literature review on health and safety in the workplace pdf

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Systematic literature review on the effects of occupational safety and health (OSH) interventions at the workplace

Affiliation.

1 Johan Hviid Andersen, Professor, Department of Occupational Medicine, Danish Ramazzini Centre, Regional Hospital West Jutland - University Clinic, Gl. Landevej 61, 7400 Herning, Denmark. [email protected].
PMID: 30370910
DOI: 10.5271/sjweh.3775

Objectives The aim of this review was to assess the evidence that occupational safety and health (OSH) legislative and regulatory policy could improve the working environment in terms of reduced levels of industrial injuries and fatalities, musculoskeletal disorders, worker complaints, sick leave and adverse occupational exposures. Methods A systematic literature review covering the years 1966‒2017 (February) was undertaken to capture both published and gray literature studies of OSH work environment interventions with quantitative measures of intervention effects. Studies that met specified in- and exclusion criteria went through an assessment of methodological quality. Included studies were grouped into five thematic domains: (i) introduction of OHS legislation, (ii) inspection/enforcement activity, (iii) training, such as improving knowledge, (iv), campaigns, and (v) introduction of technical device, such as mechanical lifting aids. The evidence synthesis was based on meta-analysis and a modified Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results The search for peer-reviewed literature identified 14 743 journal articles of which 45 fulfilled the inclusion criteria and were eligible for meta-analysis. We identified 5181 articles and reports in the gray literature, of which 16 were evaluated qualitatively. There was moderately strong evidence for improvement by OHS legislation and inspections with respect to injuries and compliance. Conclusions This review indicates that legislative and regulatory policy may reduce injuries and fatalities and improve compliance with OHS regulation. A major research gap was identified with respect to the effects of OSH regulation targeting psychological and musculoskeletal disorders.

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Health Safety & Wellbeing at Work: A review of the literature

In the changing world of work, health, safety and well-being are matters of continued and increasing concern for governments, employers and workers. The following document reviews the amassing body of literature in this field, focusing on topics and themes that are relevant to both local and global contexts. The key question guiding the review is a deceptively simple one: What makes for good health and safety at work? More specifically, the review is driven by the following questions: 1) What are the key factors of health, safety and well-being at work? 2) What can New Zealand learn from other jurisdictions? 3) What is the future of health, safety and well-being at work?

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When a worker leaves his residence to work for the upkeep of his family and contribute to the economy of his society and nation, he does so with a believe that he will come back to the warm embrace of his family at least the way he was when he left them. He does not expect that the work will howsoever lead to his death or disability or injury or ill health. There is therefore no gainsaying that he has a right to demand this from the society and the nation and that his employer, the society and nation have a duty to ensure that this right to safety and health at work is respected.

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Powerful and ongoing changes in how people work, the workforce, and the workplace require a more holistic view of each of these. We argue that an expanded focus for occupational safety and health (OSH) is necessary to prepare for and respond rapidly to future changes in the world of work that will certainly challenge traditional OSH systems. The WHO Model for Action, various European efforts at well-being, and the Total Worker Health concept provide a foundation for addressing changes in the world of work. However, a paradigm expansion to include the recognition of worker and workforce well-being as an important outcome of OSH will be needed. It will also be vital to stimulate transdisciplinary efforts and find innovative ways to attract and train students into OSH professions as the paradigm expands. This will require active marketing of the OSH field as vibrant career choice, as a profession filled with meaningful, engaging responsibilities, and as a well-placed investment for ind...

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Impact assessment of e-trainings in occupational safety and health: a literature review

Mohammad Mahdi Barati Jozan ORCID: orcid.org/0000-0002-5197-6260 1 ,
Babak Daneshvar Ghorbani 2 ,
Md Saifuddin Khalid ORCID: orcid.org/0000-0002-3731-2564 3 ,
Aynaz Lotfata ORCID: orcid.org/0000-0002-7511-1755 4 &
Hamed Tabesh ORCID: orcid.org/0000-0003-3081-0488 1

BMC Public Health volume 23 , Article number: 1187 ( 2023 ) Cite this article

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Metrics details

Implementing workplace preventive interventions reduces occupational accidents and injuries, as well as the negative consequences of those accidents and injuries. Online occupational safety and health training is one of the most effective preventive interventions. This study aims to present current knowledge on e-training interventions, make recommendations on the flexibility, accessibility, and cost-effectiveness of online training, and identify research gaps and obstacles.

All studies that addressed occupational safety and health e-training interventions designed to address worker injuries, accidents, and diseases were chosen from PubMed and Scopus until 2021. Two independent reviewers conducted the screening process for titles, abstracts, and full texts, and disagreements on the inclusion or exclusion of an article were resolved by consensus and, if necessary, by a third reviewer. The included articles were analyzed and synthesized using the constant comparative analysis method.

The search identified 7,497 articles and 7,325 unique records. Following the title, abstract, and full-text screening, 25 studies met the review criteria. Of the 25 studies, 23 were conducted in developed and two in developing countries. The interventions were carried out on either the mobile platform, the website platform, or both. The study designs and the number of outcomes of the interventions varied significantly (multi-outcomes vs. single-outcome). Obesity, hypertension, neck/shoulder pain, office ergonomics issues, sedentary behaviors, heart disease, physical inactivity, dairy farm injuries, nutrition, respiratory problems, and diabetes were all addressed in the articles.

According to the findings of this literature study, e-trainings can significantly improve occupational safety and health. E-training is adaptable, affordable, and can increase workers’ knowledge and abilities, resulting in fewer workplace injuries and accidents. Furthermore, e-training platforms can assist businesses in tracking employee development and ensuring that training needs are completed. Overall, this analysis reveals that e-training has enormous promise in the field of occupational safety and health for both businesses and employees.

Peer Review reports

Introduction

Occupational injuries and diseases are among the most serious public health issues [ 1 ]. According to the most recent International Labor Organization report (2017), over 2.78 million workers die each year as a result of occupational accidents and work-related diseases [ 2 ]. The most serious negative consequences of occupational accidents and injuries are long-term disabilities [ 3 ] reduced ability to perform job duties [ 3 , 4 , 5 ], early retirement [ 3 ], medical care expenditure [ 4 , 5 ], absenteeism [ 4 , 5 , 6 ], presenteeism [ 4 , 5 ], and death [ 3 ]. These cost the global economy 3.94% of the global Gross Domestic Product (GDP) [ 2 ]. In various countries, these costs range from 1.8 to 6% of GDP [ 3 ].Treatment and preventive interventions are two types of interventions used to reduce occupational diseases and injuries, as well as the negative consequences of these events [ 7 ].

Preventive interventions in occupational health aim to change the work condition to prevent occupational accidents and reduce their harmful effects. There are three types of preventive interventions: primary preventive interventions, secondary preventive interventions, and tertiary preventive interventions [ 7 ]. Primary preventive interventions aim to create conditions that will help to prevent occupational disease and injury. In other words, these interventions aim to eliminate or reduce workers’ exposure to workplace hazards. Secondary and tertiary preventive interventions attempt to prevent disease or injury progression in the post-accident steps [ 7 ]. The primary preventive interventions are divided into three types: Environmental interventions, clinical interventions, and behavioral interventions are the first three [ 8 ]. Environmental interventions attempt to eliminate the causes of occupational accidents by altering work methods, equipment, and physical space [ 9 ]. Clinical interventions (for example, pre-employment medical examinations [ 10 ]) use therapeutic methods to prevent disease [ 8 ]. Behavioral interventions aim to change workers’ behavior in order for them to be safer at work [ 8 ].

Many developing and developed countries implement occupational safety and health programs (OSH) for workers due to the importance of safe behavior in reducing the costs of occupational accidents and their negative consequences [ 11 ]. The most important component of the OSH program has been introduced as education [ 12 , 13 , 14 , 15 , 16 ]. The World Health Organization (WHO) has also identified worker, employee, and occupational medicine specialist training as a key component in improving worker health [ 17 ].

The two main approaches in occupational education are class-based education and e-learning. Simple and low-cost solution [ 18 , 19 , 20 , 21 , 22 , 23 , 24 ], greater convenience [ 21 ], availability [ 18 , 21 , 22 , 24 ], high acceptance among the workforce [ 25 ], enhanced self-management and adherence in the target population [ 26 , 27 , 28 ], primary source for health-related information [ 29 , 30 ], internet availability for users [ 31 , 32 , 33 ], mobile phone availability for users [ 34 , 35 ], ability to use a personalized approach [ 23 ], flexibility to fit the users’ schedules [ 33 ], reach large numbers of participants [ 23 , 33 ] and prefer technology-enhanced educational programs [ 29 ] are the most important reasons that have made e-learning as a suitable alternative to traditional and class-based education.

In the last decade, studies [ 20 , 36 , 37 , 38 , 39 ] have been conducted to evaluate the provision of online and personalized occupational health and safety training content. Systematic reviews have been conducted on the impact of occupational health and safety e-training in limited cases [ 23 , 40 , 41 , 42 ], such as limiting studies to a geographical area [ 41 ], an occupational safety and health problem [ 23 , 40 , 42 ], a type of intervention [ 23 ], and etc. The limitations of systematic reviews did not have the comprehensive outlook on e-training role in the behavioral change and improve health. Given these relevant premises, the goal of this study is to conduct a systematic review of published studies that have used e-training to reduce occupational accidents through the end of 2021.

With the increasing use of technology in the delivery of training programs, e-learning has become a popular mode of training delivery with several potential benefits, such as flexibility, accessibility, and cost-effectiveness. This study seeks to evaluate the impact of e-trainings in occupational safety and health by conducting a comprehensive literature review. The findings of this study contribute to the ongoing discussions on how technology can be leveraged to improve workplace safety measures and reduce accidents and injuries. Moreover, it is essential to understand the effectiveness of e-training programs compared to traditional training methods and identify best practices for developing effective e-training programs. This study aims to fill this gap in current knowledge by providing a comprehensive analysis of the existing literature on e-trainings in occupational safety and health.

This study has two primary objectives: providing up-to-date details on online occupational health and safety training interventions and offering recommendations, discussing research gaps and challenges in online occupational health and safety training interventions.

Materials and methods

As a paper selection methodology, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 43 ] was utilized, which involves four phases: identification, screening, eligibility, and included. The first phase sets the search technique and databases used in the search. The title, abstract, and full text of the publications are assessed in the following steps, based on the inclusion-exclusion criteria set for the systematic review. The included articles are then determined. The qualitative synthesis is completed after the finalization of the included articles.

Identification phase: search strategy

A computer-based literature search in the PubMed and Scopus databases was carried out. These databases were searched until the end of 2021. The search used a combination of text terms and a hierarchically regulated vocabulary that was tailored to each database. The text terms were divided into workplace safety and health (Group 1) and e-training (Group 2). These groups were joined together with “AND.“ Group 1 terms included occupational health, occupational safety, workplace health, and workplace safety. e-Training, e-Education, online training, online learning, mobile training, and mobile education were all included in Group 2. The terms from each of the three categories were then joined together with “OR.“

Screening and eligibility phase

Determining the inclusion and exclusion criteria and the screening process are two important activities of this phase.

Inclusion/exclusion criteria

The inclusion criteria for this study involved educational interventions aimed at improving occupational safety and health among workers (Intervention) and published in English (Language) by the end of 2021 (Publication period). The interventions were designed for workers (Population) and delivered educational content through web or mobile-based platforms (Technology). The final inclusion criterion was that the interventions evaluate primarily outcomes related to occupational safety and health.

However, certain types of studies were excluded from the analysis. The interventions that were considered included those which examined multiple components or did not isolate the impact of training as a specific intervention component. The study population was also limited to excluding students, health professionals, disabled workers, military personnel, and drivers (Population). Outcome measures related to mental health, sleep, stress, and addiction were also excluded (Outcome). Similarly, studies utilizing 3D animation, Virtual Reality, Virtual game-based simulation, and 360-degree panoramas were excluded (Technology). Lastly, studies forced to use online education due to Coronavirus Disease 2019 (COVID-19) conditions were not considered.

Screening process

Two reviewers independently reviewed titles, abstracts, and full texts based on inclusion/exclusion criteria. Disagreements between the two reviewers on the inclusion/exclusion of an article were settled by consensus and, if required, by a third reviewer.

Included phase: analysis

A meta-analysis of the impact of e-training on enhancing occupational safety and health is impossible due to the different nature of the literature on the type of treatments, study design, primary and secondary outcomes, and evaluation approaches. As a result, this study explains the nature of the included studies’ implementation practice models in order to highlight the studies’ strengths and limitations and make recommendations for future research.

The comparative analysis method is used for the analysis and synthesis in order to extract the themes emerging from the evidence [ 44 ]. This method, like other qualitative data analysis methods, involved coding data into themes and then categorizing and drawing conclusions based on them. These codes contained a concept associated with that part of the article from which the code is extracted. To maintain consistency and create non-overlapping code sets, a clear definition was provided for each code [ 45 ]. The qualitative content analysis process includes eight steps: data preparation, reading the article carefully several times to obtain a sense of the whole, determining the critical information of each part of the article (transcripts), defining the unit of analysis using themes, development of coding scheme to organize data, coding the entire article based on the developed coding scheme, conclusion based on the coded data, and describing and interpreting the findings [ 45 ]. Two reviewers independently read the articles in-depth and coded them. The reviewers and the lead author compiled the obtained results, and if there were any differences, they tried to resolve them. The disagreements were resolved by discussion.

Each article was reviewed to extract methods, parameters, and the purpose of evaluating e-training. The following codes were extracted for each article: the purpose of study, study design, population study, the unit of allocation (workplace/individual), country, primary/secondary outcomes, platform, educational content structure, and evaluation of the study.

The computer-based literature search yielded 7,497 articles, of which 7,325 were identified after removing 172 duplicate papers. Six thousand four hundred articles were removed during the title review phase and 777 articles were removed during the abstract review phase. 64 articles were removed during the title review phase. Finally, 25 articles met the criteria for inclusion. Figure 1 depicts PRISMA flow diagram of this systematic review study. The articles included in this review are listed in Table 1 in appendix .

