Protecting healthcare workers during a pandemic: what can a WHO collaborating centre research partnership contribute?

Objectives: To ascertain whether and how working as a partnership of two World Health Organization collaborating centres (WHOCCs), based respectively in the Global North and Global South, can add insights on "what works to protect healthcare workers (HCWs) during a pandemic, in what contexts, using what mechanism, to achieve what outcome". Methods: A realist synthesis of seven projects in this research program was carried out to characterize context (C) (including researcher positionality), mechanism (M) (including service relationships) and outcome (O) in each project. An assessment was then conducted of the role of the WHOCC partnership in each study and overall. Results: The research found that lower-resourced countries with higher economic disparity, including South Africa, incurred greater occupational health risk and had less acceptable measures to protect HCWs at the onset of the COVID-19 pandemic than higher-income more-equal counterpart countries. It showed that rigorously adopting occupational health measures can indeed protect the healthcare workforce; training and preventive initiatives can reduce workplace stress; information systems are valued; and HCWs most at-risk (including care aides in the Canadian setting) can be readily identified to trigger adoption of protective actions. The C-M-O analysis showed that various ways of working through a WHOCC partnership not only enabled knowledge sharing, but allowed for triangulating results and, ultimately, initiatives for worker protection. Conclusions: The value of an international partnership on a North-South axis especially lies in providing contextualized global evidence regarding protecting HCWs as a pandemic emerges, particularly with bi-directional cross-jurisdiction participation by researchers working with practitioners.

Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country?

BACKGROUND: Notwithstanding extensive general discussion of the effects of upstream forces on health, there has been limited empirical examination, let alone systematic evidence documenting policy responses to such pathways in the area of tuberculosis (TB) management and control. Our study aimed to gain insight into how macro level drivers of TB are perceived by key stakeholders involved in TB management and control in a high-endemic country, and to assess how such concerns are being addressed in policy initiatives in this setting. South Africa was chosen for this case study due to our team's long-standing collaborations there, its very high burden of TB, and its introduction of a strategic plan to combat this disease. METHOD: Semi-structured interviews were conducted with 20 key informants who were purposively selected for their knowledge and expertise of TB in South Africa. South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 was then reviewed to examine how identified themes from the interviews were reflected in this policy document. RESULTS: A history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges including TB governance, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be major drivers of the epidemic. Although South Africa's current National Strategic Plan makes a firm discursive commitment to addressing the structural or macro-level drivers of TB, our analysis revealed that this commitment was not clearly reflected in projected budgetary allocations. CONCLUSION: As in many other high burden settings, macro-level drivers of TB are widely recognized. Nonetheless, while micro-level (biomedical and clinical) measures, such as improving diagnostic procedures and investment in more efficacious drugs, are being (and well should be) implemented, our findings showed that macro-level drivers of TB are underrepresented in budgeting allocations for initiatives to combat this disease. Although it could be argued that structural drivers that undermine health-promoting actions are beyond the purview of the health sector itself, we argue that strategic plans to combat TB in high burden settings need more attention to directly considering such drivers to prompt the necessary changes and reduce the burden of this and other such diseases.

Predictors of household food insecurity and relationship with obesity in First Nations communities in British Columbia, Manitoba, Alberta and Ontario.

OBJECTIVE: To further understandings of household food insecurity in First Nations communities in Canada and its relationship with obesity. DESIGN: Analysis of a cross-sectional dataset from the First Nations Food, Nutrition and Environment Study representative of First Nations communities south of the 60th parallel. Multivariate logistic regression was used to assess associations between food insecurity and sociodemographic factors, as well as the odds of obesity among food-insecure households adjusting for sociodemographic characteristics. SETTING: Western and Central Canada. PARTICIPANTS: First Nations peoples aged ≥19 years. RESULTS: Forty-six percent of First Nations households experienced food insecurity. Food insecurity was highest for respondents who received social assistance; had ≤10 years of education; were female; had children in the household; were 19-30 years old; resided in Alberta; and had no year-round road access into the community. Rates of obesity were highest for respondents residing in marginally food-insecure households (female 56·6 %; male 54·6 %). In gender-specific analyses, the odds of obesity were highest among marginally food-insecure households in comparison with food-secure households, for both female (OR 1·57) and male (OR 1·57) respondents, adjusting for sociodemographic variables. For males only, those in severely food-insecure (compared with food-secure) households had lower odds of obesity after adjusting for confounding (OR 0·56). CONCLUSIONS: The interrelated challenges of food insecurity and obesity in First Nations communities emphasise the need for Indigenous-led, culturally appropriate and food sovereign approaches to food security and nutrition in support of holistic wellness and prevention of chronic disease.

