research articles on health and safety

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• Published: 25 November 2022

A study on occupational health and safety

• Lídia Maria Costa Araújo Magalhães 1 ,
• Ketyllem Tayanne da Silva Costa   ORCID: orcid.org/0000-0003-0304-2639 2 ,
• Gustavo Nepomuceno Capistrano 2 ,
• Maryanna Damasceno Leal 3 &
• Fábia Barbosa de Andrade 4  

BMC Public Health volume  22 , Article number:  2186 ( 2022 ) Cite this article

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This study aimed to evaluate and describe the indicators of occupational health, with a focus on the medical expertise and periodic medical examination.

This is exploratory-descriptive, cross-sectional, documentary, quantitative, and retrospective research, in the historical series: 2011 to 2015.

The number of lost days of work per worker and the frequency of licenses increased despite the decrease in the Absenteeism Duration Index and stabilization of the Frequency of Medical Workers. As for the adhesion of the workers to the Periodic Medical Examinations, it was decreasing, with a higher percentage in the year 2012 (35.3%). During the analyzed period, 5,186 workers performed the Periodic Medical Examination, and the majority (60.6%) presented non-ideal weight, 41.1% were sedentary, 33.2% had dyslipidemia, 29.0% were alcoholic, 3.2% were smokers, 5.9% had diabetics, and 16.4% reported high noise in the workplace, 27.8% inadequate lighting and 35.9% inadequate work furniture.

Conclusions

The results highlight the need to maintain and strengthen the Worker Health and Safety Policy with emphasis on surveillance, aiming at the promotion and protection of the health of the workers, based on the elaboration of the epidemiological profile of health and, consequently, the implementation of positive impact strategies.

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Introduction

Historically, in Brazil, Occupational Health and Safety (OHS) is strongly associated with the political-social and economic evolution of the country and is presented as the achievement of rights resulting from claims and struggles of the workers. Work is one of the determinants that most impact man’s conditions, quality of life, and health.

Working is essential for human beings since it is the way in which respect, integration, sociability, recognition, and bonds of friendship are obtained. On the other hand, the living conditions of Brazilian workers are aggravated by the alternation of stages of growth and accelerated industrialization with moments of recession, resulting in the government’s adoption of adjustment measures and financial cuts in social policies, such as education, health, safety, transportation, housing, and work, among others [ 1 , 2 ].

Nowadays, the epidemiological profile of workers' morbidity and mortality in Brazil is characterized by the coexistence of diseases that have an intrinsic relationship with working conditions: diseases related to work and typical work accidents, which have their frequency, appearance, and severity modified by the activity. Added to this reality are diseases common to the population as a whole, which have no etiological relationship with work [ 3 ].

Health Promotion and Surveillance refer to the pillar of the Occupational Safety and Health Care Policy (PASS, in Portuguese) that encompasses quality of life and vigilance actions in the environmental and work processes. Standing out among these are the institution of guidelines and programs in the area of mental health and occupational diseases of higher prevalence; the mandatory provision of Periodic Medical Examinations (PME) for all employees; the training in health and safety at work; the creation of an Internal Committee on Health and Safety at Work and a survey of environmental risks, with a stimulus to the active participation of employees in processes involving their health [ 4 , 5 ].

The PME aims, mainly, the prevention, enabling the health surveillance of the employees of a certain company or institution, contributing to the early identification of diseases related or not to work. It is carried out by an occupational doctor and employers must provide examinations for employees at specific times such as dismissal, admission, leaves of absence or change of function, in addition to periodic examinations, which will vary in frequency according to the workers' age (every two years for those between 18 and 45 years old and annually for those outside this age group) [ 6 ].

The PME is performed through clinical examinations, anamnesis, general and specific laboratory tests, according to the function developed by each worker. In addition, the occupational physician must adapt the exams to the particularities of each case, for example, people with disabilities or people who work with noise and may experience deafness caused by this fact. The result of the PME is not given by score or a question of approve or disapprove workers, it is related to the early diagnosis of health problems [ 6 ].

It is noteworthy that the information generated during the expertise act are important indicators of worker's health, privileged instruments for the construction of the morbidity and mortality profile of public servants, which will help to conduct the development of health promotion actions, since the expert databases issue a variety of data on the most prevalent diseases and the professionals who get sick [ 7 ].

It is of great importance to deepen the study in relation to the health of the federal public servant, considering the need to research, know and analyze the determining and conditioning factors of health problems related to processes and work environments. In this way, it is important to analyze workers' health indicators, which are reflections of the real health conditions of the server, with the objective of guiding managers in the planning and control of activities, in addition to allowing deductions regarding the effects of decisions and their results.

From this perspective, this study aimed to evaluate and describe occupational health indicators focusing on the Official Health Expertise and PME of federal public servants, including professors from the institution and administrative technicians from the education sector of the Federal University of Rio Grande do Norte.

Materials and methods

This is a cross-sectional, retrospective study with a quantitative approach, where secondary data were obtained regarding PME and official health expertise, specifically the SIAPE HEALTH module of federal public servants of a public institution of higher education in Brazil.

The information contained in this system is federal level and is entered by the experts who perform the exams, uploading them directly into the system, enabling access to the information by users. For the study, secondary and aggregated data from the SIAPE SAÚDE system database were evaluated, as well as management reports made available by the SIASS Unit (Subsistema Integrado de Atenção à Saúde do Servidor) from UFRN, responsible for storing such data.

The study was carried out at the Federal University of Rio Grande do Norte, Central Campus, especially at the Directorate of Attention to Servant Health (DAS), where the SIASS Unit is located, the latter being responsible for coordinating actions in attention to the health of the institution's servants, specifically, the performance of the Periodic Medical Examination and the Official Health Survey, objects of this study.

The period chosen for the study was from 2011 to 2015. The preference for this time interval was justified by the fact that the year 2011 marks the beginning of the PME through the computerized system SIAPE HEALTH, and the end of the study period in 2015 characterizes five complete years and the historical nature of epidemiological studies.

The population chosen for the study can be divided into levels of education, the teachers, technical-administrative in education, higher level positions are level E, while the technical-administrative in education, middle and basic level positions are levels C and D.

The official health expertise and the PME were used as a dependent variable. For each indicator, independent variables were selected: a) Official Health Expertise: gender, age, position, number of active statutory employees away, number of days of leave and number of days away; and b) PME: Gender, age, position, ethnicity, smoking, physical activity, BMI, hypertension, diabetes mellitus, dyslipidemia, spinal pain, inadequate furniture, inadequate lighting, likes what you do, good relationship with the boss, good relationship with colleagues and fast pace. In addition, the following indicators were observed: Absence Severity Index (IGA), Medical Frequency Leave (FML), Frequency of Workers on Sick Leave (FWML) and Absenteeism Duration Index (IDA), as recommended by the Permanent Commission and International Association on Occupational Health [ 8 ] and the authors Hensing et al. [ 9 ].

The information was obtained from Microsoft Excel spreadsheets, being possible to organize and sort the variables into categories. Then, the data were exported and analyzed in the software Statistical Package for the Social Science (SPSS). Relative and absolute frequency distribution was used for categorical variables, as well as measures of central tendency (average), measures of dispersion (standard deviation), and student's t-test for quantitative variables.

For data analysis, the chi-square test and the calculation of the odds ratio were used for correlation of the indicators, adopting a confidence interval of 95% and a significance level of 5% ( p  < 0.05) for all tests.

Concerning the ethical aspects, the project was submitted to the Research Ethics Committee of Federal University of Rio Grande do Norte where it was appraised and subsequently approved under opinion no. 1.707.691, from the principles of ethical and legal aspects that govern scientific research on human beings, as recommended by Resolution no. 466/12 [ 10 ], and the principles expressed in the Declaration of Helsinki.

The results showed that there were 4,293 (35%) departures from administrative records and 7,946 (65%) absences from work granted by expert examination.

This expert examination is a procedure carried out by a medical expert, whose function is to identify if there is the presence of an illness or to identify if there has been an accident that has made you totally or partially, temporarily, or permanently unable to perform your professional activities [ 11 ]. The magnitude of these absences can be portrayed when we calculate the sum of lost work time over the five years, which generated 179,916 days of absenteeism due to illness.

Data regarding the sociodemographic characteristics of the studied population revealed that 67.9% (8,312) of the departures occurred in female workers and, for males, 32.1% (3,927). Regarding the age group, 34.6% (4,234) of the licenses were approved for workers between 51 and 60 years old, 24.0% (2,934) from 41 to 50 years, 19.2% (2,355) from 31 to 40 years, 11.8% (1,449) from 18 to 30 years, and 10.4% (1,267) over 60 years.

In relation to the post variable, the number of workers occupying the position of administrative technician in education levels C and D predominated, with a prevalence of 62.2% (4,941), while 23.8% (1,889) workers were in higher-level positions.

Figure  1 shows the absence of workers at work due to health care in the period from 2011 to 2015. It is noteworthy that there is an increase between 2011 and 2013, when there is a peak of 7.1 days not worked. The following years show an oscillation, but with a tendency for growth.

Source: Elaborated by the Authors

Indicators of absenteeism, 2011–2015. Natal/RN, Brazel, 2017. Legend IGA = Absenteeism Severity Index; FLM = Frequency of Medical Licence; IDA = Absenteeism Duration Index; FTLM = Frequency of Workers on Medical Licence.

In this sense, it is also relevant to present the individual absence duration, according to the cause of illness, in order to facilitate the adoption of specific measures focused on the pathologies with the greatest impact on lost days of work. Figure  2 shows the IDA according to each International Classification of Diseases (ICD), 10 chapter, and the highest indexes refer to neoplasms (45.64), mental disorders (32.40), congenital malformations (27.00), and diseases of the circulatory system (23.96), respectively. These findings reveal that absences of longer duration were caused by pathologies of a chronic non-transmissible nature, except for causes of absences in chapter XVII of ICD-10.

Source: Elaborated by the author

Distribution of IDA, 2011–2015. Natal/RN, Brazil, 2017. Legend: C = ICD.10 chapter.

Figure  3 presents the results of this study regarding the adherence of the workers to the Periodic Medical Exam (PME), considering the historical series from 2011 to 2015, when an average of 4,362 workers were called.

Source: Elaborated by the authors

Distribution of call, adhesion, non-adhesion, and coverage ratio to PME, 2011–2015. Natal/RN, Brazil, 2017.

The Periodic Medical Exam consists of the periodic clinical and laboratorial evaluation of the worker, due to the existing risks in the work environment and occupational or professional diseases. The PME foresees the adoption of prevention, tracking, and early diagnosis measures for work-related diseases, besides those more prevalent in the general population, such as diabetes mellitus, hypertension, neoplasms, dyslipidemias, and ophthalmologic diseases. Also, the PME will be carried out during working hours, without any burden or need for compensating schedules on the part of the employees. It is important to point out that absenteeism is taken into consideration only due to the worker's personal illness, and this diagnosis cannot be related to someone in the employee's care.

Regarding the operationalization for the PME, it is important to mention that at the moment the server is called for the evaluation of occupational health, through personal e-mail, he/she must fill out the consent form as a way to prove the agreement to participate in periodic medical examinations. Thus, going from the situation "INVITED" to "CONFIRMED". It is worth pointing out the importance and potential of the PME, once it allows the early identification of risk factors for getting sick, as well as the construction of collective diagnoses in the Worker's Health area, which makes this action a health management instrument, for monitoring the health situation and work conditions, and the subsidies for interventions to improve the quality of life of the workers.

It can be observed that the call-up ratio increased by 42.0% from 2011 (0.49) to 2012 (0.91). From the year 2013 (0.84), there were oscillations characterized by drop and growth in the calls.

As for non-adherence, in 2012, there was a decrease, and in 2013 (0.78), 2014 (0.8), and 2015 (0.86), there was an increase in the results, characterizing a relevant increase of 15. 0% between the years of 2011 (0.71) and 2015 (0.86).

About PME membership, it is clear that growth occurred only in 2012 (0.35). Then, the index decreased throughout the series, namely: 2013 (0.22), 2014 (0.2) and 2015 (0.14), which explains the non-adherence data, that comprehends the number of called servers that didn't do the PME in the analyzed year, having as reference the total number of UFRN's servers summoned in the evaluated year as being an unfavorable reality in relation to the PME recommendation. This may be related to factors such as excessive work activities of workers, periodic examinations performed through private health insurance, and to the lack of recognition of the importance of PME by workers.

The coverage ratio of the PME represents the servers that have concluded the PME and those that have an updated Occupational Health Certificate in the analyzed year, with the total number of servers at UFRN in the analyzed period as a reference. This coverage ratio increased significantly in the year 2012 (0.4), showing a growth of 26.0% in relation to 2011. Thereafter, the ratio decreased, with an average of 0.26 between the years of 2013 (0.33), 2014 (0.26) and 2015 (0.2), as shown in Fig.  3 .

In the list of risk factors, health indicators of different epidemiological natures were analyzed. Among them, those related to cardiovascular diseases and occupational risk factors, such as the existence of inadequate work furniture and accelerated work rhythm, are presented in Tables 1 and 2 .

In the list of chronic pathologies covering categories II and III of the Schilling classification, the most common causes of morbidity among workers are: Systemic Arterial Hypertension (SAH), chronic respiratory diseases, diseases of the locomotor system and mental disorders. These are pathologies of multiple etiology in which work is considered a risk factor associated with the increased probability of occurrence of these diseases [ 12 ]. Thus, the present study highlights cardiovascular diseases, especially SAH.

Table 1 shows the distribution of the aforementioned risk factors associated with SAH. It is pointed out that 60.6% (3,143) of the workers that performed the EMP presented non-ideal weight; 58.7% (3,044) practiced some type of physical activity; 70.8% (3,670) denied alcohol use; 96.5% (5.005) did not smoke; 93.9% (4,870) did not have diabetes mellitus (DM); and 66.6% (3,453) did not have dyslipidemia. The association between hypertension and all correlated variables was significant at p  < 0.001. As for the Odds Ratio calculation, we considered the hypertension disease in relation to the following variables: BMI, sedentary lifestyle, alcoholism, smoking, diabetes, and dyslipidemia. The OR calculation does not imply a cause-and-effect relationship, it only suggests that there is an association.

In Table 2 , it is possible to observe that 35.9% of the interviewed workers are not adequate for their activities. In addition, 16.4% report loud noise in the workplace and 27.8% do not have adequate lighting. Social factors were also obtained, noting that 3.7% of the workers surveyed say they do not have a good relationship with their co-workers, while 4.4% do not have a good relationship with their boss and 2.5% show dissatisfaction with what they are doing.

It should be noted that absenteeism is a term used to denote the employee's absence from work [ 13 ]. The International Organization of Work (OIT) defines it as the period of absence of work that is accepted as attributable to an incapacity of the individual, except for that derived from normal pregnancy or prison [ 14 ].

According to the report of the National Audit Office [ 15 ], in the city of Guernsey, United Kingdom, approximately 3.8% of working time was lost due to illness, and civil workers became sick for an average of 8.7 days in 2005. In Chile, health workers belong to the category that has the highest rates of disability due to illness, with 14.3 days of absence per worker per year; unlike the university workers, who present 6 days of work lost per year, similar to the results of this research [ 16 ]. These findings highlight the data shown in Fig.  1 .

Studies found an average of 7.5 lost days of work per year per worker in the nursing area of a university hospital in Brazil [ 17 ]. Santos and Mattos [ 18 ] observed 9.3 days of absenteeism due to disease for each municipal worker of the city of Porto Alegre in 2005. The studies reported 9.1 and 10.3 days of absence due to illness for each public worker of the municipalities of Goiânia and São Paulo, respectively [ 19 , 20 ].

The worker and financial conditions can cause work accidents and environmental conditions, increase work capacity and the market, which may exclude work and consumption capacity. The employee is also hit with productivity, lack of manpower, loss of manpower and/or equipment damage [ 21 ].

The World Health Organization (WHO) estimates about 36 million annual deaths from Chronic Non-Communicable Diseases (NCDs), composed mainly of circulatory diseases, neoplasms, chronic respiratory diseases and Diabetes Mellitus (DM), which have risk factors.—smoking, alcohol, physical inactivity, unhealthy diet and obesity—modifiable in common [ 22 , 23 ].

An important characteristic of epidemiological patterns in Brazil concerns the changes in the composition of morbidity and mortality by groups of causes. Thus, the high prevalence of deaths from infectious and parasitic diseases, present at the beginning of the twentieth century, gave way to NCDs and injuries related to accidents and violence [ 24 ].

In Brazil, according to the Ministry of Health [ 23 ], NCDs are among the main causes of hospital admissions, and the financial cost to the Unified Health System (SUS) represents a growing impact. Estimates for Brazil suggest that the loss of productivity at work and the decrease in family income resulting from chronic pathologies such as diabetes, heart disease and stroke involved spending of US$ 4.18 billion between 2006 and 2015 [ 25 ].

