A n n a l s o f G l o b a l H e a l t h

ª 2 0 1 5 T h e A u t h o r s . P u b l i s h e d b y E l s e v i e r I n c .

o n b e h a l f o f I c a h n S c h o o l o f M e d i c i n e a t M o u n t S i n a i

V O L . 8 1 , N O . 4 , 2 0 1 5

I S S N 2 2 1 4 - 9 9 9 6

h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . a o g h . 2 0 1 5 . 0 8 . 0 2 3

OR IG INAL RE S EARCH

Evaluation Studies on Education in Occupational Safety andHealth: Inspiration for Developing Economies

Frank J. van Dijk, MD, PhD, Marija Bubas, MD, PhD, Paul B. Smits, MD, PhD

Leusden, the Netherlands and Zagreb, Croatia

All authors

From the L

Health Pro

vandijk@ldo

Abstract

B A C K G R O U N D Education and training of students, workers, and professionals are essential for

occupational safety and health (OSH). We noticed a lack of debate on how to advance coverage and

quality of OSH education given high shortages in developing economies.

O B J E C T I V E S International discussion on future options might be stimulated by an overview of

recent studies.

M E T H O D S We employed a search of the Cochrane Library and PubMed/MEDLINE databases for

articles from the last decade on evaluation of OSH education.

F I N D I N G S We selected 121 relevant studies and 6 Cochrane reviews. Most studies came from the

United States, Western Europe, and Asia. Studies from low-income countries were scarce. From a global

perspective, the number of evaluation studies found was disappointingly low and the quality needs

improvement. Most commonly workers’ education was evaluated, less often education of students,

supervisors, and OSH professionals. Interactive e-cases and e-learning modules, video conferences, and

distance discussion boards are inspiring educational methods, but also participatory workshops and

educational plays. Ways to find access to underserved populations were presented and evaluated, such

as educational campaigns, farm safety days, and OSH expert-supported initiatives of industrial branch

organizations, schools, and primary, community, or hospital-based health care. Newly educated groups

were immigrant workers training colleagues, workers with a disease, managers, and family physicians.

C O N C L U S I O N S Developing economies can take advantage of a variety of online facilities improving

coverage and quality of education. Blended education including face-to-face contacts and a participatory

approach might be preferred. For workers, minor isolated educational efforts are less effective than enhanced

education or education as part of multifaceted preventive programs. Collaboration of OSH experts with other

organizations offers opportunities to reach underserved worker populations. Increasing international collab-

oration is a promise for the future. National legislation and government support is necessary, placing OSH

education high on the national agenda, with special attention for most needed professionals and for under-

served workers in high-risk jobs such as in the informal sector. International support can be boosted by a high-

level international task force on education and training, funded programming, and a global online platform.

K E Y W O R D S education, training, occupati onal health, safety, evaluation, developing economies,

developing countries

© 2015 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is

an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conflict of interest for all authors: none.

had access to the data and a role in writing the manuscript.

earning and Developing Occupational Health (LDOH) Foundation, Leusden, the Netherlands (FJvD, PBS); and the Croatian Institute for

tection and Safety at Work, Zagreb, Croatia (MB). Address correspondence to F.J.v.D. (v.dijk.workandhealth@gmail.com). or (frank.

h.net).

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I N T RODUC T I ON

A Need for Education and Training. A recent over-view of global working conditions and adverseeffects on health and safety presented as WorldHealth Organization (WHO) and InternationalLabor Office (ILO) conclusions that of all fatalitiesin industrial countries, some 5%-7% are attributedto work-related illnesses and occupational injuries.The economic cost is equivalent to a range of 1.8%-6% of gross domestic product (GDP).1 Based onthe “Workers’ Health: Global Plan of Action”(2007), WHO encourages strongly the education ofworkers, employers, primary health care practi-tioners, and professionals for occupational healthservices. Workers’ health should be integrated inbasic training for health care.2 It is regarded as aworkers’ right in all countries to be well informed,educated, and trained in safety and health at work.

Education in occupational safety and health(OSH) is needed urgently in developing economies.i

A few examples may serve as illustration. Kumaret al reported about welders in India exposed to fly-ing sparks and particles, ultraviolet radiation, metalfumes, and many other risks. Awareness of hazardsand safety precautions was limited and only 20% ofthem had institutional training.

The authors refer to studies on welders in SaudiArabia, Pakistan, Nigeria, and South Africa withsimilar observations and recommend an educationalcampaign, besides enforcement of safety regulatorymeasures to control the informal sectors.3 Migrantworkers in Oman exposed to pesticides in green-houses were studied by Esechie et al. Hygiene waspoor, personal protective equipment (PPE) washardly used, and health symptoms were reported fre-quently. The authors recommend adequate legisla-tion for mandatory PPE provisions and regulartraining programs.4 Education on safe handling ofpesticides in a high-risk region in India was evaluatedby Sam et al. Knowledge, attitude, and practiceimproved. They too recommend continuous educa-tion and training programs for agricultural workers.5

Anderson et al concluded, after studying farmers’concerns in Alabama, USA, that medical studentsshould be educated in farming practices including

iMost publications in health sciences use the termdeveloping countries for all nonehigh-income countries.Presumably it is more correct nowadays to use the termnewly industrialized countries to refer to, for example,China, India, Brazil, Turkey, and South Africa. Wehave chosen the term developing economies, aware of stillexisting problems in terminology.

occupational exposures when interested in a ruralarea practice.6 A training course for health care pro-fessionals on farmers’ occupational health needsstarted in Iowa, USA, in 1974 and expanded grad-ually. This 40-hour course is now also given in Tur-key and Australia.7 In addition, because only about10%-15% of the global workforce has access tooccupational health services, it is a great challengeto educate large numbers of OSH professionalsbeing experts in OSH prevention and health caretasks. Rantanen et al estimated a global need of312,000 more OSH experts to be educated.8 A tre-mendous task has to be done in newly industrializedand least developed countries. Delclos et al started adiscussion about competencies and curricula indeveloping and developed countries.9 The Occupa-tional Hygiene Training Association (OHTA) cre-ated free high-quality e-modules for occupationalhygiene and ergonomics to meet a growingdemand.10

Education of Workers Alone Is Insufficient. One ofthe reasons why improvement of working condi-tions stagnates is the absence of effective educationof workers. Some authors believe that working con-ditions will improve over the long term when theeducated, trained worker becomes an integral partof workplace safety programs.11 Others havestrong concerns over the influence of education andtraining in the real-life situations.12 We agree thateducation and training alone cannot solve all prob-lems in health and safety. Just offering educationcan be an inadequate answer to complex problemswhen legislation and inspection are needed as wellas comprehensive prevention programs in whichworkers and employers cooperate not only in edu-cation but also in improving working conditions andsocial relationships. On the other hand, health risksand high job demands cannot always be eliminated.High-demand jobs can even be challenging such asteaching adolescents, firefighting, removing asbestosin demolition work, or treating patients with AIDSor Ebola. Therefore, education in how to cope withrisks is necessary for many jobs, today and in thefuture.

