At the start of the new millennium, technological innovation and social transformations are leading to rapid changes in the workforce and the types of occupational risks. The protection of workers' health at the workplace therefore requires a re-orientation of research in this field in order to respond to the growing and varied requirements of prevention.

This need has also been reported by international organisations such as the European Commission (as in a 1995 report), and in the document "Occupational Health for All" produced by the WHO Collaboration Centres in the occupational health sector.

Over recent years, wide-ranging initiatives have been conducted in some countries in order to identify and orient the demand for research in the sector on the basis of a priority-identification system. The initiative of the US National Institute of Occupational Safety and Health (NIOSH) is of particular interest; through a programme of numerous debates among the experts themselves and with representatives of the social partners with regard to American labour, 21 priority research areas for the protection of workers' health and safety at the workplace were identified.

Up to now, the results already achieved by the programme co-ordinated by the NIOSH, known as the National Occupational Research Agenda (NORA), have allowed for a more rational re-allocation of the resources available for research in the sector, as well as the development of a greater synergy by all the parties involved in order to identify and achieve the priority objectives in the safeguarding of occupational health.

In Europe, we should recall the study conducted by Professor J.M. Harrington in the UK. This study shows methodological differences compared to the NIOSH research. Occupational physicians from both the universities and private enterprises were contacted using the Delphi technique, with questionnaires being sent in two stages. In the first stage, there was an open request to the interviewee to state which of the three OSH sectors required research priority. On the basis of the results, the areas most frequently indicated in the responses were identified, and these were then inserted in a new questionnaire. The interviewees were then ask to assign points to each area in order of priority.

A subsequent extension of the study, conducted with the same methodology, enabled researchers to identify the priorities within sector according to the employer viewpoint.

The scientific nature of the method used and the wide-ranging participation of all the parties involved provided a model for the ISPESL study.

We should also recall a very recent survey by Professor E.B. Macdonald and collaborators in the UK; on the basis of a Delphi questionnaire, divided into two stages and sent to the members of the European Association of Schools of Occupational Medicine (EASOM), the Occupational Medicine Section of the Union of European Medical Specialities (UEMS) and the European Network of Societies of Occupational Physicians (ENSOP), the questionnaire led to the identification - on the basis of the answers provided by qualified experts from all the European Union countries - of the common basic skills that occupational physicians in Europe should have.

PROCEDURE

The ISPESL, as the national research institute and reference centre for the National Health Service regarding the safeguarding of health and safety at the workplace, as well as the Italian reference institution for the European Agency in Bilbao, aimed at identifying and ranking the research demand in this sector in our country. In conducting this study, the ISPESL utilised the experience accrued in the research initiatives mentioned above, also actively involving their promoters.

The methodological approach was chosen on the basis of the particular situation in Italy.

In identifying qualified interviewees, it was decided to involve two main areas operating daily in the OSH sector in Italy, with partially different approaches and aims. On the one hand, there are the university chairs and institutes in occupational hygiene and medicine, represented by full professors, associate professors and researchers, who produce most of the research in the OSH sector.

On the other hand, there are the Local Health Agencies (ASL), represented by the Directors of the Departments of Prevention, working on a day-to-day basis on the local level in surveillance and checking of workplaces. We should also recall that in many Local Health Agencies there are active research groups financed on the national and/or regional level.

Social partners were also involved, on the basis of the specific role they play in this context.

The survey was conducted using a questionnaire, with the Delphi technique. This consists in contacting (in a series of cycles, each based on the results of the previous one) experts in a given sector as qualified interviewees, trying to identify consensus on a topic by the convergence of the opinions expressed.

In the case concerned, two cycles (or stages) of sending and retrieving specially produced questionnaires were considered to be enough. In the first stage, each interviewee was asked to identify - by an open question - three areas, which in their opinion were a priority research topic in the OSH sector. On the basis of the responses received, a second questionnaire was drawn up, showing the answers given most frequently in the first stage, grouped by thematic area.

The processing of the data of the first stage led to the formulation of a single questionnaire for the Local Health Agencies and Universities, since the most frequently reported topics coincided. The latter was sent to the same interviewees, asking them to assess each of the items shown, assigning points ranging from 1 (lowly relevant) to 5 (highly relevant). The feedback for this second stage was processed separately for the University Institutes and Local Health Agencies, defining the corresponding master lists according to the order of priority identified.

The involvement of Social Partners were preceeded by a meeting with qualified national representatives. They were entrust with the identification of experts successively included into the study. The last one was carried out with a methodology similar to the one used for the Universities and Local Health Agencies, leading to the identification of 20 areas ranked by priority.

