Behavioural interventions to promote workers' use of respiratory protective equipment
Respiratory hazards are common in the workplace. Depending on the hazard and exposure, the health consequences may include: mild to life‐threatening illnesses from infectious agents, acute effects ranging from respiratory irritation to chronic lung conditions, or even cancer from exposure to chemicals or toxins. Use of respiratory protective equipment (RPE) is an important preventive measure in many occupational settings. RPE only offers protection when worn properly, when removed safely and when it is either replaced or maintained regularly. The effectiveness of behavioural interventions either directed at employers or organisations or directed at individual workers to promote RPE use in workers remains an important unanswered question.
To assess the effects of any behavioural intervention either directed at organisations or at individual workers on observed or self‐reported RPE use in workers when compared to no intervention or an alternative intervention.
We searched the Cochrane Work Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 07), MEDLINE (1980 to 12 August 2016), EMBASE (1980 to 20 August 2016) and CINAHL (1980 to 12 August 2016).
We included randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time‐series (ITS) comparing behavioural interventions versus no intervention or any other behavioural intervention to promote RPE use in workers.
Data collection and analysis
Four authors independently selected relevant studies, assessed risk of bias and extracted data. We contacted investigators to clarify information. We pooled outcome data from included studies where the studies were sufficiently similar.
We included 14 studies that evaluated the effect of training and education on RPE use, which involved 2052 participants. The included studies had been conducted with farm, healthcare, production line, office and coke oven workers as well as nursing students and people with mixed occupations. All included studies reported the effects of interventions as use of RPE, as correct use of RPE or as indirect measures of RPE use. We did not find any studies where the intervention was delivered and assessed at the whole organization level or in which the main focus was on positive or negative incentives. We rated the quality of the evidence for all comparisons as low to very low.
Training versus no training
One CBA study in healthcare workers compared training with and without a fit test to no intervention. The study found that the rate of properly fitting respirators was not considerably different in the workers who had received training with a fit test (RR 1.17, 95% Confidence Interval (CI) 0.97 to 1.10) or training without a fit test (RR 1.16, 95% CI 0.95 to 1.42) compared to those who had no training. Two RCTs that evaluated training did not contribute to the analyses because of lack of data.
Conventional training plus additions versus conventional training alone
One cluster‐randomised trial compared conventional training plus RPE demonstration versus training alone and reported no significant difference in appropriate use of RPE between the two groups (RR 1.41, 95% CI 0.96 to 2.07).
One RCT compared interactive training with passive training, with an information screen, and an information book. The mean RPE performance score for the active group was not different from that of the passive group (MD 2.10, 95% CI ‐0.76 to 4.96). However, the active group scored significantly higher than the book group (MD 4.20, 95% CI 0.89 to 7.51) and the screen group (MD 7.00, 95% CI 4.06 to 9.94).
One RCT compared computer‐simulation training with conventional personal protective equipment (PPE) training but reported only results for donning and doffing full‐body PPE.
Education versus no education
One RCT found that a multifaceted educational intervention increased the use of RPE (risk ratio (RR) 1.69, 95% CI 1.10 to 2.58) at three years' follow‐up when compared to no intervention. However, there was no difference between intervention and control at one year's, two years' or four years' follow‐up. Two RCTs did not report enough data to be included in the analysis.
Four CBA studies evaluated the effectiveness of education interventions and found no effect on the frequency or correctness of RPE use, except in one study for the use of an N95 mask (RR 4.56, 95% CI 1.84 to 11.33, 1 CBA) in workers.
Motivational interviewing versus traditional lectures
One CBA study found that participants given motivational group interviewing‐based safety education scored higher on a checklist measuring PPE use (MD 2.95, 95% CI 1.93 to 3.97) than control workers given traditional educational sessions.
