Background: Severe acute respiratory syndrome coronavirus-2, the virus causing coronavirus disease-2019, is a biological hazard in workplaces. Thus, protective measures should be applied. Despite their potential role, the perspective of workplace representatives on coronavirus disease-2019 measures is rarely investigated.
Aims: To assess the perspective of workplace union representatives on coronavirus disease-2019 measures in their workplaces in the first year of the pandemic in Turkey.
Study Design: A descriptive observational study.
Methods: This national descriptive study included workplace chief representatives of 33 workers’ unions. A 42-item electronic survey was used to collect data to evaluate the practice of job organization, social distancing and personal protective equipment use, sanitization, and occupational safety and health training.
Results: The study included 509 workplace chief representatives’ responses. Results showed that several administrative measures, including suspending production or work, encouraging workers to take leave, implementing alternate work schedules, isolating any coronavirus disease-2019 case from other workers in a designated room, and avoiding face-to-face meetings, were not available in more than half of the workplaces. The mean number of available measures was significantly high (p < 0.001) in the industrial sector and workplaces with 250 or more workers. Almost all union representatives (98.8%) reported at least one diagnosis of coronavirus disease-2019 among workers, and 12.6% reported a positive history of coronavirus disease-2019-related mortality. The regression model for any history of coronavirus disease-2019 mortality in workers demonstrated a significantly increased association with workplaces with 250 or more workers compared with workplaces with less than 250 workers (odds ratio =2.99, 95% confidence interval =1.65-5.44, p < 0.001).
Conclusion: The results indicate failure in administrative measures and the need for improvement in medium- and small-sized workplaces and the non-industrial sector. All local and national stakeholders need to pay special attention to address these issues. Future studies should evaluate on-site coronavirus disease-2019 workplace measures and their effectiveness.

INTRODUCTION

The coronavirus disease-2019 (COVID-19) pandemic declared by the World Health Organization is classified as a humanitarian crisis due to the extent of the outbreak and the level of preventive measures.¹ After lockdowns during the pandemic, concerns have been raised regarding infection transmission in workplaces while the government attempts to revive economies. The virus causing the disease, Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a biological hazard requiring control through a comprehensive program, and measures should be taken per the hierarchy of control.² Maintaining physical distance, providing respiratory hygiene, using personal protective equipment (PPE), sanitization, appropriate ventilation, adjusting the working conditions, and decreasing human contact are among the measures taken to decrease workplace transmission and have been emphasized since the early phases of the pandemic.³ Upon availability, vaccination is a key multilevel approach for protection against infection, and the measures differ according to vaccination status.⁴

During the pandemic, various measures and interventions have been developed to prevent or diminish workers’ exposure to SARS-Cov-2. Researchers also investigated the compliance and effectiveness of these workplace measures.⁵ A multinational study conducted by the G20 Occupational Safety and Health (OSH) Experts Network in partnership with the International Labour Organization (ILO) evaluated workplace measures against COVID-19 in 12 countries, including Turkey, and found the most common measures were remote working (82%) for administrative measures and use of PPE (82%) for other measures.⁶ A meta-analysis evaluating effective workplace measures and control applications against SARS-CoV-2 infection highlighted that these applications might provide workers with a safe return to work in terms of COVID-19 and future outbreaks.⁷ Wong et al.⁸ studied workers’ perspective regarding the effect of workplace policies on the health-related quality of life during the COVID-19 pandemic and depicted that workplace policies are crucial to relieve the negative health results of the pandemic. Kawasumi et al.⁹ demonstrated a positive correlation between the number of workplace measures for infection control and the practice of personal behavior for infection prevention. A 12-month prospective study with full-time workers showed the protective role of workplace COVID-19 measures against psychological distress.¹⁰

The Bureau for Workers’ Activities (ACTRAV) of the ILO implements the Employment and Decent Work for Peace and Resilience Recommendation (R205) as an effective tool in fighting COVID-19 for governments, employers, and workers’ unions. R205 has a strong level of social dialog, appoints crucial duties to the employers and workers’ unions, and calls unions to ensure the continuity of work and help support workers with education, recommendation, and supply of equipment.¹¹ The strong role of workers and unions in policy application and decision-making may contribute to combat the outbreak.¹² A study on the role of workers’ unions during the COVID-19 pandemic in the United States predicted that a 10% increase in unionization could result in a 5% decrease in COVID-19 cases within 100 days. This forecast can be attained by increasing the transparency of the role of unions in regulating the relationship between workers and employees and adjusting workplace conditions with the power of collective voice. Thus, unions have essential responsibilities in guiding policies related to COVID-19 and applying recommended directives.¹³

