Swedish Entrepreneurs Use of Occupational Health Services

by Kristina Gunnarsson, PhD, Ing-Marie Andersson, and Malin Josephson

RESEARCH ABSTRACT
Small-scale enterprises are less often covered by occupational health services and have insufficient awareness about health and risks in the work environment. This study investigated how Swedish entrepreneurs in small-scale enterprises use occupational health services. The study used a questionnaire sent in two waves, 5 years apart. At baseline, 496 entrepreneurs responded, and 251 participated 5 years later. The questionnaire included items about affiliation with and use of occupational health services, physical and psychosocial work environments, work environment management, sources of work environment information, and membership in professional networks. Only 3% of entrepreneurs without employees and 19% of entrepreneurs with employees were affiliated with an occupational health service. Entrepreneurs affiliated with occupational health services were more active in work environment management and gathering information about the work environment. The occupational health services most used were health examinations, health care, and ergonomic risk assessments. Affiliation with occupational health services was 6% at both measurements, 4% at baseline, and 10% 5 years later.

ccupational health services coverage for smallscale enterprises (i.e., fewer than 50 employees) in Sweden is 10% to 55%, depending on trade and size of the enterprise, compared to 75% for large enterprises (Swedish Work Environment Authority, Statistics Sweden, 2003). Although no legislation requires compaABOUT THE AUTHORS
Dr. Gunnarsson is occupational health nurse and Ms. Josephson is Associate Professor, Department of Occupational and Environmental Medicine, Uppsala University Hospital, Uppsala, Sweden. Ms. Andersson is Professor, Hgskolan Dalarna, School of Technology and Business Studies, Falun, Sweden. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. The authors thank Marianne Ekdahl, Elisabet Rydstedt, and Tobias Nordqvist, Department of Occupational and Environmental Medicine, Uppsala University Hospital, Uppsala, Sweden, for their assistance with this survey. Address correspondence to Kristina Gunnarsson, PhD, Department of Occupational and Environmental Medicine, Uppsala University Hospital, Uppsala, Sweden SE 75185. E-mail: kristina.gunnarsson@akademiska.se. Received: September 13, 2010; Accepted: July 12, 2011. doi:10.3928/08910162-20110927-02

nies to be affiliated with occupational health services, the structure and organization of occupational health services are described in Work Environment Law (Swedish Work Environment Authority, 2009). The provision of systematic work environment management requires occupational health professionals to have broad knowledge of work organization, behavioral science, ergonomics, health care, rehabilitation, and technology (Swedish Work Environment Authority, 2001, 2003). The main functions of this provision are to regulate and improve safety at work. Furthermore, no statutory requirements for quality standards of occupational health services exist in Sweden. A voluntary quality system, based on ISO 9001 and leading to certification issued by the official Swedish Accreditation Agency, SWEDAC, was introduced in 1996 (Westerholm, 1999). Occupational health services are not included in the public health care system in Sweden; instead, they are part of the free market. The Swedish public health care system is regulated by The National Board of Health and

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Applying Research to Practice

Occupational health service units can arrange networks for entrepreneurs in small-scale enterprises to encourage them to join occupational health services. Dialogue with occupational health services can increase entrepreneurs awareness of work environment risks and thereby increase the health and safety of workers, even in the smallest enterprises.

