literature review on health and safety in construction

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• v.55(3); 2017 May

Occupational safety and health in construction: a review of applications and trends

Fabián alberto suÁrez sÁnchez.

1 Universidad de Nariño, Department of Civil Engineering, Colombia

Gloria Isabel CARVAJAL PELÁEZ

2 Universidad de Medellín, Department of Civil Engineering, Colombia

Joaquín CATALÁ ALÍS

3 Universidad Politécnica de Valencia, Department of Construction Engineering and Civil Engineering Projects, España

Due to the high number of accidents that occur in construction and the consequences this has for workers, organizations, society and countries, occupational safety and health (OSH) has become a very important issue for stakeholders to take care of the human resource. For this reason, and in order to know how OSH research in the construction sector has evolved over time, this article–in which articles published in English were studied–presents an analysis of research conducted from 1930 to 2016. The classification of documents was carried out following the Occupational Safety and Health Cycle which is composed of five steps: regulation, education and training, risk assessment, risk prevention, and accident analysis. With the help of tree diagrams we show that evolution takes place. In addition, risk assessment, risk prevention, and accident analysis were the research topics with the highest number of papers. The main objective of the study was to contribute to knowledge of the subject, showing trends through an exploratory study that may serve as a starting point for further research.

Introduction

In most industrialized countries, the construction industry is one of the most significant industries in terms of contribution to gross domestic product (GDP). It also has a significant impact on the health and safety of workers. The construction industry is both economically and socially important 1 ) . In construction, workers perform a great diversity of activities, each one with a specific associated risk. The worker who carries out a task is directly exposed to its associated risks and passively exposed to risks produced by nearby co-workers 2 ) . Building design, materials, dimensions and site conditions are often unique, which requires adaptation and a learning curve from site to site. Injuries may occur in a number of ways and at every juncture of the process 3 ) .

As a result of this situation there is a high frequency of accidents in construction, which makes it an unsafe industry. Degree of safety in this selected sector of the economy is not indicated by a single accident but by a set of accidents that have occurred within a specified time interval. Knowledge about the noticeable trends in accidents is required in order to assess the level of safety and also directions for changes 4 ) .

Occupational safety and health is an area concerned with the development, promotion, and maintenance of the workplace environment, policies and programs that ensure the mental, physical, and emotional well-being of employees, as well as keeping the workplace environment relatively free from actual or potential hazards that could injure employees 5 ) . However, the number of articles regarding OSH in construction was small until fifteen years ago. Since 2001 the number of OSH publications relating to construction has increased. From different perspectives and using different tools researchers have studied occupational hazards in construction. Sousa, Almeida, and Dias 6 ) state that there are several tools and methods to investigate and understand occupational accidents in the construction industry.

In a systematic review of construction safety studies, Zhou et al. 7 ) found that of all the research topics 44.65% were pertinent to safety management process, 20.27% to the impact of individual and group/organizational characteristics, and 33.03% to accident/incident data. The body of research on safety management process involves safety planning, safety monitoring, safety assessment, safety measurement, safety performance etc.

Taking into account the previously stated remarks, the aim of our paper was to review the literature and define current trends in research in occupational safety and health applied to the construction industry. Trends were obtained through chronological evolution. Thus, they can be properly analyzed and further research can be developed from them.

Methodology

Our literature search analyzed only peer-reviewed papers associated with occupational safety and health in construction, because the state-of-the-art of a discipline is defined in these forums; some very relevant articles from conferences were also considered, and the scope of the research was determined by the following parameters:

• – Language: English.
• – Period: from 1930 to 2016
• – Key descriptors: occupational risk; occupational accident; occupational safety; occupational prevention; occupational health; occupational safety and health and construction
• – Databases: Ebsco Host, Science Direct and Scopus. These were selected as sources of information due to their size and the quality of the publications found in them, however for future research other sources may be considered

The first problem needing to be addressed was how to suitably classify all the information. Occupational safety and health is not a homogenous issue; quite the opposite, there are many stakeholders involved. Besides, it can be considered a multi-stage process. This process approach has already been suggested by many authors in risk management, as traditionally applied to project management 8 ) which proposes a similar process based on four stages: identification, analysis, response, and control. Moreover, the OHSAS 18001:2007 Standard 9 ) proposes a cycle based on continuous improvement which comprises of: establish corporate policies, plan, implement and operate, check and correct, review, and improve. These steps are compatible with the ISO 9001:2008 quality management system 10 ) . Finally, Carvajal 11 ) proposed a five-step cycle: regulation, education and training, risk assessment, risk prevention, and accident analysis. A new Occupational Safety and Health Cycle that includes safety climate was developed, adapting the cycle suggested by Carvajal, which is created in phases of education and training, risk assessment and risk prevention ( Fig. 1 ).

Occupational Safety and Health Cycle. Adapted from Carvajal, G. I. (2008). Modelo de cuantificación de riesgos laborales en la construcción: RIES-CO . (Doctoral Thesis). Universidad Politécnica de Valencia, Valencia, España.

However, a shortcut in this Occupational Safety and Health Cycle could appear if regulations (either from the company or from public agencies) are not analyzed, improved on, or at least implemented; and later, if education and training is not provided.

A company that does not seriously apply an occupational safety and health management system may enter into a spiral of unsafeness, trying to take the easiest way out of the cycle, and making it shorter and shorter each time until a serious accident takes place. In any event, a “culture of construction safety” should be implemented; this is defined 12 , 13 ) as the whole group of knowledge, habits, and behaviors that drive companies to the willing application of safety and health approaches and procedures in the construction industry. This is a good way to achieve a “climate of safety”, which implies a subjective perception and evaluation of safety issues related to the organization, its members, structures and processes, based on experience of the organizational environment and social relationships 14 ) .

For this article, the previous cycle was taken as an example of a logical and continuous process with feedback, which allowed for an analysis of the evolution of research in occupational safety and health in construction. Risk assessment comprises risk identification and analysis, as stated in traditional risk management literature. Likewise, risk prevention consists of response and control. In order to highlight the importance of setting objectives and of organizational learning through time, two previous steps and a final one are added. Regulation is included to emphasize the significance of corporate policies issued by companies on one hand, and laws and standards issued by public agencies on the other. Training and education reflects the impact that the former steps have upon the people involved if some improvement needs to take place. Finally, accident analysis is needed to investigate the cause of accidents; thus, lessons can be learned and other accidents may be avoided in the future - obviously, this step is skipped if no accident occurs.

Articles were analyzed and classified in the Occupational Safety and Health Cycle, according to the suitability of their content according to each of the steps. Nevertheless, our goal was not to develop a bibliometric study, but to define chronological trends in research by using noteworthy articles to display the main milestones. Thus, in our second analysis of the papers, we chose only those significant articles that offered an added-value and could be used as references in a research trend. In this opportunity, the selection was developed by taking several aspects into consideration. Mainly, in order to be chosen, a paper must have enough qualitative references from other papers even if it does have many citations. Besides, we have rated the paper’s degree of importance according to our assessment of the novelty of its ideas and the future influence of this particular manuscript on others. The analysis of the evolution of research was conducted following a logical sequence of ideas in the selected papers.

Bibliographic analysis

In the first search we undertook, 285 articles were selected from 32 journals or proceedings. Papers chosen by journal and by time period are displayed in Table 1 . It can be noted from this table that the number of papers has recently increased: in the period between 2001 and 2010, a total of 129 papers related to OSH in construction were published. This amounts to 45.3% of all articles included. Likewise, in the period between 2011 and 2016, a total of 57 papers were published. Although this period is shorter, it can be observed that the amount of published papers is greater than that of the periods prior to 2001. The Journal of Construction Engineering and Management is the one with the most articles selected, followed by Safety Science and the International Journal of Project Management.

Selected articles are displayed in Table 2 according to topic, showing absolute and relative values. Risk assessment is the most popular topic, appearing in 35.4% of the papers. Accident analysis and risk prevention each get more than 20% of the share.

It is surprising not to find many papers on regulations, either from the company’s point of view (corporate policies) or from public agencies’ point of view (standards and norms). Maybe the reason is that some articles deal not just with regulations, but also with other approaches to occupational safety and health; thus, they are categorized under other steps of the cycle, mainly risk assessment or risk prevention. In our study, we observed how research has influenced the development of laws and regulations by providing new forms and tools for risk assessment and for the implementation of preventive measures at the workplace. The analyzed papers propose measures to assess results achieved and to know whether regulations are being applied and if they are meeting the objectives for which they were created.

It is not so unexpected to discover that education and training get very little attention from researchers. Pietroforte and Stefani 15 ) already found that only 1.8% of the papers published in the Journal of Construction Engineering and Management from 1983 to 2000 were related to education and professional development. Furthermore, in their analysis of trends in project management, Crawford, Pollack, and England 16 ) selected forty-seven topics relevant to the field of project management; none of them was related to education and training. Because so few articles are found for these two steps, no research trends are developed for regulations and for education and training. Safety culture and safety climate are new factors that have also few publications. According to research on occupational safety and health applied to the construction industry, three main topics obtained from our previous bibliographic analysis are described: risk assessment, risk prevention, and accident analysis (which represent 85% of the total), and this paper focuses on those subjects.

Trends in risk assessment

For the topic of risk assessment, the search started with Fine’s seminal article “Mathematical evaluation for controlling hazards” 17 ) , in which a formulation to quantify risks is proposed. It is based on three factors that define risk: probability of the accident happening, personnel exposure to the risk, and consequences of the accident (or severity). From his approach, three basic lines of research were identified: management of occupational safety and health, quantifying occupational risk through modeling, and quantifying risk through probability analysis. They are displayed in Fig. 2 .

Trends in risk assessment.

Al-Bahar and Crandall 18 ) applied traditional risk management approaches to the construction industry to obtain a useful strategic tool for managers. Mohamed 19 ) introduced the influence of management and risk systems at the workplace. Koehn and Datta 20 ) analyzed ISO Standards (9000 for quality, 14000 for environment, and 18000 for safety and health), and proposed an integrated system for construction companies. Sparer and Dennerlein 21 ) created and evaluated different approaches for establishing rewards based on a threshold score, for use in safety incentive programs. Pinto 22 ) introduced safety climate variables within the calculation of the level of risk in a Qualitative Occupational Safety Risk Assessment Model (QRAM).

On the issue of quantifying risk through modeling, Knab 23 ) put forward a mathematical model based on insurance premiums. Whereas Jannadi and Almishari 24 ) developed a computer model based on Fine’s formulation. Mitropoulos and Namboodiri 25 ) developed a technique for measuring the safety risk of construction activities according to the characteristics of the activity and independent of the workers’ capabilities, and Liu and Tsai 26 ) proposed a fuzzy risk assessment method which related hazard types with construction items and hazard causes with hazard types.

On the other hand, Kaplan and Garrick 27 ) followed Fine’s assumptions to calculate the probability factor of his formulation. Using this work as reference, Cuny and Lejeune 28 ) analyzed the severity factor. Then, to solve the problem of uncertain and insufficient statistical data Gürcanli and Müngen 29 ) used fuzzy logic. Bowers 30 ) approached the probability factor by using quantitative data (e.g., historical ratios) or qualitative data (e.g., interviews). Santoso et al. 31 ) identified, analyzed, and categorized potential risk factors in construction.

In summary, three main branches of research were identified: management of occupational safety and health in construction, risk quantification through modeling, and probability applied to risk quantification. From them, twelve active lines of research were highlighted, and a representative paper for each was pointed out.

Trends in risk prevention

Heinrich’s seminal article 32 ) is the starting point of the two other topics: risk prevention and accident analysis. He suggested the concept of risk prevention based on historical accident statistics, and focused on cost reduction due to the adoption of prevention techniques. Fifty years later, Helander 33 ) discussed several interesting issues: high accident ratios, increasing costs due to accidents, lack of research, and inexperience in implementing policies and plans; unfortunately, many of these problems still remain in today’s construction industry. From this line of thought on risk prevention, three main trends were outlined, one concerning business strategy, and the other two regarding the main phases of the project life cycle: design and construction. They are displayed in Fig. 3 .

Trends in risk prevention.

Business strategy to achieve better safety performance in construction was introduced in work by Jaselskis, Anderson, and Russell 34 ) . Their article analyzes the main factors that lead to success in occupational safety and health in the construction industry. Two branches are developed from this idea, depending on the emphasis of the implementation: laws and standards at the managerial level 35 ) and plans, guidelines and checklists at the operational level 36 ) .