PRISMA flow diagram

The summary of the evaluation of the articles is shown in Table 1 . E-training has been used in 9 areas of occupational safety and health: sedentary behaviors, obesity, neck/shoulder pain/stiffness and Low Back Pain (LBP), physical inactivity, office ergonomics, hypertension, nutrition, respiratory, and multi-topic. The number of the included studies based on the year of publication, topic and country is given in Figs. 2 and 3 , and Fig. 4 respectively.

The number of the included studies based on the publication year

The number of the included studies based on the topic

The number of the included studies based on each country. USA (n = 8); Australia, South Korea, UK, Germany, Belgium (n = 2), Japan, Turkey, Norway, Canada, Spain, China, Netherlands (n = 1)

Sedentary behaviors

A sedentary lifestyle is a significant public health concern in modern society [ 32 , 35 , 46 , 47 ], as it can lead to poor physical and mental health [ 48 , 49 , 50 ] and the development of serious diseases such as cancer, obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease [ 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. Sedentary behavior is defined as any waking behavior (sitting, reclining, or lying posture) that consumes 1.5 metabolic equivalents of energy [ 52 ] and is prevalent in office settings [ 60 , 61 , 62 , 63 , 64 ]. Inactive activities account for nearly 65–82% of working time in industrialized countries [ 64 , 65 , 66 ], and 54–77% of office workers sit all day [ 66 , 67 , 68 ]. To address the negative consequences of sedentary behavior in the workplace, effective interventions must be designed, including encouraging desk-based employees to spend at least 2–4 h standing or doing light activity, taking regular breaks from sitting [ 69 ], considering environmental factors [ 70 , 71 ]., addressing concerns about productivity [ 72 ], and increasing awareness among employees and employers through training programs [ 73 ]. E-training has been used in [ 36 , 73 , 74 , 75 , 76 ] to reduce sedentary behavior and address the mentioned challenges.

A theory-driven, web-based, computer-tailored application called Start to Stand has been developed to reduce sedentary behavior at work [ 36 ]. The application includes both mandatory and optional components. In the mandatory component, personalized advice on how to interrupt and reduce sitting was provided, and the optional component has five non-committal sections: interruptions in sedentary behaviors, replacing sedentary behaviors with standing, sedentary behaviors during commuting, sedentary behaviors during work breaks (e.g., lunch), and developing a sedentary behavior change action plan that motivates participants to achieve their objectives by creating an action plan. The application uses various theories, such as the Theory of Planned Behavior [ 77 ], self-determination theory [ 78 , 79 ], and self-regulation theory [ 80 ], to provide recommendations to users. In order to evaluate the implemented application, the accessibility of participants and the acceptability were reported. One hundred and twelve employees from public city service were invited to participate in the study. The feasibility test showed that education, employment status, level of breaks at work, and attitudes towards interrupting sitting at work were influential in requesting advice, and 39% of participants requested at least one non-committal section from the optional component. The acceptability test revealed that most participants found the advice interesting, relevant, and motivating. The majority of participants (98.0%) reported that they had reduced their sedentary behavior or intended to do so.

The effects of the Start to Stand application [ 36 ] have been evaluated among Flemish employees in a field-based approach [ 75 ]. In order to assess a Randomized Controlled Trial (RCT) study designed with three groups; tailored group: the participants received the Start to Stand application, generic group: participants received a web-based application that provided general information on reducing or interrupting workplace sitting, and control group: participants did not receive any intervention. Two hundred thirteen employees participated in the intervention (tailored group n = 78, generic group n = 84, and control group n = 51). Outcomes were measured at baseline, one month, and three months after the intervention (follow-ups). Results showed a statistically significant difference in total workday sitting, sitting at work, other leisure time sitting, and break at work in the intervention group compared to the other two groups over time.

The dissemination evaluation of the Start to Stand application [ 36 ] in the Finnish population was done by [ 73 ]. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework (RE-AIM framework) [ 81 , 82 ] has been used for this proposal, which evaluates the potential public health impact of behavioral interventions from five perspectives ‘reach’, ‘efficacy/effectiveness,’ ‘adoption,’ ‘implementation,’ and ‘maintenance.’ The main dissemination methods used were partner websites, emails, newsletters, and social media. Over the evaluation period (12 October 2016 until 6 February 2018), 6,906 unique users visited the site. The evaluation results of the RE-AIM framework components are reported as follows. Firstly, Reach, which compares the characteristics of the study population with the target population (population in Flanders), showed that participants significantly differed from the target population in terms of age, gender, Body Mass Index (BMI), and Physical Activity (PA). Secondly, Efficacy/Effectiveness refers to the application’s positive and negative consequences in optimal and real-world conditions, respectively. The results of this section are presented in [ 75 ]. Thirdly, Maintenance refers to a continuous effort to make the software available to the target audience. In this case, the website was available to the public from 12 to 2016 to 6 February 2018. Fourthly, Adoption assesses delivery staff and setting variables. This item is outside the scope of this article [ 74 ]. Lastly, Implementation refers to intervention fidelity and resources (cost and time) to be used to implement the system in a real-world setting. The time spent on the dissemination activities was about 25.6 h, and the cost paid to the staff to perform these activities was 845 EUR.

The effect of the action plan section of the Start to Stand application [ 36 ] on changing sedentary behavior was evaluated in [ 76 ]. Creating an action plan was a non-committal section of the optional component of the application. The study had two goals: to examine the characteristics of users who made action plans (Goal 1) and the content of those action plans (Goal 2). The action plans consisted of four parts: what behavior to change when the action plan is triggered, where the action plan takes place, how long/frequent the breaks from sitting, and the purpose of the action plan. Participants in this study (n = 1,701) were divided into two groups, participants who had made at least one action plan (Group 1, n = 231) and those who had not made any action plans (Group 2). The study found significant differences between the two groups in terms of age, sedentary behavior at work, and awareness of health risks related to prolonged sitting. The participants in Group 1 were older, more sedentary at work, and more aware of the negative consequences of prolonged sitting (Goal 1). Most generated action plans focused on breaks from sitting every 30 min and replacing sitting with periods of standing (Goal 2).

A mobile-based application has been developed by [ 73 ]; the study aims to investigate the feasibility of implementing the application to reduce sedentary behavior in desk-based office workers. The application provides feedback on prolonged sitting, educational facts, setting goals to reduce sitting and reminders to achieve these goals, and self-monitoring features. The intervention was designed for eight weeks, and a feasibility cluster randomized controlled study with three groups has been designed to evaluate the application: Mobile Application Group (MA Group): the participants received the application, Mobile Application and Sit-Stand Work Desk Group (MA + SSWD Group): in addition to the application, a sit-stand work desk (SSWD) also provided for the participants and control group. Fifty-six workers participated in the study that 20, 20, and 16 participants were allocated in the MA, MA + SSWD, and control group, respectively. The feasibility of the application was assessed using several measures, including recruitment and retention, engagement, intervention delivery, and acceptability. The recruitment of companies to participate in the study was challenging; however, the retention rate was high among the recruited groups. Regarding engagement, the MA group showed better response time than the MA + SSWD group, and they acknowledged the reminders more. However, technical issues and diminishing user engagement have compromised the delivery of the intervention. In terms of acceptability, most participants in both MA and MA + SSWD groups found the intervention appropriate. Nonetheless, the MA group reported higher satisfaction levels than the MA + SSWD group.

Obesity is a major risk factor for non-communicable diseases such as diabetes, cardiovascular diseases, and some cancers [ 83 , 84 ]. Over 1.9 billion adults were overweight, and over 600 million were obese in 2014 [ 85 ]. Obesity is a significant global health challenge [ 86 , 87 , 88 , 89 ] and requires considerable healthcare resources to manage and prevent associated complications [ 90 , 91 , 92 , 93 ]. However, it is a modifiable disease [ 94 , 95 ], and multicomponent behavioral interventions have been shown to significantly affect weight loss and obesity-related complications in adults [ 96 , 97 , 98 , 99 ]. E-training has been used as a behavioral intervention for weight loss in the workforce [ 37 , 100 , 101 , 102 ]. An integrated and personalized mobile application for weight loss in work environments has been developed and evaluated by [ 37 ]. It includes a personalized diet prescription algorithm, a PA prescription algorithm, a convenient method of tracking daily diet and PA, and behavior change strategies for encouraging weight reduction to maximize user adherence. Weight reduction was the primary outcome. Thirty obese participants used the application for 12 weeks. They experienced a statistically significant mean weight reduction of 5.8%, along with improvements in secondary outputs such as anthropometric measures, metabolic profiles, fat measures, and bioimpedance measurements.

An online weight loss program for weight loss in work environments has been developed and evaluated by [ 100 ]. The percent weight loss and the achievement of clinical cut-points by class attendance were the primary and secondary outcomes, respectively. The intervention included a 10-week intervention focusing on the modification of eating habits (mindful eating, healthy eating, and stop-eating cues), medical considerations, weight loss, PA, weight maintenance, and self-monitoring. Data from 140,445 employees of different companies in the U.S. who used the program were analyzed, and class attendance and education level were found to be significantly correlated with percent weight loss. Evaluation of secondary outcomes determined that 71% of participants lost less than 3% of their starting weight, 16% achieved clinically beneficial weight loss (3-4% weight loss), and 13% achieved clinically significant weight loss (more than or equal to 5% weight loss).

The effectiveness of a weight loss mobile app based on WeChat is evaluated by [ 101 ] in a 6-month cohort study with 15,310 employees who worked in government agencies and enterprises in the Shunyi District of Beijing. The application was sent to the participants through messages on WeChat and allowed Participants to interact with others and receive expert feedback. Additionally, a weight loss unit rankings component was developed to motivate and encourage participants. Three thousand four hundred sixty-seven participants were in the control group, and 11,843 participants were in the intervention group. Those in the intervention group lost significantly more weight than those in the control group, with weight loss varying based on age (< 40 and ≥ 40) and educational level. The more active the intervention group members were, the more weight they lost.

An online lifestyle-intensive behavioral therapy-based intervention for weight loss and weight management for workers has been evaluated by [ 102 ]. The intervention was designed for 52 weeks, which included weekly 30-minute sessions that focused on education about PA, healthy eating, savvy food shopping, managing stress, sleep, and motivation. The content was based on the Centers for Disease Control and Prevention (CDC) DPP curriculum [ 103 ]. An entertaining television-like series was also shown during the classes to introduce a healthy lifestyle. In addition, personalized PA, meal plans, and exercise aids were provided for the first 16 weeks. In addition to the training section, there is a dashboard based on self-reported information and information on exercise. Sixty-nine thousand five hundred ninety-eight workers from 96 companies in the United States participated in this intent-to-treat cohort study. Participants were divided into three categories based on their attendance: those who attended at least one session, those who attended at least four active sessions (active participants), and those who completed the entire program (program completers). The participants who attended at least one session lost an average of 2.8% body weight, with 23% achieving 5% weight loss. The active participants lost an average of 3.5% body weight, with 29% achieving 5% weight loss. The program completers lost an average of 4.3% body weight, with 36% achieving 5% weight loss. Based on the results, gender, number of classes attended, obesity, and age are predictors of 5% and higher weight loss.

Neck/shoulder pain/stiffness and low back pain

Musculoskeletal pain is one of the common medical complaints in the working population [ 104 , 105 ]. Neck pain, shoulder pain, neck stiffness, shoulder stiffness, and LBP are the most important musculoskeletal pains in the workplace [ 25 , 34 ]. Factors that contribute to the increase in work-related musculoskeletal pains can be divided into three categories: sedentary lifestyle in work factors [ 106 , 107 , 108 ], physical factors such as poor posture or muscle weakness [ 106 ], and psychological factors [ 109 ].

Based on moderate-to-strong evidence, exercise therapy can significantly relieve pain and improve musculoskeletal disease function [ 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 ]; however, adherence to prescribed exercises is a significant challenge [ 120 , 121 ]. The lower the adherence to the exercise, the lower the effect of the treatment [ 122 ]. Therefore, adherence to the exercise should be considered in the design of interventions [ 123 ]. The attractiveness of the programs [ 122 ], expert feedback and interaction [ 124 , 40 , 122 , 125 , 126 , 127 , 128 , 129 ], performance evaluation [ 122 ], support by experts [ 122 , 123 ], and review sessions [ 123 ] are strategies that affect increasing adherence. In all three papers in this Sects. [ 25 , 34 , 130 ], interventions have been designed to improve commitment to the prescribed exercises.

An exercise-based artificial intelligence (AI)–assisted Chatbot on the LINE application has been implemented and evaluated by [ 25 ]. LINE is the most popular social media application in Japan [ 131 ]. The Chatbot included interactive features to improve participants’ adherence to the exercise program. The degree of pain and the improvement of pain were the primary outcomes. A RCT was designed to evaluate the application, and 121 participants with either neck/shoulder stiffness/pain or LBP or both were randomly assigned to intervention (n = 61) and control (n = 62) groups. The intervention group received exercise and educational instructions for 12 weeks. The result showed that the intervention group had statistically significant improvements in pain levels and exercise adherence compared to the control group. The adherence rate in the intervention group was 92% during the intervention.

A smartphone-based exercise program has been implemented and evaluated by [ 34 ]. This program divided the office workers into four categories based on the type of neck pain and offered corresponding exercise programs for each category. For this purpose, an algorithm has been implemented to help the user determine the kind of neck pain using simple tests. A single-group repeated-measures study was designed to evaluate the application. The developed program was given to 23 office workers suffering from neck pain to follow an exercise program for 10–12 min per day, three days per week, for eight weeks. The primary outcomes evaluated in the study were pain intensity and functional disability, both of which showed significant improvements after the intervention. Some secondary outcomes were also evaluated in the study. Quality of life also improved significantly, while fear avoidance and cervical spine ranges of motion (cervical ROM) did not show significant changes. The patient satisfaction was 3.91 (5.0). The adherence rate was 91.85%. The average time duration per exercise session was 16.86 ± 7.38 min.