Welfare and organized by each of the 20 county councils in Sweden (The Swedish Board of Health and Welfare, 2011). All residents of Sweden choose a local primary care physician. If necessary, the primary care physician refers clients to other specialists in the hospital or to physiotherapists. However, primary care physicians and nurses working in public health have limited knowledge of physical or psychosocial work environments. Entrepreneurs and employees in small-scale enterprises also have limited understanding of work environment risks. Both entrepreneurs and employees can be exposed to adverse work conditions, as they often must work at all tasks within the enterprise (Antonsson, Birgersdotter, & Bornberger-Dankvardt, 2002; Hasle & Limborg, 2006). Small companies also experience few absences due to sickness; however, entrepreneurs and employees in small enterprises are not necessarily healthier than those in larger enterprises. The absence of any employee in a small enterprise can negatively impact production (Bornberger-Dankvardt, Ohlson, & Westerholm, 2003). Occupational health services are an important resource for improving the work environment and the health and safety of workers, even in the smallest enterprises (Bornberger-Dankvardt, Ohlson, Andersson, & Rosn, 2005). If affiliated with occupational health services, smallscale enterprises are most often part of units that provide services to companies of various sizes and with a variety of trades. Entrepreneurs affiliate with occupational health services for a variety of reasons (i.e., to improve workplace health and safety, improve employees health, and increase productivity) (Brosseau & Li, 2005). For farmers, the size of the farm, the owners level of education, and the workers chronic illnesses are factors associated with joining occupational health services (Kinnunen, Manninen, & Taattola, 2009; Thelin, Stiernstrm, & Holmberg, 2000). Entrepreneurs in small-scale enterprises are often unaware of occupational health services (Hasle & Limborg, 2006), which are not marketed to small enterprises because entrepreneurs may not find them useful (Antonsson et al., 2002). In Sweden, occupational health services are not funded by the government, so services are paid via an annual fee per employee levied on affiliated enterprises. Fee-for-service contracts or agreements imply that payment for services is due as they are purchased

and consumed. Block arrangements, access to a defined range of services and facilities provided in return for an annual fee, exist. The fee is commonly calculated as a standard cost per employee and negotiated between client companies and occupational health services. Such arrangements are common and are often supplemented by tariff lists of services that may be added to the standard package (Westerholm & Walters, 2007). Payment per employee sometimes creates economic problems for occupational health services, as the provision of service often takes more time per employee in small enterprises than in larger enterprises (Antonsson et al., 2002). The utilization of occupational health services can be an indicator of how entrepreneurs regard the value of these services. Entrepreneurs in small-scale enterprises affiliated with occupational health services consider rehabilitation, ergonomics, psychosocial tasks, and health care to be services required from occupational health services (Westerholm & Bostedt, 2004). General health examinations and health care provided by occupational health nurses and occupational physicians are most contracted; health examinations, as listed in the provisions of the Swedish Work Environment Authority, are purchased by many affiliated enterprises. Risk assessment and work environment risk education are requested less often (Josephson, Gunnarsson, Palm, & Rydstedt, 2007). For entrepreneurs, regional or local professional networks may be one way to improve worker health and safety in the company (Vinberg, 2006). A professional network provides opportunities to discuss topics of common interest and ideas on how best to provide care (Antonsson et al., 2002; Svensson, Jakobsson, & berg, 2001). New ideas on how to design attractive services could be gathered from information on whether entrepreneurs participating in professional networks are more likely to be affiliated with occupational health services or if the network may replace occupational health services. In a previous study, musculoskeletal pain and mental health issues were the most frequent health problems identified by the same cohort of entrepreneurs as in the current study from the middle region of Sweden, and were associated with poor job satisfaction and poor physical work environment (Gunnarsson, Vingrd, & Josephson, 2007). An association between self-reported good health and good social life was reported; other activities besides work are also important (Gunnarsson & Josephson, 2011). The entrepreneurs use strategies such as planning, control over work, and physical exercise to maintain health (Gunnarsson & Josephson, 2011). To promote affiliation of small-scale enterprises with occupational health services, the aim of this study using a two-wave questionnaire was to investigate how entrepreneurs in small-scale enterprises approach and use occupational health services. The research questions posed were: Do entrepreneurs affiliated with occupational health services have better or worse working conditions than entrepreneurs not affiliated with occupational health services? Was the affiliation with and use of occupational health services stable during the past 5 years?