Hinze and Wiegand 37 ) were the first to show the importance of safety prevention in the design phase. They state the important role of designers in occupational safety and health because the success of construction works depends on their decision-making. Gambatese et al. 38 ) deepened this idea through several interviews, revealing keys for successful implementation of designing for safety. Fonseca et al. 39 ) proposed a model of risk prevention integrating production and safety through three different levels of anticipation (analysis of design, planning/scheduling of services and implementation). One year later, Zhang et al. 40 ) applied Building Information Modeling BIM-based safety to fall hazard identification and prevention in construction safety planning.

Nevertheless, most work produced on the topic of risk prevention focuses on the construction phase. Many authors explore different approaches. Hinze 41 ) analyzed human behavior in risk prevention and Chi and Han 42 ) analyzed 9,358 accidents that occurred in the U.S. construction industry between 2002 and 2011 and incorporated systems theory into Heinrich’s domino theory to explore the interrelationships of risks. Laufer and Ledbetter 43 ) assessed the efficiency of several safety tools used in the construction workplace through surveys; according to these authors, simultaneous methods should be used to achieve better levels of safety. Burkart 44 ) called for site-specific safety plans, adapted to each workplace, and useful and reliable for every stakeholder.

Along another line, Hinze 45 ) analyzed the influence of economic incentives, concluding that low-value incentives, combined with good prevention tools, are more successful, and Imriyas 46 ) developed a workers´ compensation insurance (WCI) premium-rating model for building projects.

Summing up, our exploration detected ten lines of research within risk prevention in construction. Three of them deal with business strategy, three with the design phase, and six others with the construction phase.

Trends in accident analysis

Accident analysis (or accident investigation, as it could also be called) makes it possible to determine the what, how, and why of an accident; thus, in the future, similar accidents can be avoided based on the lessons learned. This topic also originates from Heinrich’s work (1930). He considered accident statistics as the baseline for any analysis of occupational safety and health. Many years later, Leplat 47 ) approached the principle of accident causation, discussing the relationship between accidents and the work in progress at the time of the accident. Kjellen and Larsson 48 ) proposed a conceptual model to investigate accidents across two levels: the sequence of facts about an accident, and factors affecting work at the time of an accident. From these articles, three main branches are displayed in Fig. 4 .

Trends in risk analysis.

The first branch deals with different models of workplace accident causation. DeJoy 49 ) focused on human factors. Abdelhamid and Everett 50 ) reviewed different techniques and offered a theoretical explanation for root causes of accidents. Suraji et al. 51 ) described a global model for the project cycle. Rozenfeld et al. 52 ) developed a structured method for hazard analysis and assessment for construction activities called Construction Job Safety Analysis (CJSA).

The second branch is about the statistical analysis of accidents. Kisner and Fosbroke 53 ) analyzed injuries from 1980 to 1989 in the United States. Hinze et al. 54 ) supported by Occupational Safety and Health Administration (OSHA) data from 1985 to 1995, categorized accident causes and sources of injures. Huang and Hinze 55 ) also examined OSHA data on construction worker’s accidental falls from 1990 to 2001. Cheng et al. 56 ) used data mining to establish the cause–effect relationships within occupational accidents in construction in Taiwan during the period 2000–2007. Finally, Irumba 57 ) investigated the causes of construction accidents in Kampala, Uganda using ordinary least squares regression and spatial regression modeling.

The last branch evaluated occupational accidents in terms of their cost. Leopold and Leonard 58 ) assessed several British construction firms to analyze accident costs in relation to their insurance premiums. On the other hand, Everett and Frank 59 ) showed a comparative study on the actual costs of accidents and injuries in the construction industry.

The main lines of research in accident analysis can be summarized within three topics: causal model of accidents, statistical analysis of accidents, and economic cost of accidents.

Conclusions

Our paper sought to establish current research trends in occupational safety and health in the construction industry. We described an “Occupational Safety and Health Cycle” based on traditional risk management approaches with five basic steps: regulations, education and training, risk assessment, risk prevention and accident analysis. Because of a scarcity of articles in the first two steps, no trends were proposed for regulations, education or training.

Three main branches (i.e. management of occupational safety and health in construction, risk quantification through modeling and probability applied to quantifying risk) were outlined within the topic of risk assessment, which is the topic with the highest amount of publications, and were subsequently broken up until obtaining the twelve current trends. Likewise, three main branches (business strategy, focus on the design phase and focus on the construction phase) were obtained for risk prevention. These were in turn split into the ten current trends. Finally, there were three solid trends within accident analysis: a causal model of accidents, their statistical analysis, and their economic cost.

The findings of this study show the following future subjects as trends of research and implementation in OSH in construction: rewards in safety incentivization programs; increasing the usage of information technology tools; production process automation; implementing proactive measures rather than reactive measures; integrating quality, environmental and OSH management system standards and using technological tools to train workers.

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Opportunities and challenges for construction health and safety technologies under the covid-19 pandemic in chinese construction projects.

1. Introduction

2. literature review, 2.1. impacts of covid-19 on the construction industry, 2.2. overview of h&s technologies in construction, 2.3. diffusion of innovation (doi) theory, 3. research method, 4. results and discussion, 4.1. impacts of the covid-19 pandemic on the chinese construction projects, 4.2. anti-epidemic measures, 4.3. the adoption of h&s technologies in construction projects during and in the post pandemic, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest, appendix a. interview questions.

• Please, for record purpose, what service does your company render, what is your position, how many years of work experience in the industry, and where is your current project?
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• Can you describe how you respond to COVID-19 pandemic and how you manage/engage in construction projects under COVID-19 pandemic?
• From your experience, can you identify the technologies you know that can be of benefit to minimize the spread of COVID-19 at the jobsite and maintain occupational safety and health? Are these technologies used on your sites? How effective are they?
• Are you satisfied with the health and safety-related technologies used in the construction sector? If no, what do you think are the issues affecting the use of these technologies for construction projects?
• There has been a saying that the construction sector is slow to adopt innovative technologies. Do you think that the pandemic has speeded the adoption of technologies? If yes, how?
• Can you please estimate the change of investment (in %) in the health and safety-related technologies between before and after COVID-19 pandemic?
• Can you describe the prospect of the health and safety-related technologies in the construction industry?
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Yang, Y.; Chan, A.P.C.; Shan, M.; Gao, R.; Bao, F.; Lyu, S.; Zhang, Q.; Guan, J. Opportunities and Challenges for Construction Health and Safety Technologies under the COVID-19 Pandemic in Chinese Construction Projects. Int. J. Environ. Res. Public Health 2021 , 18 , 13038. https://doi.org/10.3390/ijerph182413038

Yang Y, Chan APC, Shan M, Gao R, Bao F, Lyu S, Zhang Q, Guan J. Opportunities and Challenges for Construction Health and Safety Technologies under the COVID-19 Pandemic in Chinese Construction Projects. International Journal of Environmental Research and Public Health . 2021; 18(24):13038. https://doi.org/10.3390/ijerph182413038

Yang, Yang, Albert P. C. Chan, Ming Shan, Ran Gao, Fengyu Bao, Sainan Lyu, Qingwen Zhang, and Junfeng Guan. 2021. "Opportunities and Challenges for Construction Health and Safety Technologies under the COVID-19 Pandemic in Chinese Construction Projects" International Journal of Environmental Research and Public Health 18, no. 24: 13038. https://doi.org/10.3390/ijerph182413038

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Factors Affecting Safety Performance of Construction Projects: A Literature Review

N H Abas 1,3 , N Yusuf 2,3 , N A Suhaini 1,3 , N Kariya 1,3 , H Mohammad 2,3 and M F Hasmori 1,3

Published under licence by IOP Publishing Ltd IOP Conference Series: Materials Science and Engineering , Volume 713 , The 2nd Global Congress on Construction, Material and Structural Engineering 26–27 August 2019, Melaka, Malaysia Citation N H Abas et al 2020 IOP Conf. Ser.: Mater. Sci. Eng. 713 012036 DOI 10.1088/1757-899X/713/1/012036

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1 IBS Cluster, Jamilus Research Centre, Faculty of Civil and Environmental Engineering, Universiti Tun Hussein Onn Malaysia (UTHM), 86400 Batu Pahat, Johor, Malaysia

2 Site Office Saloma Link, Level 1, Lot 2400, Jalan Raja Muda Musa, 50300 Kuala Lumpur, Malaysia

3 Centre for Diploma Studies, Universiti Tun Hussein Onn Malaysia, Hab Pendidikan Tinggi Pagoh, KM1, Jalan Panchor, 86400 Pagoh, Muar, Johor, Malaysia.

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The construction industry is known as the most hazardous industry and has always been plagued with accident for a long time. Incidents or accidents that happened at construction sites has caused several drawbacks of project performance, such as delay in project completion, increase project cost, reduce productivity and create negative impressions to the organization. Therefore, it is crucial for employer to ensure safety and health at the workplace is taken care of to avoid accident. This paper presents the review of the factors affecting safety performance of construction project, focusing on project level. Among the most frequently cited factors that affect safety performance of construction project in project level are safety training, implementation of safe working environment and implementation of safe plant and equipment. The outcomes of the paper may serve as a starting point for further research in investigating the main.

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Building Information Modeling on Construction Safety: A Literature Review

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• Orlean G. dela Cruz 27 , 28 &
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Building information modeling (BIM) technology has a significant contribution to construction safety, such as the automated detection of possible safety hazards and the prevention of potential risks likely to occur. The technology has been implemented in the architecture, engineering, and construction (AEC) industry for decades and has recently been introduced in construction safety. The technology can bring significant benefits to safety management in accident prevention and provide valuable reference material for rescue activities. Therefore, construction safety management must understand the technology, application, and challenges for better utilizing BIM as a safety tool. With these BIM safety tools, we should hope to see a shift in how safety is handled. To overcome this gap, concerning the challenges discussed, future research should consider: (1) generalization of the enhancement of BIM's technicality and functionality, (2) the cost–benefit analysis, and (3) construction practitioners' perspective on BIM applications on the results generated from different tools. It also recommends developing a database of all uncertain identified hazards and potential control measures subject to expert validation.

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The authors would like to extend appreciation to the PUP Engineering Science students' assistants for their untiring support in completing this research study.

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Orlean G. dela Cruz & Jason Maximino C. Ongpeng

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dela Cruz, O.G., Ongpeng, J.M.C. (2022). Building Information Modeling on Construction Safety: A Literature Review. In: Altan, H., et al. Advances in Architecture, Engineering and Technology . Advances in Science, Technology & Innovation. Springer, Cham. https://doi.org/10.1007/978-3-031-11232-4_8

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Literature Review: Improving health and safety in the construction industry through cultural transformation

Natalie skeepers, publisher: ieom society international, track: construction management.

The construction industry require a different approach to their management of health and safety in the workplace from the functional hierarchical line management approaches adopted to connecting with employees on floor level who are executing projects. The study suggests a cultural transformation approach in creating safety as a value, rather than a priority. Organisations that successfully create high performing committed employees who share the same culture and values that aligned to improving safety performance and reducing potential workplace disasters. Although no universal definition of corporate culture exists, it appears to reflect shared behaviours, beliefs, attitudes, values, organisational goals, functions and procedures. Organisational or corporate culture seems to be the only glue that holds together common values of improving the health and safety performance. Leaders think about the future all the time, they are also responsible constructing a culture in the workplace that promotes safer workplaces and influencing employees to work safer. These principles and characteristics of effective leadership reflect contemporary beliefs and behaviors based on the fact that today’s leaders recognise the need to define a vision and mission for success, build trust, share power in effective ways, develop positive relationships, lead by serving first, and build a sense of community within the organisations they support. The ultimate benefit for the employee is that they are actively engaged, engerised, confident about their organisation’s health and safety strategy, changes that are occurring, rather than confused and resigned. Employees know what they are supposed to be doing and how that relates to the tasks to that of their colleagues.

Keywords : Safety culture, cultural transformation, leadership behaviour, and safety performance

Published in : 2nd North American International Conference on Industrial Engineering and Operations Management

Publisher : IEOM Society International Date of Conference : September 23-26, 2016

ISBN : 978-0-9855497-5-6 ISSN/E-ISSN : 2169-8767

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Please note you do not have access to teaching notes, safety climate in construction: a systematic literature review.

Engineering, Construction and Architectural Management

ISSN : 0969-9988

Article publication date: 12 April 2023

Safety climate plays an important role in the high-risk construction industry. Advances have been made in the understanding of construction safety climate in terms of four interrelated themes, specifically, its definition, measurement, antecedents and consequences. However, knowledge remains fragmented as the studies are scattered, and a systematic review covering these four themes is lacking. To address this research gap, this study aims to perform a systematic literature review of construction safety climate literature regarding the four themes.

Design/methodology/approach

Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) protocol guidelines, 178 eligible articles were obtained. This study provided thematic analysis of the 178 papers to identify what is known and what is not yet fully known regarding the four themes of construction safety climate. This study also conducted a descriptive analysis to identify the influential scholars, keywords, theories and research methods used by the literature, and finally presented an integrative framework directing future research.

