C:\Users\UNIVERSA MEDICINA\Docu 171 ABSTRACT UNIVERSA MEDICINA Relationship of occupational health and safety training with health literacy among employees working in the various lines of business Nergiz Sevinc* and Burcu Korkut** BACKGROUND Health literacy is vital for people’s ability to manage health. It has been known for a long time that the importance of education in increasing health literacy is an undeniable fact. The first aim of this study was to investigate the health literacy levels of employees working in different business lines receiving service from the occupational health and safety unit. The second aim was to reveal how health literacy levels are affected according to the training duration. METHODS A cross-sectional study was conducted on 202 employees receiving service from the Karabuk occupational health and safety unit. The employees were divided into three groups as workers, officers and others. All employees were given the questionnaire consisting of 31 questions including sociodemographic characteristics and the adult health literacy scale. A face-to-face interview was performed with each of the employees. Kruskal- Wallis H and Mann-Whitney U tests were used to analyze the data. RESULTS The range of adult health literacy scale scores of the employees was 4-23. There was no significant difference in adult health literacy scale scores between age groups (p=0.38). The percentage of employees who received more than 16 hours training course was 19.3%, 20.6%, and 46.7% for workers, civil servants and other employees, respectively. Adult health literacy scale scores increased in proportion to the amount of training the employees received (p=0.001). CONCLUSION This study reveals that occupational health training has a positive effect on health literacy. Keywords: Health literacy, employees, various lines of business, occupational health and safety unit, adult health literacy scale ORIGINAL ARTICLE pISSN: 1907-3062 / eISSN: 2407-2230 DOI: http://dx.doi.org/10.18051/UnivMed.2020.v39.171-177 September-December 2020 Vol.39- No.3 Cite this article as: Sevinc N, Korkut B. Relationship of occupational health and safety trai ning with health literacy among employees working in the vari- ous lines of business. Univ Med 2020; 39:171-7 . doi : 10 .18 051/ Uni vMed. 2020.v39.171-177 *Department of Public Health, School of Medicine, Karabuk University, Turkey **Provincial Health Directorate, Karabuk, Turkey Correspondence: Nergiz Sevinc, MD Karabuk University School of Medicine, Balhklar Kayasi Mevkii, Demir Celik Campus Karabuk, Turkey Phone: +905054793362 Email: dr.nergizsevinc@gmail.com ORCID ID: 0000-0003-4763-1902 Date of first submission, August 2, 2020 Date of final revised submission, October 16, 2020 Date of acceptance, October 20, 2020 This open access article is distributed under a Creative Commons Attribution- Non Commercial-Share Alike 4.0 International License 172 Sevinc, Korkut Occupational health and safety training INTRODUCTION Even though health literacy (HL) is defined in various forms by many researchers, the World Health Organization (WHO) has defined it as cognitive and social skills which determine the motivation and “ability of individuals to gain access to, understand, and use information in wa ys wh ic h p romote and main ta in go od health.”(1) Developed countries started to work hard to improve HL when it was determined that low HL was associated with increased hospitalization, decreased vaccination uptake, and low participation in cancer-screening activities in the following years.(2,3) They realized that an individuals’ skills are an important part of improving HL and they increased it by using plain language in both verbal and written communication.(4,5) Since HL provides a significant contribution to the health quality of all segments of society, developed and developing countries have prepared health and safety programs to provide occupational health services and increase HL. The content of these programs, which are generally offered by the occupational health and safety (OHS) units and prepared within the framework of laws, vary according to countries. There are a few studies evaluating the HL status of different occupational gr oups such as farmers, students and employees. For example, a study involving 282 workers at a factory who received the OHS training routinely showed that 13.5% had inadequate, 47.5% problematic, 30.9% sufficient, and 8.2% excellent HL scores.(6) There was also a study conducted on 421 farmers working in Thailand, which reported that the farmers’ mean HL level was found to be 34.98 (SD=6.87) points over a range of 0-50 points.