The researchers Moura, Carvalho and Silva (2007) [ 26 ] carried out a study on the repercussion of CNCDs in the granting of social security benefits by the National Institute of Social Security (INSS) and identified musculoskeletal and circulatory system diseases as the main causes for granting sick pay.

This reality is also revealed among public servants in several studies that present the main groups of causes of sick leave for this category of workers, with high rates of absenteeism due to diseases of the musculoskeletal system and connective tissue, mental and behavioral disorders, chronic respiratory diseases and circulatory system diseases [ 7 , 19 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].

The implementation of strategies to reduce absenteeism is a great challenge for employers, and it is necessary to analyze the events in the workplace to delineate situational diagnoses and guarantee actions to promote worker health. For the authors, the change in the epidemiological profile of illness and the increase in the prevalence of chronic diseases, as shown in Fig.  2 , reveal concern for the global scenario regarding the impact of these diseases on workers' health, due to the growth in the number of lost workdays [ 21 ].

The epidemiological profile of morbidity and mortality in Brazilian workers is characterized by the coexistence of diseases that have an intrinsic relation with working conditions, and in addition, diseases common to the population are observed, which are not etiologically related to the work [ 3 ]. In this reality, it is important to emphasize the importance of the employees performing the Periodic Medical Examination (PME), for the prevention and/or possible early detection of the pathologies that generate the greatest impact on the lost days of work, highlighting the neoplasms [ 22 ].

The importance of performing the PME in the screening of risk factors for chronic non-communicable diseases, such as dyslipidemia, sedentary lifestyle, obesity, arterial hypertension, diabetes mellitus, alcoholism, and smoking is highlighted. In addition, through the PME, the workers will be guided and sent to participate in the various health promotion programs offered by the institution. Through these strategies, it is possible to reduce the prevalence of diseases of the circulatory system, another important cause of absenteeism, as shown in Fig.  2 .

As for Fig.  3 , which shows data on the PME, despite weaknesses, it is evident that the most satisfactory results of PME adherence occurred in the year 2012, a time when workers composed the Integrated Subsystem Unit (SIASS in Portuguese), as well as the constant discussion in forums, national meetings, and events related to the PASS, in a context of articulation in defense of the strengthening of the actions of attention to workers' health, which may have contributed to the results [ 23 , 24 , 25 ].

On the other hand, the situational diagnosis of low PME adherence throughout the historical series was possibly influenced by the recent history of PASS construction and the negative impact of the lack of structuring, planning, and evaluation of the actions. Plus, the largest investments and training, by the Ministry of Planning of Brazil, were related to the expert area which reflects as the main activity of the PASS [ 4 ].

The implementation of actions of health surveillance and promotion are major challenges for the consolidation of SIASS, since it is still a recent practice to promote health in public sector workplaces. It is necessary to elaborate indicators to support the actions and allow the evaluation of the results, considering that the information generated through indicators consolidates the control and planning of the organizational processes, as well as supports the decision making [ 25 , 26 ].

This is a prevention tool that has been implemented in Brazil with workers from federal agencies to identify risk factors associated with future illnesses. This approach in the federal public service has had an impact on the quality of preventive health, avoiding the removal of workers from their workplace for a cause classified as a possible prevention of this disease. Another aspect is the increasing number of absences that have been occurring in recent years, that is, the numbers of absenteeism due to physical and mental illnesses, a fact that occurs at increasingly younger workers' ages, which reveals the need for special attention and protector follow-up in their quality of life.

The results presented in this study deserve attention and can contribute to discussions between the professionals of the technical team and managers of the SIASS Unit and PROGESP/UFRN, as it is believed that the production of knowledge about the subject under study can provide the University with instruments, as well as other institutions at the federal public service level, through the PME as an indicator for planning and evaluating Occupational Health actions.

Thus, continuous investments in health policies aimed at public servants are suggested, which contributes to the reduction of illness and early retirement, resulting from disability. In this sense, investment in research that allows a better understanding of the relationship between health and work in the public service is also recommended.

It should be noted that this study had some limitations, as the use of self-reported data by employees who completed the PME may underestimate or overestimate the results presented.

In order to meet the proposed objective, there was the occurrence of neoplasms, mental disorders, and diseases of the circulatory system in terms of duration of absenteeism (IDA), which were the causes of the absences with a longer duration, which ratifies the epidemiological importance and the impact of non-communicable chronic diseases on workers' health. The gravity index of absenteeism revealed that the number of lost days of work per year per worker increased over the historical series, as well as the frequency of absences.

With regard to the epidemiological profile of the employees who underwent the PME throughout the historical series, it was possible to identify a significant prevalence of overweight in the population. The working conditions were considered satisfactory in the perception of the workers. It should be noted that this study presented some limitations, since the use of self-reported data by the workers may underestimate or overestimate the presented results.

Also observed through this study is the need to maintain and strengthen the PASS with emphasis on surveillance, aiming at the promotion and protection of the health of the workers, based on the elaboration of the epidemiological health profile and, consequently, the implementation of strategies of positive impact for OHS.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

International Classification of Diseases 

Diabetes mellitus

Frequency of Medical Licence

Frequency of Workers on Medical Licence

Occupational Health and Safety

Absenteeism Duration Index

Absence Severity Index

International Organization of Work

Occupational Safety and Health Care Policy

Periodic Medical Examinations

Systemic Arterial Hypertension

Integrated Subsystem Unit

Statistical Package for Social Science

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This study was partially funded by the Coordination for the Improvement of Higher Education Personnel—Brazil (CAPES)—Financial Code 001. Funders have no role in the study design, data collection and analysis, publication decision or preparation of the manuscript.

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Lídia Maria Costa Araújo Magalhães

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Ketyllem Tayanne da Silva Costa & Gustavo Nepomuceno Capistrano

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L.M.C.A.M. was the principal investigator of the project and responsible for administration, coordination, and funding acquisition. L.M.C.A.M. and F.B.A. were involved in conceptualization and in the study design. L.M.C.A.M. carried out the investigation. L.M.C.A.M., K.T.S.C., G.N.C. and M.D.L. were involved in formal analysis and data curation and wrote the main manuscript text. F.B.A. reviewed and edited the manuscript. All authors reviewed the manuscript. The author(s) read and approved the final manuscript.

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Magalhães, L.M.C.A., Silva Costa, K.T., Capistrano, G.N. et al. A study on occupational health and safety. BMC Public Health 22 , 2186 (2022). https://doi.org/10.1186/s12889-022-14584-w

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ORIGINAL RESEARCH article

A comparison of safety, health, and well-being risk factors across five occupational samples.

• 1 School of Nursing, Johns Hopkins University, Baltimore, MD, United States
• 2 Oregon Healthy Workforce Center, Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, United States
• 3 OHSU-PSU School of Public Health, Portland State University, Portland, OR, United States
• 4 Occupational and Environmental Health, University of Iowa, Iowa City, IA, United States
• 5 School of Medicine, Oregon Health & Science University, Portland, OR, United States
• 6 College of Osteopathic Medicine, Western University of Health Sciences, Lebanon, OR, United States
• 7 Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, United States
• 8 Confluence Health, Wenatchee, WA, United States

Objective: The aim of this study was to present safety, health and well-being profiles of workers within five occupations: call center work ( N = 139), corrections ( N = 85), construction ( N = 348), homecare ( N = 149), and parks and recreation ( N = 178).

Methods: Baseline data from the Data Repository of Oregon's Healthy Workforce Center were used. Measures were compared with clinical healthcare guidelines and national norms.

Results: The prevalence of health and safety risks for adults was as follows: overweight (83.2%), high blood pressure (16.4%), injury causing lost work (9.9%), and reported pain (47.0%). Young workers were least likely to report adequate sleep (46.6%). Construction workers reported the highest rate of smoking (20.7%). All of the adult workers reported significantly lower general health than the general population.

Conclusion: The number of workers experiencing poor safety, health and well-being outcomes suggest the need for improved working conditions.

Introduction

There is growing awareness in the literature that providing a healthy labor force requires integrated consideration of each workplace's impact on employees' safety, health, and well-being ( 1 ). This relationship between work and well-being is further impacted by changing trends within the American workforce as well as the nature of work. For example, there is a growing number of working older adults. It is estimated that by 2024, the employment rate of workers 65–74 years is projected to grow by 55% and that of workers 75 years and older is expected to grow by 86% ( 2 ). Further, while physically hazardous jobs with high risk of injury and illness continue to exist, jobs that increase the risk of chronic illness are becoming increasingly prevalent as employees remain inactive for long hours, experience high job stress and burnout, and face greater job insecurity and occupational health disparities.

Moreover, the prevalence of preventable chronic health conditions across all age groups is increasing ( 3 ). About 60% of the U.S. population suffers from at least one chronic health condition ( 4 ), and healthcare costs associated with these conditions account for 75% of healthcare spending ( 5 ). Modifiable exposures and health risk factors such as stress, physical inactivity, and obesity account for ~26% of employer healthcare costs, at $761 per employee ( 6 ).

Occupational injuries in the U.S. workforce continue to be a concern, with 3.2 cases per 100 full-time workers in the private sector and 5.0 per 100 in the public sector in 2014 ( 7 ). Furthermore, there are bi-directional interactions of safety and health. For example, workers with obesity who experience workplace injuries experience 80.0% greater working time loss and incur 81.4% higher costs than workers without obesity ( 8 ). Another example can be found among commercial truck drivers, where drivers with untreated sleep apnea have a five-fold risk of a serious crash ( 9 ). A holistic intervention approach that targets workplace safety, health, and worker well-being can curtail costs from largely preventable workplace injuries and chronic illnesses.

To this end, in 2011, the National Institute for Occupational Safety and Health (NIOSH) launched Total Worker Health ® (TWH), an approach that recognizes that work is a key determinant of one's health and well-being. This approach prioritizes a hazard-free work environment and emphasizes integrated interventions that collectively target worker safety, health, and well-being. TWH is defined as policies, programs, and practices that integrate protection from work-related safety/health hazards with promotion of injury and illness prevention efforts to advance worker well-being ( 10 , 11 ). As part of this effort, NIOSH funded the Total Worker Health Centers of Excellence ( 12 ), one of which is the Oregon Healthy Workforce Center (OHWC) ( 13 ).

An integrated effort first requires monitoring of the safety, health, and well-being risk factors at employee and organizational levels; doing so will help us identify targets for change. At OHWC, we have created a repository of data collected via a set of common measures used across multiple projects, with the goal of comparing safety and health data of participants from various industry sectors. This fairly novel approach has the potential to improve the quality and utility of occupational health research by facilitating stronger comparisons across populations.

Common Measures Approach vs. Meta-Analyses

Occupational health meta-analyses have helped identify relationships between workplace risk factors and employee health outcomes, including correlations between job strain and leisure-time physical inactivity ( 14 ), and work stress and tobacco smoking ( 15 ). Although such meta-analyses can be powerful, measuring the same construct using different survey items on different scales of measurement, can add error to the conclusions. Meta-analyses can overcome differences in measurement tools by using effect sizes that serve as a standardized measure. Although this approach works well when examining the relationship between different variables, it cannot be applied when comparing single-risk factors across different occupational groups. Using the same measure across studies is a way to increase the precision of the measurement by reducing variability due to the way the survey items are measured.

A common measures approach has multiple advantages. We can utilize the same measures across different study populations to benchmark comparisons of the data. Further, given that there are 19,256 unique industry sectors in the U.S. workforce ( 16 ), standardizing the safety and health measures across sectors within occupational safety and health intervention studies allows us to test the effectiveness of program components within and between populations. In turn, this will expedite the process of translating and disseminating interventions to diverse work settings ( 17 ). The goal to increase standardization in measurement is consistent with NIH's funding to develop and promote PROMIS®, a set of standard measures that assess physical, social, and mental health among adults and children ( 18 ).

Comparing Common Outcomes Across Studies vs. Population-Based Studies

Most studies examining health risks have focused on a specific occupational setting or have used random sampling to estimate the overall population risk ( 19 – 23 ). Although both of these methods make important contributions to understanding the relationship between work and health, both methods leave some gaps. For example, general population studies typically include working and non-working individuals. Further, information about occupations may be limited to broad categories such as white-collar vs. blue-collar occupations ( 22 ). All of the population-based studies we found were conducted among working populations outside of the United States, often in European countries where governments sponsor recurring studies on working conditions ( 15 , 20 , 21 , 24 ). Generalizations to the U.S. are limited due to possible differences in national policies, work experiences, organizational culture, population health status, and occupational health risk factors. Moreover, large population studies are costly and are conducted only periodically. For example, the European Working Conditions Surveys are collected every 5 years and focus on work-related exposures, not on the impact of work on individual health behaviors ( 21 ).

A common measures approach has unique strengths and weaknesses. It can be a powerful research strategy to surveil the safety and health of the workforce, make comparisons between occupations, and inform intervention strategies that are best suited within and across workplace settings. A challenge of the common measures approach is that it can involve a high degree of coordination and buy-in from separate collaborators. However, the advantage is the ability to use individual data on the same scale of measurement to make direct comparisons. This approach may be less expensive and resource-intensive than larger population-based studies. The advantage of a less expensive approach is that it can be done more frequently or fill in the gaps between costly population-based occupational groups. These “grass roots” efforts can be especially helpful in continuously monitor the safety and health of workers as the nature of the work continues to evolve with changes in technology, shifts in economic policies, and other changing factors in the landscape of work.

We found one other study that uses this common measures approach: Community Interventions for Health (CIH)—a collaboration that seeks to understand the impact of health behavior interventions on health outcomes in developing countries ( 25 ). Each country agrees to use a core set of measures designed in a way that adds culturally relevant examples and appropriate items. This approach enables CIH to assemble large datasets from multiple countries and highlight the relationships that are common across different countries ( 26 – 28 ).

The OHWC Common Measures Data Repository currently includes data from five separate studies, and we have compared the safety, health, and well-being outcomes of working populations across different occupations. OHWC presents collective and unique profiles of these worker groups: call center workers, corrections officers, construction workers, homecare workers, and parks and recreation workers. Each work setting includes unique hazards and risk factors, and physical and psychological demands ( 29 ). For example, homecare workers often receive little safety training or health benefits, work primarily alone, and are responsible for lifting and moving their consumer-employers multiple times per day ( 30 – 32 ). Construction workers also face considerable physical demands, but have a great deal more supervision and adhere to rigid schedules, making them particularly susceptible to issues regarding work-family conflicts and psychological stress ( 33 ).

Baseline data were gathered from five studies funded by NIOSH. A standardized set of measures was agreed upon prior to data collection for each study. From this set, individual study teams selected the measures that best fit their needs. Thus, not every sample reported data on every variable. For purposes of our study, we chose measures of safety (injuries), health [pain, body mass index (BMI), blood pressure], health behaviors (smoking, sleep, exercise), and well-being (health status) used by at least three of our studies. Where possible we computed these variables so that they could be compared with clinical healthcare recommendations or national norms. Additionally, biomarker assessment was conducted by a trained research assistant unless otherwise indicated.

Injuries were measured with a single item: “In the last 6-months, if you had 1 or more injuries at work that required you to miss work on following shifts, how many total work days did you miss?” Responses were coded 0 (No missed days) or 1 (Yes, 1 or more missed days). The 6-month timeframe was chosen because research indicates that participant recollection of medical events are less accurate for 1-year than for 1-month ( 34 ) however, injuries are rare and thus 1-month was not ideal. Given this 6-months seemed a reasonable compromise between exposure and accuracy.

Musculoskeletal pain that interfered with normal activities was measured with four items adapted from the Standardized Nordic Questionnaires for the Analysis of Musculoskeletal Symptoms ( 35 ). The items asked how often in the last 3 months pain interfered with normal activities at work or at home. The following body areas were included: neck/shoulder, lower back, wrist or forearm, and lower extremities. For the present study, participants were coded as 0 if they answered “not at all” to all questions and 1 if they reported any interference with work on any of the four items.

Health Status

Health status was measured using the SF12v2, which contains 12 survey items measuring eight subscales: general health, physical functioning, role physical, role emotional (i.e., ability to perform role-related responsibilities due to emotional or physical health issues) bodily pain, mental health, vitality, and social functioning. The scale has been validated for use in general U.S. populations, in 10 other countries, and in populations of individuals with a variety of health conditions. Extensive information about the reliability and validity of the SF12v2 can be found in the SF12v2 instruction manual ( 36 ). Scores were normed using means and standard deviations from a representative sample of the general U.S. population described in the Participants section of the present paper. Per instructions in the manual, z -scores were computed by subtracting the provided mean for each subscale from the general U.S. sample and dividing by the provided standard deviation for the subscale from the general U.S. sample. Following the instructions in the manual t -score transformations were computed by adding 50 and multiplying by 10. This facilitated a comparison to that national representative sample with a mean of 50 and a standard deviation of 10.

BMI and cut-offs for overweight and obesity were calculated based on CDC guidelines ( 37 ). Participants were weighed with clothes on, pockets emptied, and no shoes, belts or heavy jewelry/watches, etc. For adults, BMI was calculated using the standard formula: weight (kg)/height (m) 2 . For workers under 18y, BMI was computed based on sex-specific age growth charts. For both groups, individuals were coded as overweight if they had a BMI of 25.0–29.9 and obese if they had a BMI of 30.0 or greater.

