The IRANOSH quantitative analysis indicated that the target population of the OSH services was estimated to be around 34% of the country’s population with about 41% of workplaces and 15% of workers under the direct coverage of OSH services. According to the IRANOSH qualitative analysis, one of the reasons for not achieving the desired coverage is the lack of OSH inspectors and the underdeveloped infrastructure of the OSH systems. In Iran, a targeted inspection plan has been designed and implemented by categorizing workplaces (grades 1 to 3) based on occupational exposures. This allows for occupational health inspections to be carried out on workplaces with more dangerous exposures, including carcinogenic exposures [22]. All employed workers, self-employed workers, part-time employed workers, housewives, and students who are engaged in some kind of occupational exposure should be prioritized in the country’s research programs.
The IRANOSH quantitative analysis revealed that the priority of executive and research interventions should be based on the demographic distribution pattern of the workers and workplaces. Out of approximately 24 million workers, the majority were in the service sector (49%). The IRANOSH qualitative analysis suggested that the lack of attention to exposure in the service and agriculture sectors is due to underestimating exposure risks in these sectors compared to industry, and the lack of professional health organizations in the service and agriculture sectors. One reason to focus more on the exposure of the agricultural sector is that it is often a family business, with the entire family, including vulnerable groups like children and sometimes pregnant women exposed to occupational hazards. Reviving previous programs like Bagha (carpet weavers’ health plan) and agricultural work health, with a tripartite perspective and inter-sectoral cooperation and community-oriented initiative, is necessary for the full implementation of these regulations. Several studies have emphasized the risks and the need to pay more attention to OSH in agricultural workplaces [23,24,25] and services [22] as both an executive and research priority [23, 26].
The IRANOSH quantitative analysis showed that the majority of the working population was in the private sector. However, only a small percentage are directly covered by OSH inspection systems. The reason for not reaching the desired coverage is the lack of OSH inspectors. Previous studies have also highlighted this shortcoming and the need to target inspection [22]. A large portion of private sector workers are covered by trade union laws, and activating the OSH self-assessment system of trade unions can partially compensate for the shortcomings of service coverage and supervision in this sector. In recent years, focusing more on OSH in small workplaces has been an important priority of past studies [23, 27,28,29,30,31]. On the other hand, a small part of the workers are employed in governmental and publicsectors. However, the lack of integration of these services with the PHC system has hindered the full utilization of the OSH units in the public sector. Establishing the OSH system in line with the responsibility of public and governmental organizations has improved OSH indicators [32].
The qualitative analysis indicated that working women have been largely neglected in the country’s implementation and research programs, which primarily focus on industrial activities. It is essential to consider the physiological, psychological, and social differences between male and female workers in evaluating and controlling occupational exposures, as confirmed byfindingsof previousstudies [32, 33].
Furthermore, the IRANOSH quantitative analysis revealed that workers in small workplaces often have limited access to OSH services, making it crucial to prioritize them in interventions and research programs [34]. Previous studies emphasized the importance of addressing occupational exposures in smallworkplaces due to the nature of work and the vulnerability of the workers [35,36,37]. Based on qualitative findings, at each provincial health network, there is a regional health system through which PHC services are provided following a hierarchy down to health bases in cities and health houses in rural areas, with supervising inspectors in urban areas and healthcare workers in rural areas.The PHC system is one of the most successful health service delivery systems in the world [6, 38,39,40,41].Workplace OSHstructures have provided a platform for progressing the PHC system to almost all workers in workplaces with more than 20 employees.The PHC and OSH systemsin Iranhave proven to be effective in various fields, including the COVID-19 pandemic [31, 34].
According to quantitative findings, almost allworkplaces with more than 25 workers have at least one OSH structure and almost all small workplaces with less than 25 workers lack any OSH structure at the workplace. The most common OSH structure is the workplace OSH Committee. OSH Committee is an executive structure including representatives from workers, employers, and OSH graduated experts. This committee conducts at least one meeting monthly and is responsible for OSH interventions at the workplace. According to regulations, the responsibility for providing primary care and OHS services lies with health stations for workplaces with 20–50 workers, worker health houses for workplaces with 50–500 workers, and occupational health centers for workplaces with 500 or more employees [6, 22, 29].
According to qualitative findings, during COVID-19, health protocols were developed and implemented by workplace OSH structures. Medium and large workplaces with OSHstructures performed well in adhering to these protocols [31, 34].Large organizations and workplaces with access to OSH specialists and structures performed better in preventing COVID-19 compared to smaller workplaces [30].The pandemic assessed countries’ responses, health systems, and OSH organizations in workplaces worldwide [42].