(7) Recently, 686 university students were evaluated for HL status by Gamsýzkan et al., who found that 21.1% (n=145) of the students had inadequate HL, 41.8% (n = 287) had limited HL, 30.9% (n=212) sufficient, and 6.1% (n=42) excellent HL.(8) None of these studies were c o nd u c t e d s imu l t ane o u sl y i n va r i o us occupational groups by including a large labor force in the community. The first studies on the state of HL in Turkey was initiated by improving the Adult Health Literacy Scale (AHLS) in 2012.(9) The difference of this study with the previous studies lies in the fact that the subjects were from various occupational groups including civil servants and employees. In the present study, the first objective was to investigate and compare the HL status of civil servants and employees receiving healthcare services from the OHS unit. The second objective was to reveal how HL levels are affected according to the training duration received from the OHS unit. METHODS Design of the study This cross-sectional study was conducted among employees working in different business lines receiving service from the Karabuk OHS unit from April to May in 2020. Study subjects A total of 213 workers who received the OHS training routinely, were invited to participate in this study. Participants enrolled in the study were selected based on the following criteria; (a) aged 18 to 60 years; (b) received training from OHS unit; c) had no significant, untreated chronic disease. Those who did not consent or had chronic disease were excluded. After receiving information about the study, 11 refused to take part. A total of 202 workers were analysed. The profession groups involved in the study consisted of the groups of workers (hairdressers, barbers, auto industry workers, cleaning staff), civil servants (railway workers, family health center employees) and ‘others’ (dentists, x-ray technicians, medical secretaries). According to the training duration received from the OHS unit, participants were divided into three subgroups. The first subgroup consisted of 58 participants receiving 8 hours of training or less. The second subgroup consisted of 96 participants receiving 173 between 9-16 hours of training. The third subgroup consisted of 48 participants receiving more than 16 hours of training. Instruments and measurements Da ta we r e c ol l e c t e d th r o u gh a questionnaire containing 12 questions aimed at evaluating the socio-demographic characteristics of the employees (such as age, gender, marital status, level of education, occupation, and economic status) and the AHLS. Thirty-one institutions and organizations receiving service f r om K a r a b uk OHS u n it w e r e vi si t e d . Occupational health and safety training provided by the workplace doctor and occupational health specialist was mainly aimed at establishing safe working and correct health behaviors in order to prevent occupational accidents and diseases. The training topics provided by OHS unit are shown in Table 1. Individuals were informed about t he study, and verbal cons ent was obtained. The questionnaire and scale were then applied to individuals who agreed to participate in the study. Adult health literacy scale The Adult Health Literacy Scale (AHLS) was developed in 2012 by Sezer (9) who tested its validity and reliability. The Adult Health Literacy Scale includes health information to determine the competence of adult individuals in health literacy and drug use and one image showing the organs in the body. Thirteen of the items in the scale are yes/no questions, 4 are fill-in-the blank, 4 are multiple choice, and 2 are matching questions. Each question type is scored separately. In the Yes/No questions, 1 point is given to those who select positive expressions and 0 points is given to those who select negative expressions. In multiple choice questions, 1 point is given to those who mark two or more correct answers, and 0 points to those who do not know at all or who mark the wrong answer together with the true. In matching-type questions, 1 point is given to more than two correct matches and 0 points were given to others. Scores that can be obtained from the scale vary between 0 and 23 and the total Cronbach Alpha value of the scale was determined to be 0.77. The scale has no cut-off point. Higher scores indicate a higher level of HL.