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Commentary on the paper by de Boer et al (see page 792)
Construction is big business. In the UK it is now the country's biggest industry and the same is true for many economically developed countries. It is also a dangerous business and construction workers do not enjoy good health: studies in Britain, Europe and the USA have shown that construction workers have high overall mortality rates independent of social class—both those employed in specific trades and “construction workers not otherwise classified”. There are increased mortality risks for all malignant neoplasms including lungs, stomach and thyroid gland, high levels of mesothelioma deaths, chronic obstructive pulmonary disease and high rates of transportation and other injuries. Psychological ill health is also common with high rates of alcohol and drug abuse. Construction used to be a young man's industry because of the high attrition rate resulting from poor work conditions and premature ill health and disability. Now, as with other industries, the workforce is getting older. Unlike other industries, the work cannot be exported.
The last decade has seen an explosion of interest in the construction industry and its hazards1 but most of the literature is shot through with expressions of concern and frustration at the very nature of the industry and the people who work in it mitigating against improvements in occupational health. One of the main problems faced by the industry is how to retain early aging workers and provide meaningful work for them. The paper by de Boer et al2 has tried to address this knotty problem by instituting counselling and education programmes using a case‐control approach. They selected employees with a high risk of disability of 38% or more anticipated in the succeeding four years. These employees were assessed using the Workability Index, given a health education programme and then followed up at 9, 18 and 26 months after the start of the intervention. The rates of disability pensions granted were also recorded. The control group were offered occupational health “care as usual”, which apparently incorporates voluntary periodic health examinations every 2–5 years depending on age. The study was done in the Netherlands. It should be noted that in other countries, including Britain, occupational health “care as usual” means, generally, no care.
The authors clearly found difficulties (there are always difficulties) in this intervention study and the process and the reasons why it was difficult are covered in their discussion at the end of the paper. There were problems in recruiting for the study: they had hoped that the majority of participants would be selected on the grounds of their potential disability by an occupational physician, but in fact a large proportion of the participants enrolled themselves in the programme. Then a number (57%) did not accomplish the programme for various reasons. It is speculated that some of them might have left because the assessment of workability which was performed did not please them because it prompted a realisation of the tenuousness of their position in the labour market.
The intervention was generally not successful. Any improvement in workability in the intervention group was minimal and the effect on the likelihood of receiving a disability pension was no different to that of the control group. The authors cite many reasons for the apparent failure of this health educative intervention: maybe it was pitched at the wrong level; maybe at 38% the workers were too far down the road of ill health and reduced workability. Perhaps health education does not work (although the intervention group reported more job satisfaction) or perhaps construction workers are simply a recalcitrant bunch of human beings different from other kinds of workers. There is some evidence of this—construction is notoriously a “fall back” occupation, levels of education are not high in general, and the work is by its very nature transient and attracts drifters and migrants and people avoiding the authorities. Actually in this study a majority of the construction workers were carpenters or bricklayers and, as mentioned already, self‐selected—probably a more stable group than the average. Another explanation not given by the authors might be that these employees were already receiving reasonably effective occupational health care.
Does this mean that assessment and health education to groups of workers with already existing disabilities (or at least workability scores over 38%) cannot prevent functional decline or prolong disability‐free working life and loss to the industry? Well, the authors seem to be saying, at least in the circumstances they describe, “yes”.
Occupational safety in the construction industry has improved over the years as evidenced by many countries' national statistics reporting systems and this has been achieved by a combination of better and safer design of new buildings and structures, permits to work safely as used in the process construction industry (oil and gas etc) attention to ergonomics (manual handling and work in awkward spaces) and strong inspection and enforcement activities instituted by the state. Better control of hazardous substances and dust has also been achieved. These improvements have been more notable in the larger, well organised companies and less so in the small companies in which many construction workers work and in the demolition/renovation industry.
These have largely been employer‐led initiatives stimulated by the shameful health and safety record beginning to be recognised in the early 1980s, forceful targeting by national labour inspectorates and concerns expressed by trade unions and occupational health and safety professionals. The workforce itself—poorly unionised, incoherent and generally poorly informed—has been quite well served in some countries by occupational health services (Bygghalsen in Sweden, in its heyday, was one of the notable pioneers), but occupational health provision to construction workers remains extremely patchy throughout the economically developed world and practically non‐existent in the developing world. Whether interventions of this kind done in precisely this way and with this particular workforce will work to reduce disability and prolong active work life is still open to question and of course to further research.
Competing interests: None declared.