|Year : 2019 | Volume
| Issue : 2 | Page : 57-63
Systematic review: Factors related to injuries in small- and medium-sized enterprises
Behdin Nowrouzi-Kia1, Nirusa Nadesar2, Jennifer Casole3
1 Centre for Research in Occupational Safety and Health, Laurentian University, Sudbury; Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
2 Faculty of Science, McMaster University, Hamilton, Ontario, Canada
3 Department of Special Education, Loretto College, Toronto, Canada
|Date of Web Publication||26-Jun-2019|
Dr. Behdin Nowrouzi-Kia
University of Toronto, Toronto, Ontario
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The purpose of this systematic review was to identify the antecedent factors of workplace injuries in small- and medium-sized enterprises (SMEs). A customized systematic review protocol included the research question, literature search, quality appraisal, data management and extraction, and evidence synthesis. The evidence was evaluated using the Critical Appraisal Skills Programme checklists and the Cochrane Collaboration “Risk of Bias” assessment tools. A total of 1355 articles were identified before duplicate removal. Ten articles were relevant to the study objective. Of these, two articles examined antecedents related to physical injuries, three examined those related to psychological injuries, and four focused on a combination. Antecedent factors included older workers, unsafe acts, unsafe working conditions, accident type and type of work performed, trips and falls, loss in productivity, social isolation, financial stress, and lack of employer support during the return to the workplace. The findings of this systematic review support the need for increased research to identify antecedent factors associated with injury in SMEs. Research should focus on interventions to mitigate injury rates that associate employees with employers, thus promoting collaboration in augmenting health and safety in SMEs.
Keywords: Antecedent factors, injury, medium-sized enterprises, occupational health and safety, small-sized enterprises
|How to cite this article:|
Nowrouzi-Kia B, Nadesar N, Casole J. Systematic review: Factors related to injuries in small- and medium-sized enterprises. Int J Crit Illn Inj Sci 2019;9:57-63
|How to cite this URL:|
Nowrouzi-Kia B, Nadesar N, Casole J. Systematic review: Factors related to injuries in small- and medium-sized enterprises. Int J Crit Illn Inj Sci [serial online] 2019 [cited 2020 Dec 1];9:57-63. Available from: https://www.ijciis.org/text.asp?2019/9/2/57/261462
| Introduction|| |
Globally, small- and medium-sized enterprises (SMEs) are a crucial part of the economy in Europe, the USA,, Australia, and Canada. However, occupational health and safety are worse in SMEs in comparison to large enterprises. For example, fatal accidents are nearly eight times more likely in SMEs and nonfatal injuries are as much as 50% more likely to happen. SMEs are also less likely to have formed associations and safety committees because they are difficult to establish given their limited resources. Limited resources and fewer employees pose problems because SMEs may find it difficult to identify expertise and/or leaders in prevention activities. There is evidence that the risk for injury including fatalities occurs at higher rates for SMEs compared to sectors dominated by large-sized organizations. Exacerbating matters is that SMEs are often exempt from occupational health and safety legislation.
A Canadian study identified facilitators and barriers to occupational health and safety in SMEs. The authors reported the importance of regular safety inspections in SMEs in fostering a safe work environment in the municipal, education, and health sectors. Moreover, studies have identified challenges for SMEs including a lack of financial resources, insufficient expertise in rural areas, challenges with identifying and communicating with SMEs, and the inherently transitory nature of SME.
Therefore, interest in SME occupational health and safety has grown considerably in the past decade., Barbeau et al. suggest that the size of a company should not be a barrier to putting forth occupational health and safety standards. Rather, the barriers seem to include unclear roles and responsibilities, insufficient training, and often greater pressure for task completion and production.