The health, safety, and environment (HSE) units of governmental and public organizations have an impact on OSH indicators [32, 43].These HSE units operate independently from the PHC system in providing OSH services. MOHME has developed a guideline for basic health services for government employees, necessitated by the pandemic, leading to successful inter-sectoral collaborations [31, 34].
Most private sector employees work in small workplaces, where exposure recording, and supervision are conducted by inspectors due to a lack of OSH experts and structures. Previous studies highlighted the occupational health challenges in small workplaces [27, 29]. A targeted inspection system, prioritizing higher-risk workplaces, has addressed supervisory deficiencies in medium and large workplaces [22]. However, small workplaces may not be prioritized due to the workplace grading mechanisms and inspectors’ inability to accurately identify exposures during short inspections. Epidemiological studies have shown that these small business workers are exposed to high occupational exposures [8, 44, 45].
According to the current findings, workplace exposure assessmentprovided byOSH companies needs quantitative and qualitative improvement. They are the most specialized organizations providing occupational exposure assessment services to evaluate difficult and hazardous occupations as per regulations. While providing quantitative exposure assessments, criticisms exist regarding the quantity and quality of workplace exposure assessments conducted by OSH companies. Workplace exposure measurements cannot be generalized to occupational exposures or suitably used in occupational medical examinations or for specific control interventions. Annualexposure measurements instead of exposure control services are another deficiency. Previous studies identified the lack of OSH services in small workplaces as a challenge and intervention priority [27, 33].
Another OSH structure providing occupational health services is the authorized occupational medical examination centers. These centers are established to outsource services to the private sector and obtain operating licenses from the regional health system. They include occupational medicine centers, a general practitioner’s office with an occupational medicine license, and an occupational examination center at the workplace.While occupational examination centersfacilitate early diagnosis, criticisms exist regarding licensing and supervision processes leading to quantitative and qualitative deficiencies. The number of these centers is insufficient due to a shortage of occupational medicine physicians and obstacles in issuing licenses to general practitioners. Results from previous studies show that such limitations do not exist in developed countries like Italy [46], Germany [47], the United Kingdom [48], and the United States [49]. A study in the United States examined the qualifications of physicians practicing occupational medicine. The findings showed that 60% had occupational medicine certifications, and 68% had completed specialty board programs in other specialties [49].
In addition, limited authorized centers and high private-sector costs have hindered access to occupational medical examinations for underprivileged workplaces, especially small ones.A gradedreferral system for occupational medical examinations is proposed to address deficiencies. It involves (1) initial assessment of exposures by OSH experts or companies, (2) occupational medical examinations by trained practitioners based on the exposure assessment, (3) referral of suspected cases to occupational medicine physicians, (4) specialized medical examinations for diagnosed cases referred to the surveillance system, and (5) provision of therapeutic interventions, rehabilitation, and workplace corrections.
Redesigning the structures and procedures of occupational medical examinations aiming to achieve a surveillance system is essential. Establishing such surveillance systems has been a priority emphasized in previous studies [50] and the national health systems of countries such as Italy [46], Germany [47], and the United Kingdom [48] with emphasis on optimizing collaboration between specialists and improving mechanisms for occupational medical examinationsand healthcare services.
In Iran, human resources providing occupational safety and health services include OSH inspectors, workplace OSH experts, Behgar (workplace primary healthcare worker), Behvarz (rural primary healthcare worker), authorized general practitioners for occupational examination, and occupational medicine specialists. The findings indicate that Iran, like other countries, faces a shortage of human resources to provide OHS services.The lack of OSH professionals has been declared a global challenge by the WHO [51].The findings showed that while Iran has more OSH inspectors than the International Labor Organization’s recommendation of one inspector per 10,000 workers [52], the country has also implemented a trained OSH Behvarzs program. These Behvarzs serve as the primary service providers in rural workplaces, helping to address the shortage of inspectors and enhance workers’ health in those areas. Additionally, with Behgar’s initiative as a provider of PHC services in workplaces, Iran could somewhat overcome the lack of occupational health experts, especially in small workplaces. In Iran, access to OSH services includes one workplace OSH expert for every 61 workplaces and 278 workers. In England, only 7% of small and medium-sized workshops with less than 250 employees employed occupational health advisors, and 10% employed full-time or part-time occupational health nurses. In European countries, the ratio of occupational health nurses to workers varies from 1 to 500 to 1 to 5,000 workers [48]. Iran is facing a severe lack of access to authorized general practitioners (one for every 970 workplaces and 4,414 workers) and occupational medicine specialists (one for every 3,270 workplaces and 14,877 workers) for occupational examinations. In England, only 12% of workers have access to medical services and there are five occupational medicine specialists available per 100,000 workers [48].