Organizational factors associated with health worker protection during the COVID-19 pandemic in four provinces of South Africa.

BACKGROUND: Health workers, in short supply in many low-and-middle-income countries, are at increased risk of SARS-CoV-2 infection. This study aimed to assess how South Africa, prepared to protect its health workers from SARS-CoV-2 infection. METHODS: This was a cross-sectional study design applying participatory action research in four provinces of South Africa. A semi-structured questionnaire and a qualitative observational HealthWISE walkthrough risk assessment was carried out to collect data on occupational safety and health (OSH) systems in 45 hospitals across four provinces to identify factors associated with health worker protection. Adapting the International Labour Organization (ILO) and World Health Organization (WHO) HealthWISE tool, we compiled compliance scores through walkthrough surveys. We used logistic regression to analyze the relationship between readiness indicators and the actual implementation of protective measures. RESULTS: We found that health facilities in all four provinces had SARS-CoV-2 plans for the general population but no comprehensive OHS plan for health workers. Provincial Departments of Health (PDoH) varied in how they were organized to respond: Provinces A and D had an OSH SARS-CoV-2 provincial coordinating team and a dedicated budget for occupational health; Province A had an occupational health doctor and nurse; while Province B had an occupational health nurse; Province A and D PDoHs had functional OSH committees; and Province D had conducted some health risk assessments specific to SARS-CoV-2. However, none of the assessed health facilities had an acceptable HealthWISE compliance score (≥ 75%) due to poor ventilation and inadequate administrative control measures. While the supply of personal protective equipment was adequate, it was often not worn properly. Our study found that having an OSH SARS-CoV-2 policy was significantly associated with higher personal protective equipment and ventilation scores. In addition, our analysis showed that hospitals with higher compliance scores had significantly lower infection rates (IRR 0.98; 95% CI: 0.97, 0.98). CONCLUSIONS: Despite some initial preparedness, greater effort to protect health workers is still warranted. Low-and-middle-income countries may need to pay more attention to OSH systems and consider using tools, such as ILO/WHO HealthWISE tool, to protect health workers' health.

Correction to: Tackling injustices of occupational lung disease acquired in South African mines: recent developments and ongoing challenges.

Following publication of the original article [1], the author has request the addition of 'Deputy' to endnote number 1 (addition highlighted in bold).

Tackling injustices of occupational lung disease acquired in South African mines: recent developments and ongoing challenges.

BACKGROUND: South Africa's mineral resources have produced, and continue to produce, enormous economic wealth; yet decades of colonialism, apartheid, capital flight, and challenges in the neoliberal post-apartheid era have resulted in high rates of occupational lung disease and low rates of compensation for ex-miners and their families. Given growing advocacy and activism of current and former mine workers, initiatives were launched by the South African government in 2012 to begin to address the legacy of injustice. This study aimed to assess developments over the last 5 years in providing compensation, quantify shortfalls and explore underlying challenges. METHODS: Using the database with compensable disease claims from over 200,000 miners, the medical assessment database of 400,000 health records and the employment database with 1.6 million miners, we calculated rates of claims, unpaid claims and shortfall in claim filing for each of the southern African countries with at least 25,000 miners who worked in South African mines, by disease type and gender. We also conducted interviews in Johannesburg, Eastern Cape, Lesotho and a local service unit near a mine site, supplemented by document review and auto-reflection, adopting the lens of a critical rights-based approach. RESULTS: By the end of 2017, 111,166 miners had received compensation (of which 55,864 were for permanent lung impairment, and another 52,473 for tuberculosis), however 107,714 compensable claims remained unpaid. Many (28.4%) compensable claims are from Mozambique, Lesotho, Swaziland, Botswana and elsewhere in southern Africa, a large proportion of which have been longstanding. A myriad of diverse systemic barriers persist, especially for workers and their families outside South Africa. Calculating predicted burden of occupational lung disease compared to compensable claims paid suggests a major shortfall in filing claims in addition to the large burden of still unpaid claims. CONCLUSION: Despite progress made, our analysis reveals ongoing complex barriers and illustrates that the considerable underfunding of the systems required for sustained prevention and social protection (including compensation) needs urgent attention. With class action suits in the process of settlement, the globalized mining sector is now beginning to be held accountable. A critical rights-based approach underlines the importance of ongoing concerted action by all.