RESULTS

Out of the 300 questionnaires sent to specific persons in the group including the University Institutes and Local Health Agencies (131 people among full professors, associate professors and researchers as well as 179 Directors of Prevention Departments) over half were filled in and returned for the first stage. In this stage, the response rate was higher in the Universities (70% and more) compared to the Local Health Agencies (not over 50%). In the second stage, the percentage of responses was on the whole higher (75%) compared to the first stage, almost equally distributed between Universities and Local Health Agencies. A total of 203 'stage II' questionnaires were available for the analysis of results.

As we can see from the priority lists shown below (Tables 1 and 2), the survey results first of all show that for the Local Health Agencies and Universities, the broad area directly concerning the methodological approach to research in the sector has priority. This includes numerous aspects, ranging from worker training, the problem of quality in occupational medicine, the development of methods and indicators to identify risk exposure and precocious effects to the problem of optimising prevention and safety services at the workplace.

The broad sector of identifying the mechanisms of action of risk agents then followed (a premise for the development of sensitive and specific indicators for exposure/effect).

Least important were the priorities in areas related to the assessment of single occupational risks or topics regarding single occupational sectors.

With regard to the individual thematic items, top priority is assigned to occupational carcinogenesis and quality assessment in occupational medicine, for which there follows a more detailed comment by two Italian experts in the sector.

Other priority items are the problems linked to research on the health impact of exposure to low doses of environmental pollutants and multiple exposure to several risk factors (an aspect especially stressed by University Institutes). Among the top items, there is also the development of approaches and methods for an effective, correct and adequate worker training, as well as their effective participation in prevention activity (a problem most highlighted by the Local Health Agencies).

As already mentioned, items such as single risks, diseases or working areas were assigned lower priority. Nevertheless, the same item is often assessed differently by the University Institutes and the Local Health Agencies.

For example, the topic of individual susceptibility to the action of risk factors is considered to have quite high priority by the University Institutes (perhaps because it directly involves techniques and methodologies typical of advanced biomedical research), ranking in 5^{th place, while for the Local Health Agencies it ranks only 24th.}

Another example is the problem of load handling at the workplace, quite relevant for the Local Health Agencies (13th place), much less for the University Institutes as a whole (26th place).

In general, with respect to the Universities, the LHA Prevention Departments are more in favour of orienting research activity to topics like quality assessment, worker training, prevention services, labour accidents and the topic of load handling.

On the other hand, for the University Institutes, topics like individual susceptibility to risk factors, occupational exposure to chemical pollutants and occupational diseases of the respiratory tract (in particular asthma) are considered to be more relevant for the development of research with respect to the views of the Local Health Agencies.

With regard to the answers provided by the Trade Unions (the data in tables 3 and 4 are derived from the processing of these responses), the examination of the 30 'stage II' questionnaires received confirms the priority role of the occupational cancer sector (ranking in 1st place) and training (sharing 1st place), as well as considerable concern for the problems regarding work organisation and the new types of work.

Among the production areas requiring priority research commitment in the OSH sector, the Trade-Union Organisations indicate small-sized enterprises.

In agreement with the Directors of the LHA Prevention Departments, occupational accidents are considered to be a priority research area.

Table 1. Research areas with overall identification according to the order of priority, as derived from the results of the questionnaires submitted by Professors and Researchers of the University Institutes for Occupational Medicine and by the Prevention Departments of the Local Health Agencies.

Table 2. Research topics with overall identification according to the order of priority, as derived from the results of the questionnaires submitted by professors and researchers of the University Institutes for Occupational Medicine and by the Prevention Departments of the Local Health Agencies.

* (elderly, minors, disabled people)

Table 3. Research areas with overall identification according to the order of priority, as derived from the results of the questionnaires submitted by qualified interviewees indicated by the Trade Unions.

* The score of the macro-sector is calculated as median of the single variables included in the macro-sector itself.

Table 4. Research topics with overall identification according to the order of priority, as derived from the results of the questionnaires submitted by qualified interviewees indicated by the Trade Unions.

For the two topics to which priority was assigned, occupational carcinogenesis and quality in occupational medicine, experts in the sector were contacted in order to obtain an assessment of the perspectives for the development of research in the sector.

