Applying evidence-to-decision to construction safety: A review of safety culture evidence in Taiwan

Problem prioritisation

This step of the assessment asks whether this problem is a priority, which, in this case, refers to whether the Taiwanese construction industry or the Taiwanese government prioritises improved safety outcomes. Taiwan's Ministry of Labor 2024 policy commitment focuses on continuously and actively safeguarding the rights and interests of workers through adherence to the administrative principles of “stability,” “peace of mind,” and “safety.” In terms of safety outcomes for workers, a clear policy priority is set through “safe labor,”. This forms a key governance principle for labour protection policies. According to 2023 Taiwanese government data, the number of reported construction incidents was the second lowest on record over the last decade. Despite the reduced number of incidents in 2023, with 100 deaths recorded, the highest number of fatalities over the last decade. ²⁹

For the ten years from 2005 to 2015, there were a total of 1219 deaths on Taiwanese construction sites. ²⁹ A review of the incident data revealed that 74% of the accidents were at least partially caused by unsafe worker actions or behaviours. Together, small enterprises (<10 workers, 66% of deaths) and small to medium enterprises (10-29 workers, 29% of deaths) account for 92% of all fatalities on Taiwanese construction sites. ⁹ Thus, targeting SMEs for worker safety interventions will have the most significant impact on construction worker safety. SMEs undervalue safety, with limited initiative to drive improvement. ³⁰ Therefore, to improve safety outcomes, SMEs must prioritise safety, including training staff, hiring qualified personnel and implementing effective safety procedures.^10–31

Overall, the review shows that benefits can be made to worker health and safety, driving the prioritisation of safety policy. However, there is insufficient evidence to understand the priority from either the enterprises’ or the workers’ perspective, but it may be undervalued. In fact, government data reveals a paradoxical trend: a decrease in reported incidents without a corresponding decline in fatalities. The reason for this trend in accident rates is unclear and requires further research.

Desirable effects

This question examines the evidence of desirable effects on worker safety achieved through well-established safety climate initiatives. Due to the highly variable nature of the statistical analyses used across the literature, a qualitative approach was adopted to assess the substantive significance of the desired effects. The effects were considered desirable when the literature reviewed showed a statistically significant association or increase in safety climate factors related to safety behaviour.

Research consistently maintains a crucial link between safety climate and behaviours on construction sites.^3,32,33 Supporting the link with behaviour, Zahor et al. ³⁴ confirmed the significant positive impact of safety climate on safety compliance and safety participation, with a decline in the number of self-reported accidents/injuries. Consistent with international literature, Chen et al., ³¹ found a link between safety climate and behaviour on Taiwanese construction sites. Results show that the safety climate level positively impacts safety behaviour and overall safety perception.

In terms of the link between injuries, Golubovich et al., ³⁵ found a reduced rate of musculoskeletal injuries on worksites with a favourable safety climate. Lyu et al., ³⁶ identified that ethnic and migrant construction workers are more likely to be injured at work than locals. The study showed that a good safety climate leads to safer behaviour for ethnic and migrant construction workers. Historically, migrant workers in Taiwan's construction industry have needed more safety and health training. ³⁷ Man et al.,^38,39 examined how optimism affects risk-taking in construction workers, finding that optimism about safety in construction work makes workers more likely to take risks.

Al-Bayati ³² linked safety climate, with actions by upper management and safety personnel also affecting safety behaviour and motivation. Despite the potential for management to support improved safety climate, management approaches do not always support positive safety outcomes. ⁴⁰ The relationship between the implemented management strategies and safety performance is complex. If not carefully managed, communication can harm safety performance, whereas strategies in labor management, supervision, planning, and construction management improve safety outcomes. However, safety investments can be linked to accident prevention, especially for projects with a high hazard level and a strong safety climate. ⁴¹

The research reviewed consistently reports statistically significant associations between strong safety climates and increased safety compliance and participation, as well as reduced incident rates.^33,34,42 Additional benefits include reductions in musculoskeletal injuries ³⁵ and increased awareness among ethnic and migrant workers, who are often at elevated risk. ³⁶ Management involvement in safety initiatives also improves performance; however, evidence suggests that poor communication and leadership can undermine these outcomes. ⁴⁰ The key limitation is that, while positive effects are established, the influence on SMEs cannot be readily quantified from the literature.