Protecting health workers from infectious disease transmission: an exploration of a Canadian-South African partnership of partnerships.

BACKGROUND: Health workers are at high risk of acquiring infectious diseases at work, especially in low and middle-income countries (LMIC) with critical health human resource deficiencies and limited implementation of occupational health and infection control measures. Amidst increasing interest in international partnerships to address such issues, how best to develop such collaborations is being actively debated. In 2006, a partnership developed between occupational health and infection control experts in Canada and institutions in South Africa (including an institute with a national mandate to conduct research and provide guidance to protect health workers from infectious diseases and promote improved working conditions). This article describes the collaboration, analyzes the determinants of success and shares lessons learned. METHODS: Synthesizing participant-observer experience from over 9 years of collaboration and 10 studies already published from this work, we applied a realist review analysis to describe the various achievements at global, national, provincial and hospital levels. Expectations of the various parties on developing new insights, providing training, and addressing service needs were examined through a micro-meso-macro lens, focusing on how each main partner organization contributed to and benefitted from working together. RESULTS: A state-of-the-art occupational health and safety surveillance program was established in South Africa following successful technology transfer from a similar undertaking in Canada and training was conducted that synergistically benefitted Northern as well as Southern trainees. Integrated policies combining infection control and occupational health to prevent and control infectious disease transmission among health workers were also launched. Having a national (South-South) network reinforced by the international (North-south) partnership was pivotal in mitigating the challenges that emerged. CONCLUSIONS: High-income country partnerships with experience in health system strengthening - particularly in much needed areas such as occupational health and infection control - can effectively work through strong collaborators in the Global South to build capacity. Partnerships are particularly well positioned to sustainably reinforce efforts at national and sub-national LMIC levels when they adopt a "communities of practice" model, characterized by multi-directional learning. The principles of effective collaboration learned in this "partnership of partnerships" to improve working conditions for health workers can be applied to other areas where health system strengthening is needed.

Carbon pollution increases health inequities: lessons in resilience from the most vulnerable.

Climate change is a social justice as well as an environmental issue. The magnitude and pattern of changes in weather and climate variables are creating differential exposures, vulnerabilities, and health risks that increase stress on health systems while exacerbating existing and creating new health inequities. Examples from national and local health adaptation projects highlight that developing partnerships across sectors and levels are critical for building climate-resilient health systems and communities. Strengthening current and implementing new health interventions, such as using environmental information to develop early warning systems, can be effective in protecting the most vulnerable. However, not all projected risks of climate change can be avoided by climate policies and programs, so health system strengthening is also critical. Applying a health inequity lens can reduce current vulnerabilities while building resilience to longer-term climate change. Taking inequities into account is critical if societies are to effectively prepare for and manage the challenges ahead.

Barriers to HIV counseling and testing uptake by health workers in three public hospitals in Free State Province, South Africa.