The literature has not reached a consensus on the definition and measurement of construction safety climate. While it has identified the impact of safety climate on both behavioral and accident consequences, it has paid less attention to the antecedents and their underlying mechanisms regarding safety climate. Fang D. and Lingard H. are identified as the most influential authors in this field. “Questionnaire” and “safety behavior” are the keywords most closely related to safety climate. Unfortunately, the existing evidence for the causal relationships between safety climate and its antecedents and consequences is weak, as many studies lack clear theoretical substance, use a concurrent research design and focus only on individual-level climate perceptions. Finally, to support the development of construction safety climate around the four themes, potential research directions and research methods supporting them are illustrated.

Originality/value

This review makes contributions by integrating existing construction studies covering its definition, measurement, antecedents and consequences. This review also makes contributions to specific themes: no review exists on the antecedents of construction safety climate, and this review fills that gap; with regard to consequences, the existing reviews focus either on safety outcomes or safety behavior, but this review included both of them and further elaborated the different theories underpinning the relationships between safety climate and them. It is hoped that this systematic review will be helpful to the research community toward developing a nomologic network and promoting knowledge integration with respect to construction safety climate.

• Construction safety
• Safety climate
• Systematic literature review

Acknowledgements

This study was supported by the National Natural Science Foundation of China (Grant number 72002030), the Natural Science Foundation of Jiangsu Province (Grant number BK20200383), the Humanities and Social Sciences Fund of the Ministry of Education of China (Grant number 20YJCZH183) and the Outstanding Chinese and Foreign Youth Exchange Program of China Association for Science and Technology (CAST), 2019. The authors are also indebted to the editor and the reviewers for their effort in developing this article.

Xia, N. , Ding, S. , Ling, T. and Tang, Y. (2023), "Safety climate in construction: a systematic literature review", Engineering, Construction and Architectural Management , Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/ECAM-11-2022-1074

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Occupational safety and health in construction: a review of applications and trends

Affiliations.

• 1 Universidad de Nariño, Department of Civil Engineering, Colombia.
• 2 Universidad de Medellín, Department of Civil Engineering, Colombia.
• 3 Universidad Politécnica de Valencia, Department of Construction Engineering and Civil Engineering Projects, España.
• PMID: 28179610
• PMCID: PMC5462637
• DOI: 10.2486/indhealth.2016-0108

Due to the high number of accidents that occur in construction and the consequences this has for workers, organizations, society and countries, occupational safety and health (OSH) has become a very important issue for stakeholders to take care of the human resource. For this reason, and in order to know how OSH research in the construction sector has evolved over time, this article-in which articles published in English were studied-presents an analysis of research conducted from 1930 to 2016. The classification of documents was carried out following the Occupational Safety and Health Cycle which is composed of five steps: regulation, education and training, risk assessment, risk prevention, and accident analysis. With the help of tree diagrams we show that evolution takes place. In addition, risk assessment, risk prevention, and accident analysis were the research topics with the highest number of papers. The main objective of the study was to contribute to knowledge of the subject, showing trends through an exploratory study that may serve as a starting point for further research.

Keywords: Accident; Construction industry; Health; Occupational safety; Risk.

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Occupational Safety and Health Cycle.…

Occupational Safety and Health Cycle. Adapted from Carvajal, G. I. (2008). Modelo de…

Trends in risk assessment.

Trends in risk prevention.

Trends in risk analysis.

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Occupational Health and Safety Risk Analysis in Construction Projects: A Systematic Literature Review

IJIEM - Indonesian Journal of Industrial Engineering and Management

The construction service business world always wants the best results in every project activities carried out. One of the best desired outcomes is the timely completion of a construction project, but this is often not achieved for several reasons, one of which is occupational health and safety incidents that occurs in a construction project. Based on the background of the problem and the results of a literature review sourced from 40 journals from 2011-2021, the journals collected and reviewed discussed occupational health and safety in construction projects. Therefore, it is very necessary to implement an OHS (Occupational Health and Safety) management system during construction work. Occupational health and safety aims to create conditions that support work comfort for workers, so as to improve risk management. Using sources based on previous research, the following will identify the types of occupational safety and health risk factors that most often occur in construction work. T...

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IEREK press

Construction is a high-risk industry owning to several accidents that take place in construction sites. Fatalities and workplace injuries are a major issue. Construction managers concentrate on profitability as far as cost, quality, and time are concerned. Unless experts end up mindful of safety-related issues, development tasks can never reach their targets. The main aim of this paper is to review the literature that highlights the result of the implementation of occupational health and safety practices in construction sites. The research examines the impact of the implementation on the number of accidents in construction sites and the precautions that should be taken into consideration starting from the pre-construction stage. Previous research suggested that early introduction of occupational safety & health management systems (OHSMS) and elements within the project implementation is an important asset in decision-making. It aims toward the abatement of occupational hazards in the workplace. The paper explores through a literature review the root causes of construction accidents and factors causing risks in construction sites. The research explains OSHMS, and its effects, and how they can be integrated into the pre-construction stage in projects. The impact of the implementation of occupational health and safety practices at construction sites will be discussed as well. The study concluded that due to implementing OHSMS, there is a significant reduction in accidents. In order to improve security and health, safety measures should be included starting from the preparation of contract documents. It is recommended that the managers of top construction companies commit more to safety and health procedures. There is a need to provide funding for the regulatory body that oversees health and safety in the construction industry.

eSAT Journals

Accidents at construction sites are identified as a major problem throughout the world. Apart from the accidents at construction sites, people working in the construction industry suffer from several occupational health disorders. In this backdrop, implementation of an effective occupational health and safety measures are gaining importance these days across the world. In line with this discussion, the present paper aims at assessment of occupational health and safety management w.r.t. different phases of construction activates i.e. pre-construction, construction and post-construction phases. It is observed that, the concept of occupational health and safety is not only applicable construction phase but also equally applicable to both pre-construction and post-construction.

International Journal of Occupational and Environmental Safety

João Matias

Background: This study was conducted to demonstrate the importance of occupational health and safety (OHS) management in construction project environments, taking into account the successful development of those projects. The associated problems in OHS management projects were also studied, as substantial empirical research has shown this is a complex theme with a large number of associated factors. Methods: In this study three projects developed in the Portuguese petrochemical industry were analysed using documentary analysis, on-going interaction with workers and direct observations of work activity. A systematic literature review was also carried out. Results: Strengths and weaknesses related to OHS management of the three analysed projects were identified. Grounded on the case studies results a proposal of OHS management in construction projects, in a recommendations format, is also presented. Conclusion: Good results from OHS management in projects can be obtained as long as it...

Olushola Okigbo

Muhammad Akram Akhund

International journal of occupational safety and ergonomics : JOSE

Mohd Saidin Misnan

The construction industry plays a significant role in contributing to economy and development globally. During the process of construction, various hazards coupled with the unique nature of the industry contribute to high fatality rates. This review was carried out by referring to previous published studies and related Malaysian legislation documents. Four main elements consisting of human, worksite, management and external elements which cause occupational accidents and illnesses were identified. External and management elements are the underlying causes contributing to occupational safety and health (OSH), while human and worksite elements are more apparent causes of occupational accidents and illnesses. An effective OSH management approach is required to contain all the hazards at construction sites. An approach to OSH management constructed by elements of policy, process, personnel and incentive developed in previous work is explored. Changes on the sub-elements according to pre...

INDUSTRIAL HEALTH

Víctor Yepes

HARYATI SHAFII

Abstract: The unsatisfactory OSH record of the construction industry has always been highlighted. It is because the OSHP system is a neglected area and a function that has not been pursued systematically in the construction industry. Safety is an important issue, but many employers do not feel it is vital to the success of companies. For a long time, the construction industry has been labeled as with poor OSHP and performance, which needs stern attention and in-depth research to put forward solutions to this issue. The objectives of this research are to investigate problems of OSHP in construction projects, to study the benefits of OSHP in construction projects and to recommend measures to promote OSHP in construction projects. The research was take place in Johor Bahru the capital of Johor State. The research based on quantitative research by using questionnaire to carry out the research. The questionnaire was designed based on the objectives each objective has ten statements with ...

International Journal of Research in Engineering, Science and Management

Ruba Rohini

The construction industry has become a hazardous industry, because of the high rates of accidents. This paper investigates safety management in construction companies for improving worker's safety as one of the ergonomics aims. In order to survey the safety and health management in construction companies a questionnaire was prepared and all aspects in construction safety management structure were included. The main important problems of safety and health management in construction include: lack of safety training, lack of provision of personal protection equipment, absence of safety and health specialized staff in construction sites, disuse of safety regulations and lack of updated rules, not following OSHA regulations, traditional management attitudes toward safety as a cost. The Indian society and economy have suffered human and financial losses as a result of the poor safety record in the construction industry. The purpose of this study is to examine safety management in the construction industry. The study will collects data from general contractors, who are involved in major types of construction. Collected data include information regarding organizational safety policy, safety training, safety meetings, safety equipment, safety inspections, safety incentives and penalties, workers' attitude towards safety, labor turnover rates and compliance with safety legislation. The study will also reveal several factors of ergonomics and poor safety and health management.

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Implementation of Health, Safety and Well-Being Laws and Regulations in the UK Construction Industry

17 Pages Posted: 22 Jun 2024

Xianhai Meng

affiliation not provided to SSRN

Suyash Uday Kapadnis

Construction is a major industry in the United Kingdom (UK). It is also one of the most high-risk industries in terms of health, safety and well-being (HSW). Although many generic and construction-specific HSW laws and regulations have come into force, few studies to date have systematically investigated the comprehensive implementation of various HSW laws and regulations in the UK construction industry. This research aims to fill in the knowledge gap by performing a thorough investigation of how HSW laws and regulations are implemented in the UK construction industry, based on a combination of a literature review, a questionnaire survey as a quantitative research method, and a group of interviews as a qualitative research method. The findings of this research include: (1) HSW laws and regulations are properly implemented on the whole; (2) the implementation of HSW laws and regulations has a significant impact on the reduction of HSW risks; (3) some problems/challenges may still exist to hinder the effective implementation of HSW laws and regulations; (4) appropriate strategies can be developed to overcome the problems/challenges and improve the implementation of HSW laws and regulations; and (5) construction organizations and practitioners can use emerging technologies to enhance the implementation of HSW laws and regulations. Although this research is based on the UK construction industry, the information and experience gained from this research will be useful for the implementation of HSW laws and regulations in the construction industry of other countries.

Keywords: Health, Safety, Well-being, Law, Regulation, Construction industry

Suggested Citation: Suggested Citation

Xianhai Meng (Contact Author)

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Architecture Sciences eJournal

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• Published: 26 June 2024

Climate change and heat stress resilient outdoor workers: findings from systematic literature review

• Peymaneh Habibi 1 ,
• Jaleh Razmjouei 2 ,
• Amirhossein Moradi 3 ,
• Farank Mahdavi 1 ,
• Saeed Fallah-Aliabadi 4 , 5 &
• Ahad Heydari 6  

BMC Public Health volume  24 , Article number:  1711 ( 2024 ) Cite this article

74 Accesses

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Global warming has led to an increase in the number and intensity of extreme heat events, posing a significant threat to the health and safety of workers, especially those working outdoors, as they often have limited access to cooling strategies. The present systematic literature review (a) summarizes the current knowledge on the impacts of climate change on outdoor workers, (b) provides historical background on this issue, (c) explores factors that reduce and increase thermal stress resilience, (d) discusses the heat mitigation strategies, and (e) provides an overview of existing policy and legal frameworks on occupational heat exposure among outdoor workers.

Materials and methods

In this systematic review, we searched scientific databases including Scopus ( N  = 855), Web of Science ( N  = 828), and PubMed ( N  = 202). Additionally, we identified relevant studies on climate change and heat-stress control measures through Google Scholar ( N  = 116) using specific search terms. In total, we monitored 2001 articles pertaining to worker populations (men = 2921; women = 627) in various outdoor climate conditions across 14 countries. After full-text assessment, 55 studies were selected for inclusion, and finally, 29 eligible papers were included for data extraction.

Failure to implement effective control strategies for outdoor workers will result in decreased resilience to thermal stress. The findings underscore a lack of awareness regarding certain adaptation strategies and interventions aimed at preventing and enhancing resilience to the impact of climate change on heat stress prevalence among workers in outdoor tropical and subtropical environments. However, attractive alternative solutions from the aspects of economic and ecological sustainability in the overall assessment of heat stress resilience can be referred to acclimatization, shading, optimized clothing properties and planned breaks.

