period of sustained growth with nominal inflation has been attributed primarily to the improved productivity resulting from new technology. Communication advances, access to information, and business efficiencies brought about by the Internet and wireless telephones are only a few of the many examples that have improved the success of business enterprises. More recently, business leaders, economists, and health professionals have focused attention on the role of health as a competitive advantage.1 How the enhanced health of the workforce can lead to improved productivity has been the subject of a variety of symposia and new organizational initiatives. The purpose of this article is to review the relationship of health to productivity, particularly as it pertains to occupational health professionals, and to propose areas worthy of further pursuit.

    Health and Income

    A recent article in Science posed a novel way of viewing the relationship between health and income, an observation that may provide support to occupational health professionals in promoting the value of a healthy workforce.2 Traditionally, the correlation between income per capita and health has been acknowledged as one of the best-known relations in economic development.3 In essence, those who are better off financially and have the concomitant material advantages, theoretically, have the best access to medical care and the ability to afford the treatment and other measures that may be recommended. A new economic perspective, however, suggests the converse relationship; that is, good health leads to enhanced income.

    Advanced by two economists, the theory is based on four contributing factors: productivity, education, investment in physical capital, and demographic dividends. It should be unsurprising that healthier populations tend to have higher labor productivity because the workers are more physically energetic and mentally more robust. Increased education tends to promote greater productivity and higher income. Improvements in longevity, in turn, create a greater need for people to save for their retirement, resulting in a corresponding increase in investments. Finally, a demographic dividend results from reduced mortality and improved fertility, which lead to a greater number of people in the working-age cohorts. This alternative way of linking health to income is supported by a recent World Health Organization publication, in which health status (as measured primarily by life expectancy) is described as a significant predictor of subsequent economic growth.3

    In general, economists have treated health care like a consumer good and have assumed that the relationship was driven from income to health; however, good evidence now supports the concept that health improvements stimulate economic development. This finding bears direct relevance to occupational health professionals, who in the past have tended to receive support for preventive activities when organizations are extremely large, very successful, or (ideally) both. For the most part, efforts directed to prevention and health promotion activities have been undertaken primarily as an effect of success, as opposed to being considered a reason for the success of the organization.

    The relationship of ill health to declines in income becomes obvious when one considers the economies of certain countries. Witness for example, the misfortunes of Russia, which over the past 10 years has witnessed a dramatic decline in life expectancy and in its economic well-being. A similar case can be made for the tragedy of sub-Saharan Africa, which is plagued with a high prevalence of human immunodeficiency virus infection.4

    The economist authors of the Science article claim that a revolution in economic thinking now supports the concept that “increased health is another aspect of human capital that enters into production.” They conclude that a long life expectancy may be the fundamental force that creates the demand for education and encourages domestic savings as a key determinant to economic growth. From this broad perspective, one can conclude that investing in the health of the workforce should be an essential ingredient to the success of any organization.

    As in the past, various topics have a way of coming in and out of favor. The idea that healthy people will work better, however, was advanced over 200 years ago by Adam Smith in his book, The Wealth of Nations:

    …that men in general should work better when they are ill fed than when they are well fed, when they are disheartened than when they are in good spirits, when they are frequently sick than when they are generally in good health, it seems not very probable. Years of dearth, it is to be observed, are generally among the common people. Years of sickness and mortality, which cannot fail to diminish the produce of their industry.

    Occupational Health Services

    In keeping people healthy and productive at work, it is wise to recognize that health, although of critical importance, is only one of the factors that can enhance productivity. Corporate culture, interpersonal relation, the physical environment, the flexibility of the organization, and other factors can affect performance. Although obvious to occupational health professionals, a safe and healthy work environment with control of physical, chemical, and biological hazards is an essential first step. Provision of a physical environment conducive to productivity, along with the establishment of systems for early recognition of and responses to work-related illnesses and injuries, provide further support for productive activity.

    Occupational health services primarily include those performed prior to and during employment, although in some cases, retirees may also receive services, including clinical evaluations in the monitoring of certain diseases, primarily those with long latency. Clinical services range from pre-placement evaluations to periodic monitoring to effective treatment and rehabilitation of injuries and illnesses. Non-clinical services include those directed toward health promotion and other preventive activities. A relatively unrecognized challenge to occupational health professionals is minimizing the effect on work performance of non-work-related illnesses and their treatment. This topic is discussed in more detail later in this article.