Undesirable effects

With the desirable effects established, it is essential to establish the undesirable effects associated with a safety climate focus on construction sites. The research reviewed primarily focuses on the desirable outcomes of improved safety climate, with scant attention to its undesirable effects. However, it could be posited that there would be a link with perceptions of barriers, such as costs associated with ‘non-productive’ time spent on safety programs and additional resources required to support safety. Emphasising poor safety climate as the leading cause of construction incidents can foster a blame culture that targets individuals over systemic issues. ⁴³ Relying on behaviour-based measures to offset hazards rather than eliminate them can be problematic. Prioritising safety climate may also provide false assurance and hinder ongoing efforts to improve technology, site conditions, and construction methods. ⁴⁴

Information is insufficient to make an evidence-informed decision on the precise nature and magnitude of potential and actual undesirable effects, or on how to effectively manage them. The skewed focus on desirable effects in the literature makes it difficult to make a definitive judgment and presents a significant gap in the existing body of literature on construction safety. The evidence reviewed indicates that overemphasis on behavioural metrics may inadvertently foster blame-oriented cultures, detracting from systemic hazard mitigation.^43,44 Additional concerns that may arise include increased administrative burden, misallocation of resources, and the risk of complacency if perceived improvements are not effectively managed for undesirable effects.

Certainty of the effects evidence

The reviewed body of research evidence provides high confidence in the beneficial impacts of safety climate improvements on worker behaviour and site-level safety outcomes. However, the absence of research on potential harms, cost structures, and implementation feasibility limits the overall confidence in generalizability and transferability to the Taiwanese SME context. Research on safety climate focuses on its beneficial effects, but there is limited information on the corresponding undesirable effects. Further research to develop a balanced understanding of the evidence is crucial for informing effective policies to enhance construction safety in Taiwan. Overall, the available information is too limited to make a fully informed and balanced decision regarding the certainty of the effects of undesirable effects on safety behaviours.

Values and stakeholder perspectives

This section examines important uncertainties or variability in how much key stakeholders value the outcomes of a safety climate approach. The body of research reviewed supports the importance of safety climate/culture in improving safety internationally. From the perspective of the Taiwan government, the current policy objectives support and value improvement in workplace safety. The Ministry of Labor ⁴⁵ set out the following policy objectives:

“The ministry takes “secure work”, “safe workplace”, and “safe labour” as its governance goals, and strives to create a smoother employment network, improve the quality of labour, and promote active personnel exchanges, while working towards the construction of a full range of labour protection policies and efforts to provide workers in the workplace with reasonable labour rights protections, a safe and secure work environment, and stable labour relations and a stable labour market, while enhancing the work satisfaction of workers and the implementation of work-life balance.”

From the six target policy objectives and priorities of the Ministry of Labor for 2022:

“5. Complete the occupational accident insurance system and strengthen the workplace safety and health protection mechanism:

While the Taiwan government's position as a critical stakeholder on the value of labourer safety is clear, a gap exists in quantifying the value it places on improving safety behaviour from the perspectives of SMEs and individual workers. While national labour policy prioritises safety, there is a gap in supporting research on how workers and employers in Taiwan value or perceive improvements in the safety climate. A range of factors, including education, employment style, and project duration, can influence awareness and engagement on matters of worker safety. ³¹

The review indicates that stakeholder value for safety culture initiatives on construction sites is crucial, particularly in the presence of uncertainty or variability. Internationally, public support for workplace safety initiatives is generally high. ⁴⁶ The same assumption is applied to Taiwan from a policy perspective. However, empirical validation of worker and enterprise perceptions across all organisational sizes is needed, representing an important area for future investigation.