The purpose of this systematic review was to identify the antecedent factors related to workplace injuries in SMEs.
| Methodology|| |
A systematic literature search was conducted using the following databases: Ovid Medline (1946 to present), Embase (1980 to present), and CINAHL and PsychInfo (1806 to present) to identify all articles (regardless of publication date) associated with workplace injuries in SMEs. A total of 1354 articles were collected, and all articles were restricted to English language using a population or problem intervention or exposure comparison outcome (PICO) framework to refine and execute the search strategy. The approach was adapted according to the requirements of each database [for the full search strategy, Appendix 1]. The search syntax was verified with the assistance of a second librarian using the Canadian Agency for Drugs and Technologies in Health Peer Review Checklist for Search Strategies. Letters, conference proceeding abstracts, and unpublished manuscripts/theses were excluded. Moreover, all search strategies were verified October 17, 2016, and the search was updated on December 12, 2017 [Figure 1]. After duplicates were excluded from the review, the articles were screened based on relevance and were removed based on inclusion criteria. The systematic review was also registered with the PROSPERO with the following registration number: CRD42018108111.
|Figure 1: PRISMA flow diagram of the inclusion process.|
*References included per database before removing duplicates: Medline (404), PsycINFO (121), CINAHL (157), Embase (673)
Click here to view
This systematic review used the European Union definition of SMEs: SMEs have <250 persons employed, micro enterprises are those with <10 employees, whereas small enterprises are those with between 1 and 49 employees and medium-sized enterprises are those with 50–249 employees.
Studies included in this review were those assessing occupational injury due to physical, chemical, biological, and psychological or a combination of these factors that lead to a workplace injury in any sector as long as it includes SMEs. In addition, the studies included in this review had to have been written in English. The screening criteria for the relevant literature were the following:
- Studies that cite occupational disease (not injury) in any SME workforce.
- Studies written in English
- Studies that cite occupational injuries in any SME workforce
- Studies on SMEs that had <250 persons employed.
Two reviewers independently extracted all relevant data from eligible studies, and the data were entered and recorded using Rayyan. Data were extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Data extracted included study design and process; results, facilitators, and barriers of injuries in SMEs; and study findings and outcomes. For the first stage of screening, two reviewers independently read the titles and abstracts of all the citations from the electronic repository and removed all citations not related to facilitators and barriers to injuries in SME. In the second stage of screening, if the title and abstract showed that the study might meet the inclusion criteria, then each reviewer examined the full article. Disagreements were discussed and resolved on a consensus basis with the rest of the research team. A total of 19 disagreements were identified during the inclusion process and reviewed with the research team.
The Critical Appraisal Skills Programme (CASP) checklist was used to assess the study quality by guiding the assessment of validity and reliability of the included studies [Table 1] in two stages. The CASP checklist was applied to various study designs (e.g., randomized controlled trials, systematic reviews, and observational studies) in this systematic review. During the first stage, each reviewer read the title and abstract of all the citations retrieved. During the second stage, each reviewer critically reviewed the full-text articles and identified facilitators and barriers to occupational injuries identified in each study related to SMEs. All data analyses were conducted using the statistical program R.
The risk for bias was assessed using the Cochrane Collaboration “Risk of bias” assessment tool across six domains of bias including selection, performance, detection, attrition, presorting, and other. Furthermore, a reviewer rated a study as “unclear” risk if there were insufficient information regarding the six domains of bias. Disagreements were discussed and resolved with the research team. A total of two disagreements regarding the “Risk of bias” were identified and reviewed with the research team.
| Results|| |
A total of ten articles were critically examined and reviewed from across the globe (North America, Europe, Asia, and Oceania). Of these, two articles examined antecedents related to physical injuries,, three examined those related to psychological injuries,,, and four focused on a combination.,, Regarding the quality appraisal of each article, the average CASP score was 7.40 (±0.70) out of 10, with a range of scores between 6 and 8. The articles were categorized based on antecedent factors related to injury (e.g., physical, psychological, or combination) identified in the study [Table 2].
|Table 2: Study characteristics and types of injury examined in small- and medium-sized enterprises|
Click here to view
The physical work environment is an important facilitator of employee health and well-being and may be related to mitigating occupational injuries in SMEs. In the absence of a healthy workplace setting (e.g., ergonomics, proper functioning equipment), injuries are more likely. An analysis of correlation coefficients identified older workers, unsafe acts, unsafe working conditions, accident type, and type of work performed as antecedent factors associated with physical injuries. Another study in Ireland investigated the factors associated with low back pain in this type of farming environment. The study identified repeated activities including lifting/pushing/pulling, animal handling, tractor driving, and trips/slips/falls as statistically significant antecedents of physical injuries in SMEs.
