Appendix: Occupational Hazards Faced By Health Workers in Resource-Constrained Settings

Biological
Cartoon strip: health workers facing OSH risks Insufficient access to clean water, lack of universal precautions for protection against blood-borne diseases, lack of sterile equipment and proper waste management, and exposure to bacteria, fungi, parasites, or blood-borne viruses such as HIV and hepatitis as well as communicable diseases such as tuberculosis, avian flu, or swine flu. Habitually rationing water for only the most important tasks, health workers may wash their hands less frequently. The additional workload of procuring water reduces health workers’ productivity by taking them away from direct patient care. Latex gloves in short supply are rinsed and hung to dry for reuse. In Ethiopia, nurses have a 29% and 31% lifetime risk of unsafe exposure to bodily fluids and needlesticks, respectively (Reda et al. 2010). In 2000, 39 Ugandan health workers died from exposure to the Ebola virus while caring for infected patients (Republic of Uganda Ministry of Health 2008).

While blood-borne disease safety has received more financial and institutional backing—notably from HIV programs—than other OSH issues in the developing world, the World Health Organization (2002) estimates that three million health workers are exposed to blood-borne viruses each year: two million to hepatitis B; 900,000 to hepatitis C; and 300,000 to HIV. Over 50% of HIV infection cases among health workers in an East Asian study were nurses, followed by laboratory staff and blood collectors (Gold et al. 2004). However, internal stigma is cited as the single most important obstacle to accessing HIV prevention and treatment services. One study suggested that nurses fear HIV disclosure more than they fear infection itself (Houtman, Jettinghoff, and Cedillo 2007).

Chemical
Bleach, lead, harsh detergents, flammables, solvents, noxious vapors, allergens, radiation, and other exposures often found in laboratories. International chemical standards have improved in recent years, but enforcement lags in developing countries. Where task-shifting occurs, staff may not be adequately trained to handle chemicals properly. They may lack an adequate supply of masks, gloves, and eyewear, and may work in buildings with inadequate ventilation. A study revealed that 71% of Nigerian dentists surveyed were regularly exposed to dangerous levels of dental amalgam, which could result in mercurial poisoning (Fasunloro and Owotade 2004). In many developing contexts where new technologies and chemical processes are introduced to the health system, the extent of chemical exposures is not easily quantified, and additional research is needed.

Physical
Slips, trips, falls, physical strain, heavy lifting, long hours, fatigue, and violence. Health workers may work in buildings that do not meet safety codes. Depending on the severity of an injury, blame may be placed on the person injured. Some cultures consider pain a weakness and ergonomics an unnecessary comfort rather than a preventive measure. In Malaysia, ergonomics was the area of OSH where health workers demonstrated the least knowledge (Lugah et al. 2010). For such reasons, health workers may not report an injury or strain; therefore, they often don’t receive proper treatment, and little is documented.

In conflict situations, health workers risk their lives to reach communities in need. In Afghanistan, Côte d’Ivoire, Democratic Republic of the Congo, Iraq, Libya, Pakistan, Somalia, Sri Lanka, and the West Bank, health workers, facilities, pharmacies, first-aid posts, and ambulances have been targeted by warring factions (ICRC 2011). The issue of violence against the health sector in humanitarian emergencies has grown such that it was specifically addressed at the 65^th World Health Assembly (WHO 2012).

Psychosocial
Stress, fear caused by violence, emotional or verbal abuse, work-related drug or alcohol consumption, depression, and intimidation in the workplace. These psychosocial hazards can have a variety of different impacts:

Physiological: Hypertension, tense muscles, headaches, and migraines. Stress was documented to increase cardiovascular disease among health workers in Colombia, Mexico, and Brazil (Houtman, Jettinghoff, and Cedillo 2007). Health workers may be more likely to engage in unhealthy behaviors, such as smoking or alcohol abuse, in an attempt to relieve stress

Emotional: Nervousness or irritation, negative attitudes, and poor team morale. In Ethiopia, health worker stress was shown to increase due to lack of universal precaution materials to protect themselves from bodily fluids (Reda et al. 2010). A negative psychosocial environment may adversely affect interactions with colleagues and patients and could increase the likelihood of physical injury. In areas heavily affected by the AIDS epidemic, caring for large numbers of extremely sick patients for whom they can do little can be stressful and take an emotional toll (Baleta 2008; Van Dyk 2007).

Cognitive: Forgetfulness, loss of focus, reduced attention, and aggressive or impulsive behavior. This could result in procedural or judgment errors, which reduces productivity and service provision quality (Houtman, Jettinghoff, and Cedillo 2007).

Psychosocial occupational hazards may be veiled beneath cultural norms and perceived differently depending on the health worker’s gender, age, education, social status, or perception of mental health issues; however, they are the least likely to be recognized as OSH hazards in the workplace by health workers in developing-country contexts (ibid.). In countries without contextualized mental health resources and few psychiatrists or psychologists, psychosocial health services remain highly stigmatized and access is low (WHO 2006).

Gender-based violence and discrimination
Unwelcome advances, assaults, touching, verbal or emotional abuse, differential treatment, and marginalization on the basis of gender from colleagues, supervisors, or patients. Many health workers, most of them female, face gender-based discrimination such as being assigned to lower-level or more dangerous tasks. Gender inequality, discrimination, and violence were cited as major reasons for absenteeism and diminished productivity in Rwanda among the country’s largely female health workforce (Newman et al. 2011). Further, women’s double role at home and work often leads to additional physical burden (WHO 2007). In Ethiopia, health worker cadres with a higher social status (also male-dominated) knew more about OSH than lower-level, majority female, administrative staff (Reda et al. 2010), indicating the gender disparities in workplace safety knowledge.