Interestingly, education is also a component innew OSH interventions such as on how to retaina job while having a chronic disease as rheumatoidarthritis or serious hearing loss. Workplace healthpromotion, motivated by epidemics threateningthe working population and facilitated by companiesaccepting social responsibility, can include trainingsuch as on how to prevent obesity, cardiovasculardiseases, or HIV/AIDS.

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Information and Education. Education and infor-mation are more closely related than in the past.Facilities exist in many countries offering access toreliable online OSH information such as offeredby the Canadian Centre for Occupational Healthand Safety in Canada.13 Online question andanswer facilities can be organized gaining both onquality of the information and efficiency14,15; theUS National Institute for Occupational Safety andHealth (NIOSH) and the European Agency forSafety and Health at Work (EU-OSHA) investedin online interactive risk assessment and controltools,16 and the International Labor Office (ILO)developed apps for the same goal. Access to reliableonline OSH information and tools initiates greatopportunities for developing economies, especiallywhen sources are available as m-health on mobilephones and tablets. OSH professionals can betrained in how to find up-to-date, reliable OSHinformation and tools on the Internet.17

Target Groups and Lifelong Learning. Variousgroups of participants need OSH education. First,education is, or should be, organized for studentsin vocational training learning how to protect them-selves in the future. Other students are educated aspart of studies at, for example, medical faculties,schools for occupational health nurses, or physio-therapy schools. For them workers’ health is a partof future professional practice. Second, we neededucation of informal workers, formal employees,and the self-employed to learn how to preventoccupational diseases and accidents. Supervisors andmanagers ought to be educated, which would have acrucial impact on the quality of work of others. Inunions and communities, selected workers andleaders may demand training to be a good trainer inOSH. Third, education has to be organized forprofessionals functioning as experts in OSH and forother professionals who are often challenged byworkers’ health issues. In most countries, OSHprofessionals include safety experts, occupationalphysicians, occupational health nurses, occupationalhygienists, ergonomists, and occupational psychol-ogists. Relevant non-OSH professionals can becommunity health workers, family physicians, der-matologists, pulmonologists, clinical psychologists,physiotherapists, occupational therapists, andhuman resource managers.

Vocational training in work and health includesor has to be followed by training on the job, to learnessential details and practicalities. Given all kind ofchanges, education is needed during the wholecareer. Therefore facilities for lifelong learning,

continuous professional development, and continu-ing medical education (CME) have to be structured.Goals and Outcomes. For an evaluation, clear goalsand outcomes should be defined. Education of stu-dents, workers, and professionals can be directed ongaining knowledge, skills, attitude, self-efficacy,motivation to act, and competencies, described asimmediate outcomes by Robson et al.18 Behavior,hazard controls, hazards, and exposures are dis-tinguished as intermediate outcomes. The final out-come or impact of education is mostly the improvedhealth or safety of workers as visible in a lowerincidence of occupational accidents and diseases.The practice of occupational health care has beenextended in many countries, currently includingprevention and control of sickness absence and workdisability, support of good work functioning, andpromotion of healthy lifestyles. Corresponding goalsand outcomes are lower work disability pensionrates, better functioning at work, and lower rates ofobesity, cardiovascular diseases, or HIV/AIDS.Evaluation of Education, Contribution of Scien-ce. Robson et al published a systematic review onthe effectiveness of OSH training covering publica-tions from 1996-2007.18 Studies were reviewed oneducation of workers related to primary preventionof occupational illnesses and injuries, selecting onlypre-post randomized trial studies. Based on 22studies, strong evidence was found for the effec-tiveness of training on workers’ behaviors butinsufficient evidence for effectiveness on healthoutcomes. A lack of studies with a fair or goodmethodologic quality resulted in the conclusion ofinsufficient evidence for studies with “knowledge” or“attitudes and beliefs” as outcomes. For futurereviews, it was advised to include also non-randomized studies. A recommendation for practicewas to “consider more than just education andtraining when addressing a risk in the workplace.”

OB J E C T I V E S

The purpose of this study is different from that ofRobson et al. Our goal is to stimulate the discussionon policies needed to improve coverage and qualityof OSH education in developing economies. There-fore, we decided to investigate evaluation studiespresented in the recent international peer-reviewedliterature: which countries were active, and what tar-get groups, topics, and outcomes were chosen?Implementation strategies and educational methodsevaluated might show us new perspectives toencourage education in developing economies.

Table 1. Selection Questions and Inclusionary Responses

Questions Inclusionary Response

Is the article written in

English?

Yes

Is education or training named

as one of the components?

Yes

Is the article presented with

abstract?

Yes

Is the study including

education, training, or

learning as topic of

the study?

Yes

Is education related to an

outcome in the area of work

and health?

Yes

Is the study evaluating the

quality or the outcomes of

educational interventions?

Yes

Is education delivered through

a lesson, training, course, or

workshop or as a part of a

complex intervention or

program?

Yes

Is the study dealing with

patient care or with patient

education, without

work-related topics?

No

Is the article only concluding

or recommending that

education of workers or

professionals is needed?

No

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Being primarily interested in an overview of recentinitiatives, we did not select primarily on a highquality of methodology. Consequently, we did notreconsider the concluded effectiveness of the educa-tion presented by the authors. Finally, we reviewedrelevant Cochrane studies on their judgment ofstudy quality and effectiveness of OSH education.

For our study we included publications on educa-tion in OSH, regardless of subject, level, and methodof education, but excluding mere dissemination ofinformation. We often abbreviated “education andtraining” using only the term “education.” First wepresent an overview of recent scientific studies onthe evaluation of education, limited to publicationsof the last 10 years accessible via PubMed/MED-LINE and to Cochrane systematic reviews. Second,considerations are given about the findings, followedby recommendations on how to improve coverageand quality of education and training in OSH, espe-cially in developing economies.