Despite these findings and foresight on workers’ unions and unionization in controlling COVID-19 in workplaces, a national study evaluating the perspective of workplace representatives of Turkish workers’ unions is lacking. Thus, the current work aimed to assess the perspective of workplace union representatives on COVID-19 measures in their workplaces in Turkey.

MATERIALS AND METHODS

Study Design, Participants, and the Survey

This descriptive study involved 5,260 workplace chief representatives of 33 workers’ unions of the Confederation of Turkish Trade Unions (TURK-IS), the largest trade union confederation in Turkey according to the number of members. The study protocol was approved by the Ministry of Health Directorate General of Health Services and the Non-interventional Researches Ethical Board of Hacettepe University (decision number: 2021/06-48). The TURK-IS board gave permission for the study and sent the online survey link to all workplace chief representatives via e-mail on May 21, 2021. Three reminders were sent on the 5^th, 10^th, and 14^th days, and data collection was terminated on June 21, 2021.

Data were collected via a 42-item online survey through Google Forms. Three national guidelines (i.e., The Ministry of Health’s Guideline for the Management of COVID-19 Outbreak and Work, the Ministry of Industry and Technology’s Hygiene, Prevention and Control of Infection Guideline for Industrial Organizations, and the Ministry of Family, Work, and Social Services’ Guideline for Workplace Measures Against COVID-19) were used in preparing survey items.^14-16 The survey included five subheadings: workplace features, job practice, social distancing and PPE use, sanitization, and OSH training on COVID-19. Participants were asked to choose among four options: always, partially, no idea, and no. In addition to measures, any diagnosis of COVID-19 among workers and any mortality related to COVID-19 were also questioned. The last open-ended item included any other issues to mention. The survey questions were adjusted after feedback from a pretest conducted in a factory in Ankara, Turkey, that is, the inclusion of 15 workers other than the workplace chief representatives of a union. The pretest results were not included in the study data.

Statistical Analysis

Descriptive statistics were presented as mean ± standard deviation  or median and interquartile range (IQR) for continuous variables and as number and percentage for categorical variables. The answer of “always” was accepted as the availability of the measure and compared with any other answers. The mean numbers of available measures under each subheading were compared according to workplace characteristics using Student’s t-test. Categorical variables were compared using chi-square or Fisher’s exact tests. Univariate and multiple logistic regression analyses were performed to evaluate the relationship between workplace characteristics and history of any COVID-19 infection and mortality due to COVID-19 in workers. For all comparisons, type 1 error (alpha) was accepted as 0.05. Statistical analyses were performed using IBM SPSS for Windows v.25.0 (IBM Corp., Armonk, NY).

RESULTS

This study included 509 workplace chief representatives (9.7% of the study universe). Most workplaces were private enterprises (62.3%) and from the industrial sector (66.6%). The OSH services were internal in 80.9%. The median number of workers was 235 (IQR: 100-649), and the number of workers was between 50 and 249 in 41.1%. The distribution of workplace characteristics is shown in Table 1.

Table 2 shows the distribution of workplace measures. The most frequent measures were visual and auditory warnings on COVID-19 measures (93.3%), training the workers on what to do in case of a history of risky contact (91.6%), measuring the body temperature of workers during the entry (91.4%), training the workers on what to do in case of COVID-19 symptoms (90.2%), and providing an adequate amount of hand sanitizers in easy-access areas (89.2%). Most measures were applied in more than half of the workplaces. The measures enacted in less than half of the workplaces were suspending production or work (27.5%), checking the workers’ COVID-19 status using the HES-code provided by the Ministry of Health to allow sharing of COVID-19 status with third parties (36.9%), isolating any COVID-19 case from other workers in a designated room (44.4%), encouraging workers to take vacation leave, paid leave, or unpaid leave (44.8%), applying alternate working (46.8%), and avoiding face-to-face meetings (49.1%). The responses for short employment allowance and history of dismissal with Code-29 (i.e., a dismissal by the employer due to the worker’s violation of the code of ethics and goodwill) between March 2020 and April 7, 2021 were 54.0% and 8.1%, respectively. The most frequent measures for workers’ transportation services, social distancing at the entry and exit areas, cafeterias, break areas, and dressing rooms are presented in Supplementary Table 1.

