Conducting organizational-level occupational health interventions

Work & Stress
Vol. 24, No. 3, JulySeptember 2010, 234259
Conducting organizational-level occupational health interventions:
What works?
Karina Nielsena*, Raymond Randallb, Ann-Louise Holtenc and
Eusebio Rial Gonzálezd
a
National Research Centre for the Working Environment, Copenhagen, Denmark; bSchool of
Psychology, University of Leicester, Leicester, UK; cNational Research Centre for the Working
Environment, Copenhagen, Denmark; dEuropean Agency for Safety and Health at Work,
Bilbao, Spain
In recent years, there has been an increasing interest in how organizational-level occupational
health interventions aimed at improving psychosocial working conditions and employee health
and well-being may be planned, implemented and evaluated. It has been claimed that such
interventions have the best chance of achieving a significant impact if they follow an
intervention process that is structured and also includes the participation of employees. This
paper provides an overview of prominent European methods that describe systematic
approaches to improving employee health and well-being through the alteration of the way
in which work is designed, organized and managed. The methods identified are the Risk
Management approach and the Management Standards from Great Britain, the German
Health Circles approach, Work Positive from Ireland and Prevenlab from Spain. Comparative
analyses reveal that these methods all consist of a five-phase process and that they share a
number of core elements within these phases. However, overall the five methods have not been
thoroughly validated. To examine the validity of the core elements, we review them in the light
of current research in order to support their appropriateness in conducting organizationallevel occupational health interventions. Finally, we discuss where we still need more research to
determine the working ingredients of organizational-level occupational health interventions.
Keywords: occupational health interventions; participation; evaluation
Introduction
In recent years, there has been an increasing interest in organizational-level
occupational health interventions aimed at improving psychosocial working conditions and employee health and well-being. Organizational-level occupational health
interventions can be defined as planned, behavioural, theory-based actions to
remove or modify the causes of job stress (stressors) at work and aim to improve the
health and well-being of participants (e.g. Giga, Cooper, & Faragher, 2003;
LaMontagne, Keegel, Louie, Ostry, & Landsbergis, 2007; Richardson & Rothstein,
2008). Ideally such organizational-level interventions should improve the working
*Corresponding author. Email: [email protected]
ISSN 0267-8373 print/ISSN 1464-5335 online
# 2010 Taylor & Francis
DOI: 10.1080/02678373.2010.515393
http://www.informaworld.com
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environment and help democratize the workplace (Mikkelsen & Saksvik, 1998). It
has been found that such interventions are complex and many factors may influence
whether they succeed or not (Egan, Bambra, Petticrew, & Whitehead, 2009; Murta,
Sanderson, & Oldenburg, 2007). It appears that occupational health interventions
have the best chance of achieving a significant impact if they follow a structured and
participatory intervention process. Nytrø, Saksvik, Mikkelsen, Bohle, and Quinlan
(2000) defined process as ‘‘individual, collective or management perceptions and
actions in implementing any intervention and their influence on the overall result of
the intervention’’ (p. 214).
The importance of intervention planning and implementation processes in
determining intervention outcomes is now being widely acknowledged. For example,
the Danish government initiated a consortium between the Danish Working
Environment Authority and the National Research Centre for the Working
Environment (NRCWE) that is working together towards identifying methods that
organizations may employ in order to improve the psychosocial working environment. As part of this task researchers from the NRCWE have reviewed intervention
methods from a number of European countries that describe the important features
of organizational-level occupational health intervention processes. In this paper we
summarize the key components of these methods and present a critical evaluation of
the research that has examined the links between these components of interventions
and occupational health outcomes. The main objectives of this paper are three-fold:
(1) to highlight which components could be included in organizational-level
occupational health intervention programmes to enhance intervention effectiveness,
(2) review the empirical support for these components and (3) to discuss where we
have yet to develop our knowledge on how to conduct successful occupational health
interventions.
Reviewing European methods for improving employee health and well-being
To identify methods that describe organizational-level primary occupational health
interventions, seven criteria were used. These were developed based on discussions in
the consortium and within a wider circle of Danish labour inspectors specializing in
the psychosocial working environment (The Psychosocial Taskforce). These labour
inspectors conduct inspections in organizations with a special focus on psychosocial
issues and therefore have in-depth knowledge of the needs of organizations.
The seven criteria that were identified were as follows: (1) Interventions should
focus on organizational-level solutions (primary interventions) aimed at changing
the way work is designed, organized and managed. (2) Participatory principles
should be a core component of intervention. (3) Methods for conducting interventions should systematically consider all phases during an intervention project, from
planning to evaluation. (4) Intervention methods should include considerations of
how organizational-level occupational health programmes may be integrated with
existing procedures and organizational cultures and the management of occupational
safety and health within the organization. (5) Communication/education in and
raising awareness of the risks posed by features of work design, organization and
management should constitute part of the methods. (6) Methods should take into
account the organization’s existing experiences with dealing with psychosocial risk
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factors. (7) Small and medium-sized companies (SMEs) should be able to use the
method.
We sought intervention methods meeting these criteria in a number of European
countries (Norway, Poland, Great Britain, Ireland, Spain, Italy and Germany), thus
providing a good geographical and cultural spread of potential data sources. In some
of the countries, for example, Italy and Poland, no such methods were identified. For
a discussion of approaches at the national level, see Leka, Jain, Zwetsloot, and Cox
(2010).
The following five methods (or models) that met the majority of the seven criteria
were identified: (1) The Risk Management approach developed at the University of
Nottingham, UK (Cox et al., 2000; Cox & Rial-Gonzalez, 2000). (2) The Management Standards, UK, developed by the UK Health and Safety Executive (Cousins
et al., 2004; Mackay, Cousins, Kelly, Lee, & Mccaig, 2004). (3) Work Positive,
developed by the Health and Safety Authority, Ireland and NHS Health Scotland
(http://www.healthscotland.org.uk/workpositive/). The Management Standards and
the Work Positive are closely related and are both based on the Risk Management
approach. (4) The Prevenlab method, Spain, developed at the University of Valencia
(Peiró, 1999; Peiró, 2000, 2006, 2007, 2008). (5) The Health Circles method,
Germany, developed partly at universities in Düsseldorf and Berlin (Aust & Ducki,
2004; Schröer & Sochert, 2000). The Health Circles consist of two different schools
that vary slightly with regard to the focus: In the Berlin model, health circles consist
of employees only, while in the Düsseldorf model both employees and managers
participate. In recent years, the distinction has become smaller and the Düsseldorf
model now dominates. As a result we do not distinguish between the two methods in
this paper (for a detailed review of the differences, see Aust & Ducki, 2004).