A tailored web-based exercise intervention for physically untrained office workers with sub-acute non-specific LBP has been evaluated by [ 130 ]. This study aimed to assess: the impact of an intervention on exercise-related behavior to improve LBP and its correlation with functional disability improvement. For the first purpose, participants’ health status was categorized into five categories (pre-contemplation, contemplation, preparation, decision/ action, and maintenance), and their behavior change was evaluated and updated after the intervention. Participants were then classified into three categories based on their behavioral changes: no change, negative behavioral change, or positive behavioral change. One hundred participants in the RCT study were equally divided into two intervention groups (intervention and standard care) and control groups (usual care only). The intervention group received educational content and exercises via the Internet, and after nine months, most participants were in maintenance status and willing to continue the program (first objective). For the second purpose, the intervention group’s positive behavioral change was statistically significant, and there was a strong correlation between the stage of change and functional disability levels.

Physical inactivity

Physical inactivity is another occupational problem related to exercise that increases the risk of cardiovascular disease [ 132 ], cancer [ 133 ], musculoskeletal disorders [ 134 ], mental disorders and health conditions [ 135 ], and mortality [ 136 ]. It also leads to decreased quality of life [ 137 ] and daily activity performance [ 138 , 139 ]. Therefore, the low level of PA in the workplace is a crucial health challenge [ 140 ], causing about 3.2 million deaths per year globally [ 136 ]. Based on the data collected from 122 countries, almost one-third of the adult population of these countries had a low level of PA [ 141 ]. Adherence to prescribed exercises is a challenge for promoting PA interventions in the workplace. Only 40–45% of studies reported positive effects [ 142 , 143 ]. E-training has improved PA in the work environment [ 144 , 145 ].

The impact of a pedometer-based intervention for the promotion of PA has been evaluated by [ 130 ]. This 6-week intervention is designed based on the socio-cognitive learning theory [ 146 ], the theory of planned behavior [ 147 ], and the Health Action Process Approach (HAPA) model [ 148 ]. The intervention incorporated gamification features such as quizzes that aim to improve participants’ knowledge on PA and general health, the ability for each participant to select up to three health goals per week from a pool of 60 predetermined options, and the participants can determine the number of steps as step goals. Participants can join the weekly team or even individually challenge and compare themselves with others based on the results of game elements. One hundred seventy-six workers participated in the RCT study, with 99 in the intervention group and 77 in the control group. Direct health promotion outcomes, such as PA-related knowledge, intentions, and self-efficacy, and intermediate health outcomes including, Time spent on vigorous PA per week, Time spent on moderate PA per week, and Time spent walking per week, were measured. The results showed significant differences in all direct health promotion outcomes and only in Time spent walking per week among intermediate health outcomes between the control and intervention groups.

The feasibility and effectiveness of a web-based program to increase PA have been evaluated by [ 145 ]. The intervention used a PA monitor (PAM) and a website to provide personalized PA recommendations. Participants could upload their scores on the PAM to the website and plan and evaluate their recommendations based on earned scores, preferences, and PA goals. A RCT study was designed with the participation of 102 workers from eight work sites in Amsterdam to evaluate the intervention. Participants were randomly assigned into control groups (n = 51) and intervention groups (n = 51). The intervention group received a PAM and Web-based tailored PA advice for three months. The control group received a brochure on increasing PA and brief general PA recommendations. Primary outcomes included time spent on light-intensity, moderate-intensity, and vigorous-intensity activity. Several secondary outcomes were also evaluated through measurements (body weight, body height, waist and hip circumference, BMI, etc.) or questionnaires (attitude, social influences, self-efficacy, etc.). The outcomes were evaluated before the intervention (Baseline), immediately after the intervention (Post-Test), and five months after the intervention (Follow-up). Results showed no significant differences in primary and secondary outcomes between the intervention and control groups at post-test and follow-up. Some process measures were also measured in the study. Most intervention group participants reported wearing the PAM regularly and setting personal goals on the website, but some found the advice unappealing, not personal enough, or impractical.

Office ergonomics

Long-term computer use is crucial in office work [ 149 ] due to the increasing reliance on data-based technologies, which has made many office tasks heavily reliant on computers [ 150 ]. In the European Union, 50% of men and 45% of women use computers at work every day [ 151 ]. However, this prolonged computer use can lead to [ 152 , 153 , 154 , 155 , 156 ], eye strain [ 157 , 158 , 159 , 160 , 161 ], and psychosocial stress [ 162 , 163 , 164 ]. To mitigate these adverse effects, interventions at work fall into four categories: ergonomic workplace design, employee selection and placement, aggressive medical management, and employee training and education [ 165 ]. When the first three options are not always available, providing educational materials is a viable option [ 166 , 167 , 168 ]. E-training is used to reduce office ergonomics issues [ 38 , 169 ].

Online office ergonomics training has been implemented and evaluated by [ 169 ]. The educational content includes six animated and interactive modules: Introducing office ergonomics, ergonomics awareness, ergonomics assessment/self-assessment, healthy work behaviors and Environment, how to Set up a Workstation, and Exercise at Work. Three hundred programmers or typists participated in this study, 250 of which were in the study group, and 50 were in the pilot group. The participants were assessed before training and immediately after training using knowledge and behavior assessments. A workplace interaction questionnaire and Rapid Upper Limb Assessment (RULA) were used to assess the behavior. Based on the score obtained from the questionnaire, the risk level of the participants was divided into four categories: Low, Mild, Moderate, High, and Very High. The RULA assesses working posture and identifies risks associated with the shoulder, hand, and wrist postures. Results showed statistically significant improvements in knowledge assessment scores, workplace interaction scores, RULA scores, and a decrease in complaints of health-related pains (Pain, Aching, Burning, Numbness, Tingling, Tenderness, Stiffness, and Cramp).

The position of the computer monitor relative to the eyes is an important factor in eye strain [ 158 , 169 ], especially for those who wear glasses, particularly for presbyopic users [ 170 ]. Adjusting chairs can also reduce visual symptoms [ 171 , 172 , 173 ]. Therefore, the ergonomic design of a computer workplace has been introduced as an effective intervention [ 174 ].

A website has been evaluated by [ 38 ] to help employees adjust their computers in the work environment without expert support. The content presented on the website is divided into two parts: sitting position, table, keyboard and lighting, and the adjustment of the monitor in dependence on the kind of eyewear. Three categories of data were collected to evaluate the intervention: the table height, depth, width, and the height and width of the monitor and its inclination relative to vertical, the posture of participants during their natural working, gaze inclination, viewing distance, head inclination, and complaints (eye strain, headache symptoms, and musculoskeletal strain). Data were collected before the study and one week and five weeks after the intervention from 24 workers using computers. Participants were divided into two groups: those who were not presbyopic and those who were. The intervention lasted six weeks, and 23 of the 24 participants modified their computer workstations (6, 6, and 11 participants adjusted the monitor positioning, the chair, and both the monitor and the chair, respectively). The relationship between changes in ergonomics settings and complaints was investigated based on the reported complaints. The chair adjustment had a statistically significant effect on reducing musculoskeletal complaints. Lowering one’s gaze resulted in fewer visual complaints, which was statistically significant.

Hypertension

Hypertension is a major risk factor for various cardiovascular diseases [ 175 ], and only a small percentage of people follow blood pressure treatment [ 176 ]. Worse cardiovascular outcomes and increase in treatment costs are negative consequences of poorly controlled hypertension [ 177 , 178 ]. Interventions like weight loss [ 179 , 180 ], exercise [ 181 , 182 ], workplace health programs [ 183 , 184 , 185 ], and community education [ 186 ] are the most important category of interventions to reduce hypertension. Only one intervention [ 187 ] evaluated e-training in controlling hypertension in workers.

The effect of using a digital health intervention to control blood pressure has been investigated by [ 187 ] on 3,330 workers throughout the U.S. for more than a year. Participants were given educational and motivational materials and individualized care plans to help them manage their hypertension. Participants were divided into two categories: users: participants who visited the application five times or more during a year, and nonusers: participants who visited the application less than five times. Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DSP), weight, and BMI were the primary outcomes in this study. Based on the reported result, the decrease in SBP, DSP, and BMI in users was significant compared to nonusers. Increasing login frequency was significantly associated with reducing SBP, DSP, weight, and BMI.

A nutrient-poor diet is a major health risk for the workforce [ 188 ], leading to obesity, diabetes, and heart disease [ 189 ], harming work productivity [ 190 , 191 , 192 , 193 ], and absenteeism [ 191 , 192 , 193 ]. Therefore, investing in nutrition improves the health of society and national economies [ 190 , 194 ]. Only one intervention [ 195 ] evaluated e-training in improving diets in the workplace.

Online self-paced training to improve knowledge and increase the healthy behaviors of construction workers has been developed and evaluated by [ 195 ]. The topics covered in this intervention are the importance of nutrition in occupational performance and health, obstacles to healthy eating, and solutions to promote healthy eating. It takes about 50 min to complete the training content. A pre-test and post-test design has been used to evaluate the intervention. Changes in knowledge and behavior were the primary outcomes. The changes were evaluated before the intervention (Baseline), immediately after the intervention (Post-training), and 12 weeks after the intervention (Follow-up). This intervention involved 62 apprentices from ten highway construction trades that were divided into two control and intervention groups. The intervention group provided online nutrition training, and the control group provided online content about positive thinking. The participants in the intervention group showed improvements in knowledge and positive behavior (reducing the consuming sugary snacks, reducing sugary beverages such as soda and coffee, reducing the eating of fast food, and increasing the consumption of fruits and vegetables) changes compared to the control group from baseline to post-training. However, these improvements were not maintained at the follow-up evaluation. In addition to the primary outcomes, accessibility was also evaluated. According to the published results, 70% of the participants in the intervention group reported they would highly recommend the training for others, and 75% believed that more training for occupational health and safety issues should be provided to the workforce.

Respiratory

Occupational respiratory illnesses are one of the most important diseases of workers. Working conditions cause 15% of chronic obstructive lung diseases [ 196 ] and 15-23% of new-onset asthma in adults [ 197 ]. Education plays an important role in reducing these negative consequences. Only one intervention [ 198 ] evaluated e-training in respiratory safety.

A computer-based multimedia respiratory safety training has been evaluated by [ 198 ]. The content was prepared for two groups, young and old workers, according to working memory constraints and cognitive load theory [ 209 , 210 , 211 , 212 ] and the levels of learning. The educational content was designed in three formats: text (TXT), text with pictures/animations (TAP), and text with pictures/animations and audio narration (NAP). The educational content of all three types was the same and included: the employer’s responsibilities, how to clean respirators, how respirators work, etc. This intervention included 81 factory workers randomly assigned to one of three groups. The participants’ knowledge and ability to solve tasks relevant to the delivered information were examined immediately following the intervention. According to the findings, knowledge acquired by young and old participants is the same, regardless of educational content format. Still, the NAP group had the most significant effect on applying knowledge to the real world for both age groups. Additionally, the NAP group had a significant difference in problem-solving ability between young and old groups.

Multi-topic

Training in previous studies was limited to one topic. Some studies cover various aspects of occupational safety and health and provide educational content on various topics. E-training has been used to learn several topics in [ 18 , 199 , 200 , 201 , 202 ].

The effect of web-based health promotion programs on improving the productivity of employees has been assessed by [ 199 ], including weight management, chronic pain management, overcoming depression, and overcoming insomnia. The review did not include depression and sleep programs. There was no restriction on how many programs could be run concurrently. However, the reported results included employees who only participated in one program. Weight loss was the primary outcome of the weight management program, and pain intensity and pain unpleasantness were the primary outcomes of the chronic pain management program. Work productivity and activity impairment were assessed in addition to the primary outcome. The program included over 200,000 employees (weight: 218,081, pain: 7,145) and assessed primary outcomes at 30, 60, and 180 days following the interventions. Results showed that more than half of the participants experienced improved health status (reduction of pain and weight) compared to baseline, and work productivity and activity impairment scores were significantly lower than baseline at all time points. Furthermore, the findings revealed that improved worker health had a significant relationship with reduced productivity impairment.

Education and awareness, early detection, and disease management intervention have been evaluated by [ 200 ]. This workplace intervention aims to reduce the risk factors associated with metabolic syndrome. This multifaceted workplace intervention focuses on metabolic syndrome risk factors. The intervention is designed in the form of a website that comprises several sections. Firstly, the health risk assessment tool @live [ 203 ] is available to help users identify their risk factors. Secondly, on-site screening and clinical visits with registered nurses are offered. Thirdly, call-back interviews are conducted to address disease management, one of the most critical topics discussed during the phone calls. Finally, on-site educational programs are organized to enhance participants’ knowledge and awareness about the risk factors associated with metabolic diseases. The four risk factors for MetS (blood pressure, blood glucose, total cholesterol, and waist circumference) were primary clinical outcomes. Disease management was the secondary clinical outcome. The study involved 2,000 employees from over 30 worksites in British Columbia, and data was collected and analyzed over one year. The results showed a significant reduction in blood pressure and cholesterol levels, as well as a 15% reduction in the number of risk factors between baseline and six months after the intervention. The most important changes in disease management were medication changes, lifestyle changes, and visits to a family doctor.

A mobile-based educational intervention for U.S. dairy farm workers has been evaluated by [ 39 ], which aimed to address difficulties in providing occupational safety and health training due to an increase in the number of workers on the job, as well as immigrant workers with limited English proficiency. Providing a multilingual personalized learning environment based on the characteristics above is the solution presented in this study. The educational content consisted of general training on safety and health issues and specific training for three job categories in dairy farms: general and outside jobs, milker and calf caretaker, and feeder. After completing the first part, the participants followed the second part according to their job category. Kirkpatrick’s Four-Level Training Evaluation Model is used to evaluate training effectiveness [ 199 ], and 1,432 dairy workers from 40 farms participated in this study. The study found that participants reported good learning experiences (Level 1), and there was a statistically significant increase in their occupational health and safety knowledge before and after the training (Level 2). To evaluate Level 3, 3 months after the training, 9 out of 40 farms were randomly evaluated. 95% and participants applied the safety techniques learned in the workplace and stated they do their job more safely.

