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Background: Occupational injury rates among construction workers are the highest among the major
industries. A number of injury-prevention interventions have been proposed, yet the effective-
ness of these is uncertain. Thus a systematic review evaluating the effectiveness of interventions
for preventing occupational injuries among construction workers was conducted.
Methods: Seven databases were searched, from the earliest available dates through June 2006, for
published findings of injury prevention in construction studies. Acceptable study designs
included RCTs; controlled beforeafter studies; and interrupted time series (ITS). Effect
sizes of similar interventions were pooled into a meta-analysis in January 2007.
Results: Of 7522 titles found, four ITS studies and one controlled ITS study met the inclusion
criteria. The overall methodologic quality was low. No indications of publication bias were
found. Findings from a safety-campaign study and a drug-free-workplace study indicated
that both interventions significantly reduced the level and the trend of injuries. Three
studies that evaluated legislation did not decrease the level (ES 0.69; 95% CI1.70, 3.09)
and made the downward trend (ES 0.28; 95% CI0.05, 0.51) of injuries less favorable.
Conclusions: Limited evidence was found for the effectiveness of a multifaceted safety campaign and a
multifaceted drug program, but no evidence was found that legislation is effective to
prevent nonfatal or fatal injuries in the construction industry.
(Am J Prev Med 2008;35(1):77 85) 2008 American Journal of Preventive Medicine
C
onstruction workers are frequently exposed to
ity of nonfatal injuries result from falls from heights,
various types of injury-inducing hazards. Poor
from slips and trips on the level, and from being struck
construction safety and associated fatal and non-
fatal occupational injuries have been reported in many by a moving or falling object.3,8
studies around the world.1 6 In 2003 the fatal injury The construction industry is an important industry
incidence rates of 4.0 (UK) to 11.7 (U.S.) per 100,000 worldwide, in terms of its contribution to both employ-
construction workers were reported.3,7 The majority of ment and regional and national economies. The costs
related to occupational incidents can be substantial.
From the Finnish Institute of Occupational Health (Lehtola, Ver- Direct workers compensation costs due to slips, trips,
beek), Centre of Expertise for Good Practices and Competence, and falls varied from $0.04 in insulation work to $20.56
Team of Knowledge Transfer in Occupational Health and Safety and in roofing, with an average of $4.3 per $100 payroll
the Cochrane Occupational Health Field of the Cochrane Collabo-
ration, Kuopio, and the Finnish Institute of Occupational Health costs during a large construction project in the U.S.9
(Lappalainen), Centre of Expertise for Human Factors at Work, Indirect costs related to medical expenses, productivity,
Team of Occupational Safety, Tampere, Finland; the Coronel Insti-
tute of Occupational Health (van der Molen), Academic Medical
supervisory, and liability costs increase the financial
Center, University of Amsterdam and Arbouw, Dutch National Insti- losses even more.6,10 Thus, effective interventions to
tute for Safety and Health in the Construction Industry, Amsterdam, prevent occupational injuries are the basis of an effec-
and the Safety Science Group (Hale), Delft University of Technology,
Delft, the Netherlands; the Center for Quality and Production tive health and safety policy to ensure the health of
Improvement, University of Wisconsin (Hoonakker), Madison, Wis- construction workers and to reduce the societal burden
consin; the National Institute for Occupational Safety and Health related to direct and indirect occupational injury costs.
(Hsiao), Morgantown, Pennsylvania; and the Department of Human
Sciences, Loughborough University (Haslam), Leicestershire, UK Various interventions to prevent occupational inju-
Address correspondence and reprint requests to: Marika M. Leh- ries have been proposed and studied, such as organiza-
tola, MSc, Finnish Institute of Occupational Health, P.O. Box 93
(Neulanimentie 4), FI-70701, Kuopio, Finland. E-mail: marika. tional interventions, safety programs, incentives, and
lehtola@ttl.fi. legislation.1114 However, the effectiveness of these
interventions on occupational injuries remains un- framework for judging the methodologic quality of ITS
clear.15 Attempts have been made to summarize the studies.23 Checklists, like EPOCs quality criteria, were used
effectiveness of safety interventions in some reviews, but for assessing the strengths and weaknesses of the study design,
these reviews are not systematically updated, and they and especially the vulnerability of the study to different biases.