Blood Pressure

Blood pressure was taken after 3 min rest followed by 3 measurements, each 1 min apart; then we took the average of those three measurements. Blood pressure cut-offs for pre-hypertension and hypertension were based on NIH National Heart, Lung, and Blood Institute (NHLBI) recommendations ( 38 ). Cases were coded as pre-hypertensive if they had a systolic blood pressure of 120–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg, and as hypertensive if they had a systolic blood pressure of ≥140 or a diastolic blood pressure of ≥90 mm Hg. We did not inquire as to whether workers were participating in anti-hypertensive treatment at the time of data collection.

Participants were asked: “In the past 7 days, have you smoked any cigarettes?” Responses were coded 0 (no) or 1 (yes). This is consistent with the U.S. Department of Health and Human Services' initiative to end the tobacco epidemic ( 39 ).

Sleep was measured using two items from the Pittsburgh Sleep Quality Index ( 40 ) to compute time spent in bed. Minimum guidelines for sleep were adopted from the CDC ( 41 ). Adults were coded as meeting the minimum guidelines if they got at least 7 h of sleep; young workers were coded as meeting the minimum guideline if they got at least 9 h of sleep per night.

For all of the adult participants, exercise was coded as “yes” if the participant reported engaging in moderate or vigorous exercise for 30 min on 5 or more days per week [per CDC recommendations ( 42 )] and “no” if they did not. In the young worker sample, participants were not asked about intensity (“moderate/vigorous”).

Participants

Call center workers.

Participants included 139 employees from two customer service call centers. There are ~29,000 customer service employees in Oregon ( 43 ). Employees were recruited by study advertisements and completed all study activities during work hours. Participants received a $25 gift card for completing the study. Data were collected in the summer through fall of 2015. All study procedures were approved by Oregon Health & Science University (OHSU) IRB #0753.

Correction Officers

Participants in the first study included 85 corrections officers from four Oregon Department of Corrections institutions. Oregon employs ~2,300 correction officers in 14 state prisons ( 44 ). Prior to recruiting participants, permission was granted by the Superintendent of each institution. Participants were full-time security staff at the institutions. Data were collected between June 2011 through May 2013. All study procedures were reviewed and approved by OHSU IRB #7925.

Construction Workers

Participants in the second study included 349 construction workers from two public works agencies with a total of 520 construction workers, giving us a response rate of 67.12%. There are ~80,000 construction workers in Oregon ( 43 ). The results from the main study are published in the article cited here ( 45 ). Data were collected on company time in the summer of 2012. Participants were provided a $25 gift card for their participation. All study procedures were reviewed and approved by Portland State University IRB #111884.

Homecare Workers

Participants in the third study included 148 Oregon homecare workers recruited from the population of caregivers enrolled in a publicly funded home care system overseen by the Oregon Home Care Commission ( 31 ). There were ~12,000 homecare workers registered with the OHCC in the spring of 2013 when we collected these data ( 46 ). Within this system, caregivers work as independent contractors and are hired directly by “consumer-employers” who qualify for Medicaid-funded in-home services. With the assistance of the Service Employees International Union SEIU and the Commission, workers were recruited in-person at training classes, but also through emails, mailed fliers, and referrals. All study procedures were reviewed and approved by OHSU IRB #5473. The results of the main study are published in the article cited here ( 31 ).

Parks and Recreation Workers

In the summer of 2013, we sent emails to 436 young workers (14–24 years of age) from a city parks and recreation department who were seasonal summer employees. Throughout the results and discussion we refer to this sample of 14–24 year olds as young workers and our other samples of workers aged 25 and older as adult workers. Of those invited to participate 178 completed baseline surveys, a response rate of 40.83%. Results from the main study are published in the article referenced here ( 47 ). There are about 1,800 parks and recreation workers in the state of Oregon ( 43 ). Participants were recruited during new hire orientation; parental consent letters were distributed to minors. No biomarkers were assessed in this study. All study materials and procedures were approved by OHSU IRB #0753.

U.S. General Population Norming Means and SD

The means and SD for norming the scores for comparison to the U.S. general population are in the SF12v2 scoring manual ( 36 ). These data are from the 1998 National Survey of Functional Health Status (NSFHS), conducted from October to December 1998 by the National Research Corporation (NRC). Surveys were mailed to randomly selected members of the National Family Opinion (NFO) panel; 7,069 participants responded (overall response rate: 67.8%). The population contained both working and non-working adults. Sampling weights were applied to adjust the sample to match the age, gender, and age-by-gender distribution of the 1998 census.

Descriptive statistics, frequencies, means, and standard deviations were computed to create profiles for these participating workers. One-sample t -tests were used to test whether the normed scores from our participants on the SF-12 subscales were statistically different from a nationally representative sample, with a mean of 50 for all subscales. Alpha was set at p = 0.05 for a two-tailed test for determining statistical significance.

Demographics and Work Characteristics

A comparison of the demographics and work characteristics of the five samples in Table 1 .

Table 1 . OHWC descriptive statistics, demographics, and work characteristics.

Comparison Across Measures of Safety, Health, Health Behaviors, and Well-Being

Table 2 provides an overview of the safety and health profiles for all worker samples. Ten percent of older adult workers (i.e., 65 and above; call center, construction, corrections, and homecare) reported work-related injuries that resulted in missed work during the past 6 months. Such injuries were highest among construction workers at 16.2%. Forty-seven percent of adult workers reported experiencing pain in the last 6 months that interfered with normal activities. More than 70% of all participants were overweight or obese. In the young worker sample, just over 21% were overweight or obese. Conversely, 83.2% of older adult workers were overweight or obese. Among the adult participants, 16.4% had high blood pressure (HBP) and 41.0% were pre-hypertensive. Approximately 15% of all workers reported smoking in the last week/month. Smoking was lowest among young workers employed by parks and recreation department (4.5%) and highest among construction workers (20.7%). Approximately 60% of all workers reported getting sufficient sleep; as recommended by NIH. Sleep sufficiency was lowest in the young worker sample (46.6%) for whom more sleep is recommended. Only 35% of the workers were getting 150 min of moderate to vigorous physical activity per week as recommended by the CDC. Young workers were more likely to meet exercise guidelines, yet even in this sample, just over 50% met the guidelines. Physical activity was lowest among corrections officers and homecare workers, at just over 20%.

Table 2 . OHWC descriptive statistics for health, safety, well-being, and health behaviors.

One-sample t -tests indicated that construction workers and homecare workers reported being pain-free significantly less often than the U.S. general population ( p < 0.001); young parks and recreation workers were significantly more pain free ( p < 0.001). All four of the adult samples had significantly poorer general health ( p < 0.001) than a nationally representative sample. No evidence could be found that the general health of young workers was significantly different from that of a nationally representative sample. The homecare workers, who were also our oldest sample, had significantly poorer physical functioning than a nationally representative sample ( p < 0.001). However, all of the other occupational samples had significantly better physical functioning ( p < 0.010 all 4 samples ). Homecare workers scored significantly lower than the nationally representative sample in both role physical and role emotional ( p < 0.010); that is, they reported feeling limited in their ability to perform role-related responsibilities due to emotional or physical health issues. The other worker groups were significantly healthier than the U.S. general population on role functioning ( p < 0.010), but not statistically different from the U.S. general population on role emotional. All of our adult samples reported poorer mental health than the U.S. general population ( p < 0.010). The parks and recreations workers scored significantly higher on vitality than the US general population ( p < 0.001). We found no difference between any of the adult samples and the U.S. general population on vitality. Corrections officers and homecare workers scored significantly lower than the general US population on social functioning ( p < 0.010).

Overview of Findings

Our findings point to a workforce with both health and safety concerns. With regard to safety, 11% of adult workers reported work-related injuries that resulted in missed work and 47% were experiencing pain that interfered with normal activities. Further, many workers in our studies are at risk for chronic health conditions. Over 70% of the overall sample was overweight or obese and 57% of older adult workers were hypertensive or pre-hypertensive. Our findings show that working populations such as those in our studies can benefit from a Total Worker Health approach that targets factors that can improve health, safety, health behaviors, and well-being.

Role of the Work Environment on Safety and Health Outcomes

Studies at the Oregon Healthy Workforce Center have found that while individual behaviors play a role in worker health, safety, and well-being, the workplace environment can also have a large impact, such as access to safety equipment, access to healthy foods, reasonable working hours and breaks, access to opportunities to engage in physical activities at or near work ( 48 – 51 ). In addition, workers who are stressed or injured at work may engage in unhealthy behaviors such as poor diet, lack of physical activity, lack of sleep, and substance abuse, which in turn can contribute to further injuries or chronic health conditions such as obesity or HBP ( 52 , 53 ). Our findings suggest that there is much need to study and improve working conditions for these occupational groups, with the goal of promoting health, safety, and well-being. Specifically, organizations should influence employee lifestyles through structural changes to the design of work and working conditions that would facilitate engaging in these activities, along with programs that target individual motivation and participation.

In our study, there was a high rate of pain reported among workers in corrections, construction and homecare. Population-based studies indicate that levels of musculoskeletal pain in adults range from 6 to 55% ( 19 , 54 ). In a large random sample of working adults from one UK region, the prevalence of adults with pain in upper limbs and neck was 50.5%. This UK region had a large percentage of manufacturing workers; however, only 13% reported pain that interfered with functioning. In a large random sample of people from Sweden, 55% of the population perceived consistent pain for three 3 months or more ( 54 ). This sample consisted of residents from two regions of the country: one with a high percentage of industrial manufacturing and blue-collar workers and the other with a high percentage of fishing and agricultural workers. Factors found to be associated with musculoskeletal pain included the following: repetitive lifting of heavy objects, prolonged neck bending, working with arms at shoulder height or higher, low job control, low supervisor support, blue-collar occupations, and female gender. Growing evidence suggests that work-related injuries play a part in the opioid epidemic ( 55 , 56 ). Occupations that require a high degree of manual labor such as construction show a higher likelihood that a worker will develop a dependency on prescription opioids ( 55 ).

All of our adult samples had lower levels of mental health than the general US population. Workplace factors associated in the literature with decreased mental health include: high job strain—which is a combination of high demands and low discretionary control over work—low social support at work, effort-reward imbalance, shift work (especially night shift), and long work hours ( 20 , 57 – 61 ). Organizational interventions to prioritize mental health by reducing sources of job stress and providing access to employee-assistance programs such as confidential counseling are critical. Similarly, increasing job control may help to decrease stress, improve work-life balance, thereby reducing the risk for stress-related outcomes such as hypertension.

Occupational Differences

A crucial component in identifying cross-population factors related to risks and general wellness at the occupation-level lies in comprehensively understanding the distinct challenges, contexts, and profiles of the workers within each setting ( 62 ). Differences between samples could be evidence of structural barriers in workplaces that do not prioritize safety and health behaviors. Research has demonstrated that aspects of the physical environment or nature of work impact safety and health behaviors and related outcomes. For example, at a public health level, the following are related to greater participation in physical activity: accessibility of fitness facilities, the presence of sidewalks, and low-traffic ( 48 ). In the work environment, examples of facilitators of physical activity could include pedal stands, having proper work breaks, and safe spaces to walk at work.

Homecare workers had poorer health across several measures compared to the other occupational groups; they also reported greater pain, poorer physical functioning, and role functioning than the U.S. general population. Our previous qualitative research indicated that these homecare workers, who were employed by the consumers or their families, reported low support for safety ( 32 ). In an institutional care organization, lifting would be done by a group of workers whereas homecare workers must often do this lifting alone. Because homecare workers are dependent on their consumer and the consumer's case manager to request safety equipment, the process is often unclear for the worker. They also reported poorer well-being as indicated by lower emotional and social functioning than the nationally representative sample. In our previous work we found that homecare workers also reported feeling socially isolated, having almost no contact with co-workers other than during training sessions. This isolation could contribute to lower well-being among homecare workers. These are some aspects of the work environment that could be targeted to decrease injuries and pain, and improve well-being.

Construction workers had the highest rate of injuries and, like homecare workers, reported a high degree of pain interfering with normal activities. Of all the occupational groups, construction workers had among the highest occupational exposure to posture-related risk factors for injury ( 21 ). The vast majority of construction workers were overweight or obese and were pre-hypertensive or hypertensive. Smoking was also more prevalent among construction workers than among the other occupations we assessed. Construction workers would benefit substantially from interventions focused on reducing hazardous exposures and work-related injuries, smoking cessation programs ( 63 ), and by training supervisors to better support work-life integration ( 64 ), and safety communications ( 65 ).

Corrections workers reported less pain than our other samples. They also showed better outcome measures of health (i.e., general health) and well-being (e.g., mental health and social functioning) than the U.S. population in general. They did, however, have among the highest percentage of overweight and pre-hypertension/hypertension of our occupational groups. Further research into how the work environment could be modified to reduce risks of preventable diseases could be particularly useful for these workers.

Younger and Older Workers

There were a variety of notable differences between the younger and older workers. The older workers generally had poorer general and mental health than the general U.S. population. On the other hand, younger workers were no different than the general U.S. population. Research has indicated that reports of pain increase as workers age ( 54 ). We saw evidence of this in our sample: two of the older worker samples (homecare and construction) reported significantly more bodily pain than the general population while the young workers reported significantly less pain than the general population. Young workers scored significantly higher on vitality than the U.S. general population ( p > 0.001); there was no difference between the adult samples and the U.S. general population on vitality. Younger workers, who need more sleep than older adults, were more likely to report inadequate sleep than older workers. TWH interventions geared toward older adults would include healthy pain management strategies (at the individual level) in combination with addressing important changes to the work environment such as providing tools for safe lifting and preventing worksite risks for injuries and accidents. Although young workers are healthier compared with older workers, they could benefit from interventions to increase sleep and physical activity. Intervening with younger workers to establish prevention strategies that are reinforced through their career could be a worthwhile approach that may help to prevent worsening of health conditions as career paths progress ( 47 ).

Limitations

Our study has some limitations. All samples were chosen to address the main aims of the sub-studies making up the OHWC. These occupational groups are not meant to be representative of the entire national workforce but rather these specific occupational groups within Oregon. These were convenience samples within single organizations and thus may not be as representative of their respective occupational groups compared to a study using random sampling of all individuals in a certain occupation. The OHWC targets working populations with high burden and need, which should be considered when generalizing our results. When comparing our samples to the national representative sample, we could not match the age or gender of our samples because we did not have the individual data for the national sample. We cannot rule out the influence of other factors beyond working conditions on workers' health, as the data is cross-sectional and we did not measure pre-existing conditions. In addition, more detail on several of our outcomes would allow conclusions that are more precise. For example, we asked about smoking in the past week. We did not ask how long workers had smoked or whether some may have only recently quit. When including common measures across multiple studies that may not be relevant to other aims in is necessary to trade off details for efficiency. Next, all of these data were collected in the State of Oregon. It is possible that regulations in other states or other state-level variables could influence safety and health behaviors and outcomes for workers in similar occupations. In addition, after we began our data collection for these studies, the NIH published PROMIS measures ( 66 – 68 )—a set of freely available, well-validated measures of various aspects of health, with the objective of standardizing measures across studies. We have adopted these measures for subsequent data collection across projects, but unfortunately, they could not be part of this study. Finally, some measures referenced varying reflective time periods (e.g., smoking a cigarette in the last week vs. last month); thus, direct comparisons on these specific variables should be made with caution. Nonetheless, the Common Measures Data Repository is a promising approach to learning and addressing the unique and shared needs of worker populations across occupations.

Practical Implications and Conclusions

Growing literature suggests that lifestyle behaviors such as getting adequate sleep, exercising regularly, eating a healthy diet, and not smoking can be influenced by work exposures, conditions, and policies ( 69 ). Because adults spend a significant amount of their awake hours at work and because work plays an important role in our lifestyle and well-being, the workplace is an opportune platform from which to address health behaviors and outcomes.

Using a common measures approach to understand occupational safety, health, and well-being outcomes across studies can serve to compare and contrast risks, and highlight avenues for interventions to reduce work-related hazards and promote health and well-being. The findings of our common measures analyses point to the potential benefit of a Total Worker Health approach, in particular, integrated interventions that can decrease work-related risk factors and improve facilitators for pursuing health, safety, and well-being among workers across industries and along the age spectrum. For example, early interventions to reduce risk for injury at work can prevent the experience of pain among older workers, which in turn could improve health and safety behaviors, enhance health outcomes, and overall facilitate long-term quality of life.

Data Availability Statement

The datasets presented in this article are not readily available because they must be approved by the OHWC Steering Committee. Requests to access the datasets should be directed to Ginger Hanson, ghanson4@jhu.edu .