Using these five methods we developed a model that presents the important
phases of an occupational health intervention, together with the components that
should be considered under each phase. The model can be seen in Figure 1. The
methods differ slightly in terms of the number of phases and, to some extent, the
components included in each phase. For the purpose of this paper, we chose to
develop an overall model that focuses on five phases.
Validation of the five reviewed methods
In terms of their overall effectiveness, these methods have only been sporadically
validated. Aust and Ducki (2004) identified 11 reports or papers about Health
Circles. Only three studies used statistical analyses to review the outcomes but their
review identified the potential for Health Circles to bring about improvements in the
psychosocial working environment and reduce sickness absenteeism. Reports on the
Risk Management approach show that it has the potential to improve working
conditions, and result in a decrease in absenteeism, intention to leave and symptoms
of stress (Cox, Randall, & Griffiths, 2002). Two doctoral theses have focused on the
Risk Management method; one describing and discussing the scientific implications
of the method (Rial-González, 2000), and another focusing on the evaluation of
intervention initiatives (Randall, 2002). Both of these describe positive outcomes of
the risk management approach. The AMIGO (Analysis, Management, and Intervention Guidelines for Organizations) model which forms the basis for the Prevenlab
has been validated in a doctoral thesis (Chambel, 1998; Peiró & Martinez-Tur, 2008).
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Figure 1. Model of occupational health interventions that shows the five phases of an
intervention and their associated core elements, as derived from five major intervention
methods. Employee participation is important at all stages.
The results indicate that when changes are introduced that are perceived by
employees to be a violation of the psychological contract, the responses are lower
job satisfaction and higher intentions to quit (Chambel, 1998). To the best of our
knowledge there have been no published evaluations of Work Positive and the
Management Standards.
Overall, there is little evidence of which elements in the methods may actually be
important to ensure a smooth and effective intervention process. This lack of
evidence should be seen in the light of three challenges. First, it is a lengthy process
for organizations to conduct organizational-level occupational health interventions,
and thus it will be some time before the results can be analyzed and evaluated.
Second, organizations differ in terms of occupational sectors and within sectors in
terms of organizational cultures, contexts and management structures. Therefore, a
large number of intervention studies are needed in order to reach conclusions on
generalizability of the methods. Third, currently many high impact journals are
reluctant to publish intervention studies, as they seldom follow the ‘‘Gold Standard’’
of experimental design and/or have small sample sizes (Cox, Karanika, Griffiths, &
Houdmont, 2007; Semmer, 2006). In the following, we move away from the overall
evaluation of the methods to highlight the five phases of the intervention cycle and
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their constituent elements as shown in Figure 1, and review the current research
about those elements.
Phases of intervention methods and their constituent elements
A review of the five intervention methods revealed a number of common elements at
the various stages of the recommended intervention process. These included, among
others, the establishment of a steering group to ensure participation, using
sophisticated risk assessment to identify psychosocial risk factors and the development of tailored initiatives to combat psychosocial risk factors.
Some elements were not considered by all methods or the emphasis differed.
These included the importance of considering the context of the intervention and of
reviewing the existing culture and management systems in place to deal with
occupational health issues. Therefore in the remainder of this review we have, for
each component of the process, made it clear which methods emphasize that
component. We also offer a brief review of the research that supports each
component. The components are arranged under headings representing five phases.
However, first we discuss employee participation, which is common to all phases.
Employee participation as a guiding principle
All the methods that we reviewed emphasized the importance of employee
participation. Although participation may vary throughout the problem-solving
cycle, this is vital to the success of occupational health intervention programmes
(Aust & Ducki, 2004; Cox et al., 2000; Cox et al., 2002; Peiró, 1999; Peiró, 2000; RialGonzalez, 2000; Schröer & Sochert, 2000). All methods emphasize the importance of
establishing a steering group composed of both employers and employees as a first
step to ensure participation. The steering group has a number of tasks. These are to
represent all interests in the organization, identify groups at risk (the parts of the
organization that may be of particular need of occupational health interventions)
and set the ethical boundaries (e.g. how anonymity is ensured). They also approve
the assessment strategy, plan and implement a communication strategy, monitor the
risk assessment process, discuss the results before they are fed back to employees and
participate in feeding back information. Steering groups will be discussed further in
the section on the preparation phase.
Employee participation is important for three reasons. The first is that it can help
to optimize the fit of the intervention to the organizational culture and context. This
is because it provides a way of making use of employees’ job expertise and knowledge
of the organizational context; this provides an important supplement to the expertise
of intervention experts (LaMontagne et al., 2007).
The second reason is that it can be viewed as an intervention in its own right.
Several studies have identified that a participatory approach was one of several
working mechanisms that explained the effects of an organizational intervention
(Bond & Bunce, 2001; Heaney, Price, & Rafferty, 1995; Lavoie-Tremblay et al., 2005;
Le Blanc, Hox, Taris, & Peeters, 2007; Mikkelsen, 2005). Participatory action
research treats employees as co-learners in an empowerment process (Mikkelsen,
2005), adding an element of respect, esteem and reward for participants (Andersen &
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Svarer, 2007). Participation by those directly involved is likely to increase worker
control, sense of fairness and justice and support (all of which are working
conditions that have been shown to be linked to employee health). Mikkelsen and
Saksvik (1998) reported that participation led to a change in perceived responsibility;
where employees had felt that ensuring a good working environment had previously
been the responsibility of managers they now realized that they also themselves
played an important role. In a study of two interventions to reduce burnout, Hätinen,
Kinnunen, Pekkonen, and Kalimo (2007) found that a participatory approach
minimized burnout whereas a traditional approach without employee participation
had no effect. Hätinen et al. (2007) and Bond and Bunce (2001) found that increased
job control seemed to be the working mechanism of their successful participatory
interventions.
The third reason is that participation can also smooth the change process and
increase exposure to the intervention. Lines (2004) found that participation was
negatively related to resistance to change, and positively related to achievement of
goals and organizational commitment. Nielsen, Randall, and Albertsen (2007)
showed that influence over the content of an intervention was an important part of
the mechanism that predicted participation in intervention activities (and, in turn,
intervention outcomes such as behavioural stress symptoms and job satisfaction).