(9) Statistical analysis The data were digitally evaluated by SPSS software. Descriptive statistics were presented as frequency, standard deviation and percentage distribution. The Kolmogorov-Smirnov test was used to analyze the suitability of quantitative data for normal distribution. The scores of AHLS had abnormal data distribution. Kruskal-Wallis H and Mann-Whitney U tests were used to compare the AHLS scores of the groups formed according to sociodemographic characteristics. A p<0.05 was considered statistically significant in all analyses. Ethical clearance Univ Med Vol. 39 No.3 8-hours course 16 -hours course >16 hours course - General occupational health and safety rules, - Causes of work accidents and occupational diseases and risks in the workplace, - Safe use of work equipment, - Accident, injury and disease prevention principles and implementation of protection techniques, - Safe use of work equipment, - Hygiene - Legal rights and responsibilities of employees, - Establishing safe environment and systems in the workplace - Use of personal protective equipment, - Working with screened equipment, - Warning signs, - Risks arising from chemical, physical and biological substances - Fire incidence and fire protection, - Thermal comfort conditions, - Electricity, dangers, risks and precautions, - First aid, rescue. Table 1. Training topics provided by OHS unit 174 Sevinc, Korkut Occupational health and safety training A B C Ethical approval was obtained from the Faculty of Medicine of Karabuk University (2020/ 217) and administrative permission was obtained from the Provincial Health Directorate. RESULTS Of the 202 employees participating in the study, 25.2% were female, 74.8% were male, while the age range was 18 -51 years. In addition, 16.8% of the employees were at least university graduates, 54.5% were married, and 88.6% had social secur ity. There was no significant difference between male and female participants in terms of marital status, number of children, economic income, and educational status (p>0.05). The characteristics of the employees are shown in the Table 2. The range of AHL S sc ores of the employees was 4-23. While there was no difference in AHLS score between age groups (p=0.03). AHLS score s increased with educational status of the employees (p=0.001). Although those with social security and good economic status obtained higher scores from the scale, there was no significant difference in terms of disease history and number of children. The scores of employees according to some variables are shown in Table 3. Although the AHLS scores were higher in the ‘others’ occupational group (dentist, x-ray technician, medical secretary), the difference was not significant (p>0.05). The percentages of employees who received 2 or more training sessions from the OHS unit were 19.3%, 20.6%, and 46.7% for workers, civil servants and other employees, respectively (p=0.001) Training duration significantly increased HL levels (p<00.01) (Table 3). DISCUSSION In the present study carried out in various occupational groups, it was shown that the mean AHLS score was 16 (49.0%) out of 23 points, indicating that the employees had moderate HL. In addition, we found that as the number of periodic health training received by the employees from the OHS unit increased, the score obtained from scale also increased. Although there are many studies in the literature on HL there is no study evaluating HL in different occupational groups receiving OHS training. In a study conducted by Joveini et al.(10) , it was found that 39.4% of individuals between the ages of 18-65 years had adequate health literacy. Similarly, Güner et al. (6) conducted a study in Turkey on 282 factory workers, and reported that 39.1% Characteristics n % Age groups (years) 18-29 92 45.5 30-39 60 29.7 40+ 50 24.8 Gender Male 151 74.8 Female 51 25.2 Educational Status Primary School 12 5.9 Middle School 43 21.3 High School 113 55.9 University and above 34 16.9 Social Security Yes 179 88.6 No 23 11.4 Economic Status Good 46 22.8 Moderate 133 65.8 Poor 23 11.4 Number of children 0 99 49.0 1 40 19.8 2 54 26.7 3 9 4.5 Chronic disease Yes 77 38.1 No 125 61.9 Occupation Worker 109 54.0 Civil Servant 63 31.2 *Others 30 14.8 Training duration 8 hours and less 58 28.7 9-16 hours 96 47.5 > 16 hours 48 23.8 Table 2. Distribution of participants according to various characteristics (n=202) *: dentist, x-ray technician, medical secretary 175 Univ Med Vol. 39 No.3 had adequate health literacy. In a recent study, Svendsen et al.