* Discuss the methods used in this study to develop the list of occupational health needs arising after disasters.
* Become familiar with the six-phase classification of disasters and the nine categories of occupational health needs developed for the study.
* Review the authors' conclusions on the effectiveness and coverage of the list of occupational health needs, and its appropriate use following disasters.
Various types of disasters such as natural disasters, industrial accidents, and crimes that threaten workers' health occur in the workplace.1 In times of such crises, a broad range of employees engaged in emergency, recovery, or reconstruction work, as well as injured personnel, may suffer adverse health effects from exposure to hazards.
Preparedness, such as developing an emergency response plan and conducting exercises for crisis scenarios, is regarded as an essential element to cope quickly and appropriately with various disaster-related problems.2–5 However, because actual crises do not correspond exactly to planned scenarios, it is also necessary to collect and analyze relevant information to permit appropriate action for particular circumstances. Depending on those circumstances, occupational health specialists are expected to act to protect workers or to minimize deleterious health effects if a disaster occurs. However, because the occupational health specialists at a site may not have directly experienced a crisis situation, they may have to act in a trial-and-error manner when a disaster occurs even if they have undergone basic training. Having a checklist or manual for workplace occupational health services during the phases of disaster and recovery based on the empirical investigation of occupational health needs would allow these occupational health specialists to conduct prevention programs proactively when faced with a disaster in the workplace.
With regard to health issues related to disasters, many studies have been conducted on the long-term health effects on emergency responders,6–12 health effects on local residents after accidents at chemical plants,13,14 and programs dealing with traumatic stress.15–24 Except for studies by external occupational health experts examining the occupational health needs arising at workplaces during large-scale disasters,25,26 few case reports on this matter have been published.27,28 When the cause of the disaster is attributable to errors on the part of the company, they may be reluctant to disclose information on health issues during disasters. For this reason, we explored occupational health needs through a joint analysis of several cases of disaster rather than producing an individual case report for each disaster.
In this study, we made two suppositions: (1) disasters occur in several phases and occupational health needs vary according to those phases and (2) there are points in common related to health issues for workers experiencing different types of disasters. Accordingly, we investigated disasters that occurred in Japanese workplaces and aimed to develop a comprehensive list of occupational health needs that arose during the phases of disaster and recovery.
Composition of Study Team
The study team comprised four senior researchers and seven junior researchers, who accurately described the occupational health needs that arose after disasters and categorized them without preconceptions. The former members had more than 10 years of experience and were certified as specialist occupational physicians by the Japan Society for Occupational Health. Two of them belonged to University of Occupational and Environmental Health, Japan (UOEH) and the others were full-time occupational physicians of private companies. This group had experience with occupational health activities after disasters such as the nuclear disaster at the Fukushima Daiichi Nuclear Power Plant and major industrial accidents.26 The latter members were occupational health residents engaged in postgraduate programs in the UOEH. This group had no experience with disaster activities.
Selection of Disaster Cases
This study examined industrial accidents, natural disasters, and criminal acts that threatened the lives or health of workers in Japan. Because it would have been difficult to obtain detailed information about what occurred after a disaster without a trusting relationship between the researchers and the companies, we selected disaster cases at sites where one of the senior researchers could provide an introduction. We listed applicable cases occurring over the last 4 years that were published with company names on the Japan Advanced Information Center of Safety and Health Web site, operated by the Japan Industrial Safety and Health Association.29 The senior researchers also added their knowledge to the list. From the completed list, we selected 10 sites where one of senior researches had a trusting relationship with the person in charge of occupational safety and health at the company concerned. The researcher with this preexisting contact then asked the relevant companies to participate in the study, and eight agreed to participate. Table 1 presents the details of each case. Among them, four were industrial accidents, one was an industrial accident in conjunction with a natural disaster, two were natural disasters, and one was a criminal act.
Interviews With Site Occupational Health Specialists
Two senior researchers and one junior researcher visited each site to identify the occupational health needs that arose. At each site, they conducted a semistructured interview with an occupational health specialist (the main interviewee) familiar with the health issues that occurred after the disaster. The interviewers asked the interviewee to describe an outline of the disaster and then asked what health issues arose among employees during the disaster and the recovery and what the interviewee had done to protect their health. Other occupational health specialists or general affairs staff members at the sites were permitted to attend these interviews if the main interviewee wished them to do so. In these interviews, the interviewers confirmed the details of the site and the disaster, and they requested that the interviewees describe the workers' health issues that arose after the disaster. Each interview lasted 90 to 120 minutes. All remarks were recorded by means of digital voice recorders, and we generated verbatim reports.