The theory underpinning the impact of participation appears strong (Rosskam,
2009).
The impact of participation also extends beyond those directly involved in
intervention decision-making. Park et al. (2004) found that after a participatory
problem-solving intervention in a number of stores all employees in the participating
stores reported improvements in social climate, organizational support and interaction with the supervisor. Participation can also have protective effects during
turbulent times or difficult organizational change processes. The more involved that
employees reported being during the change, the more their managers reported that
the intervention had had an impact on daily work practices (Petterson & Arnetz,
1998). Although causality could not be established, it may be that engaged managers
are better able to involve their employees or involved employees influenced the
managers’ perceptions positively. Similarly, Lines (2004) found that participation was
negatively related to resistance to change and positively related to the achievement of
goals and organizational commitment. In a review of 18 organizational-level
occupational health interventions using participatory methods, Egan et al. (2007)
found that in 12 controlled studies, eight of these found improvements in health and
well-being. Overall, it appears that the use of participatory approaches brings about
positive effects through a number of different mechanisms across a wide variety of
organizational contexts and intervention activities.
Preparation phase
All intervention methods emphasize the importance of the preparation phase.
During this phase organizations become familiar with the method and consultants
learn about the organizational structure and culture. The phase consists of a number
of component elements, as follows.
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Establishment of a steering group
All methods recommend the use of steering groups. These steering groups should
consist of both employer and employee representatives who are empowered to
participate as equal partners in decision-making. Employees, managers, middle
managers and outside experts (occupational health consultants) are all important
members of the such groups because of the complementary skills and expertise they
have (Cox et al., 2002; Schröer & Sochert, 2000). Establishing a steering group
involves identifying key stakeholders and agents to drive all aspects of the
intervention. The steering group should also determine how initiatives may be
planned and implemented. Some methods indicate that, when appropriate, the
development of initiatives will be carried out by the steering group. The steering
group should also monitor the progress of implementation and plan the evaluation
of initiatives and the program itself (Cox et al., 2000, 2002).
There is some research on the importance of steering groups. The lack of an
efficient steering committee to some extent explained disappointing results in a
Norwegian study (Mikkelsen & Saksvik, 1999). Here the steering group failed to
have regular meetings and project participants received little feedback on how to
progress. In another study, Mikkelsen, Saksvik, and Landsbergis (2000) suggested
that part of the reason the intervention programme had only limited impact was
because the steering group failed to take responsibility for action, by sending
problems back to the employee groups without making suggestions or providing
help. This research provides examples of the consequences of malfunctioning
steering groups; the benefits of well-functioning steering groups have yet to be
explored.
Employee readiness for change
Most intervention methods describe the importance of taking into account the extent
to which those involved want, and will accept, change, that is, their readiness for
change. The importance of employee ‘‘buy in’’ is identified in most models.
Developing readiness involves organizational stakeholders learning about the
intervention method (Cox et al., 2000; Peiró, 1999; Schröer & Sochert, 2000). Pryce,
Albertsen, and Nielsen (2006) found that it can take time for the potential benefits of
an intervention (in that case an open-rota system) to be recognized by employees. In
order for participants to welcome change they need to (1) perceive their current
situation as being unhealthy, (2) be convinced that change is necessary and (3) of
benefit, and (4) be motivated to actively work towards the implementation of change
initiatives (Weiner, Amick, & Lee, 2008). Jones, Jimmieson, and Griffiths (2005)
found that a perceived positive organizational culture predicted readiness for change
which in turn predicted usage of a new computer system. Cunningham et al. (2002)
found that a healthy work environment predicted readiness for change which in turn
predicted employees’ participation and active contribution to re-organization
activities. The importance of ‘‘buy-in’’ at all levels has been stressed from the top
level to the shop floor worker (Bourbonnais, Brisson, Vinet, Vézina, & Lower, 2006;
Cox et al., 2002; Kompier, Cooper, & Geurts, 2000b).
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Organizational readiness for change
The Risk Management and the Prevenlab approaches focus on the importance of
organizations having a certain level of maturity (or healthiness) and experience with
organizational-level interventions (Cox et al., 2000, 2002; Peiró, 1999). Organizations
with low levels of employee stress and a good working environment (e.g. in terms of
autonomy and social support combined with low demands) may have better
opportunities to develop and implement intervention initiatives (Taris et al., 2003).
Mikkelsen and Saksvik (1999) reported that employees experienced difficulties in
developing action plans when they had little previous experience of addressing
psychosocial risks: they knew they had a problem but had little idea what to do about
it. A recent study by Nielsen and Randall (2009) found that pre-existing levels of role
clarity, social support and a meaningful work among employees influenced the
degree to which middle managers played an active part in implementing intervention
initiatives. Also, Nielsen and Randall (2008) found that employees’ levels of role
clarity, social support and involvement in the organization predicted the degree to
which employees and middle managers were ready for change. In other words, the
organizational structures and organization of work influence the perceptions and
actions of the members of the organization and thus also intervention outcomes.
This presents a paradox in intervention work: organizations in the most need of
intervention are those least well equipped to design and implement them. Naturally,
the opposite is also true: in a study of human service organizations, Dellve, Skagert,
and Eklöf (2008) found that organizations with systematic occupational safety and
health structures had higher levels of work attendance. They concluded that
problems with occupational disorders must be visible and systematically dealt with
in order to influence employee attendance.
Senior management support
There is also general agreement among the various intervention methods that in
order for an organization to successfully plan, implement and evaluate an
occupational health intervention programme there must be good management
support (Aust & Ducki, 2004; Cox et al., 2000, 2002; Peiró, 2000). Some empirical
studies have validated this recommendation. In a study of stress coping training,
Lindqvist and Cooper (1999) found that when senior management released staff
from their duties to participate in workshops, attendance was 100%, but at follow-up
when staff had to participate during their leisure time, participation dropped to 66%.
Most of the available research evidence focuses on the deleterious impact of lack
of management support for interventions. In a qualitative process evaluation, DahlJørgensen and Saksvik (2005) concluded that lack of support from senior managers
influenced the attitudes of employees. Because managers demonstrated the intervention was an intrusion to their daily responsibilities employees were also resentful.