Six standard criteria were used for the quality assessment
typically focus on the prevention of one injury-related
(Table 1), and each criterion was scored with 1 point if it was
event (e.g., falling,16,17), or on one source of injury or met and with 0 if it was unclear or not met. The Downs and
injury type.18 This review systematically summarizes the Black checklist24 was intended to be used for randomized and
most current scientific evidence on the effectiveness of nonrandomized studies, but these types of studies were not
interventions to prevent the occupational injuries asso- found.
ciated with construction work.
Data Extraction
Data extraction and all other assessments were done
Methods
independently.
The methods described in the Cochrane Handbook19 were
used to collect the best currently available evidence from Measuring Intervention Effect
evaluation studies on the topic and to report the findings by In order to obtain comparable and reliable effect sizes from
synthesizing the evidence in the best possible way. If suffi- ITS studies, data from original papers were extracted and
ciently homogenous, studies are combined in a meta-analysis re-analyzed, according to the recommended methods, in
whenever statistically possible to get more precise results.19 December 2006.25 These methods utilize a segmented time-
series regression analysis to estimate the effect of an interven-
Searching Trials
tion, while taking into account secular time trends and any
The search terms construction workers, injury, safety, and study autocorrelation among individual observations. If a control
design were used in the search strategy. The strategy was group was used for the ITS study, the difference in rates
created by combining the most important job titles20 with the between the intervention and the control group was used.
method of Robinson and Dickersin21 for RCTs and the Re-analysis made it possible to estimate regression coeffi-
method of Verbeek et al. 22 for nonrandomized studies. Seven cients corresponding to two standardized effect sizes for each
databases were searched through June 2006: MEDLINE study: a change in level and a change in trend before and
(from 1966); EMBASE (from 1988); OSH-ROM (including after the intervention.25 A change in level was defined as the
NIOSHTIC and HSELINE); the Cochrane Central Register of difference between the observed level at the first intervention
Controlled Trials; the Cochrane Injuries Groups specialized time point and that predicted by the pre-intervention time
register; PsycINFO (from 1983); and the Ei Compendex trend. A change in trend was defined as the difference
(from 1990). Also, topic-related websites were searched. Tri- between post- and pre-intervention slopes. A negative change
als in any language were considered for inclusion. in level or trend represents an intervention effect in terms of
a reduction in injuries both in the uncontrolled and con-
Eligibility of Studies trolled interrupted time series. Data were standardized by
For inclusion, the study participants had to be construction dividing the outcome and SE by the pre-intervention SD as
workers on one of these types of construction sites: building/ recommended by Ramsay (C. Ramsay, poster presentation,
housing/residential; road/highway/civil engineering; offices/ 9th Annual Cochrane Colloquium, 2001), and entered into
commercial; or industrial installations. All types of interven- the Review Manager (RevMan) 4.2 computer program as
tions that had fatal or nonfatal injuries reported as outcome effect sizes and SEs.
measure were included. Only RCTs; cluster RCTs; controlled
beforeafter studies; and interrupted time-series (ITS) studies Data Synthesis
were eligible. Other study designs were considered to be too Results were pooled in January 2007 for studies that evaluated
much prone to bias to be used as evidence of effectiveness. similar interventions, participants, and outcomes. Where suf-
ficient quantitative data were available, meta-analyses were
Methodologic Quality
performed. For interrupted time series, the standardized
The quality criteria developed by the Effective Practice and changes in level and trend were used as effect measures.
