Respiratory research Work- related respiratory health conditions among construction workers: a systematic narrative review Elijah Frimpong Boadu ,1 Sylvester Reuben Okeke,2 Caleb Boadi,3 Emmanuel Osei Bonsu,4 Isaac Yeboah Addo2 To cite: Boadu EF, Okeke SR, ABSTRACT Boadi C, et al. Work-r elated Background Emerging evidence in both developed and WHAT IS ALREADY KNOWN ON THIS TOPIC respiratory health conditions developing countries indicate that occupational health ⇒ Does the hazardous nature of construction activities among construction workers: hazards and diseases among construction workers and materials expose construction workers to respi- a systematic narrative constitute a significant public health challenge. While ratory health conditions? review. BMJ Open Respir occupational health hazards and conditions in the Res 2023;10:e001736. doi:10.1136/ construction sector are diverse, a burgeoning body of WHAT THIS STUDY ADDS knowledge is emerging about respiratory health hazards ⇒ Construction activities and materials expose work-bmjresp-2023-001736 and diseases. Yet, there is a notable gap in the existing ers to harmful hazards such as dust, silica, fumes, ► Additional supplemental literature in terms of comprehensive syntheses of the asbestos and these hazards are associated with a material is published online available evidence on this topic. In light of this research range of health problems ranging from mild respi- only. To view, please visit the gap, this study systematically reviewed the global evidence ratory symptoms to severe ones such as respiratory journal online (http://d x. doi. on occupational health hazards and related respiratory cancers and silicosis. org/ 10. 1136/ bmjresp-2 023- 001736). health conditions among construction workers. Methods Using meta- aggregation, guided by the HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY Received 31 March 2023 Condition (respiratory health conditions), Context Accepted 13 June 2023 (construction industry) and Population (construction ⇒ This review systematically examines the nature and workers) (CoCoPop) framework and Preferred Reporting frequency of respiratory hazards and diseases, be- Items for Systematic Reviews and Meta- Analyses yond just conditions related to COPD, among con- guidelines, literature searches were conducted on struction workers and identifies effective mitigating Scopus, PubMed, Web of Science and Google Scholar for strategies for reducing respiratory health conditions relevant studies on respiratory health conditions affecting among construction workers. construction workers. Four eligibility criteria were used in scrutinising studies for inclusion. The quality of the included studies was assessed based on Joanna Briggs occupational health programme is essential. Such a Institute’s Critical Appraisal tool, while the reporting of the programme would extend beyond the mere provision of results was guided by the Synthesis Without Meta- analysis personal protective equipment and would incorporate guidelines. a range of proactive measures aimed at controlling © Author(s) (or their employer(s)) 2023. Re- use Results From an initial pool of 256 studies from the the hazards and mitigating the risk of exposure to the permitted under CC BY- NC. No various databases, 25 studies published between 2012 occupational health hazards. commercial re- use. See rights and October 2022 were identified as meeting the inclusion and permissions. Published by BMJ. criteria. In all, 16 respiratory health conditions were 1 identified, with cough (ie, dry and with phlegm), dyspnoea/Department of Civil breathlessness and asthma emerging as the top three INTRODUCTION Engineering, Kumasi Technical respiratory conditions among construction workers. The The construction work sector is unarguably University, Kumasi, Ghana 2 study identified six overarching themes of hazards that one of the most hazardous work environ-Centre for Social Research in Health, UNSW, Sydney, New are associated with respiratory health conditions among ments. 1 This is because the materials and South Wales, Australia construction workers. These hazards include exposure to processes involved in the sector expose its 3Department of Operations dust, respirable crystalline silica, fumes, vapours, asbestos workers to health hazards and accidents and Management Information fibres and gases. Smoking and extended period of with significant public health implications.1 Systems, University of Ghana, exposure to the respiratory hazard were found to increase The construction work environment is Legon, Greater Accra, Ghana 4 the risk of contracting respiratory diseases. 2Department of Epidemiology both complex and dynamic with a range Conclusions Our systematic review indicates that and Biostatistics, KNUST, of hazardous work materials, processes and construction workers are exposed to hazards and Kumasi, Ashanti, Ghana conditions that have adverse effects on their health activities. In addition to the risks associated and well- being. Given the considerable impact that with direct or indirect exposure to hazardous Correspondence to Dr Elijah Frimpong Boadu; work- related health hazards can have on the health and materials, the construction workforce, elijah. bfrimpong@ kstu. edu. socioeconomic well- being of construction workers, we particularly in the informal sector of devel- gh suggest that the implementation of a comprehensive oping countries, is often characterised by low Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 1 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access levels of formal education. This lack of education may better equipped to make informed decisions about occu- compound the challenges faced by workers in this sector, pational health