Saksvik, Nytrø, Dahl-Jørgensen, and Mikkelsen (2002) reported on inadequate
possibilities to engage in participatory workshops due to senior management only
allowing employees time to participate in two-hour workshops. They also reported
on problems with getting temping staff to cover for staff on workshops. The lack of
support from senior management had a ‘‘trickle down’’ effect on the commitment of
middle managers, who reported being unenthusiastic about the programme as they
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were allocated no resources to implement initiatives. In summary, there is
considerable evidence about the negative impact that a lack of management support
can have on interventions. There is less evidence about the positive impact of the
management support component of intervention processes.
Communication
Communication and information are advocated by all the intervention methods as
an important part of the preparation phase. Employees must be informed of the
project in order to facilitate critical success factors such as participation and buy-in
(Cox et al., 2000; Peiró, 1999; Schröer & Sochert, 2000). If good risk assessment
evidence is not available to them, ill-informed middle managers and employees will
try to make sense of events (Weick, Sutcliffe, & Obstfeld, 2005) and invent their own
local theories of justifications for change. These local theories are seldom formally
formulated but will nevertheless drive the behaviour of participants. A study by
Mattila, Elo, Kuosma, and Kylä-Setälä, (2006) found that the participatory
approach did not positively influence health and well-being of employees because
employees were not adequately informed about the intervention programme and
therefore did not see the purpose of participating in it. Laing et al. (2007) found that
without improvements in communication, employees did not report increases in
decision latitude and influence when they were exposed to an intervention. The
positive benefits of adequate information and communication have also been
identified. Nielsen et al. (2007) and Hurtz and Williams (2009) found that perceived
levels of information about an intervention predicted employee participation in
intervention initiatives. The Risk Management approach warns against making
‘‘empty promises’’ to dilute disappointment (Cox et al., 2002). If communication has
raised high expectations among employees but they do not have the opportunity to
participate in initiatives or see any real changes being implemented, employees may
become cynical. This was confirmed in the study by Nielsen et al. (2007), who found
that if employees had heard about the project but not participated in intervention
activities they reported a decrease in working conditions at the follow-up. Laing et al.
(2007) found that a participative approach increased expectations; where these were
not met, decreases in decision latitude were reported.
These results suggest that organizations need to carefully consider their
communication strategies and ensure that there is realistic communication about
expected outcomes and the employees’ role in bringing about these changes.
Drivers of change
The Risk Management approach, Prevenlab and Health Circles rely on consultants
external to the organization as drivers of change at several stages of the process (Cox
et al., 2000, 2002; Peiró, 2000; Schröer & Sochert, 2000). The role of external
consultants may facilitate the process if they possess expertise in process consultation
and knowledge about occupational health issues. Furthermore, as external to the
organization they may be objective and avoid taking sides (Cox et al., 2002). There is
only a small amount of evidence to support the validity of these mechanisms.
Bourbonnais et al. (2006) found that the use of external consultants enabled
participants to translate problems into higher-level constructs that could be dealt
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with more easily. Others have, however, pointed to the dangers of using external
consultants. Dahl-Jørgensen and Saksvik (2005) found that their use meant that the
participants did not feel ownership for the intervention initiatives, making it difficult
to ensure a long-lasting effect.
The Prevenlab method has identified eight competencies that external consultants
should have. These concern change management skills, expert knowledge of
psychosocial risk factors, awareness of regulations and laws, and practical skills to
conduct risk assessment and evaluation (Peiró, 2007). The Health Circles method
requires facilitators to have an understanding of the method, knowledge about the
occupational sector of the participating organization, knowledge of the organization’s structure and experience of process consultation (Aust & Ducki, 2004). To our
knowledge, there has been no systematic mapping of the competencies required of
internal or external consultants.
Screening phase
All methods prescribe that an assessment of the risks is conducted as a means of
informing initiatives. This is to identify the psychosocial risk factors and to get an
overview of the health and well-being of staff. Most often this risk assessment is
quantitative, using questionnaire surveys. In the Risk Management approach,
interviews are conducted with employees and managers and the results used to
tailor the content of a questionnaire in order to make it relevant and usable.
Respondents are then asked to rate whether specific aspects of the working
environment are problematic; these are analyzed in terms of frequency and are
also linked to health and well-being outcomes (Rial-González, 2000). The screening
phase consists of the following elements.
Selection of methods
In the Prevenlab method, a questionnaire consisting of both quantitative and
qualitative parts is used. Employees are asked to describe specific situations that are
of concern and to rate their intensity and frequency (Peiró, 2008). This can
be followed up by further investigations if the picture is incomplete. The Work
Positive method and the Management Standards use a standardized questionnaire
that is designed to apply to any employee regardless of their work situation or the
organizational context. The Health Circles also include organizational absence data
(Aust & Ducki, 2004).
Alternative methods of risk assessment
A vast majority of intervention studies have used surveys to assess psychosocial risk
factors; however, problems with small samples, statistical power and ethical issues
regarding anonymity and confidentiality mean that survey approaches may not be
appropriate in small- and medium-sized enterprises (SMEs). Harris and colleagues
employed cognitive mapping to assess the psychosocial risks in eight organizations
using a card-sorting technique in which participants were asked about the causes and
consequences of negative and positive emotions at work (Harris, Daniels, & Briner,
2002). They concluded that this technique was appropriate for revealing the negative
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emotions experienced at work and their causes in the psychosocial working
environment: it also encouraged employees to suggest ways of improving working
conditions and their current individual coping mechanisms to handle risks.
Auditing existing systems
The Risk Management method also conducts a supplementary audit of the existing
support and management systems (Cox et al., 2000, 2002). In this the activities of
Human Resources, training, and the organization’s occupational health and related
services are audited in order to reveal the activities that they offer to ensure the
health of workers, and how they are used. If services are found to be malfunctioning
these may be targeted for intervention. If they are working well, these systems may
become models, exemplars or delivery mechanism for future intervention activity.
Also, Prevenlab incorporates information on the existing systems, recurrent
organizational changes and the integration of the core task and job design in their
working model (Peiró, 2000; Peiró, 2008). However, the method offers little
information about how this audit should be integrated in the preventive stages.
Both the Risk Management and the Prevenlab models could be said to measure
the organizations’ readiness for change and maturity level. To our knowledge, there
has been no research explicitly examining the effects of conducting such systems
audits.