There is very low quality evidence that behavioural interventions, namely education and training, do not have a considerable effect on the frequency or correctness of RPE use in workers. There were no studies on incentives or organisation level interventions. The included studies had methodological limitations and we therefore need further large RCTs with clearer methodology in terms of randomised sequence generation, allocation concealment and assessor blinding, in order to evaluate the effectiveness of behavioural interventions for improving the use of RPE at both organisational and individual levels. In addition, further studies should consider some of the barriers to the successful use of RPE, such as experience of health risk, types of RPE and the employer's attitude to RPE use.
Bao Yen Luong Thanh, Malinee Laopaiboon, David Koh, Pornpun Sakunkoo, Hla Moe
Plain language summary
Ways to encourage workers to wear protective equipment to stop them breathing in harmful substances
It is common at many workplaces for the air to contain substances that are harmful to health. These may include bacteria and viruses, various fumes and smoke, and dusts and particles such as asbestos or grain. Depending on what and how much of it is inhaled, the health consequences may vary from mild to life‐threatening. These consequences range from feelings of irritation to short‐ and long‐term illness including cancer. In many work settings respiratory protective equipment (RPE) is used to prevent workers from inhaling harmful substances. Various ways have been introduced to teach workers how to use RPE effectively. However it is unclear how well they work. Therefore, we wanted to find out if there are interventions that can encourage workers to use RPE correctly or more often.
Studies found - We searched for relevant research studies up to 20 August 2016. We found 14 studies that analysed the effectiveness of behavioural interventions to promote RPE use. We also located one ongoing study. Studies had been conducted with 2052 farm, healthcare, production line, office and coke oven workers as well as nursing students and people with mixed occupations. We did not find any studies where the researchers conducted and assessed an intervention at the level of a whole organization.
What the research says - All included studies compared different education and training interventions to encourage workers to use RPE correctly or more often. We found very low quality evidence that behavioural interventions such as education and training do not increase the number of workers that use RPE or that use RPE correctly.
What is the bottom line - We conclude that there is low to very low quality evidence that behavioural interventions do not encourage workers to use RPE correctly or more often. It is likely that our conclusions will change when new studies are published. We need better quality studies that look at the effectiveness of different types of interventions. These interventions should be targeted at both individuals and organisations, to improve effective RPE use. In addition, further studies should consider some of the barriers to the successful use of RPE, such as experience of health risk, types of RPE and the employer's attitude to RPE use.
Bao Yen Luong Thanh, Malinee Laopaiboon, David Koh, Pornpun Sakunkoo, Hla Moe
Implications for practice
According to the evidence provided by this Cochrane review, behavioural interventions ‐ namely education and training ‐ do not have a considerable effect on the frequency or correctness of RPE use in workers. This may be due to a lack of studies with a low risk of bias. Interventions to promote the correct use of RPE need to be better evaluated to provide evidence for their effectiveness before any strong recommendations can be made. There were no studies on incentives.
Implications for research
There is a lack of studies with a low risk of bias that evaluate the effectiveness of behavioural interventions to promote RPE use. The interventions used in the studies included in this Cochrane review focus primarily on education and training. We need studies evaluating the effectiveness of other interventions and combinations of interventions to improve RPE use in workers compared with education only. Examples of these other interventions include: legislation and enforcement; incentives (e.g. monetary or positive feedback); sanctions and negative feedback; and changes in the organisational safety climate or culture.
Given the small effects reported in studies included in this Cochrane review, the sample size of new studies should be at least 400 participants. This sample size is based on an estimate of a small effect size of 0.2 (Norman 2012). New studies should use and clearly report randomised sequence generation, allocation concealment and assessor blinding. New studies should evaluate the effectiveness of behavioural interventions for improving the use of RPE at both an organisational and individual level using different types of workers. Studies should be conducted in both high‐income as well as low‐ and middle‐income country settings. Behavioural interventions targeted at the worker level should be carried out in small‐scale industries in low‐ and middle‐income countries, while those targeted at the national or organisational level should be conducted in larger organisations in high‐income countries. Future studies should also consider and take into account the impact of known barriers to RPE use, such as perception of health risk, employers' attitude, and ease and comfort of use.