and safety and promote the well-b eing of as they may be less equipped to understand and respond workers in an ever- changing work environment. The aim to the potential health risks associated with their work.2 3 of our systematic review is in twofold. First, we aimed to Although the range of occupational health hazards understand, through the synthesis of recent evidence, the and conditions encountered within the construction nature and frequency of respiratory hazards and diseases, sector is broad and multifaceted, there is a growing body beyond just conditions related to COPD, among workers of research focused specifically on respiratory health in the construction sector. Our second aim was to identify hazards and diseases. This emerging field of inquiry is effective strategies that could be responsive in reducing if motivated by the recognition of the unique health chal- not totally eradicating respiratory health diseases among lenges faced by workers in this industry, particularly in construction workers. light of the ongoing expansion of construction activities Conducting a systematic review is indeed justified in across both developing2 4–6 and developed7–10 regions of our case. Our objective was to ensure a comprehensive the world. Addressing occupational respiratory health evaluation of the existing evidence on the topic, which hazards and diseases among construction workers would has not been systematically assessed elsewhere. We aimed require research- oriented occupational health strate- to provide a thorough and unbiased analysis of the avail- gies. Notably, evidence indicates there has been a posi- able studies, identifying research gaps and assessing the tive impact of occupational health strategies over the last quality of the evidence. By conducting this review, we 60 years.11 Continuous improvement would depend on have successfully identified areas where further research recent research capturing changing dynamics in work is needed and highlighted methodological inconsis- conditions and work- related legislation. This is particu- tencies, conflicting findings and limitations within the larly critical considering that the construction sector is existing studies. known to pose significant occupational health hazards Moreover, our systematic review serves as a valuable and conditions.1 For instance, recent studies have shown tool for evidence-b ased decision-m aking. Policy-m akers, that workers in the construction industry are frequently practitioners and researchers can rely on our review to exposed to a range of airborne pollutants and irritants that make informed decisions and take appropriate actions. can lead to respiratory ailments.12 13 Despite the evident By synthesising the available evidence in a transparent risk to worker health, there is a dearth of comprehen- and rigorous manner, we provide a reliable foundation sive research on the specific respiratory health hazards for evidence- based practice and policy development. encountered by construction workers and the levels of Therefore, our systematic review contributes significantly impact of these hazards on respiratory health. This gap to the field by filling the gap in knowledge and informing in knowledge hinders the development and implemen- evidence- based decision- making. It is a vital step in tation of effective interventions to mitigate these hazards advancing our understanding of ‘work-r elated respira- and protect worker health. Borup et al14 conducted a tory health conditions among construction workers’ and prior systematic review that synthesised evidence on guiding future research endeavours. respiratory health conditions among construction workers. However, their review solely focused on chronic obstructive pulmonary diseases (COPDs) and was limited MATERIALS AND METHODS to studies published between 1990 and 2016. Search strategies Given the dynamic nature of working conditions and This systematic review was conducted in line with the legislative frameworks, it is imperative to undertake a Preferred Reporting Items for Systematic Reviews and contemporary and comprehensive synthesis of available Meta- Analyses (PRISMA) guidelines. The study adopted evidence. The working environment is continuously the CoCoPop framework,15 that is, Condition (respira- evolving, with new occupational hazards emerging and tory health conditions), Context (construction industry) existing ones changing in their manifestation. This under- and Population (construction workers) to determine scores the need for periodic reviews of available evidence the keywords for the literature search, and to form the to ensure that interventions and policies remain current basis for the inclusion or exclusion of retrieved articles, and effective in mitigating risks and promoting occu- as well as to inform the approach to data analysis. The pational health and safety. A contemporary synthesis of CoCoPop framework was used because it is suitable for the available evidence is vital in order to provide current addressing questions which are relevant to issues such insights into the status of working conditions, potential as types of health conditions and their prevalence in a hazards and effective interventions. Such a synthesis specific population.15 could facilitate an assessment of trends and changes in Two authors (EFB and CB) conducted literature the nature and prevalence of hazards, an evaluation of searches on Scopus, Web of Science, Google Scholar the efficacy of current interventions and identification and PubMed for relevant studies on respiratory condi- of gaps in knowledge that require further research. By tions affecting construction workers. Within the context conducting a current synthesis of available evidence, of this