An online safety and health training intervention to increase knowledge and promote safe behavior of the young workforce has been evaluated by [ 198 ]. Promoting U through Safety and Health (PUSH) training is used in this study. PUSH training expands the content of Youth@Work [ 204 , 205 ], a classroom-based curriculum to address the safety needs of young workers. PUSH develops this curriculum, including protection from workplace hazards, promoting health, and improving communication in the workplace. In addition to expanding the content, the format has changed from classroom-based to online format [ 206 , 207 ]. One of the most important advantages of this course is covering a wide range of industries [ 208 , 209 , 210 , 211 ]. To evaluate this study, the knowledge of participants is measured before the intervention (Baseline), after the intervention (Post-training), and three months after the intervention (Follow-up). One hundred and twenty-four young workers participated in the pretest-posttest study. Based on the results, the increase in knowledge score in the post-training had a statistically significant difference from the baseline. The decrease in knowledge score after three months was significant compared to the post-training. In addition, the website’s likeability and acceptability, applying workplace training and changing behaviors was assessed. Participants reported that the training was interactive and informative, which improved their ability to identify and control hazards in the workplace, communicate with managers, and behave more safely.

The Massive Open Online Course (MOOC) Occupational Health that launched in 2015 and developed for Low- and Middle-Income Countries (LMIC) has been introduced by [ 201 ] to share knowledge on occupational safety and health. This study aims to explain the different characteristics of LMIC participants in MOOCs. Because there were no restrictions on using the MOOC, people from any country could register in the MOOC. The educational content included six modules, one module per week. The educational content includes: Module (1) basic concepts, Module (2) chemical and biological safety, Module (3) physical safety, Module (4) work-related diseases, Module (5) psychosocial safety, and Module (6) Care of the Worker. Each module contains 24–28 sections and takes approximately 4 h to complete. In addition, a discussion and feedback environment has been created for the participants. Of the 5,866 people who registered, 72.4% were from an LMIC, only 5% of the participants completed the training courses, and 23,547 comments were posted. 46.7% of the participants were females. Age is divided into 7 categories: <18, 18–25, 26–35, 36–45, 46–55, 56–65, and > 65 years. 0.3%, 12.1%, 38.3%, 26.7%, 11.1%, 7.8%, and 3% of participants were in the stated age groups, respectively. In terms of the employment sector, most participants (50.9%) were employed in the health and social sector. Regarding employment status, 57.8% reported that they are employed full-time, and 91.2% of the participants reported having education above secondary level. Improving career prospects, learning new things, and adding a fresh perspective to current work were the most important motivations for participating in this training course. The satisfaction of different parts of the MOOC (design and content) was 83–95%.

A digital toolkit to facilitate employees’ understanding of health screening at the workplace has been developed and evaluated by [ 18 ]. The development of this toolkit involved four stages: an online survey to examine employees’ views on health checks in the workplace and identify educational content and tool usage guide; stakeholder consultation to gather feedback and improve the guidance materials created in the first step; toolkit development and expert peer review to evaluate relevance, utility, and accessibility of the toolkit; and toolkit fidelity testing to evaluate the user experience, content relevance, utility, and accessibility of the implemented toolkit. The most important content suggested by stakeholders and experts is the business case for workplace health initiatives, the employer’s responsibility to provide a safe workplace, and providing information about occupational diseases and health. The implemented toolkit was given to 20 pilot employers, and fidelity (delivery and engagement) and implementation qualities (practicability, resource challenges, attitudes toward the toolkit, acceptability, usability, and cost) were assessed. The extent to which the intervention was delivered in accordance with the protocol (fidelity of delivery) and the extent to which the user engages with the content (fidelity of engagement) are measured in the fidelity assessment. According to the reported results, the toolkit had high fidelity of delivery and engagement. Based on the results of the evaluation of implementation qualities, a score is calculated for each item in implementation qualities, and the toolkit achieved the predetermined success rate in all items except the cost.

Educational program implementation necessitates both financial and human resources. Due to limited resources and infrastructure in developing countries, allocating resources for training is not a priority for managers, making providing effective training difficult. These constraints are less severe in developed countries, but because of the competitive environment and rising costs, managers must prioritize resource optimization to reduce costs.

Because of its benefits, e-training has been introduced as an alternative method of traditional learning in a variety of fields. E-training has been considered as an alternative to classroom-based occupational health and safety training methods in the last decade [ 20 , 36 , 37 , 38 , 39 ]. As illustrated in Fig. 2 , e-training has received a lot of attention since 2013, and the number of published studies has almost always increased.

The most important features in reducing costs in e-training programs are the ability to create content once and reuse it multiple times, access to content at any time and from any location, and the presence of infrastructures to simulate classroom-based training activities such as discussion forums [ 18 , 33 ]. In addition, personalization of educational content based on needs, preferences and concerns, which are expensive to provide in class-based training, can increase the richness of educational content [ 20 , 36 , 37 , 38 , 39 ].

In addition to affecting workforce health, effective classroom-based training fosters a sense of usefulness and importance in the workforce. As a result, it can boost work productivity, which is one of the most effective competitive advantages in industries. Concerning the distinction between classroom-based training and e-training, few studies examined the relationship between e-training and work productivity; more studies should be designed to investigate this relationship.

The difference in the number of studies conducted in developing and developed countries is significant. Out of 25 studies, 23 studies were conducted in developed countries (USA, Australia, Korea, UK, Germany, Belgium, Japan, Norway, Canada, Spain, and Netherlands) and only 2 studies were conducted in developing countries (Turkey and China). Due to the contextual differences, the results obtained in developed countries are not valid for developing countries. Therefore, there is a need for developing countries to conduct more research.

Occupational health and safety training covers a wide range of topics: chemical safety, electrical safety, fire safety, machine guarding safety, noise safety, lighting safety, etc. But educational interventions support a limited range of these topics. Although sedentary behaviors, obesity and physical inactivity, and office ergonomics problems are very important, interventions should also be designed to evaluate the impact of e-training on other topics.

Paying attention to the limited occupational safety and health topics has caused the effect of e-training to be investigated only in a narrow category of jobs. For example, sedentary behaviors and office ergonomics interventions focus on office workers. On the contrary, the audience of chemical safety or machine guarding safety training includes mostly workers who work in production lines and non-office environments. Considering the significant differences in the work environment, work activities, and capabilities of workers in different jobs, there is a need to design interventions to evaluate the impact of e-training in all topics. The lack of balance in the coverage of occupational health and safety topics prevents providing a big picture of the impact of e-training.

One of the most significant benefits of e-training is the ability to personalize content based on the needs, preferences, and concerns of the learners [ 20 , 36 , 37 , 38 , 39 ]. One of the most difficult challenges for content personalization is the high diversity of learner characteristics in occupational safety and health training compared to other environments (such as university education). The most important differences are age, education level, work activities and work environments, language, ethnicity, race, familiarity with information technology, and prior knowledge. Often, workers, from newly hired young workers to older people nearing retirement, work alongside each other. Additionally, the workforce may have differing levels of education, ranging from elementary to higher education. Work activities and work environments vary greatly, from heavy manual work in high-risk environments to light office activities in low-risk environments. The responsibility for injury also differs among workers. In countries with a large immigrant workforce, language proficiency, ethnic differences, and racial differences can present significant challenges when providing educational programs. Familiarity with information technology is another area where there are differences among workers, as the degree of mastery and availability of tools such as phones, tablets, and internet access varies. Finally, workers’ prior knowledge may differ widely due to variations in completed occupational and health training programs. Due to the high diversity of learner characteristics, there is a need for occupational health and safety trainings to provide higher degrees of personalization.

The cost of implementation plays a significant role in managers’ decisions to implement interventions, particularly in developing countries. Educational interventions can increase costs in two ways: by producing educational content with complex and expensive technologies such as virtual reality [ 212 , 213 , 214 ] and augmented reality [ 215 , 216 , 217 ], and by using expensive intervention design tools such as ActivPAL [ 80 ], PAM [ 145 ], and SSWD [ 73 ]. ActivPAL recorded total sitting time awake, sitting at work, standing at work, and breaks at work. It is an inclinometer that can distinguish periods of sitting or lying from standing and assess breaks from sitting in adults [ 80 ]. The PAM is a device for recording PA (pedometer, accelerometer and etc.) automatically [ 145 ]. When these interventions are implemented in real-world settings, the costs rise exponentially. Because rising costs are a major impediment to implementing interventions in the real world, effective low-cost interventions should be developed. According to the reviewed interventions, simple content creation methods are also highly effective.

Some workers with special circumstances, such as the elderly [ 218 , 219 , 220 ], those with physical disabilities [ 221 ], immigrants [ 222 , 223 , 224 ], and others [ 225 ], have received less attention in studies. Because a number of workers are usually working in a shared working environment, the error of one worker may result in injury to other workers. As a result, there is a need to provide occupational health and safety training to all workers while taking into account their individual and social differences.

The use of social networks to implement educational interventions has received a lot of attention. Interventions based on WeChat [ 101 ], WhatsApp [ 33 ], and LINE [ 131 ] were designed for this review. Accessibility and the absence of the need to install additional software are two significant advantages of using social networks in educational interventions. Because these tools are intended for public discussions, they are not ideal for educational interventions. Of course, they can meet many of the needs of researchers.

Because confidential information about learners may be transferred during health education interventions, the use of social networks should be used with greater caution. Creating infrastructure, such as designing questionnaires, developing follow-up capabilities, and implementing structures to protect personal data, can greatly assist researchers in designing educational interventions. These features are also available on other websites, such as YouTube.

Two important aspects that receive little attention in studies are cost-effectiveness analysis and examining interventions in real-world settings. Real environments differ greatly from controlled environments. These distinctions can be seen in areas such as cost management. The difference in evaluation measures between the interventions performed in the controlled environment and the real environment can be seen in this review. Although lessons learned in controlled environments can increase the percentage of success in real-world situations, evaluating interventions in real-world situations provided a more complete picture of their effectiveness.

Occupational diseases and injuries typically involve multiple risk factors. For example, extensive research has been conducted to identify the risk factors of obesity. Some common risk factors for obesity include physical inactivity [ 226 , 227 , 228 , 229 ], unhealthy diet [ 230 , 231 ], education level [ 232 , 233 , 234 , 235 , 236 ], length of sleep time [ 227 , 228 , 237 ], and stress/depression [ 230 , 232 , 234 , 237 ]. As part of some research studies, efforts have been made toward categorizing risk factors. For instance, in [ 232 ], the authors have classified risk factors into four distinct categories: individual factors such as genetic factors (e.g., sex, ethnicity), depression, etc., social factors including family influences (e.g., marriage), peer influences, etc., lifestyle/behavioral such as food consumption (e.g., energy intake), PA, etc., environmental factors including community characteristics (e.g., rural-urban, access to unhealthy food options, crime), state policies, marketing, etc.

Limitations

To effectively address health issues in educational interventions, it is necessary to take a comprehensive and holistic approach that considers all relevant factors. For example, studies surrounding obesity tend to prioritize low activity levels as a risk factor, while other areas may go unaddressed. We need to broaden our perspective and include a wider range of factors when designing and implementing occupational safety and health education interventions.

Because our search was confined to two databases and articles written in English, it is probable that some relevant articles were overlooked. This systematic review also omitted studies that employed e-training for Corona epidemic research. Second, we removed interventions related to psychological risk variables from our analysis. Taking these aspects into account can provide a complete picture of the success of occupational health and safety training interventions, in future studies. Finally, the studies in this systematic review used various assessment methodologies and outcomes, making comparison impossible.

In this study, the literature review focuses on the possible impact of e-trainings on occupational safety and health. Technology has transformed how we approach training programs, and e-training has been proven to have various advantages in terms of flexibility, accessibility, and cost-effectiveness. The findings have demonstrated that e-trainings can be an effective tool for improving knowledge and skills among workers, which can ultimately lead to a reduction in workplace accidents and injuries. Additionally, e-training platforms can allow employers to track employee progress and ensure that training requirements are met. Further research is needed to explore this topic in greater depth and to identify best practices for implementing e-training programs in various industries.

Data Availability

The datasets used and/or analyzed during the current study are available from the first author on reasonable request.

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MMBJ: developed search strategy, conducted literature search, identified and selected studies, extracted data and assessed functionalities, drafted and revised manuscript. BDG: identified and selected studies, extracted data and assessed functionalities, drafted and revised manuscript. MSD, AL, and HT: provided guidance and supervised the research project, revised manuscript for important intellectual context. All authors reviewed and approved manuscript.

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Barati Jozan, M.M., Ghorbani, B.D., Khalid, M.S. et al. Impact assessment of e-trainings in occupational safety and health: a literature review. BMC Public Health 23 , 1187 (2023). https://doi.org/10.1186/s12889-023-16114-8

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Developing a culture of safety for sustainable development and public health in manufacturing companies—a case study.

1. Introduction

2. literature review, 3. materials and methods, 4.1. questionnaire survey, 4.2. questionnaire interview, 5. discussion, 6. conclusions.

The company’s employees rate the level of safety culture highly, reflected in an average score of 4.59 out of 5.
The highest scores were given to components such as “psychological, social, and organizational factors” (4.96), “safety management” (4.94), and “values” (4.84), highlighting the importance of training and management involvement.
A high level of safety culture correlates with fewer workplace accidents and improved overall employee health.
Increased awareness of occupational safety and employee engagement in safety activities contribute to a safer working environment.