The integration of climate change adaptation strategies into occupational health programs can enhance occupational heat resilience among outdoor workers. Conducting cost-benefit evaluations of health and safety measures for thermal stress adaptation strategies among outdoor workers is crucial for professionals and policymakers in low- and middle-income tropical and subtropical countries. In this respect, complementary measures targeting hydration, work-rest regimes, ventilated garments, self-pacing, and mechanization can be adopted to protect outdoor workers. Risk management strategies, adaptive measures, heat risk awareness, practical interventions, training programs, and protective policies should be implemented in hot-dry and hot-humid climates to boost the tolerance and resilience of outdoor workers.

Peer Review reports

Introduction

Extreme weather events and severe heat pose significant hazards to the safety and health of workers, leading to increased accidents, mortality, and morbidity during hot climate conditions [ 1 , 2 , 3 ]. Global warming presents a new and formidable challenge for most countries [ 4 , 5 ]. Global climate change substantially affects physiological and perceptual responses through both direct and indirect effects on core body temperature [ 6 ], heart rate, skin temperature, and thermal comfort [ 7 , 8 , 9 ]. Working in hot and humid environments during long shifts with high physical activity can jeopardize the safety and health of worker populations [ 7 , 10 ]. Increased exposure to thermal stress among workers in outdoor environments has been documented in tropical and subtropical countries with hot seasons [ 11 ]. Exposure to hot working environments, and the resulting elevated physiological and perceptual responses, can lead to occupational heat stress, reducing safety, health, and work capacity [ 12 ], and increasing the risk of heat-related illnesses (HRI) [ 13 ]. The increment in the levels of ambient temperature, radiation and shifts in the distribution of daily peak temperature can cause indirect and direct effects on outdoor workers [ 14 , 15 ]. High temperatures and high humidity can exacerbate the effects of physical workload on individuals working outdoors during long shifts in developing and tropical countries [ 16 ]. Working in high-temperature and high-humidity environments can have adverse health effects on workers, particularly agricultural workers, construction workers, drivers, sellers, brick-making workers, and daily wage workers [ 17 , 18 ]. High hot-humid and hot-dry temperatures can lead to occupational heat strain when core body temperature rises above 38 °C [ 19 ]. Exposure to heat radiation, either when working outdoors with exposure to the sun or around hot machinery, can greatly increase physiological pressure and lead to reduced work capacity [ 20 ].These physiological mechanisms worsen under high climate conditions and climate change, emphasizing the need to identify strategies to increase occupational heat stress resilience and develop solutions and policies to protect the health and safety of outdoor workers [ 21 , 22 ]. Projected future global warming conditions will dangerously affect the anticipated occupational heat stress resilience of outdoor workers worldwide. There is insufficient knowledge regarding strategies to increase occupational heat stress resilience, necessitating protective measures against heat stress and climate change to reduce health risks and fatalities for future outdoor workers in hot and humid work environments. The findings of this study can inform planning for increasing occupational heat stress resilience, developing heat acclimation strategies, and identifying risk factors to mitigate heat stress caused by global warming, particularly in middle- and low-income communities.

Search strategy

This systematic literature review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [ 23 ]. We searched scientific databases, including PubMed, Scopus, and Web of Science, and identified additional records through Google Scholar. We used Mesh terms in PubMed to identify synonyms for ‘climate change’ and ‘thermal resistance.’ We also consulted specialists to identify relevant keywords. Our search syntax was developed and applied to title, abstract, or keyword queries in selected databases. To ensure the specificity and accuracy of our search strategy, we tested the number needed to read (NNR) in the Web of Science database. We also investigated the references of included studies and searched key journals via Scopus to identify potentially relevant articles. The full search strategy in three main databases has been mentioned in Appendix 1. Our search syntax was as follows:

PubMed: (“heat wave”[tiab] OR “heat stress”[tiab] OR “climate change*”[tiab] OR (climate[tiab] AND change[tiab]) OR “extreme weather”[tiab] OR “extreme heat”[tiab] OR “global warming”[tiab] OR “hot day*”[tiab] OR “warm day*”[tiab]) AND (“heat tolerance“[tiab] OR “heat resilien*“[tiab] OR (heat[tiab] AND resilien*[tiab]) OR (heat[tiab] AND tolera*[tiab]) OR “Heat resistan*”[tiab] OR thermotolerance[tiab] OR “heat endurance”[tiab] OR (heat[tiab] AND endur*[tiab])) AND (worker*[tiab] OR Firefighter*[tiab] OR “fire fighter*”[tiab] OR firem*[tiab] OR “fire m*”[tiab] OR nurs*[tiab] OR operator*[tiab] OR driver*[tiab] OR farmer[tiab]* OR welder*[tiab] OR miner*[tiab] OR employee[tiab] OR laborer*[tiab] OR labour*[tiab]).

Inclusion criteria

The research question components (PECO) were as follows: P (workers), E (Exposure), C (heat stress), and O (increase occupational heat stress resilience). We included studies that (a) measured physiological and perceptual responses in workplaces and resting environments of workers; (b) studied working populations, including both males and females (healthy and unhealthy populations); (c) assessed the impact of climate change on occupational heat strain, as well as the health, safety, and well-being of workers including work-related variables (income, work type, time), environmental variables (wet-bulb globe temperature (WBGT), relative humidity), physiological variables (heart rate, respiratory, rate of perceived exertion (RPE)), and demographic variables (age, sex, body mass index (kg/m 2 ); (d) focused on air temperature, relative humidity (RH), heat waves, solar radiation, climate change, UV radiation, and thermal stress; (e) considered local and international contexts, countries, and workplaces; and (f) investigated workers’ perceptions of climate change, occupational heat strain, and their knowledge and attitudes toward adaptation strategies.

Exclusion criteria

Studies were excluded if they (a) studied climate change-related phenomena such as storms, cyclones, rainfall, rising sea levels, and drought; (b) evaluated the impact of climate change on plants, crop yields, pest dynamics, soil processes, water availability, and animals; (c) had inaccessible full-texts; or (d) focused on indoor workplaces.

Screening and selection

We entered all identified studies into EndNote and removed duplicates. One team member (PH) screened studies based on their titles and abstracts, and two members of the research team (AH and PH) independently selected relevant studies by reviewing the full texts. Disagreements regarding study inclusion were resolved through team discussion. We also conducted searches in three key journals: environmental research, urban climate, and global environmental change, but did not identify any additional studies.

Data extraction and quality assessment

Two team members (AH and PH) independently assessed the eligibility of included studies based on our inclusion and exclusion criteria. They also evaluated the methodological quality of selected studies using the quality assessment tool for studies with diverse designs (QATSDD), which consists of 16 items and is a reliable and valid tool for assessing the methodological quality of various types of studies [ 24 ]. Any disagreements regarding study inclusion were resolved through team discussion.

Search results

The numbers of identified studies and the studies reviewed during the screening and selection stages are presented in Fig.  1 . The initial search yielded 2001 articles including the additional articles sourced from Scholar Google. After full-text assessment, 55 studies were selected for inclusion, and finally, 29 eligible papers were included for data extraction. No additional studies meeting our eligibility criteria were identified after the full-text investigation. Similarly, no studies were identified through searches of key journals and the references of included studies. Table  1 provides details on the selected studies, including author/year, study location, document type, population/sample size, climate conditions, assessment of physical, perceptual, and physiological factors, authors’ conclusions, and quality ratings. Table  2 presents suggestions for increasing and decreasing occupational heat stress resilience among outdoor workers.

Flow diagram of the screening process of included studies the strategies to increase occupational heat stress resilience among outdoor workers

Descriptive analysis

Out of the 29 selected studies, 18 addressed global warming’s impact on occupational heat stress resilience, risk management strategies, and adaptation strategies for warming conditions. Most of these studies emphasized that climate change will exacerbate the health impacts of extreme heat. The prevalence of negative effects due to climate change will intensify workers’ health risks in future work scenarios, particularly in regions with hot and humid climates and poor economic conditions. As of our selection period until 2023, 20 studies (68.96%) were published between 2016 and 2023. Of the 29 assessed papers, 18 (62.06%) directly investigated the effects of climate change and adaptation strategies for outdoor workers in various countries, including Australia, the USA, China, Japan, Africa, Korea, Slovenia, Taiwan, Indonesia, Ghana, Korea, India, Iran, and Pakistan. The predominant themes identified in these papers revolved around strategies to increase occupational heat stress resilience. In conclusion, the study’s findings were categorized into main themes, including risk factors that decrease occupational heat stress resilience and suggestions for increasing occupational heat stress resilience among outdoor workers.

Thematic content analysis

This systematic review provides a summary of evidence published to date regarding strategies to enhance occupational heat stress resilience, especially in hot outdoor workplaces. Despite variations in study design and analytical approaches, the evidence presented in this systematic review consistently highlights a strong association between thermal stress resulting from global warming and occupational heat stress. Broad findings from these studies indicate that exposure to heatwaves and global warming is linked to adverse health impacts on workers.

Furthermore, several studies underscore the need for sentinel effects and leading indicators to facilitate surveillance of climate-related occupational heat stress effects, as well as strategies and interventions for preventing the impact of climate change on outdoor workers. Finally, the review identifies interventions and adaptation strategies for outdoor workers, including the provision of accessible cool drinking water [ 13 , 26 , 41 , 44 , 47 ], optimized work-rest schedules [ 12 , 13 , 16 , 26 , 36 , 43 , 44 , 47 ], the availability of proper resting shade [ 16 , 47 , 49 ], training and awareness programs [ 20 , 38 , 40 ], self-paced work [ 13 , 38 , 40 , 44 , 47 ], and the use of supportive protective equipment [ 41 ].

Factors that reduce resilience to climate change among outdoor workers

Resilience to climate change among outdoor workers can be reduced by various factors, categorized into personal risk factors, environmental risk factors, and occupational-related heat exposure risk factors during work.

Individual-related heat exposure risk factors

Personal factors associated with reduced resilience to climate change, identifiable from outdoor workers’ data, include dehydration [ 20 , 25 , 28 , 32 , 34 , 37 , 40 , 46 , 47 , 48 ], unique medical characteristics [ 41 , 47 ], pregnancy [ 38 , 40 , 47 ], BMI [ 29 , 30 , 37 , 40 , 47 , 49 ], obesity and body fat [ 29 , 30 , 32 , 34 , 47 ], overall health status [ 33 , 34 , 37 , 47 ], lack of sleep [ 33 , 34 , 40 , 47 ], experience of a previous HRI [ 32 , 34 , 44 , 45 , 46 , 47 ], presence of certain concurrent diseases and chronic disease [ 35 , 47 ], kidney disease [ 20 , 26 , 38 , 43 , 46 , 47 ], consumption of caffeine and alcohol [ 26 , 28 , 30 , 34 , 37 , 40 , 41 , 46 , 47 ], smoking [ 30 ], use of drugs [ 26 , 37 , 40 , 41 , 47 ], age [ 16 , 33 , 35 , 38 , 39 , 40 , 41 , 46 , 47 ], older workers with low education [ 38 , 40 , 43 , 44 , 46 , 47 ], physical fitness [ 26 , 32 , 40 , 47 ], metabolism rate [ 40 , 47 ], type of clothing [ 40 , 47 ], prior heat injury [ 40 , 46 , 47 ], physical activity and heavy workload [ 16 , 27 , 31 , 34 , 38 , 39 , 40 , 46 , 47 , 48 ], gender [ 16 , 33 , 35 , 38 , 39 , 40 , 41 , 46 , 47 ], education level [ 16 , 39 , 41 , 44 , 46 , 47 ], wearing PPE [ 16 , 26 , 27 , 31 , 38 , 39 , 44 , 46 , 47 ], and non-acclimatization [ 29 , 32 , 37 , 40 , 41 , 43 , 44 , 47 ]. Physiological risk factors most frequently expressed by outdoor workers included excessive heart rate [ 30 , 45 , 47 , 49 ], oral [ 47 , 49 ], skin [ 45 , 46 , 47 , 49 ], core temperature [ 26 , 27 , 29 , 31 , 32 , 34 , 45 , 46 , 47 , 48 , 49 ], sweating [ 39 , 47 ], and blood pressure [ 45 , 46 , 47 , 49 ]. This is often followed by heat exhaustion [ 47 , 48 ] or tiredness [ 47 ], headaches [ 47 ], heat rash [ 47 ], and fainting [ 47 ]. Older adults are more vulnerable to chronic dehydration [ 28 , 45 ], especially those living with multiple chronic diseases [ 43 , 47 ]. Aging is also associated with reductions in sweat production [ 8 ]. Consequently, studies have generally reported greater elevations in body heat storage and core temperature in older compared to younger adults during environmental heat exposure [ 26 , 37 , 46 , 47 ]. Additionally, personal factors correlated with occupational heat strain include the adequacy of water intake [ 41 , 47 ].

