This article concerns interventions by health professionals in small workplaces (less than 50 employees). In Quebec, according to the Occupational Health and Safety Act, these interventions are conducted by health professionals (doctors, nurses, hygienists) located in public health units on a local or regional basis. For each workplace under their authority, these professionals must identify health hazards and recommend an occupational health program consisting of primary, secondary and tertiary prevention measures that should be approved by the workplace's joint health and safety committee before being implemented by the employer. Although this model of intervention is biomedical in nature, the context of the intervention places occupational health professionals in relationship with the socioeconomic actors in the workplace. Our research aimed to develop an understanding of the dynamics of undertaking occupational health in small firms, and of health professionals' interventions in such workplaces. There are very few studies on interventions in occupational health in small firms. A recent literature review by Hulshof et al. (1999) found no specific study of small businesses. The studies that do exist indicate a low degree of interest and involvement of employers regarding health and safety at work and highlight the importance for health professionals to build a relationship of trust with the employer and workers when intervening (Champoux and Brun 1999 ; Eakin 1997; Eakin and Weir 1995; Gignac 1997, 1996; Limborg and Hasle 1997). We used system theory and a psychodynamics-of-work approach to study occupational health interventions in small workplaces. Interventions were conceptualized as a process that should be influenced by two levels of inputs. At a first level, provisions of the Act and of the contract between the Health and Safety Board and the health units orient health professionals toward a biomedical model of intervention and the production of a relatively high quantity of occupational health programs. At a second level, inputs from the host-workplace, particularly the nature of health hazards and the process of undertaking health at work, should also influence the process of intervention, though we presume that, at this level, the first input (the nature of hazards) is more influential than the second (the dynamics of the process). The research was conducted in eight small industrial firms located in the province of Quebec, Canada. We use purposeful sampling in order to take into account: (1) different industrial sectors, (2) different firm sizes (less than 20, 20-50), (3) the presence or not of a union and of a joint health and safety committee. In each firm, data were collected through: (1) individual semi-structured interviews with the employer, supervisor, and the president of the union, (2) group semi-structured interviews with workers and the joint health and safety committee, (3) a closed-format questionnaire completed by a representative sample of workers (n = 126). In addition, interviews were also conducted with health professionals from the local health unit and with inspectors of the regional authority. Results presented in Table 2 show that the dynamics of health interventions in small workplaces are more diversified that one might expect. We distinguished between cultural aspects (attitudes and behavior of employers, supervisors and workers regarding health at work) and structural aspects (the presence of a joint health and safety committee, and basic prevention activities). There are substantial variations on both dimensions between firms. As for manager and worker perceptions of interventions by professionals in occupational health, some of them are common to most workplaces while others vary according to the cultural dimension of the dynamic of undertaking health at work in the workplace. Indeed, managers and workers from most workplaces consider that external health professionals do not take enough time to get an appropriate knowledge of the workplace before intervening and do not give efficient support in the implementation of the health program by the workplace. On the other hand, in workplaces with a stronger cultural dimension, managers and workers see external interventions as less useful than in workplaces with a weaker cultural dimension. However, in those latter workplaces, managers and workers do not perceive this usefulness in the same way. Health professionals interviewed largely agree with this critical evaluation regarding their insufficient knowledge of the workplace at the time of intervention, which is generally limited to health hazards, and their limited support in the follow-up of recommendations. They attribute these weaknesses to time constraints and a biomedical approach that orient them to focus on hazards and disregard other aspects of the workplace. On the other hand, they observe that workers do not have an adequate knowledge of workplace health hazards and they question the stated interest of employers for occupational health and safety, given that the latter resist meetings between health professionals and workers during the intervention and in the follow-up. Moreover, they feel that economic vulnerability of some small businesses forces them to face a dilemma: either apply the law and regulations strictly and endanger the survival of the business or apply the law with flexibility and potentially endanger workers’ health. In the light of these results, a renewed model of intervention in occupational health could be more appropriate and efficient in small workplaces. This renewed model would consist of the following five steps. First, before intervening, health professionals could get a basic knowledge of the small workplace by consulting existing data from the Occupational Health and Safety Board. Second, a short period of field observation and data collection should be conducted before intervention by the team of health professionals (doctor, nurse, industrial hygienist) in order not only to identify and measure health hazards, but to put those into the real socioeconomic context of the workplace. This period of observation should also enable professionals to interact with managers and workers and build a trust relationship, which is critical for the success of the intervention. Third, the team should analyse data on hazards and the context in order to fix priorities and the strategy for intervention. Fourth, the team should elaborate a health program that seeks to: (1) reconcile necessary actions on the most important hazards with the economic constraints of the workplace, and (2) provide means to strengthen the internal dynamic of promoting health at work in the small workplace. Finally, after having presented and discussed the health program, the team should fix with managers and worker representatives a follow-up protocol allowing professionals to give adequate support to the workplace and to evaluate the progress and results of their interventions. In conclusion, we discuss the organizational conditions for the implementation of this renewed model. Some require changes in the organization of work in occupational health units; others point to the need for better communication and coordination with inspectors from the Occupational Health and Safety Board