The overall mean number of available measures was 19.52 ± 4.45 and was significantly high (p < 0.001) in the industrial sector and workplaces with 250 or more workers (Table 3). Similar findings were also observed in the subheadings of job practice, social distancing, and PPE use. Moreover, the industrial sector and workplace size ≥ 250 were related to a high mean number of available measures of sanitization (p = 0.007) and OSH training on COVID-19 (p = 0.043), respectively.

Almost all participants (98.8%) reported at least one diagnosis of COVID-19 among workers. Furthermore, 12.6% of union representatives reported a positive history of COVID-19-related mortality. The relationship between workplace characteristics and any history of COVID-19 infection and mortality among workers was evaluated using univariate and multiple logistic regression (Table 4). The multiple regression model for any COVID-19 case among workers did not reveal any significant association. The model for any history of mortality among workers due to COVID-19 showed a significant relationship with workplaces with 250 or more workers compared to workplaces with less than 250 workers (OR =2.99, 95% CI =1.65-5.44, p < 0.001).

DISCUSSION

The Ministry of Health and other related ministries have published guidance on COVID-19 precautions in workplaces since the early days of the pandemic;^14-16 however, data related to workplace practices (e.g., availability or effectiveness of the measures) are scarce. This study aims to contribute knowledge about the availability of COVID-19 measures in a wide range of workplaces located in Turkey from the perspective of workplace chief representatives of unions, one of the critical stakeholders of OSH applications. Findings revealed that the measures, including visual and auditory warnings, training the workers on what to do in case of a history of risky contact or COVID-19 symptoms, and measuring the body temperature of workers on entry, were available in more than 90% of workplaces. By contrast, some administrative measures, including suspending production or work, encouraging workers to take leave, implementing alternate work schedules, isolating any COVID-19 case from other workers in a designated room, and avoiding face-to-face meetings, were not available in more than half of the workplaces. This variation related to the availability of some measures was observed in other studies. A research conducted at 103 Indonesian workplaces reported complete compliance with a number of measures, including education related to COVID-19, sanitation, body temperature measurements, and limitation of visitors, although most workplaces did not conduct a COVID-19 emergency response drill.¹⁷ The current study was conducted when the daily cases decreased in Turkey (average daily number of new cases: 6,724) after the third peak of COVID-19 cases (average daily number of new cases: 50,114) in April 2021.^18,19 The study period may affect the frequency of compliance with the measures because the number of workplace precautions may increase progressively during the course of the pandemic. However, Kawasumi et al.⁹ showed that less than half of the workplaces completed the infection control measures set by national guidelines in their e-survey conducted during the third peak of cases in Japan. These results emphasized the importance of active surveillance with regard to availability and compliance with each measure.

The mean number of available measures was also significantly low in small- and medium-sized workplaces with < 250 workers. Similarly, three Japanese studies conducted in different periods found few available COVID-19 measures in small companies.^20-22 A study with 60 Italian companies also demonstrated that the work organization involving COVID-19 measures was better in large enterprises than in small-sized workplaces.²³ ILO points out that the pandemic has economic and social impacts on all sectors and workplace types, but the effects are particularly devastating on workers in small- and medium-sized workplaces.²⁴ As highlighted by the pandemic, the potential economic problems in small- and medium-sized workplaces may limit the budget available for OSH services. A survey on the effects of the COVID-19 pandemic on Turkish enterprises documented that micro and small-sized enterprises experienced a significant impact.²⁵ In addition to financial issues, problems related to the insufficiency of inspections or sanctions lead to failure in embracing an OSH culture. Nagata et al.²⁶ documented the contribution of health culture to the practice of infection control measures in workplaces during the pandemic. As a component of OSH culture, corporate health culture in large enterprises may contribute to the availability of COVID-19 measures.