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 Are entrepreneurs affiliated with occupational health services more active in professional networks and in work environment management? What sources do entrepreneurs use for securing information about work environment issues? METHODS This study involved a two-wave questionnaire distributed 5 years apart (i.e., baseline year 2001 and follow-up year 2006) to a single cohort. At baseline, the questionnaire was sent to 788 small-scale entrepreneurs identified from the customer register of an insurance company and located in the middle region of Sweden. Every tenth entrepreneur was selected from the register, including the following: agriculture; manufacturing; construction; retail; hotel and restaurant; transport; finance; education; health and medical services; and other services. Only 100 entrepreneurs from each trade were included. If necessary, the questionnaire was followed by two reminders. The response rate was 66% (n = 523). Of the respondents, 27 were excluded because of age (i.e., they were 65 years or older, the stated age of retirement in Sweden). Thus, at baseline, the group consisted of 496 small-scale entrepreneurs (Gunnarsson et al., 2007). In 2006, the same questionnaire, with three reminders if necessary, was sent to 466 of the 496 entrepreneurs who responded to the questionnaire at baseline. Three hundred six completed the questionnaire (i.e., response rate of 66%), of whom 55 had retired. Thus, 251 entrepreneurs participated both at baseline and 5 years later. The questionnaires included items about the entrepreneurs health and work conditions (Gunnarsson et al., 2007). The questions were from other surveys (e.g., Surveys of Living Conditions [Statistics Sweden, 2006] and the population study Life & Health [Life & Health, 2000]). For this study, ten questions were chosen about physical work environment, two questions about psychosocial work environment, six questions about work environment management, two questions about occupational health services, one question about membership in professional networks, four questions about work environment management, and two questions about gathering information on the work environment. Actual physical work environment was assessed by nine questions about how often the entrepreneur was exposed to the following factors: heavy lifting, noise, chemicals (including vapor and gas), repetitive data work, repetitive manufacturing work, work in difficult postures, vibrations, dust and smoke, and hot or cold work. Response options were every day, some days a week, seldom, and never. The options every day and some days a week were classified as exposed to the specific factor listed. In the tenth question, the entrepreneur was asked, How do you regard your current physical work environment? Response options were very good, good, poor, and very poor. The options poor and very poor were classified as poor physical work environment. Psychosocial work environments were evaluated by two questions about how the entrepreneur regarded time

pressure and mental strain. The response options were too high, high, low, and too low. The responses too high and high were classified as high time pressure and high mental strain. Affiliation with occupational health services and membership in professional networks were covered by two questions. Ten types of services traditionally offered by occupational health services were exemplified in the questionnaire. Activities in work environment management were evaluated by four questions. One question asked about performing safety inspection tours. Response options were never, if required, 1-2 times a year, 3-4 times a year, and more than 4 times a year. One question asked if action plans were current, a second was about having a written work environment policy, and a third was about discussing work environment with employees. Respondents provided 11 examples of information sources. Statistical calculations were completed using SPSS, version 17.0. Differences in work environment and work environment management between entrepreneurs affiliated and not affiliated with occupational health services were analyzed using the chi-square test. Where baseline and ongoing data analyses revealed similar frequencies and distribution, only baseline results are presented. The study was approved by The Regional Ethical Committee, Uppsala, Sweden. RESULTS The characteristics of the participating entrepreneurs at baseline and 5 years later are presented in Table 1. Most were men. Most had secondary or postsecondary education. Half of the entrepreneurs had employees, generally one to nine permanent or temporarily employed individuals. Ten trades were represented. Eleven percent were affiliated with occupational health services at baseline and 17% 5 years later. Only 3% to 4% of entrepreneurs without employees were affiliated with occupational health services. Being a member of a professional network was common39% at baseline and 46% 5 years later. Among entrepreneurs without employees, 34% were members of professional networks. The entrepreneurs were not consistently affiliated with occupational health services or professional networks. Only 6% of the 251 respondents were affiliated with occupational health services at both measurements. Four percent of the 251 were affiliated only at baseline and 10% were affiliated only 5 years later. Membership in professional networks was 31% at both baseline and 5 years later. Ten percent were members only at baseline and 16% were members only 5 years later. Of the members of professional networks at baseline, 17 (17%) had joined occupational health services 5 years later, compared with 10 (7%) not being members of professional networks at baseline (p = .05). Only 10 of the 248 entrepreneurs without employees were affiliated with occupational health services on at least one occasion. In the analyses of the occupational health services used and differences in work conditions

