Non-Communicable Diseases and Mental Health Disorders in Indian Workplaces: 'Elephant in the Room' or 'Future of Occupational Health Practice'.

Workers and workplaces are dynamic and so are the health issues associated with them. Efficiency of occupational health services is a measure of dynamic adaptation to this changing ecosystem to achieve the best possible health, productivity, and socio-economic development.

India's liberal economic policy in 1990s opened doors for globalization and industrialization. Ensuing and progressive urbanization, technology revolution, has led to Non-Communicable Diseases (NCDs) emerging as a major public health problem in the country. The proportion of deaths due to NCDs has increased from 38% of all deaths in year 1990 to 64.9% in year 2019.[1] In absolute numbers an estimated 6.89 million people succumbed to NCDs in year 2019, of which around 60% are premature deaths.[12] With rise in NCDs, risk factors for NCDs and mental health disorders in general population, concurrent rise of the same in the sub-set of 'working population' is expected.

Anticipating this transition, the need for integrating NCD and mental health care into existing workplace health systems is often debated and skeptic zed. Occupational Health (OH) professionals may choose to ignore this 'elephant in the room' or 'capitalize this elephant' to bring a paradigm shift in OH practice – expecting that the OH professional community is divided on this choice; this editorial discusses the associated opportunities for occupational health practice in India.

NCDs, NCD risk factors and mental health disorders in workplaces – the elephant in the room

India is home to more than 1.3 billion people of which about 730 million are aged between 15-59 years (60%). Workers account for nearly 40% of India's population (537 million workers) and 65.4% of persons aged between 15-59 years in India.[3] The age group of 15-59 years is not only the productive section of the population but also the age where NCDs and NCD risk factors manifest and progress. Given the above numbers, changes in the epidemiology of NCDs and mental health disorders are likely to be reflected in workplaces. These statistics indicate that the 'working population' is a priority group for NCD prevention and control in India.

Though nationwide representative studies of NCDs, their risk factors and mental health disorders in workplaces are not available for India, a recently conducted review implied a significant burden of NCDs, NCD risk factors and mental health disorders among workers in India [Table 1].[456] However, variations in study design, sample size, ascertainment methods, place and time across the reviewed studies, limit generalization of results. Nevertheless, even assuming similar prevalence as in general population, the sheer number of workers needing care is substantial. The number of workers estimated to be affected by NCDs, their risk factors and mental health disorders and needing care is too huge to ignore 'the elephant in the room' [Table 1].

Table 1

Select Non-Communicable diseases, NCD risk factors and mental health disorders in Indian workplaces: summary of review of available studies

NCD, NCD risk	Number of studies	Sample size	Prevalence (low, high)	Median prevalence	Number of workers affected (in million)	Number of organised sector workers affected (in million)
Coronary Heart Disease	7	10654	1.28%, 37.2	7.3%	34.9	3.6
Metabolic syndrome	10	27649	8.1%, 57.6	28.1%	134.3	14.1
Diabetes (lab investigated)	46	56675	3.9%, 65.5%	10.05%	48.3	5.1
Hypertension	51	54344	3.4%, 60.8%	21.5%	102.7	10.8
Tobacco use	92	79793	2%, 91.1%	28.0%	133.8	14.0
Alcohol Use	66	51896	3%, 85.1%	29.95	143.1	14.9
Physical Inactivity	19	37447	18.9%, 79%	41.3%	197.3	20.6
Extra salt intake	5	3711	3.4%, 89.4%	47.2%	225.5	23.6
Low intake - fruits & vegetables	10	4102	9.1%, 100%	88%	420.4	44.1
Overweight/Obesity	35	19006	6.1%, 58.2%	17%	81.2	8.5
Hyperlipidemia	6	18826	18.5%, 40.2%	26%	124.2	13.0
Depression	10	3143	10.1%, 52.9%	30%	143.3	15.0
Anxiety	6	1421	7%, 57%	18%	86.0	9.0
Workplace stress	18	4194	3.8%, 75.5%	25.5%	121.8	12.8

Source-(6)

The need to capitalize on this 'elephant in the room'

Table 1 indicates that 'working population' accounts for a significant burden of NCDs and NCD risk factors in India. Conversely, it implies that reducing NCDs among workers holds the key to reduce NCD burden in India. Any efforts to reduce NCDs in the country would have to capitalize on this 'elephant in the room' to make a significant impact and achieve expected reductions in national NCD targets and NCD-related Sustainable Development Goals (SDGs). Though national programs for prevention and control of NCDs and mental health disorders are implemented for the general population, workplace-specific programs have some inherent advantages.

Workplace interventions are relatively easier than population-based interventions from an implementation perspective, due to well-known reasons. Workplace interventions have the potential to reduce national burden of NCDs by reducing mean risk factor levels in adult population (15–59 years), resulting in lesser yield of NCD cases in years to come. Spillover effect to families is a collateral advantage.

There is an argument that workplace interventions are feasible, relatively easier to implement and evaluate benefits in organized sector workplaces, which account for 8–10% of the workforce.[37] However, considering the sheer number of workers that are expected to be benefited (30–50 million workers), it is worthwhile to have a workplace specific program for NCDs in the organized sector and build on the experiences to upscale it to unorganized sectors. Meanwhile, building on the principles of Basic Occupational Health Services, specific interventions for unorganized workers in existing national programs within primary health care systems, can be developed and strengthened.