Author Contributions

Institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Click here to enlarge figure

No.	Author (Year of Source)	Definition	Semantic Characteristic
1	Uttal, 1983 [ ]	Shared values and beliefs that interact with an organization’s structures and control systems to produce behavioral norms.	- Behavioral patterns; - Values; - Norms, attitudes, and roles.
2	Schein, 1985 [ ]	A pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way you perceive, think, and feel in relation to those problems.	- Behavioral patterns.
3	Turner et al., 1989 [ ]	A set of beliefs, norms, attitudes, roles, and social and technical practices that are concerned with minimizing the exposure of employees, managers, customers, and members of the public to conditions considered dangerous or injurious.	- Norms, attitudes, and roles; - Minimizing the exposure of employees to harm.
4	International Atomic Energy Authority (IAEA), 1991 [ ]	That assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.	- Norms, attitudes, and roles. - Safety management.
5	Pidgeon, 1991 [ ]	A set of beliefs, norms, attitudes, roles, and social and technical practices that are concerned with minimizing the exposure of employees, managers, customers, and members of the public to conditions considered dangerous or injurious.	- Norms, attitudes, and roles; - Minimizing worker exposure.
6	Cox and Cox, 1991 [ ]	Safety culture reflects the attitudes, beliefs, perceptions, and values that employees share in relation to safety.	- Norms, attitudes, and roles; - Safety management.
7	Confederation of British Industry (CBI), 1991 [ ]	The ideas and beliefs that all members of the organization share about risk, accidents, and ill health.	- Activities that protect life and health.
8	Advisory Committee on the Safety of Nuclear Installations (ACSNI), 1993 [ ]	The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.	- Values; - Behavioral patterns; - Safety management; - Norms, attitudes, and roles.
9	Health and Safety Commission, 1993 [ ]	A set of individual and group values, attitudes, competencies, and behavior patterns that determine the organization’s health and safety policies and programs.	- Values; - Behavioral patterns; - Safety management.
10	Ostrom et al., 1993 [ ]	The concept that the organization’s beliefs and attitudes, manifested in actions, policies, and procedures, affect its safety performance.	- Values; - Behavioral patterns; - Safety management.
11	Geller, 1994 [ ]	In a total safety culture (TSC), everyone feels responsible for safety and pursues it on a daily basis.	- Behavioral patterns; - Responsibility.
12	Berends, 1996 [ ]	The collective mental programming towards safety of a group of organization members.	- Safety management.
13	Lee, 1996 [ ]	The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, and organization’s health and safety management.	- Values; - Behavioral patterns; - Norms, attitudes, and roles; - Activities that protect life and health.
14	Studenski, 2000 [ ]	A set of psychological, social, and organizational factors activating or supporting activities that protect life and health both at work and non-professional activities.	- Psychological, social, and organizational factors; - Activities that protect life and health.
15	International Maritime Organisation (IMO), 2003 [ ]	A safety culture can be defined as a culture in which there is considerable informed endeavor to reduce risks to the individual, ships and the marine environment to a level that is as low as is reasonably practicable.	- Reduce risks.
16	Mearns et al., 2003 [ ]	Safety culture forms the environment within which individual safety attitudes develop and persist and safety behaviors are promoted.	- Behavioral patterns; - Safety management.
17	Von Thaden and Gibbons, 2008 [ ]	Safety culture is defined as the enduring value and prioritization of worker and public safety by each member of each group and in every level of an organization.	- Values; - Behavioral patterns.
18	Butler, 2016 [ ]	Establishing exceptional organizational safety culture is vital, as it directly affects performance and profit.	- Values; - Efficiency (profit).

Demographic Factor	Demographic Relationships
Department	Administration	Production worker	Leader	Manager	Maintenance
Department	49 (16%)	160 (52%)	19 (6%)	18 (6%)	61 (20%)
Gender	Man	Woman
Gender	162 (53%)	145 (47%)
Age	18–29	30–39	40–49	50–59	60 and more
Age	52 (17%)	101 (33%)	87 (28)	31 (10%)	36 (12%)
Professional experience	0–3	4–6	7 and more
Professional experience	166 (54%)	96 (31%)	45 (15%)
Education level	Primary education	Vocational education	High School	Bachelor/Master and above
Education level	9 (3%)	136 (44%)	47 (15%)	115 (38%)
Accident experience in the last 6 years	Yes	No
Accident experience in the last 6 years	17 (6%)	290 (94%)

	Percentage Distribution of Answers [%]
Components	1 Point	2 Points	3 Points	4 Points	5 Points	Average
Behavior patterns	0	0	4	28	68	4.64
Norms, attitudes, and roles	0	0	15	22	63	4.49
Values	0	1	1	11	87	4.84
Safety management	0	0	0	6	94	4.94
Activities that protect life and health	0	4	12	19	65	4.45
Minimizing worker exposure	0	1	6	24	69	4.61
Reduce risk	0	0	17	33	50	4.34
Psychological, social, and organizational factors	0	0	0	4	96	4.96
Responsibility	0	1	30	5	64	4.34
Efficiency (profit)	0	1	21	25	53	4.31
Overall score						4.59

Causes of Accidents at Work	Year
Causes of Accidents at Work	2017	2018	2019	2020	2021	2022
Improper conduct by the employee	8	7	5	3	3	2
Improper state of material activity	0	0	2	1	0	0
Improper organization of work	1	0	3	1	1	0
Improper organization of the workplace	1	0	1	1	0	2
Not using protective equipment	4	6	3	2	1	1
Inappropriate arbitrary behavior by an employee	2	3	2	2	1	0
Improper psychophysical condition by the employee	0	1	2	3	0	1
Other reasons	0	1	2	2	3	1

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Kabiesz, P.; Tutak, M. Developing a Culture of Safety for Sustainable Development and Public Health in Manufacturing Companies—A Case Study. Sustainability 2024 , 16 , 7557. https://doi.org/10.3390/su16177557

Kabiesz P, Tutak M. Developing a Culture of Safety for Sustainable Development and Public Health in Manufacturing Companies—A Case Study. Sustainability . 2024; 16(17):7557. https://doi.org/10.3390/su16177557

Kabiesz, Patrycja, and Magdalena Tutak. 2024. "Developing a Culture of Safety for Sustainable Development and Public Health in Manufacturing Companies—A Case Study" Sustainability 16, no. 17: 7557. https://doi.org/10.3390/su16177557

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Published: 02 September 2024

Ecological care in nursing practice: a Walker and Avant concept analysis

Golshan Moghbeli 1 ,
Amin Soheili 2 ,
Mansour Ghafourifard 1 , 3 ,
Shahla Shahbazi 1 &
Hanieh Aziz Karkan 1

BMC Nursing volume 23 , Article number: 614 ( 2024 ) Cite this article

Metrics details

Today, the human population faces an increasing array of emerging environmental challenges. Despite its importance, nurses often neglect ecological issues, which can compromise patient health. While the ecological nursing perspective has the potential to lead to innovative care approaches that benefit patients, the nursing profession, and the environment, the concept of ecological care lacks a clear definition and its dimensions remain unclear. This study aimed to analyze and clarify the concept of ‘ecological care’ in the nursing discipline.

Walker and Avant’s analysis method was used to identify descriptions, antecedents, consequences, and empirical referents of the concept of ‘ecological care’ in nursing. We searched the databases (PubMed, Scopus, PsycINFO, CINAHL, ERIC, SID, and IranDoc) using the keywords “ecological,” “nurse,” and “nursing” using Boolean operators “AND” and “OR” in the title and abstract fields both in English and Persian to identify relevant literature on ecological care in nursing.

Ecological care, as a multidimensional concept, encompasses ecological thinking, ecological attitude, ecological awareness, ecological sensitivity, and ecological literacy. This entails the optimal utilization of environmental factors to provide patients with high-quality care and preserve ecological sustainability through environmentally friendly behaviors.

Conclusions

The findings highlight the need to elucidate, endorse, and solidify ecological thinking in all aspects of nursing care including nursing management, education, and research, which can lead to improved care quality, patient safety, and sustainability. Within this framework, nursing educators could play an essential role in integrating ecological care into nursing education. The study emphasizes the need to integrate ecological thinking into all aspects of nursing.

Peer Review reports

Ecology, the study of interactions between living organisms and their environments, encompasses physical and social surroundings that impact all living beings. From a human science perspective, ecology emphasizes these interconnected relationships, fostering a deeper understanding of nursing and caring practices [ 1 ]. Currently, environmental concerns are considered significant threats to public health. However, healthcare professionals often lack sufficient awareness of the importance of ecological issues [ 2 ].

As the largest group of healthcare professionals, nurses play a crucial role in decisions regarding product use, energy consumption, and chemical selection in healthcare settings. However, they face a significant challenge: balancing environmental concerns and ecological principles with their professional duties [ 3 ]. Although nurses can advocate reducing exposure to harmful chemicals and adopting less toxic products, their work environments often require high energy consumption and generate substantial medical waste [ 4 ]. This medical waste encompasses both hazardous (infectious, pathological, chemical, pharmaceutical, cytotoxic, and radioactive) and non-hazardous or general waste, posing potential risks to patients, communities, and broader ecological health [ 5 ]. Multiple studies have highlighted the critical role of ecological considerations within healthcare in the overall health of ecosystems [ 6 , 7 , 8 , 9 ]. Consequently, ecological issues have become a high priority for nurses, demanding attention and action [ 10 ].

The importance of environment, ecosystems, and ecology in nursing practice has been recognized by pioneers like Florence Nightingale as the founder of modern nursing (published in 1992, originally written in 1959) [ 11 ] and subsequently by Fawcett (1984) [ 12 ]. This vision is further reflected in the International Council of Nurses (ICN) Code of Ethics, which states that “nurses contribute to the population’s health and work to achieve the sustainable development goals.” By adopting sustainable practices, nurses can significantly reduce their environmental footprint and contribute to achieving the UN 2030 Agenda for Sustainable Development [ 9 ]. Recognizing this crucial role, nursing organizations such as the American Nurses Association actively promote nurses’ participation in environmental protection initiatives [ 13 ].

The concept of ecological care in nursing, as a multidimensional concept, encompasses several aspects. Lausten (2006) proposed a nursing ecological theory to broaden nurses’ perspectives by incorporating concepts of global ecosystems, communities, and interrelationships from the ecological sciences. This theory recognizes that human interactions with the environment extend beyond the personal sphere and encompass professional activities. Consequently, nurses can integrate ecological principles into their practice, fostering new directions in care that benefit patients, healthcare professionals, and the environment [ 14 ]. Dahlberg et al. (2016) conducted an empirical study to explore how a phenomenological life-world theory could expand the concept of holistic care into “ecological care.” They argued that the traditional approach to holistic care has neglected environmental and ecological dimensions. Their findings suggested that ecological care goes beyond fighting illnesses. It emphasizes understanding patients within the context of their world, a world that they both influence and are influenced by. This approach helps patients reintegrate into their rhythm of existence [ 1 ].

Al-Shamaly (2021) highlights “ecological awareness,” which emphasizes creating a safe and comfortable patient environment through noise, light, color, and temperature control [ 15 ]. Sattler (2013) adds another dimension, suggesting that nurses can act as catalysts for transforming hospitals into environmentally sustainable spaces. This can be achieved through practices such as adopting environmentally friendly purchasing policies (e.g., waste management strategies, reduced chemical use, and proper disposal of hazardous materials such as batteries), promoting healthy food options, and favoring mercury-free products [ 16 ].

Although ecological factors could influence the quality of care, patient safety, individual and community health, resource preservation, and sustainable practices [ 16 , 17 , 18 , 19 ], nurses’ awareness of ecological care and its dimensions remains limited [ 2 ]. Moreover, there is no universally accepted definition of ecological care as a complex concept [ 20 ]. Therefore, this study aimed to analyze and clarify the concept of ‘ecological care’ within the nursing discipline.

Walker and Avant’s concept analysis method was used as a rigorous and systematic approach to identify descriptions, antecedents, consequences, and empirical referents of the concept of ‘ecological care’ in nursing. Ecological care is a widely applicable concept that extends beyond the confines of nursing care. Therefore, the literature review encompasses all the various applications of ecological care, including both implicit and explicit aspects. The stages of the concept analysis method are as follows: (A) selecting a concept, (B) determining the aims or purposes of the analysis, (C) identifying all uses of the concept that you can discover, (D) determining the defining attributes, (E) identifying a model case, (F) identifying borderline, related, contrary, invented, and illegitimate cases, (G) identifying antecedents and consequences, and (H) defining empirical referents [ 21 ].

Literature search

A systematic literature review was conducted using multiple health databases, including PubMed, Scopus, PsycINFO, CINAHL, ERIC, SID, and IranDoc. The concepts “ecological,” “nurse” and “nursing” were searched using Boolean operators “AND” and “OR” in the title and abstract fields of each database. No temporal limits were applied and articles published in either English or Persian until July 2023 were retrieved.

Initially, 1083 records were identified by searching the titles and abstracts of these databases. Subsequently, 16 additional records were manually included, resulting in a total of 1099 records. Duplicate records were removed, leading to an initial selection of 1068 records. The titles and abstracts of these records were screened, and the eligibility criteria were applied to the full text of the selected records. Eventually, 36 records met the criteria and underwent a comprehensive review of concept analysis (Fig. 1 ). A detailed overview of the included studies, including publication year, title, country, and key findings, can be found in Appendix A.

Flow diagram of the study (data search and selection process)

Concept selection

The importance of a specific concept is influenced by a variety of factors both within and outside its field over time. Consequently, concepts lacking clear definitions warrant further analysis [ 21 ]. Considering the interconnectedness of ecosystems and human health, as well as the imperative to maintain environmental sustainability, particularly within healthcare, the concept of ecology has gained prominence in nursing and other health professions. Nightingale’s emphasis on the environment underscores this importance. Given the increasing significance of ecological care in healthcare and the lack of a clear, unified definition, this concept was selected for analysis to elucidate its dimensions and characteristics.

Determining the aims of the analysis

The concept of “ecological care” has been insufficiently analyzed within the healthcare context, resulting in a lack of a clear definition. This study aims to refine the meaning of ecological care in nursing by identifying its descriptions, antecedents, consequences, and empirical referents.