Feedback of survey and audit results
For all methods a detailed description of how results of the risk assessment (and the
audit of management systems and employee support) is provided that should be fed
back to employees (Cox et al., 2000; Cox et al., 2002; Peiró, 1999; Schröer & Sochert,
2000). Some studies have focused on the effects of risk assessment and feedback in
determining the scale and impact of intervention activity. Eklöf, Hagberg,
Toomingas, and Tornqvist (2004) found that feeding back risk assessment results
to employees led to more intervention activities; however, the effects on actual
changes in the working environment and employee health and well-being were not
examined. The authors themselves report that the number of activities does not mean
that the most appropriate initiatives were developed. In a later study, Eklöf and
Hagberg (2006) significant changes in social support were found where supervisors,
and to a lesser extent work groups, had received feedback on risk assessment results.
Bourbonnais et al. (2006) concluded that the success of a participatory intervention
programme could be partly explained by the feeding back to employees the results of
thorough risk assessment prior to developing action plans.
Action planning phase
Following the feedback to employees, all intervention methods describe a distinct
phase of activity that focuses on the development and implementation of initiatives
to improve the psychosocial work environment and employee health and well-being.
All methods emphasize the importance of prioritization of the problems that have
been identified so that efforts focus on a relatively small number of powerful and
well-delivered initiatives. As already mentioned, most intervention models stress that
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employees should play an active role in developing initiatives, to ensure the use of
their local knowledge. Risk Management and Prevenlab both emphasize the
importance of screening the factors that may facilitate or hinder the development
and implementation of change initiatives (Nielsen, Cox, & Griffiths, 2002; Peiró,
2000, 2008). These two approaches also emphasize the importance of evaluating
previous occupational health intervention programmes to learn from past successes
and failures.
This phase of an intervention includes the formulation of a clear action plan
which clearly states the initiatives that are planned, the targets of initiatives, the
deadlines and the people responsible for driving the initiatives. The Prevenlab and
the Risk Management approach also emphasize that part of the action plan should
include the criteria for success, that is, the examination of whether an intervention
fulfilled its purpose and worked as intended (Cox et al., 2000, 2002; Nielsen et al.,
2002; Peiró, 2008). Part of the action plans developed within the Management
Standards framework and the Prevenlab includes information on how to communicate initiatives and their outcomes. As such communication forms an integrated
part of these action plans.
Developing activities
The various intervention methods suggest that different types of interventions should
be considered during the action planning phase, with the first priority being the
identification of primary interventions whenever possible. The Risk Management
approach and the Health Circles recommend a mix of primary interventions,
secondary interventions (those aimed at giving employees the skills to respond to
stressors) and tertiary interventions (rehabilitative interventions). Hunt et al. (2005)
found that primary and secondary intervention initiatives supported each other such
that when primary initiatives supplemented secondary interventions the uptake at
secondary interventions increased significantly. Similarly, results by Larsson,
Setterlind, and Starrin (1990) suggested that secondary interventions may release
inner resources in employees that can be applied in the outer world, thus leading to
better well-being. For instance, Leppänen, Hopsu, Klemola, and Kuosma (2008)
found that formal training enhanced the effects of a work process knowledge
(knowledge useful for work) intervention. Furthermore, research on action plans
has found that their development may lead to participants questioning existing
routines and ways of doing business and therefore may be effective in making
changes happen (Lavoie-Tremblay et al., 2005). Saksvik et al. (2002) found that some
initiatives were not implemented because action plans had not been properly
developed.
Participatory workshops
The development of action plans is typically done in workshops (Risk Management
approach), focus groups (Management Standards) or in Health Circles (groups
consisting of managers and employees that meet about 610 times over a period of
about 6 months) (Aust & Ducki, 2004; Nielsen et al., 2002;). The Risk Management
(Nielsen et al., 2002) and the Health Circles (Aust & Ducki, 2004) approaches both
emphasize the importance of structured workshops and meetings that are clearly
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distinguished from daily work to allow participants the opportunity to reflect and
concentrate on the development of action plans. Indirect support for this need for
boundaries was found by Dahl-Jørgensen and Saksvik (2005). Management did not
prioritize such meetings but instead held conferences in open rooms where people
would walk in and out and this impaired the commitment of participants and the
development of action plans.
Implementation phase
In the next phase, a number of initiatives are implemented, as follows.
Monitoring
The methods that we reviewed included the monitoring of intervention activities.
However, they offer little description of exactly how this should be done (Cox et al.,
2000; Schröer & Sochert, 2000), only that progress should be monitored and
adjustments made if necessary. This is a problem, because the literature points to the
importance of monitoring whether intervention initiatives are being implemented as
planned. The various methods contain little information about how steering groups
should hand over intervention plans to middle managers.
Drivers of change: middle managers
Kompier, Aust, van den Berg, and Siegrist (2000a) found that in 13 case studies
across Europe, middle managers were responsible for implementing intervention
initiatives. Nielsen and Randall (2009) found that employees’ reports of intervention
outcomes were most likely to be positive when middle managers had taken
responsibility for, and involved their subordinates in, the implementation
of organizational-level initiatives. Laing et al. (2007) and Nielsen, Fredslund,
Christensen, and Albertsen (2006) found that employing engaged and committed
managers during the intervention programme enhanced the positive outcomes of the
programme. Of course, middle managers can also ‘‘block’’ the process: DahlJørgensen and Saksvik (2005) found that middle managers prevented employees
spending time on intervention initiatives.
Communication
Especially, the Risk Management approach emphasizes communication during
implementation. There is some evidence to suggest the importance of communicating
the ongoing progress of implementation of initiatives. Landsbergis and VivonaVaughan (1995) found that while members of the steering group felt the project had
been moderately or very effective, this perception was not shared by those less close
to the epicentre of the intervention and had been little informed about progress: they
believed the intervention programme to only have been slightly effective or even
ineffective. This points to the fact participation is important throughout all phases employees need to be made aware of progress and have their say in the
appropriateness of interventions, including during implementation.
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Evaluation phase
All the intervention methods that we reviewed include some mention of the
importance of evaluation. The Health Circles method includes evaluation of the
views of those employees involved in health circle discussion groups. The Health
Circles and the Risk Management approaches and the Management Standards
include, as a first step, the importance of evaluating whether planned initiatives were
actually implemented (Aust & Ducki, 2004; Cox et al., 2002). If initiatives only exist
as plans that have not been implemented they are unlikely to improve the
psychosocial working environment.
