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The bronchitic patient: a study of his employment problems
Br. J. Dis. Chest (1981) 75, 31
THE BRONCHITIC PATIENT: A STUDY OF H I S E M P L O Y M E N T P R O B L E M S R. A. CLARK,* J. ANDERSONAND C. SKINNER]" Department of Respiratory Diseases, University of Sheffield
~mmaFy Ninety-three male chronic bronchitics aged 40-64 years, 41 employed and 52 unemployed, were studied by structured interviews to evaluate factors leading to unemployment. Age was not important. Those employed were a little less disabled, and more were skilled, married, had working wives, had given up smoking, had tolerant employers and had suitable jobs, and fewer had travel problems. Of those unemployed most were not actively seeking work and, in half, income had not fallen with unemployment. Those interviewed felt that the Disablement Resettlement Officer, Industrial Rehabilitation Unit and their trade union did little to help with their problems. Ways to improve employment prospects for bronchitics are discussed.
INTRODUCTION A number of reports have dealt with the social and emotional problems of chronic bronchitic patients (Capel & Caplin 1964; Neilsen & Crofton 1965; Johnston 1970; Rubeck 1971). All have emphasized employment difficulties. By comparing employed and unemployed bronchitics we hoped to gain some idea of the relative importance of physical disability, working conditions, travel difficulties and financial considerations in determining whether a bronchitic was employed or not. Sheffield is particularly suitable for such a study because the problem is greater in an industrial community where many jobs entail work in adverse conditions (College of General Practitioners 1961 ; Parliamentary Question 1971), there is a higher prevalence of chronic bronchitis in steel workers (Lowe 1968; Gilson 1970) and the hilly terrain presents travel problems for people with physical disabilities. Patients and Methods
The survey was confined to male chronic bronchitics (Medical Research Council 1965) aged 40-64 yearswho were working or available for work. The intention was to recruit roughly equal numbers of employedand unemployed patients. End-stage respiratory cripples were excluded. The Department of Health and Social Security provided a random sample of Sheffield men who had been off work for more than two weeks in the preceding year with 'bronchitis' ; of 75 men, 27 were found to have chronic bronchitis and were included. Twenty-three men were referred by the Department of Employment from among those seeking work through the Sheffield * Present address: King's Cross Hospital, Clepington Road, Dundee DD3 8EA. t Present address: East Birmingham Hospital, Birmingham.
32
R. A. Clark, J. Anderson and C. Skinner
office. All general medical practitioners in Sheffield were approached for suitable patients and five were referred. Finally we recruited 38 patients attending the Sheffield Chest Clinic. Ninety. three patients were therefore interviewed, 41 employed and 52 unemployed. For each subject a standard short questionnaire on respiratory symptoms (Medical Research Council 1960) and a questionnaire covering details of recent health, work and travel conditions was completed, and the forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were recorded (litres, ATPS). Patients were later visited at home by a social worker who completed a detailed questionnaire on the home, financial and social status, advice received aboul work and efforts to obtain and retain suitable work.
Table I. Employed and unemployed bronchitic men: characteristics of each group compared
Employed
Unemployed
(%;n=41)
(%;n=52)
Aged 55 + Aged 60-65
64 44
72 39
Married Single Widowed, divorced, separated
85 5 10
71 15 14
Ex-smokers
39
29
Social Class 5
15
27
Dyspnoea Grades 1 and 2 Grade 3 Grade 4
29 44 27
14 28 58*
FEV1 > 2.0 litres 1.5-2.0 litres 1.0-1.5 litres < 1.0 litres
19 29 26 26
19 16 30 35
Morning symptoms None 0-2 hours > 2 hours
22 48 30
6* 42 52 ~
Average time off sick/year in last two working years < 1 week 1-8 weeks > 8 weeks
12 44 44
17 36 47
* Difference significant at the 5 % level (Xe test).
RESULTS
General characteristics (Table I) T h e t wo g r o u p s w e r e similar in age d i s t r i b u t i o n an d in r e s p e c t of t i m e off w o r k in the last t wo w o r k i n g years. T h e u n e m p l o y e d g r o u p i n c l u d e d m o r e single m e n an d m o r e m e n in Social Class 5.