Balance of effects

Upon reviewing the balance of evidence on desirable and undesirable effects, this section asks whether the evidence favours the safety climate option or the maintain current practice comparison. There is straightforward evidence that safety climate initiatives can improve safety performance on construction sites. ²⁸ The Taiwanese government policy anticipates desirable effects from targeted safety measures. The current Taiwanese regulatory approach has facilitated a reduction in accident rates across a range of construction enterprises by implementing more stringent safety requirements. However, the paucity of research on the desirable or undesirable effects limits assessments of SMEs and a more robust understanding of larger enterprises.

As shown in Table 3, the overall balance of evidence supports the implementation of safety climate-focused initiatives. While there are substantial knowledge gaps regarding undesirable effects, the documented benefits of increased compliance, fewer injuries, and improved organisational safety culture likely outweigh potential downsides. However, caution is advised when generalising findings to SMEs without contextual adaptation. The overall assessment is that the balance between desirable and undesirable outcomes probably favours the implementation of safety climate initiatives. More research characterising undesirable outcomes is required to build certainty in this EtD judgment.

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Table 3.

GRADE evidence to decision summary for a safety culture focus on Taiwanese construction sites: problem and effects questions.

Question	Assessment	Judgement	Summary comments
Problem	Is the problem a priority?	Probably yes	Implementing safety climate initiatives is generally feasible for larger construction firms with structured management systems, whereas for SMEs it is uncertain due to limited infrastructure and resources.
Desirable effects	How substantial are the desirable anticipated effects?	Moderate	Chen et al. 31 found that a positive safety climate at Taiwanese construction sites was significantly associated with increased safety behaviour and improved safety perceptions. Similarly, Zahoor et al. 34 reported that a positive safety climate increased compliance and participation while reducing self-reported accidents. Mazzetti et al. 33 linked safety climate to greater risk perception and safety knowledge, which in turn enhanced safety behaviour.
Undesirable effects	How substantial are the undesirable anticipated effects?	Don’t Know	Some literature considered the potential downsides of initiatives to improve safety climate on construction sites. These downsides include overfocus that detracts from a holistic safety approach, the formation of a blame culture, and the creation of false confidence in safety performance. While reasonable considerations, the absence of empirical research makes a definitive judgement difficult.
Certainty of the evidence	What is the overall certainty of the evidence of effects?	moderate	While the collective evidence supports positive outcomes for Taiwanese construction workers, significant research gaps remain on undesirable effects.
Value placed on main outcomes	Is there important uncertainty about, or variability in, how much people value the main outcomes?	Possibly important with uncertainty or variability	Research highlights the importance of a safe workplace climate. In Taiwan, government policy prioritises workplace safety, significantly influencing enterprise-level safety practices. The assessment assumes government support for these initiatives.
Balance of the effects	Does the balance between desirable and undesirable effects favour the comparison?	Probably favours the option	Evidence shows that safety climate-focused initiatives lead to greater compliance, fewer injuries, and better organisational safety culture. While negative effects are not well-documented, the benefits are clear. Caution is advised when applying these findings to small enterprises, given contextual and operational differences.

Resources required

With the balance of evidence suggesting that desirable safety outcomes can be achieved, the next step is to review the magnitude of resources required to support a safe climate approach. The review provides broad evidence suggesting that investing in improving the safety climate yields positive outcomes. For example, training and awareness were found to yield positive returns in terms of worker safety behaviours on Taiwanese construction sites.^10,31,47,48 Safety behaviour interventions, to influence organisational and site management attitudes, do incur costs either directly or indirectly. ⁴⁹ However, information on the exact resourcing required to support safety climate programs limits the judgments that can be made.