Ethics Statement

The studies involving human participants were reviewed and approved by Oregon Health and Science University and Portland State University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

Author Contributions

GH, AR, TB, LH, DR, RO, BW, KK, and NP: conception and design of study. GH, AR, TB, LH, DR, RO, BW, KK, NP, ST, and MP: acquisition of data. GH, AR, TB, and NP: analysis and/or interpretation of data. GH, AR, LA, and AS: drafting the manuscript. AR, TB, LH, DR, RO, BW, and KK: revising the manuscript critically for important intellectual content. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

This results reported herein correspond to specific aims of grant (U19 OH010154) to LH and RO from the National Institute for Occupational Safety. This work was also supported by funding from the Oregon Institute of Occupational Health Sciences. In addition, we would like to recognize the work of Rob Wright, Annie Buckmaster, and Kristy Luther Rhoten in the collection of COMPASS data.

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Keywords: health promotion, health behaviors, occupational safety, health, well-being

Citation: Hanson GC, Rameshbabu A, Bodner TE, Hammer LB, Rohlman DS, Olson R, Wipfli B, Kuehl K, Perrin NA, Alley L, Schue A, Thompson SV and Parish M (2021) A Comparison of Safety, Health, and Well-Being Risk Factors Across Five Occupational Samples. Front. Public Health 9:614725. doi: 10.3389/fpubh.2021.614725

Received: 06 October 2020; Accepted: 06 January 2021; Published: 05 February 2021.

Reviewed by:

Copyright © 2021 Hanson, Rameshbabu, Bodner, Hammer, Rohlman, Olson, Wipfli, Kuehl, Perrin, Alley, Schue, Thompson and Parish. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ginger C. Hanson, ghanson4@jhu.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 20 April 2024

A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare

• Jean-Philippe Miller 1 ,
• Jennie Hutton 1 , 2 , 7 , 8 ,
• Claire Doherty 1 ,
• Shannen Vallesi 3 ,
• Jane Currie 4 ,
• Katrina Rushworth 1 ,
• Matthew Larkin 5 ,
• Matthew Scott 1 , 6 ,
• James Morrow 6 &
• Lisa Wood 3  

BMC Health Services Research volume  24 , Article number:  492 ( 2024 ) Cite this article

Metrics details

Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort.

A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman’s multidimensional quality model. People with lived experience of homelessness were employed as part of the research team.

Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America ( n  = 17), United Kingdom ( n  = 5), Australia ( n  = 5) and Canada ( n  = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of ‘accessible and timely’, ‘person-centred’, and values of ‘dignity and respect’ and ‘kindness with compassion’ were most prevalent. Among the three patient experience surveys identified, ‘accessible and timely’ and ‘person-centred’ were the most frequent domains. The least frequently highlighted domains and values were ‘equitable’ and ‘holistic’. No questions addressed the ‘safety’ domain.

Conclusions

The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of ‘Kindness and compassion’ require further emphasis when seeking feedback on healthcare experiences and the domains of ‘safety’, ‘equitable’, and ‘efficiency’ are not adequately represented in existing patient experience surveys.

Peer Review reports

Homelessness is associated with large disparities in health, including a much higher prevalence of both chronic conditions and acute illness and injury [ 1 , 2 , 3 ]. This perpetuates disproportionate rates of unplanned hospital use [ 4 ] and a three-decade gap in life expectancy [ 5 , 6 ]. Despite significant health needs, people experiencing homelessness (PEH) face numerous barriers to accessing health services and preventive healthcare [ 7 , 8 ] and are more likely to seek emergency or unplanned healthcare [ 4 , 9 ]. This is often at a later stage of ill health, leading to lengthy and costly hospital admissions [ 7 ]. Individual and structural factors associated with homelessness impact peoples’ capacity to attend appointments, advocate for the support they need and maintain regular contact with health providers that is necessary to improve their health and wellbeing. Among PEH, structural barriers and discrimination are ubiquitous experiences when accessing healthcare [ 8 , 10 ]. Current evidence associates the experience of stigma for PEH with the perpetuation of existing health inequalities, service avoidance, and subsequent poorer physical and mental health [ 10 , 11 , 12 ]. The anachronistic and hierarchical design of many conventional health services is counterproductive to the required trauma-informed approach that facilitates PEH or those experiencing marginalisation and vulnerability to access healthcare when they need it. It is clear that the traditional approach to designing healthcare services could be much improved if PEH were engaged in the process and their voices prioritised”.

Continual improvement of healthcare informed by patient experience is critical for all populations, particularly for PEH given the substantial health disparities and known barriers to healthcare access and engagement. In an effort to tackle health inequities for PEH, health systems must continuously monitor and improve the quality of healthcare they provide [ 8 ]. Capturing patient experience across healthcare settings is paramount to drive service improvement [ 13 ] and promote more equitable access, especially among PEH. In 2001, the Institute of Medicine (IOM) conceptualised quality principles across six dimensions for improvement (safe, effectiveness, patient-centred, timely, efficient and equitable) in an effort to raise the quality of health care [ 14 ]. Measurements of quality healthcare have previously focused heavily on access, clinical care processes, disease-specific indicators and mortality [ 15 ]. As part of contemporary healthcare delivery, patients’ experiences of healthcare are considered an indicator of the quality of care [ 15 ]. Patient experience is central to improvements in the provision of quality health care [ 13 , 14 , 16 ] and has been positively associated with patient safety and clinical effectiveness [ 13 , 17 ], higher levels of treatment adherence and less healthcare utilisation [ 13 , 17 ]. Patient experience is distinct from patient satisfaction in that it asks about the person’s experience of healthcare rather than simply whether they were satisfied or not. This experience-focused feedback provides valuable insights into the quality of care provided and is fed back to providers [ 16 ]. Experiences may differ according to the vulnerability of population groups and patient expectations [ 16 ]. Surveys and reports on patient experience provide a means of intrinsically evaluating and measuring aspects of care quality from the patient’s perspective, principally offering healthcare services an opportunity to capture and appraise ‘patient-centred care’ as a domain of quality [ 14 , 15 ]. Patient-centred care is key to the provision of quality health care [ 17 ] and has been highlighted as a priority for homeless healthcare [ 8 ].

The aim of this scoping review was to examine the areas of patient experience that are most frequently reported by PEH when seeking healthcare, and how the patient experience for people experiencing homelessness is represented and discussed in the literature and what deficits exist. A secondary objective of this review is to understand what surveys, or components of surveys, are being used to ask about patient experience for PEH.

Study context and rationale

The study was undertaken in Australia to inform the development of evidence-based strategies for homeless health services. In Australia, the number of PEH is rising [ 18 ]. In 2021, there were over 122,000 estimated PEH on any given night, an increase of more than five percent over five years [ 18 ]. Existing structured patient-reported experience survey methods have limited applicability for vulnerable populations in Australian hospitals [ 19 ]. For example, the Australian Hospital Patient Experience Question Set (AHPEQS) [ 20 ], does not adequately report the perspectives of people with low health literacy – a population that is over-represented among PEH [ 21 ]. Furthermore, patient experience measures in Australian Primary Healthcare (PHC) settings are not well established, nor standardised [ 22 ] and therefore little is known about the accessibility or experiences of these services for PEH. The impetus for this study was thus to identify the ways in which patient experiences of healthcare for PEH has been measured or captured in the international literature to inform the development of homeless healthcare services at the organisation.

Search strategy

A scoping review was undertaken to explore the broad research aim reported here using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 23 ]. The search strategy was identified and refined by the authorship team, comprising health service managers, academics, people with lived experience of homelessness and clinicians, through an iterative process. Two of the authors had significant experience in providing healthcare to PEH, and three were experienced researchers in homeless health. A librarian was engaged to assist with the initial identification of search terms. The PICO framework was used to develop the search terms and eligibility criteria, as shown in Table  1 . The intervention of interest was patient experience for PEH when seeking and receiving healthcare.

Three preliminary searches were conducted to identify and test search terms. The final search terms were as follows: Patient reported outcome measures OR patient outcome assessment OR patient satisfaction; Health facilities OR health services OR quality of healthcare OR patients OR (health* or hospital* or patient* or outpatient* or emergency department*.ti,ab,kw. ) Health services accessibility OR access*.ti,ab,kw. Searches were grouped with the relevant keyword terms of (patient* or outpatient* or inpatient*) OR (consumer* or client* or adult* or people*) and matched with a set of adjectives with a defined adjacency of two in an effort to capture patient experience. The adjectives utilised were experience* or reported* or perspective* or perceive* or feedback* or complaint* or view* or voice* or preference* or satisfaction* or insight*.ti,ab,kw.

The final search was conducted on 2 February 2024 across the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (Embase), American Psychological Association PsychINFO and Current Index to Nursing and Allied Health Literature (Cinahl). The final search strategy and terms adapted for each database are available (See Additional file 1 ).

All search results were exported to EndNote (X9.3.3, Clarivate) and uploaded to the online systematic review collaboration software Covidence (Veritas Health Innovation, Melbourne, Australia) (Available at www.covidence.org ). Duplicates were automatically discarded. The titles and abstracts were screened independently by two authors. Conflicts were resolved by a third author. Screening of full-text papers was conducted as described above. To ensure alignment with PHC and hospital services, recency of reported experience and the Australian healthcare system, articles focusing on specialised health services/diseases, accessibility, years 2008/2009, and non-OECD countries were excluded. Systematic reviews that were identified during the screening process were reviewed for any eligible references.

Data items and extraction

Data extraction occurred through three phases. In Phase 1, the primary author extracted the following core characteristics from included papers: author, year, country, title, study design, objective, population, setting, exposure (inclusive of type of health service) and patient experience measure. To ensure the accuracy of this process, an independent review of the extraction was undertaken by two authors.

In Phase 2, the authorship team sought a framework to meaningfully extract and then code the qualitative patient experience data from the included studies and three were identified: the National Institute for Health and Care Excellence (NICE) guidelines for integrated health and social care for people experiencing homelessness [ 24 ], the Institute of Medicine (IOM) Framework for Health Care Quality [ 25 ], and Lachman’s multidimensional quality model [ 26 ]. The NICE guidelines, developed in the United Kingdom, are a comprehensive resource for working with PEH. The IOM framework is a well-established quality framework used in healthcare to align policy and practice. The IOM domains are a set of principles that are used to guide and improve the quality of healthcare delivery. Lachman’s quality framework builds on the existing IOM principles, offering a new and novel means of assessing quality in healthcare. These three frameworks were modified by removing any overlap to form one extraction framework. The authors added the domain of ‘communication’ to address an obvious deficit in existing frameworks as identified in the NICE guidelines [ 24 ] and recent literature [ 27 ]. See Tables 2 and 3 for established definitions.

The findings of the included papers were extracted against the modified framework by six authors (JPM, JH, CD, LW, SV, JC) simultaneously over three meetings. In some instances, the patient-reported outcomes overlapped between the two domains, perhaps indicating the complexity and subjectivity of patient-reported experiences. Final decisions were made by two authors (JM, CD).

In Phase 3, data from quantitative studies that used a survey to measure patient experience were extracted. Two surveys were excluded from the analysis because they did not have patient experience measures [ 28 , 29 ]. The following data points were extracted from patient experience surveys: 1) survey name, 2) authors utilising survey, 3) number of survey items 4) number of domains (referred to as scales hereafter to ensure differentiation from the term used in the extraction framework), 5) survey setting, 6) survey questions 7) assignment of survey questions to IOM domains and core values. Data were grouped together for surveys appearing in multiple articles. Data points were extracted directly from articles with the exception of data point 7 which was completed by reviewers (See Additional file 2 ). Four authors individually analysed each survey question and assigned a primary domain or core value to each. Responses were reviewed by all authors, and any disagreements were discussed and resolved through a consensus vote.

Study selection

One thousand eight hundred thirty-eight records were identified through the database searches, ultimately thirty-two studies were included in this scoping review. Details of the screening process are shown in Fig.  1 .

PRISMA flow diagram

Study characteristics

Of the 32 included studies, 22 were qualitative, seven were quantitative and three were mixed-method study designs (see Tables 4 , 5 and 6 ). Seventeen studies were from the United States of America (US), five from the United Kingdom (UK), five from Australia and four from Canada. Seventeen studies examined the provision of primary health care, with the remaining studies examining outpatient case management [ 30 ], acute care [ 28 ], emergency care [ 31 ], and hospital-based healthcare [ 29 , 32 ]. Twelve studies did not define a specific health service context and instead reported information on general patient experiences engaging with any area of health services. The tools utilised across the studies included interviews ( n  = 20), focus groups [ 29 , 31 , 33 , 34 , 35 , 36 ] ( n  = 7), surveys [ 32 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ] ( n  = 8), and qualitative ranking exercise [ 44 ] ( n  = 1) to facilitate exploration of patient experience. The qualitative ranking exercise asked PEH and experts to prioritise 16 aspects of PHC.

Most ( n  = 24) studies did not detail how PEH were identified. Of those that did, five studies used the International Classification of Diseases (ICD)-9 or ICD-10 code to identify PEH [ 32 , 38 , 39 , 41 , 43 ], one study used Veterans Health Administration administrative records [ 42 ], one study used clerical staff to identify PEH by accommodation status on arrival to ED [ 49 ] and one study used staff to recruit participants as per the homeless definition in the Stewart B. McKinney Homeless Assistance Act [ 57 ]. Sample sizes of PEH ranged from five [ 52 ] to 68 [ 31 ] for qualitative studies and 33 [ 32 ] to 5,766 [ 42 ] for quantitative studies. Three of the studies from the US examined homeless veterans [ 39 , 40 , 41 ].

Qualitative study results

This section describes firstly the results from the 24 qualitative studies reviewed including the frequency of domains and core values and key themes (Table  7 ).

The most frequent domain identified was ‘accessible and timely’, appearing across 21 of the 24 included articles. Accessible and timely incorporates timeliness and access to care, the availability and flexibility of services, and geographic and financial accessibility. The most common patient experiences reported within this domain were timeliness of treatment [ 31 , 33 , 34 , 35 , 36 , 59 ], flexibility and convenience of services [ 45 , 46 , 51 , 56 ] (especially those offering co-located [ 46 , 53 , 54 , 55 ] or drop-in services [ 34 , 45 , 53 , 56 , 59 ]), the physical and organisational environment [ 46 ], and the location of services [ 33 , 34 , 53 , 54 , 55 ].

The domain of ‘person-centred’ was cited in 18 of the qualitative articles. Person-centred care incorporates the diverse experiences of individuals and their specific needs and priorities. Repeatedly, participants valued services that recognised the complexities relating to homelessness and which tailored services to meet their needs [ 33 , 34 , 52 , 53 ]. PEH greatly appreciated the social capital gained from health services, in particular positive social interaction, shared norms and decreased feelings of isolation [ 30 , 46 , 53 ]. Participants described experiences of institutional practices inconsistent with patient-centred care [ 31 , 51 , 54 ], rushed treatment [ 35 , 45 , 56 ] and a lack of awareness of PEH and the complexity of their healthcare needs [ 28 , 29 , 45 ].

The domain of ‘Safety’ encompassed physical and psychological safety, trauma-informed care and health accountability, and was raised in 17 of the 23 qualitative articles. Safety for PEH was most often discussed in relation to the physical environment of health services [ 46 , 53 ], discharge practices [ 28 , 31 , 53 ] and rapport with healthcare personnel [ 30 , 54 , 59 ]. However, cases of physical assault by security personnel [ 36 ], mechanical restraint [ 31 ], and stigma from health professionals had a negative impact on their willingness to access services [ 33 , 45 , 52 ]. While accountability was considered an important characteristic [ 44 ], in only one paper did PEH expressed concerns that health services were not accountable [ 29 ].

The ‘equitable’ refers to care being fair and impartial regardless of individual traits or circumstances, and was domain identified in 16 of the articles reviewed. Examples of equity arose most commonly regarding prejudicial care [ 29 , 31 , 33 , 48 , 51 , 52 , 55 , 56 , 58 ] and healthcare service exclusions [ 29 , 45 , 49 , 50 ], with one example reported describing a possible violation of the Emergency Medical Treatment and Labor Act [ 50 ].

‘Efficient’ appeared in 14 articles, referring predominantly to the navigation and coordination of services across providers and settings. A common issue raised was the struggle PEH experienced navigating healthcare systems [ 30 , 33 , 34 , 45 , 50 , 52 , 58 ]. Instances varied from difficulty understanding health systems [ 45 , 52 , 58 ] to the inherent complexity of referral systems [ 50 ] and paperwork [ 58 ]. A lack of healthcare insurance also exacerbated difficulties with service navigation in a US-based paper [ 52 ]. Case workers or navigators who could help facilitate the navigation of services were seen as critical enablers [ 30 , 33 , 34 , 36 , 52 ]. In circumstances where PEH accessed ‘navigational aids’, greater usage and higher levels of satisfaction with health services were reported [ 52 ]. Although in a paper by Steward (2016), coordination ranked as one of the four most important characteristics of homeless healthcare service provision [ 44 ], multiple negative accounts were reported describing episodes of fragmented care [ 35 , 36 ], wasted time [ 33 ], service gaps [ 31 ], a lack of coordination between services [ 28 ] and problematic relationships with interdisciplinary teams [ 33 ]. In one study, 44% of PEH delaying healthcare attributed this to previous experiences and concerns that they would not receive appropriate healthcare [ 28 ]. Positive experiences recounted the arrangement of hospital admissions [ 53 ], seamless system navigation [ 31 ], centralised care coordination that reduced the need for ED presentations [ 33 ], and effective coordination and timely referrals that alleviated service user stress [ 34 ].

