Understanding the awareness of health and safety signs amongst health care workers in Pakistan

Abstract

BACKGROUND:

Safety signs are very important communication tools for accident prevention, fire safety, health hazard information, and emergency evacuation. However, they are helpful only when properly designed and understood by employees.

OBJECTIVES:

The purpose of the present study was to assess the awareness of health and safety signs amongst health care workers including doctors, dentists and paramedics in different health care sectors across Pakistan.

METHODS:

Data was collected via Google forms circulated through WhatsApp social media to predetermined groups of health care professionals to assess their understanding of safety signs across different health sectors. The survey included questions pertaining to awareness of 19 different health and safety signs complied with International Organization for Standardization 1710 and the Safety Signs and Signal Regulations 1996 chosen randomly.

RESULTS:

A total of 987 people participated in our study and were asked to comprehend the meaning of nineteen health and safety signs. The mean comprehension score for 19 signs was 42.2%. The mean score for warning signs was the lowest and fire safety signs was highest. The lowest comprehension scores were for oxygen cylinder sign (W029) 7.5% and highest for first aid sign (E003) 75.9%. Only two signs, that are first aid (E003) and mandatory gloves (M009) had acceptable comprehensive score of 75.9% and 73.7% respectively as per ISO 7010 i.e. >67%. Statistically significant differences were found only for trip hazard sign (W007) with respect to education and for risks of bomb explosion (W002), ionising radiation (W009), evacuation assembly point (E007), location of automated external heart defibrillator (E010) and mandatory gloves (M009) with work experience.

CONCLUSION:

Based on our results, we conclude that there is dire need of special and frequent training to better recognize the safety signs amongst health care employees since these kinds of interventions promote early detection of hazards and their associated risks. Thus, we propose that health care safety sign training must be included in every health care profession curriculum.

Keywords

Safety health care accident prevention workplace curriculum emergencies

1 Introduction

The occupational health and safety debate is of worldwide significance since its implications may help minimize workplace morbidities, accidents, wage losses, absenteeism and compensation costs, thus reduces losses of both the employer and the employees.

Safety signs serve as essential measures and most common approach for accident and injury prevention, emergency evacuation, fire safety and health hazard information, since they take up only limited space, promoting better interactions between people and their surroundings. However, they are beneficial only when properly designed and comprehended by staff [1, 2].

Healthcare professionals make up total 47% of the global labor market and are usually employed in what is considered to be one of the high risk occupational settings. In addition to potential environmental hazards including noise, high temperature, illumination, electrical injuries and fire [3], they are also exposed to a variety of additional risks as a result of their work related activities such as exposure to ionising and non ionising radiation used for diagnostic radiology purposes in the field of medical, dentistry and other allied health sciences which may cause severe irreversible damage to their health [4 –7].

Numerous studies have documented how prolonged exposure to radiation can cause low haemoglobin and mean corpuscular volume in blood of exposed employees. Other than the use of dosimeter, the level of risk depends largely on healthcare professional’s knowledge regarding its potential health consequences and safe application in work practices [8, 9].

Moreover, with development of new technologies and alteration of properties and utilization of solvents and chemical overtime studies claim that hospital cleaning staff may develop occupational asthma and contact dermatitis [10 –14].

The World Health Organization and International Labor Organization have implemented measures for chemical safety over last two decades such as the establishment of Global Harmonized System of Classification and Labelling of Chemicals (GHS), the Strategic Approach to the International Management of Chemicals, and Inter-Agency Programme for the Correct Management of Chemicals [15 –17]. However provision of information is only valuable when comprehended by user appropriately. A recent study on household chemicals claimed that only 1.8% of participants read the information label on chemical containers [18].

According to literature, human errors are the leading cause of occupational accidents making it hard to institutionalize implementation of safety measures. Thus it is of deem importance to realize that effective compliance of health and safety occupational measures require its understanding in order to change the behavior of employees rather relying solely on engineering solutions and enforcing safety laws and regulations [19].