Although several studies report positive returns from investments in safety training and management systems,^41,50 few quantify the costs associated with implementing improvements specific to safety climate. In Taiwan, the government incurs substantial financial burdens from construction-related injuries and fatalities, over NT$982 million in 2021 alone. ²⁹ While indirect benefits such as reduced insurance payouts and increased worker productivity are plausible, detailed benefit-cost analyses are lacking. Luo ⁴⁹ and Bautista-Bernal et al. ⁵¹ suggest that safety investments can enhance financial performance, but context-specific data for Taiwan are needed to confirm cost-effectiveness. Overall, the judgment on resourcing is: don’t know, with insufficient information to make an informed decision on resource requirements.

Certainty of evidence of required resources

The next step after evaluating resourcing is to ensure the decision was made based on the evidence. While there are clear economic benefits from improving construction safety outcomes, the assessment is constrained by a scarcity of research investigating the resourcing requirements associated with improving safety climate on construction sites in Taiwan. In the literature from the systematic review, no cost evaluation of implementing safety climate initiatives was provided. An evidence-based evaluation of resourcing for measures such as training, systems development, safety improvements, and hazard control would provide valuable information. In total, the review found insufficient information to make a certain EtD judgment on precise resource requirements.

Cost-effectiveness

At this stage, the assessment considers whether the option is cost-effective relative to the comparison, in this case current practice. The cost-effectiveness consideration in this review was the cost avoidance for labour insurance and compensation to the Taiwan government following construction site injuries and fatalities. Based on government data for 2021, 2805 cases where subsidies were approved for construction workers, both covered and not covered by Labour Insurance. These subsidies totalled NT$256.99 million. Additionally, in the 2021 reporting year, construction accident rates were four times higher than those of all other industries, except manufacturing.

Data from the Ministry of Labor ²⁹ for 2021, benefit payments related to construction injuries, illness, and death amounted to NT$982,285,000, including:

7406 injury claims (NT$361,692,000)

Investing in safety, through creating a positive safety culture and improving safety performance, can reduce labour insurance and medical costs. ⁴¹ For Taiwan, improved safety behaviour could reduce labour insurance and medical costs. Research has shown that safety management system improvements can also have a significant return on investment. ⁵⁰ Luo ⁴⁹ linked safety-related costs with management attitudes and policies. Firm financial performance can also be considered in the benefit-cost analysis of safety programs. A longitudinal study by Luo ⁵¹ found that a company's safety culture and performance significantly impact its finances, with reduced accidents leading to increased profits.

The balance of evidence suggests that, from a financial perspective, there is an opportunity to reduce government insurance and disability pension costs by improving safety performance. However, extensive research is required to characterise the actual cost-effectiveness to support fully informed decision-making. A summary of the findings is provided in Table 4.

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Table 4.

GRADE evidence to decision summary for a safety culture focus on Taiwanese construction sites: resourcing and cost questions.

Question	Assessment	Judgement	Summary comments
Resources required	How large are the resource requirements (costs)?	Don't know	The key resource requirements focusing on safety climate cannot be estimated
Certainty of evidence of required resources	What is the certainty of the evidence of resource requirements (costs)?	No included studies	The information on resource requirements is too limited to assess this item
Cost-effectiveness	Does the cost-effectiveness of the option favour the option or the comparison?	Don't know	In 2021, 2805 subsidies totalling NT$256.99 million were approved for construction workers in Taiwan, where accident rates are four times higher than in other industries. Despite these costs, a proper benefit-cost analysis of safety interventions is constrained by a lack of data on intervention costs.

Equity

This step examines the impact of a safety climate focused on the health equity of construction workers, both within industry subgroups and with other industries. Following public health practice judgment regarding the implications for health equity is based on comparisons with other occupational groups and socioeconomic background factors. Taiwan government data shows that construction workers are significantly overrepresented in terms of workplace injury and death rates compared to all other occupation groups except for the manufacturing industry.

Further consideration was given to vulnerable subgroups employed within the construction industry. A survey of 302 construction workers in Taiwan conducted by Chen et al., ³¹ found that 67% of respondents had secondary school qualifications with no further trade or specialist qualifications. In general, people with higher levels of education have better health outcomes. ⁵² Within this group, an improved safety climate and corresponding safety behaviours, resulting in reduced accident rates, has potential to improve health equity by educational level.