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Table 1

Characteristics of the Entrepreneurs Responding to the Questionnaire in 2001 and 2006

2001 All (n = 496)
Age (years) M SD Gender Male Female With permanent employees 1-4 5-9 10-19 20-49 With temporary employees 1-4 5-9 10-19 20-49 Education
a

2006 All (n = 251)

47.8 9.6 (n = 250) 172 (69%) 76 (31%) 173 (69%) 77 (31%) 116 (46%) 88 (76%) 28 (24%) 116 (100%) 64 (55%) 21 (18%) 6 (5%) 10 (9%) 62 (53%) 8 (7%) 6 (5%) 4 (3%) (n = 246) 71 (28%) 88 (35%) 87 (35%) 34 (29%) 35 (30%) 47 (41%) 10 (9%) 16 (14%) 12 (10%) 7 (6%) 9 (8%) 17 (15%) 9 (8%) 7 (6%) 20 (17%) 9 (8%) 37 (32%) 64 (55%)

With Employees (n = 248)

46 10

With Employees (n = 116)

52.4 9.5

47.3 9.9 (n = 493) 340 (69%) 153 (31%) 248 (50%)

248 (100%) 138 (56%) 36 (15%) 21 (9%) 19 (8%) 105 (42%) 20 (8%) 14 (6%) 11 (4%)

Compulsory school Upper secondary school Postsecondary Trade Agriculture Manufacturing Construction Retail Hotel and restaurant Transport Finance Education Health and medical services Other services Affiliated with occupational health services Member of professional network
Note. aNot asked for in 2001.

40 (8%) 59 (12%) 61 (12%) 41 (8%) 53 (11%) 58 (12%) 43 (9%) 42 (9%) 53 (11%) 46 (9%) 56 (11%) 193 (39%)

14 (6%) 23 (9%) 20 (8%) 15 (6%) 47 (19%) 38 (15%) 20 (8%) 12 (5%) 42 (17%) 17 (7%) 46 (19%) 110 (44%)

20 (8%) 38 (15%) 32 (13%) 21 (8%) 11 (4%) 29 (12%) 19 (8%) 24 (10%) 27 (11%) 30 (12%) 42 (17%) 116 (46%)

and work environment management activities between affiliated and non-affiliated entrepreneurs, only entrepreneurs with employees were included.

The most common adverse work conditions reported by entrepreneurs were high time pressure (i.e., more than 80%) and high mental strain (i.e., approximately 70%).

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Table 2

Differences in Affiliation With Occupational Health Services Between Entrepreneurs With Employees (n = 248) Reporting Adverse Working Conditions or Not in 2001
Self-Reported Factor in Work Environment
Heavy lifting (> 25 kg) Noise Chemicals Repetitive office work Repetitive manufacturing work Loading work posture Vibrations Dust and smoke Hot or cold work Poor physical work environment Time pressure High mental strain

Entrepreneurs Reporting Adverse Working Conditions

105 90 41 48 31 76 46 59 45 27 204 175

Entrepreneurs Affiliated With OHS

18 (40%) 17 (42%) 7 (16%) 6 (13%) 7 (15%) 10 (22%) 10 (22%) 9 (20%) 5 (11%) 4 (9%) 40 (87%) 33 (75%)

Entrepreneurs Not Affiliated With OHS

87 (45%) 73 (39%) 34 (18%) 42 (22%) 24 (13%) 66 (34%) 36 (19%) 50 (26%) 40 (21%) 23 (12%) 164 (85%) 142 (74%)

p
.57 .75 .72 .19 .64 .13 .65 .36 .12 .61 .73 .93

Note. Due to internal missing in the specific items, the number of respondents varied between 229 and 240. The differences were analyzed using the chi-square test. OHS = occupational health services.