review, ‘respiratory conditions’ referred to any policy-m akers, employers and other stakeholders can be symptom or disease affecting parts of the body involved in 2 Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access breathing, such as the sinuses, throat, airways or lungs.16 Inclusion and exclusion criteria Thus, in the context of our manuscript, the term ‘condi- After a thorough literature search, a set of criteria was tions’ encompasses a broad range of health outcomes, developed to ensure that only the most relevant studies including both diseases and symptoms. For the purpose were included in this review. The review was restricted to of clarity and comprehensiveness, we define conditions studies that had been published in English and focused as encompassing the following: on any type of respiratory health condition associated ► Diseases—health conditions including various patho- with any construction work and affecting construction logical processes characterised by specific structural or workers. Construction work referred to any work carried functional abnormalities in the body. These diseases out in connection with construction, alteration, conver- may have well-d efined clinical manifestations, diag- sion, fitting- out, commissioning, renovation, repair, maintenance, refurbishment, demolition, decommis- nostic criteria and treatment approaches. Examples sioning or dismantling of a structure.17 Studies related of diseases within the scope of our study may include to the prefabrication of elements, other than at a place respiratory, lung and larynx cancers, which are char- specifically established for the construction work, for use acterised by the presence of malignant tumours in in the construction work and those focusing on mining the respective organs. or the exploration of or extraction of minerals were not ► Symptoms—health conditions encompassing symp- classified as construction work. Also, within the construc- toms, which refer to subjective experiences or tion workers’ category, original research that focused manifestations of an underlying health issue. Symp- on different subgroups including professional and non- toms may be reported by individuals and can vary professional, gender, site and non- site based, etc in any in nature and severity. Examples of symptoms rele- type of construction activities (demolishing, excavation, vant to our study may include cough, wheezing and concreting, etc) was included. We also excluded litera- dyspnoea. ture reviews and editorials. Using keywords based on the dimensions of the CoCoPop framework, a thorough search was conducted Patient and public involvement in the electronic databases with word builders (such as None. Scopus) as follows (also see online supplemental file— search strategy). Condition: ‘respiratory health’, ‘respiratory disease’, Study screening and selection The study selection process involved the removal of ‘respiratory sick*’, ‘respiratory ill*’, ‘respiratory disorder’, duplicate studies (n=73) from the search results using ‘respiratory problem’, ‘respiratory infection’, ‘respiratory the ‘Find Duplicates’ function in the Endnote software cancer’, ‘respiratory well*’, ‘occupational lung disease’, before the screening process. The titles and abstracts of ‘respiratory condition’, ‘respiratory exposure*’, ‘respira- the remaining studies were exported from Endnote to tory symptom*’, ‘lung function’, ‘respiratory pressure’, Microsoft Office Excel. During the screening process, ‘respiratory disorder’ each study’s title and abstract were independently exam- Context: ‘construction industr*’, ‘construction sector’, ined for eligibility against the inclusion and exclusion ‘construction work*’, ‘construction activit*’, ‘building criteria by all authors. The Excel sheet was used to mark work*’, ‘building industr*’, ‘building site’, ‘construc- included studies as green, excluded studies as red and tion site’, ‘construction firm’, ‘construction compan*’, undecided studies as yellow. A dedicated column was ‘construction job’. created for reviewers to provide reasons for excluding Population: ‘construction labo*’, ‘manual work*’, ‘ineligible’ studies. ‘construction worker*’, ‘contractor’, ‘manual labo*’, Studies with four or more green marks were automat- ‘construction personnel*’, ‘building worker*’. ically selected for full- text review, while those with four Databases were searched using combinations of these or more red marks were automatically excluded from keywords, for instance ‘OR’ was used for the terms within further consideration. Any discrepancies in study inclu- each dimension and ‘AND’ for combining the three sion or exclusion were resolved through group discus- dimensions. An asterisk at the end of a search keyword sions. For instance, there were disagreements on the inclusion or exclusion of six of the studies and on thor- was used to cover a broad range of results within the ough group discussions, two of the studies were included keyword. Additionally, the following search term was and four were excluded. This screening process resulted used in Google Scholar, which is a database without in the removal of 199 articles, leaving a total of 29 studies word builders: ‘respiratory diseases among construction for further evaluation. These remaining studies under- workers’. The first five pages in Google Scholar were went a detailed full-t ext reading, which followed the screened. Also, the searches were restricted to studies inclusion and exclusion criteria and study objectives. published within the last 10 years, that is, studies between The resultant lists from the full-t ext reading were inde- 2012 and 2022 were considered. In total, 256 publica- pendently prepared by all research team members and tions were