The diagram shows an obvious connection between the work schedule and the perceived health protection (e.g. shift work leads to a poor level of perceived health protection). However, it also indicates that the individually estimated degree of freedom ('autonomous decision making') in work has an even greater effect, as it acts not only directly on the perceived health protection, but also indirectly through an influence on working time. The latter suggests that employees perceive the possibility of influencing their own working time as an important part of their work autonomy. If decision latitude within the specific work task is restricted, due to mechanical alignments or customers (e.g. in call centres) then the ability by individual employees to influence their shift plans, holidays or start and finish times becomes even more important. Work autonomy is equally important for blue collar workers as for white collar workers, only in a different way.

The second major factor influencing perceived health protection is job security and being informed about the company's strategy. Work autonomy and transparency are important factors shaping health perceptions - the connection has been long understood (Karasek, 1979): Personally important circumstances that are unknown and cannot be controlled cause high levels of stress – which is a reason for many psychological and physical illnesses. Finally, the diagram shows the major impact a direct supervisor's behaviour has on employees' work autonomy and job clarity and therefore on their perceived health protection. Effectively, the health protection perceived by workers depends to a very high degree (62%) on their supervisor's behaviour.

A close correlation has been made between employee perceptions of their health protection and actual sickness rates. This was revealed in a comparison of sickness figures with employees' responses in structurally comparable business units at Bertelsmann. Moreover, it also matches the long-time observation of Ilmarinen (2005) that the direct supervisor exerts a crucial influence on the long-term work ability of employees.

Addressing health in EfH employee surveys

Based on these findings, a number of member companies of the Enterprise for Health network formed a working group to seek ways to broaden their survey instruments to include more outcome-related aspects of health, as a step further towards improving health management for their own organisations and others.

The group’s overall objective is to:

• work out the key dimensions or aspects of health that should be included in a general attitude survey, based on the WHO broad definition of 'health' as 'a state of complete physical, mental and social well-being'
• suggest/provide a pool of corresponding items for companies to use in their surveys, which would also allow informative comparisons between company results.

The working group identified the need to:

• position the topic
• start a communication process
• provide an early indicator 
• initiate a process of improvement
• prepare further analyses, promote the business case

Apart from the signalling function and the communicative effect of an explicit 'health category' in a survey, subjective estimations or the anticipation of individual health can contribute to indicate potential diseases, thus facilitating the implementation of prevention and intervention measures. However, we need to be aware of the general limitations with respect to the validity of subjective ratings: evidence from empirical findings, as well as from company experience, show that a specific group of individuals - mainly younger, highly-motivated employees and those in senior positions - tend to report actual good health and low strain in specific health or stress questionnaires although they are actually highly stressed and have a poor work-life balance. This effect, though, may be reduced by asking for anticipated future work ability. After all, the additional assessment of subjective estimates of the individual state of health or well-being provides valuable complementary data with regard to the prediction of presenteeism or future illness, and leads to valuable results, above all if it is combined with further objective measures, such as e.g. medical data.

Main topics in current company surveys

A review of employee attitude surveys in EfH member companies showed a largely common structure, with similar categories, questions and scales relating to specific subjects, such as leadership, organisation and personnel development. Many questionnaires also contained items relating to health or its determinants, but in the majority of cases there was no explicit, visible section that gave due recognition to the relevance and importance of the topic. In these surveys, the field of health was represented rather indirectly, with questions scattered under different headings, such as job satisfaction, company values, working conditions.

Examples:
• Job satisfaction (‘My present job is mentally taxing and causes stress.’)
• Values (‘Much emphasis is placed on people and their well-being.’)
• Job and working conditions (‘How satisfied are you with the protection against work-related health issues?’)
• Company (‘How satisfied are you with the balance between your private and  
 professional life?’)