    To properly assess the value of occupational health services on an organization's productivity, it is essential to define terms. Productivity assessments, as customarily performed in most studies, refer primarily to absenteeism as the key metric. In some cases, productivity has been quantified to include, for example, the number of claims adjusted, telephone calls handled or boxes packed onto a truck, or items produced during an 8-hour shift. However, assessing productivity associated with cognitive tasks, such as product development, academic work, and design activities, is much more challenging.5

    A number of dichotomies have been observed with regard to productivity, most notably that, despite its importance to private and public business sectors worldwide, it is rarely measured. As used in business and science, the term productivity lacks uniform standards of definition and measurement. Coupled with the absence of an established research database, the lack of a uniform definition of productivity, especially for cognitive tasks, complicates the challenge in demonstrating the corresponding economic value of occupational health services. What follows is a summary of the major clinical occupational health services provided in the United States, with commentary on their potential value in enhancing productivity.

    Pre-Placement Evaluations

    An essential role of occupational health professionals is properly placing people in jobs to ensure compatibility between the workers' health and their required tasks. Appropriate selection ideally benefits both the employer and the applicant. Pre-placement evaluations, however, must conform to various regulations, most notably the Americans With Disabilities Act. In addition, as work continues on the human genome project and genetic information becomes more widely available, additional challenges will surface regarding the use and access of such information in employment-related decisions. Such advances in genetics now appear imminent for the mapping of the human genome, as evidenced by the recent success with the fruit fly genome.6 In fact, some have described the sequencing of this 120-megabase genome as the “Rosetta stone for deciphering the human genome.”7 Recently, President Clinton signed an executive order banning discrimination in employment related to genetic tests.

    Demonstrating the value on productivity from pre-placement evaluations is a difficult exercise. Nevertheless, proper placement minimizes incompatibilities between a person's health and job, especially those activities that may cause a higher risk of injury or illness. Effectiveness can be demonstrated, however, through the prevention of work-related ailments and the resulting absenteeism. Certainly, the value of a pre-placement program depends on the nature of the work. Regulatory compliance, although a factor in any organization's success, is not usually considered an element of productivity, but it is of clear value in many preplacement efforts.

    Maintenance of Health

    As noted earlier, the assertive control of physical, chemical, and biological hazards remains an essential component of occupational health practice. The provision of a healthy environment also includes optimal indoor air quality along with systems that enable employees to come forward when there is any potential for illness or injury.

    The periodic evaluation of people potentially exposed to certain hazards is required by some Occupational Safety and Health Administration (OSHA) standards; it is also considered standard practice for some job duties, according to professional guidelines and the OSHA general duty clause. Although the direct value of these preventive activities is difficult to quantify, the obvious benefits with financial implications are regulatory compliance (ie, avoidance of fines) and prevention of illness (reduced workers' compensation and legal costs). Further investigative work in this area, especially that relating to productivity, would be valuable.

    Management of Work-Related Illness and Injury

    One of the most direct ways to improve productivity in occupational health practice is by reducing workers' compensation costs, approximately two-thirds of which provide income replacement for lost time resulting from injury or illness. Comprehensive management of work-related injuries and illnesses includes not only competent medical care, but also a worksite return effort, conducted with an understanding of the workplace and job duties. Transitional assignments can be instrumental both to the patient in enhancing recovery and to the employer for the additional work done during the later phases of the treatment process. Such approaches, however, depend on quality health care, assertive follow-up, and access to specialists who efficiently use diagnostic and ancillary studies to facilitate a timely return to work.8 Policies that limit or delay diagnostic studies may interfere with efficient efforts to reduce lost time. In fact, oversight of occupational injuries or illnesses processed through workers' compensation programs may greatly minimize lost work time, largely by reducing time needed for studies and appointments with specialists. In light of the enormous expenditures associated with certain occupational disorders, such as back pain, even minimal efforts in reducing lost time can be financially viable.9

    Management of Non-Work-Related Illness and Injury

    A previously unrecognized challenge for occupational health professionals is understanding the impact on performance of  "traditional" non-work-related illnesses and their treatment. Consider, for example, depression, migraine headaches, diabetes mellitus, allergic disorders, and influenza and other viral infections conditions that tend be highly prevalent among working-age populations. What seems not fully appreciated, however, is that these ailments tend to be under-recognized and under-treated and to have both subtle and dramatic effects on work performance. Recent epidemiological studies, for example, have shown a relatively high prevalence of unrecognized depression that is untreated and has significant effects on work.10-13

    Migraine headaches, which tend to occur with the greatest frequency among 25- to 35-year-olds, significantly affect a person's ability to work effectively. In fact, policies that cover the costs of certain medications (which initially may seem expensive) can have favorable cost-benefit ratios.14 One recent study evaluating the treatment of migraines with sumatriptan showed substantial cost savings for the employer through funding the medication.15

    Allergic disorders affect as much as 30% of the adult population, most of whom either seek no treatment or self-treat with over-the-counter medications, some of which (diphenhydramine) have profound sedating effects.16 In fact, the use of non-sedating antihistamines (in contrast to over the-counter drugs) has been evaluated in the context of productivity and accidents at work. Among over 3000 Health Maintenance Organization members, the risk of injury was significantly elevated in those who used sedating antihistamines.17 Another study addressed the relationship between the types of treatment for allergic disorders (sedating vs non-sedating antihistamines) and found that those workers who took sedating antihistamines had lower levels of productivity.18 In fact, the use of non-sedating histamines can have a profound impact on alertness and driving safety19 and can otherwise affect productivity.20 The preferred treatment of allergic disorders for people who can risk no compromise on mental clarity may include non-sedating anti-histamines, allergic desensitization, and corticosteroid nasal sprays.