One of the legal requirements for any occupational sector, from high street store or a luxury office to manufacturing facility, construction site or a nearby school or hospital, is the display of clear, readable, visibly placed and well maintained safety sign, in order to warn against potentially dangerous and prohibited action, highlight safeguard procedures that must be implemented or mandate the wearing of protective equipment. According to accident statistics, humans are the primary cause of most of industrial accidents, making it hard to institutionalize safe behavior using solely technological engineering solutions and enforcing safety laws and regulations.

Even though Pakistan’s OSHA Act was passed in 2018 with the goal of assisting organizations and institutions in variety of sectors under the federal government jurisdiction with guidance, education and training on health and safety measures to ensure safe working condition, the country’s health and safety laws are still out of date. Furthermore, majority of workplace accidents remain unreported due to lack of legislation, poor infrastructure and low literacy rate of workforce which supports the fact that country still lacks independent policies addressing these issues [20, 21].

During our daily routine, we all encounter a range of safety signs, from boards to pictograms, visual or auditory. It is very important that we must be able to recognize and comprehend them not only for our safety but surrounding individuals and environment. We all come across a variety of safety signs in the form of boards, pictograms, visual or auditory on a daily basis but it is equally important that we must we be able to recognize and comprehend them for the safety of ourselves, but for surrounding individuals and environment. Since we are a third world nation where poor infrastructure, absence or ignorance of law and regulations, poor literacy rate are obvious major hurdles, the result of this study will help us promote the awareness amongst health care workers regarding increase risk of preventable occupational hazards, take necessary measures for prevention and highlight the need of training to concerned authorities in order to create an effective and safe environment. Thus considering the importance of recognizing and understanding health and safety signs in health sector and lack of research in this field, the present study was designed to assess the awareness of health and safety signs amongst health care workers including doctors, dentists and paramedics in different health care sectors across Pakistan.

2 Methods and materials

2.1 Study design

This cross-sectional study was conducted after approval from institutional ethical review committee, Pakistan. All the procedures in this study were in compliance with the Helsinki Declaration.

2.2 Sample population and characteristics

A total of 987 (participation rate 93.9%) out of 1051 health care professionals participated in the survey. The participants included doctors, dentists and supporting staff. A simple random sampling by chit-pull lottery method was used to compile a list of total 5 WhatsApp groups related to health care professional associations, educational institutions and community groups across the country. The participation was made voluntarily and a statement related to informed consent was included at the beginning of the survey form. The participants who showed their willingness were further given full disclosure of research plan, its intent, procedure and whom to contact for answers to pertinent questions about research and subjects rights. None of the participants received any incentives. To maintain anonymity and confidentiality, no identifying information was recorded except the profession and qualification. Since emails were sent to the participants, the data was handled solely by principal investigator.

2.3 Survey tool and data collection

The data was collected via Google forms circulated through WhatsApp social media to predetermined groups of health care professionals to assess their understanding of safety signs across different health sectors. The questionnaire was in English and Urdu language for feasibility of participants.

The survey consisted of two parts: part 1 demographics and part 2: awareness of 19 different health and safety signs complied with International Organization for Standardization (ISO) 1710 and the Safety Signs and Signal Regulations 1996 [22, 23] chosen randomly. Each sign was accompanied with one correct answer, two plausible but incorrect and one “don’t know” option as adopted by Cafarro F et al. [24, 25]. The participants were asked to select only one option. Each sign was kept of equal size i.e. 2.3 cm×2.3 cm and displayed in color as per the standard ISO 7010 the shape and color of each safety sign conforms to the standard ISO 3864-1 [26] and the design of the graphic symbols conforms to the standard ISO 3864-3 [27].

Two e-mails were sent to willing participants within 3 weeks: a questionnaire and a reminder mail.

2.4 Reliability of questionnaire

The questionnaire was piloted on 15 randomly selected health care workers to ensure clarity, practicability of the questions, and ease of completion. The reliability of the questionnaire was assessed based on findings of this pilot study. Cronbach alpha was used as a measure of reliability (0.84).