Environmental-related heat exposure risk factors

The environmental factors contributing to thermal stress include high air temperature [ 12 , 16 , 26 , 27 , 31 , 34 , 40 , 45 , 46 , 47 , 48 , 49 ], heat wave [ 43 , 47 , 48 ], airspeed and movement around the workplace [ 16 , 43 , 45 , 47 , 48 , 49 ], high levels of heat exposure (WBGT = 37.5–49 ℃) [ 38 , 46 , 47 ], tropical nights [ 48 ], working in sun- exposed conditions [ 16 , 38 , 39 , 47 ], solar radiation [ 26 , 40 , 43 , 46 , 47 , 48 ], high humidity [ 16 , 27 , 31 , 34 , 40 , 43 , 45 , 47 , 48 , 49 ], UV radiation [ 26 , 47 , 48 , 49 ], the moisture content of the outdoor settings or workplaces [ 16 , 39 ], radiant heat [ 16 , 26 , 31 , 36 , 45 , 47 , 48 ], and the air-pollution index [ 30 ].

Occupational-related heat exposure risk factors

However, workers encounter various barriers, such as inadequate cool housing designs for rest [ 38 ], a lack of management and engineering commitment [ 41 , 42 , 47 ], heavy physical workloads for long hours [ 16 , 47 ] or physically demanding jobs [ 44 , 46 ], insufficient awareness and prevention training [ 38 , 40 , 41 , 43 , 47 ], a lack of knowledge regarding adaptive behavior [ 41 , 43 ], the absence of occupational heat stress guidelines and adaptation strategies [ 38 , 41 , 46 , 47 ], a lack of regular training on adaptation measures [ 41 ], limited management commitment [ 41 ], the nature of the physical workload [ 16 , 40 , 41 , 46 , 47 ], the absence of specific thermal stress-related policy regulations [ 41 ], working in proximity to heat sources [ 16 , 44 , 47 ], the type of protective clothing [ 16 , 40 , 47 ], limited access to innovative technology and equipment [ 41 ], the nature of the work [ 40 , 41 , 46 , 47 ], inadequate management commitment, work-break regimes [ 43 , 47 ] and cooling systems [ 26 , 28 , 40 , 41 , 47 , 48 ]. Additionally, workers face challenges such as inadequate knowledge of adaptive behavior [ 41 , 46 ], a lack of regular training on thermal stress risk, adaptation, and safety measures [ 41 , 47 ], a deficiency in specific heat-related policies and regulations [ 41 ], limited management commitment to heat-related health and safety measures [ 41 ], restricted access to innovative equipment and technology [ 41 ], insufficient regular breaks and work-rest time [ 35 , 39 , 41 , 46 , 47 ], limited access to shade [ 38 , 43 , 47 ], inadequate financial resources [ 38 , 41 ], the absence of an acclimatization program [ 41 , 43 , 47 ], suboptimal water management [ 47 ], and insufficient medical attention when implementing adaptation strategies for climate change and occupational heat stress.

Factors that enhance resilience to climate change among outdoor workers

Enhanced resilience to climate change can be achieved through various means, including personal, managerial, and engineering protective factors.

Personal protective factors

Outdoor workers can take several measures to protect themselves. They should consider adjusting their work schedule [ 35 , 47 ], maintaining adequate hydration [ 28 , 33 , 35 , 37 , 38 , 39 , 40 , 47 ], adjusting their clothing [ 31 , 35 , 47 ], drinking more water [ 35 ] or drinking plenty of cool water frequently before feeling thirsty [ 13 , 26 , 41 , 44 , 47 ]. It’s important to take more frequent planned breaks [ 35 , 38 , 44 ], wear broad-brimmed hats [ 35 , 39 , 41 , 47 ] and ventilated helmets [ 28 ], understand how to self-pace [ 13 , 38 , 40 , 44 , 47 ], wear sun-protective gear [ 38 , 49 ], including sunglasses and gloves during hot weather conditions [ 41 ], and take work breaks and rest in cooler or shaded areas [ 13 , 28 , 33 , 35 , 38 , 39 , 40 , 41 , 43 , 44 , 47 ]. Using sunblock [ 38 , 39 , 44 ], and having a higher education level [ 39 , 44 , 47 ], are also beneficial. Workers should consider wearing loose and light-colored clothing [ 28 , 34 , 35 , 38 , 39 , 41 , 44 ] and opting for short-sleeved shirts and shorts when possible [ 13 ]. Using cooling vests [ 27 , 47 ], implementing a ‘Buddy system’ [ 47 ], acclimatization [ 26 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 40 , 47 ], maintaining normal anthropometric measures [ 29 ], and changing clothing ensembles to more breathable single-layer garments [ 43 ] can further enhance personal protection.

Managerial protective factors

Maintaining good quality working conditions and a suitable climate can significantly improve worker performance, productivity, and company profits [ 37 ]. Workplace management and training programs [ 16 , 35 , 38 , 40 , 41 , 47 , 49 ] are crucial for worker well-being. Developing prevention strategies [ 12 , 13 , 38 , 48 ], improving guidelines for worker safety, health, and productivity, and adhering to occupational health standards [ 12 , 38 , 47 ] are essential. Scheduling heavy routine outdoor work during the early morning [ 47 ] or evening hours or in shaded areas [ 13 , 41 , 44 , 49 ] can help mitigate heat stress. Providing access to cooling systems, such as air conditioning and fans [ 13 , 16 , 26 , 38 , 39 , 40 , 41 , 44 , 47 ], and offering climate change adaptation strategies [ 13 , 48 , 49 ] are beneficial. Adjusting the duration of breaks/rest periods [ 12 , 13 , 16 , 26 , 36 , 43 , 44 , 47 ], ensuring access to shade [ 16 , 47 , 49 ], and providing access to drinking water or implementing programs to improve hydration status [ 13 , 16 , 20 , 25 , 44 , 47 , 49 ] are important managerial measures. Training workers in heat-related illness prevention [ 20 , 38 , 40 ], providing access to medical attention [ 20 ], sharing heavier jobs and rotating job assignments on shift schedules [ 13 , 41 , 47 , 49 ], offering air-conditioned vehicles [ 13 , 38 , 47 ], promoting climate change awareness to support healthy lives and decent jobs [ 39 ], implementing work stoppages if the daily maximum temperature exceeds 40 °C [ 13 , 44 , 47 ], raising worker awareness about heat risks [ 47 ] modifying work habits [ 49 ], considering the TWL [ 30 ], and promoting the understanding of the need for workers to self-pace during hot weather [ 13 , 38 , 47 ] are all valuable managerial protective factors.

Engineering protective factors

Providing and designing regular breaks in shaded areas [ 38 , 47 ], implementing strategies to eliminate or replace thermal stress risks [ 37 , 44 ], installing a central cooling system [ 13 , 44 , 47 ], halting work during periods of high thermal stress and supplying mechanical equipment [ 41 , 47 ], initiating heat-shield projects [ 47 ], and enhancing ventilation [ 38 , 39 , 44 , 47 ].

Our systematic review’s outcomes help us understand strategies for increasing occupational heat stress resilience and assessing the effects of global warming on outdoor workers’ adaptation strategies. This is particularly crucial in numerous warm workplaces, especially in low- and middle-income countries. The implementation of strategies to ensure adequate hydration, including access to drinking water and programs to improve hydration status [ 13 , 16 , 20 , 25 , 44 , 47 , 49 ], is one of the most critical interventions for managing warm workplaces. Hydrated workers [ 28 , 33 , 35 , 37 , 38 , 39 , 40 , 47 ] are more likely to maintain an acceptable work rate and physical activity without health risks in various hot-dry and hot-humid weather conditions [ 25 ]. Employers bear the responsibility of providing a safe work environment, conducting training and awareness programs [ 16 , 35 , 38 , 40 , 41 , 47 , 49 ], supervision [ 50 ], and providing suitable protective equipment to mitigate the negative effects of thermal stress due to global warming on safety and health [ 26 , 49 ]. Cooling the core body temperature through wearable liquid cooling garments (SCG) [ 27 ], evaporative cooling garments (ECGs) [ 15 ], fluid cooling garments (FCGs) [ 51 ], hybrid cooling (HBCGs) [ 52 ], and phase change materials (PCMs) [ 53 ] worn by individuals who require personal protective equipment [ 47 , 54 ], including firefighters and construction workers, significantly reduces occupational heat strain and enhances thermal comfort and performance [ 32 ]. Chan et al. recommend implementing appropriate protective measures, such as work-rest schedules and heat tolerance guidelines, to ensure the safety and health of personnel exposed to hot weather conditions [ 28 ]. Therefore, it’s advisable to conduct further research on work-rest schedule optimization models for workers, particularly in the context of construction workers [ 28 ]. It is recommended that safe work durations should be modified based on expected type of clothing and work intensity [ 55 ]. Our review’s results indicate that personal risk factors such as dehydration [ 20 , 25 , 28 , 32 , 34 , 37 , 40 , 46 , 47 , 48 ], smoking [ 30 ] and alcohol-drinking habits [ 26 , 28 , 30 , 34 , 37 , 40 , 41 , 46 , 47 ], age [ 16 , 33 , 35 , 38 , 39 , 40 , 41 , 46 , 47 ], BMI [ 29 , 30 , 37 , 40 , 47 , 49 ], and non-acclimatization [ 29 , 32 , 37 , 40 , 41 , 43 , 44 , 47 ]; as well as work-related factors like work-rest cycles [ 35 , 39 , 41 , 46 , 47 ] and environmental risk factors such as air temperature [ 12 , 16 , 26 , 27 , 31 , 34 , 40 , 45 , 46 , 47 , 48 , 49 ], relative humidity (RH) [ 16 , 27 , 31 , 34 , 40 , 43 , 45 , 47 , 48 , 49 ], heat radiant [ 16 , 26 , 31 , 36 , 45 , 47 , 48 ], and Thermal Work Limit (TWL) [ 30 ], are significant predictors for determining the physiological responses to HRI among outdoor workers [ 30 ]. More efforts should be made to educate workers and employers about the effects of occupational heat stress on safety, health and performance, and appropriate screening protocols (pre-employment and periodic examinations) should be included in health and safety legislation [ 56 ].

Educating outdoor workers about physiological and perceptual responses to HRI [ 20 , 38 , 40 ] and heat acclimation under uncompensated thermal stress [ 26 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 40 , 47 ], as well as emphasizing cooling techniques and fluid intake [ 28 , 33 , 35 , 37 , 38 , 39 , 40 , 47 ], is essential. Furthermore, it’s necessary to investigate the impact of gender (both women and men) [ 16 , 33 , 35 , 38 , 39 , 40 , 41 , 46 , 47 ] and aging on heat tolerance and psychophysiological adaptation during work in hot-dry and hot-humid environmental conditions. This is especially crucial since elderly workers [ 38 , 40 , 43 , 44 , 46 , 47 ] display increased susceptibility to HRI in future studies, even if they haven’t engaged in prolonged or strenuous physical labor [ 31 ]. Pogačar et al.‘s study revealed that the most common symptoms of heat stress include excessive sweating, thirst, and fatigue. Interestingly, there was a significant difference among age groups regarding thirst and excessive sweating [ 35 ]. Gender differences in temperature regulation become more apparent under varying heat loads [ 8 ]. In general, women lose more heat through convection [ 11 ], which is advantageous in hot-humid environments [ 57 ], while men lose more heat through evaporation, which is more pronounced in hot-dry environments [ 58 ]. The resilience of vulnerable worker groups to heat stress can be compromised despite existing standards and knowledge. This vulnerability is particularly relevant when considering outdoor workers exposed to different climate conditions in tropical and subtropical countries [ 12 , 38 , 47 ]. Kjellstrom et al.‘s study underscores that mine workers remain the most significant population in terms of preventing the impact of thermal stress. This also extends to many construction workers, agricultural workers, and individuals laboring in warm workplaces without effective cooling systems [ 20 ]. Lui et al. demonstrated that wildland firefighters experience heat acclimatization across the thermal stress and fire season, leading to significant decreases in physiological and perceptual responses. These adaptations can reduce the risk of HRI [ 32 ]. Implementing acclimatization [ 26 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 40 , 47 ] and adaptation programms [ 13 , 48 , 49 ] for workers exposed to thermal stress is crucial. Adaptation policies aim to increase climate change resilience and reduce climate vulnerability [ 48 ]. Managers and occupational health professionals should also assess workers’ health status and individual habits, such as sleep deprivation [ 33 , 34 , 40 , 47 ], dehydration, and alcohol consumption before work [ 34 ]. International agencies have proposed various climate change adaptation and prevention strategies, including conducting training and awareness programs, using cooling mechanisms [ 13 , 16 , 26 , 38 , 39 , 40 , 41 , 44 , 47 ], and ensuring the availability of cool drinking water [ 13 , 16 , 20 , 25 , 44 , 47 , 49 ]. The most effective solutions at mitigating occupational heat strain were heat acclimation [ 26 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 40 , 47 ], wearing specialized cooling garments [ 27 , 47 ], cold water immersion [ 59 ], improving aerobic fitness [ 15 ], and applying ventilation [ 49 ]. Extending the exposure time to thermal stress leads to an increase in core body temperature and dehydration levels [ 60 ]. Acclimatized workers, with beneficial physiological adaptations like an efficient sweating system, lower heart rate, and core body temperature, can tolerate higher levels of dehydration and lose more water through sweat per shift. This means that the maximum allowable exposure time is greater for acclimatized workers compared to non-acclimatized workers [ 38 , 42 , 47 ]. Venugopal et al. demonstrated a strong correlation between physical workload, thermal stress exposures, Heat Strain Indicators (HSIs), and HRIs, leading to adverse health outcomes among outdoor workers [ 46 ]. There is a pressing need for evidence-based reviews and interventions to prevent occupational heat stress and enhance comprehensive resilience labor policies for outdoor workers in low and middle-income countries as climate change progresses. Increased awareness and consciousness among workers can lead to better adaptability to climate change risks [ 31 ]. Workers often implement conscious and flexible behavioral attitudes to manage their heat stress, especially in extremely hot workplaces, such as outdoor work [ 49 ]. Understanding the relationship between endurance time and WBGT values is crucial for training workers in very hot environments and ensuring their health and safety [ 43 ]. Elevated carbon emissions in the atmosphere contribute to extremely hot environments and climate changes, exacerbating occupational heat strains for outdoor workers [ 61 ]. A high-quality air and work environment can enhance worker safety, health, productivity, and company profitability [ 37 , 49 ]. Sustainable adaptation to warming climatic conditions [ 13 ] and social protection strategies during exposure to occupational heat stress depend on the availability of financial resources and collaborative efforts to overcome adaptation barriers [ 48 ]. The severity of occupational heat stress caused by climate change depends on workers’ sensitivity and vulnerability to different weather conditions. Additionally, the extent of adaptation capacity and resilience planning plays a crucial role [ 33 , 38 ]. Also, establishing a program that can assess how thermal stress due to climate change may increase heat-related effects on outdoor workers and document future heat-related events leading to relevant occupational health and safety regulations, seems essential [ 15 ].