    Acute viral infections, in particular, influenza, are well known to result in substantial time away from work and to interfere with human performance. 22 In fact, the average person misses approximately 3 days of work per episode, although the full impact of impaired productivity may be much longer, depending on the severity of the illness.23 Recent studies have demonstrated favorable results from the immunization of employees for influenza by reducing absenteeism.24 Other studies have shown promising effects from the use of new antiviral agents (neuraminidase inhibitors) in modifying the severity and duration of influenza and in improving worker productivity.25/28 Even more promising is the use of an intranasal vaccine–both in preventing the illness and improving productivity.29,30

    Other work related to health and productivity has evaluated the effect of indoor air quality,31,32 health risk factors,33 and computer design and rest breaks on productivity.34,35 Clearly, the challenge of demonstrating the benefit of quality occupational health services on productivity is multidimensional, with opportunities in a variety of perspectives.36

    Health promotion programs and other wellness initiatives can substantially benefit productivity. Efforts designed to curb smoking, enhance fitness, and screen for preventable disorders (eg, nutritional disorders) are standard features in many organizations. Although the challenge of demonstrating cost effectiveness can be considerable, well-designed health promotion programs also offer numerous intangible benefits, such as improved morale and enhanced organizational image.37-40

    In light of the diversity of occupational health services and the amount of information they generate, integrated data management is essential to monitor and evaluate the impact of these services.41 Efforts to link the direct and indirect costs related to health and disability can help focus attention on the most beneficial health promotion programs.

    Discussion

    Occupational health services enhance productivity in a variety of ways, many of which would profit from further documentation. Although reduced absenteeism has been the key method for achieving improvements in productivity, more refined measures have recently been introduced. What remains elusive is assessing the productivity and output of people performing cognitive activities. It is likely that self-assessments of job duties, followed by validation studies, will be necessary.

    Despite the relative dearth of investigative work linking occupational health services with improved productivity, recent studies suggest that fundamental principles of prevention directed to ergonomics, indoor air quality, and risk factor reduction can be effective. Clearly, further research is warranted, because the ability to demonstrate the economic benefit of occupational health services enhances the effectiveness of the health professional in any organization. In fact, the astute practitioner will recognize the opportunity to perform straightforward and uncomplicated investigative work based on information obtained in the routine provision of services. Some examples follow.

    An assessment of an organization’s workers; compensation experience is a reasonable first step in identifying high-risk jobs, the major types of injuries, and the means for their prevention. Subsequent benchmarking of data against industry averages can shed further light on areas that need improvement. Fundamental approaches to assessing workers' compensation claims have been proposed.42

    As noted earlier, a relatively unrecognized challenge is the assessment of the impact of non-work-related illnesses on productivity.43 Traditionally, occupational health professionals have focused little attention on this topic.37 Recent research, however, points to the critical importance of assessing the impact of the side effects of medication on work performance.26 Five brief questions posed during routine clinical evaluations for any type of occupational health encounter can offer valuable insights. For example, an inquiry directed to a patient’s past medical history, including surgery, hospitalizations, medications, allergies, and illnesses that require periodic attention, will provide the professional with an opportunity for counseling when appropriate.

    Another area not routinely addressed by occupational health professionals is the content of pharmaceutical formularies of health benefits plans, especially those of Health Maintenance Organizations. Certainly, the medication available for treatment can affect a person’s ability to perform optimally at work.

    In light of the rapid advances in computer technology and the importance of such corresponding activities as the Internet, attention to the health implications of these types of jobs seems worthwhile. Proper workspace design with ergonomically appropriate equipment is a key factor in preventing workrelated ailments and improving performance.

    Summary

    Productivity enhancement of business operations will likely continue to be a pressing economic concern in the immediate future. The physical context of the work environment, the equipment used, and the mental clarity of the workers all contribute to the success of an organization. Occupational health services, as currently performed, clearly enhance productivity, primarily through reduced absenteeism by the prevention of short- and long term disability. An awareness of the effects on performance of non-work-related illnesses and their treatment is another challenge to occupational health professionals. Further work on the role of occupational health in productivity is worthy of pursuit, including education, research, and publications.

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