Developing a List of Occupational Health Needs Following Disasters
A list of occupational health needs after disasters was developed in two stages to allow us to estimate how well the list could cover the needs arising in additional cases. We analyzed five cases (cases 1 to 5) in the first stage and three cases (cases 6 to 8) in the second stage. In the first stage, one of the junior researchers read out the verbatim report of each case at a study meeting. When at least one senior researcher identified an item that could be related to workers' health, the full research team discussed whether it could be considered a health issue that resulted from the disaster.
We then developed a new phase classification for analyzing occupational health needs after a disaster. Several time-based classifications of disaster response have been proposed.30–33 However, it may be anticipated that occupational health needs will change according to efforts related to restoration and the resumption of operations and that the time needed for such resumption will differ depending on the level of disaster damage. Therefore, we decided to develop a classification for disasters on the basis of the activities undertaken after a disaster. The progress of operations in typical cases where facilities are severely damaged follows several phases: emergency response, stabilizing work, restoration planning, reoperation preparation, and reoperation. In addition, some needs will arise that are not related to the phases, but with the season when the accident occurs. Consequently, through discussion between the researchers, we developed a new phase classification consisting of five operational phases and seasonality and applied it in this study (Table 2).
We developed a card related to each health issue for the workers at each site (case). If the same health issue extended over two phases, we created a card for each phase. Next, we grouped similar health issues among the different cases, and after discussion among the researchers, we assigned a name to each group of similar health issues. We then took that name as signifying an occupational health need. If there was only one case in which that health issue occurred, we decided—after discussion—whether it was an independent need. We applied the same procedure to identify occupational health needs for each phase. We also classified occupational health needs into categories according to health issues and worker characteristics. We developed a matrix of the phases and categories of health needs, which became our tentative list of occupational health needs after disasters.
In the second stage, we developed a card related to each health issue for each case, using the same method described earlier for the first stage. Then, we discussed whether the issue written on each card was included in one of the needs on the tentative list or should be regarded as a new need. When it was decided that a new need had been identified, we assigned a name signifying that occupational health need and added it to the tentative list. At the end of this stage, we completed the list, the Occupational Health Needs Following Disasters.
This study was approved by the ethical review committee at the UOEH, Japan (H25-098). We obtained prior informed consent before conducting any interviews.
We classified occupational health needs after disasters into nine categories according to health issues and worker characteristics as indicated in Table 3. These categories included establishing routes for sharing necessary information and the infrastructure needed for the provision of occupational services, securing minimum lifelines, and ensuring safety in the work environment. In addition, employees who might suffer from various health issues were classified into five categories on the basis of their characteristics. Using these categories, we identified occupational health needs by phases as follows: nine needs in the “emergency response phase,” 31 needs in the “stabilizing work phase,” 26 needs in the “restoration planning phase,” 17 needs in the “reoperation preparation phase,” 13 needs in the “reoperation phase,” and 4 needs in “seasonality.” Tables 4 and 5 present the Occupational Health Needs in Workplaces Following Disasters, together with phase and category details.
Occupational health staff members established routes for sharing necessary information for providing occupational health services in the emergency response phase and the stabilizing work phase. These routes included collecting information on what had happened at the site, communicating with management and line managers, providing information about access to occupational health services, sharing information among occupational health staff members, and consulting outside specialists on relevant issues. In the reoperation phase, hazard maps and the emergency response manual were reviewed and revised. Occupational health staff members also secured the necessary personnel and materials to deal with arising occupational health needs at the earlier phases and then reconfirmed the roles of staff members and used outside specialist resources to cope with changing needs, mainly related to traumatic stress disorders.
Occupational health specialists advised those in charge to secure a minimum amount of hygienic food, water, and shelter as essential fundamentals for maintaining workers' safety and health during the disaster and recovery and supported them to keep the office environment comfortable during the stabilizing work phase. They also gave advice on hazardous materials at the site to employees, monitored the dispersion if necessary in the earlier phases, and reinforced routine industrial hygiene programs in the reoperation preparation and reoperation phases. Countermeasures against heat illness also became necessary in some cases that occurred in the hot season.
Various types of health issues occurred in employees between the stabilizing work phase and the reoperation preparation phase, and some of these issues continued until the reoperation phase. These health issues were categorized by the interviewees into direct victims and employees exposed to health hazards, employees coping with arising issues such as dealing with complaints from neighbors and care of victims and their families, employees involved in the causes of the disaster, and vulnerable people such as employees who have a history of mental health disorder and who were close friends with direct victims. The health issues experienced changed as time passed. In the earliest phase, occupational health specialists supported injured employees to be treated appropriately. Then, occupational health specialists understood the issues with information from inside and outside, and they took care of the employees with the assistance of outside specialists beginning in the stabilizing work phase. In addition to the care of the specific employees, mental and physical health care programs were provided to other employees directly and through their supervisors. The occupational health specialists prioritized the high-risk groups first, while screening the others, and then provided general health care to all.