Employment Problems of the Bronchitic Patient
33
Smoking. All men in both groups were cigarette smokers or ex-smokers. Of those with Grades 1, 2 or 4 dyspnoea, the proportion who smoked was similar in both employed and unemployed groups; of those with Grade 4 dyspnoea over 60% still smoked. Of those with Grade 3 dyspnoea, however, 70% of those employed had stopped smoking compared with only 26% of the unemployed ( P < 0.05), which accounts for the excess of smokers in the unemployed group. Disability. T h e unemployed were more disabled as judged by greater dyspnoea, lower FEV1 values and more prolonged and severe morning symptoms. Grade of dyspnoea and FEV1 were correlated but not closely so (r = 0.60) and of patients with Grade 3 or Grade 4 dyspnoea, 13 ( 1 8 ° ) had an FEV1 over 2 litres. Table II. Patient's view of present or last job: comparison of those rated 'suitable' and 'unsuitable'
'Suitable'
' Unsuitable'
(% ; n = 44)
(% ; n = 49)
Job-related factors Heavy manual work Working outdoors Exposure to fumes or dusts Adverse temperature or humidity Inadequate ventilation Start before 6.30 a.m. Shift work Essential overtime
5 25 39 52 14 25 25 55
33* 36 69* 78* 27 24 27 61
18 41
24 37
75 45 30 30
20* 35 53* 51"
Patient-related factors Social Class 5 Change of job in last five working years Feels his employer makes allowance for his chest Aged 60-65 years Morning symptoms for two or more hours Travel difficulties
* Difference significant at the 5 % level (X~ test).
Suitability of employment (Table H) Each man assessed his present job (or last job if unemployed) as 'suitable' or 'unsuitable'. Jobs were considered suitable by 75% of those employed but only 25% of those unemployed (P < 0.05). Suitable and unsuitable jobs are compared in Table II. Suitable jobs tended to be lighter, with less exposure to dust, fumes, heat, cold or damp, with more tolerant employers and with fewer difficulties in getting to work. A tolerant employer and ease of getting to work also allowed a n u m b e r of men to continue working despite an unsuitable job. T h u s seven of 10 men working in unsuitable jobs reported a tolerant employer compared with three of 39 unemployed men who rated their last job as unsuitable ( P < 0.05). Similarly only two of 10 reported travel problems as compared with 16 of 39 ( P < 0 . 0 5 ) .
R. A. Clark, J. Anderson and C. Skinner
34
Of 10 patients who continue to work despite having unsuitable jobs nine were married, whereas of 13 patients who had given up work despite having suitable jobs only five were married (P< 0.05). As a check on the validity of the stated job suitability or unsuitability each job was given an 'unsuitability score' corresponding to its number of adverse features: heavy manual work; outdoor work; exposure to dust or fumes; adverse humidity or temperature; poor ventilation; early start; shift work. A score between 0 and 7 was thereby
W
employed P = ~0.05 ~ unemployed
26% 24% 20%
21%
IIIIII IIIIII
21%
t9%
III!11l/ l F-
8%
o
W__EJ 0
1
2
3
4
5
6
7
'undesirability score'
Fig. 1. T h e relationship b e t w e e n j o b u n s u i t a b i l i t y score a n d e m p l o y m e n t status. P < 0.05 for the difference b e t w e e n t h e e m p l o y e d a n d the u n e m p l o y e d
given to each job. The scores related quite well to the stated job suitability or unsuitability. Jobs rated suitable had lower scores (mean 2.2) than those rated unsuitable (mean 3.5). The employed tended to have jobs which were lower scoring (more suitable) than those last held by the unemployed (Fig. 1). Six patients were self-employed. All had jobs where daily attendance was required. Only two were able to keep working.
Efforts to obtain work (Table III) More of the unemployed had had advice about work, had registered as disabled and had been accepted for an Industrial Rehabilitation Unit. Of those who were registered disabled (employed and unemployed) 11 of the 36 (31%) were still working. Of the
Employment Problems of the Bronchitic Patient
35
27 men (20 unemployed) accepted for an Industrial Rehabilitation Unit only three found the experience of value. 0nly eight of 80 men who were members of a trade union had had help from this source. Over half the patients had changed or attempted to change jobs because of bronchitis, mainly through the Department of Employment or through the newspapers. However, of those who secured (and retained) a suitable job most had done so through their employer. A change of job did not necessarily entail a change in social class; when it did, the change was more often down (10) than up (two).
Table iII. Advice received and efforts made to get work Employed (%; n=41)
Unemployed (%; n=52)
44 44 27 27 27 17
73* 29 35 50* 46 39*
59
64
48 50 36
66 66 27
Changed job in last five working years Employer as source of new job (% of those changing) Suitability of new job (% of those changing)
46
33
58
24*
79
18"
Realistic assessment of own capabilities Highly motivated to work
90 66
46* 15"
Advice received about work Advice given while still working Advice given by doctor Seen by Disablement Resettlement Officer Registered disabled Accepted for Rehabilitation Unit Changed job or sought to because of bronchitis Effort to get work (% of those seeking) Through the Department of Employment By personal effort An approach to employer
* Difference significant at the 5% level (X2 test). The employed were felt to have a more realistic view of their physical state and work capability and also to be more highly motivated to work than their unemployed counterparts. Among the latter 18 ( 3 5 ° ) had no wish to work and only 10 (19%) were actively seeking work; ten (19%) had been out of work for less than a year, 12 (23%) for one to two years, 19 (37%) for two to five years and 11 (21~o) for over five years. Twentytwo (42%) of the unemployed had been discharged because of ill-health, 21 (40%) had left voluntarily because of working or travel conditions and nine (18~o) had been made redundant.