Recommendation
The study proposes several practical initiatives based on both quantitative and qualitative findings. These include:
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Enhancing current OSH services by adapting the existing IRANOSH framework for integration into national health systems.
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Extending the PHC system to small workplaces and public organizations.
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Revising guidelines to ensure that OSH companies’ services are focused on control-based exposure assessment.
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Expanding OSH companies’ exposure assessment and control services to small workplaces through revising relevant guidelines.
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Establishing an OSH self-monitoring and self-care system, involving active participation from trade unions, guilds, and small businesses.
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Integrating HSE units in governmental organizations with the PHC network.
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Considering the physiological, psychological, and social differences between male and female workers in evaluating and controlling occupational exposures.
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Access to occupational examination centers needs quantitative and qualitative improvement.
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Revising regulations governing OSH service providers and occupational medical examination centers, with a focus on controlling harmful factors and ensuring maximum coverage, especially in small workplaces.
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Implementing regulations for OSH education, alongside the establishment of OSH training centers prioritizing small workplaces.
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Improving the quality of OSH registration systems and participatory monitoring of occupational exposures in small and rural workplaces.
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Revising the inspection system to increase coverage of small workplaces, and delegating exposure assessment tasks to the OSH committee.
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Enhancing OSH services in small and rural workplaces.
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Activating a self-assessment system for OSH services with a community-based approach could compensate for service coverage deficiencies in the private sector.
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Integrating exposure assessment services with inspection systems, occupational examinations, interventions for difficult and hazardous occupations, and other exposure controls.
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Redesigning operational and supervisory mechanisms for service delivery by OSH companies, including procedures, quality control systems, and supervisory systems.
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Conducting master of occupational health courses for practitioners and implementing referral systems from authorized general practitioners to occupational medicine specialists to compensate for the lack of access to occupational medicine specialists.
Further research required
The study proposes several future research directions based on quantitative and qualitative findings. These include:
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Redesigning the operational system for monitoring exposures and defining all operators and operations within a management process.
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Preparating the OSH image of the country and planning to cover the entire active population of the country with a focus on service sectors, agriculture, small workplaces, self-employed workers, and part-time employed workers.
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Customizing the NPOSH framework for other countrieswith various health system contexts would enhance the credibility of the findings for researchers and practitioners in promoting OSH services globally.
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Updating this study and comparing current findings with other data sources will help validate the current findings.
Conclusion
The study outlines a protocol for the development of the NPOSH framework and tailors it for Iran (IRANOSH). A total of 44 IRANOSH indicators were identified and categorized into nine domains and six types. The IRANOSH quantitative indicators revealed thatmost workplaces have fewer than 20 workers. Small workplaces including those with fewer than 20 workers and home-based workshops, accounted for about 98% of all workplaces. The development of OSH services for small and agricultural workplaces was identified as a significant challenge and priority in Iran. The implementation of the OSH self-assessment system by trade unions could help address the gap in service coverage in small workplaces. Extending the PHC system to include OSH structures in public and governmental organizations could facilitate the advancement of OSH services.
The most important OSH programs in Iran include targeted inspections, occupational medical examinations, harmful factors monitoring and controlling, regulations and guidelines, and service registration and sustainability systems. The most important measure in the context of OSH plans and programs is revisingcountry OSH services based on the IRANOSH framework developed in this study and ensuring their sustainability through an integrated system synchronized with other PHC systems.
Based on inspection data, almost allworkplaces with more than 25 workers have at least one OSH structure and almost all small workplaces with less than 25 workers lack any OSH structure at the workplace.Workplace OSHstructures have provided a platform for progressing the PHC system to almost all workers in workplaces with more than 25 employees.The development of OSH services for small and agricultural workplaces was identified as a significant challenge and priority in Iran. The implementation of the OSH self-assessment system by trade unions could help address the gap in service coverage in small workplaces. Extending the PHC system to include OSH structures in public and governmental organizations could facilitate the advancement of OSH services. The most crucial intervention in the context of the OSH structure is extending the PHC system, including the OSHstructure, to guilds and governmental and public bodies.
The findings indicate that Iran, like other countries, faces a shortage of human resources to provide OHS services. Iran could somewhat overcome the lack of OSH human resources by Behvarzs (rural primary healthcare workers) for rural workplaces, Behgars (workplace primary healthcare workers) for small workplaces, and authorized general practitioners for occupational medical examinations.
The NPOSH framework and its indicators, as outlined in this study can be adapted for use in other countries. Since the information sources of the IRANOSH study were limited to the Iranian context, customizing the NPOSH framework for other countries with various health system contexts is recommended. Updating this study and comparing current findings with other data sources will help validate the current findings.
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