No significant differences in reported adverse work conditions between affiliated and non-affiliated entrepreneurs were found. At baseline, the most pronounced tendency was a difference in loading work postures. The results from baseline are presented in Table 2. Data from the second questionnaire revealed similar results. No significant differences between affiliated and non-affiliated entrepreneurs were found (data not shown). Among possible occupational health services, those most used at baseline and 5 years later were ergonomic risk assessments, physical work environment stress for psychosocial factors, and health examinations and health care in health services (Table 3). Activities in work environment management (i.e., performing safety inspections 1 to 5 times a year, producing action plans for improving the work environment, developing a written work environment policy, and formally discussing work environment management at personnel meetings) were more common among entrepreneurs affiliated with occupational health services than entrepreneurs not affiliated with occupational health services (Table 4). Affiliated entrepreneurs were more informed about work environment issues (84%, n = 38) than those not affiliated with occupational health services (61%, n = 119; p = .003). Differences in the way entrepreneurs gathered information were identified. Entrepreneurs affiliated with occupational health services secured information from regional safety representatives and employers associations.

Entrepreneurs not affiliated with occupational health services informed themselves through newspapers. Both affiliated and non-affiliated entrepreneurs reported gaining information from provisions and trade journals (Table 4). Five years later, the results were similar, except that using the Internet to obtain information was higher among affiliated entrepreneurs (67%) than non-affiliated entrepreneurs (35%; p = .004). DISCUSSION This study confirmed that health examinations, health care, and ergonomic risk assessments were the most used occupational health services. However, entrepreneurs affiliated with occupational health services reported using more services associated with work environment management (i.e., performing risk assessments, creating action plans, and developing work environment policies). No differences were found in reported adverse work conditions between entrepreneurs affiliated and not affiliated with occupational health services. Information about the work environment was obtained from regional safety representatives and employers more often among entrepreneurs affiliated with occupational health services than entrepreneurs not affiliated with occupational health services or members of professional networks. This study had several limitations. Generalization of the results requires caution, as participating entrepreneurs were drawn from an insurance companys customer register, which may indicate that participants were more in-

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Table 3

Use of Occupational Health Services by Entrepreneurs With Employees Affiliated With Occupational Health Services in 2001 (n = 46) and 2006 (n = 37)
Type of OHS Service
Issues about Chemical risks Physical work environment Ergonomic risk assessments Psychosocial factors Stress Bullying Cooperating problems Violence and menace Job satisfaction Health services Health examinations Health care Rehabilitation 37 (80%) 32 (86%) 36 (78%) 28 (76%) 25 (54%) 18 (49%) 27 (59%) 19 (51%) 8 (17%) 11 (24%) 12 (26%) 5 (14%) 8 (22%) 5 (14%) 11 (24%) 6 (16%) 14 (30%) 13 (35%) 29 (63%) 24 (65%)

Using OHS in 2001

Using OHS in 2006

20 (44%) 12 (32%)

Note. OHS = occupational health services.

terested in the work environment. The entrepreneurs also represented different trades, which could have resulted in varying demands on occupational health services. However, low affiliation with occupational health services was similar to other studies (Antonsson & Schmidt, 2003, Fedotov, 2005; Swedish Work Environment Authority, Statistics Sweden, 2003), strengthening the validity of these results. An additional limitation was that findings were based on self-reported data, which may lead to information bias due to recall bias or social desirability response bias. Entrepreneurs often consider their own work environments better than average in the trade (Blomqvist & Johnsson, 2003). Entrepreneurs affiliated with occupational health services may also have more knowledge about work environment management and therefore may overreport activities in that area. The two-wave questionnaire was a strength in this study. Data from two occasions 5 years apart indicated consistent work conditions, how companies used the occupational health services, and activities in work environment management. Results were similar for the two surveys. However, variations in affiliation with occupational health services and membership in professional networks were found. The response rate for the two surveys (66%) was considered acceptable for the target group. No differences were found between affiliated and