Organization of Care (EPOC) review group were used as a Meta-analysis was performed, using the generic inverse vari-
Study Participants, country Intervention and form of intervention Study design Outcomes and used data points
27
Derr (2001) Construction workers in 50 states in U.S. Fall-protection standard issued in ITS based on 5 years before Fatal falls per 1,000,000 workers
(nnot clearly reported) 1995; compulsion by legislation and 5 years after (per year): 50 (1990;); 48
intervention (1991;); 45 (1992;); 41
(1993); 45 (1994); 46 (1995);
45 (1996); 48 (1997); 40
(1998); 42 (1999)
Lipscomb (2003)15 16,215 carpenters in U.S. Vertical Fall Arrest Standard issued in ITS based on 2 years before Fall related injuries per 100
1991 requiring personal protective and 8 years after person-years (per year):
equipment, fall-protection plan, and intervention 3.85 (1989); 3.15 (1990; );
risk-reducing activities; compulsion 2.85 (1991); 2.80 (1992); 2.31
by legislation (1993); 2.15 (1994); 1.86
(1995); 1.21 (1996; ); 1.58
(1997); 1.45 (1998)
Spangenberg (2002)28 Construction workers in Denmark Multifaceted safety campaign issued in ITS based on 3 years before Injuries per 100 person-years
involved in demolition, excavation, 1996 including attitudinal and and 3 years after (per year): 2.98 (1993);
tunnels, bridges, and finishing work behavioral aspects (e.g., newsletter, intervention 3.70 (1994;); 6.86 (1995);
(n4250 man-years) best practices, safety inspections, 5.34 (1996); 3.74 (1997);
financial safety award, themes on 4.80 (1998)
injury risks); information; facilitation
(feedback); enforcement
(inspection)
Suruda (2002)13 About 5 million construction workers in Trench and excavation standard ITS based on 6 years before Fatal injuries per 1,000,000
47 states in U.S. issued in 1990; compulsion by and 6 years after workers (per year):
legislation intervention 15.59 (1984); 16.29 (1985);
13.50 (1986); 13.73 (1987);
10.94 (1988); 10.94 (1989);
9.54 (1990); 5.82 (1991); 5.82
(1992); 6.52 (1993);
7.45 (1994); 5.35 (1995)
Wickizer (2004)29 Construction workers (at follow-up, Drug-free-workplace program issued in Controlled ITS based on 3 Injuries per 100 person-years
intervention group: n3305 person- 1996 including formal policy; drug years before, 3 years (per year): Intervention:
years; control group: n65,720 testing; treatment; worker assistance; during, and 1 year after 29.03 (1994); 28.09 (1995);
person-years) education workers; supervisors, and intervention 26.28 (1996); 24.21 (1997);
managers; information; education; 18.08 (1998); 20.90 (1999);
facilitation (financial incentives); 20.53 (2000)
enforcement (drug testing) Control: 30.58 (1994);
27.68 (1995); 25.92 (1996);
26.48 (1997); 26.21 (1998);
www.ajpm-online.net
CI1.79, 0.81) for initial effect and progressive tion was observed, with an injury rate difference of
effect, respectively. 1.97 per 100 person-years per year between the
intervention and control group. This yielded effect
Effectiveness of a Drug-Free-Workplace Program sizes of 6.78 (95% CI10.01, 3.55) and 1.76
on Nonfatal Injuries (95% CI3.11, 0.41) for initial effect and pro-
Re-analysis of results of the original study. One study29 gressive effect, respectively.
showed a significant initial intervention effect of a
drug-free-workplace program with a nonfatal-injury Discussion
rate difference of 7.59 per 100 person-years between
the intervention and control group (Table 3). The In this review evidence was found that a multifaceted
study had a downward trend of injuries over time safety campaign, as well as a multifaceted drug-free-
pre-intervention. A progressive effect of the interven- workplace program, reduce nonfatal injuries, but no
Figure 1. Meta-analysis of the legislation interventions with interrupted time-series design. Outcomes are reported as effect sizes
and SE for A Level: Describes the immediate effect of an intervention on annual injury rate, and for B Trend: Describes the
long-term effect of an intervention on the annual injury rate.