METHODS

PubMed Search. For this article we chose to searchin PubMed/MEDLINE, considered a database ofchoice in health sciences. The recall ratio of MED-LINE for high-quality intervention studies inoccupational health is close to 90%. Psychiatric andpsychological topics are relatively less often indexedin MEDLINE than somatic studies.19 We searchedonly for articles in English. In addition, we searchedfor systematic reviews in the Cochrane Library.

Abstracts published from 2005-2015 (last searchdate June 20, 2015) were screened to find originalstudies on evaluation of education in OSH, withoutselection on participants. A first string of searchterms was related to occupational safety and health,a second to education, and a third to evaluation out-come terms.

The search filter was:

(“Chemical Safety”[Mesh] OR “Occupational Injur-ies”[Mesh] OR “Disability Evaluation”[Mesh] OR“Accidents, Occupational”[Mesh] OR “Return toWork”[Mesh] OR “Occupational Diseases”[Mesh] OR“Occupational Health”[Mesh]) AND (“Learning”[Mesh]OR “Education”[Mesh]) AND (Coverage ORReach ORKnowledge OR Literacy OR Skills OR Coping ORAttitude OR Competence OR Competenc* OR Self-efficacy OR “Self efficacy”OR PPE OR Participation)

In a next step, we used inclusion criteria to selectrelevant articles. Selection questions and inclusion-ary responses are shown in Table 1.

Education or training could be part of a compre-hensive intervention but had to be specified as edu-cation. Outcomes in the area of work and healthcould be related to prevention or control of hazardsor risks at work; prevention, diagnosis, guidance, ortreatment of occupational and work-related dis-eases, injuries, work disability, or sickness absence;improvement of work functioning; and workplacehealth promotion.Cochrane Library Search. We searched the databaseof the Occupational Safety and Health review group(www.osh.cochrane.org) within the subtopic “occu-pational health outcomes” (last date: June 26, 2015).We found 101 reviews and 20 protocols. Weselected reviews with “education” or “training” inthe title or abstract.Data Extraction and Management. The searchresults were reviewed for duplicates by the mainauthor. Publications not written in English or with-out abstract were excluded. Next, selection ques-tions were applied (Table 1). We did not select on

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the design or scientific quality of the study. Pub-lications were assessed on the basis of titles andabstracts to gauge their potential relevance. The fulltext was reviewed to determine the appropriatenessfor presentation as an example in this paper.

R E SU L T S

PubMed Search. Using the search filter as describedwe found 1549 titles. The number of citations peryear before 2014 varied between 134 and 218, fol-lowed by only 115 and 5 titles in, respectively,2014 and the first half of 2015. These low scoresoriginated in the MEDLINE database becauseapplying the MeSH terms “occupational health”and “diabetes mellitus” showed similar results.Therefore, we were actually covering around 10years of publications. Relevant articles were selectedin a second step using inclusion criteria, so we couldinclude 121 studies (Fig. 1).Countries. Most studies were completed in theUnited States, followed by Japan, 3 European coun-tries, China, and Australia (Table 2). NorthAmerica generated 46 publications, 35 came fromEurope, 26 from Asia, 5 from Australia, 3 fromLatin America, and 1 from Africa. Publications byan international group of authors were noted since2009. There was a lack of studies from LatinAmerica, Eastern Europe, and Africa. Almost nostudies came from low-income countries.Participants and Topics. Different groups of partic-ipants and various topics of education weredescribed in the selected publications (Table 3).

Students. Much attention was given to healthdisciplines. The main goal could be different: nursestudents were trained to protect themselves forwork-related health effects; medical and pharmacystudents to diagnose occupational diseases andintoxications in patients. Compulsory education ofmedical students to improve the attitude towardoccupational health (OH) was evaluated in Braziland Germany. The education, consisting of lecturesand online virtual patient cases, improved self-ratedknowledge and interest in OH in both countries.20

In Germany, 521 health care trainees were eval-uated after a 3-year training period. The interven-tion group received a regular training program toprevent irritant contact dermatitis, including evalu-ation of the hand skin condition. In this group,hand washing was reduced compared with the con-trol group. A significantly better skin condition ofthe hands was found in the intervention group atthe end of the training period than in the control

group.21 In a study in Taiwan, a series of 14 e-lec-tures on OH promotion for music performersenhanced music students’ awareness on music prac-tice and performance issues. An online interactivediscussion board with experts, a form of distancelearning, generated many questions and answers.22

Another study reported on education of occupa-tional skin hazards at German high schools (n ¼1015); students were seriously interested.23

Workers. We found relatively high numbers ofstudies in the agriculture, health care, and construc-tion sector. Audiovisual aids and printed literaturewere used in India, teaching farmers to reducehigh levels of work-related musculoskeletal prob-lems. Knowledge scores after education increasedsubstantially in farmers, males and females, creatingawareness.24

Many studies aimed at risk reduction in 1 occu-pation or occupational group (Table 3). A Brazilianstudy analyzed work-related voice problems affect-ing teachers. Vocal care improved as a result of avoice workshop educating in decreasing vocal ten-sions. Changes were recommended in the schoolenvironment and organization to prevent vocaloverload.25 Chinese military personnel were suc-cessfully trained for activities as civil emergency res-ponders, adapting coping styles.26 Municipalkitchens participated in participatory workshops inFinland to optimize musculoskeletal load. Morethan 400 changes were implemented in 59 kitchens,and knowledge and awareness increased. Afterward,physical load was perceived as decreased and muscu-loskeletal health as improved.27

Education was evaluated of 204 stone-quarryworkers in India about using protective eyewearagainst eye injuries. An enhanced education packageincluding group education, individual discussions,and educational plays was compared with a singleeducational session and follow-up visits. Enhancededucation increased the use of protective eyewear.Enhanced education plus using eyewear reducedthe incidence of eye injuries. Because the provisionof suitable protective eyewear played an importantrole, it can be argued that it is not education perse making the successful change, but enhanced edu-cation contributed to continuous use of protectiveequipment. 28

Some studies were aimed explicitly at under-served workers’ populations, such as Latino daylaborers in US construction and agriculture29 orfemale migrants in China with a high risk ofunwanted pregnancy and sexually transmittedinfections.30

Figure 1. Overview of the search and selection procedures.