Employees in SMEs may be uninformed about the psychological risk factors in their workplaces. Qualitative approaches have been used to explore owners' perspectives on occupational health and safety and injury. In 2007, a qualitative study explored owners' behaviors and attitudes toward modified work in the Danish metal and construction industries following a physical injury. Some examples of the antecedent factors associated with injury include whether the employees have mentally recovered from their injuries and their mental well-being after recovering from their injury. In Northern Ireland, SME managers identified the need to protect and preserve employees, prevent their injury, and promote their quality of daily living through workplace health promotion in SME.
Owner-managers tend to believe that many of the injuries that occur in the workplace are due to the clumsiness of employees. One of the ways owner-managers addressed health and safety was avoidance or taking minimal control of the identified needs due to their belief that it was a waste of time and money. Some owner-managers reported complying with occupational health and safety legislation, whereas others believed that it would contribute to the success of their business.
Micheli and Cagno (2014) proposed a model of safety performance in SME and identified eight antecedents that contribute most saliently to the safety performance and occupational injuries of SMEs. The eight factors include company culture, levers, staff behavior, working environment, labor force characteristics, company and local characteristics, labor recruitment and retention, and frequency of accidents. Evidence also suggest that injury rates may be related to the size of SMEs, with ten or less employees experiencing higher injury rates compared to those between 10–50 and 5–250 employees.
Safety and health education at work (SHEW) was found to be significantly associated with the incidence of injury in SME. A study of 2089 South Korean supervisors and managers reported that 75.3% of the respondents identified safety and health human resources as essential antecedent factors related to injury prevention and safety and health in the workplace. The majority of SMEs had fewer than thirty employees (77.8%) and 15.0% reported the occurrence of an occupational injury in the previous year. A lack of SHEW was associated more with an increased likelihood for occupational injury in the previous year (odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.27–2.21). A New Zealand study examined noise-induced hearing loss among farmers and demonstrated a need for safety education. The impacts of noise-induced hearing loss included decreased employment opportunities and loss of productivity and social isolation.
A Canadian study examined barriers and facilitators as antecedent factors to occupational injury among SMEs in the education, health, and municipal government sectors. The findings emphasized the importance of regular safety inspections (OR 2.88, 95% CI: 1.57–5.27) in SMEs in fostering a safe work environment in the municipal, education, and health sectors.
| Discussion|| |
To the best of our knowledge, this is the first systematic review of the types of occupational injuries in SMEs. The purpose of this systematic review was to identify the antecedent factors of workplace injuries in SMEs. The categorization of these antecedent factors (e.g., physical, psychological, or a combination) identifies indicators that may be used in developing and implementing an injury prevention approach in SME.
Our review identified numerous antecedent factors related to occupational injuries in SMEs (e.g., type of occupation, equipment, physical and psychological factors, attitudes and perceptions toward occupational health and safety, work modifications, and accommodations). Moreover, we did find that SMEs face more hardship in controlling for occupational health and safety compared to larger enterprises due to some limitations. For example, the lack of resources plays a significant role in SMEs in properly identifying and monitoring injuries.
To identify the types of injuries in SMEs and explain their potential influence on workplace policies and procedures, there is a need to create a framework that is specific to the sources of injury among SME employees. In this systematic review, we identified antecedent factors in Oceania, Europe, and North America, largely because of established occupational health and safety legislation, policy, or procedures. These rules provide a framework for the identification and monitoring of occupational injuries. Such a framework considers the various stakeholders (e.g., health care, government, employers and employees, and workers' compensation boards) to address the issues of injury in SMEs.