Travel difficulties Travel to and from work was usually by bus (50~o), less often by car or scooter (27%), on foot (22%) or by bicycle (1%). T h e r e was no difference between the employed and
36
R. A. Clark, J. Anderson and C. Skinner
unemployed (in their working days) in this respect. However, travel difficulties were more often reported by the unemployed (52% as compared with 27~o). This did nol relate to any evident difference in the quality of bus service. A car did not guarantee trouble-free travel; several patients found it hard to walk to the car after work; others had difficulty when their shift clashed with that of the car driver.
p<
married
o.ool
employed non-married 63%
married
m
unemployed
56%
non-married
44%
59% 51% m
5%
33%
4•
•
•
26%
•4 •• •
•
o%
Income of l e s s than 50% of national average Wage
11%
4%
Income between 50% and 100% of national averag8 wage
5%
Income above the national average wage
Fig. 2. Family income according to employment and marital status
Social circumstances Rather more of the employed were married (85% as compared with 71%), owned their home (22% as compared with 10~o), had home central heating (20% as compared with 10%) or owned a ear (40% as compared with 12%, P < 0.05). The great majority of patients (90~o) cited at least two of the following as a leisure interest: reading, listening
Employment Problems of the Bronchitic Patient
37
to radio, watching television, hobbies. More of the employed (44~o as compared with 23Yo, P< 0.05) were interested in all four. More of the unemployed (29~o as compared with 9~o, P < 0.05) had help from the Social Services.
Income The total family income of the employed bronchitics (Fig. 2) was around the national average wage with roughly half above and half below this level. This relatively favourable situation was substantially dependent on the wives' income, with over half the employed bronchitics having working wives. The unmarried working bronchitics were worse off athough none had an income of less than half the national average wage. The unemployed bronchitics fared less well on two counts. First, their personal income was less than that of their working counterparts. Secondly, fewer of them (23~o as compared with 53%, P < 0.05) had working wives. Hence almost a third of the unemployed bronchitics had a total family income of less than half the national average wage. The contribution to family income from children was small. It was relatively greater among the unemployed, accounting for over half of income additional to the patient's personal income. In half the unemployed men personal income had either increased or remained unchanged as a result of stopping work and only 8~o of the unemployed had suffered a fall of more than £10.00 in weekly income. DISCUSSION The bronchitics we studied were a typical cross-section of patients with disease severe enough to cause recurrent chest infections and breathlessness on effort. Most were skilled workers, some were semi-skilled or unskilled and few had professional or managerial jobs. Unemployment usually stemmed from a combination of several factors relating to the man--skills, family support, severity of disease, motivation--and to his job--conditions atwork, travel difficulties, pay. More of the employed were married and skilled, thereby having both~domestic'and financial incentives to work. Indeed, many of the married bronchitics soldiered on in unsuitable jobs, whereas the single men often gave up working in suitable jobs. Perhaps, too, those accustomed to a higher standard of living struggled harder to stay at work. Certainly more of those working owned their homes, had central heating; owned a car and had diverse leisure interests. The disease was a little more severe among the unemployed. Those with severe disease who remained at work had often held the same skilled job for several years and had an employer who made allowances for their disability and for frequent time off work. A finding which may reflect greater motivation among the employed is that of those with Grade 3 dyspnoea far more of the employed had given up smoking (70~o) than of the unemployed (26%). Of the employed with no travel difficulties half went by car from door to door. Travel by bus was less satisfactory. The main difficulty was being unable to walk a reasonable distance in bad weather or at the end of a shift when physically exhausted. It is unfortunate if a bronchitic gives up work because of travel difficulties without recourse to
38
R. A. Clark, J. Anderson and C. Skinner