Recent WHO/ILO/UNAIDS guidelines recommend priority access to HIV services for health care workers (HCWs), in order to retain and support HCWs, especially those at risk of occupationally acquired tuberculosis (TB). The purpose of this study was to identify barriers to uptake of HIV counselling and testing (HCT) services for HCWs receiving HCT within occupational health units (OHUs). Questions were included within a larger occupational health survey of a 20% quota sample of HCWs from three public hospitals in Free State Province, South Africa. Of the 978 respondents, nearly 65% believed that their co-workers would not want to know their HIV status. Barriers to accessing HCT at the OHU included ambiguity over whether antiretroviral treatment was available at the OHU (only 51.1% knew), or whether TB treatment was available (55.5% knew). Nearly 40% of respondents perceived that stigma as a barrier. When controlling for age and race, the odds of perceiving HIV stigma in the workplace among patient-care health care workers (PCHWs) were 2.4 times that for non-PCHWs [95% confidence interval (CI): 1.80-3.15]. Of the 692 survey respondents who indicated a reason for not using HIV services at the OHU, 38.9% felt that confidentiality was the reason cited. Among PCHWs, the adjusted odds of expressing concern that confidentiality may not be maintained in the OHU were 2.4 times (95% CI: 1.8-3.2) that of non-PCHWs and were higher among Black [odds ratio (OR): 2.7, CI: 1.7-4.2] and Coloured HCWs (OR: 3.0, 95% CI: 1.6-5.6) as compared to White HCWs, suggesting that stigma and confidentiality concerns are still barriers to uptake of HCT. Campaigns to improve awareness of HCT and TB services offered in the OHUs, address stigma and ensure that the workforce is aware of the confidentiality provisions that are in place are warranted.

Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program.

BACKGROUND: Focus on "social determinants of health" provides a welcome alternative to the bio-medical illness paradigm. However, the tendency to concentrate on the influence of "risk factors" related to living and working conditions of individuals, rather than to more broadly examine dynamics of the social processes that affect population health, has triggered critical reaction not only from the Global North but especially from voices the Global South where there is a long history of addressing questions of health equity. In this article, we elaborate on how focusing instead on the language of "social determination of health" has prompted us to attempt to apply a more equity-sensitive approaches to research and related policy and praxis. DISCUSSION: In this debate, we briefly explore the epistemological and historical roots of epidemiological approaches to health and health equity that have emerged in Latin America to consider its relevance to global discourse. In this region marked by pronounced inequity, context-sensitive concepts such as "collective health" and "critical epidemiology" have been prominent, albeit with limited acknowledgement by the Global North. We illustrate our attempts to apply a social determination approach (and the "4 S" elements of bio-Security, Sovereignty, Solidarity and Sustainability) in five projects within our research collaboration linking researchers and knowledge users in Ecuador and Canada, in diverse settings (health of healthcare workers; food systems; antibiotic resistance; vector borne disease [dengue]; and social circus with street youth). CONCLUSIONS: We argue that the language of social determinants lends itself to research that is more reductionist and beckons the development of different skills than would be applied when adopting the language of social determination. We conclude that this language leads to more direct analysis of the systemic factors that drive, promote and reinforce disparities, while at the same time directly considering the emancipatory forces capable of countering negative health impacts. It follows that "reverse innovation" must not only recognize practical solutions being developed in low and middle income countries, but must also build on the strengths of the theoretical-methodological reasoning that has emerged in the South.

Occupational Health Barriers in South Africa: A Call for Ubuntu.

Many low- and middle-income countries (LMICs) grapple with shortages of health workers, a crucial component of robust health systems. The COVID-19 pandemic underscored the imperative for appropriate staffing of health systems and the occupational health (OH) threats to health workers. Issues related to accessibility, coverage, and utilization of OH services in public sector health facilities within LMICs were particularly accentuated during the pandemic. This paper draws on the observations and experiences of researchers engaged in an international collaboration to consider how the South African concept of Ubuntu provides a promising way to understand and address the challenges encountered in establishing and sustaining OH services in public sector health facilities. Throughout the COVID-19 pandemic, the collaborators actively participated in implementing and studying OH and infection prevention and control measures for health workers in South Africa and internationally as part of the World Health Organizations' Collaborating Centres for Occupational Health. The study identified obstacles in establishing, providing, maintaining and sustaining such measures during the pandemic. These challenges were attributed to lack of leadership/stewardship, inadequate use of intelligence systems for decision-making, ineffective health and safety committees, inactive trade unions, and the strain on occupational health professionals who were incapacitated and overworked. These shortcomings are, in part, linked to the absence of the Ubuntu philosophy in implementation and sustenance of OH services in LMICs.

Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guidelines for the health workforce.