Effect evaluation
Effect evaluation receives less attention in the Health Circles approach than the
satisfaction with health circles themselves (Aust & Ducki, 2004; Schröer & Sochert,
2000). The Prevenlab includes a comprehensive evaluation of the degree to which
initiatives had the intended effect, how the process was perceived by participants, and
organizational learning (e.g. the degree to which the organization has become better
equipped to deal with psychosocial risk factors in the future; Peiró, 2008); it also
considers whether the organizations are continually undergoing change, deliberate or
not (Peiró, 2000). The Risk Management approach heavily emphasizes the
importance of evaluation (Randall, 2002). This approach emphasizes the importance
of effects being measured at several levels, including both proximal changes (in
procedures and working conditions) and distal changes (in levels of absenteeism,
turnover and employee health and well-being). Complex analyses of process and
effect evaluation have been conducted and published in peer-reviewed journals
(Randall, Cox, & Griffiths, 2007; Randall, Griffiths, & Cox, 2005). These include
qualitative evaluation in smaller groups (Randall et al., 2007) and the use of
emergent variability in quantitative research. Intervention initiatives tend not to be
uniformly implemented across employees and therefore can only be expected to
improve the health and well-being of those employees that actually were affected by
them (Randall et al., 2005). It is important to evaluate not only the effects of the
actual intervention initiatives but also the processes which may have facilitated or
hindered their implementation.
Process evaluation documentation
The Management Standards, the Risk Management and the Prevenlab approaches
also consider documentation of the processes. Combining the evaluation of both
process and effect is increasingly being advocated (Egan et al., 2009; Murta et al.,
2007; Semmer, 2003; Semmer, 2006). There is a body of research (primarily
Scandinavian) that has provided evidence for the benefits of integrating process
and effect evaluation to get an increased understanding of why and how
interventions work (Dahl-Jørgensen & Saksvik, 2005; Mikkelsen et al., 2000; Nielsen
et al., 2006; Nielsen et al., 2007; Nielsen & Randall, 2009; Nielsen, Randall, &
Christensen, in press; Pryce et al., 2006). Nielsen, Randall, and Christensen (2010)
presented an evaluation model which examined the intervention process at three
levels: the importance of the organizational context, the documentation of initiatives
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developed and implemented, and the importance of individual appraisals of the
quality of intervention activities.
The importance of evaluating the impact of context is well acknowledged (Egan
et al., 2009; Murta et al., 2007). For the use of context in intervention research the
concepts of omnibus and discrete context may be useful (Johns, 2006). Omnibus refers
to the story told, for example, who are the participants? There is evidence that
intervention activities form a transactional relationship with the intervention
omnibus. In a study by Dahl-Jørgensen and Saksvik (2005), it was found that the
actual requirements of the job (i.e. face-to-face relationships) bound service
providers to the needs of the customer and hindered participation in intervention
initiatives. Mikkelsen and Saksvik (1999) report that finding cover for staff involved
in participatory intervention processes can use up more time and effort than the
development of action plans themselves. Saksvik et al. (2002) found that being part
of a larger organization or having a bureaucratic organization hindered the
development of intervention activities.
The discrete context, that is, specific events that took place throughout the
intervention project, also receives little attention in established occupation health
intervention approaches. Many concurrent events can facilitate or hinder implementation. For example, in one study the introduction of a non-smoking policy
created resistance among participants (Nielsen et al., 2006). In another, threats of
lay-offs distracted the participants’ focus on the intervention project (DahlJørgensen & Saksvik, 2005; Nielsen et al., in press). Egan et al. (2007) found in
their review that where redundancies and downsizing took place at the same time as
participatory intervention programmes, positive effects on employee health and wellbeing were diluted.
Process evaluation emergent variability
The Risk Management approach, the Management Standards and Prevenlab also
consider how intervention activities have been received by participants. The impact
of context raises the important issue of fidelity of implementation processes.
Research shows that the degree to which interventions are actually implemented is
imperative to the outcomes of the intervention. Nielsen et al. (2006) and Landsbergis
and Vivona-Vaughan (1995) found that where few of the planned interventions were
implemented, improvements in psychosocial working conditions and employee
health and well-being were not detected. Nielsen et al. (2007) found that actual
participation in intervention initiatives predicted whether employees reported that
their working conditions had improved at time 2. Randall et al. (2005) demonstrated
that unintended and unplanned variations in intervention exposure explained
differences in health at the follow-up.
Measurement of exposure to an intervention is not an explicit part of the risk
management processes that we identified in our research. Linked to this is the
important issue of participants’ appraisals of intervention initiatives. The way
individuals perceive situations are likely to drive their behaviour (Johnson-Laird,
1983). Oreg (2006) found that the lack of trust in management and that others did
not support change predicted behavioural resistance to change. Randall et al. (2005)
found that the reason middle managers did not communicate changes in procedures
were because they felt the changed procedures would make it difficult for them to
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control their budgets. Nielsen, Randall, Brenner, and Albertsen (2009) found that
employees who had participated in intervention initiatives and found them to be of
value also reported improved working conditions. Bunce and West (1996) found that
positive appraisals of initiatives were associated with higher levels of job satisfaction
and lower levels of stress. In an extension of the study by Bond and Bunce (2001),
Bond, Flaxman, and Bunce (2008) found that among employees who had flexibility
(i.e. employees had the ability to persist with or change their behaviours in order to
achieve their goals) the positive effects of a participatory effect were stronger.
Cynicism due to previous failed projects has been found to hinder successful
intervention projects (Nytrø et al., 2000). Saksvik et al. (2002) and Dahl-Jørgensen
and Saksvik (2005) found that employees were resistant to change because they knew
from experience that although interventions were initiated they were not followed
through and failed to bring about the desired results. This has been termed ‘‘initiative
fatigue.’’
Discussion
This aim of this paper has been to provide an overview of the phases and their
constituent elements as incorporated in major European approaches to organizational-level occupational health interventions. In collaboration with labour inspectors with a special expertise in psychosocial issues, we used seven criteria to identify
methods with may bring about sustainable improvement in the psychosocial work
environment and employee health and well-being. Shared components in the
methods were identified and held up against current research in an attempt to
validate the processes prescribed in these methods. These elements for the most part
received support from research. Although this paper brings us one step further in
how to conduct such interventions, it also highlights the significant gaps in our
knowledge. Below we discuss where more knowledge is needed.
Future directions
In the following, we discuss some issues that we feel need to be addressed in order
move the field of organizational-level interventions forward.
Conducting occupational health interventions to reduce risk or to improve employee
development?
