The evidence suggests that providing access of health workers to HIV and TB prevention, diagnosis, treatment, care and support can best be done on-site at the workplace, provided that the other aspects of concern, particularly confidentially, can be strictly maintained. In an evaluation of the 70 ART delivery sites reported by Charalambous and colleagues (2007b), different sites were used for the services provided - including hospital clinics (8), occupational health centres (29), primary health care clinics (2) and General Practitioner offices (31). While these authors did not compare results by site, other authors did. Specifically, the cluster-randomized controlled trial by Corbett and colleagues (2006), did indeed show that uptake of on-site rapid testing was significantly and substantially higher than that achieved through standard-of- care provision of free vouchers for off-site. The healthcare workplace also is an ideal environment in which to provide basic primary health care services to staff in addition to occupational health services. (Uebel, 2007)
There are numerous international guidelines related to occupational health services, issued by both the WHO and ILO, including the WHO Global Strategy on Occupational Health for All. 1994; the WHO Guidelines on Quality Management in Multidisciplinary Occupational Health Services. 1999; the WHO Occupational Health: A Manual for Primary Health Care Workers. 2001; the WHO Declaration on Workers Health. 2006; and the WHO. Basic Occupational Health Services: Strategy, Structures, Activities, Resources, 2005, amongst others. These build on the ILO Convention definition of Occupational Health Services (OHS) as "services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on- (i) the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work; and(ii) the adaptation of work to the capabilities of workers in the light of their state of physical and mental health..."
Additionally, a discussion of what should constitute Basic Occupational Health Services (BOHS) is found in the evidence supporting the model BOHS framework, published jointly by the WHO, ILO, International Commission for Occupational Health (ICOH), and the Finnish Institute of Occupational Health (FIOH) (2005). This framework provides guidance on the principles, content, models, and resources needed for a BOHS. The ultimate objective of the BOHS initiative is to provide occupational health services for all working people in the world, regardless of the sector of economy, mode of employment, size of the workplace, or geographic location (ie. according to the principle of universal services provision).
Many countries indeed have developed legislation, policies or guidelines, some of which directly applies to the healthcare sector. Many of these were discussed in the Synthesis Report (Yassi et al. 2009a). The Swaziland Ministry of Health and Social Welfare's Monitoring & Evaluation Framework for the Health Sector Response to HIV/AIDS 2006-2008 constitutes one such example.
There is widespread agreement in the literature that occupational health services should be provided by a multidisciplinary team and that health and safety committees are important. As other statements in these guidelines address the role of the various parties, including health and safety committees, no further elaboration is needed here, and instead attention is turned to financial implications of improving occupational health services.
According to ILO Convention No 161 on occupational health services, the financial responsibility for providing such services rests with the employer. In Finland, the costs of occupational health services provided by municipal health centers were USD 25 for preventive activities and USD 49.2 for curative activities per covered worker per year (i.e., a total of 74.2 USD per covered worker per year in 2001). Most of the costs consisted of salaries of the occupational health personnel. As salary levels in most low and middle income countries are substantially lower than in Finland, the costs per covered worker in those countries may be on the order of 20 USD per year, and for preventive activities alone about USD 5 per year.
In February 2007, the Community Guide Task Force released the findings of a systematic literature review focused on the health and economic impacts of workplace health promotion (WHP). Using established rigorous guidelines for their review, the Task Force examined the literature for work site programmes that include an assessment of health risks with feedback, delivered verbally or in writing, followed by health education or other health-improvement interventions. Additional health-promotion interventions included counselling and coaching of at-risk employees, invitations to group health education classes, and support sessions aimed at encouraging or assisting employees in their efforts to adopt healthy behaviours. Intervention included enhancing access to physical activity programmes (exercise facilities or time off for exercise), providing healthy food choices in cafeterias, and enacting policies that support a healthier work site environment (such as a smoke-free workplace). In most cases, unfortunately, WHP interventions did not include measures to improve the safety of the work environment. Health and productivity outcomes from these interventions were reported from 50 studies qualifying for inclusion in the review. The outcomes included a range of health behaviours, physiologic measurements, and productivity indicators linked to changes in health status. Although many of the changes in these outcomes were small when measured at an individual level, such changes at the population level were considered substantial. More specifically, the Task Force found strong evidence of WHP programme effectiveness in reducing tobacco use among participants, fat consumption as measured by self-report, high blood pressure, total serum cholesterol levels , the number of days absent from work because of illness or disability, and improvements in other general measures of worker productivity.
Moodley and Bachmann (2002) found that when free primary health care was withdrawn from the occupational health clinic in one hospital in South Africa, absenteeism in the facility increased. This finding suggests that comprehensive occupational health programmes have the potential to increase overall health system capacity by better enabling health workers to continue providing care to those in need. Another study by Falagas and colleagues from 2006 in Greece assessed the utilization of services of a hospital-based employee health clinic. The study demonstrated that occupational health services are indeed frequently used by hospital employees, especially nurses, suggesting that these services have the potential to provide high uptake rates among hospital staff for HIV and TB treatment services.