the assistance which is available in the form of a subsidized taxi service (Department of Health and Social Security 1977, 1978). Only a quarter of the unemployed had working wives (as compared with half of the employed) and these wives earned less than the wives of the employed men. This does not support the idea of role reversal whereby wives of the unemployed go out to work to maintain family income. Nor was there any evidence that the wives of the unemployed had stopped working to look after their husbands. There was not a large fall in income with unemployment and in half the cases personal income was unchanged or increased, which must be a disincentive to continued struggling in a dirty, lowly paid, manual job. Over a third of the unemployed no longer wished to work. Most of these were over 60 years old or had been out of work for more than five years ; many mentioned the lack of any financial incentive to work. Of those who registered as disabled only a minority found suitable work through the Disablement Resettlement Officer. Many felt that the jobs offered were unsuitable, with heavy manual work or exposure to dust, fumes or bad weather, indicating a failure to understand their disability on the part of those making recommendations. Some hid the fact that they were registered disabled when seeking work through personal contacts and two patients felt that they had been refused jobs on account of their registration as disabled. Most of those who attended industrial rehabilitation courses felt that programmes were not geared to the particular problems of the bronchitic and that suitable jobs were rarely available afterward. A number of men approached their employer who found them alternative more suitable work in recognition of their reliability over many years, although this often meant a drop in income. The bronchitic patient ideally requires a clean, light, indoor job. These are traditionally female jobs but the Sex Discrimination Act should help to make such jobs more available for physically handicapped males. Our severe bronchitics often suffered from disabling chest tightness and breathlessness for several hours after rising and a job which permitted a later start would be a distinct advantage, in contrast to the require: ment of Remploy. Many of our bronchitics felt that their trade unions might have done more to help improve working conditions. The establishment of the Health and Safety Executive may help with this aspect. Other avenues which might be explored include the setting up of local registers of suitable employment, comprising an index of suitable jobs and a list of employers willing to consider part-time work at off peak times, and efforts to expand sheltered workshops or home employment agencies (Neilsen & Crofton 1965). For such schemes to be feasible changes would be necessary in the regulations covering payment of sickness benefit to part-time workers but the saving in the benefits paid to bronchitics would be substantial (Johnston 1970). Much can be achieved locally by cooperation among doctors, social workers, Disablement Resettlement Officer, employers and unions (Johnston 1970), but this initiative was never built on nationally. The longer the patient remains out of work the more disillusioned he becomes with increasing psychological problems (Rubeck 1971). Most of those we interviewed stressed that the wish to work was for reasons of self-respect and the need to keep an active mind, as much as for financial reasons. If improvements could be made in the type of work offered and the travel problems overcome then, after a period of suitable rehabilitation, many disabled bronchitics could be slotted into appropriate work without delay.
Employment Problems of the Bronchitic Patient
39
ACKNOWLEDGEMENTS We wish to t h a n k t h e Chest, H e a r t a n d S t r o k e A s s o c i a t i o n for t h e i r financial s u p p o r t of the study, D r C. S. D a r k e for e n c o u r a g i n g t h e survey, P r o f e s s o r J. K n o w e l d e n for his help with d e s i g n i n g t h e q u e s t i o n n a i r e , P r o f e s s o r Sir J o h n C r o f t o n for advice on t h e analysis and presentation of t h e m a t e r i a l a n d M r s A. F e r r i e r a n d M r s M . Jervis for secretarial assistance.
Requests for reprints to Dr R. A. Clark, King's Cross Hospital, CIepington Road, Dundee DD3 8EA. REFERENCES
CAPEL,L. H. & CAPLIN, M. (1964) Chronic Bronchitis in Great Britain. London: Chest and Heart Association. COLLEGEOF GENERAL PRACTIONERS(1961) Chronic bronchitis in Great Britain. Dr. reed. ft. 2, 973. DEPARTMENTOF HEALTH AND SOCIAL SECURITY (1977) Help for Handicapped People, Leaflet HB 1. London : H M S O . DEPARTMENT OF HEALTH AND SOCIAL SECURITY (1978) Mobility Allowance, Leaflet N 1. 211. London : H M S O . GILSON,J. C. (1970) Occupational bronchitis. Proc. R. Soc. Med. 63, 857. JOHNSTON,~VL (1970) Social Problems of Chronic Bronchitis, A Study in Remedial Action. London: Chest and Heart Association. LOWE, C. R. (1968) Chronic bronchitis and occupation. Proc. R. Soc. Med. 61, 98. MEDICALRESEAIRCHCOUNCIL (1960) Standardized questionnaires on respiratory symptoms. Dr. reed. ft. 2, 1665. MEDICALRESFARCHCOUNCIL (1965) Definition and classification of chronic bronchitis for clinical and epidemiological purposes. Lancet 1, 775. NEILSEN,M. G. C. • CROFTON,E. (1965) The Social Effects of Chronic Bronchitis, a Scottish Study. London: Chest and Heart Association. PARLIAMENTARYQUESTION (1971) Bronchitis and asthma deaths. Dr. reed..7. 1, 616. RUBECK, M. F. (1971) Social and Emotional Effects of Chronic Bronchitis. London: Chest and Heart Association.