Organizational-level interventions are often referred to as stress management
interventions (SMIs) (Murta et al., 2007; Randall et al., 2005, 2007, Randall,
Nielsen, & Tvedt, 2009); however, in this paper we have adopted the term
organizational-level occupational health interventions. This reflects a need for
intervention goals to be set above and beyond the absence of ill-health (Linley &
Joseph, 2004). Organizational-level interventions may not only reduce ill-health but
can sometimes promote positive well-being at work (Jackson, Sprigg, & Parker, 2000;
Mikkelsen et al., 2000; Sprigg, Jackson, & Parker, 2000). Approaches to interventions need to offer explicit guidance for organizations about how change may bring
personal growth, engagement, and positive affective well-being (Bakker & Schaufeli,
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2008; Hackman, 2009; van Horn, Taris, Schaufeli, & Schreurs, 2004). Many of the
methods examined in this paper provide some mention of the importance of
the positive aspects of work, but give little information about how they can be
incorporated into an intervention strategy (Cox et al., 2000; Peiró, 2008). This focus
on problems with health and work is also reflected in the language of these methods
such as ‘‘stress,’’ ‘‘risk assessment,’’ ‘‘risk analysis’’ and ‘‘prevention’’; more work is
needed to test and describe intervention frameworks that include the positive aspects
of work, and employee development and engagement.
Employee participation
While employee participation constitutes a central part in all methods, and is generally
recommended in the literature (Egan et al., 2007; Rosskam, 2009), there is still a need
to explore the form that participation should take. During the preparation phase
employees should play a role in planning the project, whereas in the risk assessment
phase participation may be limited to responding to questionnaires or, in the action
planning phase, to prioritizing and planning interventions. However, although
participation is generally thought to be a good thing, more research is needed to
better understand why and when participation works. A recent study by Nielsen et al.
(2006) found that where employees were unaccustomed to dealing with occupational
health issues a more directive intervention process seemed to be more effective than a
participatory approach.
Joint ownership of problems and solutions is an important part of participation
that is rarely discussed. When external consultants play a part in the intervention
process, dealing with occupational health issues must become part of daily practice
for employees to ensure that responsibility for the intervention is not shifted to the
external consultants. This establishes a feeling of joint responsibility and minimizes
the risk that the process will stagnate when the external consultant leaves the
organization. This approach to participation also helps to ensure that empowerment
and learning are integrated in the organizations’ daily practices.
An over-dependence on ‘‘drivers of change’’ can also leave the intervention
vulnerable. Intervention programmes that depend on middle managers are vulnerable to changes in management personnel, since newly appointed managers may not
feel responsible for the project (Dahl-Jørgensen & Saksvik, 2005; Mikkelsen &
Saksvik, 1999; Nielsen et al, 2006). Through the participatory processes, joint needs
should develop so that intervention programmes will be less dependent on
individuals and have a better chance of bringing about sustainable changes.
The use of occupational health professionals
The methods described in this paper focus heavily on the use of external consultants;
however, it should be examined whether this is always necessary. Small and medium
enterprises (SMEs) may have neither the resources nor the interest to employ such
consultants and because large organizations may already have in-house resources
that may take on the role as facilitator. It should be possible to map the competencies
required by these facilitators so that those wishing to be involved in implementing
an intervention can be trained. The ethical issues regarding bias, power and
confidentiality are somewhat different and perhaps more challenging for those
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working within the organization than external consultants, and may therefore require
careful selection and training of those leading intervention programmes. Although
both the Risk Management approach and Prevenlab point to certain competencies
being needed, no research has been conducted to validate these suggestions.
Validating which competencies are required should result in a mapping tool that
organizations could use to identify people within the organization who might take on
this role.
Risk assessment
Most screening methods focus on using questionnaires. Although these have many
advantages, disadvantages, (e.g. their lack of suitability in SMEs) must also be
acknowledged. For practical and ethical reasons, new tools should be developed that
capture important data throughout the intervention process. Standardized questionnaires make it difficult to interpret the results since normative interpretation does
not always identify the need for the intervention and fails to consider the specific
organizational context. For example, white collar workers traditionally have more
influence and control than blue-collar workers and therefore employees in a whitecollar organization may experience problems even if their questionnaire results
compare favourably to the national average. For a discussion of which factors should
be assessed see Nielsen, Taris, and Cox (2010).
There is a need to explore alternative risk assessment tools for several reasons.
First, problems exist with translating the results of standardized questionnaires to
concrete initiatives. Second, many current questionnaires fail to consider the
importance of individual appraisal. Harris and Daniels (2007) provide powerful
evidence that it is not the objective working environment that influences employee
well-being but how individuals appraise the working environment. The importance of
appraisals is crucial in dominant theories of (1) work stress (Lazarus & Folkman,
1992), (2) sense-making in determining behaviour in organizations (Weick et al.,
2005) and (3) theories of planned behaviour (Ajzen, 1991). Third, survey methods
are not appropriate in SMEs for ethical and statistical reasons. Alternative methods
that integrate dialogue methods may offer a way forward while also taking into
consideration the social, regulatory and professional conditions of SMEs. And
fourth, there is a need to explore the interplay between risks (problems) and
resources (opportunities). Most of the above methods pay little attention to how the
organizational and individual resources may be best employed to minimize risks and
ensure individual well-being and growth. For example, the audits of organizational
support systems have not been scientifically validated, nor has it been extensively
discussed how such audits may be used in preventing risks and developing
employees.
Maturity and ceiling effects: intervening in sick or healthy organizations?
Previous research has found that organizations with little experience of, and few
formalized systems for, dealing with occupational health issues struggle to implement
organizational-level occupational health interventions that bring about the desired
outcomes. On the other hand, organizations where employees report good working
conditions and employee health and well-being due to well-developed occupational
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health practices in their daily business may benefit only marginally from organizational-level occupational health intervention programmes. While both the Prevenlab
and the Risk Management approaches emphasize the importance of taking into
consideration systems that already exist within the organization to deal with
occupational health issues, they fail to consider whether organizations are ready
for intervention programmes.
It may be useful to develop an initial screening tool that determines whether or
not an organization would benefit from participating in an intervention programme,
and what measures need to be put into place to make it ready for intervention. The
maturity of an organization is only likely to reveal itself during the risk assessment
process, by which time researchers have already invested so much time and effort that
they cannot turn away from the organization; expectations will have been raised
among employees about the programme such that it may have negative consequences
if risk assessment is not followed by initiatives to improve the working environment
(Nielsen et al., 2007). This situation may require a re-consideration of the suitability
of the criteria for success, with modest goals being set and more sensitive evaluation
methods being used.