OCCUPATIONAL CARCINOGENESIS

Vito Foà, Professor of Industrial Hygiene
Department Clinica del Lavoro “Luigi Devoto”, University of Milan

Pietro Apostoli, Chair of Industrial Hygiene, University of Brescia
Silvia Candela, Prevention Department, Azienda USL Reggio Emilia (Reggio Emilia Local Health Agency)

The promotion and formal recognition of the competence of parties providing services, including health-care services, are related to the need to improve and guarantee the quality of the services and to regulate competition. Forms of guaranteeing the quality of services provided (certification, accreditation) will be indispensable in order to continue working in certain sectors in Italy and in the other European Union countries. The procedures will be governed by the rules of specialised bodies (ISO, UNI) or by actual legislation such as the national and regional laws on the accreditation of hospital facilities. In the specific area of the protection and promotion of workers' health, the recognition of competence is also stimulated by the need, increasingly felt by enterprises that have already obtained the certification of their products or services, to maintain the so-called 'quality chain'. This is the assurance that all the parties (contractors, sub-contractors) that the enterprises work with also respect quality standards.

In dealing with the topic of quality in occupational medicine, there are some special aspects that must be focused in order to allow appropriate intervention by those who will deal with the verification and certification process.

First of all, we should recall the number of parties involved, all having legitimate but not necessarily coinciding interests and expectations, such as workers, employers, company managers and shareholders, the authorities and supervisory bodies, public opinion, customers and contractors, insurance companies. According to the most widespread certification models, workers and public and other supervisory bodies could be identified as customers, the employer as contractor, and the occupational physicians or facilities providing checkups, instrument checks and analyses as sub-contractors.

Another major element is the variety of clinical facilities, instrument diagnostics and laboratories providing the services and which may include private health-care facilities, public hospitals and local public agencies, Universities and Research Institutes, and with a significant 'independent professional' component often represented by individual physicians.

Finally, there are some critical aspects closely regarding the activities undertaken by occupational physicians. They may come under external constraints such as legal obligations (Presidential Decree No. 303/56) requiring them to make checkups at a rate established on an a priori basis without taking risk levels into account. Sometimes "social" constraints are involved (agreements between the parties for providing additional health-care services) justified not by proven occupational risks but rather by the need (wholly legitimate) to improve industrial relationships.

It is not infrequent to see "unjustified" services being provided such as medical checkups not targeting risks, dose indicators that are non-specific or inadequate for the existing exposure level, and non-specific liver- or kidney-function tests. This aspect is related to the continuing difficulty in achieving (experimental) confirmation of the efficacy of many biological-monitoring and health-care surveillance activities, due to the absence of indicators or validated methods of measurement.

The objective of the services or individuals practising occupational medicine is the protection and promotion of health for people who work, aiming at the inclusion of prevention in company culture as well as technical and organisational choices.

The historical activity of health-care surveillance, even today mainly if not wholly understood as a medical check-up, should rather be taken in the broader sense including diagnosis, information, training, organisation and management, starting from an awareness of occupational risks (active participation in their assessment) and, as we have said, dealing with the formation of company choices and decisions.

These are the areas where the quality of occupational physicians and occupational-medicine services must be measured and acknowledged with formal measures.

Until now, the most frequently studied aspect is the company health-care services, dealing in particular with the forecasting, providing and assessment of clinical, laboratory and instrumental activity, together with their cost-benefit analysis.

There is a widespread impression that preventive activity on the whole may be over-dimensioned. This makes it all the more important to have a systematic approach to the problem in order to assess the real needs and importance, the adequacy of the instrument and methods used and the capability of updating them to the continuous and rapid changes under way in work.

On the international level, there are already the organisational models of the occupational-medicine services, specifically aimed at guaranteeing the quality of the services provided, user satisfaction and improvement in the productivity of these services.

The special feature of these services is that they form a "system", i.e. the result of a controlled designing process based on a policy, goals, organisational and management procedures, the identification of roles and responsibilities, and the checking of the system's effectiveness and efficiency.

The health and safety of workers are seen as the "product" which Occupational Medicine must guarantee, ensuring compliance with specific legal, contract and technical requirements; as such, health can be guaranteed solely by a properly planned and controlled organisational model.

It should perhaps be recalled that the topic of definition of standards for occupational-medicine services, where the quality-certification procedures are to be implemented, has already been examined by qualified institutes like the ISO. In a specific 1996 workshop, it was concluded that it was unsuitable to proceed in a situation where the interests of the social partners and governments were pressing as well as differing from country to country and within the same country. These reasons prevailed over the ones for an overall improvement of the activities in any case produced by the introduction and verification of standards, the integration of the company quality system in preventive activities and the stimulus to undertaking standardised activities.

In the specific Italian situation, it should be stressed that the transfer to Occupational Medicine of accreditation procedures, called for under current legislation for public and private health-care facilities, may not be pertinent since the services provided are not directly financed by the National Health Service. This might lead to the unusual condition of fewer "guarantees" for activities deserving particular attention because of their complexity and social and economic importance.