retrieved. compared. Any differences that arose were resolved Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 3 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access study designs, interventions, health conditions, etc) which breach the condition of ‘heterogeneity’ required for meta- analysis.20 Following the analysis, the results of the review were reported using the PRISMA framework. Addressing publication bias and heterogeneity To mitigate the potential influence of publication bias, we implemented a series of robust strategies within our systematic review. First and foremost, we conducted an extensive literature search encompassing various data- bases, including Scopus, PubMed and Web of Science. This comprehensive search approach allowed us to capture a broad spectrum of relevant studies. Further- more, we recognised the importance of including grey Figure 1 Flow diagram of literature search and selection literature in our analysis, as it often provides valuable for the systematic review. insights not found in traditional peer- reviewed publica- tions. Hence, we used Google Scholar to identify perti- nent grey literature sources, thereby ensuring a more comprehensive representation of the available evidence. through discussion, ultimately leading to the retention Moreover, in the interest of transparency and scientific of 25 studies for the review. This sample size (n=25) is integrity, we have diligently reported the methodologies considered adequate for a comprehensive review of the employed throughout our review process. By providing topic, as it falls within the range of published system- a detailed account of our literature search strategy and atic reviews of a similar nature (eg, Frimpong et al18). the steps taken to identify and include grey literature, To provide a visual representation of the study selection we offer transparency to readers and potential users of process, a flow diagram is presented in figure 1. this manuscript. Moreover, this transparency serves as a cautionary note, enabling readers to discern any specific Data extraction strategy information that may not have been explicitly reported To extract the data for the included study, Microsoft in this review. Through the rigorous implementation of Office Word was used to create a template containing these strategies, we have strived to augment the robust- various relevant thematic areas, including authors and ness, rigour and comprehensiveness of our work while publication date, study design, country of study, research minimising the potential impact of publication bias. participants, number of participants, respiratory condi- Regarding heterogeneity present in the data, we tions identified, hazards workers were exposed to, length employed a qualitative synthesis method, specifically of exposure and key conclusions of the study. Data were narrative synthesis, as the most appropriate approach. extracted by five of the authors independently and the This involved categorising the studies based on shared resultant extracted data were examined by the remaining characteristics or factors and conducting separate anal- author independently. Any disagreements that arose yses of their respective results. The primary focus of among the reviewers were consistently resolved through this synthesis approach was to provide a comprehen- discussion. Summaries of the extracted data are presented sive summary of the findings, identifying recurring in the online supplemental table. themes and patterns across the included studies without employing statistical pooling techniques. By adopting this approach, we were able to accommodate the inherent Data synthesis and presentation heterogeneity observed within the available evidence. The study sought to provide a narrative review of the Also, by adhering to rigorous inclusion criteria, we literature, and not to statistically analyse the variables of ensured methodological consistency and rigour in our interest, and therefore, the data were synthesised (narra- systematic review, thereby enhancing the robustness and tives, tables and visuals) using meta-a ggregation instead validity of our findings. of meta-a nalysis.18 19 Typically, meta-a ggregation seeks to provide a true picture of the existing body of literature by merging and not reinterpreting findings obtained from Method for assessing the quality of the included studies the studies included in a systematic review.19 Thus, meta- The methodological quality of the included studies was aggregation was appropriate for this current review which assessed by four authors (EFB, IYA, CB, and EOB) using focuses on providing a clearer overview of the respiratory the Joanna Briggs Institute’s (JBI) standardised critical health conditions among construction workers. Meta- appraisal instrument (table 1). A quality appraisal assess- analysis is deemed inappropriate to use in this review ment using the JBI method typically involves evaluating because there are significant differences in the attributes the studies included in the systematic review based on of the included studies (ie, sample types, study contexts, several criteria. In this systematic review, a list containing 4 Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 5 Table 1 Results of quality appraisal using the Joanna Briggs Institute’s critical appraisal tool Were the Were the criteria for study Was the Were objective, Were the inclusion in subjects and exposure standard Were Were strategies outcomes the sample the setting measured in criteria used for confounding to deal with measured in Was appropriate clearly described in a valid and measurement of factors confounding a valid and statistical Study/criteria defined? detail? reliable way? the condition? identified? factors