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Workers with a disease. The aim of education ofworkers with a disease can be better coping withhazards and demands at work, retention of thejob, and sometimes curation of health problems.In a German study, long-term effectiveness wasevaluated of a 6-month dermatologic-educationalintervention program inclusive of workplace inter-ventions for hairdressers with a chronic occupationalskin disease. The control group only received der-matologic treatment. Positive effects were found onknowledge, behavior, and not giving up workbecause of an occupational skin disease.31

Supervisors and managers. Seven studies hadthe education of supervisors or managers as thestudy object related to their high responsibilityin preventing and controlling risks. With supportof workers’ compensation insurance and the res-taurant trade association, trainers conducted work-shops in California, USA, for more than 200restaurant and foodservice owners or managers.The aim was to develop a program helping theowners/managers in conducting short training ses-sions with their own employees, addressing haz-ards and making changes. Interaction with the

Table 2. Country in Which Education Was Object of Study in121 Abstracts on OSH Education Evaluation in PubMed/MEDLINE, Published 2005-2015

Country

Number of

Selected Abstracts

United States 42

Japan 10

United Kingdom 8

Germany 7

Netherlands 7

China 6

Australia 5

International group 5

Canada 4

India 3

Sweden 3

Brazil 3

Turkey, Norway,

Taiwan, Italy, Finland

2

Malaysia, Ireland, Iran,

Nigeria, Greece, Spain,

Thailand, Denmark

1

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other owners and managers was a key to the pro-gram’s success.32

OSH professionals. Studies on education ofOSH experts mainly came from Europe (8 of 13).The effectiveness of e-learning was compared withlecture-based learning in a Dutch study of CMEfor occupational physicians. Both approaches wereequally effective regarding gain in knowledge.33 Inthe United States, tours were organized to historicalOSH sites to bridge often separated OSH fields.OSH disciplines were successfully trained in amultidisciplinary approach, ultimately oriented onprevention of future exposures.34 Evaluation studiesconcentrating on occupational health nurses werenot found. However, in several studies nurses wereincluded, such as in a UK study on the effectivenessof a musculoskeletal training package.35

Non-OSH professionals. In Scotland the generalpopulation, workers, and non-OSH health careprofessionals were targeted in an effective compre-hensive multimedia campaign (1777 radio adver-tisements, leaflets, website) about “rest or stayingactive” in case of back pain.36 In another UK projectmore than 1000 health care professionals completedan interactive e-learning module on occupationalasthma. The result was increased knowledge andmore use and awareness of the guidelines.37 InCanada CME was organized to increase knowledgeof occupational health for primary care physiciansand medical specialists. Online learning and

videoconferencing were both evaluated as equallyeffective compared with traditional conference lec-tures and small group face-to-face education.38 Inthe United Kingdom and Norway some studiesfocused on sick note certification or functionalassessments in long-term sickness absence by hos-pital doctors and general practitioners.39-41

Knowledge and self-confidence increased. Advi-sory extension agents for farmers such as financialcounselors and agribusiness officers were success-fully trained in Australia in recognizing, supporting,and referring mental health problems in farmers.These officers are often “the first port of call foremotional support and referral for farmers.”42

Organization by industrial branch or occupationalgroup. Many studies were on safety, stress manage-ment, and ergonomics. Studies on training how tocope with asbestos or nanoparticles exposure werenot found. Education was mostly organized sectoror branch-wise or for specific occupational groups.This practice reflects presumably not only theexistence of institutions able to organize higherquality OSH courses. Another attractive factormight be the occurrence of common risk factors,social conditions, and technical solutions in onebranch or occupational group. This forms anattractive starting point for concerted educational,social, and technical efforts, also in low-incomecountries.

New methods. Case-based e-lessons for medicalstudents developed by an international group werecompared with the use of written material: textbookpages, practice guidelines, and articles. The increasein knowledge and satisfaction was similar; surpris-ingly the attitude toward occupational health wasmore negative in the e-lesson group.43 High-quality interactive e-cases with virtual patientsdeveloped in Germany and Latin America wereused by more than 2000 students and evaluated asfeasible and helpful.44 Five European universitiesdeveloped a comprehensive online teaching moduleon occupational medicine for undergraduate medi-cal students.45 The module was evaluated positivelyon effectiveness in a blended application.46

New methods were evaluated for workers. Ineducation on patient transfers of nurses in Sweden,occupational health was combined with patientempowerment. The training improved staff move-ments, body awareness, and musculoskeletal com-plaints and also their communication encouragingpatients to move independently.47,48 The use ofultraviolet face photographs and cancer informationsessions educating male outdoor workers in the

Table 3. Participant Groups and Most Frequent Topics of Education in 121 Publications on Evaluation of OSH Education Found inPubMed/MEDLINE (2005 to June 2015)

Students

Workers and

Health and

Safety Committees

Supervisors and

Managers Professionals

Total 16 studies

4 Student nurses

6 Medical students

3 Students in higher music

education

3 Other categories:

students in general

secondary schools,

high school students,

pharmacy students

Total 88 studies

15 Agriculture sector

13 Health care sector

9 Construction sector

5 Office work including

computer users

4 Education sector

14 Workers from another

sector or from >1 sector

26 Specific occupations or

worker/patient groups*

2 Health and safety

committees, including

immigrant safety liaisons

Total 7 studies

5 Supervisors/ foremen

2 Managers

Total 20 studies

OSH professionals

3 Occupational physicians

2 Occupational hygienists

3 Social insurance physicians

1 OSH trainers

4 OSH professionals from > 1

discipline

Non-OSH professionals

3 Family physicians

1 Occupational therapists

1 Advisory Extension Agents

for farmers

2 Non-OSH professionals from > 1

discipline

Most frequent

topics

Most frequent

topics

Most frequent

topics

Most frequent

topics

3 Variety of hazards

2 Infectious diseases

2 Skin risks, skin diseases

2 Stress management

16 Ergonomics/

musculoskeletal

disorders

12 Safety including eye

protection

7 Stress management

4 Hearing loss

4 A variety of hazards

3 Skin risks, skin diseases

3 Chemical exposure

including pesticides

3 Stress management Specific topics

of various kinds

* Workers with a work-related skin disorder (5), kitchen work (2), stone quarry work (2), sake brewery work, work with high Lyme disease risk, computer engineers,police officers, workers in noise, poultry factory, military, university custodians, information technology work, motorcyclists, family caregivers, beryllium industrywork, firefighters, outdoor workers, manual handling work, Latino day laborers, workers with cognitive dysfunctions.