The health service sector has a vital role to play in delivering human immunodeficiency virus (HIV) and tuberculosis (TB) prevention, treatment and care, yet evidence indicates that healthcare workers (HCWs) themselves lack adequate access to HIV and TB services. HCWs are also at increased risk from TB and other infectious diseases at work, and therefore accessing HIV services is particularly important. A systematic review was therefore conducted to inform the development of World Health Organization (WHO) guidelines to improve access to HIV and TB services, and specifically, to assess the evidence regarding providing such services through workplace-based programmes. We identified any study published since 1984 that addressed outcomes of interest as defined through multi-stakeholder consultations, and were related to workplace interventions in (1) the healthcare workplace and (2) any workplace that included HIV and/or TB diagnosis and/or treatment. Interventions focusing solely on primary prevention with no diagnostic or treatment services were excluded, as they were the subject of other guidelines. A minimum of two reviewers independently extracted data and assessed the articles against pre-set selection criteria; studies were also profiled and quality assessed by a minimum of two reviewers. Three studies met these criteria specifically for HCWs; all showed a preponderance of positive benefits, with minimal negative outcome. Seven studies met these criteria regarding workplace HIV and/or TB diagnosis and/or treatment from other sectors, public or private. Again, all showed positive results. The paucity of high-quality evidence in this field of research was itself an important finding, beckoning further research on workplace-based programmes for health workers. Nonetheless, while more well-designed intervention studies are definitely desirable, providing programmes for HCWs to obtain HIV and TB diagnosis and treatment at the workplace is supported by the literature and is consistent with the values of the stakeholders, justifying the WHO-International Labour Organization-UNAIDS guidelines that emerged.

Effectiveness of joint health and safety committees: a realist review.

BACKGROUND: Joint health and safety committees (JHSCs) are widely acknowledged as important to a healthy and safe work environment. However, it is also generally believed that having a JHSC is necessary but not sufficient; the JHSC must be effective. METHODS: A systematic review was undertaken to find empirical studies regarding the effectiveness of JHSCs; realist review methodology was applied to determine context-mechanism-outcome patterns. Experts from across Canada and from various sectors and perspectives including government, employers, and unions, were brought together to inform the synthesis. RESULTS: Thirty-one studies met inclusion criteria. Mechanisms identified as important determinants of JHSC effectiveness across various jurisdictions include adequate information, education and training; appropriate committee composition; senior management commitment to JHSCs; and especially a clear mandate with a broad scope and corresponding empowerment (through legislation and/or union presence). CONCLUSIONS: Consistent empowerment mechanisms emerge as determinants of successful JHSCs across contexts despite few evidence-based details for best practice implementation. Intervention research is warranted.

Mapping Potential Population-Level Pesticide Exposures in Ecuador Using a Modular and Scalable Geospatial Strategy.

Human populations and ecosystems are extensively exposed to pesticides. Most nations lack the capacity to control pesticide contamination and have limited availability of pesticide use information. Ecuador is a country with intense pesticide use with high exposure risks to humans and the environment, although relative or combined risks are not well understood. Here, we analyzed the distribution of application rates in Ecuador and identified regions of concern because of high potential exposure. We used a geospatial analysis to identify grid cells (∼8 km × 8 km) where the highest pesticide application rates and density of human populations overlap. Furthermore, we identified other regions of concern based on the number of amphibian species as an indicator of ecosystem integrity and the location of natural protected areas. We found that 28% of Ecuador's population dwelled in areas with high pesticide application rate. We identified an area of ∼512 km2 in the Amazon region where high application rates, large human settlements, and a high number of amphibian species overlapped. Additionally, we distinguished clusters of pesticide application rates and human populations that intersected with natural protected areas. Ecuador exemplifies how pesticides are disproportionately applied in areas with the potential to affect human health and ecosystems' integrity. Global estimates of population dwelling, pesticide application rates, and environmental factors are key in prioritizing locations to conduct further exposure assessments. The modular and scalable nature of the geospatial tools we developed can be expanded and adapted to other regions of the world where data on pesticide use are limited.

Systematizing Information Use to Address Determinants of Health Worker Health in South Africa: A Cross-sectional Mixed Method Study.