stated? reliable way? analysis used? Krishnakumar et al30 Yes Yes Yes Yes Yes Unclear Yes Yes Mo et al31 Yes Yes Yes Unclear Yes Unclear Yes Yes Sari et al43 Yes Yes Yes Yes Yes Yes Yes Yes Mandal and Dutta37 Yes Yes Yes Yes Yes Yes Yes Yes Keer et al9 Yes Yes Yes Yes Yes Unclear Yes Yes Sachdeva et al29 Yes Unclear Yes Yes Unclear Unclear Yes Yes Sulaiman et al13 Yes Yes Yes Yes Unclear Unclear Yes Yes Rose et al32 No Yes Yes Yes Yes Unclear Yes Yes Rando et al42 Yes Yes Yes Yes Yes Yes Yes Yes Rachiotis et al36 Yes Yes Unclear Yes Yes Yes Yes Yes Tüchsen et al21 Yes No Yes Yes No NA Yes Yes Mariammal et al35 No No Yes Yes Yes Yes Yes Yes Doney et al22 Yes NA Yes Yes No NA Yes Yes Alicandro et al23 Yes No Yes Yes No NA Yes Yes Ghimire and Neupane40 Yes No Yes Yes Yes No Yes Yes Kurth et al33 Yes Yes Yes Yes Yes Unclear Yes Yes Hamid et al34 Yes Yes Yes Yes Yes Unclear Yes Yes Boelter et al24 Yes Yes Yes Yes No No Yes Yes Banerjee et al25 Yes Yes Yes Yes No No Yes Yes Vallières et al38 Yes Yes Yes Yes Yes Yes Yes Yes Nicol et al26 Unclear Yes Yes Yes No No Yes Yes Fareed et al27 Yes Yes Yes Yes No No Yes Yes Mohankumar et al28 Yes Yes Yes Yes No No Yes Yes Tavakol et al12 Yes Yes Yes Yes Unclear Unclear Yes Yes Wang et al41 Yes Yes Yes Yes Yes Yes Yes Yes All these studies were included in the systematic review. BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access links to the published included studies was exported into considered moderate, but this should be interpreted in Excel and shared among four authors (EFB, IYA, CB, conjunction with the weaknesses described. EOB) for review. Eight questions were used to assess the quality of each included study, namely: ‘Were the criteria RESULTS for inclusion in the sample clearly defined?’, ‘Were the Overview of included studies study subjects and the setting described in detail?’, ‘Was A total of 25 studies were included in the review. Most the exposure measured in a valid and reliable way?’, of the studies (n=24) were published as peer- reviewed ‘Were objective, standard criteria used for measurement journal articles between 2012 and 2022 and 1 was a case of the condition?’, ‘Were confounding factors identi- report. In terms of the study designs, the majority were fied?’, ‘Were strategies to deal with confounding factors cross-s ectional studies (n=14) and quantitative cohort stated?’, ‘Were the outcomes measured in a valid and reli- studies (n=4). The review encompasses a collective sample able way?’ and ‘Was appropriate statistical analysis used?’. size of at least 1 684 516 individuals who are employed in Four response options were provided for each question: the construction industry. Sample sizes within this popu- ‘yes’, ‘no’, ‘unclear’ or ‘not applicable’. Generally, we lation vary considerably, ranging from as few as six indi- resolved to include studies with at least five ‘yes’ answers viduals to a maximum of 1 068 653—including 8 studies to the eight questions. However, each author was given the with sample sizes less than 100, 11 studies with sample freedom to decide whether a paper should be included sizes between 100 and 1000 and 6 studies with sample or otherwise and a column was provided for comments sizes more than 1000. The study samples were mainly on why a paper should be excluded. Following that, one dominated by males. The studies focused on various author (IYA) compiled and vetted all the decisions; and construction workers such as tradespeople, labourers all discrepancies were settled through discussion. and construction supervisors. A total of 15 countries were represented, with the USA (n=6) and India (n=6) having the highest number of studies. Additional details on the Quality assessment results studies included in this review are provided in online As shown in table 1, all the twenty-f ive studies were supplemental table. included in the final decision as all the studies were eval- uated positively in five or more questions. Specifically, the results from the appraisal show that all the studies Work-related respiratory conditions affecting construction conducted appropriate statistical analysis and measured workers outcomes validly and reliably. However, there were ‘no’ A total of 16 specific respiratory conditions were derived responses to some questions indicating the possibility from the included studies (see figure 2). The frequencies, of bias in some of the results. Based on our assessment, as shown in table 2, have been used to rank each respira- 11 out of the 25 studies12 13 21–29 either did not identify tory condition according to how often they were identi- confounding factors or provided unclear confounders fied in the included studies. The top three respiratory which suggest a potential risk of bias in those studies. conditions identified are cough (ie, dry and with phlegm) Additionally, 6 studies9 30–34 out of the 14 studies that (n=13), dyspnoea/breathlessness (n=7) and asthma identified the presence of confounders provided unclear (n=6), while the least identified conditions included strategies used to deal with the confounding factors. This pneumoconiosis (n=1), emphysema (n=1), haemoptysis implies that causality should not be assumed in those (n=1) and acute respiratory distress syndrome (n=1). studies. Altogether, majority of the frequent conditions identi- We found that three studies26 32 35 did not clearly define fied relate to respiratory symptoms—these include cough the criteria for inclusion in their samples indicating that (n=13), dyspnoea/breathlessness (n=7), wheezing/ the selection of participants in those studies may be whistling in chest (n=5) and chest congestion/tightness subjective, leading to potential bias in the results. This (n=4). However, though not the most