2.5 Statistical analysis

Data were analyzed using SPSS 20.0 (IBM Corp., Armonk, NY, United States). Since we used a structured survey form consisting of closed– ended questions with pre-determined response options, this study was suitable for quantitative analysis. Overall mean scores were calculated for five categories of safety signs along with frequency and percentage for individual variables to analyze and summarize numerical data. Chi- square test was applied with significance level≤0.05 to examine the association between demographic variable (education level and work experience) and awareness of safety signs. Since the data sets were too large for the exact P-value to be calculated which is a more reliable result compared to asymptomatic method, we also used the Monte Carlo method to provide an unbiased and reliable estimate of the exact P-value [28].

3 Results

A total of 987 participants contributed in this study.

Table 1 shows the sociodemographic characteristics of health care workers that participated in this study. Most of the participants were females 677 (68.5%) whereas males accounted for 310 (31.4%). Majority of the participants were dentists (n = 415; 42.0%), followed by doctors (n = 376; 38.1%) and supporting staff (n = 196; 19.9%). Most of the participants had Masters’ degree (n = 588; 59.6%). In terms of geographic location, most of the participants were from Sindh region (n = 805; 81.6%), followed by Punjab, and Khyber-Pakhtunkhwa 3.9% (38) least were from Baluchistan. Almost half of our sample size had up to 10 years of work experience whereas more than a quarter had 11–20 years of experience and only 157 (15.9%) participants had 21–30 years of experience. We also noted that 557 (56.4%) participants were employed in government sector whereas 430 (43.6%) participants were working in private setting.

Table 1
Socio demographics of participants (n = 987)

PARTICULARS (n = 987) TOTAL %

GENDER Males 677 68.6

Females 310 31.4

PROFESSION Dentist 415 42

Doctor 376 38.1

Supporting staff 196 19.9

QUALIFICATION Masters 588 59.6

Bachelors 387 39.2

Intermediate 12 1.2

EXPERIENCE Up to 10 years 485 49

11–20 years 345 35

21–30 years 157 15.9

EMPLOYEMENT SECTOR Public 557 56.4

Private 430 43.6

GEOGRAPHIC LOCATION Sindh 805 81.6

Punjab 129 13

Khyber-Pakhtunkhwa 38 3.9

Baluchistan 15 1.5

PARTICULARS (n = 987)	TOTAL	%
GENDER	Males	677	68.6
	Females	310	31.4
PROFESSION	Dentist	415	42
	Doctor	376	38.1
	Supporting staff	196	19.9
QUALIFICATION	Masters	588	59.6
	Bachelors	387	39.2
	Intermediate	12	1.2
EXPERIENCE	Up to 10 years	485	49
	11–20 years	345	35
	21–30 years	157	15.9
EMPLOYEMENT SECTOR	Public	557	56.4
	Private	430	43.6
GEOGRAPHIC LOCATION	Sindh	805	81.6
	Punjab	129	13
	Khyber-Pakhtunkhwa	38	3.9
	Baluchistan	15	1.5

The comprehension scores for each sign ranged from the lowest score of 7.5% for W029 to the highest score of 75.9% for E003. Only 2 safety signs (E003 {75.9% } and M009 {73.7% }) achieved a comprehension score of 67.0% or higher which is established as the acceptance criterion for safety-related symbols in ISO 3864 (Table 2 & Supplementary appendix of Table 2).

Table 2

Detailed distribution of participant responses regarding health and safety signs. For details, refer to the Supplementary index of Table 2

ISO 7010	Q: Can you tell us the meaning of		n	%
	following sign from below option
P014		•Correct answer•Incorrect answer•don’t know	438231318	44.423.432.2
W002		•Correct answer•Incorrect answer•don’t know	328475184	33.248.218.6
W009		•Correct answer•Incorrect answer •don’t know	273547171	27.755.417.3
P007		•Correct answer•Incorrect answer•don’t know	447294246	45.3 29.7 24.9
W007		•Correct answer•Incorrect answer•don’t know	32563032	32.963.83.2
E003		•Correct answer•Incorrect option•don’t know	7498751	75.918.95.2
E010		•Correct answer•Incorrect option•don’t know	21662304	2.16730.8
M017		•Correct answer•Incorrect answer•don’t know	307377302	30.638.131.1
F005		•Correct answer•Incorrect answer•don’t know	615272100	62.327.510.1
W003		•Correct answer•Incorrect answer•don’t know	97722168	9.87317.0
W005		•Correct answer•Incorrect answer•don’t know	31458291	31.858.99.2
W004		•Correct answer•Incorrect answer•don’t know	233469285	23.647.528.9
P004		•Correct answer•Incorrect answer•don’t know	324515148	32.85215.0
E034		•Correct answer•Incorrect answer•don’t know	31460964	31.861.76.5
E007		•Evacuation assembly point•Incorrect answer•don’t know	380303304	38.530.630.8
E013		•Stretcher•Incorrect answer•don’t know	617244126	62.524.712.8
M009		•Correct answer•Incorrect answer•don’t know	727136124	73.713.712.6
W016		•Correct answer•Incorrect answer•don’t know	20277312	20.578.31.2
W029		•Correct answer•Incorrect answer•don’t know	7487835	7.588.93.5