Background: Recognizing that access to safe and healthy working conditions is a human right, the World Health Organization (WHO) calls for specific occupational safety and health (OSH) programs for health workers (HWs). The WHO health systems' building blocks, and the International Labour Organization (ILO), highlight the importance of information as part of effective systems. This study examined how OSH stakeholders access, use, and value an occupational health information system (OHIS). Methods: A cross-sectional survey of OSH stakeholders was conducted as part of a larger quasi experimental study in four teaching hospitals. The study hospitals and participants were purposefully selected and data collected using a modified questionnaire with both closed and open-ended questions. Quantitative analysis was conducted and themes identified for qualitative analysis. Ethics approval was provided by the University of Pretoria and University of British Columbia. Results: There were 71 participants comprised of hospital managers, health and safety representatives, trade unions representatives and OSH professionals. At least 42% reported poor accessibility and poor timeliness of OHIS for decision-making. Only 50% had access to computers and 27% reported poor computer skills. When existing, OHIS was poorly organized and needed upgrades, with 85% reporting the need for significant reforms. Only 45% reported use of OHIS for decision-making in their OSH role. Conclusion: Given the gap in access and utilization of information needed to protect worker's rights to a safe and healthy workplace, more attention is warranted to OHIS development and use as well as education and training in South Africa and beyond.

Tool, weapon, or white elephant? A realist analysis of the five phases of a twenty-year programme of occupational health information system implementation in the health sector.

BACKGROUND: Although information systems (IS) have been extensively applied in the health sector worldwide, few initiatives have addressed the health and safety of health workers, a group acknowledged to be at high risk of injury and illness, as well as in great shortage globally, particularly in low and middle-income countries. METHODS: Adapting a context-mechanism-outcome case study design, we analyze our team's own experience over two decades to address this gap: in two different Canadian provinces; and two distinct South African settings. Applying a realist analysis within an adapted structuration theory framing sensitive to power relations, we explore contextual (socio-political and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels. RESULTS: Technological limitations hindered IS usefulness in the initial Canadian locale, while staffing inadequacies amid pronounced power imbalances affecting governance restricted IS usefulness in the subsequent Canadian application. Implementation in South Africa highlighted the special care needed to address power dynamics regarding both worker-employer relations (relevant to all occupational health settings) and North-south imbalances (common to all international interactions). Researchers, managers and front-line workers all view IS implementation differently; relationships amongst the workplace parties and between community and academic partners have been pivotal in determining outcome in all circumstances. Capacity building and applying creative commons and open source solutions are showing promise, as is international collaboration. CONCLUSIONS: There is worldwide consensus on the need for IS use to protect the health workforce. However, IS implementation is a resource-intensive undertaking; regardless of how carefully designed the software, contextual factors and the mechanisms adopted to address these are critical to mitigate threats and achieve outcomes of interest to all parties. Issues specific to IS development, including technological support and software licensing models, can also affect outcome and sustainability - especially in the North-south context. Careful attention must be given to power relations between the various stakeholders at macro, meso and micro levels when implementing IS. North-South-South collaborations should be encouraged. Governance as well as technological issues are crucial determinants of IS application, and ultimately whether the system is seen as a tool, weapon, or white elephant by the various involved parties."You may call me a fool, But was there a rule The weapon should be turned into a tool? And what do we see? The first tool I step on Turned into a weapon. - Robert Frost""White (albino) elephants were regarded as holy in ancient times in Thailand and other Asian countries. Keeping a white elephant was a very expensive undertaking, since the owner had to provide the elephant with special food and provide access for people who wanted to worship it. If a Thai King became dissatisfied with a subordinate, he would give him a white elephant. The gift would, in most cases, ruin the recipient. - The Phrase Finder"

Psychological Distress in South African Healthcare Workers Early in the COVID-19 Pandemic: An Analysis of Associations and Mitigating Factors.