The HEAT-SHIELD project is a customized occupational heat stress-related warning system that provides short- and long-term heat warnings to safeguard workers’ health and productivity. This project represents a useful adaptation strategy aimed at protecting workers, particularly those exposed to the effects of climate change [ 55 , 62 , 63 , 64 , 65 , 66 ].

The findings of this study are valuable for policymakers and professionals in the field of occupational health. They can use this information to develop guidelines and regulations aimed at preventing occupational heat stress and strengthening the resilience of outdoor workers during exposure to heat stress caused by climate change. However, it’s important to note that developing countries face a higher risk of negative occupational health outcomes compared to developed countries due to their lower adaptive capacity [ 46 ], increased poverty, and insufficient technological progress to combat climate change-induced temperature increases [ 6 , 47 ]. Outdoor workers often lack awareness of heat-related risks and HRI due to global warming [ 67 , 68 ]. Therefore, there is a critical need to raise awareness of heat-related hazards, bolster heat stress education, and update existing heat prevention measures. This includes optimizing current heat-related laws and adaptation policies to ensure effective implementation and compliance, especially in hot-dry and hot-humid work environments, particularly in low-middle-income countries [ 44 , 48 ]. Studies of this nature are essential among workers in these countries to provide health professionals and senior managers with the necessary knowledge to inform occupational heat stress adaptation policies, social protection measures, and resilience strategies for sustainable development.

Limitations

One limitation of this systematic review was the limited focus on female workers. Consequently, the results may not accurately represent the perspectives of women working outdoors, which is an important demographic to consider. Another significant limitation of this study is its heavy reliance on cross-sectional and experimental studies. Incorporating clinical aspects into data collection could greatly enhance and advance occupational health interventions. Furthermore, there is an evident scarcity of research exploring the social dimensions and the broader effects of occupational heat stress. Additionally, there is insufficient investigation into the adaptation strategies employed by workers in the context of increasing thermal stress and climate change, particularly in tropical and subtropical countries. These research gaps highlight the need for further studies to provide a more comprehensive understanding of this critical occupational health issue.

Addressing the health risks associated with occupational thermal stress among outdoor workers requires a multi-level approach that includes standard procedures and safety interventions. Currently, there is a lack of formal guidelines for outdoor workers, and most advisory systems do not adequately support this workforce in implementing solutions to mitigate occupational heat stress and enhance climate change resilience. While many workers acknowledge the importance of increased hydration and clothing adjustments during hot-dry and hot-humid climate conditions, a smaller proportion attempt to modify the nature of their work or seek rest in cooler areas. It is crucial to recognize that occupational heat stress remains a prevalent issue among these populations. To address these challenges, we recommend conducting further research to enhance our understanding of strategies aimed at bolstering the resilience of outdoor workers against heat stress resulting from climate change. This research should encompass diverse fields such as medicine, climatology, occupational health, and epidemiology. Additionally, there is a need to improve information dissemination, develop relevant regulations, and implement protective strategies among outdoor workers. These efforts will aid in identifying and preventing heat stress-related policies, including mitigation and adaptation measures.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on request.

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Peymaneh Habibi & Farank Mahdavi

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Jaleh Razmjouei

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Accident Prevention and Crisis Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

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Habibi, P., Razmjouei, J., Moradi, A. et al. Climate change and heat stress resilient outdoor workers: findings from systematic literature review. BMC Public Health 24 , 1711 (2024). https://doi.org/10.1186/s12889-024-19212-3

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Patient and family engagement in patient safety in the Eastern Mediterranean Region: a scoping review

• Zhaleh Abdi 1 ,
• Hamid Ravaghi 2 ,
• Samaneh Sarkhosh 3 ,
• Hamideh Nafar 3 ,
• Sedigheh Khani 4 &
• Mondher Letaief 2  

BMC Health Services Research volume  24 , Article number:  765 ( 2024 ) Cite this article

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Patients can play a key role in delivering safe care by becoming actively involved in their health care. This study aimed at reviewing the literature for evidence of patients’ and families’ engagement in patient safety in the Eastern Mediterranean Region (EMR).

We conducted a scoping review of the literature published in English using PubMed, Medline, CINAHL, Scopus, ISI Web of Science, and PsycINFO until June 2023.

A total of 9019 studies were screened, with 22 meeting the inclusion criteria. Our review found few published studies of patient and family engagement in patient safety research in the EMR. Thirteen studies explored the attitudes, perceptions, and/or experiences / preferences of patients, families, and healthcare providers (HCPs) regarding patient engagement in patient safety. Nine publications reported patient involvement in patient safety activities at varying levels. Three categories of factors were identified that may affect patient involvement: patient-related (e.g., lack of awareness on their role in preventing harms, unwillingness to challenge HCPs’ authority, and cultural barriers); HCP-related (e.g., negative attitudes towards patient engagement, poor patient-provider communication, and high workload); and healthcare setting-related (e.g., lack of relevant policies and guidelines, lack of training for patients, and HCPs, and lack of patient-centered approach).

This review highlighted limitations in the current literature on patient and family engagement in patient safety in the EMR, including both the depth of evidence and clarity of concepts. Further research is needed to explore how to actively involve patients and their families, as well as to determine whether such involvement translates into improved safety in practice.

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Patient safety is recognized as a serious public health concern in both developing and developed countries [ 1 ]. Despite substantial efforts over the past two decades, patient safety incidents remain a leading cause of disability and death, contributing significantly to increased healthcare costs worldwide [ 2 ]. Patient safety is fundamental to delivering high-quality essential health services and is core to achieving universal health coverage (UHC) and optimal healthcare delivery worldwide [ 3 ].

Engaging patients in promoting safety and reducing adverse events has become an international policy priority [ 4 , 5 ]. The World Health Organization (WHO) has recognized the necessity of empowering patients, families, and communities to ensure their sustained and effective engagement at all levels of health care as a core strategy to make healthcare services safer [ 6 ]. The World Alliance for Patient Safety was established by the WHO with the goal of coordinating and expediting global initiatives to enhance patient safety [ 7 ]. Patient and community engagement was one of the six original core focuses of the World Alliance for Patient Safety [ 3 ]. Despite the emphasis on involving patients in promoting safety and reducing adverse events, insufficient progress has been made worldwide in this area [ 8 , 9 ].

Evidence suggests that most patients are willing and able to participate and engage in their safety, and their participation has been associated with enhancing patient safety [ 10 , 11 ]. When patients and their family members participate in the process of care, they can provide a safety net by compliance with prescriptions and self-management, observing and checking care processes, alerting care teams on concerning symptoms, speaking up and raising concerns, identifying and reporting possible treatment complications and adverse drug events, checking the accuracy of medical records, and practicing in targeted interventions to promote safety [ 12 ]. During the COVID-19 pandemic, the lower level of family participation in the care processes, due to restrictions prohibited them from visiting patients, was linked to a rise in the number of adverse events experienced by patients [ 13 ].

Patient engagement efforts in quality and safety span a range of healthcare services, including community primary care (such as ambulatory care settings and home-based care), secondary healthcare, and tertiary specialized care [ 14 ]. This engagement occurs along a continuum, ranging from consultation (i.e., one-way communication through receiving information in the context of their own care) to involvement (i.e., two-way communication between patients and HCPs by patient participation in safety improvement projects) to extensive partnership (i.e., patients work together with the HCPs to improve patient safety in the context of their own care). Moving from mere consultation to extensive partnership, each stage requires greater participation and cooperation from all parties engaged in the process [ 15 ].

In the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), lack of data on the quality and safety of healthcare remains a challenge. Nonetheless, one regional study revealed that up to 18% of hospital admissions might involve adverse events, of which 80% are deemed preventable [ 16 ]. Countries in the EMR have demonstrated a strong commitment to improving the safety of care. In 2005, they endorsed a resolution (EM/RC52/R.4) by the Regional Committee aimed at improving patient safety in the EMR. Since then, several endeavors have been undertaken to advocate for patient safety, raise awareness among health professionals and policymakers, and develop national and regional strategies to implement safe practices. One of the most important strategies is the Patient Safety Friendly Hospital Initiative (PSFHI), launched in the Region in 2011 to promote and encourage safe health practices in hospitals [ 17 ]. Patient and public involvement is a key domain of the PSFHI manual, which includes standards related to raising awareness of patients on their rights, empowering patients and their relatives in shared decision-making, gathering feedback from patients, addressing patient’s concerns and complaints, and involving the community in various patient safety activities [ 18 ].

Mapping existing literature on a given topic helps foster an understanding of the subject's academic development, identifies gaps in existing research, and potentially supports future research and practice directions. Despite the growing research on patient participation in patient safety globally [ 9 , 11 , 14 ], there is a lack of information on this topic among EMR member states. Therefore, we conducted a scoping review to examine the current state of the evidence on patient engagement in patient safety in the EMR. The review aimed to describe the breadth and depth of research regarding patients' engagement in safe care among EMR member states.

The scoping review was conducted to systematically describe the breadth and depth of the literature about patient engagement in safe care among member states of the EMR, which include Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Occupied Palestinian Territory, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen. Scoping reviews are increasingly utilized to identify gaps in evidence, guide research priorities, and identify implications for policy or practice [ 19 ]. A scoping review typically involves five main steps: scoping, searching, screening, data extraction, and data analysis [ 20 ]. Reporting of the scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 21 ].

Research questions

The research question for this study is: “What is known regarding patient engagement in patient safety among member states of the EMR? ” We included studies focused on the following objectives: to investigate patients’ and families’ attitudes, perceptions, and experiences regarding their role in enhancing safety, and/or to investigate HCPs’ attitudes and beliefs about patient participation in patient safety practices, and/or to examine strategies and interventions for involving patients in safety activities within hospital settings.

Search strategy

Following the guidelines for conducting systematic scoping reviews [ 22 ], a comprehensive literature search was conducted by a librarian using the electronic databases including PubMed, Medline, PsycINFO, CINAHL, Scopus, and ISI Web of Science with no date restriction in June 2023. Our search strategy consisted of combinations of three key blocks of terms related to “patient safety”(for example, medical error, adverse event, iatrogenic disease, infection control) “patient involvement” (for example, participat*, empower*, involv*, engag*), and “patients, families, and healthcare providers” (for example, patient, representative*, parent*, family, families, caregiver*, health provider, healthcare provider, clinician, physician, doctor, nurse, health professional, health worker). The search strategy for PubMed databases is provided in Additional file 1. The same strategy was adopted for other databases mentioned above, taking into account their different characteristics.