THE BRONCHITIC PATIENT: A STUDY OF H I S E M P L O Y M E N T P R O B L E M S R. A. CLARK,* J. ANDERSONAND C. SKINNER]" Department of Respiratory Diseases, University of Sheffield
~mmaFy Ninety-three male chronic bronchitics aged 40-64 years, 41 employed and 52 unemployed, were studied by structured interviews to evaluate factors leading to unemployment. Age was not important. Those employed were a little less disabled, and more were skilled, married, had working wives, had given up smoking, had tolerant employers and had suitable jobs, and fewer had travel problems. Of those unemployed most were not actively seeking work and, in half, income had not fallen with unemployment. Those interviewed felt that the Disablement Resettlement Officer, Industrial Rehabilitation Unit and their trade union did little to help with their problems. Ways to improve employment prospects for bronchitics are discussed.
INTRODUCTION A number of reports have dealt with the social and emotional problems of chronic bronchitic patients (Capel & Caplin 1964; Neilsen & Crofton 1965; Johnston 1970; Rubeck 1971). All have emphasized employment difficulties. By comparing employed and unemployed bronchitics we hoped to gain some idea of the relative importance of physical disability, working conditions, travel difficulties and financial considerations in determining whether a bronchitic was employed or not. Sheffield is particularly suitable for such a study because the problem is greater in an industrial community where many jobs entail work in adverse conditions (College of General Practitioners 1961 ; Parliamentary Question 1971), there is a higher prevalence of chronic bronchitis in steel workers (Lowe 1968; Gilson 1970) and the hilly terrain presents travel problems for people with physical disabilities. Patients and Methods
The survey was confined to male chronic bronchitics (Medical Research Council 1965) aged 40-64 yearswho were working or available for work. The intention was to recruit roughly equal numbers of employedand unemployed patients. End-stage respiratory cripples were excluded. The Department of Health and Social Security provided a random sample of Sheffield men who had been off work for more than two weeks in the preceding year with 'bronchitis' ; of 75 men, 27 were found to have chronic bronchitis and were included. Twenty-three men were referred by the Department of Employment from among those seeking work through the Sheffield * Present address: King's Cross Hospital, Clepington Road, Dundee DD3 8EA. t Present address: East Birmingham Hospital, Birmingham.
32
R. A. Clark, J. Anderson and C. Skinner
office. All general medical practitioners in Sheffield were approached for suitable patients and five were referred. Finally we recruited 38 patients attending the Sheffield Chest Clinic. Ninety. three patients were therefore interviewed, 41 employed and 52 unemployed. For each subject a standard short questionnaire on respiratory symptoms (Medical Research Council 1960) and a questionnaire covering details of recent health, work and travel conditions was completed, and the forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were recorded (litres, ATPS). Patients were later visited at home by a social worker who completed a detailed questionnaire on the home, financial and social status, advice received aboul work and efforts to obtain and retain suitable work.
Table I. Employed and unemployed bronchitic men: characteristics of each group compared
Employed
Unemployed
(%;n=41)
(%;n=52)
Aged 55 + Aged 60-65
64 44
72 39
Married Single Widowed, divorced, separated
85 5 10
71 15 14
Ex-smokers
39
29
Social Class 5
15
27
Dyspnoea Grades 1 and 2 Grade 3 Grade 4
29 44 27
14 28 58*
FEV1 > 2.0 litres 1.5-2.0 litres 1.0-1.5 litres < 1.0 litres
19 29 26 26
19 16 30 35
Morning symptoms None 0-2 hours > 2 hours
22 48 30
6* 42 52 ~
Average time off sick/year in last two working years < 1 week 1-8 weeks > 8 weeks
12 44 44
17 36 47
* Difference significant at the 5 % level (Xe test).
RESULTS
General characteristics (Table I) T h e t wo g r o u p s w e r e similar in age d i s t r i b u t i o n an d in r e s p e c t of t i m e off w o r k in the last t wo w o r k i n g years. T h e u n e m p l o y e d g r o u p i n c l u d e d m o r e single m e n an d m o r e m e n in Social Class 5.