Identifying the use of the concept

To explore the concept of ecological care, it is crucial to understand the distinct meanings of each word from a variety of sources such as dictionaries, thesauruses, websites, and scholarly literature.

According to the Merriam-Webster dictionary, the term ‘ecological’ is an adjective related to the science of ecology. This refers to the environment of living things or the relationships between living things and their environments [ 22 ].

According to the Merriam-Webster dictionary, the term ‘care’ functions both as a noun, representing responsibility for or attention to health, well-being, safety, or solicitude, and as a verb, meaning to feel interest or concern and to provide care [ 23 ].

Ecological care in nursing literature

The concept of ecological care, originating from the theory of biological ecology, aims to offer solutions that effectively minimize the adverse impacts of nursing care on the ecosystem [ 14 ]. Ecological care can be classified into two types: individuals and professionals. The individual approach focuses on raising public awareness, shaping attitudes and behaviors, and promoting responsible actions regarding energy consumption, the production of toxic substances (such as greenhouse gases), chemical usage, and healthy and organic diet adoption. Conversely, the professional approach emphasizes the importance of sensitivity, awareness, attitude, behavior, and responsible actions among individuals when carrying out their professional responsibilities [ 9 , 24 ].

Clinical environments require ecological care, which can be achieved through two distinct approaches: environmental and organizational care. Environmental care involves maintaining equipment and machines, ensuring workplace safety, minimizing risks, managing noise levels, optimizing lighting conditions, regulating temperature, and employing creative designs to create a comfortable and relaxing environment. It also involves facilitating visits from family members and pets and improving patients’ sleep quality. Additionally, the use of digital technology helps ensure a healthy and safe treatment environment for patients in the Intensive Care Units (ICU). On the other hand, organizational care focuses on time and resource management. This includes strategies such as reducing paper and ink consumption by utilizing electronic records, which aids in efficient time management. Organizational care aims to streamline nurses’ tasks and improve overall work efficiency by minimizing their workload and improving access to patient information. Finally, waste management practices play a crucial role in maintaining an environmentally conscious approach in healthcare settings [ 15 ].

Determining the defining attributes

Ecological thinking.

According to Balgopal and Wallace (2009), ecological thinking is a combination of ecological understanding and ecological awareness [ 25 ]. Understanding ecology involves understanding concepts such as biotic, abiotic, and biological interactions. This serves as the initial stage of ecological thinking, which is further developed by comprehending the impact of human activities on the ecosystem [ 26 ]. Ecological understanding can be conceptualized as a continuum, with one end representing the capacity to identify problems and propose ecological decisions, considering their potential consequences. On the other end of the continuum is a lack of understanding, where the ability to explain the impact of human actions on the ecosystem is insufficient [ 25 ].

Ecological thinking causes a transformation in people’s presuppositions and attitudes towards the surrounding world, enabling them to recognize that we are interconnected and evolving alongside nature. Embracing an ecological perspective requires acknowledging ourselves as integral components of nature rather than being superior to it. This encompassing concept embodies various underlying principles such as ecology, wholeness, interdependence, diversity, partnership, energy flows, flexibility, cycles, and sustainability [ 17 , 27 ]. Hes and de Plessis (2014) refer to this set of principles as the ‘ecological worldview.’ Shifting towards an ecological perspective entail altering our perspective on the world and ourselves. The fundamental essence of this transformation involves moving away from egocentric and anthropocentric thinking, which emphasizes separateness, and instead adopting a holistic perception that aims to counterbalance environmental damage. Enhancing ecological thinking can be achieved through the instruction of ecological concepts and behaviors [ 28 ].

Ecological attitude

Ecological attitude is a complex construct that encompasses various key components such as emotions, perceptions, personal norms, values, and relationships with the environment. The emotional dimension of ecological attitude plays a pivotal role in preparing individuals to address environmental issues and cultivate ecological behaviors in all aspects of life [ 29 , 30 , 31 ], as it determines the extent to which individuals will act in environmentally responsible ways [ 32 ].

Predicting a specific behavior entails possessing a specific attitude towards that behavior, as attitudes alone do not guarantee behavior, but predict or influence it [ 2 , 33 ]. Ecological behavior can be defined as the actions taken by a nurse to protect the environment, and it varies depending on the individual’s context and circumstances. Achieving the goal of ecological behavior can be challenging in certain situations, but it is crucial to promote sustainable living and preserve the planet’s natural resources [ 31 ].

Ecological awareness

Ecological awareness refers to knowledge, attitudes, and behaviors related to the environment. Its focus is on increasing responsibility toward achieving ecological sustainability [ 34 ]. One of its important characteristics is the perception of natural objects from a subject’s perspective [ 35 ]. As a theoretical and practical science, ecological awareness includes two stages: awareness of environmental changes, and feelings of concern about environmental problems and trying to solve them. People with ecological awareness try to be actively responsible for their interactions with the environment and exhibit positive behaviors towards the surrounding environment [ 9 , 20 ].

Ecological awareness is also a level of cognitive thinking that enables nurses to focus on protecting the environment while providing nursing care. This concept requires nurses to pay attention to the potential of nature and the surrounding environment that promotes, maintains, and restores human health [ 9 , 14 ]. This raises important questions about whether nurses are aware of the positive effects of recycling medical equipment and materials, or the harmful effects of greenhouse gases (CO2, NO, etc.) caused by fossil fuels and smoke from medical waste incinerators. It also highlights how much nurses are aware of the impact of their care activities on ecosystem damage and public health [ 9 , 19 , 36 ]. The role of nurses with ecological awareness is crucial in raising awareness among colleagues, managers, patients, and students [ 8 , 37 , 38 , 39 ].

Ecological sensitivity

Ecological sensitivity refers to the inclination to actively address environmental threats and the extent to which healthcare providers demonstrate awareness of hazardous and protective circumstances [ 40 ]. Individuals with varying psychological traits, such as extroversion or introversion, exhibit distinct levels of sensitivity to environmental health [ 41 ].

Ecological sensitivity is a multidimensional concept that contributes significantly to sustainable development. This serves as an emotional foundation for cultivating an ecological worldview and establishing personal norms for pro-environmental actions. This dynamic framework takes shape within families during childhood and is strengthened throughout professional life. Therefore, an essential initial step in enhancing ecological sensitivity among healthcare providers is to impart ecological education and raise awareness levels [ 42 , 43 , 44 ]. The development of ecological sensitivity is influenced by various factors, including families, educational institutions, mass media, and non-governmental organizations [ 45 , 46 , 47 ]. In general, nurses who actively engage in staying informed about ecological news and trends, participate in ecological protection activities and events, and demonstrate awareness of ecologically detrimental behaviors, both in themselves and their colleagues exhibit higher levels of ecological sensitivity [ 42 , 43 ].

Ecological literacy

Ecological literacy is a crucial concept that includes three core components: cognitive, emotional, and behavioral. According to UNESCO, there are five key characteristics of ecological literacy: awareness and sensitivity to the environment; comprehension of environmental issues; having values and sentiments towards environmental concerns; possessing skills, desire, and commitment; and actively engaging in identifying and resolving ecological problems. Generally, ecological literacy can be defined as the integration of environmental sensitivity, knowledge, skills, attitudes, values, responsibilities, and active engagement, which enables nurses to make informed and responsible decisions to promote environmental sustainability [ 48 , 49 ].

Model and additional cases

A model case serves as a paradigmatic illustration of the application of a concept encompassing all its defining elements. In addition to the model case, two other types of cases are presented: (A) the borderline case, which shares most of the essential characteristics of the concept but exhibits some differences; and (B) the contrary case, which presents an apparent example that contrasts with the concept, highlighting what it is not [ 21 ].

A 65-year-old woman was admitted to the neurology ward with a diagnosis of transient ischemic attack during the night shift. The attending nurse approached the patient’s bedside and introduced herself and the inpatient department. During the evaluation, the nurse observed the patients’ uneasiness, homesickness, and concerns regarding sleep disturbance due to changes in sleeping arrangements. She addressed the situation by repositioning the patient’s bed next to the window, aiming to provide a more comfortable environment and alleviate feelings of homesickness. Careful attention was paid to ensure that the bed and equipment were securely locked. During medication administration, the nurse utilized a tablet for dosage calculations, opting for a paperless approach to reduce waste. Proper disposal procedures were followed after medication administration, with empty vials discarded in the chemical waste bin, and needles placed in a safety box. During the initiation of infusion, the nurse noticed loose screws on the electronic infusion device and promptly sought assistance from a colleague to rectify the issue. Toward the end of her tasks, the nurse dimmed unnecessary lights in the ward and adjusted the alarm range of the device to an audible level for more comfort. Immediately before leaving the ward, the nurse noticed a leaking water tap and promptly contacted the facility manager to initiate immediate remedial action.

Borderline case

The head nurse of the pediatric ward conducted a clinical round when she heard the cries of a hospitalized 4-year-old child who was upset due to the absence of her cherished doll. Regrettably, the nurses disregarded the situation and continued down the corridor. Several months later, the nurse was invited to join a committee responsible for making decisions regarding hospital equipment procurement. Drawing from the recent knowledge acquired through a TV program highlighting the hazards of mercury to human health, she recommended the acquisition of mercury-free medical equipment.

Contrary case

A nurse, aged 35, with ten years of experience in surgery, approached the patient who had undergone laparotomy to perform a dressing change. The nurse inadvertently wore a pair of sterile gloves instead of non-sterile gloves while removing the contaminated dressing and disposed of it in the general waste bin. Subsequently, sterile gloves were replaced with a fresh pair, the wound was cleansed using six sterile gauzes, and an additional seven gauzes were applied to dress the surgical site, although a smaller quantity would have sufficed. During the hand washing process, the nurse’s mobile phone rang, and without turning off the water tap, he engaged in a conversation until the patient’s family intervened and turned off the tap. Finally, despite the patient expressing mild pain at the surgical site, the nurse chose to administer a painkiller instead of utilizing non-pharmacological methods to alleviate pain.

Identify antecedents and consequences

Walker and Avant (2011) provided a clear definition of antecedents as events or attributes that precede the occurrence of a concept, whereas consequences refer to events that ensue from the concept’s occurrence [ 21 ]. In this study, it was crucial to identify and examine the associated antecedents and consequences (Fig. 2 ). Therefore, the antecedents and consequences investigated are as follows:

Attributes, antecedents, and consequences of ecological caring in nursing practice

Antecedents

The ecological care provided by nurses can be influenced by both personal characteristics and organizational policies. Personal characteristics include creativity, innovation, responsibility, environmental friendliness [ 41 ], kindness, empathy, and strong communication skills [ 9 ]. Meanwhile, organizational policies encompass the establishment of a supportive organizational culture, provision of training courses [ 14 ], and design of a creative and humanitarian environment within hospitals and healthcare facilities. Moreover, ensuring a safe environment equipped with adequate resources, services, technology, and competent human resources is essential for delivering ecological care in therapeutic settings [ 15 ].

Consequences

Ecological care yields numerous benefits to patients, their families, healthcare providers, healthcare systems, and the environment. Among these benefits, one of the most significant is the provision of high-quality holistic care, which leads to increased patient satisfaction. Additionally, ecological care contributes to patient and staff safety by minimizing hospital infections, conserving energy (electricity, gases, and water), optimizing equipment and time utilization, reducing employee workload, managing hospital procurement costs, and eliminating hospital waste. It also plays a vital role in preventing the entry of pathogens, chemical pollutants, and radioactive substances into the water, soil, and air. Furthermore, ecological care promotes ecological sustainability, safeguards the ecosystem, and helps protect food and agricultural resources by preventing food waste in the hospital setting. These considerations highlight the wide-ranging positive consequences of ecological care [ 14 , 41 ].

Empirical referents

According to Walker and Avant (2011), the final step in concept analysis is to identify the empirical referents of attributes. Empirical referents do not directly serve as instruments for measuring a concept, but they provide illustrations of how defining characteristics or attributes can be recognized or measured. By presenting real-world examples, empirical referents assist in measuring the concept and validating its significance [ 21 ]. Although this study did not identify a specific independent instrument for measuring ecological care in nursing, the following examples demonstrate instruments that measure the defining characteristics or attributes of the concept.

The Nurse’s Environmental Awareness Tool (NEAT) was developed by Schenk et al. in 2015 to measure nurses’ awareness of and behaviors associated with the environmental impact of their practices. The NEAT consists of 48 two-part items in six subscales and three paired subsets as follows: nurse awareness scales, nurse professional ecological behaviors scales, and personal ecological behaviors scales [ 9 ].

The Ecological Risk Perception Scale, developed by Slimak and Dietz in 2006, examines not only the attributes of the risk itself but also the characteristics of individuals perceiving the risk. Consisting of 24 ecological risk items, the scale encompasses four subscales: ecological, chemical, global, and biological [ 50 ].

The Environmental Literacy Questionnaire (ELQ) was derived from part of Michigan State University’s project and was originally used by Kaplowitz and Levine (2005) [ 51 ]. Later, Kahyaoğlu (2011) revised the ELQ. The revised version consisted of four components: knowledge (11 items), attitude (12 items), uses (19 items), and concern (9 items) [ 52 ].

Based on the current analysis, ecological care is a multidimensional integration of thinking, attitudes, awareness, sensitivity, and literacy to deliver high-quality holistic care while maintaining environmental sustainability and promoting energy conservation.

Analysis of the concept of ecological care has significant implications for the nursing profession. Given the limited exploration of ecological care within nursing practice, conducting an analysis can empower nurses to utilize ecological factors in delivering high-quality care and embracing environmentally friendly behaviors. The objective of this study was to present a comprehensive and practical definition of ecological care, thereby establishing a shared platform for not only nurses but also other healthcare professionals to promote pro-environmental behaviors.