While the global COVID-19 pandemic has been widely acknowledged to affect the mental health of health care workers (HCWs), attention to measures that protect those on the front lines of health outbreak response has been limited. In this cross-sectional study, we examine workplace contextual factors associated with how psychological distress was experienced in a South African setting where a severe first wave was being experienced with the objective of identifying factors that can protect against HCWs experiencing negative impacts. Consistent with mounting literature on mental health effects, we found a high degree of psychological distress (57.4% above the General Health Questionnaire cut-off value) and a strong association between perceived risks associated with the presence of COVID-19 in the healthcare workplace and psychological distress (adjusted OR = 2.35, p < 0.01). Our research indicates that both training (adjusted OR 0.41, 95% CI 0.21−0.81) and the reported presence of supportive workplace relationships (adjusted OR 0.52, 95% CI 0.27−0.97) were associated with positive outcomes. This evidence that workplace resilience can be reinforced to better prepare for the onset of similar outbreaks in the future suggests that pursuit of further research into specific interventions to improve resilience is well merited.

Impacts of economic inequality on healthcare worker safety at the onset of the COVID-19 pandemic: cross-sectional analysis of a global survey.

OBJECTIVES: To assess the extent to which protection of healthcare workers (HCWs) as COVID-19 emerged was associated with economic inequality among and within countries. DESIGN: Cross-sectional analysis of associations of perceptions of workplace risk acceptability and mitigation measure adequacy with indicators of respondents' respective country's economic income level (World Bank assessment) and degree of within-country inequality (Gini index). SETTING: A global self-administered online survey. PARTICIPANTS: 4977 HCWs and healthcare delivery stakeholders from 161 countries responded to health and safety risk questions and a subset of 4076 (81.2%) answered mitigation measure questions. The majority (65%) of study participants were female. RESULTS: While the levels of risk being experienced at the pandemic's onset were consistently deemed as unacceptable across all groupings, participants from countries with less income inequality were somewhat less likely to report unacceptable levels of risk to HCWs regarding both workplace environment (OR=0.92, p=0.012) and workplace organisational factors (OR=0.93, p=0.017) compared with counterparts in more unequal national settings. In contrast, considerable variation existed in the degree to which mitigation measures were considered adequate. Adjusting for other influences through a logistic regression analysis, respondents from lower middle-income and low-income countries were comparatively much more likely to assess both occupational health and safety (OR=10.91, p≤0.001) and infection prevention and control (IPC) (OR=6.61, p=0.001) protection measures as inadequate, despite much higher COVID-19 rates in wealthier countries at the time of the survey. Greater within-country income inequality was also associated with perceptions of less adequate IPC measures (OR=0.94, p=0.025). These associations remained significant when accounting for country-level differences in occupational and gender composition of respondents, including specifically when only female care providers, our study's largest and most at-risk subpopulation, were examined. CONCLUSIONS: Economic inequality threatens resilience of health systems that rely on health workers working safely to provide needed care during emerging pandemics.

Collaboration between infection control and occupational health in three continents: a success story with international impact.

Globalization has been accompanied by the rapid spread of infectious diseases, and further strain on working conditions for health workers globally. Post-SARS, Canadian occupational health and infection control researchers got together to study how to better protect health workers, and found that training was indeed perceived as key to a positive safety culture. This led to developing information and communication technology (ICT) tools. The research conducted also showed the need for better workplace inspections, so a workplace audit tool was also developed to supplement worker questionnaires and the ICT. When invited to join Ecuadorean colleagues to promote occupational health and infection control, these tools were collectively adapted and improved, including face-to-face as well as on-line problem-based learning scenarios. The South African government then invited the team to work with local colleagues to improve occupational health and infection control, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases. As the H1N1 pandemic struck, the online infection control course was adapted and translated into Spanish, as was a novel skill-building learning tool that permits health workers to practice selecting personal protective equipment. This tool was originally developed in collaboration with the countries from the Caribbean region and the Pan American Health Organization (PAHO). Research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work.The products developed have been widely heralded as innovative and interactive, leading to their inclusion into "toolkits" used internationally. The tools used in Canada were substantially improved from the collaborative adaptation process for South and Central America and South Africa. This international collaboration between occupational health and infection control researchers led to the improvement of the research framework and development of tools, guidelines and information systems. Furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst Northern and Southern researchers in terms of sharing resources, experiences and knowledge.