Employment Problems of the Bronchitic Patient
33
Smoking. All men in both groups were cigarette smokers or ex-smokers. Of those with Grades 1, 2 or 4 dyspnoea, the proportion who smoked was similar in both employed and unemployed groups; of those with Grade 4 dyspnoea over 60% still smoked. Of those with Grade 3 dyspnoea, however, 70% of those employed had stopped smoking compared with only 26% of the unemployed ( P < 0.05), which accounts for the excess of smokers in the unemployed group. Disability. T h e unemployed were more disabled as judged by greater dyspnoea, lower FEV1 values and more prolonged and severe morning symptoms. Grade of dyspnoea and FEV1 were correlated but not closely so (r = 0.60) and of patients with Grade 3 or Grade 4 dyspnoea, 13 ( 1 8 ° ) had an FEV1 over 2 litres. Table II. Patient's view of present or last job: comparison of those rated 'suitable' and 'unsuitable'
'Suitable'
' Unsuitable'
(% ; n = 44)
(% ; n = 49)
Job-related factors Heavy manual work Working outdoors Exposure to fumes or dusts Adverse temperature or humidity Inadequate ventilation Start before 6.30 a.m. Shift work Essential overtime
5 25 39 52 14 25 25 55
33* 36 69* 78* 27 24 27 61
18 41
24 37
75 45 30 30
20* 35 53* 51"
Patient-related factors Social Class 5 Change of job in last five working years Feels his employer makes allowance for his chest Aged 60-65 years Morning symptoms for two or more hours Travel difficulties
* Difference significant at the 5 % level (X~ test).
Suitability of employment (Table H) Each man assessed his present job (or last job if unemployed) as 'suitable' or 'unsuitable'. Jobs were considered suitable by 75% of those employed but only 25% of those unemployed (P < 0.05). Suitable and unsuitable jobs are compared in Table II. Suitable jobs tended to be lighter, with less exposure to dust, fumes, heat, cold or damp, with more tolerant employers and with fewer difficulties in getting to work. A tolerant employer and ease of getting to work also allowed a n u m b e r of men to continue working despite an unsuitable job. T h u s seven of 10 men working in unsuitable jobs reported a tolerant employer compared with three of 39 unemployed men who rated their last job as unsuitable ( P < 0.05). Similarly only two of 10 reported travel problems as compared with 16 of 39 ( P < 0 . 0 5 ) .
R. A. Clark, J. Anderson and C. Skinner
34
Of 10 patients who continue to work despite having unsuitable jobs nine were married, whereas of 13 patients who had given up work despite having suitable jobs only five were married (P< 0.05). As a check on the validity of the stated job suitability or unsuitability each job was given an 'unsuitability score' corresponding to its number of adverse features: heavy manual work; outdoor work; exposure to dust or fumes; adverse humidity or temperature; poor ventilation; early start; shift work. A score between 0 and 7 was thereby
W
employed P = ~0.05 ~ unemployed
26% 24% 20%
21%
IIIIII IIIIII
21%
t9%
III!11l/ l F-
8%
o
W__EJ 0
1
2
3
4
5
6
7
'undesirability score'
Fig. 1. T h e relationship b e t w e e n j o b u n s u i t a b i l i t y score a n d e m p l o y m e n t status. P < 0.05 for the difference b e t w e e n t h e e m p l o y e d a n d the u n e m p l o y e d
given to each job. The scores related quite well to the stated job suitability or unsuitability. Jobs rated suitable had lower scores (mean 2.2) than those rated unsuitable (mean 3.5). The employed tended to have jobs which were lower scoring (more suitable) than those last held by the unemployed (Fig. 1). Six patients were self-employed. All had jobs where daily attendance was required. Only two were able to keep working.
Efforts to obtain work (Table III) More of the unemployed had had advice about work, had registered as disabled and had been accepted for an Industrial Rehabilitation Unit. Of those who were registered disabled (employed and unemployed) 11 of the 36 (31%) were still working. Of the
Employment Problems of the Bronchitic Patient
35
27 men (20 unemployed) accepted for an Industrial Rehabilitation Unit only three found the experience of value. 0nly eight of 80 men who were members of a trade union had had help from this source. Over half the patients had changed or attempted to change jobs because of bronchitis, mainly through the Department of Employment or through the newspapers. However, of those who secured (and retained) a suitable job most had done so through their employer. A change of job did not necessarily entail a change in social class; when it did, the change was more often down (10) than up (two).
Table iII. Advice received and efforts made to get work Employed (%; n=41)
Unemployed (%; n=52)
44 44 27 27 27 17
73* 29 35 50* 46 39*
59
64
48 50 36
66 66 27
Changed job in last five working years Employer as source of new job (% of those changing) Suitability of new job (% of those changing)
46
33
58
24*
79
18"
Realistic assessment of own capabilities Highly motivated to work
90 66
46* 15"
Advice received about work Advice given while still working Advice given by doctor Seen by Disablement Resettlement Officer Registered disabled Accepted for Rehabilitation Unit Changed job or sought to because of bronchitis Effort to get work (% of those seeking) Through the Department of Employment By personal effort An approach to employer
* Difference significant at the 5% level (X2 test). The employed were felt to have a more realistic view of their physical state and work capability and also to be more highly motivated to work than their unemployed counterparts. Among the latter 18 ( 3 5 ° ) had no wish to work and only 10 (19%) were actively seeking work; ten (19%) had been out of work for less than a year, 12 (23%) for one to two years, 19 (37%) for two to five years and 11 (21~o) for over five years. Twentytwo (42%) of the unemployed had been discharged because of ill-health, 21 (40%) had left voluntarily because of working or travel conditions and nine (18~o) had been made redundant.