Most importantly, workplace health promotion interventions to reduce NCDs are proven to be effective. The World Health Organization (WHO) recommends 16 interventions called 'Best Buys' which are cost effective and feasible for implementation.[8] Workplace interventions targeting high-risk employees have shown to have the best impact.[9] Apart from WHO, many multinational companies have already implemented effective worksite health programs. Evaluating implementation feasibility and customization to Indian settings maybe required.

Apart from proven effectiveness to reduce NCD risk, worksite programs have added collateral benefits. From a management and business perspective, worksite NCD prevention programs are associated with decreased health-care costs, improved productivity and reduced absenteeism.[9] Though there is inconsistent evidence regarding Return On Investment (ROI), most studies reported positive ROI. For every dollar spent on worksite health promotion programs the savings ranged between US$1.88 – US$6.00.[10]

Many stakeholders in workplaces also perceive the need for NCD and mental health program for workplaces. A survey of 140 workplace stakeholders from across India, conducted in year 2019 revealed that >60% of stakeholders perceived that NCDs, NCD risk factors, mental health disorders and work-related stress are common health problems of workers, along with respiratory and musculoskeletal problems. Majority of stakeholders (95%) perceived a need for integrating NCDs in workplace health services and 97% expressed need for periodic screening for NCDs, their risk factors and mental health among employees. Of these 63% felt it was feasible to implement workplace NCD programs.[6]

Implications for the OH practice

India is home to 222,120 registered factories (factories under The Indian Factories Act).[11] where OH professional implement health services. Apart from factories, universities, multi-national IT companies and other large-sized workplaces are employing in-house OH staff to provide health services. These numbers are only expected to rise in coming years, hereby fueling need and demand for OH professionals in the country.

In the current epidemiological situation of NCDs in India, OH professionals will be invariably expected to plan, implement, monitor and evaluate NCD and mental health programs in workplaces, apart from implementing regular occupational health programs and basic occupational health services. This expectation is an opportunity to impact lives of 65% of population and their families. This opportunity can be viewed through different lenses but cannot be undermined. With service and IT sector growing by the day, expectation from OH professionals leans towards NCD prevention and ergonomics, rather than physical or chemical exposure-related disease prevention. This could result in paradigm shift in roles of OH medical officers, their career progression, financial growth and as well as training of OH professionals – it could well be the future of occupational health.

Commonly pursued capacity-building courses for OH professionals run for 3 months (Associate Fellow in Industrial Health) which is relatively short to effectively build capacities to meet expectations of the current workplace ecosystems. Strengthening capacities of the OH fraternity in primary NCD case management, epidemiology and public health along with industrial health is much needed to address the changing health priorities in workplaces. This requires redesigning of existing post-graduate courses, curriculum and skill sets to define “Occupational Health officer”. Laxity at this stage could risk an incremental dependence with internal medicine, community medicine and family medicine over time. In a broader sense, it is a key step to ensure human resource preparedness to manage the NCD epidemic in India and redefine future of OH practice in India.

Challenges and way forward

The opportunities to capitalize on 'the elephant in the room' have specific challenges. Workplace health systems and services function according to policies and specific legislations. Review of Acts and Rules enacted by the Ministry of Labour and employment reveal that NCDs are not mentioned specifically in these Acts. The recently passed 'The Occupational Safety, Health And Working Conditions Code, 2020[12] which consolidated and replaced 13 old central labor laws, also largely ignored NCDs and mental health disorders. This is a significant challenge to overcome.

However, caution needs to be exercised to not categorize and include NCDs as 'notifiable diseases', as they are a part of a larger macro-level ecosystem and not specific to occupational environment alone. The silver lining is that the National Programme on Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) specifically mentions the need for workplace interventions to reduce NCDs with some specific intervention components.

There is a need for debate, consensus and advocacy amongst OH professionals, Institutes of occupational health and stakeholder ministries to pursue integration of prevention of NCDs, NCD risk factors and mental health in workplaces. While legislative provision is a sustainable solution, availability of minimum set of guidelines for prevention and control of NCDs and mental disorders in workplaces to suit different categories of workplaces, would help in uniform interventions across the country. There is much benefit in establishing standard and periodic screening systems for NCDs, NCD risk factors and mental disorders in all workplaces in the country. Studies have indicated it is feasible to screen for NCDs and mental disorders in factories.[13] Health Management Information Systems (HMIS) for NCDs and mental disorders, as an off-shoot of screening mechanism would contribute to better NCD reporting in the country. Care has to be taken to align workplace HMIS systems for NCDs with National monitoring targets for NCD control and SDGs to ensure uniformity in NCD programming in the country and for reliable estimations of program effectiveness. For the unorganized sector, strengthening national programs (NPCDCS, National Mental Health Programme) to increase coverage in the existing primary health care systems with probable involvement of the Employee State Insurance health facilities is a feasible option.

Finally, the constitution of India is committed to safeguard health of workers in the directive principles of state policy (article 24, 39(e), 42, 43 and 43A)[6] and to provide secure humane working conditions, safety and health of employees. Integrating NCDs and mental disorders in workplace health systems is appropriate to achieve the constitutional mandate.