The mean comprehension score for eight warning signs (W002, W003, W004, W005, W007, W009, W016 and W029) was 20.6%. The overall mean comprehension score for nineteen safety signs was 42.2% as shown in Table 3.

Table 3

Mean comprehensive scores for different categories of safety signs

CATEGORY	MEAN COMPREHENSIVE
	SCORE
PROHIBITORY SIGNS (P004, P007, P014)	40.8%
FIRE SAFETY SIGNS (F005)	62.3%
MANDATORY SIGNS (M017, M009)	51.95%
WARNING SIGNS (W002, W003, W004, W005, W007, W009, W016, W029)	20.6%
EVACUATION SIGNS (E003, E007, E010, E013, E034)	42.16%
OVERALL MEAN SCORE	42.2%

The only significant value with chi square test = 0.011 and Monte Carlo method = 0.018 with reference to level of education was for W007, “safety sign of trip hazard”. However, in cross-tabulation with work experience, the only statically significant values were noted for warning signs W002, “risk of bomb explosion” (chi square test = 0.034 and Monte Carlo method = 0.035 and for sign W009, “ionizing radiation” (chi square test = 0.034 and Monte Carlo method = 0.034) as shown in Table 4.

Table 4

Statistical analysis of warning signs with regards to work experience and educational level

DEMOGRAPHIC		PERCEPTION LEVEL REGARDING
VARIABLE		WARNING SAFETY SIGNS
ISO 7010 Safety sign codes	W002 (bomb explosion)	W009 (ionizing radiation)	W007 (trip hazard)	W003	W005	W004	W016	W029
Education level	- Chi square Asymptomatic sig:(2-sided) value	0.896	0.217	0.011	0.355	0.505	0.242	0.184	0.736
	-Monte Carlo Sig (2-sided) value	0.906	0.211	0.018	0.342	0.501	0.234	0.205	0.748
Work experience	-Chi square Asymptomatic sig:(2-sided) value	0.034	0.034	0.440	0.365	0.421	0.849	0.610	0.238
	-Monte Carlo Sig (2-sided) value	0.035	0.034	0.441	0.362	0.420	0.852	0.609	0.243

Table 5 shows that the work experience and educational level were insignificant in regards to the prohibitory signs (P014, P007and P004).

Table 5

Statistical analysis of prohibitory signs with regards to work experience and educational level

DEMOGRAPHIC VARIABLE		PERCEPTION LEVEL REGARDING
		SAFETY SIGNS
ISO 7010		P014	P007	P004
Safety sign codes
Education level	-Chi square Asymptomatic sig: (2-sided) value	0.590	0.569	0.387
	-Monte Carlo Sig (2-sided) value	0.585	0.571	0.376
Work experience	-Chi square Asymptomatic sig: (2-sided) value	0.059	0.080	0.481
	-Monte Carlo Sig (2-sided) value	0.060	0.080	0.479

Statistically significant values were noted for emergency signs E010, “location of AED” (chi square test = 0.002 and Monte Carlo method = 0.002) and for sign E007, “assembly point” (chi square test = 0.025 and Monte Carlo method = 0.025) with reference to work experience as seen in Table 6.