Travel difficulties Travel to and from work was usually by bus (50~o), less often by car or scooter (27%), on foot (22%) or by bicycle (1%). T h e r e was no difference between the employed and
36
R. A. Clark, J. Anderson and C. Skinner
unemployed (in their working days) in this respect. However, travel difficulties were more often reported by the unemployed (52% as compared with 27~o). This did nol relate to any evident difference in the quality of bus service. A car did not guarantee trouble-free travel; several patients found it hard to walk to the car after work; others had difficulty when their shift clashed with that of the car driver.
p<
married
o.ool
employed non-married 63%
married
m
unemployed
56%
non-married
44%
59% 51% m
5%
33%
4•
•
•
26%
•4 •• •
•
o%
Income of l e s s than 50% of national average Wage
11%
4%
Income between 50% and 100% of national averag8 wage
5%
Income above the national average wage
Fig. 2. Family income according to employment and marital status
Social circumstances Rather more of the employed were married (85% as compared with 71%), owned their home (22% as compared with 10~o), had home central heating (20% as compared with 10%) or owned a ear (40% as compared with 12%, P < 0.05). The great majority of patients (90~o) cited at least two of the following as a leisure interest: reading, listening
Employment Problems of the Bronchitic Patient
37
to radio, watching television, hobbies. More of the employed (44~o as compared with 23Yo, P< 0.05) were interested in all four. More of the unemployed (29~o as compared with 9~o, P < 0.05) had help from the Social Services.
Income The total family income of the employed bronchitics (Fig. 2) was around the national average wage with roughly half above and half below this level. This relatively favourable situation was substantially dependent on the wives' income, with over half the employed bronchitics having working wives. The unmarried working bronchitics were worse off athough none had an income of less than half the national average wage. The unemployed bronchitics fared less well on two counts. First, their personal income was less than that of their working counterparts. Secondly, fewer of them (23~o as compared with 53%, P < 0.05) had working wives. Hence almost a third of the unemployed bronchitics had a total family income of less than half the national average wage. The contribution to family income from children was small. It was relatively greater among the unemployed, accounting for over half of income additional to the patient's personal income. In half the unemployed men personal income had either increased or remained unchanged as a result of stopping work and only 8~o of the unemployed had suffered a fall of more than £10.00 in weekly income. DISCUSSION The bronchitics we studied were a typical cross-section of patients with disease severe enough to cause recurrent chest infections and breathlessness on effort. Most were skilled workers, some were semi-skilled or unskilled and few had professional or managerial jobs. Unemployment usually stemmed from a combination of several factors relating to the man--skills, family support, severity of disease, motivation--and to his job--conditions atwork, travel difficulties, pay. More of the employed were married and skilled, thereby having both~domestic'and financial incentives to work. Indeed, many of the married bronchitics soldiered on in unsuitable jobs, whereas the single men often gave up working in suitable jobs. Perhaps, too, those accustomed to a higher standard of living struggled harder to stay at work. Certainly more of those working owned their homes, had central heating; owned a car and had diverse leisure interests. The disease was a little more severe among the unemployed. Those with severe disease who remained at work had often held the same skilled job for several years and had an employer who made allowances for their disability and for frequent time off work. A finding which may reflect greater motivation among the employed is that of those with Grade 3 dyspnoea far more of the employed had given up smoking (70~o) than of the unemployed (26%). Of the employed with no travel difficulties half went by car from door to door. Travel by bus was less satisfactory. The main difficulty was being unable to walk a reasonable distance in bad weather or at the end of a shift when physically exhausted. It is unfortunate if a bronchitic gives up work because of travel difficulties without recourse to
38
R. A. Clark, J. Anderson and C. Skinner