The ‘effective’ domain that pertains to care following evidence-based guidelines and standard operating procedures was the least frequently articulated domain in the qualitative papers reviewed (10 citations), with Steward et al. (2016), independently reporting that PEH highly prioritised ‘evidence-based decision making’ [ 44 ]. On the few occasions the effective domain was highlighted in the literature, it involved treatment based on individual biases and stereotypes [ 33 , 50 ], inconsistent discharge practices [ 45 ] and pain management regimens [ 35 , 36 ].

Core values

The core values of ‘dignity and respect’ and ‘kindness with compassion’ were detected in 20 articles. Key features of these core values included the acceptance and respect of all views in decision-making, warm and welcoming clinicians and the provision of empathetic and non-judgmental care. For PEH, respectful [ 46 , 49 , 51 , 53 , 54 , 55 ] and non-judgmental care was important [ 29 , 47 , 49 , 51 , 53 , 56 , 59 ]. Positive experiences were characterised by welcoming and approachable staff [ 29 , 34 , 52 , 59 ], human connection [ 54 ], being known by name [ 46 ], rapport and trust [ 29 , 54 , 59 ], compassionate care [ 29 ], the preservation of anonymity [ 51 ] and confidentiality [ 55 ], and recovery-oriented approaches that led them to feel included in society [ 54 ]. Yet there were occasions where PEH perceived health professionals as uncaring [ 31 ], demeaning [ 57 ], dismissive [ 35 , 36 , 50 ] and judgemental [ 31 , 35 , 50 , 52 , 56 , 57 ]. Many PEH reported experiences of stigmatisation when accessing healthcare [ 29 , 31 , 45 , 53 , 55 , 56 , 59 ]. Furthermore, some PEH held concerns of prejudicial information in medical records influencing the provision of medical care [ 35 , 36 , 55 ]. Negative experiences created power dynamics [ 33 ], strained relationships [ 51 ], adversely impacted care [ 33 ], were associated with a loss of self-confidence [ 56 ], and contributed to a reluctance to engage healthcare services in the future [ 29 , 31 , 33 , 45 , 51 , 52 , 56 ]. In contrast, positive experiences encouraged health-seeking behaviour and service engagement [ 34 , 45 ], upheld dignity [ 29 ] and decreased feelings of shame among PEH [ 30 ].

‘Partnership and co-production’ was raised in 17 of the articles reviewed. This value refers to how PEH can be engaged and active partners in designing healthcare and the delivery of services. Integral to this core value is patients at the centre of control. PEH placed high value on decision-making [ 55 ]; they wanted to set their own agendas, be asked what they needed, and be allowed to decide for themselves [ 54 ]. In one circumstance, PEH perceived that they were full partners with a sense of control over their care, even reporting freedom and an increased choice to change health providers [ 33 ]. However, the characteristic of patients as a ‘source of control’ in PHC was ranked relatively low (10 out of 16) [ 44 ], and some patients were ambivalent about control when discussing pain and controlled substances [ 55 ]. PEH appreciated continuity of care and being able to see the same providers consistently [ 55 , 59 ]. Although care could be inconsistent or suboptimal [ 45 ], overly prescriptive [ 52 ], or constrained by distrust in healthcare professionals [ 29 , 46 , 52 , 53 ], there was acknowledgement that experiences and engagement improved with time and upon building therapeutic relationships. [ 35 , 36 , 46 , 53 , 56 ]

The ‘Holistic’ core value was identified in 16 articles. It refers to care that is integrated and addresses physical, emotional, social, spiritual and mental wellbeing. Several articles highlighted failures to provide holistic care [ 31 , 33 , 45 , 49 ]. In one article, PEH reported a lack of inquiry into their housing status, with only 44% being assessed during an acute care episode [ 28 ]. On the contrary some publications demonstrated endeavours to provide holistic care [ 30 , 46 ] and the positive effects of treating patients as individuals with personal needs and goals [ 34 ].

The core value of ‘communication’ incorporates communication methods, information sharing and awareness of services and was raised in 14 articles. On several occasions, it was apparent that PEH were unaware of their health entitlements and existing outreach, after-hours or primary health care services due to a lack of signposting and communication [ 35 , 45 , 49 , 51 , 54 , 55 ]. This insufficiency in communication extended beyond the realm of access and navigation of services and into treatment care and follow-up, and PEH reported circumstances where communication with kin did not occur [ 31 ], unclear post discharge management plans [ 53 ] and a system-level reliance on postal and telecommunication methods that was unsuitable for this cohort [ 55 ]. PEH ranked ‘shared knowledge and the free flow of information’ in the top 25th percentile of important characteristics of homeless care [ 44 ]. People experiencing homelessness called for greater communication between hospitals and shelters during discharge in an effort to improve the coordination of care [ 28 ].

Quantitative study results

The following section reports on the characteristics, settings and frequency at which domains and core values were reported in surveys across the quantitative papers.

Ten articles were initially identified with survey components [ 28 , 29 , 32 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], however two were excluded from the analysis, as the surveys contained no patient experience questions [ 28 , 29 ]. The remaining eight articles utilised an original or adaptation of one of three patient experience surveys [ 32 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. Surveys ranged from having 15 items to 33 items and four to seven scales. Across different scales and their respective questions, the frequency of domains and values identified and authenticated ranged from one to seven, and of the 16 scales reviewed, only six scales were identified to exclusively reflect a single domain or value.

The Primary Care Quality-Homeless (PCQ-H) questionnaire was the most frequent survey tool, appearing in five articles. The Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) was utilised twice, and one study utilised a modified version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Each of these three survey tools are discussed below in additional detail. Across all three patient experience surveys, the majority of questions pertained to the ‘person-centred’ and ‘accessible and timely’ domains, followed by the core values of ‘dignity and respect’ and ‘communication’. Together, these four domains and values constitute 67% of survey questions. The fewest questions were dedicated to the domains of ‘effective’ ‘equitable’, ‘holistic’ and ‘partnership and co-production’. The least frequently highlighted domains and values were ‘equitable’ and ‘holistic’, with one out of three surveys detailing corresponding questions. No questions addressed the ‘safety’ domain (See Table 8 ).

Primary Care Quality-Homeless (PCQ-H) questionnaire

The PCQ-H was the most comprehensive survey; it covered all domains and values with the exception of ‘safety’ and ‘holistic’. General constructs of the PCQ-H survey were based on IOM publications [ 25 , 63 ], a card sort exercise [ 44 ] and qualitative interviews and focus groups with PEH and homeless care provider experts [ 60 ]. The PCQ-H is advantageous, as it is the only survey reviewed that has been specifically developed for and that has had its validity and reliability determined for PEH [ 60 ]. This is important because the concerns and needs of PEH differ from those of the general population and may be overlooked in standard survey instruments. The PCQ-H has been specifically designed to account for low literacy comprehension (seventh grade reading level) to ensure understandability [ 60 ]. The majority of authors utilised the PCQ-H in its entirety with the exception of Jones (2021), who only utilised the 11-item Access/Coordination scale from the PCQ-H.

Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS)

The CG-CAHPS survey questions identified eight of the 11 IOM domains and core values, with the exception of ‘safety’, ‘effective’ and ‘equitable’. The CAHPS surveys were originally designed to compare service providers and assist consumers in judging health plans [ 64 , 65 ]; however, the CG-CAHPS was initially developed to measure patient experiences in ambulatory care [ 61 ]. Behl-Chada, (2017) and Jones, (2017) both utilised modified surveys based on version 2.0 of the CG-CAHPS, with supplementary Patient-Centered Medical Home (PCMH) items to allow for a more comprehensive assessment of PHC and patient experience. The psychometric properties of the CG-CAHPS have been reported to be acceptable [ 61 ].

Modified Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey

The HCAHPS survey covered just over half of the IOM domains and core values. The standard HCAHPS survey is typically 27 items; however, Vellozzi-Averhoff utilised fewer items in their study [ 32 ]. The HCAHPS survey is used among hospitals for inpatient care, which allows for cross-industry service quality comparison. A study on the psychometric properties of HCAHPS raised concerns about the consistency, reliability and validity of multiple-item measures for service quality [ 66 ]. Furthermore, the sampling frame utilised for the development of HCAHPS excluded patients who were not discharged ‘home’ based on the premise that these patients were less likely to respond to surveys [ 67 ]. As a result, differing responses from PEH may not be reflected within the existing psychometric properties of HCAHPS.

Summary of results for domains and core values

‘Accessible and timely’ and ‘person-centred’ domains were identified in the literature as the most prominent domain 20 and 18 times in the literature respectively. Moreover in two out of the three patient experience surveys, these two domains were more commonly identified in survey questions. The core values of ‘dignity and respect’, ‘partnership and co-production’ and ‘communication’ were highlighted between 14 and 20 times and were reported across all three surveys. ‘Efficient’ and ‘kindness with compassion’ were highlighted 14 and 20 times, respectively, and both were reported in two surveys. The ‘effective’ domain was described the least in the literature (10 times) but was identified in two surveys. The ‘equitable’ and ‘holistic’ domains were described in 15 articles each; however, ‘equitable’ only appeared in the PCQ-H survey, and ‘holistic’ only appeared in the CAHPS survey. The ‘safety’ domain was cited in 17 articles; however, no survey questions addressed the safety domain.

The most frequent domains and core values that emerged upon review of the literature for PEH healthcare experiences were ‘accessible and timely’, ‘person-centred’, ‘dignity and respect’ and ‘kindness with compassion’. Of the three existing patient experience surveys identified in this field, the PCQ-H most accurately encompasses the findings voiced in the qualitative literature. Less emphasis was found in the patient experience data on ‘communication’, ‘effective’ and ‘efficient’ than seen in the surveys.

Accessible and timely care

‘Accessible and timely’ care was the domain raised most throughout the literature, and the corresponding survey questions were plentiful and comprehensive. Quantitative survey questions positively encompass the preferences of PEH, giving consideration to wait times, flexibility, convenience and location of services. Historically, PEH have reported significant barriers to accessing care [ 68 ], with accessibility highlighted as a top priority by both patients and providers [ 44 ]. Given the competing priorities of PEH to meet physiological needs such as shelter and food, it is understandable that health needs are best met in an opportunistic fashion.

Kindness, compassion, dignity and respect, and person-centred care

Provision of ‘person-centred’ care was highlighted across both types of studies and is considered fundamental to the provision of quality care; it is associated with improved health outcomes and healthcare utilisation [ 69 ]. In the literature, PEH consistently valued healthcare that acknowledged homeless-specific needs and tailored services. Perhaps the most fitting question measuring patient experience for ‘person-centred’ care was: ‘My primary care provider makes sure health care decisions fit with the other challenges in my life’ from the PCQ-H.

‘Kindness with compassion’ and ‘dignity and respect’ were the most common values identified in qualitative articles and were moderately represented in patient experience surveys. These core values are central to patient-centred care frameworks [ 24 , 70 ]. Patient experience of health care services are impacted by a multitude of factors including the behaviours and attitudes of healthcare and professional staff [ 19 ]. Respect is considered an essential part of building trusting relationships between PEH and providers [ 71 ]. Whilst, kindness with compassion embodied as non-judgemental and empathetic communication can enhance service engagement among PEH [ 71 ].

Survey questions relating to the value ‘dignity and respect’ were aimed at authenticating the provision of treatment with courtesy and respect, as well as addressing concerns of anonymity and confidentiality. Whereas survey questions relating to the value ‘kindness and compassion’ affirmed the provision of non-judgemental care non-directly, they did not explicitly ask to what extent were clinicians and non-clinicians empathetic, non-judgmental, warm and welcoming. Questions addressing these values may be less common in surveys due to an inherent difficulty related to quantifying, assessing and measuring abstract ideas such as kindness, respect and dignity.

Safety, choice, control and holistic care

There is extensive literature documenting the clear relationship between exposure to trauma, poor mental health, and chronic homelessness [ 72 ]. For people who have experienced significant trauma, a sense of choice and control over their healthcare is important [ 73 ]. In order to engage in effective and meaningful healthcare, individuals must connect and feel safe in the therapeutic relationship.

Primary care is often best placed to develop safe relationships and access community-based services. The ‘safety’ domain was cited in 17 articles; however, no patient experience survey questions explicitly addressed whether providers made them feel safe. Physical and psychological safety was identified by PEH as being important to patient experience. Of note four articles emphasised the importance of trauma-informed care [ 29 , 35 , 46 , 52 ] and one article raised cultural safety [ 29 ]. Although these topics were highlighted by their respective authors and not raised categorically by PEH themselves.

Within the ‘partnership and coproduction’ value, it is clear that PEH value autonomy around decision-making. Yet the survey questions pertaining to this value allude more so to ‘consultation’ in designing health as opposed to patients as a source of control. There were no survey questions directly related to the strength of therapeutic relationships with healthcare professionals, although some questions assigned to the person-centred domain do reflect the quality of patient-provider relationships. Authors, including researchers with lived experience; observed the notable absence of cultural safety and gender sensitivity in the articles. and gender minorities are disproportionately represented in youth homelessness [ 74 , 75 , 76 ] and experience higher rates of trauma [ 75 ]. The same minority groups are subject to increased safety risks, and report lower levels of perceived safety when entering shelters and services [ 75 ]. Cultural safety is an indigenous-led model of care that was born in New Zealand [ 77 ]. There are varying interpretations of cultural safety; however, broadly speaking, definitions encompass power differentials between patient and provider and subsequent associated barriers to clinical effectiveness arising from said power differentials [ 78 ]. Distinctive from cultural competency, cultural safety focuses and reflects upon the culture of the clinician, the provision of care, and the healthcare environment [ 78 ]. Cultural safety is an important consideration when examining patient experience of PEH, as indigenous populations are overrepresented in homelessness. In 2021, one in five (20.4%) PEH in Australia identified as Aboriginal and or Torres Strait Islander [ 18 ]. Similarly, Indigenous and First Nations people from the United States, Canada and New Zealand are overrepresented among homeless populations [ 79 , 80 , 81 ]. Cultural safety is intimately linked to health equity and notions of power [ 78 ]. For this reason, it is anticipated there would be some cross-over between the safety and equity domains. Despite this potential for overlap, there were no clear examples of discrimination or racism against indigenous PEH cited under equity, and only one article detailed concerns about prejudicial care specific to ethnicity [ 51 ]. Similarly, none of the studies reviewed recounted patient experiences specific to sexual and gender minority groups. Although, several articles acknowledged potential limitations of their studies due to gender [ 28 , 34 , 35 , 51 ].

An absence of coverage on cultural safety could be reflective in that only a few studies were from Australia and Canada, where cultural safety has gained greater traction within healthcare. Furthermore, patient experience extracted from qualitative articles relating to the ‘safety’ domain may in fact be underrepresented or incomplete. It is possible that safety has not been captured in its entirety, as patients were not explicitly asked about ‘safety’ or these sentiments were captured via the ‘kindness with compassion’ value, which includes warm and approachable clinicians and empathetic and non-judgemental care. Moreover, there is an element of safety that could be assumed or interpreted via other statements from PEH or that is postulated as being built into existing health structures and models of care. Therefore, the inclusion of specific survey questions focused on the ‘safety’ domain may offer a more accurate portrayal of safety for PEH hereafter. Primary experience surveys did not routinely include questions addressing ‘safety’. The exploration of safety as a domain identified by PEH and healthcare providers is a clear gap in the literature that needs to be explored in future studies to develop a shared understanding of this important concept.

Safety, trust, choice, control and collaboration in care are important elements of trauma-informed care [ 82 ]. As a result, trauma-informed care crosses over into the ‘holistic’, ‘partnership and co-production’ and ‘kindness with compassion’ values. Consideration should be given to the inclusion of survey questions to measure safety and trauma informed care. (e.g., do you feel safe when attending healthcare services, considering both your physical well-being and emotional well-being?, how safe and supported do you feel in the healthcare setting in terms of addressing your individual needs and experiences?).

Survey questions that were exclusively assigned to the ‘holistic’ value were found to be predominantly focused on mental health, and with the exception of one question enquiring about alcohol and substance use, failed to ask patients more broadly about their wellbeing and factors affecting their health. Albeit only one of the three surveys was specifically designed for PEH, none of the surveys had questions pertaining to housing, which for PEH is a critical component to stability, security and health.