Criteria for selection

We included empirical studies that directly explored patients’, families’ or HCPs’ attitudes, perceptions, and experiences related to patient engagement in safety activities. Additionally, studies were included if they explicitly or implicitly investigated the participation of patients, caregivers, or families in the design, delivery, and evaluation of the interventions aiming at promoting patient safety in inpatient settings. We included empirical qualitative, quantitative, and mixed-methods studies published in English in peer-reviewed journals. Additionally, the reference lists of all included studies were examined to identify additional relevant articles that may have been missed during the database search. The methodological quality of included studies was not assessed, as this is optional in scoping reviews [ 22 , 23 ], and the purpose was only to describe the extent of existing research on the topic.

Titles and abstracts of the papers identified from the initial search were screened to determine if the full text should be retrieved. Two reviewers independently assessed the titles and abstracts against the inclusion criteria. Publications identified as potentially relevant were retrieved in full text and screened independently by three reviewers (ZA, SS, HN). Discrepancies regarding the inclusion of any publication were resolved through discussion and consensus among reviewers. Data extraction was conducted by two reviewers (SS, HN) using a structured abstraction form developed for this purpose. The form collected information on authors, year of publication, journal, country, research design, number and type of participants, barriers and facilitators to patient engagement, description of interventions, level of engagement, and main findings. The data extracted were cross-checked and verified by two other reviewers (HR, ZA).

The results were categorized based on the study's objectives and presented in a narrative form. We assessed the level of patient engagement in safety activities using a framework proposed by the NHS, which defines three levels of patient engagement: consultation (informing patients about patient safety and seeking patient feedback on safety issues), involvement (engaging patients in their care), and partnership (patients working together with HCPs as full team members to improve patient safety in the context of their own care) (partnership) [ 15 ].

A total of 14,532 documents were initially identified from various databases: PubMed ( n  = 2,727), Scopus ( n  = 5,189), Medline ( n  = 1,501), PsycINFO ( n  = 595), Web of Science (2,103), and CINAHL ( n  = 2,417). After removing duplicates ( n  = 5,513), 9,019 unique records were evaluated based on title and abstract. Subsequently, 268 articles were assessed for full-text eligibility. Following the eligibility criteria, 248 articles were excluded. Two additional articles were identified through reference checking, resulting in a total of 22 studies published between 2011 and 2022 included in the current review (Fig.  1 ).

Information flow in scoping review

Among the included studies, nine were qualitative studies and 13 had quantitative designs, including quantitative surveys, quasi-experimental studies, and clinical trials. Sample sizes varied from 230 to 455 for quantitative and 19 to 94 for qualitative studies. Thirteen studies explored patients’, families’ or HCPs’ attitudes, perceptions, or experiences regarding preferences for patient engagement in patient safety, while nine publications reported actual patient engagement in safety activities. The publications included in the review were from Saudi Arabia, Iran, Pakistan, Jordan, and Lebanon. Detailed characteristics of the included studies are presented in Tables 1 and 2 .

Patients’ and families’ perceptions and experiences of involvement in safe care

We included eight studies that either directly assessed patients' attitudes towards involvement in safe care as an independent study or investigated patients' knowledge and attitudes towards patient safety, incorporating components on patients' knowledge and attitudes towards patient/family involvement [ 24 , 25 , 26 , 29 , 31 , 33 , 34 , 36 ] (Table  1 ). Seven studies focused on understanding patients' attitudes and thoughts about their potential role in ensuring safety at the direct care level. One study explored patient attitudes towards involvement in safety activities along with other aspects of patient safety. Among these studies, three were quantitative cross-sectional studies, while the remaining five were qualitative.

The general findings suggest that patients reported limited involvement in patient safety initiatives and considered their role as passive [ 24 , 25 , 26 , 29 , 31 , 33 , 34 , 36 ]. For instance, a qualitative study conducted in two hospitals in Saudi Arabia reported that patients experienced limited supportive processes and strategies in place to enable them to take an active role in their own safety [ 24 ]. In a survey conducted by Novinmehr et al. (2019) among elder inpatients in Iran, 41% of the patients reported being involved in the safety of their own care [ 33 ]. Additionally, according to patients' views, healthcare organizations and providers did not consider patient engagement in safety activities as a priority. For instance, in a study conducted in Iran, only 20% of patients stated that hospitals received their feedback [ 29 ]. Several studies suggested that the lack of patient engagement in patient safety reflected a broader cultural phenomenon where patients and their families did not actively participate in medical decision-making [ 24 , 34 ].

Patient involvement was less likely for actions and behaviors that challenged and required questioning healthcare professionals. For instance, in a survey conducted in a hospital in Saudi Arabia, 76.5% of patients reported that they would not ask their physician to wash their hands before the examination [ 25 ]. Some studies noted that cultural and social norms prevalent in Middle Eastern countries contributed to patients feeling powerless to express dissatisfaction with healthcare systems or voice opinions or complaints [ 24 , 31 ].

Some studies suggested that patients who were female, younger, had higher levels of education, and have experienced errors were more willing to participate in error-prevention strategies [ 33 , 34 ]. The role of HCPs was recognized as crucial in empowering patients in the involvement process. A positive patient-provider relationship centered on trust, respect for the patients’ doubts, and listening to their questions and concerns was reported as a contributing factor in this process [ 25 , 36 ]. In summary, the mapping of the literature highlighted gaps and limitations in our current understanding of patients’ perceptions and experiences of involvement in safe care, both in terms of the depth of the evidence and clarity of the concept.

There was limited investigation of family members’ perceptions and experiences related to their participation in patient care to ensure safe care as a primary focus (Table  1 ) [ 24 , 26 , 31 ]. Three studies investigated caregivers’ and families’ attitudes about taking an active role in ensuring safe care at the direct care level. Patients' family members believed that they could play an important role in ensuring safety and preventing harms, supporting patients by voicing concerns on their behalf, facilitating the continuity of patient care, and enhancing the patient–provider relationship [ 24 , 31 ]. They asserted that the role of family members increases when patients are too ill, too old, or cognitively impaired [ 31 ].

Despite these benefits, family participation was a challenging task. Using a qualitative ethnographic approach, Alshahrani et al. (2018) investigated the extent of family members' participation in the care of patients in acute care settings in Australia and Saudi Arabia from the perspectives of nurses and relatives. In the Saudi Arabia setting, nurses reported feeling confused due to their dual role of caring for patients while also fulfilling organizational objectives that encourage partnerships with patients and their relatives. They asserted that the lack of policies and guidelines defining their roles and responsibilities in coordinating patients' and families’ involvement contributed to the role ambiguity [ 26 ]. In another qualitative study conducted by Dehghan-Nayery et al. (2015) in two general hospitals in Iran, the perspectives of patients, families, and HCPs towards family participation were investigated. Participants expressed positive attitudes towards involving family members in caregiving for elderly patients. However, they mentioned that the lack of policies and guidelines clearly outlining the roles and responsibilities of medical team members was a major barrier to patient involvement [ 31 ].

HCPs' perceptions and preferences regarding patient involvement in safe care

Nine publications examined HCPs’ perceptions regarding patients’ systematic engagement in safety, either as their primary focus or as part of broader discussions on safety behaviors [ 24 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 35 ]. Among these, four studies investigated the attitudes of patients, relatives, and HCPs, while five studies focused solely on the attitudes of HCPs (Table  1 ). The HCPs included nurses, physicians, pharmacists, medical students, and administrators with varying years of experience in their profession and from different healthcare fields. The sample sizes varied from 10 to 38 for qualitative studies and 80 to 347 for surveys.

HCPs generally believed that patients have an important role in preventing medical errors, and active involvement of patients and families can represent an opportunity to reduce harms and risks. Participants mentioned several benefits for patient engagement, including better patient outcomes, reduced harms and increased safety, fewer complaints, and higher satisfaction [ 24 , 27 , 30 , 35 ]. HCPs’ positive attitudes towards patient engagement in safety were identified as key to facilitating patient engagement in safety activities by several included studies [ 24 , 26 , 30 ]. However, a few included studies reported provider-related barriers to patient involvement in safety activities, including negative attitudes towards engagement, high workload and time constraints, lack of motivation and willingness, and lack of effective patient-provider communication [ 26 , 30 , 35 ]. Included studies emphasized that patient-provider interactions can facilitate or hinder the success of any efforts to improve safety [ 30 ]. The involvement of patients in their own care was considered as closely linked to the relationship established with health professionals [ 32 , 35 ].

Engaging patients and families in safety improvement interventions

Nine publications reported patients' and families’ participation in safety improvement interventions [ 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. We categorized the included studies into two types: (1) independent projects aimed at directly promoting patient/family engagement in safety practices; or (2) patient safety improvement projects where patient/family engagement was a key component. Details of the interventions are summarized in Table  2 .

Five quasi-experimental or randomized studies examined patient participation in safety improvement initiatives where patient involvement was not the primary focus. In a study conducted in a tertiary care ICU in Saudi Arabia, trained ICU staff audited the hand hygiene practices of HCPs and families using the WHO audit tool. Following the implementation of a stepwise multifaceted approach that included education, audit, and feedback, hand hygiene compliance significantly improved to 80%, and this improvement was sustained over several months [ 37 ]. Another study conducted in a hospital in Saudi Arabia reported active patient involvement in a wound care team aimed at reducing hospital-acquired pressure ulcers (HAPUs). The program focused on establishing a wound care team, providing education to HCPs, patients, and their families, as well as implementing surveillance and follow-up visits. The results demonstrated a significant reduction in the percentage of patients who developed pressure ulcers (PUs), decreasing from 0.20% to 0.06% over a period of 5 years [ 38 ]. Another study was a randomized, unmasked interventional trial conducted in a tertiary care teaching hospital in Lebanon. The study examined the effects of pharmacist-managed anticoagulation education and follow-up on bleeding and readmission rates among patients aged 18 years and older discharged on oral anticoagulants for treatment. The findings indicated that while the intervention did not lead to a reduction in bleeding or readmission rates, pharmacist education significantly improved patient-provider communication during the post-discharge period [ 41 ]. In another clinical trial conducted in Iran to investigate the effect of home-based education on the incidence of pressure ulcers in stroke patients, 70 family members were selected using convenience sampling and then randomly assigned to control and intervention groups. In the intervention group, educational sessions were conducted for family caregivers on stroke, pressure ulcers, and methods for preventing and treating pressure ulcers in stroke patients. The study reported a statistically significant difference in the incidence of pressure ulcers between the control and intervention groups [ 42 ]. In a study conducted in Pakistan, a comprehensive surveillance system involving HCPs and patients was implemented in a cardiac hospital to enhance the monitoring of surgical site infections post-discharge. Patients were educated about the signs and symptoms of surgical site infections and instructed to seek prompt assistance in the emergency room if any symptoms arose. The surveillance system successfully detected 22 infections out of 538 procedures, with 95% of these infections being identified during the post-discharge period [ 44 ]. All five studies evaluated the effectiveness of these strategies in reducing incidents, but none of them formally assessed patients' or families' experiences with the engagement activities.

Four out of nine studies described patient involvement in care as an institutional program designed to promote patient engagement in safe care. Three studies actively promoted engagement through educational strategies, such as learning sessions and training materials on patient safety, targeting both patients and HCPs. All three studies reported increased knowledge among patients and HCPs following these educational interventions [ 40 , 43 , 45 ]. One study conducted in an oncology unit at a hospital in Saudi Arabia, investigated the impact of patient involvement on promoting hand hygiene practices among HCPs. The study implemented several plan-do-study-act (PDSA) cycles, which were pilot-tested before full-scale implementation. Interventions included educational sessions aimed at empowering patients and improving HCPs' adherence to hand hygiene practices. The study reported that active patient involvement led to an increase in HCPs' compliance rate from 5 to 20% during the study period [ 39 ].

The included studies generally provided limited details about the involvement strategies, experiences of patients and caregivers with these strategies, and the factors that influenced their participation. Patient involvement in patient safety activities varied across a continuum, ranging from mere consultation to more active involvement and extensive partnership. Two studies reported consultation activities where patients and caregivers were educated about safety and asked for their feedback on safety incidents [ 43 , 45 ]. Six studies focused on involvement activities, where patients and families served as members of improvement project teams or provided education to other patients and family members [ 37 , 38 , 40 , 41 , 42 , 44 ]. Notably, one study went further by actively involving patients as partners in a quality improvement project aimed at enhancing hand hygiene compliance among HCPs [ 39 ].