Some occupational health needs arose that did not relate to the operational phases but rather to seasons. These needs were the prevention of food poisoning in summer, countermeasures against influenza in winter, and against hay fever in other seasons, and the prevention of heat illness in the summer, as mentioned earlier. They were not direct effects of disasters, but it was necessary to manage them carefully because they affected manpower.
Table 6 presents the total number of occupational health needs and a breakdown by category for the different cases. The percentage of health needs in the Occupational Health Needs in Workplaces Following Disasters that were applicable in each case varied between 13% and 49%. More occupational health needs arose in cases 1 (49%) and 8 (39%) than in the others. These were cases in which the companies were responsible for the disaster and one or more employees lost their lives as a result.
Of the 100 needs listed in the final version, 19 were added in the second stage. The occupational health needs included in the tentative list accounted for 8 of 13 (61.5%), 22 of 30 (73.7%), and 29 of 39 (74.4%) of the total needs in cases 6, 7, and 8, respectively.
Many studies have examined exposure to health hazards6–12 and traumatic stress after disasters,15–24 but few have analyzed disaster-related occupational health needs in workplaces.25–27 This may be because companies are reluctant to disclose data even when various occupational health needs have arisen. Indeed, in some cases in this study, the cause of the disaster was attributable to errors on the part of the company, and it is highly likely that the company would not have agreed to publish a case report about the matter if we had requested that. We therefore developed a study plan that involved a joint analysis of several cases rather than producing a case report for each. With this approach, eight companies consented to participate in the research and for the research team to disclose the results. Consequently, we were able to identify a broad range of occupational health needs through interviews with occupational health specialists familiar with health issues after disasters.
Validity of Phase Classification
In crisis management, phase classification is normally used for taking appropriate action according to the course of events after a disaster. Although many classifications exist,30–34 it was appropriate to develop a phase classification on the basis of our research objectives. Once the conditions after an emergency become stable, work undertaken and psychological factors will be affected by the progress of the restoration and resumption of operations. The time needed to resume operations differs by the type of disaster or degree of damage. We developed a new phase classification because we were unable to find an appropriate phase classification that met our objectives.
Although a fair number of occupational health needs extended over two phases, the needs generally varied according to the phase. The duration of each phase varied depending on the type of disaster and magnitude of damage of the facility or the company's reputation, but at least one need was identified in all phases for all eight cases except for the reoperation phase in case 2. The phase classification developed in this study was appropriate for applying the newly developed list, Occupational Health Needs in Workplaces Following Disasters.
Effectiveness and Coverage of the Occupational Health Needs Following Disasters List
Various types of occupational health needs arose after the disasters, and they changed as the phases progressed. Notably, health effects occurred not only in employees who were exposed to health hazards, but also in a wider range of employees. Health issues experienced by a wider range of employees included coping with arising issues and being involved in the causes of the disaster. Occupational health specialists need to deal with arising health needs in order of priority. To deal with them quickly and appropriately, occupational health specialists should anticipate such needs, and the Occupational Health Needs Following Disasters list developed in this study can be a useful tool for this purpose. However, this list was developed with a limited number of cases and will not necessarily cover all occupational health needs in a new case. Indeed, the tentative list developed in the first stage comprised 81 needs and covered between 60% and 75% of the total needs in the three cases in the second stage. Thus, the final list should not be regarded as covering all occupational health needs subsequent to disasters. Nevertheless, when we provided our final list to full-time occupational physicians at a steelworks on the day of a fire accident in which 15 workers were injured, the physicians gave us extremely positive feedback on the list's effectiveness. We believe that our final list is fairly comprehensive. Still, the maximum percentage of occupational health needs on the list occurring in any one case was 49%, and we observed that the specific health needs that arose differed according to the characteristics of the disaster. Various factors such as the severity of damage, parties responsible for causing the disaster, and the effect on local residents will influence the number and type of needs experienced. This means that only some of the needs on the list will be applicable to any given case.
Use of the List of Occupational Health Needs Following Disasters
The list of Occupational Health Needs Following Disasters will be effective for enabling occupational health specialists to take prompt and effective action in a disaster. However, when referring to the list during a disaster, occupational health specialists need to be aware that it does not cover all occupational health needs and that only some of the needs on the list may apply to a particular case. They should consider critically whether the health needs on the list apply to the case at hand, and also modify their role according to the demands of the situation. Preparedness, such as developing an emergency response plan and conducting exercises, is essential to cope with various disaster-related problems. Emergency and exercise plans should be designed with crisis scenarios, and the list developed in this study can be useful for improving the plans and making them more practical.
On the basis of our list, we are currently developing a manual with the aim of supporting occupational health specialists after disasters. In this manual, we will elaborate on how to use the list for preparedness. After results are available on the practical application of the list and the manual, we plan to use these data to adapt and improve both.
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