While there is considerable research focused on the need for primary prevention of occupational exposures in healthcare, and indeed evidence on the effectiveness of primary prevention measures (e.g. safe needle technology, respiratory protection, etc.) which have constituted the basis for existing WHO Guidelines (see Annex 1), there is considerable evidence that these measures are not being widely implemented (Rebman et al. 2008). Additionally, while there is considerable evidence for the need for secondary and tertiary prevention occupational health services, other than those aimed as early return-to-work post disability which are well-researched, secondary prevention services (e.g. post-exposure assessment and prophylaxis) are sparse (Rebman et al. 2008). Moreover, there are few studies evaluating the effectiveness of such measures, and only a small handful, as discussed below, that evaluate specific policies and practices aimed at effectively treating health workers who are HIV infected and/or at risk of becoming infected with TB within their workplace. Workplace-based treatment of HIV and TB therefore constituted the subject of one of the questions for the Systematic Review, as noted above.
As shown in Table 2, Uebel, Nash, and Avalos (2007) described staff care programmes at McCord Hospital in Durban, South Africa; Mseleni Hospital in northern KwaZulu-Natal, South Africa; and the Tshedisa Institute in Gaborone, Botswana. The interventions are described in this study as providing convenient, confidential, and holistic care for HIV-infected health workers and health workers affected by caring for HIV-infected patients. All three programmes noted an increasing acceptance of counselling, testing, and treatment among healthcare workers. The authors' urged the development of HIV care and treatment programmes for health workers that remove barriers to access, provide confidentiality in testing, are conveniently located, and are integrated with TB programmes and other treatment services.
A study by Leslie London (1998) explored the possible role of occupational health services in prevention and control of AIDS. London and colleagues conducted a telephone survey of a random sample of large manufacturing employers (N=52). London then conducted a second survey through a mailed, self-administered questionnaire that was sent to the entire membership of the local occupational health nurses association working in industry in the Cape Town region (N=98). He found that if occupational health services are to have a role, attention must be given to integrating AIDS prevention in the planning, management, and implementation of activities using appropriate teaching methods. The authors concluded that the emphasis must be on effective education programmes, developed with a critical understanding of the behavioural issues relevant to AIDS prevention. Occupational health services must also put the empowerment of women in the workplace on their agendas.
Corbett's 5-Country Study also substantiated the need to remove barriers to access, provide confidentiality in testing, and provide services which are conveniently located, and are integrated with TB programmes and other treatment services. It was particularly noteworthy that 80% of the health workers who participated in that large study were comfortable with confiding their HIV status to the doctor of nurse responsible for occupational health. The study found that while stigma associated with HIV was strong, health workers did not feel the need to be secretive about being tested or treated for TB, and the great majority indicated that they would choose to be tested at their own facility. Moreover 95% of respondents reported a high interest in annual TB screening and a similar high response to HIV, but often when combined with priority access to ART as part of the annual health assessment. (This will be discussed further in relation to the next Statement.)
With respect to this particularly statement, Corbett's finding that over half the randomly selected facilities had no one (neither a named individual nor committee) responsible for health worker safety, as was the case in 25% of the 'best practice' facilities, and only 10% of the randomly selected, and 20% of the best practice facilities had a dedicated staff clinic.
The need and likely acceptability of this recommendation regarding strengthening OHS services for health workers is highlighted as well by the findings from the 17-country Surveys, namely that currently the implementation of policies and programmes related to this area is very weak.
In response to this need to improve working conditions, the GHWA initiated the Positive Practice Environments (PPE) Campaign, a worldwide campaign to generate public awareness and political will to introduce and maintain improved working conditions and environments within health systems. This is a country and facility-centred initiative focusing on all health care settings. The campaign aims to improve the quality of health services by raising awareness, identifying good practice, and developing tools for managers and health professionals in the field. Working collaboratively, the campaign has been initiated by the International Council of Nurses, the International Pharmaceutical Federation, the World Dental Federation, the World Medical Association, the International Hospital Federation and the World Confederation for Physical Therapy, with the support of the GHWA.
It is noteworthy that the findings from the literature, including the Systematic Review, are consistent with the findings of the Five Country Study of Corbett and the 17-Country Survey. For example, it was noted that uptake of on-site rapid testing was significantly and substantially higher than that achieved through standard-of- care provision of free vouchers for off-site.
Thus , in considering that i) guidelines have been developed by WHO, ILO, ICOH and other international agencies regarding occupational health services, and many countries have developed policies in this regard; ii) the evidence indicates that OHS services are currently not being widely implemented for health workers globally; iii) OH professionals or even trained individuals responsible for OH are often lacking, as are health and safety committees; iv) studies support the cost-benefit of OH services; and there is considerable evidence of the cost-benefit of health promotion activities in the workplace.; v) several studies have been conducted of programmes in which HIV and TB service have been offered in the workplace; the evidence indicated that the uptake of such services at the workplace is high, that comprehensive occupational health programmes have the potential to increase overall health system capacity; and vi) evidence supports the desirability of the healthcare workplace as a preferred site in which to provide HIV and TB prevention, diagnosis, treatment, care and support to health workers.
In reviewing the evidence, the GG also recommended the following:
- The term "health workforce" should include traditional health professionals as well as healthcare support staff (cleaners, laundry, foodservice, maintenance, etc.) as well as volunteers, lay health workers and others who comprise the entire health workforce.
- Infection control is an essential component of occupational health, as control of biological hazards, along with physical, chemical, biomechanical and psychological hazards are all integral to an occupational health service.
- Adequate numbers of occupational health professionals and health and safety committees must be trained.
- Access to sexual and reproductive health services must be included as part of a comprehensive employee health programme.
- Campaigns such as Positive Practice Environments: Quality Workplaces for Quality Care should be supported and implemented in the workplace.