We encourage research that involves SMEs as well as respective governments in the development and implementation phases in the identification of factors related to occupational injuries. This is particularly important in building partnerships and community capacity, considering stakeholder views and providing opportunities for active and meaningful participation. In developed economies, the framework may be used as a primer to discuss the occupational health and safety challenges of SMEs to meet their unique needs such as the lack of human and financial resources and the transitory nature of SME (i.e., appearing and disappearing quickly) before safety issues are identified. Moreover, it may be used to develop legislation that deals specifically with the unique challenges facing SMEs. While these programs have been piloted and tested in various jurisdictions, there is limited empirical evidence examining their effectiveness regarding reducing occupational injuries among SMEs and in promoting healthy workers and workplaces.
In emerging economies, occupational health and safety legislation is limited,, as such, restricting the degree to which facilitators and barriers to occupational injuries can be identified in SMEs. Such legislation is particularly important in comparing factors associated with injuries in developed and emerging countries given the vast differences in regulations and resources. For example, Nelson et al. found that SMEs lack the appropriate resources to implement health promotion strategies. One approach would be to have SMEs merge their resources together to provide services to their employees, including promoting a workplace culture of safety., Moreover, there is a dearth of research examining the health and safety of workers and their workplaces in emerging economies. The need in emerging economies is on the identification of factors and hazards associated with injuries in SME, whereas in developed economies, the focus is shifting toward a work disability prevention paradigm. This paradigm applies to all countries and must be the focus of policy that focuses on SMEs' occupational health and safety.
Some factors limited this review. First, only articles written in English language were included from the databases queried for this systematic review. In addition, most of the literatures published focused on developed economies, and therefore the drivers and protective factors of injury are likely different in other areas of the world and require additional research capacity in these settings.
| Conclusion|| |
Scientific inquiry in occupational health and safety has focused on large enterprises where it is relatively easy to obtain large sample sizes. While SMEs play a crucial role in the economy, occupational health and safety issues in these settings are often ignored or lumped together with larger enterprises. Stakeholders involved in implementing preventative measures need to understand its importance to employers and employees and the success of the enterprise, particularly in emerging economies where such evidence is lacking. This review's main purpose has been met through a systematic review and evaluation of the existing literature to identify the antecedent factors of workplace injuries in SMEs. Furthermore, the review provides support to employers and owners as to why it is essential to discuss occupational health and safety standards in the workplace in SMEs.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation did not require Institutional Review Board / Ethics Committee review.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Appendix 1: Search syntax
((occupational health*)) OR ((occupational safety*)) OR ((workplace hazard*)) OR ((workplace illness*)) OR ((occupational accident*)) OR ((workplace accident*)) OR ((occupational safety)) OR ((occupation prevention*)) OR ((occupation hazard*)) OR ((occupation accident*)) OR (workplace adj3 (inur* and caus*)) OR (occupation adj3 (injur* and cause*)) OR (occupation adj3 (injur* and risk*)) OR (workplace adj3 (injur* and risk*)) OR (workplace adj3 injur* and damage*)) OR (occupation adj3 injur* and damage*)) AND ((small enterprise*)) OR ((small business*)) OR ((family business*)) OR (famil* business)) OR ((self-employ)) OR (contractor*))