frequent cases, the may further imply that the study samples may not be representative of the population of interest, or the results may be affected by other factors that were not consid- ered. Thus, it may be unclear whether participants were selected based on a specific set of characteristics or if the samples in those studies were selected randomly. All the 25 studies were rated high in terms of whether the exposure variables were measured in a valid and reliable way. However, the measurement of exposure was deemed unclear in one study.36 This means that the accuracy and consistency of the data collected for the exposure vari- able in the study may be questionable. To this end, the general results of the quality appraisal exercise using the Figure 2 Work-r elated respiratory conditions among JBI approach show that the quality of most studies can be construction workers. 6 Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access Table 2 Variable ranks of respiratory conditions among Table 3 Variable ranks of hazards causing respiratory construction workers conditions among construction workers Respiratory condition Studies, n Rank Respiratory hazards Studies, n Rank Cough (dry and with phlegm) 12 1 Dust (ie, from aggregate, wood, 15 1 Dyspnoea/breathlessness 7 2 other mixed dust, etc) Asthma 6 3 Respirable crystalline silica 8 2 Wheezing/whistling in chest 5 4 Fumes (ie, from asphalt, exhaust 6 3 fumes, welding, etc) Cancers (respiratory, lung and 4 5 larynx) Vapours 2 4 Chest congestion/tightness 4 Asbestos fibres 2 Silicosis 3 6 Gases 1 5 Lung impairment and fibrosis 3 Chronic bronchitis 2 7 works, rock drilling, road grading, milling and laying, as Sinusitis 2 well as cutting, planing and sanding of wood. After the Chronic obstructive pulmonary 2 dust, respirable crystalline silica (RCS) (n=8) ranked as disease the second highest hazard causing respiratory condi- Sneezing and rhinitis 2 tions in construction. Typically, RCS is categorised as a type of construction dust and the description of some Pneumoconiosis 1 8 of the ‘dust-c ausing activities’ above suggests that some Emphysema 1 of the dust produced may be RCS. Nonetheless, eight Haemoptysis 1 of the included studies distinctively mentioned RCS as a Acute respiratory distress 1 major hazard causing respiratory conditions in construc- syndrome tion workers. Construction activities that produced RCS include mixing of cement and concrete, demolition, rock drilling, works involving fine particles of cement, fly ash, number of studies identifying severe and chronic diseases bricks, mortar and sandstone. Other hazards identified were significant—these diseases include cancers (n=4), include fumes (ie, from asphalt, exhaust fumes, welding, silicosis (n=3) and lung impairment and fibrosis (n=3). etc), vapours, asbestos fibres and gases. Furthermore, insights from the included studies Respiratory hazards among construction workers revealed that smoking habits and the reluctance to use Figure 3 illustrates the identification of six distinct personal protective equipment among the construction themes relating to the hazards that are responsible for workers increased the risk of contracting respiratory respiratory conditions among construction workers. diseases. 34 37 38 On the length of exposure to hazards, Also, the frequencies in table 3 rank each hazard based studies such as Fareed et al, 27 Sulaiman et al13 and Mandal and Dutta37on how often they were identified in the included highlighted that the prevalence of respira- studies. In all, dust (n=15) presented the topmost hazard tory condition is higher if the construction worker has causing respiratory conditions among construction an extended exposure to the respiratory hazard. For 37 workers. These dusts were described as those produced instance, Mandal and Dutta found that the OR values as a result of construction activities such as excavation or of the prevalence of respiratory disorder with >10 years tunnelling, demolition, sandblasting, grinding, masonry of exposure to bitumen fumes varied from 2 to 4.5. Also, the finding from Fareed et al27 indicated that decrease in lung functions among tunnel workers was significantly correlated with the duration of exposure (hours per day). Recommended control measures To control the identified respiratory hazards on construc- tion sites and reduce workers’ exposure to these hazards, several strategies were recommended in the included studies. Figure 4 illustrates the categories of recom- mended control strategies. The majority of the studies advocated for the provision and proper use of appropriate personal (or respiratory) protective equipment (PPEs), because it was found that, among other factors, the reluc- Figure 3 Hazards causing respiratory conditions among tance to use PPEs (such as masks and respirators) among construction workers. the construction workers increased their risk of getting Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 7 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access most commonly reported hazards. Other hazards are asbestos fibres which ranked fourth, with vapours and gas found to be the least reported respiratory hazards. The materials and processes of work in the civil construction sector make dust a common hazard among workers in this sector, thereby predisposing them to respi- ratory and other health- related conditions. For instance, COPDs are more common among construction workers compared with workers in other occupations who are not exposed to dust.14 A similar result was found in a recent survey among construction workers whose respiratory health was compared with that of workers in non- dust- prone occupations (bus drivers and retail workers) in Figure 4 Recommended respiratory hazard