Effective and equitable care

The literature suggests that effectiveness is more likely to be recognised by health providers than by services users [ 83 ] and may in part explain why the ‘effective’ domain was infrequently cited. Paucity in articles may be due to scepticism or a lack of relevance to PEH, as evidence-based practice has previously been perceived by PEH as an authoritative top-down approach that reinforces existing modalities of care [ 84 ]. Despite the necessity of lived experience to shape the application and interpretation of evidence-based practice, lived experience perspectives and expertise are frequently omitted or poorly utilised [ 84 ]. The ‘effective’ domain tended to appear in the literature due to grievances with a lack of adherence to evidence-based guidelines and standard operating procedures and therefore may also reflect concerns about inequity as PEH received treatments based on biases and stereotypes.

The ‘equitable’ domain was not commonly investigated, but it is important because it holds the potential to quell concerns of PEH and expose incidences of prejudicial care, lesser care and or service exclusions. Example questions from the PCQ-H include (Staff at this place treat some patients worse if they think that they have addiction issues) and (At this place, I have sometimes not gotten care because I cannot pay) . A more general question that purely focuses on prejudicial care may be of benefit due to its broader applicability (e.g., in your healthcare experiences, to what extent do you feel that care is provided fairly and without bias, regardless of your individual traits or circumstances?). Potential future survey questions could include whether or not PEH felt their care adhered to required guidelines and standards.

Efficiency and communication

Despite a common theme pertaining to PEH struggling with the navigation of health care services, only one of the five efficient survey questions somewhat reflected this concern: (My primary care provider helps to reduce the hassles when I am referred to other services). No survey questions clearly enquired as to whether PEH received assistance or experienced difficulty navigating services. The remaining ‘efficient’ questions focused on the coordination of services and patient follow-up. The primary discourse for the core value of ‘communication’ related to PEH’s awareness of services and health entitlements. Yet only one survey question clearly represented this notion. Rather, the majority of ‘communication’ survey questions relate to the quality of communication provided by health professionals and whether it was understandable to the individual.

Future directions and implications for practice

In our analysis, we have made an effort to integrate findings from both qualitative research and surveys. We recognise the intrinsic value, richness and depth provided by qualitative research, which is insightful and more comprehensive than survey findings alone. Given our setting of a hospital service, we hope to gather information that can contribute to the development of patient experience measures, ultimately enhancing the healthcare provided to PEH. To ensure health services are capturing the experience of PEH accurately, surveys and measures of patient experience must be tailored to reflect what matters to PEH when accessing healthcare. For healthcare services that care for PEH, utilising patient experience measures that are adjusted to reflect the complexity of the population increases the acceptability of results and aids fairer comparison across practices [ 16 ].

Generic surveys utilised on this cohort are incomplete and inadequately inform patient experience, at times overlooking broader notions of health, and the underlying social determinants of health (such as housing) that may take precedence over outright health needs. Existing surveys do not adequately portray and incorporate all the IOM domains and core values, this is most apparent for ‘safety’, ‘equitable’, and ‘efficient’. Further research is needed to explore whether surveys are asking the correct questions to inform patient experience for PEH. Furthermore, it is possible that themes identified by PEH may also hold value for other marginalised or vulnerable groups who experience healthcare inequities and subsequently poorer health outcomes. In the interests of improving equitable care across healthcare services, themes around personal interactions, as identified in this paper, should be better considered. Further research is needed on whether sufficient patient experience data may be collected via the addition of a subset of questions specific to homelessness to an existing generic survey. Patient experience is complex and multifaceted, and positive measurements in one domain or value may not always translate to quality in other domains or values. Surveys that ask only binary or close-ended responses may fail to capture key patient perspectives and contextual information that is important to PEH [ 85 ].

The PCQ-H was most commonly utilised survey tool for PEH in primary research. It was developed with extensive involvement of PEH and has evidence of scientific rigour [ 60 ]. Potential further research could include the adaptation and validation of the PCQ-H in other healthcare settings (e.g., hospital based care). This study supports the establishment of the PCQ-H survey as the current gold standard within the primary healthcare setting for PEH. This is indicated by its reflection most closely of themes identified in the qualitative literature.

Challenges exist in routinely collecting patient experience measures in healthcare settings [ 86 , 87 ]. Whilst existing studies do not specifically examine PEH, the completion of patient experience measures is impacted by social determinant of health [ 87 ], and barriers are transferable and applicable to PEH; such as language proficiency, health literacy, technology literacy, cognitive functioning and time constraints [ 86 ]. For PEH additional barriers to survey engagement may include: stigma, poor mental health, substance or alcohol abuse, competing priorities, the transient nature of homelessness and high rates of discharging from health services against medical advice. Co-design projects and tailored approaches are required to overcome barriers and optimise the collection of patient experience data [ 88 ], in turn assessing and exploring how healthcare organisations can best respond to the findings so that healthcare for PEH can be improved. Possible directions for future research include developing the findings, such as incorporating a Delphi design and further validation studies to refine survey recommendations for these broader healthcare services.

Strengths and limitations

A strength of this study was the involvement of people with lived experience of homelessness in the design, analysis and interpretation of the papers. The inclusion of people with lived experience provided contextual understanding to the topic, ensured relevance and enhanced authenticity and validity of the study. A further strength of this paper was that it includes both qualitative and quantitative research papers, this allowed for a more comprehensive understanding of the topic and a triangulation of findings to address the scoping aim and secondary objectives. The degree of detail possible by using the extended domains framework assisted in framing the studies in domains that were especially relevant for PEH. This paper also utilised rigorous methodology by having studies reviewed by multiple researchers to reach consensus on domains and core values.

A limitation of this study was the exclusion of specialised health services or disease-focused articles, as there may have been relevant findings from these articles that were applicable to other healthcare settings and PEH. There is a possibility that in determining and allocating a singular primary domain or core value to each survey question, that survey data was simplified and lost some of its breadth. Although the research team undertook a rigorous technique for coding the domains and values, there were instances where more than one domain or value was found to be applicable despite agreed upon definitions. The majority of questions were allocated with consensus.

A significant limitation is that the majority of studies were from the US and four other OECD countries and may not extrapolate to other settings. However, the findings involving domains and core values have the potential to be interpreted universally. OECD countries were chosen so as the findings could be applied to healthcare service development for PEH at the main study site. Due to the large number of articles, grey literature on patient experience was not reviewed. Grey literature may have offered additional value to our study. Lastly, this study was also limited in that exploration of patient experience was confined to existing published research, it is possible that there are elements of patient experience for PEH that are not adequately reflected in the published literature.

When measures patient experience for PEH, questions pertaining to how the provider treats them, including if they felt respected, if they were shown kindness and compassion, if they were made to feel safe, and if they felt listened to need to be captured alongside how effective and accessible treatment was. This study identifies that ‘kindness and compassion’ questions should be further emphasised when seeking feedback on healthcare experiences from PEH. The domains of ‘safety’, ‘equitable’, and ‘efficiency’ are not adequately represented in existing patient experience surveys.

The PCQ-H was the survey that best reflected the priorities in healthcare provision identified by qualitative analysis and may be suitable to extend to other healthcare settings. Of note, although safety is identified as being a priority for PEH, this was not identified in any of the surveys.

Communication was not a feature of themes recognised as important in qualitative studies, but elements of communication may have been included in other domains. The literature shows that many of the most frequently cited domains and values that PEH expressed to be most important when seeking healthcare were reflected in the three identified survey tools used to varying affect.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Patient-centred medical home

People experiencing homelessness

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Acknowledgements

The authors would like to express their gratitude and acknowledge Helen Wilding for her assistance with this project.

A grant from St Vincent’s Health Australia’s Inclusive Health Research Award Fund was received to the value of $50,000. The grant is to fund the research component of a broader project, which is to design and implement an Outcomes Framework for people with lived experience of homelessness for St Vincent’s Health services.

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CD and JH conceived the study. JPM determined the search strategy and methodology under the guidance of JH, CD, SV, JC, KW and LW. Authors JPM, JH, CD, SV, HC, KR and LW analysed the data. JPM was the lead author with substantial contribution and editing from LW, JH, ML, CD, SV, JC and LW in all sections. All authors read and approved the final manuscript. Authors MS and JM provided a lived experience perspective to assist in study design, analysis and interpretation of data throughout.

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Miller, JP., Hutton, J., Doherty, C. et al. A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare. BMC Health Serv Res 24 , 492 (2024). https://doi.org/10.1186/s12913-024-10971-8

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Key facts about Americans and guns

Guns are deeply ingrained in American society and the nation’s political debates.

The Second Amendment to the United States Constitution guarantees the right to bear arms, and about a third of U.S. adults say they personally own a gun. At the same time, in response to concerns such as rising gun death rates and  mass shootings , President Joe Biden has proposed gun policy legislation that would expand on the bipartisan gun safety bill Congress passed last year.

Here are some key findings about Americans’ views of gun ownership, gun policy and other subjects, drawn primarily from a Pew Research Center survey conducted in June 2023 .

Pew Research Center conducted this analysis to summarize key facts about Americans and guns. We used data from recent Center surveys to provide insights into Americans’ views on gun policy and how those views have changed over time, as well as to examine the proportion of adults who own guns and their reasons for doing so.

The analysis draws primarily from a survey of 5,115 U.S. adults conducted from June 5 to June 11, 2023. Everyone who took part in the surveys cited is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the  ATP’s methodology .

Here are the  questions used for the analysis on gun ownership , the questions used for the analysis on gun policy , and  the survey’s methodology .

Additional information about the fall 2022 survey of parents and its methodology can be found at the link in the text of this post.

Measuring gun ownership in the United States comes with unique challenges. Unlike many demographic measures, there is not a definitive data source from the government or elsewhere on how many American adults own guns.

The Pew Research Center survey conducted June 5-11, 2023, on the Center’s American Trends Panel, asks about gun ownership using two separate questions to measure personal and household ownership. About a third of adults (32%) say they own a gun, while another 10% say they do not personally own a gun but someone else in their household does. These shares have changed little from surveys conducted in 2021  and  2017 . In each of those surveys, 30% reported they owned a gun.

These numbers are largely consistent with rates of gun ownership reported by Gallup , but somewhat higher than those reported by NORC’s General Social Survey . Those surveys also find only modest changes in recent years.

The FBI maintains data on background checks on individuals attempting to purchase firearms in the United States. The FBI reported a surge in background checks in 2020 and 2021, during the coronavirus pandemic. The number of federal background checks declined in 2022 and through the first half of this year, according to FBI statistics .

About four-in-ten U.S. adults say they live in a household with a gun, including 32% who say they personally own one,  according to an August report based on our June survey. These numbers are virtually unchanged since the last time we asked this question in 2021.

There are differences in gun ownership rates by political affiliation, gender, community type and other factors.

• Republicans and Republican-leaning independents are more than twice as likely as Democrats and Democratic leaners to say they personally own a gun (45% vs. 20%).
• 40% of men say they own a gun, compared with 25% of women.
• 47% of adults living in rural areas report personally owning a firearm, as do smaller shares of those who live in suburbs (30%) or urban areas (20%).
• 38% of White Americans own a gun, compared with smaller shares of Black (24%), Hispanic (20%) and Asian (10%) Americans.

Personal protection tops the list of reasons gun owners give for owning a firearm.  About three-quarters (72%) of gun owners say that protection is a major reason they own a gun. Considerably smaller shares say that a major reason they own a gun is for hunting (32%), for sport shooting (30%), as part of a gun collection (15%) or for their job (7%). 

The reasons behind gun ownership have changed only modestly since our 2017 survey of attitudes toward gun ownership and gun policies. At that time, 67% of gun owners cited protection as a major reason they owned a firearm.

Gun owners tend to have much more positive feelings about having a gun in the house than non-owners who live with them. For instance, 71% of gun owners say they enjoy owning a gun – but far fewer non-gun owners in gun-owning households (31%) say they enjoy having one in the home. And while 81% of gun owners say owning a gun makes them feel safer, a narrower majority (57%) of non-owners in gun households say the same about having a firearm at home. Non-owners are also more likely than owners to worry about having a gun in the home (27% vs. 12%, respectively).

Feelings about gun ownership also differ by political affiliation, even among those who personally own firearms. Republican gun owners are more likely than Democratic owners to say owning a gun gives them feelings of safety and enjoyment, while Democratic owners are more likely to say they worry about having a gun in the home.

Non-gun owners are split on whether they see themselves owning a firearm in the future. About half (52%) of Americans who don’t own a gun say they could never see themselves owning one, while nearly as many (47%) could imagine themselves as gun owners in the future.

Among those who currently do not own a gun:

• 61% of Republicans and 40% of Democrats who don’t own a gun say they would consider owning one in the future.
• 56% of Black non-owners say they could see themselves owning a gun one day, compared with smaller shares of White (48%), Hispanic (40%) and Asian (38%) non-owners.

Americans are evenly split over whether gun ownership does more to increase or decrease safety. About half (49%) say it does more to increase safety by allowing law-abiding citizens to protect themselves, but an equal share say gun ownership does more to reduce safety by giving too many people access to firearms and increasing misuse.

Republicans and Democrats differ on this question: 79% of Republicans say that gun ownership does more to increase safety, while a nearly identical share of Democrats (78%) say that it does more to reduce safety.

Urban and rural Americans also have starkly different views. Among adults who live in urban areas, 64% say gun ownership reduces safety, while 34% say it does more to increase safety. Among those who live in rural areas, 65% say gun ownership increases safety, compared with 33% who say it does more to reduce safety. Those living in the suburbs are about evenly split.

Americans increasingly say that gun violence is a major problem. Six-in-ten U.S. adults say gun violence is a very big problem in the country today, up 9 percentage points from spring 2022. In the survey conducted this June, 23% say gun violence is a moderately big problem, and about two-in-ten say it is either a small problem (13%) or not a problem at all (4%).

Looking ahead, 62% of Americans say they expect the level of gun violence to increase over the next five years. This is double the share who expect it to stay the same (31%). Just 7% expect the level of gun violence to decrease.

A majority of Americans (61%) say it is too easy to legally obtain a gun in this country. Another 30% say the ease of legally obtaining a gun is about right, and 9% say it is too hard to get a gun. Non-gun owners are nearly twice as likely as gun owners to say it is too easy to legally obtain a gun (73% vs. 38%). Meanwhile, gun owners are more than twice as likely as non-owners to say the ease of obtaining a gun is about right (48% vs. 20%).

Partisan and demographic differences also exist on this question. While 86% of Democrats say it is too easy to obtain a gun legally, 34% of Republicans say the same. Most urban (72%) and suburban (63%) dwellers say it’s too easy to legally obtain a gun. Rural residents are more divided: 47% say it is too easy, 41% say it is about right and 11% say it is too hard.

About six-in-ten U.S. adults (58%) favor stricter gun laws. Another 26% say that U.S. gun laws are about right, and 15% favor less strict gun laws. The percentage who say these laws should be stricter has fluctuated a bit in recent years. In 2021, 53% favored stricter gun laws, and in 2019, 60% said laws should be stricter.

About a third (32%) of parents with K-12 students say they are very or extremely worried about a shooting ever happening at their children’s school, according to a fall 2022 Center survey of parents with at least one child younger than 18. A similar share of K-12 parents (31%) say they are not too or not at all worried about a shooting ever happening at their children’s school, while 37% of parents say they are somewhat worried.

Among all parents with children under 18, including those who are not in school, 63% see improving mental health screening and treatment as a very or extremely effective way to prevent school shootings. This is larger than the shares who say the same about having police officers or armed security in schools (49%), banning assault-style weapons (45%), or having metal detectors in schools (41%). Just 24% of parents say allowing teachers and school administrators to carry guns in school would be a very or extremely effective approach, while half say this would be not too or not at all effective.

There is broad partisan agreement on some gun policy proposals, but most are politically divisive,   the June 2023 survey found . Majorities of U.S. adults in both partisan coalitions somewhat or strongly favor two policies that would restrict gun access: preventing those with mental illnesses from purchasing guns (88% of Republicans and 89% of Democrats support this) and increasing the minimum age for buying guns to 21 years old (69% of Republicans, 90% of Democrats). Majorities in both parties also  oppose  allowing people to carry concealed firearms without a permit (60% of Republicans and 91% of Democrats oppose this).

Republicans and Democrats differ on several other proposals. While 85% of Democrats favor banning both assault-style weapons and high-capacity ammunition magazines that hold more than 10 rounds, majorities of Republicans oppose these proposals (57% and 54%, respectively).

Most Republicans, on the other hand, support allowing teachers and school officials to carry guns in K-12 schools (74%) and allowing people to carry concealed guns in more places (71%). These proposals are supported by just 27% and 19% of Democrats, respectively.

Gun ownership is linked with views on gun policies. Americans who own guns are less likely than non-owners to favor restrictions on gun ownership, with a notable exception. Nearly identical majorities of gun owners (87%) and non-owners (89%) favor preventing mentally ill people from buying guns.

Within both parties, differences between gun owners and non-owners are evident – but they are especially stark among Republicans. For example, majorities of Republicans who do not own guns support banning high-capacity ammunition magazines and assault-style weapons, compared with about three-in-ten Republican gun owners.

Among Democrats, majorities of both gun owners and non-owners favor these two proposals, though support is greater among non-owners. 