Construction workers from ethnic minorities are more likely to be injured or killed on construction sites. ³⁶ Taiwan relies heavily on migrant workers, who are at increased risk of injury, disability, and death. ⁵³ Given that many construction workers in Taiwan are foreign workers and ethnic minorities, this raises questions about the equity of safety outcomes for local and foreign workers.

Current safety performance statistics also show a significant gap in accident rates between SMEs and large construction enterprises. In Taiwan, people working in SMEs represent the greatest number of serious injuries or fatalities.^9–47 Between 2000 and 2015, a negative correlation existed between organisational size and injury and fatality rates, with companies having ten or fewer workers accounting for 64% of construction site accidents. Improving safety behaviour and outcomes on construction sites could promote health equity across demographic and organisational lines. Migrant and ethnic minority workers are disproportionately affected by unsafe working conditions.^36,53 Similarly, SMEs experience higher fatality rates due to systemic resource limitations. ⁹

Enhancing safety practices and outcomes on construction sites can support health equity across demographic and organisational groups. Research indicates that migrant and ethnic minority workers experience a higher incidence of unsafe working conditions,^36–53 while smaller enterprises tend to have increased fatality rates, often due to systemic resource constraints. ⁹ In summary, directing safety interventions toward these vulnerable populations and enterprise categories may improve occupational health equity and reduce longstanding disparities.

Acceptability

When considering acceptability, the question is whether the option of safety climate focused initiatives is acceptable to key stakeholders.

Feasibility

The final consideration concerns the feasibility of implementing the proposed option. The review indicates that, given the limited available information, it is not possible to draw a definitive conclusion on the feasibility of using a safety climate approach to improve construction safety in Taiwan. However, the widespread use of safety climate improvement initiatives in the construction sector suggests that this approach could be feasible for influencing safety behaviour. Evidence also indicates that when workers perceive a positive safety climate, they may be more likely to participate in discretionary safety activities. ⁵⁵

The feasibility of implementing safety climate-focused initiatives is likely high for larger construction firms with formalised management systems, given regulatory requirements. In contrast, feasibility is uncertain for SMEs, which often lack the necessary infrastructure, training, and personnel to sustain safety initiatives. Nonetheless, the success of simplified self-assessment tools in other sectors offers a promising direction for tailored, scalable implementation.^15,56 The overall judgement reached is that the outcomes probably favour the option based on the broad application of safety climate initiatives in the literature review. The summary of key findings and research gaps for equity, acceptability, and feasibility questions is provided in Table 5.

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Table 5.

GRADE evidence to decision (EtD) summary for a safety culture focus on Taiwanese construction sites: acceptability and feasibility.

Question	Assessment	Judgement	Summary comments
Equity	What would be the impact on health equity?	Probably increased	Health equity is expected to improve with these initiatives, especially since small businesses and migrant workers, who are often the most at risk, stand to benefit the most
Acceptability	Is the option acceptable to key stakeholders?	Probably yes	The government's current policy promotes improved safety on construction sites, with industry stakeholders generally adopting the required safety initiatives. However, there is limited evidence on the acceptability to SMEs and workers due to the short project life and a highly transient workforce.
Feasibility	Is the option feasible to implement?	Probably Yes	The feasibility of implementing safety climate-focused initiatives is likely high for larger construction firms. For SMEs, there are barriers to feasibility that need to be overcome. However, evidence from other sectors suggests tailored self-assessment tools may offer scalable solutions 15–56.

Research priorities

While the literature supports a linkage between safety climate and safety behaviour, the evaluation of evidence identified notable research gaps associated with implementing initiatives to improve the safety climate on construction sites, including:

The research reviewed is on the positive influences of safety climate on construction site safety. However, there appears to be an optimism bias, in which undesirable implications are not sufficiently explored to make a full assessment of the positive and negative implications of safety culture. Characterising the undesirable consequences of improving the safety climate would assist in planning targeted strategies to overcome barriers to successful safety strategies.