Organizational-level occupational health interventions may take some time to
exert a significant effect on working conditions and well-being (Landsbergis &
Vivona-Vaughan, 1995; Mikkelsen, 2005). Before these effects are apparent,
organizations may start communicating with employees in different ways and have
a greater focus on occupational health issues, and employees may start feeling more
empowered to deal with such issues. There is a need for researchers to evaluate these
issues as well. Rather than concluding that an intervention was ineffective,
programmes should include the evaluation of micro-level changes or proximal
measures (rather than distal measures), such as improved communication to
employees about occupational health issues and empowerment. Changes in distal
measures should always be linked to changes in proximal measures; that is, the
procedures targeted by intervention activities should change in such a way that
changes in distal measures are in fact the result of the intervention. The lack of
published evaluation of changes in empowerment is curious, considering the
recommended use of participation in the methods we reviewed, where the aim is
to empower employees.
Occupational health and its links to daily performance
To date too little attention has been paid to how we may integrate occupational
health interventions into daily work practices. Occupational health interventions are
often seen as something separate from running the daily business and ensuring high
performance (that is, as a ‘‘nice to have’’ rather than as integral to the effectiveness of
the organization). There are powerful arguments for organizations to pay special
attention to occupational health issues. Bambra, Egan, Thomas, Petticrew, and
Whitehead (2007) concluded in their review that where task restructuring interventions were implemented with the sole purpose of improving performance, they had
no or detrimental effects on employee health and well-being. The effects of poor
employee well-being on organizational performance have been confirmed (Taris &
Schreurs, 2009; Wright & Cropanzano, 2000). Also, in many studies on occupational
health interventions, organizational changes and restructuring have taken place that
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have blunted the effects of the intervention. This is increasingly the case when the
intervention is not integrated into daily business and as such becomes more
vulnerable to organizational change. It is important to (a) develop tools that can
evaluate the ‘‘true’’ effects of occupational health interventions and separate them
from contextual ‘‘noise’’ and (b) develop strategies for better integrating occupational health intervention programmes into daily business.
Improving employee health and well-being: the responsibility of the organization?
Since the 89/391/EEC Framework Directive (EU-OSHA, 2002), employers across the
European Union have a legal obligation to assess and manage all workplace risks,
including psychosocial aspects. However, it is widely acknowledged that this is
challenging. According to the European Survey of Enterprises on New and Emerging
Risks (ESENER; EU-OSHA, 2010), only 26% of establishments in the 27 member
states of the European Union (EU-27) report having procedures in place to deal with
work-related stress. Higher prevalence is reported in larger establishments, and these
more formalized procedures are widespread in only a few countries; the highest
frequencies are reported in Ireland, the United Kingdom, the Scandinavian countries
and Belgium.
National and EU initiatives may increase organizations’ motivation and ability to
conduct organizational-level occupational health interventions. It is precisely in three
of the countries that report the highest prevalence of formal procedures that
examples of these initiatives are found: the UK’s Management Standards and
Ireland’s Work Positive initiatives, where inspection bodies have provided guidance
on how to improve employees’ health and well-being, and the ‘‘Prevention Packages’’
that are currently being developed in Denmark. Following the work of the Danish
consortium described in the introduction, the NRCWE and the Danish Working
Environment Authority are jointly developing ‘‘Prevention Packages’’ that consist of
occupational health intervention programmes. Organizations can apply for funding
to conduct these interventions. The projects will be scientifically evaluated using
process and effect evaluation. Such initiatives may provide financial incentives for
organizations at the same time as providing structured guidance for the content and
process of occupational health interventions. An added advantage is the built-in
evaluation which ensures that initiatives are properly evaluated.
The fact that national labour inspectorates are behind these initiatives should
represent a significant incentive for organizations, given that among those establishments that report having procedures in place to deal with work-related stress, by far
the most cited reason for addressing psychosocial risks, with an EU-27 average of
63%, is ‘‘fulfilment of legal obligation’’ (EU-OSHA, 2010).
Limitations of this review
In this paper, we have focused on five major approaches to improving the
psychosocial work environment through organizational-level interventions. This
has the advantage that we have been able to systematically review the various phases
of those major approaches. However, this also has its limitations: First, we only
reviewed four methods. It is likely that other approaches may also contribute to
existing knowledge on how to improve the psychosocial work environment. For
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instance, approaches from countries not reviewed by the Danish Consortium of the
NRCWE and the Danish Working Environment Authority, or approaches that
are less widespread, may provide valuable knowledge not covered here. That is, the
approaches that we covered may have ‘‘blind spots.’’ Second, we used a number of
criteria to select the methods that we reviewed, with the overarching principle being
methods having a focus on participation and organizational-level interventions. It is
likely that other methods exist that may also improve employee health and well-being
that have not been covered here. Furthermore, the gold standard in organizationallevel occupational health intervention research is still the (quasi-)experimental study
design. We chose not to engage in a discussion of research designs, as this has been
extensively covered elsewhere in recent years (Semmer, 2003, 2006).
Conclusions
In this paper, we have presented the main phases of an intervention and their
constituent elements as identified by five major European approaches to systematically planning, implementing and evaluating organizational-level occupational
health interventions. We have also reviewed the existing research supporting the
appropriateness of these elements and suggested avenues for future research.
We believe that this paper has two important implications: First, the major
approaches all share a set of core elements across the European borders that are
emphasized in these approaches as being essential to ensure employee health and wellbeing. There seems therefore to be a certain consensus regarding the elements that
constitute a systematic approach, even if these elements weigh differently across the
approaches. Second, it would appear that although the approaches themselves have
only been sporadically evaluated, current research supports these elements. We found
support that a vast majority of the core elements identified are important in ensuring
a good intervention process, leading to improvements in employee health and wellbeing. Some studies investigated the absence of these core elements (e.g. senior
management support and the use of a steering group).
Overall, our knowledge is developing as regards which processes of organizational-level interventions may help to ensure successful outcomes. However, more
research is still needed to explore how these factors may be best exploited to improve
the work-related health of employees.
Acknowledgements
The authors would like to thank José Marı́a Peiró for providing information on the validation of
the Prevenlab method and also colleagues from the National Research Centre for the Working
Environment and the Danish Working Environment Authority, who as members of that
consortium have been involved in the discussions on the methods reported in the Danish reports.
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