This is the reason for the basic role that the Scientific Societies should have, working together with the central and local institutions concerned, opting decisively for so called voluntary or excellence accreditation. The point of departure must be the definition of occupational-medicine activities, in order to determine procedures for promoting, updating and qualifying the parties involved in preventive activities, starting from Occupational Physicians, and going on to identify the forms of recognition, define the activities and procedures for their assessment, using suitable indicators, and to establish the organisational requirements of the services.

4. REFERENCES

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EUROPEAN COMMISSION - Work and Health Scientific basis of progress in the Working Environment. Report EUR 15980 EN DG Employment, Industrial Realtions and Social Affairs, 1995.

HARRINGTON J.M. - Research priorities in occupational medicine: a survey of United Kingdom medical opinion by the Delphi technique. Occup-Environ-Med. 51: 289-294, 1994.

HARRINGTON J.M., CALVERT I.A. - Research priorities in occupational medicine: a survey of United Kingdom personnel managers. Occup-Environ-Med. 53: 642-644, 1996.

HATTIS D. - Needs for public health intervention and needs for new research on vinyl halides and their polymers: a public policy perspective. Environ-Health-Perspect. 41: 227-231, 1981.

MACDONALD E.B., RITCHIE K.A., MURRAY K.J., GILMOUR W.H. - Requirements for occupational medicine training in Europe: a Delphi study. Occup. Environ. Med. 57: 98-105, 2000.

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ROSENSTOCK-L, OLENEC C., WAGNER G.R. - The National Occupational Research Agenda: a model of broad stakeholder input into priority setting. Am-J-Public-Health. 88: 353-356, 1998.

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SIEMIATYCKI J. - Problems and priorities in epidemiologic research on human health effects related to wiring code and electric and magnetic fields. Environ-Health-Perspect. 101 (Suppl 4): 135-141, 1993

YERXA E.J. - Research priorities. Am-J-Occup-Ther. 37: 699, 1983.

VAN DER BEEK A.J., FRING DRESEN M.H., VAN DIIJK F.J. - Priorities in Occupational Health Research: a Delphi study in the Netherlands. Occup-Environ-Med 54: 504-510, 1997.

FIRST STEP QUESTIONNAIRE SENT TO ALL EXPERTS IDENTIFIED BY THE ISPESL STUDY

Si prega di restituire il presente questionario completo di tutte le informazioni richieste preferibilmente via fax a:

ISPESL - Dipartimento di Medicina del Lavoro- V. Fontana Candida,1 00040 Monteporzio Catone (RM) - Fax. 0694181410 - 069419453

Per contatti Dott. Sergio Iavicoli, Dott.ssa Nicoletta Vonesch, Dott.ssa Cinzia Ursini Tel. 0694181407- 0694181516 - 0694181454

Prof./ Dott.__________________________________________________________

Istituzione _____________________________________________________________

Indirizzo Completo _______________________________________________________________

Tel. ________________________Fax._____________________ Email_____________________

Eventuale persona di contatto:___________________________________________________

La preghiamo di indicare in maniera sintetica e senza un ordine di priorità fra loro tre aree di medicina del lavoro sulle quali reputa importante che venga focalizzata attività di ricerca:

Negli ultimi 5 anni ha partecipato e/o condotto ricerche nel settore della medicina del lavoro per le quali siano sttai erogatifinanziamenti internazionali, nazionali e/o regionali

In caso affermativo indicare le tre aree principali oggetto di finanziamento:

Prof./ Dott.__________________________________________________________

Istituzione _____________________________________________________________

Indirizzo Completo _______________________________________________________________

Tel. ________________________Fax._____________________ Email_____________________

Eventuale persona di contatto:___________________________________________________

Di seguito sono riportate le aree risultate come prioritarie scaturite dall’analisi, secondo il metodo Delphi, del complesso delle indicazioni ricavate dal questionario della prima fase.

La preghiamo di assegnare a ciascuna delle aree di seguito indicate (avendo cura di non tralasciarne alcuna) un punteggio in relazione alla priorità attribuita secondo la seguente legenda:

SECOND STEP QUESTIONNAIRE ADMINISTRED TO THE EXPERTS OF TRADE UNIONS

Prof./ Dott.__________________________________________________________

Istituzione _____________________________________________________________

Indirizzo Completo _______________________________________________________________

Tel. ________________________Fax._____________________ Email_____________________

Eventuale persona di contatto:___________________________________________________

Di seguito sono riportate le aree risultate come prioritarie scaturite dall’analisi, secondo il metodo Delphi, del complesso delle indicazioni ricavate dal questionario della prima fase.

La preghiamo di assegnare a ciascuna delle aree di seguito indicate (avendo cura di non tralasciarne alcuna) un punteggio in relazione alla priorità attribuita secondo la seguente legenda: