Occupational health research: Challenges and opportunities in developing countries

The first Industrial Revolution in the eighteenth century had to do with steam engines and the second one in the nineteenth century saw mass production and assembly line manufacturing – when occupational health and safety (OHS) came into focus. The third Industrial Revolution with computing, internet, and nuclear energy happened in the latter half of the twentieth century and even before we could wrap our heads around this, the fourth revolution encompassing the cyber-physical systems is underway and with it will be changes in our perspectives on occupational health (OH) and occupational health research (OHR). Changes like nonstandard employment, difficulties in OHS service delivery, over-dependency on newer technologies, newer forms of accidents, social disconnection, and weak unions will cause newer challenges in the future.[1] OHR OHR focuses on the study of the health and safety of workers in the workplace. The goal of OHR is to promote safe and healthy working conditions and to prevent work-related illness and injury. The broad categories of OHR are as follows: Investigation of work-related diseases and injuries Assessment of workplace hazards and risk factors Development of interventions and preventive measures Evaluation of the effectiveness of workplace health and safety programs Historically, disasters like the Minamata Bay disaster, the Bhopal Gas tragedy, and the Upper Big Branch Mine explosion has led to OHR assessing exposures and planning preventive strategies. However, through history, OHR was not regular and did not help the employees directly. Issues raised about OHR, in general, included the accusation that research distances workers from their own sufferings; that it was more for academic curiosity than for improving the lives of those affected; that it somehow benefitted the researchers; and that research ideas and findings were confined to seminar rooms.[2] Researchers have found that OHR from developing countries is not innovative or that it is an extension of research conducted in the country of graduate training, except for the suboptimal assessment of exposures and health outcomes.[3] ADVANTAGES OH has evolved from being reactive to treating diseases and injury to preventing diseases and injury and towards promoting health via work. This was made possible by OHR going hand-in-hand with OHS. Good OHR leads to setting safety standards, hazard identification, policy changes, and planning preventive measures. OHR adds advantages to the employer, management, and policymakers and it can increase productivity directly or indirectly. In a review article published in this journal in 2005, OHR in India was assessed and recommendations given included creating public-private partnerships, exposure assessments, disease surveillance in industries, analyzing occupation on death certificates, record linkage, conducting ecological correlation studies, embarking on large scale retrospective studies, and increasing international collaborations.[4] Perhaps, it is time now after 2 decades, after advancements in OHS and enhanced resources, to assess how far we have progressed and to identify where improvements are needed. CURRENT SCENARIO IN OHR Awareness about OH, safety, and hygiene is low among the workforce and community. The review article cited above states that OHR in India is complicated by child labor, poor legislations, a vast informal sector, low attention to industrial hygiene, and poor data surveillance or dissemination.[4] There is a need for OHR to be balanced between traditional occupational diseases and modern risk factors due to mechanization and the consequences of the third and fourth Industrial Revolutions listed above. Agriculture is still the predominant industry in India but research in this sector is less due to practical difficulties (such as the informal nature of employment) and the lack of dedicated OHR personnel. The ethical dilemma of highlighting gender-specific OH issues may compromise job equality in the workplace.[5] CHALLENGES IN OHR Common hurdles in OHR are lack of access to data, limited funding, diverse workplace exposures, confounders, ethical issues, difficulty in quantifying outcomes, and lack of generalizability. Combined with this, there is a lack of funding, research personnel, and misplaced management-driven research priorities.[6] Most of the research is descriptive and there is a genuine lack of quality interventional studies. Majority of the OH researchers are old and young professionals are hesitant to come into this doubtful career path.[7] Research priorities are not always met by research output, its impact, or its funding.[8] Developing countries do not have the means to convert OHR findings into effective policies as compared to developed nations.[9] The factory medical officer is isolated in his OHS facility without any collaborations with other sectors[9] and hence unable to do meaningful research. OH journals want research done in the workplace only and not the ones covering the socio-political effects of work.[9] Funding for research may be product-driven rather than demand-driven.[10] Nuwayhid describes the OHS cycle of neglect in developing countries which includes issues such as OH being a low priority to limited resources to inadequate research leading to poor evidence and limited partnerships.[9] This cycle can be broken with a change in attitude towards the risk exposures and forming alliances with social scientists, economists, and political scientists while ignoring others in the OH profession itself. OHR in developed nations has progressed further with good funding, robust data systems, and well-placed research priorities. OHR looks at evolving further by prioritizing interventional studies, increasing data dissemination, developing a young OHR workforce, aligning research with policymakers, showcasing research needs to funders, adapting to the changing nature of workplace hazards, and looking beyond the workplace.[811] Nuwayhid constructed a model about the internal domain of OHR [Figure 1] which includes work-related factors and an external contextual domain comprising the other layers.Figure 1: Modified Nuwayhid OHR model with internal and external domains[9]It was suggested that developed nations should conduct OHR from the internal to the external domain and that this should be the other way around in developing nations. This does not mean less priority for workplace hazards but seeing the internal domain in a broader context.[12] The outer-to-inner domain approach promotes partnerships with social, economic, and political experts. Historically, there are some problems like silicosis, asbestosis, and chemical exposures, which originate in the workplace but affect the family and society. OPPORTUNITIES OHR opportunities are enormous with the scientific technology and digital communication systems that are available today. Broad opportunities include the following: Enacting robust OH laws and a team to enforce them at the ground level, Increasing trained OH personnel dedicated to research, Influencing political will and funding for OHR, Strengthening international and local collaborations including public-private partnerships, and Demonstrating the value of robust research findings to stakeholders like funders and policymakers. OHR also needs proper leadership and multisectoral coordination.[4] OHR should prioritize the validity and strength of OH interventions rather than the economic constraints and socio-political feasibility. While some systems do exist, there are several ways in which modern technology can be enhanced or incorporated into OHR. To name a few: Mobile phone-based health education (messages and videos and assessing outcomes) Using newer equipment for industrial hygiene monitoring (particulate matter, light) Using data logging machines for continuous measurements (8-h sound levels, full shift dust exposures) Using videography in ergonomic assessments Using wearable devices like a smartwatch for measuring heart rates and activity in a shift Using drones for workplace monitoring and environmental measurements. We should recognize that migrant employees form a large proportion of most workplaces, and they come with different occupational hazards owing to heterogenicity, challenging environments, different diets, less access to healthcare, and an extra burden on their physical and mental health. OHR with migrants should evolve from simple cross-sectional studies to long-term cohort studies coupled with qualitative approaches.[13] The study design should be chosen based on the research question and feasibility. Rather than doing a single big study to address all questions, it is better to tackle each research question through multiple smaller studies.[14] Study designs like ecological or longitudinal studies can be readily done with the available data. Even though they may not be robust study designs, they provide the opportunity for further research and funding.[15] OHR should not be restricted to primary prevention like health education, vaccines, or protective equipment but it should also explore opportunities in secondary and tertiary prevention in OH. Research should also look at different screening methods for a risk specific to that workplace (like exposure measurements or designing surrogate indicators) and the effectiveness of a rehabilitation program for an employee returning after injury. The first people to realize something may be going seriously wrong in an organization are usually those who work there. Workers, with weak collective bargaining powers, are not empowered enough to understand the link between workplace exposure and disease to ensure societal pressure. In this context, participatory research improves commitment and job satisfaction, productivity, and safety compliance.[2] Employees can be involved in designing safety methods, risk surveys, focused workshops, and quality circles. Any preventive or promotional intervention at the workplace can be best assessed with a randomized controlled trial but it is suggested that this can be substituted by stepped wedge experiment or observational methods like propensity scores, instrumental variables, multiple baseline design, interrupted time series, difference-in-difference, and regression discontinuity.[16] There should be a repository of data on occupational exposures from the global burden of disease studies. Training in OHS in India is considered inadequate – there is a deficit of 58% of medical officers in relation to the number of employees in the organized sector.[17] Experts recommended competency-based OH education to get more young OH professionals into the field and thereby promote OHR.[1518] CONCLUSION Research should move on from identifiable and measurable workplace hazards to a more system-based approach on how the risk factors could affect the family and society. A shift in approach from measuring exposures and injuries to economic evaluations on workplace interventions is called for. Instead of considering the workplace as a threat to health, a different perspective of the positive impact of the workplace on health and family should also be recognized. OHR should move from measuring morbidity and injuries to investigating return on investments, the number of OH researchers trained, newer interventions designed and implemented, and the validity and effectiveness of these interventions.