((occupational health*)) OR ((occupational safety*)) OR ((workplace hazard*)) OR ((workplace illness*)) OR ((occupational accident*)) OR ((workplace accident*)) OR ((occupational safety)) OR ((occupation prevention*)) OR ((occupation hazard*)) OR ((occupation accident*)) OR (workplace adj3 (inur* and caus*)) OR (occupation adj3 (injur* and cause*)) OR (occupation adj3 (injur* and risk*)) OR (workplace adj3 (injur* and risk*)) OR (workplace adj3 injur* and damage*)) OR (occupation adj3 injur* and damage*)) AND (medium adj3 (enterprise* OR business* OR family business* OR (famil* business* OR self-employ* OR contractor*))
(“small business”) OR (“small enterprise*”) OR (“family business*” OR (“contractor”) OR (“small-size* enterprise*”) AND (MH “Occupational Health+”) OR (“occupation* health”) OR (MH “Occupational safety”) OR (“occupation* safety”) OR (“workplace hazard”) OR (“workplace injury”) OR (MH “accidents, occupational”) OR (MH “Occupational-related injuries”) OR (MH Occupational safety”) OR (“occupation* AND safety”) OR (TI “occupation*” N3 “accident*”) OR (AB “occupation*” N3 “accident*”) OR (TI “occupation*” N3 “illness*”) OR (AB “occupation*” N3 “illness*”) OR (TI “workplace” N3 “illness*”) OR (AB “workplace” N3 “illness*”) OR ((TI “occupation*” (“injur*” AND “risk*”))) OR ((AB “occupation*” (“injur*” AND “risk*”))) OR (“occupational (injur* and caus*)”
(“medium enterprise*”) OR (“medium business*”) OR (TI “medium-size* business*”) OR (AB “medium-size* business*”) AND MH “Occupational Health+”) OR (“occupation* health”) OR (MH “Occupational safety”) OR (“occupation* safety”) OR (“workplace hazard”) OR (“workplace injury”) OR (MH “accidents, occupational”) OR (MH “Occupational-related injuries”) OR (MH Occupational safety”) OR (“occupation* AND safety”) OR (TI “occupation*” N3 “accident*”) OR (AB “occupation*” N3 “accident*”) OR (TI “occupation*” N3 “illness*”) OR (AB “occupation*” N3 “illness*”) OR (TI “workplace” N3 “illness*”) OR (AB “workplace” N3 “illness*”) OR ((TI “occupation*” (“injur*” AND “risk*”))) OR ((AB “occupation*” (“injur*” AND “ isk*”))) OR (“occupational (injur* and caus*)”
| References|| |
de Boer WE, Mousavi SM, Delclos GL, Benavides FG, Lorente M, Kunz R, et al.
Expectation of sickness absence duration: A review on statements and methods used in guidelines in Europe and North America. Eur J Public Health 2016;26:306-11.
Milner A, Butterworth P, Bentley R, Kavanagh AM, LaMontagne AD. Sickness absence and psychosocial job quality: An analysis from a longitudinal survey of working Australians, 2005-2012. Am J Epidemiol 2015;181:781-8.
Maiwald K, Meershoek A, de Rijk A, Nijhuis FJ. Policy on professional support in return-to-work: Occupational health professionals' experiences in a Canadian setting. Work 2015;53:143-56.
Tremblay A, Badri A. Assessment of occupational health and safety performance evaluation tools: State of the art and challenges for small and medium-sized enterprises. Saf Sci 2018;101:260-7.
Hasle P, Limborg HJ. A review of the literature on preventive occupational health and safety activities in small enterprises. Ind Health 2006;44:6-12.
Cunningham TR, Sinclair R, Schulte P. Better understanding the small business construct to advance research on delivering workplace health and safety. Small Enterprise Research 2014;21:148-60.
Eakin JM, Champoux D, MacEachen E. Health and safety in small workplaces: refocusing upstream. Canadian Journal of Public Health 2010;101:S29-33.
Nowrouzi B, Gohar B, Nowrouzi-Kia B, Garbaczewska M, Chapovalov O, Myette-Côté É, et al
. Facilitators and barriers to occupational health and safety in small and medium-sized enterprises: a descriptive exploratory study in Ontario, Canada. International journal of occupational safety and ergonomics 2016;22:360-6.