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United States stimulated sun-protecting cognitions,potentially mediating protection behavior.49 In aChinese study of frontline workers in industryworking in poor ergonomic conditions, participatoryrespectively classic didactic training of limited dura-tion did not change the prevalence of musculoskele-tal complaints 1 year after training, except for lowerextremities and “wrist and fingers.”50 In anotherChinese study, a game technologyebased safetytraining was tested for a training in operating towercranes on construction sites. Game technology hasmany advantages simulating high-risk situations inpractice, including challenging communication andcollaboration with other workers.51

Kawakami reports about participatory trainingprograms based on ILO strategies with home work-ers, construction workers, and waste collectors in

Cambodia, Thailand, and Fiji. Improving safety,health, and working conditions relies on positiveefforts of local people, direct observations of work,and learning from local good examples.52

To improve access to difficult-to-reach groups,bilingual training (English and Spanish) is used 53

as well as so-called immigrant safety liaisons.54

Training led by “worker leaders” from so calledWorker Centers, serving as Spanish speakingpeer-educators,55 or by farmers, fathers of adoles-cents,56 has been evaluated positively. A course inEnglish as a second language for teen farm workersaimed at health and safety education was used fruit-fully.57 In another US study, farm safety days forchildren were evaluated as valuable.58

Search for Cochrane Systematic Reviews. Six sys-tematic reviews were the result of our selection

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related to education and training in occupationalsafety and health (Table 4).59-64

Any educational intervention was included in areview on preventing eye injuries. The authors didnot find reliable evidence that the interventionswere effective.60 A review on occupational diseasereporting distinguished educational materials, edu-cational materials and meetings, educational meet-ings, and a multifaceted educational campaign.Interventions with educational meetings and educa-tional campaigns both provided (very low-quality)evidence for an effect on the number of physiciansreporting occupational diseases compared with nointervention. No studies were found evaluating theeffectiveness of Internet-based interventions.64

The quality of the original studies found wasassessed from moderate to (very) low. The observedeffects of the educational interventions on healthoutcomes, work functioning, job loss, or increasedreporting of occupational diseases were, in general,judged as small or absent.

D I S CU S S I ON AND R E COMMENDAT I ON S

The majority of evaluation studies on educationwere completed in North America, WesternEurope, or Asia. Studies from low-income econo-mies were scarce. Most studies evaluated educationof workers; fewer, the education of students, man-agers, or professionals. Studies related to the agri-culture, health care, and construction sectorpresumably reflect attention for high-risk sectors.Surprisingly no studies were found on educationrelated to asbestos or nanoparticles exposure. Edu-cation was often enhanced, for example, also

Table 4. Participants and Topics of Education in 6 CochraneSystematic Reviews Including Occupational Safety and HealthEducation

Workers Professionals

Teachers, education sector

Construction

Various workers

Specific patient group

(inflammatory arthritis)

Occupational physicians

Topics Topics

Voice disorders

Fatal and nonfatal injuries

Eye injuries

Hearing loss

Job loss, work functioning

Reporting of occupational

diseases

providing PPE or including a workplace inspection,or embedded in a comprehensive prevention pro-gram, improving effectiveness. New educationalmethods such as e-learning and participatory work-shops were tested on feasibility, quality, and effec-tiveness. Creative strategies were presented to findbetter access to underserved populations. Educationof new groups of participants was evaluated: stu-dents in vocational training, adolescents workingon farms, workers with a chronic disease, immigrantsafety liaisons, supervisors, and family physicians.Strengths and Weaknesses of This Study. Usingpublications indexed by MEDLINE has theadvantage of good accessibility and presumably ofselecting the best evaluation studies. On the otherhand, selecting only studies written in English andbeing indexed by the US National Library of Med-icine (MEDLINE) caused selection bias, excludingstudies published in other languages and benefitingstudies from the United States, Canada, and West-ern Europe. Because PubMed/MEDLINE focuseson health, studies on safety or mental health mayhave been missed. The sensitivity of the chosen fil-ters was not 100% and the bibliographies of thepublications found were not scanned for new sour-ces. These are important weaknesses of this study.We know several relevant studies not identified inthis search, such as from Thailand and China, eval-uating basic occupational health care initiativesincluding education.65,66 Only 1 study was foundin this search reporting about ILO WISE (smallenterprises) and WIND (neighborhood, farmers)programs.52 For example, a study of Kogi was notincluded, reporting about the successful action-oriented community approach applied in manycountries.67 Finally, the scientific quality of thestudies was not systematically analyzed, being out-side the scope of this study. Nevertheless, we couldnotice many problems, confirming reports by others.

Additional literature searches are worthwhile,including public health studies and gray literature.Specific studies may find answers to questionssuch as on behavioral changes as a result of educa-tion or on the most suited design for transfer ofknowledge or skills given a specific situation.Low Number of Studies and Problems With Qual-ity. Given about 3 billion workers in the world, activein a large number of different occupations, and pre-sumably more than 200,000 active OSH experts,8

the number of 121 studies published during 10years on evaluation of OSH education is low, eventaking into account that we have missed studies.Selecting publications in PubMed/MEDLINE in

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2013 dealingwith occupational health,ii we couldfindalmost 3300 publications, in contrast to only 20publications on evaluation of OSH education. Sur-prising is the low number of studies on education ofOSH professionals, students, supervisors, and man-agers. Schulte et al noticed the absence of literatureassessing the role and value of OSH training invocational education.68 We did find studies, but notmany.

A number of barriers may hinder evaluationstudies: lack of funds, not having a tradition of eval-uation, regarding education as a complex interven-tion, missing incentives to publish, or journals notbeing interested or even incompetent on the topic.One other main reason might be that education inOSH itself is scarce or even absent for some targetgroups in many countries, as is illustrated in theIntroduction.2-10 In many parts of the world OSHeducation came under pressure by the economic cri-sis. We recommend analyzing the barriers and pro-motion factors.

We noticed in a number of studies the lack of acontrol group, low number of participants, unrealis-tic expectations of long-term health effects after amodest isolated educational intervention, and theabsence of (cluster) randomization when that wasan option. We conclude with others that goodquantitative and qualitative study designs have tobe promoted and supported. The development ofeffective education can be improved, such as byusing focus groups of participants and a literaturesearch in the development process. Chosen out-comes can be discussed: why using knowledge out-comes and not adequate behavior, why striving forbehavior changes when concrete working conditionscan be improved? Several articles were found elabo-rating on education being able (or not) to have animpact on behavioral changes of workers via amore positive attitude and new knowledge, and itssubsequent influence on workplace safety. Becausebehavioral changes were not solely the wanted out-come of most interventions, these changes were notthe only focus of actions. We need more discussionon goals and outcomes.The Problem of Low or Modest Literacy. Hazardsare present in every workplace. Often, recognitionand control of these are not broadly introduced indeveloping economies, and in addition, are hindered

iiUsing as filter: “Occupational Injuries”[Mesh] OR“Accidents, Occupational”[Mesh] OR “OccupationalDiseases”[Mesh] OR “Occupational Health”[Mesh];next selecting only publications in English (June 2015).