Table 6

Statistical analysis of emergency signs with regards to work experience and educational level

DEMOGRAPHIC VARIABLE		PERCEPTION LEVEL REGARDING
		SAFETY SIGNS
ISO 7010 Safety sign codes	E003	E010 (Location of AED)	E034	E007 (assembly point)	E013
Education level	-Chi square Asymptomatic sig: (2-sided) value	0.735	0.313	0.855	0.066	0.131
	-Monte Carlo Sig (2-sided) value	0.715	0.290	0.866	0.068	0.128
Work experience	-Chi square Asymptomatic sig: (2-sided) value	0.616	0.002	0.415	0.025	0.548
	-Monte Carlo Sig (2-sided) value	0.618	0.002	0.412	0.025	0.545

Table 7 shows that the mandatory sign M009, “mandatory gloves” was statistically significant (chi square test = 0.044 and Monte Carlo method = 0.045) with reference to work experience.

Table 7

Statistical analysis of mandatory and fire signs with regards to work experience and educational level

DEMOGRAPHIC VARIABLE		PERCEPTION LEVEL REGARDING
		SAFETY SIGNS
ISO 7010 Safety sign codes		M017	F005	M009 (mandatory gloves)
Education level	-Chi square Asymptomatic sig: (2-sided) value	0.942	0.483	0.620
	-Monte Carlo Sig (2-sided) value	0.949	0.468	0.615
Work experience	-Chi square Asymptomatic sig: (2-sided) value	0.085	0.477	0.044
	-Monte Carlo Sig (2-sided) value	0.085	0.481	0.045

4 Discussion

Sixty-seven percent score of comprehension is generally used as the acceptance criterion for safety-related symbols in ISO 3864 [26, 27] and an 85.0% score of comprehension is used as an acceptance criterion in the American National Institute Z535.3– 2022 [29]. In our study, the comprehension scores for each sign ranged from the lowest score of 7.5% for W029 to the highest score of 75.9% for E003. Only 2 safety signs (E003 {75.9% } and M009 {73.7% }) achieved a comprehension score of 67.0% or higher which is established as the acceptance criterion for safety-related symbols in ISO 3864.

The mean comprehension score for eight warning signs (W002, W003, W004, W005, W007, W009, W016 and W029) in the present study was 20.6%. Literature [1 , 30] reported a mean score of 53.2%, 61.2% and 63.4% for the warning signs, respectively, which is quite higher than our results. The lowest comprehension score (7.5%) in the present study was for the sign “oxygen cylinder” (W029). The majority of subjects thought it as a sign of “fire extinguisher” which as per our understanding is quite alarming to notice. In comparison, Gungor C reported lowest comprehension score of 22.5% for the sign “toxic material sign” (W016) [1]. Most of the participant (73.2%) perceived this sign as “danger of death” which the author related it to the effect of cultural background. The study also reported that the wrong understanding and use of this very important sign prevented them from highlighting the real meaning. Another warning signs with a very low comprehension score we found were W003, “chemical hazard” and W016, “poison”. Most of the participants responded “radioactive hazard” and “danger” respectively.

We included only one fire safety sign (F005) and the highest responses received was for the correct answer, “fire alarm” (62.3%). Based on the symbol of fire button, it was quite easy and obvious to understand by our participants. In comparison, Gungor C reported sign for “location of a fire blanket” (F016) answered correctly by 53.3% of the subjects [1].

We included only two mandatory signs (M009 and M017) and the mandatory sign M009 was responded correctly by 73.7% participants, however for sign M017, the highest score was recorded as “avoid gas inhalation” by 32.9%. A slight lower percentage (30.6%) responded the correct response “respirator mask” which again is quite surprising to notice considering the recent events of COVID-19 which bring forward the use of face mask as a compulsion globally. In comparison, Gungor C have reported quite higher response rate for mandatory safety signs with comprehension score of this sign (M021) alone as 84.4% [1].

The mean score for prohibitory signs collectively in our study was 40.8% which is quite lower than the acceptance criterion of ISO (67.0%) [26, 27] and some other studies 53.07% and 86.8% in the literature [1, 30]. The comprehension score for P014 in our study was 44.4% which is almost half than the reported score 82.4% of Gungor C [1]. The remaining scores for P004 and P007 in our study were 32.8% and 45.3% respectively. In comparison, prohibitory safety signs (P011, P020, P041, P048) scores in literature were 83.3%, 84.1%, 89.2%, and 95.0% [1 , 30–32].