Note: This is an update of a post originally published on Jan. 5, 2016 .

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About 1 in 4 U.S. teachers say their school went into a gun-related lockdown in the last school year

Striking findings from 2023, for most u.s. gun owners, protection is the main reason they own a gun, gun violence widely viewed as a major – and growing – national problem, what the data says about gun deaths in the u.s., most popular.

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US Air Safety Agency Requires More Down Time for Traffic Controllers

WASHINGTON (Reuters) - The U.S. Federal Aviation Administration will require 10 hours off between shifts for air traffic controllers, and 12 hours off before a midnight shift, effective in 90 days, the agency's head said on Friday.

"In my first few months at the helm of the FAA, I toured air traffic control facilities around the country — and heard concerns about schedules that do not always allow controllers to get enough rest," FAA Administrator Mike Whitaker said in a statement.

"With the safety of our controllers and national airspace always top of mind for FAA, I took this very seriously – and we're taking action."

The FAA in 2023 commissioned an independent panel to assess the risks of controller fatigue and provide recommendations, which included between 10 and 12 hours off between shifts.To alleviate pressure on the workforce, Whitaker said the FAA had ramped up recruitment and was on track to meet a 2024 goal of hiring 1,800 air traffic controllers, up from 1,500 last year."I understand this lengthened rest period will be an adjustment for thousands of our air traffic controllers," Whitaker said in the statement.

(Reporting by David Ljungren and Ismail Shakil; writing by Paul Grant; Editing by Caitlin Webber)

Copyright 2024 Thomson Reuters .

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A Study of the Effectiveness of Workplace Health and Safety Programmes in a University Setting in Canada

Zakia hoque.

Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St John's, NL, A1B 3V6, Canada

Veeresh Gadag

Atanu sarkar, introduction:.

Nearly a quarter-million people work in universities in Canada, making it one of the fastest-growing sectors. Although each university provides occupational health and safety services and training programmes to their employees, there have been no studies conducted on the impact of such programmes on employees’ knowledge, attitude and behaviour. The aim of this study was to evaluate the effectiveness of dissemination of information of workplace health and safety programmes to workers at a Canadian university.

The study compared two cross-sectional online surveys of employees of a Canadian university regarding workplace health and safety with a previously conducted cross-sectional study and thematic analysis of key informant interviews to address the issues raised in the surveys.

Participation in health and safety presentations could enhance understanding and practices of safety. Age, employment status and duration of employment were associated with the levels of knowledge, attitudes and behaviour of employees and graduate students. The key informant interviews highlighted some new initiatives such as the establishment of workplace health and safety committees in all university buildings; the development of a safety app and health and safety management system; routine annual inspections of all university building offices and laboratories; new orientation for undergraduate students where general safety rules are described.

Discussion:

University should have regular presentations on the available health and safety programmes and should increase the number of safety training programmes and keep track of the employees that have not received any training, particularly for those working in hazardous environments.

I NTRODUCTION

The labour force in the university sector in Canada is large and has considerable occupational diversity. According to Statistics Canada, out of 17 million-member workforce, 1.3 million (8%) are in educational services, and almost 20% of these individuals (~250,000) work in various universities.[ 1 ] The 2016 census shows that educational services in Canada had the fourth-highest rate of growth and more than half of this increase was in universities.[ 2 ] The working environment in universities is highly diverse, as there are a wide range of disciplines involving teaching, research, administration and maintenance. Due to this multifaceted working environment in the universities, employees encounter various types of occupational health risks. Despite the complexity of occupational risks, little has been written about occupational health and safety programmes of the university employment sector.[ 3 ]

In Canada, workers are covered by provincial or federal labour codes, depending on the sectors in which they work. While workers in mining, transportation, and the federal government are covered by the Canada Labor Codes, other workers such as employees of universities are covered by provincial health and safety legislation.[ 4 ]

Venables and Allender (2007) described the occupational health services in 93 universities in the UK by drawing on data from surveys carried out in 2002, 2003 and 2004. Most survey responses were received from universities and in-house services. The surveys requested self-completed information on occupational health services from each university. The results indicated that 50% of the universities had an in-house health service, 32% relied on a contractor, 9% used the campus student health service, and a further 9% had an ad hoc arrangement or no arrangement. On average, the service was poor, as usually only one half-day doctor with one full-time nurse and a part-time clerk were available to provide service. The wide variation among universities in staffing levels suggested that some universities might have less-adequate services than others.[ 3 ] A study examining the safety concerns of faculty members of a university campus in USA (Alabama) showed that women faculty members took more personal safety precautions than men and felt more strongly about the need for the improvement of safety features on campus. A 160-item questionnaire was distributed to the faculty members asking about socio-demographic information, daily campus activities, personal safety protection taken while on campus, awareness and attitudes about safety on campus, and reported cases of victimization on campus. A few months later, the authors examined the safety awareness of male and female staff members in the same university using the same questionnaire. The results indicated that although female staff members reported more regarding acts of violence against them than male staff members, there was not much difference in their attitudes towards improving safety features on campus. Faculty and staff members identified that they like to use avoidance strategies such as walking with a friend or using objects as a weapon rather than contacting campus security.[ 5 ]

All Canadian universities have Environmental Health and Safety (EHS) or similar departments through which Occupational Health and Safety (OHS) services are provided. All the universities follow a similar practice such as a) having health and safety committees on the campus, b) promoting health and safety and providing risk management services, c) conducting regular workplace inspections and reviewing incident investigative reports, e) creating annual reports about incidents, lessons learned, and providing recommendations to senior administrators, and e) organizing health and safety information session for the employees. The EHS unit mainly offers training on fire safety, first aid, laboratory safety, biosafety, X-ray safety, radiation and laser safety, WHMIS (Workplace Hazardous Materials Information System), contractor safety, respiratory protection, ergonomics, hazardous waste management and disposal and also provides health and safety committee representative training.[ 6 ]

Despite the existence of occupational health and safety programmes in various Canadian universities, recorded evaluation of such programmes is sparse. Considering the large workforces in universities and their unabated positive growth, it is crucial to evaluate the existing occupational health and safety programmes in Canadian university settings. The aims of this study were: a) to evaluate the effectiveness of health and safety programmes through well-designed surveys of faculty members, staff and graduate students of a Canadian university (Memorial University of Newfoundland or MUN); and b) to conduct a key informant interview of the officials of MUN responsible for the operation of the health and safety unit to address the issues raised in the surveys.

In 2013, MUN contracted a third-party consultant to conduct an impartial assessment of the safety culture at the university. The consulting group was asked to do a complete assessment of the current state of health and safety programmes offered by MUN through the Office of the Chief Risk Officer and to identify gaps in the programme. The consulting group surveyed about 10% of the permanent employees of MUN in 2013 and produced a report in 2014. The Office of the Chief Risk Officer called the report a ‘Gap Analysis (GA) survey’. In 2015, to address the identified gaps and to increase awareness about the health and safety programmes, the Office of the Chief Risk Officer organized several health and safety presentations for MUN employees. We sought to examine if these presentations had any effect on the knowledge, attitudes and behaviour of the employees and graduate students at MUN and if their level of knowledge, attitudes and behaviour are sustainable over time. As a result, in consultation with the EHS Unit in 2016, we administered two identical online surveys to employees and graduate students at MUN. The purpose of the first survey was to answer the following research questions:

• Has there been any significant improvement in the perception of the workplace health and safety of MUN employees since 2013 when the survey on gap analysis in safety culture was conducted?
• Do knowledge, attitudes, and practices regarding the health and safety of MUN employees differ with respect to demographic variables?
• Is there any significant difference in the perception of safety practices between those who attended the health and safety presentations and those who did not attend these presentations?

The purpose of the second survey (using the same questionnaires of the first survey) was to assess the retention of health and safety knowledge over the period of 6 months. The intent of conducting the surveys was to gain insight into important factors that could make MUN's health and safety programmes more effective. The study also intended to explore the responses of the officials to the issues raised in the surveys.

We used a mixed-methods approach by collecting, analysing and integrating quantitative (surveys) and qualitative (interviews) data to gain in-depth understanding and corroboration while offsetting the weaknesses inherent in using each approach by itself.[ 7 , 8 , 9 ] Approval from the ethics committee was obtained. The date of the approval 23rd August 2016.

Survey participants

The survey participants in the two surveys that we conducted, included graduate students/researchers, faculty members and staff, as they work for the MUN as employees. As the surveys were anonymous, the second survey was sent to the same entire population and not to only the respondents of the first survey. This allowed us to compare the results with those of the independent surveys to determine if there are any changes in the knowledge level of the employees on health and safety-related information.

Survey design

Two identical online surveys of MUN employees were conducted between 1) October 19, 2016 and November 30, 2016, and 2) April 10, 2017 and June 10, 2017. The purpose of the first survey was to gauge the level of uptake of the information on health and safety, disseminated by the EHS Unit to the MUN Community through their safety workshops in 2015–2016 as well as through their broader reach-out mechanisms. Further, we wanted to study the effect of the knowledge about health and safety on the attitudes and behaviour of the employees and graduate students at MUN. The second survey was conducted six months after the first survey. It targeted the same population and followed the same methodology as the first survey and aimed to understand the retention of knowledge over time and whether the knowledge, attitudes and behaviour of the employees changed over time.

Our survey was developed based on input from the EHS unit. Some questions were based on questions from the GA survey with the intent of comparing the results. We also adopted some questions from the survey questionnaire of the study ‘Montana Tech Campus Safety, Security and Safety Awareness Survey’ conducted by Kristine Witt in 2011 at Montana Tech University, USA.[ 10 ] We conducted a pilot survey of some faculty members, staff and graduate students to ensure the readability, clarity, and organization of the survey questionnaire. We sent e-mails to all faculty and departments of MUN's main campus in St. John's and affiliated Grenfell campus in Corner Brooke, detailing the nature of the survey and provided a web-link (Survey Monkey ® ) to access the survey. The questionnaire with the references is presented in a supplementary file (S1) . At the beginning of the survey, online consent was obtained. The survey instrument was prepared to capture the awareness, attitudes and behaviour of employees and graduate students toward health and safety programmes offered by MUN. The questions were divided into three groups: 1. Knowledge (refers to the awareness and perception of the participants related to health and safety); 2. Attitudes (collects information on the viewpoints and beliefs of the participants about occupational health and safety); and 3. Behaviour (collects information on participants’ day-to-day safety practices/protocols at the workplace).[ 11 ] Questions 7-18, 21, 22, 25, 29, 31 and 40 were designed to test the knowledge of the participants regarding occupational health and safety; questions 19–20, 26–27 were combined to assess their attitudes; and questions 28, 30, 32, 34, 36 and 41 were grouped under behavioural questions (please refer to the questionnaire in supplementary file S1 ). The last few questions were on the perceptions of the participants about safety in specific areas on the campuses.

In the knowledge group, there are 18 questions. For each question, we assigned a score of 1 for the answer “No” and a score of 2 for the answer “Yes”. We added the scores of these 18 questions, which ranged from 18 to 36. We divided this range of responses into halves, 18–27 representing lower score and 28–36 representing higher score, following the procedure described in.[ 12 , 13 ] we used a similar procedure with four questions representing attitudes and six questions representing behaviour groups. The purpose of creating these categories was to test for the association between the levels of the knowledge, attitude, and behaviour of the participants among themselves and with the demographic variables, using frequency analysis technique.

In order to compare with the GA survey, we selected only the Yes/No-type questions (similar to the GA survey) and divided them into three broad themes: i) Environmental Health and Safety Office-related questions, ii) Faculty/Building-related questions, and iii) Department/Division-related questions.

Key informant interviews (KII)

After completing the cross-sectional surveys, we conducted KII with eight officials who have been responsible for the development and implementation of health and safety programmes at MUN. Among them, five officials were from the Environmental Health and Safety (EHS) unit, two officials were from the Workplace Health and Safety Committee (WHSC) and one official was from Facilities Management (FM). The interviews were recorded in writing. A thematic content analysis approach was used for data analysis. Each transcript was reviewed and coded to identify key emerging themes. We then compared the coding of the transcripts. The first question of the interview is about the initiatives taken by the EHS unit to raise awareness about health and safety among MUN employees after 2013. For further analysis, we divided the rest of the questions into three groups. The first group is about knowledge and awareness of safety policies. Questions 2–6, 12 are included in this group. Questions 7–10 are in the group on laboratory safety and workplace hazards. Questions 11, and 13–15 are in the group of MUN facilities and services (please refer to the questionnaire in supplementary file S2 ). The primary motivation of the KII was to collect further information related to the survey questionnaire and to find answers to some of the comments made by the participants in the surveys. Therefore, some questions asked in the KII were based on the outcomes of the survey results.

Data analysis

Apart from descriptive statistics, Chi-square tests were conducted for correlation and P - value less than 0.05 was considered significant. For data analysis, SPSS (version 24) was used. For a detailed statistical analysis, please refer to the supplementary file (S3) .

In the first and second surveys, 148 and 103 valid independent respondents were identified, respectively. Table 1 shows demographic information of survey 1 and survey 2 participants. There was an increase in the level of the participants’ knowledge/awareness about MUN's health and safety policies, when compared to GA survey (please see detailed findings in Supplementary file (S4) ). There was an increase in the level of awareness among the employees about the presence of the EHS unit at MUN and improved communication with the Health and Safety Committee compared to GA results. On the other hand, there were lower levels of knowledge about MUN's working alone procedures, and about AED (automated external defibrillator) locations. In all three surveys, the participants demonstrated little familiarity with the OHS Act.

Demographic characteristics of the university worker participants

We have observed some association between demographic variables and knowledge, attitudes and behaviour (safety practices) of employees regarding health and safety programmes. Table 2 presents the association between the knowledge level score and demographics of the employees. In the first survey, there are associations between ‘the level of health and safety knowledge of the participants’ and their (a) ‘attendance at the safety presentations’ ( P < 0.05), b) ‘employment status’ i.e., faculty/staff/graduate student ( P < 0.05) and c) ‘age’ ( P < 0.05). For a detailed statistical analysis, please refer to supplementary file (S3) [Tables # S3.3.1 , S3.3.2 , S3.3.3 ]. In the second survey, there are associations between: ‘the level of health and safety knowledge’ and (a) ‘employment status’ ( P < 0.05), b) ‘age’ ( P < 0.05), and c) ‘duration of employment’ ( P < 0.05). For a detailed statistical analysis, please refer to supplementary file (S3) [Tables # S3.3.4 , S3.3.5 , S3.3.6 ].

Cross-tabulation between demographics and Knowledge level score

* Low score: 18-27; High score: 28-36; α significant for survey 1, β significant for survey 2

Table 3 presents the attitude level score and demographics of the participants. In the first survey, there are associations between ‘the level of attitude towards safety’ and: a) ‘employment status’ a) ( P < 0.05), and b) ‘age’ ( P < 0.05). In the second survey, no association was found between any of the demographic information and attitude towards safety. Please refer to Supplementary file S3 for a detailed statistical analysis [Tables # S3.4.1 , S3.4.2 ].

Cross-tabulation between demographics and attitude level and behaviour level scores

α significant for survey 1, β significant for survey 2

Table 4 also presents the association between ‘the behaviour (safety practice) level score’ and ‘demographic variables’ of the participants. In the first survey, there are associations between ‘behaviour level score’ and: a) ‘attendance at the safety presentation’ ( P < 0.05), and b) ‘employment status’ ( P < 0.05). In the second survey, there is an association between ‘attendance of the safety presentation’ and ‘behaviour level score’ related to health and safety ( P < 0.05). Please refer to Supplementary file S3 for a detailed statistical analysis [Tables # S3.5.1 , S3.5.2 , S3.5.3 ].

Laboratory safety related responses from different groups (in percentage)

In our two surveys, we observed that those who attended safety presentations had a better level of safety practices than those who did not attend the safety presentations. Overall, there is no significant difference in the knowledge, attitudes, and behaviour of the employees and graduate students between the two surveys. In Tables ​ Tables2 2 and ​ and3, 3 , the Chi square test results indicate that the levels of knowledge, attitudes and behaviour of the employees and graduate students have not changed much over the period of six months.

The only change we observed is a decrease in the knowledge of graduate students and researchers regarding laboratory safety in the second survey [ Table 4 ]. In both surveys, the participants reported that some places on the campus are safe [ Table 4 ]. In the first survey, 70% of the faculty/staff reported that they felt safe in the campus labs, and 51% of graduate students/researchers reported that they felt safe in the campus labs. Compared to the first survey, the difference in knowledge regarding lab safety between faculty/staff/administrators and graduate students/researchers decreased in the second survey (Please refer to Table 5 for the results). It can, therefore, be stated that the graduate students/researchers need more awareness sessions and training on laboratory safety.