non-affiliated entrepreneurs in reporting work environment exposures. Although adverse work conditions would be expected to attract entrepreneurs to affiliate with occupational health services, this was not supported by this study. One reason could be the entrepreneurs lack of knowledge about the kind and quality of services available. However, a tendency at baseline was that entrepreneurs affiliated with occupational health services reported less loading work posture, which could be explained by use of the ergonomic risk assessment service. Two of the services most utilized were health examinations and health care. Small enterprises are interested in these services (Antonsson & Schmidt, 2003; Hino et al., 2005) because they are vulnerable to illness or injury absences. Prevention is less expensive than treatment (Fedotov, 2005) and could be one approach for occupational health services with small enterprises. Another barrier to affiliation with occupational health services could be occupational health services lack of responsiveness to smallscale enterprise needs. Advisers are often mentioned by entrepreneurs as a cornerstone for improving health and safety (Bornberger-Dankvardt et al., 2003). The entrepreneurs in this study were not consistently affiliated with occupational health services, and entrepreneurs affiliation with occupational health services over time is not well reported. A common assessment of small enterprises may demonstrate they are loyal to the occupational health service unit to which they are affiliated. However, entrepreneurs are aware of the cost of occupational health services in proportion to the value obtained. This could be a reason for occupational health services to measure consumer satisfaction in their effort to affiliate with and maintain small enterprises as customers (Verbeek et al., 2001). The entrepreneurs included in this study were mainly voluntary members of professional networks rather than affiliated with occupational health services. Networking may be more suitable for entrepreneurs in small-scale enterprises, as professional networks have voluntary membership and an open structure (Svensson et al., 2001). Issues concerning production are often the main reason for becoming a network member; however, health and safety are important issues for entrepreneurial networks (Gunnarsson, Andersson, & Rosn, 2010; Kurppa et al., 2006; Vinberg, 2006). In 2006, many entrepreneurs newly affiliated with occupational health services had previously been members of professional networks. This presents an opening for occupational health services to launch health and safety networks for entrepreneurs in small enterprises. Entrepreneurs without employees were rarely affiliated with occupational health services, and neither were included in regulations about work environment nor received visits from regional safety representatives. Thus, they must identify risks in the work environment themselves. The entrepreneurs affiliated with occupational health services reported more active work environment management. This finding appeared inconsistent as entrepreneurs reported health examinations and health care as the occupational health services most utilized. Affiliation with occupational health services may have increased entre-

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Table 4

Work Environment Management Activities Among Entrepreneurs With Employees in 2001 (n = 248) Affiliated With Occupational Health Services (n = 46), Not Affiliated With Occupational Health Services (n = 195), and Internal Missing (n = 7)
Self-Reported Activity
Safety inspection tour 1 to 5 times per year If required Never Internal missing Making action plans Yes No Internal missing Having a written work environment policy Yes No Internal missing Discussing work environment with employees During personal meetings with formal agenda Informal discussions No discussions Internal missing Informing themselves about work environment issues Source of information Newspapers Provisions Trade journals Seminars Radio TV Internet Regional safety representatives Employer associations Sellers Exhibitions 96 105 130 27 72 94 36 31 89 28 49 16 (42%) 29 (76%) 30 (79%) 10 (26%) 16 (42%) 17 (45%) 9 (24%) 13 (34%) 28 (74%) 6 (16%) 11 (29%) 80 (67%) 76 (64%) 100 (84%) 17(14%) 56 (47%) 77 (65%) 27 (23%) 18 (15%) 61 (51%) 22 (19%) 38 (32%) .006** .156 .469 .087 .594 .029 .899 .010** .015* .705 .730 37 142 62 0 157 16 (35%) 27 (59%) 3 (7%) 0 38 (84%) 21 (11%) 115 (59%) 59 (30%) 0 119 (61%) .003** .000*** 46 164 31 19 (41%) 23 (50%) 4 (9%) 27 (14%) 141 (72%) 27 (14%) .000*** 68 112 61 23 (50%) 18 (39%) 5 (11%) 45 (23%) 94 (48%) 56 (29%) .001*** 51 113 52 25 17 (37%) 22 (48%) 3 (7%) 4 (9%) 34 (17%) 91 (47%) 49 (25%) 21 (11%) .005**