by low or modest literacy levels of groups of work-ers. Similar situations are present in high-incomecountries where migrant workers with modest lit-eracy are employed in high-risk sectors either as aday laborer or as seasonal workers, hamperingsafety measures. Solutions were evaluated in stud-ies such as peer-to-peer education and safety liai-sons, traffic-light symbols in technical information,use of training posters in education, and picto-graphic tests.Generalizability. Although we agree that, as anillustration, increase in use of protective eyewear ina stone quarry28 is a successful behavioral change,there are no easy answers to the question of thereproducibility of this success using the sameintervention elsewhere. One reason is that successesare influenced by differences in settings, pop-ulations, educational attempts, and (changing) cul-ture. How to repeat a success is still to beexplained.69-71 Finding drivers of behavioralchanges emerging from (the environment of) aneducational intervention, the dominant culture andthe inside of a target group, belongs to the matrix ofsuccess.Recommendations for Developing Economies. Theuse of online learning and blended educationalforms may increase coverage, quality, and efficiencyof OSH education in developing economies enor-mously. Successful examples are interactive e-learn-ing modules such as on occupational asthma andoccupational hygiene, e-courses used in a blendedapplication such as EMUTOM, and virtual patientcases for medical students, videoconferencing, andonline discussion boards. We expect a rapid grow-ing use of mobile apps running on smartphones,tablets, and other mobile devices. Unfortunately,the use of mobile apps has not yet been evaluatedas far as we know. Online repositories providingaccess to quality online learning materials as partof an adequate knowledge infrastructure can supportnew developments.72-74 Integration of health andsafety issues in vocational and technical education iscrucial, as being advocated by Schulte et al in theUnited States.68 Integration of OSH education inpreventive programs and clinical treatment canincrease reach and effectiveness. OSH expertesupported initiatives of industrial sectorial or branchorganizations, agricultural consultants, schools forvocational training, and primary and communityhealth care may create new opportunities to educateunderserved worker populations. Innovative sol-utions are available to improve the educationalefforts.

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To make progress in education in developingeconomies, we recommend appropriate nationallegislation and programming. We advise focusingon the education of workers and professionalsmost in need. Low numbers of OSH expertsimpede any progress, so OSH experts have to beeducated. Programming involving OSH expertesupported primary health care to provide essentialoccupational health careeinclusive education ofworkers has the advantage of reaching many vulner-able workers in small enterprises and in the infor-mal sector.75 Basic occupational healthservices65,66 and ILO participatory strategies52,67

can be integrated and adapted to local conditions.Online learning can improve quality and reach.Prescribing and supporting OSH education invocational education shapes the awareness offuture workers. Employers’ organizations, unions,and branch organizations have to be involvedin developing programs to educate workers.Well-designed evaluation studies are stronglyrecommended.

Supporting international initiatives can beboosted by an international task force includingeducational experts, ILO, WHO, the Interna-tional Commission on Occupational Health(ICOH), the World Organization of NationalColleges, Academies and Academic Associationsof General Practitioners/Family Physicians(WONCA) (primary health care), and the Inter-national Social Security Association (ISSA). Theirunique expertise in this field can contribute to thework to be done. Funded programming and goodproject management are preconditions to avoidending up in paperwork without impact. We

recommend the organization of work conferencesand a website platform facilitating the exchangeof experiences, good practices, studies, and educa-tional materials.

CONC LU S I ON S

Given the high shortages of education in developingeconomies, there is a need to boost progress. This over-view of evaluation studies on OSH education showsmany opportunities. Use of online technologies offersefficient and effective options for better coverage andquality of education. Blended application includingface-to-face contact might be preferred. For workers,enhanced education, for example, including workplaceinspection and providing PPEs, or education inte-grated in a preventive participatory program may bemore effective. New alliances between OSH expertsand schools, sectorial or industrial branch organiza-tions, and primary or community health care may pro-vide education and care for underserved populations.

On a national level, legislation and governmentalsupport are needed in addition to concerted actionsof employers and workers. We recommend boostinginternational collaboration and support by a high-level international task force. Participation is neededof educational experts and of various internationalorganizations, such as ILO, WHO, ICOH,WONCA (primary health care), and ISSA. Thetask force may develop funded programming and aglobal online platform facilitating the exchange ofexperiences, good practices, studies, and educationalmaterials. We strongly recommend incorporatingwell-designed evaluation studies.

R E F E R E N C E S

1. Takala J, Hämäläinen P, Saarela KL,et al. Global estimates of the burdenof injury and illness at work in 2012.J Occup Environ Hyg 2014;11:326e37.

2. Workers’ health: global plan of action.Geneva: WHO; 2007.

3. Kumar SG, Dharanipriya A, Kar SS.Awareness of occupational injuriesand utilization of safety measuresamong welders in coastal South India.Int J Occup Environ Med 2013;4:172e7.

4. Esechie JO, Ibitayo OO. Pesticide useand related health problems amonggreenhouse workers in Batinah

Coastal Region of Oman. J ForensicLeg Med 2011;18:198e203.

5. Sam KG, Andrade HH, Pradhan L,et al. Effectiveness of an educationalprogram to promote pesticide safetyamong pesticide handlers of SouthIndia. Int Arch Occup EnvironHealth 2008;81:787e95.

6. Anderson BT, Johnson GJ,Wheat JR, et al. Farmers’ concerns: aqualitative assessment to plan ruralmedical education. J Rural Health2012;28:115e21.

7. Rudolphi JM, Donham KJ. Increasingthe number of trained health and safetyprofessionals in agricultural medicine:

evaluation of the “building capacity”program, 2007-2013. J Agromedicine2015;20:21e30.

8. Rantanen J, Lehtinen S, Iavicoli S.Occupational health services in selectedInternational Commission on Occupa-tional Health (ICOH) member coun-tries. Scand J Work Environ Health2013;39:212e6.

9. Delclos GL, Bright KA, Carson AI,et al. A global survey of occupationalhealth competencies and curriculum.Int J Occup Environ Health 2005;11:185e98.

10. Alesbury RJ, Bailey SR. Addressingthe needs for international training,

A n n a l s o f G l o b a l H e a l t h , V O L . 8 1 , N O . 4 , 2 0 1 5 van Dijk et al.J u l y eA u g u s t 2 0 1 5 : 5 4 8 – 5 6 0

OSH Education Review

559

qualifications, and career developmentin occupational hygiene. Ann OccupHyg 2014;58:140e51. E-modulesavailable at: www.ohlearning.com.Accessed September 23, 2015.