Backes et al. (2011) conducted a study aiming to comprehend the meaning of ecological care from the perspective of students and teachers in the healthcare field at a Public Institution of Higher Education. The study revealed several categories, including (a) ecological care as a result of relationships, interactions, and communication with the global environment (main category); (b) the development of ecological awareness (causal conditions); (c) the connection of ecological care with different systems (context); (d) the perception of human-environment-health interaction (intervention); (e) the need to foster ecological consciousness through new references (strategy); and (f) a sense of motivation to understand ecological care (result). While this study acknowledged ecological awareness and conscience as integral components of ecological care, other attributes of the concept, such as adopting an ecological perspective; ecological literacy; and the impact of values, beliefs, and organizational culture on providing holistic care, were not extensively explained [ 20 ].

The findings of a study conducted by Dahlberg et al. (2016) revealed how ecological care facilitates patients to rediscover their place in a world characterized by interconnectedness. The role of ecological care extends beyond perceiving patients within a web of relationships; it encompasses assisting patients in re-establishing their sense of self and comprehending the world anew. Ecological care entails not only combating illness but also acknowledging patients as individuals influenced by and influencing the world. Such care endeavors to facilitate rhythmic movement and create space for activity and rest, being cared for and actively participating in one’s recovery, withdrawing from the world, and re-engaging with it. This study also highlights the use of the term ecological perspective to enhance the understanding of optimal care for patients. In this study, the novel attributes of the concept of ecological care are introduced. However, the potential impacts of constructive and destructive human activities on ecosystems remain unexplored [ 1 ]. In contrast, we refer to ecological sustainability and energy conservation as significant consequences of ecological care in nursing.

In a focused ethnographic study, Al-Shamaly (2021) explored the culture of multidimensional “caring-for” practice among ICU nurses. The inclusive nature of this culture encompasses caring for oneself, patients and their families, and colleagues (including nurses and other team members) as well as ecological consciousness within the ICU environment and organization. Ecological consciousness involves caring for equipment and machines, ensuring workplace safety, reducing hazards, transitioning towards a paperless unit, maintaining thorough documentation, and demonstrating commitment and concern for the organization’s budget regarding staff and resources [ 15 ]. While this study comprehensively addresses the practical aspects of the concept, it constrains the concept of ecological care solely to ecological consciousness. However, our study revealed that ecological care is a multidimensional, and complex phenomenon that extends beyond ecological consciousness. In another study, religious values were identified as a crucial factor in promoting an ecological care orientation that can be incorporated into daily life through religious education, considering the religious and cultural context of each country. These values are instilled into individuals from childhood to adulthood through various learning activities. Therefore, religious education plays a pivotal role in shaping individuals’ commitment to ecological care [ 53 ]. According to this study, religious values significantly contribute to the development of ecological thinking and the manifestation of ecological behavior.

Moreover, a previous study by Akkuzu (2016) introduced ecological intelligence as a new type of conscience, defined as a combination of environmental awareness and the sensitivity of human beings towards adverse global alterations in nature. This understanding empowers individuals to recognize the perils faced by their communities and comprehend the underlying causes. Furthermore, it equips them with the knowledge necessary to address these perils collectively and devise effective solutions [ 54 ].

Implications for nursing practice

While our analysis primarily focused on the ecological perspective, we contend that a profound understanding of this concept is imperative for establishing cultural and political frameworks within the healthcare system. This study contributes to the limited body of research on nursing by highlighting the essentiality of ecological and holistic thinking in the domains of caregiving, treatment, management, and education. Consequently, it has the potential to yield substantial impacts in ensuring the safety of patients and healthcare providers, enhancing the quality of care, and improving patient and family satisfaction.

Limitations

The conceptual analysis is subject to several limitations. Firstly, the literature search was confined to studies published in English and Persian, potentially limiting the diversity of perspectives from other countries, cultures, and languages. To mitigate this limitation, future studies should conduct a comprehensive search in multiple languages to ensure a more holistic understanding of ecological care in nursing practice. Secondly, the analysis is susceptible to selection bias, extraction bias, and analysis bias. To address these limitations, the study selection process, data extraction, and analysis were independently conducted by two researchers. Despite these limitations, the studies were described accurately and systematically, contributing valuable insights into the concept of ecological care in nursing practice.

The results of the present analysis provide a definition of ecological care in nursing that may guide the profession to new directions of care, striving for the greater good of the patient, the profession of caring, and the environment. It is clear that more research is needed to discover the neglected importance of the environment in holistic care and to identify phenomena related to this concept in practical nursing. The literature review shows that the educational field, as the most effective factor, plays a significant role in the formation of ecological literacy and worldviews and the creation of the perceptions, attitudes, and behaviors of ecological care. In this regard, nursing professors and instructors, as the most important role models, significantly contribute to the development of the identity and character of ecological care for today’s students and future nurses.

Data availability

The data supporting the findings of this study are available upon request from the corresponding author. The data were not publicly available because of privacy or ethical restrictions.

Abbreviations

Carbon dioxide

Nitric oxide

The United Nations Educational, Scientific and Cultural Organization

Nurse’s Environmental Awareness Tool

Environmental Literacy Questionnaire

Intensive Care Unit

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Acknowledgements

This study was extracted from a research project approved and supported by the Student Research Committee, Tabriz University of Medical Sciences (grant number: 73361). The authors would like to thank all those who spent valuable time participating in this research. We are also immensely grateful to the “anonymous” reviewers for their valuable insights.

The present study was financially supported by Tabriz University of Medical Sciences, Tehran, Iran.

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Golshan Moghbeli, Mansour Ghafourifard, Shahla Shahbazi & Hanieh Aziz Karkan

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Amin Soheili

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Contributions

GM, AS: original concept and study design; GM, HA, ShS: data collection; GM, HA, AS, MGh: data analysis and interpretation; GM, HA, AS, MGh, ShS: manuscript preparation and final critique; GM, MGh: study supervision.

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This study was approved by the ethics committee of Tabriz Tehran University of Medical Sciences (code of ethics: IR.TBZMED.REC.1402.614). All methods were carried out in accordance with relevant guidelines and regulations of Walker and Avant’s concept analysis method and qualitative research.

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Moghbeli, G., Soheili, A., Ghafourifard, M. et al. Ecological care in nursing practice: a Walker and Avant concept analysis. BMC Nurs 23 , 614 (2024). https://doi.org/10.1186/s12912-024-02279-z

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Acupuncture: Effectiveness and Safety

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} What is acupuncture?

Acupuncture is a technique in which practitioners insert fine needles into the skin to treat health problems. The needles may be manipulated manually or stimulated with small electrical currents (electroacupuncture). Acupuncture has been in use in some form for at least 2,500 years. It originated from traditional Chinese medicine but has gained popularity worldwide since the 1970s.

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According to the World Health Organization, acupuncture is used in 103 of 129 countries that reported data.

In the United States, data from the National Health Interview Survey show that the use of acupuncture by U.S. adults more than doubled between 2002 and 2022. In 2002, 1.0 percent of U.S. adults used acupuncture; in 2022, 2.2 percent used it.

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National survey data indicate that in the United States, acupuncture is most commonly used for pain, such as back, joint, or neck pain.

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How acupuncture works is not fully understood. However, there’s evidence that acupuncture may have effects on the nervous system, effects on other body tissues, and nonspecific (placebo) effects.

Studies in animals and people, including studies that used imaging methods to see what’s happening in the brain, have shown that acupuncture may affect nervous system function.
Acupuncture may have direct effects on the tissues where the needles are inserted. This type of effect has been seen in connective tissue.
Acupuncture has nonspecific effects (effects due to incidental aspects of a treatment rather than its main mechanism of action). Nonspecific effects may be due to the patient’s belief in the treatment, the relationship between the practitioner and the patient, or other factors not directly caused by the insertion of needles. In many studies, the benefit of acupuncture has been greater when it was compared with no treatment than when it was compared with sham (simulated or fake) acupuncture procedures, such as the use of a device that pokes the skin but does not penetrate it. These findings suggest that nonspecific effects contribute to the beneficial effect of acupuncture on pain or other symptoms.
In recent research, a nonspecific effect was demonstrated in a unique way: Patients who had experienced pain relief during a previous acupuncture session were shown a video of that session and asked to imagine the treatment happening again. This video-guided imagery technique had a significant pain-relieving effect.

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Research has shown that acupuncture may be helpful for several pain conditions, including back or neck pain, knee pain associated with osteoarthritis, and postoperative pain. It may also help relieve joint pain associated with the use of aromatase inhibitors, which are drugs used in people with breast cancer.

An analysis of data from 20 studies (6,376 participants) of people with painful conditions (back pain, osteoarthritis, neck pain, or headaches) showed that the beneficial effects of acupuncture continued for a year after the end of treatment for all conditions except neck pain.

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In a 2018 review, data from 12 studies (8,003 participants) showed acupuncture was more effective than no treatment for back or neck pain, and data from 10 studies (1,963 participants) showed acupuncture was more effective than sham acupuncture. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. The pain-relieving effect of acupuncture was comparable to that of nonsteroidal anti-inflammatory drugs (NSAIDs).
A 2017 clinical practice guideline from the American College of Physicians included acupuncture among the nondrug options recommended as first-line treatment for chronic low-back pain. Acupuncture is also one of the treatment options recommended for acute low-back pain. The evidence favoring acupuncture for acute low-back pain was judged to be of low quality, and the evidence for chronic low-back pain was judged to be of moderate quality.

For more information, see the NCCIH webpage on low-back pain .

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In a 2018 review, data from 10 studies (2,413 participants) showed acupuncture was more effective than no treatment for osteoarthritis pain, and data from 9 studies (2,376 participants) showed acupuncture was more effective than sham acupuncture. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. Most of the participants in these studies had knee osteoarthritis, but some had hip osteoarthritis. The pain-relieving effect of acupuncture was comparable to that of NSAIDs.
A 2018 review evaluated 6 studies (413 participants) of acupuncture for hip osteoarthritis. Two of the studies compared acupuncture with sham acupuncture and found little or no difference between them in terms of effects on pain. The other four studies compared acupuncture with a variety of other treatments and could not easily be compared with one another. However, one of the trials indicated that the addition of acupuncture to routine care by a physician may improve pain and function in patients with hip osteoarthritis.
A 2019 clinical practice guideline from the American College of Rheumatology and the Arthritis Foundation conditionally recommends acupuncture for osteoarthritis of the knee, hip, or hand. The guideline states that the greatest number of studies showing benefits have been for knee osteoarthritis.

For more information, see the NCCIH webpage on osteoarthritis .

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A 2020 review of nine studies that compared acupuncture with various drugs for preventing migraine found that acupuncture was slightly more effective, and study participants who received acupuncture were much less likely than those receiving drugs to drop out of studies because of side effects.
There’s moderate-quality evidence that acupuncture may reduce the frequency of migraines (from a 2016 evaluation of 22 studies with almost 5,000 people). The evidence from these studies also suggests that acupuncture may be better than sham acupuncture, but the difference is small. There is moderate- to low-quality evidence that acupuncture may reduce the frequency of tension headaches (from a 2016 evaluation of 12 studies with about 2,350 people).

For more information, see the NCCIH webpage on headache .

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Myofascial pain syndrome is a common form of pain derived from muscles and their related connective tissue (fascia). It involves tender nodules called “trigger points.” Pressing on these nodules reproduces the patient’s pattern of pain.
A combined analysis of a small number of studies of acupuncture for myofascial pain syndrome showed that acupuncture applied to trigger points had a favorable effect on pain intensity (5 studies, 215 participants), but acupuncture applied to traditional acupuncture points did not (4 studies, 80 participants).

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Sciatica involves pain, weakness, numbness, or tingling in the leg, usually on one side of the body, caused by damage to or pressure on the sciatic nerve—a nerve that starts in the lower back and runs down the back of each leg.
Two 2015 evaluations of the evidence, one including 12 studies with 1,842 total participants and the other including 11 studies with 962 total participants, concluded that acupuncture may be helpful for sciatica pain, but the quality of the research is not good enough to allow definite conclusions to be reached.

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A 2016 evaluation of 11 studies of pain after surgery (with a total of 682 participants) found that patients treated with acupuncture or related techniques 1 day after surgery had less pain and used less opioid pain medicine after the operation.

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A 2016 review of 20 studies (1,639 participants) indicated that acupuncture was not more effective in relieving cancer pain than conventional drug therapy. However, there was some evidence that acupuncture plus drug therapy might be better than drug therapy alone.
A 2017 review of 5 studies (181 participants) of acupuncture for aromatase inhibitor-induced joint pain in breast cancer patients concluded that 6 to 8 weeks of acupuncture treatment may help reduce the pain. However, the individual studies only included small numbers of women and used a variety of acupuncture techniques and measurement methods, so they were difficult to compare.
A larger 2018 study included 226 women with early-stage breast cancer who were taking aromatase inhibitors. The study found that the women who received 6 weeks of acupuncture treatment, given twice each week, reported less joint pain than the participants who received sham or no acupuncture.

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Chronic prostatitis/chronic pelvic pain syndrome is a condition in men that involves inflammation of or near the prostate gland; its cause is uncertain.
A review of 3 studies (204 total participants) suggested that acupuncture may reduce prostatitis symptoms, compared with a sham procedure. Because follow-up of the study participants was relatively brief and the numbers of studies and participants were small, a definite conclusion cannot be reached about acupuncture’s effects.

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A 2019 review of 41 studies (3,440 participants) showed that acupuncture was no more effective than sham acupuncture for symptoms of irritable bowel syndrome, but there was some evidence that acupuncture could be helpful when used in addition to other forms of treatment.

For more information, see the NCCIH webpage on irritable bowel syndrome .

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A 2019 review of 12 studies (824 participants) of people with fibromyalgia indicated that acupuncture was significantly better than sham acupuncture for relieving pain, but the evidence was of low-to-moderate quality.

For more information, see the NCCIH webpage on fibromyalgia .

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In addition to pain conditions, acupuncture has also been studied for at least 50 other health problems. There is evidence that acupuncture may help relieve seasonal allergy symptoms, stress incontinence in women, and nausea and vomiting associated with cancer treatment. It may also help relieve symptoms and improve the quality of life in people with asthma, but it has not been shown to improve lung function.

