Systematic review: Factors related to injuries in small- and medium-sized enterprises.

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.

INTRODUCTION

Globally, small- and medium-sized enterprises (SMEs) are a crucial part of the economy in Europe,[1] the USA,[12] Australia,[3] and Canada.[4] 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.[5] SMEs are also less likely to have formed associations and safety committees because they are difficult to establish given their limited resources.[6] Limited resources and fewer employees pose problems because SMEs may find it difficult to identify expertise and/or leaders in prevention activities.[7] There is evidence that the risk for injury including fatalities occurs at higher rates for SMEs compared to sectors dominated by large-sized organizations.[8] Exacerbating matters is that SMEs are often exempt from occupational health and safety legislation.[6]

A Canadian study identified facilitators and barriers to occupational health and safety in SMEs.[9] The authors reported the importance of regular safety inspections in SMEs in fostering a safe work environment in the municipal, education, and health sectors.[9] 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.[9]

Therefore, interest in SME occupational health and safety has grown considerably in the past decade.[1011] 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.[12]

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.[13] 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)

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.[14]

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:

Exclusion criteria

Studies that cite occupational disease (not injury) in any SME workforce.

Inclusion criteria

Studies written in English

Studies that cite occupational injuries in any SME workforce

Studies on SMEs that had <250 persons employed.[14]

Two reviewers independently extracted all relevant data from eligible studies, and the data were entered and recorded using Rayyan.[15] 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[16] 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.[17]

Table 1

Critical Appraisal Skills Programme questions

Q1. Did the study address a clearly focused issue?

Q2. Did the authors use an appropriate method to answer their question?

Q3. Was the cohort recruited in an acceptable way?

Q4. Was the exposure accurately measured to minimize bias?

Q5. Was the outcome accurately measured to minimize bias?

Q6a. Have the authors identified all important confounding factors?

Q6b. Have they (the authors) taken account of the confounding factors in the design and/or analysis?

Q7a. Was the follow-up of participants complete enough?

Q7b. Was the follow-up of participants long enough?

Q8. What are the results of this study?

Q9. How precise are the results?

Q10. Do you believe the results?

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.[18] 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,[1920] three examined those related to psychological injuries,[102122] and four focused on a combination.[232425] 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

Author, years	Methodology and sample size	Type of injury examined	Antecedent factors to injury	CASP score	Risk of bias
Cheng WC, Leu SS, Lin CC, Fan C (2010) (Taiwan)	Secondary data analysis (n=638,000 construction workers and 8017 SMEs)	Physical (accident type, source of injury)	Occupational injuries in SME occur during the worker’s first day at work, poor working conditions, lack of personal protective re-equipment or its misuse, and when workers failed to espouse safeguards or ignore hazards’ warning signs	8/10	Low risk of bias
Osborne A, Finnegan G, Blake C, Meredoth D, McNamara J, Phelan J, and Cunningham C (2013) (Ireland)	Cross-sectional survey design (n=600)	Physical (low back pain among farmers)	The most common cause of low back pain was lifting/pulling/pushing activities. Low back pain impacts work disability, obtaining help for the farm, changing work habits, and taking time off work	7/10	Low risk of bias
Andersen LP, Kines P, and Hasle P (2007) (Denmark)	Qualitative interviews (n=22 owners)	Psychological (attitudes and self-reported behavior toward modified work)	A major finding of the article was that modified work in small enterprises was possible and was most likely due to the close social and reciprocal interaction between owners and employees	7/10	Low risk of bias
Hasle P, Limborg JH, Kallehave T, Klitgaard C, Anderson RT (2012) (Denmark)	Qualitative interviews (n=23 managers)	Psychological (diminished attitudes toward working environment and OHS regulations)	The majority of participants used a positive approach to the working environment, but also attempted to “talk risk down,” criticized regulation as bureaucracy, and pushed a part of the employer responsibility on to the employees	8/10	Low risk of bias
Moore V, Kaakola M, Burge C, Pantin C, Robertson A, and Burge P (2010) (Northern Ireland)	Interpretive phenomenological with a purposive sample (n=18 SME managers)	Psychological (decreased awareness and lower quality of work life)	Higher awareness activities included sustaining and safeguarding employee occupational health and safety. Low awareness activities included the fostering of training and developing along with managing human resources and environmental conditions	8/10	Low risk of bias
Canton L and Williams W (2012) (New Zealand)	Cross-sectional survey design (n=74)	Physical (hearing loss among dairy farmers) and psychological (anxiety, occupational stress)	Dairy farmers experienced anxiety, stress, resentment, depression, fatigue, and also negative ramifications that lowered their quality of work life. Loss of hearing in the dairy farm is unfortunate for both the individuals and their family	6/10	High risk of bias
Park KO. Human resource factors associated with workplace safety and health education of small manufacturing businesses in Korea (2018) (South Korea)	Secondary data analysis of the 2012 Korea Occupational Safety and Health Trend Survey (n=2089)	Physical and psychological injuries	Health and safety education at work was significantly related to organizational size and occupational injury incidence in the past year	7/10	Low risk of bias
Cagno E, Micheli LJG, Jacinto C, Masi D (2014) (Italy)	Literature review and focus group discussion (expert panel included researchers, SME management, and OHS physician)	Physical and psychological (company culture and economic links, levers*, staff behavior, working environment, labor force characteristics, and organizational factors	Factors related to occupational health and safety included company culture and economy, tools for safety improvement, staff behavior, working environment, labor force description, company characteristics, labor management, and risk level	8/10	Low risk of bias
Micheli G and Cagno E (2010) (Italy)	Secondary data analysis and cross-sectional survey design (n=396 SMEs)	Physical and psychological (number of accidents, accidents)	The frequency of accidents is higher in enterprises of smaller size. There may be less underreporting because of the restrictions in place by the Italian government. Severe accidents that required>40 days of leave from work were more difficult to hide	7/10	Low risk of bias
Nowrouzi et al. (2016) (Canada)	Cross-sectional survey design (n=153)	Physical and psychological (facilitators and barriers to occupational injuries in SME)	Conducting regular external safety inspections of the workplace was associated with a safe work environment	8/10	Low risk of bias

*Levers include health and safety tools available to management to improve health and safety. CASP: Critical Appraisal Skills Programme, SME: Small- and medium-sized enterprise, OHS: Occupational Health and Safety

The physical work environment is an important facilitator of employee health and well-being and may be related to mitigating occupational injuries in SMEs.[26] 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.[27] 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.[27]

Employees in SMEs may be uninformed about the psychological risk factors in their workplaces.[21] 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.[21] 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.[21] 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.[22]

Owner-managers tend to believe that many of the injuries that occur in the workplace are due to the clumsiness of employees.[10] 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.[10]

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.[24] 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.[23] 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.[24]

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.[28] 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.[29] The impacts of noise-induced hearing loss included decreased employment opportunities and loss of productivity and social isolation.[19]

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.[9]

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.[25]

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,[3031] 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.[32] One approach would be to have SMEs merge their resources together to provide services to their employees, including promoting a workplace culture of safety.[3334] 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.

Limitations

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

Nil.

Conflicts of interest

There are no conflicts of interest.