11. Brown G. Genuine worker participa-tiondan indispensable key to effectiveglobal OHS. New Solut 2009;19:315e33.

12. Weinstock D, Slatin C. Learning totake action: the goals of health andsafety training. New Solut 2012;22:255e67.

13. Canadian Centre for OccupationalHealth and Safety (CCOHS). Hamil-ton, ON: CCOHS; 2015. Availableat: http://www.ccohs.ca/. AccessedSeptember 23, 2015.

14. Rhebergen MD, Lenderink AF, vanDijk FJ, Hulshof CT. Can online net-works provide quality answers to ques-tions about occupational safety andhealth? Occup Environ Med2012;69:347e53.

15. Rhebergen MD, Lenderink AF, vanDijk FJ, Hulshof CT. Comparingthe use of an online expert health net-work against common informationsources to answer health questions.J Med Internet Res 2012;14:e9.

16. Online interactive risk assessmenttools (OiRA). Bilbao: EuropeanAgency for Safety and Health atWork; 2014. Available at: http://client.oiraproject.eu. Accessed Sep-tember 23, 2015.

17. Van Dijk F, Caraballo-Arias Y. Occu-pational Safety and Health Online.How to Find Reliable Information.Leusden, the Netherlands: LDOH(Learning and Developing Occupa-tional Health Foundation). Availableat, http://www.ldoh.net; 2015.Accessed September 23, 2015.

18. Robson LS, Stephenson CM,Schulte PA, et al. A systematic reviewof the effectiveness of occupationalhealth and safety training. Scand JWork Environ Health 2012;38:193e208.

19. Rollin L, Darmoni S, Caillard JF,Gehanno JF. Searching for high-quality articles about interventionstudies in occupational healthewhatis really missed when using onlythe Medline database? Scand JWork Environ Health 2010;36:484e7.

20. Russ P, Strümpell S, Carvalho D,et al. Compulsory teaching of occupa-tional health: impact on attitude ofmedical students in Brazil and Ger-many. Int Arch Occup EnvironHealth 2012;85:81e7.

21. Löffler H, Bruckner T, Diepgen T,Effendy I. Primary prevention inhealth care employees: a prospectiveintervention study with a 3-year train-ing period. Contact Dermatitis2006;54:202e9.

22. Su YH, Lin YJ, Tang HY, et al.Effectiveness of an e-learning curricu-lum on occupational health for musicperformers. Telemed J E Health2012;18:538e43.

23. Radulescu M, Bock M, Bruckner T,et al. Health education about occupa-tional allergies and dermatoses foradolescents. J Dtsch Dermatol Ges2007;5:576e81.

24. Vyas R. Mitigation of musculoskele-tal problems and body discomfort ofagricultural workers through educa-tional intervention. Work 2012;41:2398e404.

25. Silverio KC, Gonçalves CG,Penteado RZ, et al. Actions in vocalhealth: a proposal for improving thevocal profile of teachers. Pro Fono2008;20:177e82.

26. Bian Y, Xiong H, Zhang L, et al.Change in coping strategies followingintensive intervention for special-service military personnel as civilemergency responders. J OccupHealth 2011;53:36e44.

27. Pehkonen I, Takala EP, Ketola R,et al. Evaluation of a participatoryergonomic intervention process inkitchen work. Appl Ergon 2009;40:115e23.

28. Adams JS, Raju R, Solomon V, et al.Increasing compliance with protectiveeyewear to reduce ocular injuries instone-quarry workers in Tamil Nadu,India: a pragmatic, cluster randomisedtrial of a single education session ver-sus an enhanced education packagedelivered over six months. Injury2013;44:118e25.

29. Williams Q Jr, Ochsner M,Marshall E, et al. The impact of apeer-led participatory health andsafety training program for Latinoday laborers in construction. J SafetyRes 2010;41:253e61.

30. Qian X, Smith H, Huang W, et al.Promoting contraceptive use amongunmarried female migrants in one fac-tory in Shanghai: a pilot workplaceintervention. BMC Health Serv Res2007;7:77.

31. Wulfhorst B, Bock M, Gediga G,et al. Sustainability of an interdiscipli-nary secondary prevention program forhairdressers. Int Arch Occup EnvironHealth 2010;83:165e71.

32. Bush D, Paleo L, Baker R, et al. Res-taurant supervisor safety training: eval-uating a small business trainingintervention. Public Health Rep2009;124(Suppl 1):152e9.

33. Hugenholtz NI, de Croon EM,Smits PB, et al. Effectiveness of e-learning in continuing medical educa-tion for occupational physicians.Occup Med 2008;58:370e2.

34. Rosen MA, Caravanos J, Milek D,Udasin I. An innovative approach tointerdisciplinary occupational safety

and health education. Am J Ind Med2011;54:515e20.

35. Madan I, Walker-Bone K. Evalua-tion of a musculoskeletal trainingpackage for occupational health prac-titioners. Occup Med 2013;63:579e82.

36. Waddell G, O’Connor M, Boorman S,et al. Working Backs Scotland: a publicand professional health education cam-paign for back pain. Spine 2007;32:2139e43.

37. Barber CM, Frank T, Walsh K, et al.Knowledge and utilisation of occupa-tional asthma guidelines in primarycare. Prim Care Respir J 2010;19:274e80.

38. Karlinsky H, Dunn C, Clifford B,et al. Workplace injury management:using new technology to deliver andevaluate physician continuing medicaleducation. J Occup Rehabil 2006;16:719e30.

39. Alexander VR. Audit of hospital doc-tor training in sick note certification.Occup Med 2012;62:595e9.

40. Cohen D, Khan S, Allen J,Sparrow N. Shifting attitudes: theNational Education Programme forwork and health. Occup Med2012;62:371e4.

41. Østerås N, Gulbrandsen P, Benth JS,et al. Implementing structured func-tional assessments in general practicefor persons with long-term sick leave:a cluster randomised controlled trial.BMC Fam Pract 2009;10:31.

42. Hossain D, Gorman D, Eley R,Coutts J. Value of mental health firstaid training of advisory and extensionagents in supporting farmers in ruralQueensland. Rural Remote Health2010;10:1593.

43. Smits PB, de Graaf L, Radon K, et al.Case-based e-learning to improve theattitude of medical students towardsoccupational health, a randomisedcontrolled trial. Occup Environ Med2012;69:280e3.