the assistance which is available in the form of a subsidized taxi service (Department of Health and Social Security 1977, 1978). Only a quarter of the unemployed had working wives (as compared with half of the employed) and these wives earned less than the wives of the employed men. This does not support the idea of role reversal whereby wives of the unemployed go out to work to maintain family income. Nor was there any evidence that the wives of the unemployed had stopped working to look after their husbands. There was not a large fall in income with unemployment and in half the cases personal income was unchanged or increased, which must be a disincentive to continued struggling in a dirty, lowly paid, manual job. Over a third of the unemployed no longer wished to work. Most of these were over 60 years old or had been out of work for more than five years ; many mentioned the lack of any financial incentive to work. Of those who registered as disabled only a minority found suitable work through the Disablement Resettlement Officer. Many felt that the jobs offered were unsuitable, with heavy manual work or exposure to dust, fumes or bad weather, indicating a failure to understand their disability on the part of those making recommendations. Some hid the fact that they were registered disabled when seeking work through personal contacts and two patients felt that they had been refused jobs on account of their registration as disabled. Most of those who attended industrial rehabilitation courses felt that programmes were not geared to the particular problems of the bronchitic and that suitable jobs were rarely available afterward. A number of men approached their employer who found them alternative more suitable work in recognition of their reliability over many years, although this often meant a drop in income. The bronchitic patient ideally requires a clean, light, indoor job. These are traditionally female jobs but the Sex Discrimination Act should help to make such jobs more available for physically handicapped males. Our severe bronchitics often suffered from disabling chest tightness and breathlessness for several hours after rising and a job which permitted a later start would be a distinct advantage, in contrast to the require: ment of Remploy. Many of our bronchitics felt that their trade unions might have done more to help improve working conditions. The establishment of the Health and Safety Executive may help with this aspect. Other avenues which might be explored include the setting up of local registers of suitable employment, comprising an index of suitable jobs and a list of employers willing to consider part-time work at off peak times, and efforts to expand sheltered workshops or home employment agencies (Neilsen & Crofton 1965). For such schemes to be feasible changes would be necessary in the regulations covering payment of sickness benefit to part-time workers but the saving in the benefits paid to bronchitics would be substantial (Johnston 1970). Much can be achieved locally by cooperation among doctors, social workers, Disablement Resettlement Officer, employers and unions (Johnston 1970), but this initiative was never built on nationally. The longer the patient remains out of work the more disillusioned he becomes with increasing psychological problems (Rubeck 1971). Most of those we interviewed stressed that the wish to work was for reasons of self-respect and the need to keep an active mind, as much as for financial reasons. If improvements could be made in the type of work offered and the travel problems overcome then, after a period of suitable rehabilitation, many disabled bronchitics could be slotted into appropriate work without delay.
Employment Problems of the Bronchitic Patient
39
ACKNOWLEDGEMENTS We wish to t h a n k t h e Chest, H e a r t a n d S t r o k e A s s o c i a t i o n for t h e i r financial s u p p o r t of the study, D r C. S. D a r k e for e n c o u r a g i n g t h e survey, P r o f e s s o r J. K n o w e l d e n for his help with d e s i g n i n g t h e q u e s t i o n n a i r e , P r o f e s s o r Sir J o h n C r o f t o n for advice on t h e analysis and presentation of t h e m a t e r i a l a n d M r s A. F e r r i e r a n d M r s M . Jervis for secretarial assistance.
Requests for reprints to Dr R. A. Clark, King's Cross Hospital, CIepington Road, Dundee DD3 8EA. REFERENCES
CAPEL,L. H. & CAPLIN, M. (1964) Chronic Bronchitis in Great Britain. London: Chest and Heart Association. COLLEGEOF GENERAL PRACTIONERS(1961) Chronic bronchitis in Great Britain. Dr. reed. ft. 2, 973. DEPARTMENTOF HEALTH AND SOCIAL SECURITY (1977) Help for Handicapped People, Leaflet HB 1. London : H M S O . DEPARTMENT OF HEALTH AND SOCIAL SECURITY (1978) Mobility Allowance, Leaflet N 1. 211. London : H M S O . GILSON,J. C. (1970) Occupational bronchitis. Proc. R. Soc. Med. 63, 857. JOHNSTON,~VL (1970) Social Problems of Chronic Bronchitis, A Study in Remedial Action. London: Chest and Heart Association. LOWE, C. R. (1968) Chronic bronchitis and occupation. Proc. R. Soc. Med. 61, 98. MEDICALRESEAIRCHCOUNCIL (1960) Standardized questionnaires on respiratory symptoms. Dr. reed. ft. 2, 1665. MEDICALRESFARCHCOUNCIL (1965) Definition and classification of chronic bronchitis for clinical and epidemiological purposes. Lancet 1, 775. NEILSEN,M. G. C. • CROFTON,E. (1965) The Social Effects of Chronic Bronchitis, a Scottish Study. London: Chest and Heart Association. PARLIAMENTARYQUESTION (1971) Bronchitis and asthma deaths. Dr. reed..7. 1, 616. RUBECK, M. F. (1971) Social and Emotional Effects of Chronic Bronchitis. London: Chest and Heart Association.