Hasle P, Limborg HJ, Kallehave T, Klitgaard C, Andersen TR. The working environment in small firms: Responses from owner-managers. Int Small Bus J 2012;30:622-39.
Tremblay J-C, Gauthier F. Safety of machinery in hospitals: An exploratory study in the province of Quebec. Can Saf Sci 2018;103:207-17.
Pingqing L, Fang L, Chunjing G. Occupational health and safety (OHS) in Small and medium size enterprises (SMEs): A primary review. Can Soc Sci 2006;2:7.
Canadian Agency for Drugs and Technologies in Health. CADTH Peer Review Checklist for Search Strategies. Ottawa, Ontario, Canada: Canadian Agency for Drugs and Technologies in Health; 2013.
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016;5:210.
Critical Appraisal Skills Programme (CASP) Checklist. Critical Appraisal Skills Programme (CASP) Checklist. Middle Way, Oxford, United Kingdom: Critical Appraisal Skills Programme UK; 2016.
R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2016.
Cheng CW, Lin CC, Leu SS. Use of association rules to explore cause-effect relationships in occupational accidents in the Taiwan construction industry. Saf Sci 2010;48:436-44.
Osborne A, Finnegan G, Blake C, Meredith D, McNamara J, Phelan J, et al
. An evaluation of low back pain among farmers in Ireland. Occupational medicine 2012;63:53-9.
Andersen LP, Kines P, Hasle P. Owner attitudes and self reported behavior towards modified work after occupational injury absence in small enterprises: A qualitative study. J Occup Rehabil 2007;17:107-21.
Moore A, Parahoo K, Fleming P. Workplace health promotion within small and medium-sized enterprises. Health Educ 2010;110:61-76.
Cagno E, Micheli GJ, Jacinto C, Masi D. An interpretive model of occupational safety performance for small – And medium-sized enterprises. Int J Ind Ergon 2014;44:60-74.
Cagno E, Micheli GJ, Jacinto C, Masi D. An interpretive model of occupational safety performance for Small-and Medium-sized Enterprises. International Journal of Industrial Ergonomics 2014;44:60-74.
Nowrouzi B, Gohar B, Nowrouzi-Kia B, Garbaczewska M, Chapovalov O, Myette-Côté É, et al.
Facilitators and barriers to occupational health and safety in small and medium-sized enterprises: A descriptive exploratory study in Ontario, Canada. Int J Occup Saf Ergon 2016;22:360-6.
Makin A, Winder C. A new conceptual framework to improve the application of occupational health and safety management systems. Saf Sci 2008;46:935-48.
Osborne A, Finnegan G, Blake C, Meredith D, McNamara J, Phelan J, et al.
An evaluation of low back pain among farmers in Ireland. Occup Med (Lond) 2013;63:53-9.
Park KO. Human resource factors associated with workplace safety and health education of small manufacturing businesses in Korea. J Occup Health 2018;60:94-101.
Canton K, Williams W. The consequences of noise-induced hearing loss on dairy farm communities in New Zealand. J Agromedicine 2012;17:354-63.
Meswani HR. Safety and occupational health: Challenges and opportunities in emerging economies. Indian J Occup Environ Med 2008;12:3-9.
] [Full text]
Taner MT, Mihci H, Gamze K. A comparative study between human development index and work accidents in Turkey and the EU member countries. J Res Bus Econ Manag 2015;4:274-88.
Nelson CC, Allen JD, McLellan D, Pronk N, Davis KL. Integrating health promotion and occupational safety and health in manufacturing worksites: Perspectives of leaders in small-to-medium sized businesses. Work 2015;52:169-76.
Schmidt L, Sjöström J, Antonsson AB. Is ownership the decisive factor in collaborations between occupational health services and client companies? Work 2017;56:309-18.
Grooten WJ, Müller M, Forsman M, Kjellberg K, Toomingas A, Björn Olov Š, et al.
Health risk appraisals in Swedish occupational health services. Work 2016;55:849-59.
[Table 1], [Table 2]