Entrepreneurs Reporting Activities

Entrepreneurs Affiliated With OHS

Entrepreneurs Not Affiliated With OHS

Note. Differences in activities between entrepreneurs affiliated and not affiliated with occupational health services were analyzed using the chi-square test. OHS = occupational health services.*p < .05. **p < .01. ***p < .001.

preneurs interest in working with safety issues and they could have initiated this themselves or with help from

other safety intermediaries. Most entrepreneurs who did not respond to the questions about activities in work en-

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vironment management were not affiliated with occupational health services. Therefore, not responding could be due to not understanding the questions. A highly motivated entrepreneur is a prerequisite for improving health and safety in small-scale enterprises (Hedlund, teg, Andersson, & Rosn, 2010). Increasing interest in and motivation for improving the work environment and health and safety in small enterprises is an important issue for occupational health services. In the SYTY Project in Finland (Palmgren & Kaleva, 2009; SYTY2000, 2009), a key factor was to engage entrepreneurs in risk assessment, prevention of risks, and improving the work environment. Another important factor for improving health and safety was to involve employees, who are experts in their own workplace and may have valuable ideas about improvements (Birgersdotter, Schmidt, & Antonsson, 2002; Fedotov, 2005; Frick & Walters, 1998; Gunnarsson et al., 2010). Occupational health services should provide information about work environment. In this study, entrepreneurs affiliated with occupational health services appeared more aware of how to find information about health and safety (e.g., via the Internet and from regional safety representatives). In Sweden, regional safety representatives visit every small-scale enterprise with up to 50 employees once a year to provide specific information and conduct risk assessments. These visits are not dependent on affiliation with occupational health services and the entrepreneur may be more open to the information provided. In this study, Swedish conditions were examined. Variations in national approaches to occupational health services may depend on how safety at work is organized and how public health is regulated. In many European countries in the past 15 years, the focus for health and safety at work has changed. Obligation and subsidiaries from the state to be affiliated with occupational health services have been alternated (Westerholm & Walters, 2007). No differences in work conditions were found between affiliated and non-affiliated entrepreneurs. The occupational health services most utilized were health examinations, health care, and ergonomic risk assessments. However, entrepreneurs affiliated with occupational health services were more active in work environment management and chose more specific information sources about the work environment. Being a member of a professional network appeared to be a first step in affiliating with occupational health services. IMPLICATIONS FOR OCCUPATIONAL HEALTH NURSES Small-scale enterprises are less likely to affiliate with occupational health services. Occupational health service units need new strategies to interest small-scale entrepreneurs to join occupational health services. Smallscale entrepreneurs are less likely to join professional networks. One strategy might be to arrange networks for the smallest enterprises so that health and safety at work as well as other issues about managing small businesses

can be discussed. By establishing a dialogue with entrepreneurs, occupational health services can increase their awareness of risks in the work environment and thereby provide services other than health care and health examinations. Occupational health nurses in Sweden are well educated about work environment issues (rebro University, 2011) and are often responsible for bringing companies and occupational health services together. Knowledge of small-scale enterprises is crucial for effective occupational health care to improve health and safety in the smallest enterprises. REFERENCES

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