This study showed a higher mean number of COVID-19 measures in the industrial sector than in other sectors. A recent work demonstrated high compliance with infection control measures in manufacturing, construction, and mining fields.²⁷ Sectoral availability of workplace measures against COVID-19 may vary with time. In their initial study on this topic, Sasaki et al.²⁰ demonstrated that compared with those in manufacturing, the number of available measures was significantly higher in the information and technology sectors but lower in the retail, wholesale, and transportation industries. A subsequent 2-month follow-up report revealed that sectors including public services, finance/insurance/real estate, food/beverage, health and care, and hospitality were associated with an increased number of measures.²¹ Several other follow-up studies also revealed the change in available measures. For example, an 8-month follow-up research indicated that the mean number of available measures increased between March and May 2020, was unchanged between May and August 2020, and declined between August and November 2020.²⁸ These findings highlighted that the sustainability of the measures is as vital as the cross-sectional evaluation of their availability.

In this study, nearly all union representatives reported a COVID-19 diagnosis among workers, and more than 10% reported COVID-19-related mortality. Malekpour et al.²⁹ made a similar evaluation in Iran in March 2020 and demonstrated 32.6% frequency of COVID-19 report among workers. This discrepancy may be due to the present study being conducted in a later period. Despite the variability of cross-sectional studies, a surveillance program, including case and mortality data sourced from official data collected by the Ministry of Health and a detailed occupational and environmental evaluation, may be helpful to enlighten work-related risks for COVID-19 transmission.

To the best of our knowledge, this study was the first to assess a large number of workplaces and their characteristics in terms of COVID-19 measures. One of its strengths was obtaining data from active workplace representatives from the TURK-IS, the confederation with the representation power in national and international meetings and organizations due to its large number of members. However, our study has some limitations. First, the level of participation was relatively low possibly due to conditions related to an ongoing pandemic and the method of data collection (i.e., electronic survey). Although the participants were approached via a complete list of e-mail addresses provided by the TURK-IS, active use of these e-mail addresses, particularly during an ongoing pandemic, was not guaranteed and may affect participation. In addition, the study method had intrinsic limitations with regard to responses. Personal characteristics of workplace chief representatives (e.g., educational level or COVID-19 awareness) might affect the responses. Furthermore, the level of COVID-19 measures may be higher in unionized workplaces than in non-unionized workplaces; thus, our results should be interpreted with caution. As the COVID-19 measures at the workplaces have been gradually implemented during the pandemic, the study period might be a determinant of the level of measures at the workplaces. Future research comparing the level of measures at unionized and non-unionized workplaces with follow-up components may accurately document the status and help determine the urgencies.

In conclusion, this study evaluated COVID-19 measures in workplaces in the first year of the pandemic from the perspective of workers’ union representatives. Results demonstrated failure in administrative measures such as suspending production or work, encouraging workers to take leave, applying alternate working, isolating any COVID-19 case from other workers in a designated room, and avoiding face-to-face meetings. In addition, the mean number of available measures was lower in small- and medium-sized workplaces and other sectors than in large enterprises and the industrial sector, respectively. These results should guide all local and national stakeholders to address these issues. Future studies regarding on-site COVID-19 workplace measures and their effectiveness are warranted.

Acknowledgments: The authors thank the administrative board of the Confederation of Turkish Trade Unions (TURK-IS) for their collaboration and support.

Ethics Committee Approval: The study protocol was approved by the Ministry of Health Directorate General of Health Services and the Non-interventional Researches Ethical Board of Hacettepe University (decision number: 2021/06-48).

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Authorship Contributions: Concept- D.K., A.S., M.Y., A.N.Y.; Design- D.K., A.S., M.Y., A.N.Y.; Data Collection or Processing- D.K., A.S., M.Y., A.N.Y.; Analysis or Interpretation- D.K., A.S., M.Y., A.N.Y.; Literature Search- D.K., A.S., M.Y., A.N.Y.; Writing- D.K., A.S., M.Y., A.N.Y.

Conflict of Interest: No conflict of interest was declared by the authors.

Funding: The authors declared that this study received no financial support.

Supplementary: http://balkanmedicaljournal.org/uploads/pdf/2022-10-116-supplementarymaterials.pdf

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