Group wise health and safety ratings of different on-campus areas (except laboratories) (in percentage)

For KII, five officials from the Environmental Health and Safety (EHS) unit of MUN, two officials were from the Workplace Health and Safety Committee (WHSC) and one official was from Facilities Management (FM). During the interviews, the participants from the EHS unit highlighted several initiatives undertaken by their unit since the release of 2013 Gap Analysis (GA) results. Some important recent initiatives undertaken by EHS were: (a) Five to seven safety campus-wide presentations were organized, some of which were geared towards senior management and WHSC members; (b) MUN restructured 27 WHSCs on its campuses to provide adequate safety services and to meet the legislated requirements of CCOHS and the University OHS Act and Regulations. Each of the 27 WHSCs covered few buildings on campus; (c) In 2014, MUN implemented electronic safety reporting system (e-alert) (d) MUN Safe App was introduced in 2016; (e) Inspections of all university building offices and 350 laboratories are being conducted annually; (f) Orientation sessions for new undergraduate students each year are being organized, where general safety rules are described; (g) Established a chemical management system for labs; and (h) Created annual water sampling procedure for drinking water safety. The participants from WHSCs also mentioned some initiatives undertaken by the EHS unit such as (a) an increase in the participation of representatives from the EHS Unit to sit on the WHSC meetings and (b) more frequent laboratory inspections. The participant from FM mentioned some initiatives such as maintaining a good database to track the expiry date of the employee training; and more engagement in the weekly Toolbox Talks to discuss potential hazard assessment.

Most of the KII participants mentioned that the graduate students’ supervisors are responsible for providing information to the students on laboratory safety rules and whom to call first in the event of an incident/accident. They placed the responsibility for providing laboratory safety equipment on the Department Heads. The participants emphasized budget and manpower as the main bottlenecks for addressing workplace hazards in a timely manner. There were some suggestions from the KII participants to improve health and safety at MUN such as (i) making attendance of safety presentations mandatory and included as part of the new employee and student orientation packages, (ii) demonstrating the AED in every building, (iii) encouraging all university members to install the MUN Safe App on their phones, and (iv) constantly improving app on a regular basis.

D ISCUSSION

The survey results indicate that there are significant associations between: a) ‘attendance at the safety presentation’ and ‘participant's health and safety knowledge’, b) ‘level of attitude’ and ‘behaviour levels’, c) ‘employment status’ and ‘participant's knowledge level on health and safety’, d) ‘participant's age’ and 'safety knowledge level’, and e) ‘length of service’ and ‘participants’ level of knowledge on health and safety. In our two surveys, we observed that those who attended safety presentations had much better understanding and practices of health and safety than those who did not attend. It is clear from the results that there should be more emphasis on dissemination of the activities of the EHS unit to a larger number of MUN employees and students on a regular basis. The results of the cross-sectional surveys (our two surveys and the GA survey) show consistency in the three survey results. As presented in Table 2 , the respondents increased their awareness about the presence of the EHS unit at MUN and improved their (respondents) communication with the Health and Safety Committee over time. On the other hand, we identified some issues that need to be addressed such as less familiarity with MUN's working alone procedures, AED locations, and OHS Act. The dissemination of information on the OHS Act needs improvement, as this is the basis of all health and safety-related regulations, responsibilities, and rights.

Health and safety programmes should be evaluated periodically to ensure that best practices are being followed on a regular basis. Programme Evaluation always helps the institute to update guidelines as necessary, and to address areas of need or concern in the institute. In some of the previous studies, periodical evaluations were conducted to investigate any change or improvement in population health. Two cross-sectional surveys were conducted in1990 and in 1998 in Copenhagen, Denmark to investigate whether the prevalence of skin-prick-test (SPT)-positive allergic rhinitis had increased in an adult general population in Copenhagen, Denmark. A screening questionnaire on respiratory symptoms was distributed in random samples of 15–41-year-old people in 1990 and in 1998. Among the responders, random samples were invited to a health examination including SPT.[ 14 ] Two International Studies on Asthma and Allergies in Childhood (ISAAC) - questionnaires based surveys were carried out in 1994 and in 2001 among school children in Singapore to evaluate the hypothesis that the prevalence of asthma would further increase and approach to western figures over time.[ 15 ] A questionnaire-based survey was conducted in 1973 among 12 years old children in South Wales, Britain. In 1988, the survey was repeated in the same area among 12 years old children to again to observe whether the prevalence of asthma had increased.[ 16 ] Frequency of prescribed drugs use was assessed by a sample of elderly people 65 years and over in Nottingham in 1985 and 1989. The aim was to observe the change in numbers in the use of prescribed drugs.[ 17 ] Though in our study, we do not observe any significant difference overall in the knowledge, attitude, and behaviour of the employees between the two surveys, we observe a significant decrease in the knowledge regarding laboratory safety in the second survey. Our study is therefore, successful to investigate the change in perceptions of the employees regarding workplace health and safety over time.

This study used a mixed-methods approach as such a method allows for a more robust analysis.[ 14 , 15 , 16 , 17 ] We conducted online surveys as online survey can easily obtain large sample, it can control answer order, it required completion of answers, and online survey can ensure that respondents answer only the questions that pertain specifically to them.[ 18 ] Through the quantitative online survey analysis of MUN employees and graduate students, we learned of their perceptions regarding MUN's workplace health and safety programmes. These perceptions are a one-sided view of the survey participants, and quantitative survey analysis does not provide a detailed explanation of several issues. Through the KIIs, we collected further information related to health and safety programmes at MUN and clarified some of the issues raised by the participants in the surveys. Such as, the KII participants clarified that the graduate students’ supervisors are responsible for providing information to the students on laboratory safety rules and whom to call first in the event of an incident/accident; the Department Heads are responsibility for providing laboratory safety equipment; and budget and manpower are the two main bottlenecks for addressing workplace hazards in a timely manner. The KII participants also mentioned some recent beneficial initiatives such as, the arrangement of five to seven safety presentations campus-wide, restructuring of the WHS and EHS committees, the implementation of an electronic safety reporting system and the MUN Safe App, new orientation for undergraduate students where general safety rules are described, and development of the Health and Safety Management System. There had been a gap in understanding about health and safety matters between the employees and MUN health and safety officials. The qualitative analysis of the KII has filled this gap.

Our study is the first of this kind in the context of Health and Safety Program evaluation in Canadian university. Our study focused on the level of uptake of the information on health and safety disseminated by the university EHS unit through their safety presentations and workshops. We have also studied the effect of employee's and graduate student's knowledge about health and safety programmes at MUN on levels of their attitudes and behaviours. In addition, we have conducted KII interviews of the officials who are engaged in developing workplace health and safety programmes at MUN. As a result, improvements in the health and safety programmes have been planned by university officials. This is the practical implication of this study as the KII participants suggested some future procedures to improve health and safety at MUN such as making attending safety presentations mandatory for all employees and students; demonstrating the AED in every building; and encouraging all university residents to install the MUN Safe App on their phones.

There were some limitations of our study. The sample sizes of the surveys were small as participation was voluntary, and there was no incentive for participating in the surveys. The survey participants were not equally distributed across the disciplines, as the numbers of respondents from some faculties were much higher (Engineering faculty) than the number of respondents from other faculties (Arts and Education faculties). The survey data were anonymous, so our assertion on sustenance of the perceptions of the health and safety of respondents over the six-month period of time is not stronger.

In future surveys, undergraduate students should be included, as they are also exposed to similar risks as graduate students, and they outnumber graduate students. There is a sizable workforce involved in post-secondary university institutions in Canada, and this sector is growing. Varying ranges of working environments in the universities expose employees to multiple occupational risks. Safety training in a university is often not mandatory, and the survey analysis clearly indicates that there is need to increase the level of uptake on the information on health and safety programmes of university by employees and graduate students. Therefore, the universities should increase the number of safety training programmes and keep track of the employees that have not received training, particularly for those working in hazardous environments. Assured provision of financial resources is the key to maintaining a safe work environment and practices.

Key Messages

Universities should make safety training mandatory for all employees and graduate students. Therefore, there is a need to increase the number of training sessions to accommodate all eligible persons. Also, the universities should keep track of the employees and students that have not received training, particularly for those working in hazardous working conditions. The universities have to set aside financial resources for such regular trainings.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgements

We would like to thank the Associate Director of the EHS Unit of the Office of the Chief Risk Officer, Memorial University, Ms. Barbara Battcock, for her valuable suggestions throughout the survey. We would also like to thank all the anonymous participants who volunteered for the surveys and for the key informant interviews.

Supplementary File S1

Memorial University-Workplace Health and Safety Survey .

1. Did you attend the Safety-Presentation provided by Environmental Health and Safety Unit at Memorial University?

[ ] I don’t remember.

2. Employment Status

[ ]Faculty.

[ ]Researcher/Graduate student.

[ ]Administrator.

4. Which faculty/office do you belong to?

[ ] Medicine

[ ]Pharmacy

[ ]Engineering

[ ]Business

[ ]Education

[ ]Administrative office

[ ]Other (Please specify)

5. In which age group do you fall?

[ ] Less than 30

[ ] 60 or more

6. How long have you been on the Campus as an employee?

[ ] less than 5 years

[ ] 5-9 years.

[ ] 10 -14 years

[ ] 15-19 years

[ ] 20-24 years

[ ] 25 years or more

7. Are you aware of the presence of the Environmental Health and Safety Unit at Memorial University? (GA Survey, 2013)

8. Are you aware of Workplace Health and Safety Committees (WHSC- formerly known as Occupational Health and Safety Committees) of the building you work in? (GA Survey, 2013)

9. Does the WHSC in your building communicate with you? (GA Survey, 2013)

10. Do you read newsletters, brochures, bulletins, etc., relating to health and safety e-mailed by Environmental Health and Safety Unit? (GA Survey, 2013)

[ ] I don’t receive any of them.

11. Were you informed about the Occupational Health and Safety Act? (GA Survey, 2013)

12 Do you know where to report a safety concern, a safety hazard or accident? (GA Survey, 2013)

13 Do you know your role in the event of an emergency? (GA Survey, 2013)

14) Do you know the campus emergency telephone number? (GA Survey, 2013)

15. Do you know the shortest exit route from your work area (s)? (GA Survey, 2013)

16. Do you know whom you call first if you get injured at work? (GA Survey, 2013)

17. Are you aware that there are Automated External Defibrillators (AED) available in campus buildings? (GA Survey, 2013)

18. Do you know where the AEDs are located in the buildings you work? (GA Survey, 2013)

19. If AED training is made available through MUN, would you be interested in participating in the training? (GA Survey, 2013)

[ ] I am already trained in using AED.

20. In your experience, do you think that safety is a priority within your department/division/faculty/office? (GA Survey, 2013)

21. Do you understand your responsibilities for your and your colleagues’ health and safety? (GA Survey, 2013)

22. Are you familiar with MUN's health and safety policies? (GA Survey, 2013)

23. Please rate how safe you feel in the following areas on campus. (Montana Tech Safety Awareness Survey, 2011).

Please elaborate on any other particular areas you feel unsafe.

24. What precautions do you think you should take to increase your safety on campus? (Check all that apply). (Montana Tech Safety Awareness Survey, 2011).

• i) Carry a cellular phone.
• ii) Let others know where I will be.
• iii Take safety- training classes.
• iv Other, please specify.

25. Are you aware of Memorial's online reporting system for the health and safety issues/concerns? (GA Survey, 2013)

26. Do you report unsafe acts/conditions if you see them? (GA Survey, 2013)

’Toolbox Talks’ is the name of a meeting, which gives opportunity to Memorial University workers, supervisors and Department Heads a means of communicating health, safety and environmental initiatives as well as accident/incident ‘Lessons learned’ and expressing concerns, obtaining information, and resolving issues related to safety in the workplace.

27. Are toolbox talks/safety meetings relevant to your task? (GA Survey, 2013)

[ ] I do not know.

28. Have you participated in a toolbox talk/safety meeting? (GA Survey, 2013)

29. Are you aware of MUN's working alone procedures? (GA Survey, 2013)

30. Do you work after hours at least some times? (GA Survey, 2013)

31. Are you aware of MUN's safety escort service? (GA Survey, 2013)

32. Do you work at a lab or visit one frequently?

33. Please rate the following regarding laboratories on campus.

34. Is safety discussed in your workplace? (GA Survey, 2013)

35. Were you provided information/training on the safe use and maintenance of tools and equipment necessary for your job? (GA Survey, 2013)

36. Have you requested specific safety training appropriate to your position? (GA Survey, 2013)

37. Were you informed about the hazardous materials that are present in your workplace? (GA Survey, 2013)

For the purpose of this survey a hazard is defined as: ‘Any source of potential damage, harm or adverse health effects on something or someone under certain conditions at work’.

38. How many hazards have you identified in your work place in the last one year.

0 1 2 3 4 or more.

In the above question if your answer is 1 or more than 1 go to question 34 or else go to question 35.

39. How many of them have been corrected in a timely manner?

40. Are Employees given feedback on accidents that occur in your workplace? (GA Survey, 2013)

41. Do you have any concerns regarding your safety and/or security in your faculty or department?

If you answered yes please specify.

42. Which of the following do you think MUN should provide to help increase the safety of the campus community? (Check all that apply). (Montana Tech Safety Awareness Survey, 2011)

• Improve safety escort service.
• More emergency call boxes.
• Additional lighting.
• More security guards.
• More safety presentations.
• Self-defence classes.
• Other, please specify

Supplementary File S2

Key Informant Interview Questions

Q1. After the 2013 Gap Analysis survey on safety culture, can you recall any additional initiatives that EHS Unit has initiated to create awareness on health and safety among MUN employees?

Q2. In the surveys less than 50% respondents (first survey 46.6%, second survey 40.8%) notified that they had participated in the safety presentation/workshop in 2015. Is this level of participation satisfactory? If not what additional steps can be taken to reach out to more people at MUN?

Q3. The survey results indicate that, the graduate students and researchers have low level of knowledge/awareness on occupational health and safety programmes compared to the faculty and staff. Knowing that the graduate students and researchers are more exposed group to different safety critical scenarios,

• i Does this appear as a concern?
• ii How do you think the safety awareness of graduate students and researchers can be improved?

Q4. In the surveys less than 65% of the participants know whom to call first if they get injured at work. Is this level of awareness acceptable? What are the current mechanisms to educate researchers/employees about this information? How do you think this information can be disseminated more effectively?

Q5. The respondents have suggested to improve communication and implementation of the policies and to provide more auditing of safety policies by EHS department to ensure compliance, do you have a similar observation? Is there any continuing effort to improve this concern?

Q6. The surveys indicate that, among the people who said Tool Box Talk is relevant to them, the level of participation in toolbox talk decreased over time. Does your observation support this finding? If so, what can be done to increase the participation?

Q7. The survey analysis indicates that, the graduate students and researchers need more training on eyewash station and safety shower, can you explain the current mechanisms for training graduate students on these basic safety practices? Do you see any way to improve the provision of training and increase the level of participation?

Q8. The respondents suggested to install more flammable gas detectors and improve the splash proof safety goggles. In your opinion are the units/labs equipped with adequate gas detectors and splash proof safety goggles?

Q9. The respondents commented on shortage of lab space and shortage of PPE (Personal Protective Equipment).

• i) Is there any continuing effort to create more lab space?
• ii) Who is normally responsible to provide the PPE to the researchers/graduate students? How can one address the shortage of PPE in labs at MUN?

Q10. In the surveys over 50% of the respondents mentioned that, none of the hazards at their workplaces had been addressed in a timely manner.

• (i) What are the current practices for reporting, follow-up and correction of hazards?
• (ii) Do you see any bottleneck in the addressing the hazards in a timely fashion?

Q11. The survey results show that over 70% of the respondents want to participate in AED training. Is there any continuing effort to provide AED training to the employees and students at MUN?

Q12. The surveys indicate that a significant portion of the employees is not aware of MUN's working alone procedure though most of the employees are working after hours at the office. Is this a concern? If so what can be done to increase awareness on working alone procedure among the employees?

Q13. The participants have suggested repair of walkways and parking lots and removal of thick layer of ice from the parking lots to prevent slips and falls. Does this come under the purview of EHS Unit? If yes how can one address this issue?

Q14. Many respondents showed their concern about the design and usage of MUN Safe App. Is there a continuing effort to improve the App and make it user friendly?

Q15. In the surveys many of the participants have suggested the improvement of the on-campus safety escort service. How is the current safety escort service implemented and what additional steps can be taken to improve it?

Supplementary File S3

Table s3.3.1.

Chi-Square Tests for table 3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 14.02, * p-value < 0.05 considered significant

Table S3.3.2

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 6.89

Table S3.3.3

Chi-Square Tests for Table 3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 17.08

Table S3.3.4

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 6.67

Table S3.3.5

Chi Square Tests for Table 3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 12.53

Table S3.3.6

a. 1cells (25.0%) have expected count less than 5. The minimum expected count is 3.67

Table S3.4.1

Chi-Square Tests for table 4

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 8.71

Table S3.4.2

Chi-Square Tests for Table 4

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 21.79

Table S3.5.1

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 14.75

Table S3.5.2

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 6.94

Table S3.5.3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 8.87

Supplementary File S4

Comparison of surveys

R EFERENCES