Going forward, more companies are increasingly using dedicated health questionnaires, partly derived from standardised scientific instruments (such as the General Health Questionnaire or the Copenhagen Psychosocial Questionnaire COPSOQ as a stress-strain measure) and subsequently adapted to the specific company.
The most common sections cover

• state of health
• frequency of doctor's appointments
• physical complaints/disorders
• stress-related symptoms / strain
• well-being
• work ability (coping with physical/psychological demands)
• lifestyle habits
• satisfaction with work-life balance
• response to workplace pressure ('How have you felt…?')
• work-related well-being ('I feel physically or emotionally drained at the end of the working day.')

Results of the EfH working group

Based on information gained with the present instruments, enhanced by current theoretical concepts and modern research analysis, the working group has highlighted four essential fields of health to be considered in a survey. They are highly significant for employee and company well-being and performance, suitable to be addressed within an organisational context and therefore expected to provide additional value for diagnostic and intervention purposes.

They are:

• general health
• work-related health and well-being
• (future) work ability
• health-related services.

General health

An obvious question to include relates to the employee's perception of his/her state of health (e.g. degree of agreement with the statement 'My present state of health is good'). Special reference can be made to the state of physical and mental health, compared with personal optimum or peers.

(Future) Work ability 

Within the concept of work ability, defined as the ability to cope with physical and mental work demands at a given time (elaborated by H.M. Hasselhorn, chapter 3 in this booklet), health is an essential prerequisite. Responses to suggested questions such as 'Based on my present state of health, I will be able to perform my present work in the next two years', indicate whether the worker expects to be able or unable to cope with future demands because of anticipated personal poor health or because there is something in the work environment which the employee fears will damage his/her health if unchecked.

Work-related health and well-being

It is referred to the perceived impact of work as a whole or of specific working conditions on the individual health state. Work influences be can either positive (salutogenetic effect) or negative (damaging effect). For example: 'I can do my job without impairments to my health', or specifically, related to personal burnout: 'I feel emotionally empty in my work'; 'I feel inspired by my work'.

Health-related services

Here the survey asks employees how they view the company's commitment and willingness to invest in health.

• General (e.g. 'My company is concerned about my health.')
  • Health protection (e.g. 'My company takes measures to protect me from adverse work-related (physical and mental) health effects.')
  • Health promotion (WHP); e.g. lifestyle-related measures: 'My company supports me to maintain a healthy lifestyle'.
  Personal lifestyle is an important health determinant. Habits and behaviours such as physical exercise, nutrition, coping with stress play a crucial role in the development of various diseases. According to WHO estimates (2006), about 80% of cases of chronic diseases (e.g. coronary heart disease) could be avoided if we took better care of ourselves. Consequently, many companies have adopted measures to influence their employees' lifestyle, through facilities such as company sports, medical check-ups, healthy food etc. It is obvious that the promotion of a healthy lifestyle cannot be restricted to individuals in their private lives but must form part of a corporate health strategy.

Response scale of items

It is suggested to phrase items as personal statements, with a Likert 5-point response scale:
'I strongly agree – I agree – partly agree/partly disagree – I disagree – I strongly disagree'
In order to increase personal involvement and practicability the scale contains a 'neutral' response category (partly agree/partly disagree) which is an option for people who are undecided.

Recommendations

The following is recommended if you/your company are willing and in a position to start and maintain a continuous communication and improvement process to explicitly position employee health as a field of interest and action ('your health matters to us…').