control New Zealand.9 Dust from cement, sand, wood and other measures. materials when inhaled pose respiratory health threat. Importantly, the length of exposure to occupation- related 35 37 dust among construction workers further increases their respiratory diseases. In addition to the use of PPEs, vulnerability to respiratory health problems. Recent other strategies have been suggested, including applying evidence9 39 indicate that construction workers who have engineering controls—such as misting, water or chem- 13 35 been in the sector for a longer period, for example, over ical suppression and proper ventilation, applying 10 years were more likely to report respiratory health administrative controls—such as training, induction, pre- employment health screening, warning signs, etc27 35 diseases than those who have spent less than 10 years as construction workers.9 and substitution—such as using modern machinery and 37 Health-r elated problems arising from exposure to dust sophisticated techniques. also apply to other hazards such as vapours, silica, fumes and gas. Some of the studies included in this review, iden- DISCUSSION tified and stressed the adverse effect of dust and asphalt The objectives of our systematic review are twofold. First, fume inhalation on the health and well- being of construc- we aimed to comprehensively examine recent evidence tion workers in China,31 Denmark,21 India,25 29 29 37 and to elucidate the nature and frequency of respiratory Malaysia.13 Similar findings were also reported in studies hazards and diseases (beyond COPD) that are prevalent among construction workers in Canada,38 Iran,12 Nepal,40 among workers in the construction sector. Second, we Saudi Arabia,27 the UK26 and the USA.22 24 32 33 41 42 Impor- aimed to identify effective strategies that may be used to tantly, some of the studies included in our review suggest mitigate or even eliminate the incidence of respiratory that exposure to work-r elated hazards may be associated health diseases among construction workers. Overall, the with respiratory cancer incidence and prevalence among results of this systematic review indicate that construction construction workers in Canada,38 Greece,36 Italy,23 the workers are at increased risk of work- related respiratory USA24 41 and Turkey.43 Though more studies in this hazards and diseases, compared with workers from other regard are important, the evidence associating workplace sectors such as retail workers, bus drivers and other non- hazards and lung cancer among construction workers is construction workers who were used as controls in the strengthened by the fact that some of the studies included included studies. Data from our included studies show in this review used a control sample for comparability 16 specific work- related respiratory diseases commonly with non- construction workers.23 38 41 reported among construction workers. Furthermore, These respiratory health conditions may have a signifi- the result show that cough, dyspnoea, asthma, wheezing cant impact on these workers’ overall health and well-b eing and cancers of the lung and larynx rank in the top five as well as on their level of productivity. Construction work common respiratory diseases examined among workers involves the use of materials and processes that expose in the construction sector. Interestingly, smoking workers to considerable respiratory health hazards. Thus, increases both susceptibility and severity of these respira- the data synthesised from this systematic review reflect and tory health conditions. This necessitates the inclusion of align with emerging evidence on the high level of respi- health promotion and behaviour change in occupational ratory health hazards and diseases among construction health and safety efforts in the construction sector. workers in both developing and developed countries.2 4–8 Furthermore, it is also important to identify specific Consequently, occupational health and safety within the respiratory health hazards in the construction sector construction work context should extend tokenistic use to re-e ngineer both the work environment processes to of personal protective equipment. A more strategic occu- reduce, if not totally eradicate these hazards. The results pational safety process in the construction sector should of our systematic review identify six common examined begin with ensuring that individuals with underlying hazards in the literature. Ranking these hazards, we health conditions–which could increase vulnerability found that dusts, RCS and fumes ranked in the top three to and/or severity of respiratory conditions–are either 8 Boadu EF, et al. BMJ Open Respir Res 2023;10:e001736. doi:10.1136/bmjresp-2023-001736 BMJ Open Resp Res: first published as 10.1136/bmjresp-2023-001736 on 26 June 2023. Downloaded from http://bmjopenrespres.bmj.com/ on July 27, 2023 by guest. Protected by copyright. Open access encouraged to seek alternative career paths or provided review. Possibly, this could have led to the omission of greater protection. This is essential, as construction eligible studies in other languages, resulting in a poten- workers in Brazil who did not undergo pre-e mployment tial selection bias. Third, only research articles published spirometry were more likely to report respiratory health online were included, suggesting that this review could diseases.2 Thus, a proactive occupational health strategy be limited in scope, since not all case studies and cohort for workers in the construction sector should also entail studies outcomes are published online. Forth, some of a strong surveillance or biological monitoring system2 the studies included in this review have small sample sizes for early detection of carcinogenic