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A 2015 evaluation of 13 studies of acupuncture for allergic rhinitis, involving a total of 2,365 participants, found evidence that acupuncture may help relieve nasal symptoms. The study participants who received acupuncture also had lower medication scores (meaning that they used less medication to treat their symptoms) and lower blood levels of immunoglobulin E (IgE), a type of antibody associated with allergies.
A 2014 clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery included acupuncture among the options health care providers may offer to patients with allergic rhinitis.

For more information, see the NCCIH webpage on seasonal allergies .

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Stress incontinence is a bladder control problem in which movement—coughing, sneezing, laughing, or physical activity—puts pressure on the bladder and causes urine to leak.
In a 2017 study of about 500 women with stress incontinence, participants who received electroacupuncture treatment (18 sessions over 6 weeks) had reduced urine leakage, with about two-thirds of the women having a decrease in leakage of 50 percent or more. This was a rigorous study that met current standards for avoiding bias.

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Experts generally agree that acupuncture is helpful for treatment-related nausea and vomiting in cancer patients, but this conclusion is based primarily on research conducted before current guidelines for treating these symptoms were adopted. It’s uncertain whether acupuncture is beneficial when used in combination with current standard treatments for nausea and vomiting.

For more information, see the NCCIH webpage on cancer .

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In a study conducted in Germany in 2017, 357 participants receiving routine asthma care were randomly assigned to receive or not receive acupuncture, and an additional 1,088 people who received acupuncture for asthma were also studied. Adding acupuncture to routine care was associated with better quality of life compared to routine care alone.
A review of 9 earlier studies (777 participants) showed that adding acupuncture to conventional asthma treatment improved symptoms but not lung function.

For more information, see the NCCIH webpage on asthma .

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A 2018 review of 64 studies (7,104 participants) of acupuncture for depression indicated that acupuncture may result in a moderate reduction in the severity of depression when compared with treatment as usual or no treatment. However, these findings should be interpreted with caution because most of the studies were of low or very low quality.

For more information, see the NCCIH webpage on depression .

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In recommendations on smoking cessation treatment issued in 2021, the U.S. Preventive Services Task Force, a panel of experts that makes evidence-based recommendations about disease prevention, did not make a recommendation about the use of acupuncture as a stop-smoking treatment because only limited evidence was available. This decision was based on a 2014 review of 9 studies (1,892 participants) that looked at the effect of acupuncture on smoking cessation results for 6 months or more and found no significant benefit. Some studies included in that review showed evidence of a possible small benefit of acupuncture on quitting smoking for shorter periods of time.

For more information, see the NCCIH webpage on quitting smoking .

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A 2021 review evaluated 6 studies (2,507 participants) that compared the effects of acupuncture versus sham acupuncture on the success of in vitro fertilization as a treatment for infertility. No difference was found between the acupuncture and sham acupuncture groups in rates of pregnancy or live birth.
A 2020 review evaluated 12 studies (1,088 participants) on the use of acupuncture to improve sperm quality in men who had low sperm numbers and low sperm motility. The reviewers concluded that the evidence was inadequate for firm conclusions to be drawn because of the varied design of the studies and the poor quality of some of them.

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A 2018 review of 12 studies with 869 participants concluded that acupuncture and laser acupuncture (a treatment that uses lasers instead of needles) may have little or no effect on carpal tunnel syndrome symptoms in comparison with sham acupuncture. It’s uncertain how the effects of acupuncture compare with those of other treatments for this condition.
In a 2017 study not included in the review described above, 80 participants with carpal tunnel syndrome were randomly assigned to one of three interventions: (1) electroacupuncture to the more affected hand; (2) electroacupuncture at “distal” body sites, near the ankle opposite to the more affected hand; and (3) local sham electroacupuncture using nonpenetrating placebo needles. All three interventions reduced symptom severity, but local and distal acupuncture were better than sham acupuncture at producing desirable changes in the wrist and the brain.

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A 2018 review of studies of acupuncture for vasomotor symptoms associated with menopause (hot flashes and related symptoms such as night sweats) analyzed combined evidence from an earlier review of 15 studies (1,127 participants) and 4 newer studies (696 additional participants). The analysis showed that acupuncture was better than no acupuncture at reducing the frequency and severity of symptoms. However, acupuncture was not shown to be better than sham acupuncture.

For more information, see the NCCIH webpage on menopause .

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Auricular acupuncture is a type of acupuncture that involves stimulating specific areas of the ear.
In a 2019 review of 15 studies (930 participants) of auricular acupuncture or auricular acupressure (a form of auricular therapy that does not involve penetration with needles), the treatment significantly reduced pain intensity, and 80 percent of the individual studies showed favorable effects on various measures related to pain.
A 2020 review of 9 studies (783 participants) of auricular acupuncture for cancer pain showed that auricular acupuncture produced better pain relief than sham auricular acupuncture. Also, pain relief was better with a combination of auricular acupuncture and drug therapy than with drug therapy alone.
An inexpensive, easily learned form of auricular acupuncture called “battlefield acupuncture” has been used by the U.S. Department of Defense and Department of Veterans Affairs to treat pain. However, a 2021 review of 9 studies (692 participants) of battlefield acupuncture for pain in adults did not find any significant improvement in pain when this technique was compared with no treatment, usual care, delayed treatment, or sham battlefield acupuncture.

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Relatively few complications from using acupuncture have been reported. However, complications have resulted from use of nonsterile needles and improper delivery of treatments.
When not delivered properly, acupuncture can cause serious adverse effects, including infections, punctured organs, and injury to the central nervous system.
The U.S. Food and Drug Administration (FDA) regulates acupuncture needles as medical devices and requires that they be sterile and labeled for single use only.

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Some health insurance policies cover acupuncture, but others don’t. Coverage is often limited based on the condition being treated.
An analysis of data from the Medical Expenditure Panel Survey, a nationally representative U.S. survey, showed that the share of adult acupuncturist visits with any insurance coverage increased from 41.1 percent in 2010–2011 to 50.2 percent in 2018–2019.
Medicare covers acupuncture only for the treatment of chronic low-back pain. Coverage began in 2020. Up to 12 acupuncture visits are covered, with an additional 8 visits available if the first 12 result in improvement. Medicaid coverage of acupuncture varies from state to state.

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Most states license acupuncturists, but the requirements for licensing vary from state to state. To find out more about licensing of acupuncturists and other complementary health practitioners, visit the NCCIH webpage Credentialing, Licensing, and Education .

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NCCIH funds research to evaluate acupuncture’s effectiveness for various kinds of pain and other conditions and to further understand how the body responds to acupuncture and how acupuncture might work. Some recent NCCIH-supported studies involve:

Evaluating the feasibility of using acupuncture in hospital emergency departments.
Testing whether the effect of acupuncture on chronic low-back pain can be enhanced by combining it with transcranial direct current stimulation.
Evaluating a portable acupuncture-based nerve stimulation treatment for anxiety disorders.

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Don’t use acupuncture to postpone seeing a health care provider about a health problem.
Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

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Befus D, Coeytaux RR, Goldstein KM, et al. Management of menopause symptoms with acupuncture: an umbrella systematic review and meta-analysis . Journal of Alternative and Complementary Medicine. 2018;24(4):314-323.
Bleck R, Marquez E, Gold MA, et al. A scoping review of acupuncture insurance coverage in the United States . Acupuncture in Medicine. 2020;964528420964214.
Briggs JP, Shurtleff D. Acupuncture and the complex connections between the mind and the body. JAMA. 2017;317(24):2489-2490.
Brinkhaus B, Roll S, Jena S, et al. Acupuncture in patients with allergic asthma: a randomized pragmatic trial. Journal of Alternative and Complementary Medicine. 2017;23(4):268-277.
Chan MWC, Wu XY, Wu JCY, et al. Safety of acupuncture: overview of systematic reviews. Scientific Reports. 2017;7(1):3369.
Coyle ME, Stupans I, Abdel-Nour K, et al. Acupuncture versus placebo acupuncture for in vitro fertilisation: a systematic review and meta-analysis. Acupuncture in Medicine. 2021;39(1):20-29.
Hershman DL, Unger JM, Greenlee H, et al. Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: a randomized clinical trial. JAMA. 2018;320(2):167-176.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews. 2016;(6):CD001218. Accessed at cochranelibrary.com on February 12, 2021.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews. 2016;(4):CD007587. Accessed at cochranelibrary.com on February 12, 2021.
MacPherson H, Vertosick EA, Foster NE, et al. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain . Pain. 2017;158(5):784-793.
Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514-530.
Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngology—Head and Neck Surgery. 2015;152(suppl 1):S1-S43.
Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis . The Journal of Pain. 2018;19(5):455-474.
White AR, Rampes H, Liu JP, et al. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews. 2014;(1):CD000009. Accessed at cochranelibrary.com on February 17, 2021.
Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute’s conference on acupuncture for symptom management in oncology: state of the science, evidence, and research gaps. Journal of the National Cancer Institute. Monographs. 2017;2017(52):lgx005.

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Adams D, Cheng F, Jou H, et al. The safety of pediatric acupuncture: a systematic review. Pediatrics. 2011;128(6):e1575-1587.
Candon M, Nielsen A, Dusek JA. Trends in insurance coverage for acupuncture, 2010-2019. JAMA Network Open. 2022;5(1):e2142509.
Cao J, Tu Y, Orr SP, et al. Analgesic effects evoked by real and imagined acupuncture: a neuroimaging study. Cerebral Cortex. 2019;29(8):3220-3231.
Centers for Medicare & Medicaid Services. Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). Accessed at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295 on June 25, 2021.
Chen L, Lin C-C, Huang T-W, et al. Effect of acupuncture on aromatase inhibitor-induced arthralgia in patients with breast cancer: a meta-analysis of randomized controlled trials . The Breast. 2017;33:132-138.
Choi G-H, Wieland LS, Lee H, et al. Acupuncture and related interventions for the treatment of symptoms associated with carpal tunnel syndrome. Cochrane Database of Systematic Reviews. 2018;(12):CD011215. Accessed at cochranelibrary.com on January 28, 2021.
Cui J, Wang S, Ren J, et al. Use of acupuncture in the USA: changes over a decade (2002–2012). Acupuncture in Medicine. 2017;35(3):200-207.
Federman DG, Zeliadt SB, Thomas ER, et al. Battlefield acupuncture in the Veterans Health Administration: effectiveness in individual and group settings for pain and pain comorbidities. Medical Acupuncture. 2018;30(5):273-278.
Feng S, Han M, Fan Y, et al. Acupuncture for the treatment of allergic rhinitis: a systematic review and meta-analysis. American Journal of Rhinology & Allergy. 2015;29(1):57-62.
Franco JV, Turk T, Jung JH, et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database of Systematic Reviews. 2018;(5):CD012551. Accessed at cochranelibrary.com on January 28, 2021.
Freeman MP, Fava M, Lake J, et al. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association task force report. The Journal of Clinical Psychiatry . 2010;71(6):669-681.
Giovanardi CM, Cinquini M, Aguggia M, et al. Acupuncture vs. pharmacological prophylaxis of migraine: a systematic review of randomized controlled trials. Frontiers in Neurology. 2020;11:576272.
Hu C, Zhang H, Wu W, et al. Acupuncture for pain management in cancer: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2016;2016;1720239.
Jiang C, Jiang L, Qin Q. Conventional treatments plus acupuncture for asthma in adults and adolescent: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine . 2019;2019:9580670.
Ji M, Wang X, Chen M, et al. The efficacy of acupuncture for the treatment of sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2015;2015:192808.
Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Annals of Internal Medicine . 2002;136(5):374-383.
Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research. 2020;72(2):149-162.
Langevin H. Fascia mobility, proprioception, and myofascial pain. Life. 2021;11(7):668.
Liu Z, Liu Y, Xu H, et al. Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: a randomized clinical trial. JAMA. 2017;317(24):2493-2501.
MacPherson H, Hammerschlag R, Coeytaux RR, et al. Unanticipated insights into biomedicine from the study of acupuncture. Journal of Alternative and Complementary Medicine. 2016;22(2):101-107.
Maeda Y, Kim H, Kettner N, et al. Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture. Brain. 2017;140(4):914-927.
Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip osteoarthritis. Cochrane Database of Systematic Reviews. 2018;(5):CD013010. Accessed at cochranelibrary.com on February 17, 2021.
Moura CC, Chaves ECL, Cardoso ACLR, et al. Auricular acupuncture for chronic back pain in adults: a systematic review and metanalysis. Revista da Escola de Enfermagem da U S P. 2019;53:e03461.
Nahin RL, Rhee A, Stussman B. Use of complementary health approaches overall and for pain management by US adults. JAMA. 2024;331(7):613-615.
Napadow V. Neuroimaging somatosensory and therapeutic alliance mechanisms supporting acupuncture. Medical Acupuncture. 2020;32(6):400-402.
Patnode CD, Henderson JT, Coppola EL, et al. Interventions for tobacco cessation in adults, including pregnant persons: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325(3):280-298.
Qin Z, Liu X, Wu J, et al. Effectiveness of acupuncture for treating sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2015;2015;425108.
Smith CA, Armour M, Lee MS, et al. Acupuncture for depression. Cochrane Database of Systematic Reviews. 2018;(3):CD004046. Accessed at cochranelibrary.com on January 20, 2021.
US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons. US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.
Vase L, Baram S, Takakura N, et al. Specifying the nonspecific components of acupuncture analgesia. Pain. 2013;154(9):1659-1667.
Wang R, Li X, Zhou S, et al. Manual acupuncture for myofascial pain syndrome: a systematic review and meta-analysis. Acupuncture in Medicine. 2017;35(4):241-250.
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Wu M-S, Chen K-H, Chen I-F, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150367.
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Acknowledgments

NCCIH thanks Pete Murray, Ph.D., David Shurtleff, Ph.D., and Helene M. Langevin, M.D., NCCIH for their review of the 2022 update of this fact sheet.

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

NCCIH has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by NCCIH.

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