1. If you intend initiating this process, four aspects of health are highly relevant (see descriptions above):
   - the personal general health and well-being status
   - the relationship between work and health (work-related health)
   - the future (health-related) work ability
   - the satisfaction with health-related services provided by the company
2. All of the four above described aspects of health can be assessed individually or in combination. Which constellation you use depends on
   - how intensively you intend to organise the subsequent communication and improvement process and
   - how open and well prepared the organisation is
3. The inclusion of health items in a general employee attitude survey above all can help to position the topic and start the communication process. At a later stage of the process, more health-specific information is needed. Thus, the function and layout of the general survey needs to be prepared with follow-up data-gathering and communication exercises in mind.
4. A separate, highly-visible 'health' section, introducing and highlighting the relevance of the topic and ensuring confidentiality, should be included.
5. The assessment of employees' health in relation to various work factors can be organised in an indirect or direct way. Questions about the perceived influence of work on health implies a certain preparedness on the part of the company to further analyse the conditions or to take action if necessary. Questions about satisfaction with health-related services are a less direct approach to health, as the topic depends on company circumstances.
6. At the beginning of the process of including health in a survey instrument, the combination of two aspects is recommended:
   - satisfaction with health related services (which clearly signals the company’s commitment), and
   - future work ability (which serves as an early signal of a possible mismatch between work and personal health).
7. Further down the line, general and work-related health questions can be added, bearing in mind the following:
   - Some employees may be sensitive to questions which appear to link individual health to work performance. The topic should therefore be adequately introduced before being adopted, or be embedded in a specific set of questions.
   - Many of the traditionally-used questions concerning satisfaction with important workplace factors (such as leadership style, work organisation, career development, work climate etc.) may also reveal some information about the relationship between work satisfaction and health, because of the link between the two. Specific items concerning work-related health can be added to a questionnaire to obtain an indicator for the subsequent application of specific, standardised surveys or screening instruments (which are available in a great variety, in the fields of stress, strain, physical complaints etc.)
8. Questions regarding satisfaction with health-related services and the relationship between work and health both have a positive and a negative dimension: Many questionnaires focus on the negative dimension only. It is recommended that the positives be included as well, as it will lead to a more 'balanced' communication about the issues at stake and has a direct health-promoting function and a salutogenetic impact.
9. It is recommended that general data analysis is to identify relationships between drivers of health at work and health as an outcome. These results can provide important advice for further exploration and be used to initiate a comprehensive communication and/or intervention process.

Conclusion

The EfH working group has drawn up a list of questions covering the four key areas referred to above and recommends the inclusion of at least one item to represent each area in general employee surveys. Responses in these areas might indicate a need for intervention activities. Specific instruments may later be combined to conduct a more in-depth analysis.

The EfH working group strongly recommends that companies and organisations enhance their employee surveys by explicitly including the topic of health, thereby gaining knowledge about related organisational characteristics as well as business results and indicators for adequate intervention and prevention. This would represent a significant step up from basic satisfaction surveys, it demonstrates a caring approach, provides the company with a better understanding of workforce issues and establishes a platform for improvement actions. The results should reinforce the need to integrate comprehensive health management into the corporate culture.

(1)
Conducted in 2002 with over 50,000 and in 2006 with over 64,000 data records. The degree of autonomy represents quite a significant health factor as well as an identification factor, the latter influencing in turn motivation, work productivity, work diligence etc.

(2)
http://www.inqa.de/Inqa/Navigation/root,did=232344.htm#233072

REFERENCES

Badura, B., Greiner, W., Ueberle, M., Rixgens, P., Behr, M. (2008). Sozialkapital: Grundlagen von Gesundheit und Unternehmenserfolg. Springer, Berlin, Germany, pp.107 ff.

BKK Bundesverband (2006). Gesundheitsreport 2006: Demografischer und wirtschaftlicher Wandel – gesundheitliche Folgen.

Ilmarinen, J. (2005). Towards a longer worklife: Ageing and the quality of worklife in the European Union. FIOH, Helsinki, Finland.

Karasek, R.A. (1979). Job Demands, Job Decision Latitude, and Mental Strain: Implications for Job Redesign. Administrative Science Quarterly, Vol. 24, No. 2, pp. 285-308.  

Kristensen, T.S, Hannerz H., Høgh A., Borg V. (2005). The Copenhagen Psychosocial Questionnaire  (COPSOQ) - a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health.;31:438-449.

World Health Organisation Europe (2006). Tackling Europe’s major diseases: the challenges and the solutions. Fact sheet Euro/03/06. Copenhagen.