Facilitators and barriers to patient engagement in patient safety

Two studies specifically examined barriers and facilitators to patient engagement from the perspective of HCPs and managers [ 30 , 35 ]. However, several other studies have reported additional factors that serve as barriers and facilitators to patient engagement in ensuring safety of care. These reported barriers and facilitators to patient engagement in patient safety can be categorized into three main categories, as shown in Table  3 :

Patient-related factors

Higher education and younger age were associated with a greater willingness to participate in error-reduction strategies [ 33 , 34 ]. Patients’ illness-related factors, such as terminal illness, confusion, and general frailty, were identified as predictor factors for patient and their family involvement in the safety of their health care [ 31 , 35 ]. In addition, language barriers hindered patient-provider communication, resulting in patients feeling reluctant or less able to actively participate [ 30 , 31 , 35 ]. One of the primary barriers preventing patients from participating in patient safety practices was their lack of knowledge and awareness about medical errors and patient safety [ 33 ]. Inadequate health literacy and poor knowledge were reported as major barriers to patient involvement in several studies [ 30 , 34 , 35 , 42 ]. Raising public awareness, which will make patients more knowledgeable about patient safety and the possibility of medical errors, was identified as a facilitator to enhance patient involvement in safety activities [ 25 , 29 ]. Clearly defined roles for patients, along with delivering education and training programs for both patients and HCPs on patient involvement, were also identified as facilitators to actively engage patients in safety efforts [ 26 , 35 ]. Patients who believed that they were vulnerable to patient safety incidents were more willing to actively participate in error reduction strategies [ 34 ]. Patients' self-efficacy and self-care were recognized as predictors of their willingness to engage in patient safety activities [ 33 ].

Several factors were reported as negatively influencing patients' motivation to engage in their care, including fear of repercussion due to raising concerns [ 30 , 35 ], reluctance to disturb busy HCPs by asking questions, and unwillingness to question or criticize HCPs’ behaviors and decisions [ 31 , 35 ]. The latter barriers may be rooted in the Middle Eastern culture, where patients often view healthcare professionals as authorities, leading them to be unwilling to express concerns or complaints during their hospital stay [ 31 ].

HCP-related factors

The knowledge, beliefs, and attitudes of HCPs towards patients and their participation in treatment and safety issues were recognized as major factors influencing patient participation. Negative attitudes held by staff about how patients could contribute were cited as one of the main barriers toward patient involvement. The main obstacles were the hierarchical and paternalistic culture among HCPs and their unwillingness to abandon their traditional role and share their decision-making power [ 30 , 35 ], even though they may not express it overtly [ 35 ]. Additionally, the fear of legal liability further contributed to HCPs' negative attitudes [ 26 , 35 ].

The way in which HCPs interacted and communicated with patients influenced patient engagement in health care [ 36 ]. Patient participation was more likely to be achieved when healthcare professionals appreciate patients as knowledgeable partners in care and provide feedback to their concerns [ 36 ]. HCPs perceived patient and family involvement as a time-consuming and challenging task, particularly in the absence of clear rules and guidelines [ 26 , 31 , 35 , 38 , 45 ]. High workload prevented HCPs from effectively managing and coordinating patient and family participation in caregiving [ 26 , 28 , 31 , 35 ].

Healthcare setting-related factors

Successful partnerships with patients to reduce errors and enhance safety were achieved when patient participation was encouraged by organizational values and directions. However, the lack of guidance and information on how patients should be involved, coupled with insufficient clarification regarding relevant HCPs’ legal and ethical responsibilities, posed barriers to patients' involvement in safety efforts [ 26 , 35 ]. The use of appropriate mechanisms to receive patients' feedback, such as surveys and suggestion boxes, to integrate patient and family perspectives into daily activities was mentioned as a facilitator of patient engagement [ 29 ].

Lack of professional training and continuing education programs to train HCPs was identified as a barrier to meaningful patient participation [ 30 , 35 ]. Some studies emphasized the importance of investing in HCPs training to promote attitudinal changes and thereby achieve better healthcare outcomes [ 26 , 30 , 35 ]. Several studies identified a lack of patient safety culture as a factor contributing to resistance to patient involvement initiatives at different levels [ 24 , 30 , 36 ]. Organizational culture was described in some studies as a critical factor influencing patient involvement. An organization with a positive culture was characterized by leaders who prioritize safety over productivity and financial gains, adopt processes and incentives to promote patient-centered communication, and provide adequate resources, structure, and accountability to facilitate patient involvement at all levels of the organization [ 24 , 35 ].

Summary of main aims and key findings

We found that patient and family engagement is still an emerging area in patient safety research in the EMR, with few published studies. This literature review identified limitations in both the depth of evidence and the clarity of concepts. Although there has been an increase in the number of quality and safety-related studies in the region in recent years [ 46 ], the topic of patient engagement in patient safety has received less attention.

We identified eight studies that investigated the views and experiences of patients and families regarding their participation and contribution to ensuring they receive safe care. Additionally, there were nine studies that investigated HCPs' attitudes and behaviors regarding patients’ involvement and contribution in patient safety initiatives. Nine studies described the successes and challenges of implementing patient safety interventions involving patients and their caregivers. Our results indicate the necessity for further exploration of various aspects of patient involvement in safety activities, considering the perspectives of both patients/families and HCPs. Nonetheless, the findings of these studies are worth considering.

Comparison with the literature

Our review indicated that patient involvement in safety is influenced by a variety of factor associated with patients, HCPs, and organizational characteristics. Patient-related factors influencing their willingness to participate in their own healthcare process included patients’ acceptance of their new role in ensuring safe care, lack of medical knowledge, low confidence, presence of comorbidities, limited awareness of healthcare risks, reluctance to challenge or question HCPs’ knowledge and authority, low self-efficacy in preventing errors, fear of legal and technical implications when raising concerns, and various socio-demographic parameters. Our results are consistent with similar reviews examining patients' attitudes and willingness to participate in safety behaviors [ 11 , 47 , 48 , 49 ]. While healthcare organizations cannot control certain patient-related barriers to patient participation, such as personal factors, they can address others by adopting appropriate actions. Patient empowerment plays a critical role in enhancing patient participation, particularly in error-reduction strategies [ 50 ]. Patients must have sufficient information and understanding about their health conditions, healthcare processes, and systems to enable them to be knowledgeable partners in decision-making about their own health [ 6 ]. Empowering patients can increase their awareness of errors associated with modern healthcare and their potential role in reducing and eliminating such errors [ 51 ]. EMR member states, like other countries worldwide, should intensify efforts to raise public awareness of patient safety issues. This increased awareness is critical for engaging patients and their caregivers in meaningful patient safety activities. This can be achieved through several approaches, including implementing targeted educational campaigns to inform the public about key patient safety topics, providing comprehensive training for HCPs on effective communication and patient safety practices, fostering community engagement through collaboration with local organizations and non-governmental organizations (NGOs), offering patient and family empowerment tools such as informational materials and resources to promote active participation in healthcare, and establishing robust data collection systems to monitor patient safety trends and outcomes within healthcare settings [ 52 , 53 , 54 ].

The evidence indicates that HCPs’ beliefs, attitudes, and behaviors have a substantial impact on patient engagement [ 55 ]. Our results suggest that HCPs generally have a positive attitude to engaging patients; however, the existing literature is insufficient to draw concrete conclusions. The results indicate that among HCPs, the acceptance and promotion of patient participation are negatively influenced by several factors, including hierarchical and paternalistic cultures that prioritize maintaining control, personal beliefs, fear of legal liability, lack of time, and inadequate training in patient-provider communication. Similar reviews in other countries have also reported these factors, indicating a widespread challenge in fostering patient participation within healthcare systems [ 56 , 57 , 58 ]. If healthcare organizations aim to promote meaningful patient involvement in patient safety efforts, then they must actively encourage and empower HCPs to support patient participation [ 57 ]. The knowledge and beliefs of healthcare professionals are significant determinants of patient involvement [ 48 ]. To achieve meaningful and effective patient engagement, healthcare systems should strive for a cultural shift from the traditional paternalistic approach in care delivery to fostering a collaborative partnership between patients and HCPs. This shift aims to support patients and enhance their capacities to become more informed, engaged, and proactive in their care [ 11 ].

Regarding institutional obstacles, one of the primary concerns highlighted by the included studies was the absence of a patient/people-centered approach that integrates patient and family perspectives and involvement at the point of care. The presence of an organizational culture that acknowledges the significance of patient involvement in ensuring safe care was identified as a crucial success factor for fostering such participation in the literature [ 14 , 58 ]. Additionally, having leaders who focus on creating a transparent and receptive environment, along with implementing policies and mechanisms that promote patient-centered communication and shared decision-making among patients, their families, and HCPs, is recognized as essential for successful patient involvement initiatives [ 59 ].

In conclusion, promoting patient engagement necessitates the implementation of several strategies targeting patients, providers, and healthcare systems. It requires prioritizing safety at all levels of the healthcare system, ranging from direct care at the individual level to organizational governance, systems design, and policy-making [ 60 ]. A growing body of literature worldwide addresses the development and utilization of interventions to promote patient engagement in patient safety. However, mapping the literature within the EMR has revealed limitations in our current understanding of the topic and underscored the necessity for further research.

Implications for future research and practice

There is limited research on the attitudes, perceptions, and experiences/preferences of patients, families, and HCPs regarding patient engagement across EMR countries. Studies have reported improvement initiatives without specifying how they engaged patients and families. Therefore, there is a significant need for empirical research to explore first, the feasibility and acceptability of patient participation in safety-related initiatives from the perspectives of patients, families, and HCPs, and second, whether such involvement contributes to improvements in safety. Understanding the challenges encountered by patients, families, and HCPs is essential for fostering meaningful patient engagement in safety-related behaviors across different contexts. By identifying barriers and challenges, targeted interventions can be designed and implemented for patients and providers. Future research should also examine the costs and benefits of patient involvement in safety improvement initiatives, assessing their effectiveness in reducing errors and harms. This approach aligns with the PSFHI, implemented by EMR hospitals since 2011, which provides clear standards for the role of patients and the public in enhancing healthcare safety [ 17 ].

The concept of patient engagement in patient safety spans a continuum from one-way information sharing to two-way collaboration and partnership between patients and providers. While adopting an in-depth participatory approach with extensive patient and family involvement may pose certain challenges for HCPs, several studies have reported benefits from this approach [ 10 , 14 ]. Further efforts are needed to design and implement interventions that promote patient involvement to enhance patient safety in EMR countries. Future studies could focus on hospitals that have implemented the PSFHI framework to explore how patient participation in patient safety has been addressed and reinforced.

Limitations

This review has several limitations that should be considered when interpreting and utilizing the findings. Firstly, we only included papers published in English, which may have led to the exclusion of relevant papers in other languages that could have provided further insights on the topic. Additionally, some of the reviewed papers did not specifically align with the objective of this scoping review, making it challenging to extract the required information. Moreover, due to the small number of studies, we did not exclude any based on quality. Lastly, this study specifically focused on patient and family participation in hospital settings and did not encompass studies from other settings. Given the importance of this subject, we recommend further studies in diverse settings to broaden our understanding. Nonetheless, this scoping review represents the first attempt to map the status of research on patient participation in patient safety initiatives in the region.

Despite the international movement to increase patient involvement in safety, there is a lack of research evidence from the EMR on the acceptability to patients, families, and HCPs, as well as the potential impact of such involvement on enhancing safety. Available evidence suggests that patients are willing and capable of being involved in patient safety practices. There is a critical need to understand how patients, families, and caregivers can actively participate and contribute as knowledgeable partners in patient safety activities. Additional evidence is needed to understand the preferences and experiences of patients, caregivers, and HCPs regarding the involvement process, and whether such involvement leads to improved safety in practice. Future studies should aim to expand our understanding of which strategies work best in different contexts and their impact on patient safety. Particularly, there is a need for implementation studies that demonstrate how to effectively implement these concepts in clinical settings, given the diversity of the EMR countries.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Abbreviations

• Eastern Mediterranean Region

Healthcare Provider

Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review

Patient Safety Friendly Hospital Initiative

World Health Organization

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ZA, HR, and ML conceived the study and participated in its design. SK conducted the literature search and prepared the search results for analysis. ZA and HR developed the data abstraction forms and the manuscript outline. The literature was extracted by SS and HN under the supervision of HR and ZA. The final version of the manuscript was drafted by ZA and reviewed by ML and HR. All authors read and approved the final manuscript.

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Abdi, Z., Ravaghi, H., Sarkhosh, S. et al. Patient and family engagement in patient safety in the Eastern Mediterranean Region: a scoping review. BMC Health Serv Res 24 , 765 (2024). https://doi.org/10.1186/s12913-024-11198-3

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DOI : https://doi.org/10.1186/s12913-024-11198-3

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