and non-c arcinogenic and have cross-s ectional study design, suggesting that the respiratory and other health conditions. Such early detec- results cannot easily be generalised. Finally, there were tion would be vital to designing appropriate prophylactic variety in the study outcomes and exposures to respira- and therapeutic responses. tory health hazards in the construction industry, and this Other proactive and strategic efforts include occupa- did not allow for determining the specific relationships tional health education and health promotion messages among the respiratory conditions and health hazards. for workers in the construction sector. Occupational health education is required as continuous conversa- tions would increasingly improve workers’ awareness CONCLUSION of hazards in the work sector and empower them with Our systematic review indicates that construction workers requisite skills and processes to protect, maintain and are exposed to hazards and conditions that have adverse promote their health. In the same vein, health promotion effects on their health and well-b eing. Work processes in messages through information, education and communi- the construction sector expose workers in this sector to cation resources and strategies could help in preventing harmful hazards such as dust, silica, fumes, asbestos and behavioural practices such as smoking, which could other hazards. These hazards are associated with a range increase the vulnerability and severity of work- related of health problems ranging from mild respiratory health respiratory diseases among construction workers.2 7 39 conditions to severe ones such as respiratory cancers Therefore, protecting, promoting and improving the and silicosis. Evidence from our review indicates that occupational health and safety of construction workers– construction workers who have spent a longer time in beyond the correct and consistent use of effective respi- the sector have greater vulnerability and severity of work- ratory protective equipment–is important. As previously related respiratory health problems. Since exposure to mentioned, the use of these protective equipments must work- related health hazards has enormous health and not be tokenistic but a conscious proactive and effective socioeconomic well-b eing and functioning of construc- strategy to reduce the health effects of these hazards. It is tion workers, we advocate for a strategic occupational also important to engineer the physical work environment health programme for construction workers beyond the to ensure effective and adequate ventilation in enclosed tokenistic use of personal protective equipment. work settings and putting other effective reduction and Contributors EFB conceived the topic. EFB and CB conducted the literature protective practices in place. Such engineering controls search. IYA, EOB, SRO, CB and EFB conducted the screening of studies. Data were include misting, water or chemical suppression of dusts extracted independently by IYA, EOB, EFB and CB, and the extracted data were and proper ventilation. Also, it is important for contrac- scrutinised independently by SRO. EOB, SRO, CB and EFB independently assessed the methodological quality of the included studies. Differences that arose were tors to substitute hazardous equipment (such as those resolved through a discussion with the fifth author IYA. SRO and EFB conducted the producing excessive dusts, fumes and gases) with non- data synthesis and was reviewed by IYA. IYA, EOB, SRO, CB and EFB contributed to hazardous ones, and adopt different working methods drafting the manuscript and provided critical feedback on the final output. EFB acts as guarantor. to avoid the production of these hazards. Adopting all Funding The authors have not declared a specific grant for this research from any these proactive strategies is vital because chronic and funding agency in the public, commercial or not- for- profit sectors. acute respiratory health conditions resulting from short- Competing interests None declared. term or long-t erm exposure to hazardous materials and/ Patient consent for publication Not applicable. or processes in the construction sector have enormous 9 14 10 Ethics approval Not applicable.health and socioeconomic implications. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement All data relevant to the study are included in the article or uploaded as online supplemental information. Limitations Supplemental material This content has been supplied by the author(s). It has Despite the contribution of this systematic review, there not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been are a couple of research limitations worth mentioning. peer-r eviewed. Any opinions or recommendations discussed are solely those First, although the review was conducted in line with inter- of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content national protocol guidelines for conducting systematic includes any translated material, BMJ does not warrant the accuracy and reliability reviews, the findings could still be subjected to indexing, of the translations (including but not limited to local regulations, clinical guidelines, publication and reporting bias because the scope of the terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. search was limited to Scopus, Web of Science, PubMed Open access This is an open access article distributed in accordance with the and Google Scholar. Second, due to language limitations, Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which only studies published in English were included in the permits others to distribute, remix, adapt, build upon this work non-c ommercially, Boadu EF, et al. 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