(11) reported in Denmark that 60.9% of adults over the age of 25 had adequate HL. The different results obtained in the present study and other studies may be due to differences of the groups studied, economic income level, and educational status. Health literacy is expected to decrease with increasing age, due to reasons such as decrease in using health se rvices and mutual communication, difficulty in accessing health inf ormation, decr ease d internet use, and dependence on family members.(12,13) In contrast, HL increased with age in the present study and in the study of Nakayama.(14) On the other hand, Jovic et al.(15) investigated 120 people in Serbia and found that HL sc ores were lower in individuals over 44 years of age. This difference may be due to the following: the mean age of the sample in the present study was 31 years, there were no elderly employees, the sample consisted of working individuals, and the amount of training received from the OHS unit increased with age. Higher level of e duc ation and good economic income affect HL positively in terms Variables AHLS score (min-max) Comparison Age 18-29 15 (4-23) 30-39 15.50 (9-21) KW=1.93 p=0.38 40+ 17 (8-22) Gender Female 16 (8-21) Z=0.22 p=0.82 Male 16 (4-23) Education Primary school 10 (4-12) Middle school 15 (4-23) KW=31.98 p=0.001 High school 16 (8-21) University 17.50 (9-22) Marital status Married 17 (4-21) Z=1.92 p=0.05 Single 15 (4-23) Economic status Good 18 (8-23) Moderate 15 (5-22) KW=8.41 p=0.01 Poor 14 (4-21) Social security Yes 16 (5-23) Z=3.34 p=0.001 No 1 2 (4-19) Number of children No children 15 (4-23) 1 16 (4-21) KW=1.33 p=0.51 2 or more 17 (8-22) Chronic Disease Yes 16 (4-21) KW=0.74 p=0.38 No 16 (4-23) Occupation Worker 15 (4-22) Civil Servant 16 (8-21) KW=4.39 p=0.11 Other 17.50 (9-23) Training duration 8 hours and less 12 (4-16) 9-16 hours 16 (5-20) KW=118.96 p<0.001 More than 16 hours 20 (15-23) Table 3. AHLS score of the participants according to sociodemographic characteristics Note. AHLS : Adult Health Literacy Scale; KW: Kruskall-Wallis test, Z= Mann-Whitney U test 176 Sevinc, Korkut Occupational health and safety training of accessing correct information on health, using health services, follow-up, and communication.(16) In the present study, AHLS scores were higher among university graduates and employees who declared that their economic status was good (17.50 and 18.00, respectively). In a study involving 8 European countries, it was found that low education and economic status negatively affected HL.(17) Vamos et al.(18) and Nutbeam (19) have suggested that receiving any form of health education or training has a positive effect on HL. Bayati et al.(20) conducted a study on 256 health representatives in Iran, and found a significant relationship between the health literacy scores before and after health education. As mentioned above, in the present study conducted on individuals working in various professions the HL score was found to be higher in participants who received more than 16 hours of OHS training. Furthermore, a strong positive correlation was observed between training durations and HL levels. Due to lack of related literature, we could not compare the results of the study with any research. Given that health and safety training has a significant impact on HL, it can be said that this training encourages employees to access health-related resources and follow current health developments, thereby increasing HL. It is well known that HL is important for every individual of the society and covers the acquisition of health knowledge, its appraisal, and associated decision-making.(17) The results of the present study revealed that providing health literacy training to employees in the various business lines increases their HL levels. Hence, as training plays a critical role in raising and promoting HL levels of employees, it is necessary to develop and expand a training program for employees regardless of their literacy or education levels. We think that by achieving this goal, it is possible to create a national action plan with the contributions of public institutions and organizations. The main limitation of this study is that there are numerous different scales on HL and that there is no standard evaluation. Secondly, since the present study was conducted only on employees receiving services from the OHS unit, the health literacy scores obtained cannot be generalized to the whole society. In addition to health training, conducting regular examinations for employees receiving services from the OHS unit is important. In this regard, employers should be informed about this issue first and encouraged to receive services from OHS units for their employees. 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