The mean comprehension score for five evacuation signs (E003, E007, E010, E013, and E034) was 42.16% in our study. The “first aid sign” (E003) had the highest comprehension score 75.9% whereas the lowest comprehension score 31.8% noted was for E034 “exit way to the left”. On the contrary, 49.1% participants assume it as “run this way in case of emergency” which as per our understanding is a safe understanding of this safety sign. Gungor C reported that 52.6% participants in their study misunderstood this sign for “door slides left to open” [1]. Another sign “evacuation assembly point” (E007) was understood by 98.6% subject in literature however our results showed the response rate of only 38.5%. An important sign, “location of an automated external heart defibrillator device” (E010), was understood by only 2.1% participants in our study which in comparison to other side study score (27.4%) [1] is dangerously at lower side and an alarming concern to notice since it is a very important safety sign even for the common people.

As per our results, the only significant value with reference to level of education was for safety sign of W007, “trip hazard”. However, in cross-tabulation with work experience, the only statically significant values that we found were for warning signs W002, “risk of bomb explosion” and W009, “ionizing radiation”. We also noticed statistically significant values for emergency signs E010, “location of AED”, E007, “assembly point” and mandatory sign M009, “mandatory gloves”. The most sensible explanation for few significant values out of 19 safety signs is either all of them are either self-explanatory and most obvious in visuals or most commonly displayed in general or work-related surroundings.

The overall mean comprehension score 42.2% in the present study was on lower side than some of the previous studies where the mean comprehension scores were noted as 70.9% [2], 66.2% [30], 63.4% [31], 63.8% [32], and 67.5% [33]. However, our results are in some similarity with Arphorn et al. [34] where a very low scores in safety sign perception (39.2%) was noted. We presume that these differences may be due to difference in ethnic, cultural, educational background or different experimental designs (e.g., sign selection). Some previous studies indicated that different cultural backgrounds might lead to differences in sign perception [32 , 35–40].

It is important to note in here that although our scores are quite low in comparison to literature, the signals did convey the perception of a hazard to employees. However, it is very important to mention that having perception of a hazard sign solely is not sufficient in critical environments like health care facilities and that it is important to know the specific hazards and how to respond to them. It is also worth noting that comprehension errors of safety signs could be more critical for some signs than others, depending on the level of risk involved. The level of risk is determined by the likelihood and severity of harm or adverse health effects that may result from exposure to a hazard. Therefore, more attention should be paid to signs that convey higher risks to ensure effective communication and minimize the likelihood of injuries and illnesses which highlights the need for implementation of basic trainings regarding health and safety signs amongst health care workers.

5 Limitations

We did not include the rural health care sectors in our data sampling. Therefore, additional studies may be required in the future to cover remote areas and the primary, secondary, and tertiary health care sectors.

The use of closed ended question in our quantitative analysis limits the depth of understanding pf participant’s knowledge and reasoning.

We acknowledge the limited generalizability of our finding within Pakistan especially rural areas and outside the country.

6 Conclusion

Misunderstanding of safety signs can confuse employees, leading to occupational injuries and illnesses. It is not essential that the entire workforce recognize all safety signs. However, it is very important that they are comprehended by most employees. It should be noted that there is a possibility that a disaster could be caused by a simple mistake, such as only one person misunderstanding the meaning of a sign). Based on our results, we conclude that there is dire need of special and frequent training to better recognize the safety signs amongst health care employees since these kinds of interventions promote early detection of hazards and their associated risks. Thus, we propose that health care safety sign training must be included in every health care profession curriculum.

Ethical approval

Ethical approval no. LUMHS/REC/183 was received from the institutional review board of Liaquat University of Medical and Health Sciences, Pakistan.

Informed consent

A statement related to informed consent was included at the beginning of the survey form.

Conflict of interest

The authors declare no conflict of interest.

Footnotes

Acknowledgments

Not applicable.

Funding

The authors received no external/internal funding.

The supplementary material is available in the electronic version of this article: .

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Understanding the awareness of health and safety signs amongst health care workers in Pakistan – A cross-sectional study