44. Radon K, Carvalho D, Calvo MJ,et al. Implementation of virtualpatients in the training for occupa-tional health in Latin America. Int JOccup Environ Health 2011;17:63e70.

45. EMUTOM, European e-module onoccupational medicine for undergrad-uate medical students. Available at:http://www.emutom.eu/ (English andSpanish). Accessed September 23,2015.

46. Braeckman L, De Clercq B,Janssens H, et al. Development andevaluation of a new occupational med-icine teaching module to advance self-efficacy and knowledge amongmedical students. J Occup EnvironMed 2013;55:1276e80.

47. Kindblom-Rising K, Wahlstrom R,Ekman SL, et al. Nursing staff’s

van Dijk et al. A n n a l s o f G l o b a l H e a l t h , V O L . 8 1 , N O . 4 , 2 0 1 5

OSH Education ReviewJ u l yeA u g u s t 2 0 1 5 : 5 4 8 – 5 6 0

560

communication modes in patienttransfer before and after an edu-cational intervention. Ergonomics2010;53:1217e27.

48. Kindblom-Rising K, Wahlström R,Nilsson-Wikmar L, Buer N. Nursingstaff’s movement awareness, attitudesand reported behaviour in patienttransfer before and after an educa-tional intervention. Appl Ergon2011;42:455e63.

49. Stock ML, Gerrard M, Gibbons FX,et al. Sun protection intervention forhighway workers: long-term efficacy ofUV photography and skin cancer infor-mation on men’s protective cognitionsand behavior.AnnBehavMed2009;38:225e36.

50. YuW, Yu IT,Wang X, et al. Effective-ness of participatory training for preven-tion of musculoskeletal disorders: arandomized controlled trial. Int ArchOccup Environ Health 2013;86:431e40.

51. Guo H, Li H, Chan G, Skitmore M.Using game technologies to improvethe safety of construction plant opera-tions. Accid Anal Prev 2012;48:204e13.

52. Kawakami T. Human ergology thatpromotes participatory approach toimproving safety, health and workingconditions at grassroots workplaces:achievements and actions. J HumErgol (Tokyo) 2011;40:95e100.

53. Acosta MS, Sechrest L, Chen MK.Farmworkers at the border: a bilingualinitiative for occupational health andsafety. Public Health Rep2009;124(Suppl 1):143e51.

54. Ochsner M, Marshall EG,Martino C, et al. Beyond the class-room: a case study of immigrant safetyliaisons in residential construction.New Solut 2012;22:365e86.

55. Forst L, Ahonen E, Zanoni J, et al.More than training: Community-based participatory research to reduceinjuries among Hispanic constructionworkers. Am J Ind Med 2013;56:827e37.

56. Jinnah HA, Stoneman Z, Rains G.Involving fathers in teaching youthabout farm tractor seatbelt safetyea

randomized control study. J AdolescHealth 2014;54:255e61.

57. Teran S, Strochlic R, Bush D, et al.Reaching teen farm workers withhealth and safety information: an eval-uation of a high school ESL curricu-lum. J Agric Saf Health 2008;14:147e62.

58. McCallum DM, Conaway MB,Reynolds SJ. Evaluation of a farmsafety day program: participants andnon-participants over a one-year fol-low-up period. J Agric Saf Health2009;15:255e71.

59. Ruotsalainen JH, Sellman J, Lehto L,et al. Interventions for preventingvoice disorders in adults (Update July2010). Cochrane Database Syst Rev2007:CD006372.

60. Shah A, Blackhall K, Ker K, Patel D.Educational interventions for prevent-ing eye injuries. Cochrane DatabaseSyst Rev 2009:CD006527.

61. Verbeek JH, Kateman E, Morata TC,et al. Interventions to prevent occupa-tional noise-induced hearing loss.Cochrane Database Syst Rev 2012;10:CD006396.

62. Van der Molen HF, Lehtola MM,Lappalainen J, et al. Interventions toprevent injuries in construction work-ers. Cochrane Database Syst Rev2012;12:CD006251.

63. Hoving JL, Lacaille D, Urquhart D,et al. Non-pharmacological interven-tions for preventing job loss in workerswith inflammatory arthritis. CochraneDatabase Syst Rev 2014;11:CD010208.

64. Curti S, Sauni R, Spreeuwers D, et al.Interventions to increase the reportingof occupational diseases by physicians.Cochrane Database Syst Rev 2015;3:CD010305.

65. Chen Y, Chen J, Sun Y, et al. Basicoccupational health services in Baoan,China. J Occupat Health 2010;52:82e8.

66. Chancharoen S, Siriruttanapruk S,Untimanon O. Basic occupationalhealth services (BOHS) and thenational programme for farmers. In:Vainio H, Lehtinen S, eds. Proceed-ings OH&S Forum 20e22 June

2011, Espoo, Finland. Helsinki: Fin-nish Institute of Occupational Health;2012:136e9.

67. Kogi K. Roles of participatory action-oriented programs in promoting safetyand health at work. Saf Health Work2012;3:155e65.

68. Schulte PA, Stephenson CM,Okun AH, et al. Integrating occupa-tional safety and health informationinto vocational and technical educationand other workforce preparation pro-grams. Am J Public Health 2005;95:404e11.

69. Green LW, Glasgow RE. Evaluatingthe relevance, generalization, andapplicability of research: Issues inexternal validation and translationmethodology. Eval Health Prof2006;29:126e53.

70. Dombrowski SU, Sniehotta FF,Avenell AA, Coyne JC. Towards acumulative science of behaviourchange: do current conduct andreporting of behavioural interventionsfall short of best practice? PsycholHealth 2007;22:869e74.

71. World Health Organisation. TheWorld Health Report 2002. ReducingRisks to Health, Promoting HealthyLife. Geneva: World Health Organi-sation; 2002.

72. www.workershealtheducation.org andhttp://geolibrary.org/library/.AccessedSeptember 23, 2015.

73. Van Dijk FJ, Verbeek JH, Hoving JL,Hulshof CT. A knowledge infrastruc-ture for occupational safety and health.J Occup Environ Med 2010;52:1262e8.

74. Van Dijk F. Who knows the risk?Challenge to improve education andknowledge infrastructure for workersand companies. Occup Environ Med2015;72:544e5.

75. Buijs PC, Dijk van FJH. Essentialinterventions on Workers Health byPrimary Health Care; a scoping reviewof the literature. Hoofddorp, theNetherlands: TNO Report R10755;2014. Available at: http://repository.tudelft.nl/view/tno/uuid%3A66de1083-c262-4ac6-aaab-50ec6a64817a/.Accessed September 23, 2015.