Cochrane Work—championing facts since 2003

The 2013–15 Ebola virus disease epidemic put health care workers at high risk of a disease with a very high fatality rate in the epidemic areas [1]. Not only were nurses and doctors at risk, but also staff engaged in transportation, cleaning and burial of patients. At that time, it was unclear how best to minimize health care workers’ risk of infection. To cover part of those needs, Cochrane Work conducted a systematic review on personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in health care staff [1]. Now that the frenzy of the epidemic has passed, the World Health Organization (WHO) has set up a task force to use the experiences and the available scientific evidence to be better prepared for a new epidemic. The Cochrane review will be part of the evidence underpinning new guidelines that should increase protection of health care workers against either new epidemics of these same diseases or epidemics of new diseases.

The Ebola virus posed a very serious threat to occupational health but thankfully it was localized and transient. However, there are many other persistent threats to workers’ health and safety all over the world. For many of these problems, Cochrane Work tries to come up with effective solutions—or interventions as they are known in epidemiological terms—that really work in the pursuit of healthy and safe work. To be able to say what works, a review has to find all relevant intervention effectiveness studies and construct an efficient and unbiased synthesis of their results. It has already been proven that the best tool for doing so is the systematic review. In effect, Cochrane Work is an independent producer and publisher of systematic reviews within the global scientific network known as Cochrane. The organization was founded in 1993 and was named in honour of Archie Cochrane, a British medical researcher. Cochrane Work is one of 52 review groups that are based at research institutions worldwide, each focused on a specific topic of health research. Review groups support Cochrane’s primary organizational function of preparing and maintaining systematic reviews. They are all independently run and financed.

At the time of writing, Cochrane Work has 333 authors working on 57 reviews that are at various stages ranging from registered title to review update. The editorial base in Kuopio, Finland coordinates peer review and supports authors with their technical and methodological challenges. As Cochrane Work is housed at the Finnish Institute of Occupational Health, there is considerable in-house expertise to access in the form of peer reviewers and review co-authors. Cochrane Work reviews cover a wide range of topics from prevention of Ebola infection, as already mentioned, to prevention of workplace bullying. All Cochrane reviews relevant to occupational safety and health can be found via the group’s website: www.work.cochrane.org.

This is a good time to look back on Cochrane Work’s achievements over the years and look ahead at what room there is for improvement. When it comes to achievements one can examine what kinds of results have been found, what Cochrane Work has done to disseminate them and what lessons the group has learned about review methods along the way. Cochrane systematic reviews can all have one of three results: (i) the intervention works, (ii) the intervention does not work or (iii) there is insufficient evidence to say if the intervention works or not. For example, teaching health care workers cognitive-behavioural techniques helps them manage their stress [2] and blunt suture needles [3] and double gloves [4] help to prevent needle stick injuries. Conversely, just teaching people how to lift things correctly does not prevent back pain [5] and just providing ear plugs does not prevent noise-induced hearing loss [6]. The picture is of course a little more complicated as the results also incorporate the magnitude of effect (how well the intervention works) and the quality of evidence (how certain we are in that the result is true).

Nonetheless, the practical implications of each of the three kinds of result ought to be pretty clear. We should implement what works, stop what does not work and better implement what can potentially work. In cases where we still do not know if something works we can consider conducting new studies that fill in the existing gaps in evidence. Cochrane Work reviews are helpful here too as they provide concrete advice on how to design new studies to yield the maximum benefit. Ignoring this advice can lead to very disappointing studies that waste valuable resources [7]. In theory, it should be easy to disseminate and implement findings showing that something works but this is not necessarily the case. For example, in 2012 in the USA, the Food and Drug Agency (FDA), the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) issued a joint safety communication based on a Cochrane Work review stating that blunt needles must be used in surgery whenever possible [8]. However, there is still nothing similar in EU legislation or European guidelines. Similarly, health care workers are not universally taught cognitive-behavioural techniques to manage their stress even though it works. The reasons behind a Cochrane Work message being taken up or ignored can be related to how the results are understood and accepted or to how they are communicated, or both.

Sometimes Cochrane reviews are criticized for being hypercritical. We understand that a review saying there are not enough high-quality studies to draw straightforward conclusions can be frustrating. However, the absence of conclusive evidence of a beneficial effect should not always be interpreted as evidence of lack of effectiveness. Rather, it can mean that further research is very likely to impact on the conclusion. Sometimes there can be multiple explanations for the absence of a beneficial effect that could provide clues on how to develop more effective preventive interventions. For example in the review of manual material handling (MMH) advice [5], one explanation of the absence of a beneficial effect is that the current approach does not lead to such a change in MMH behaviour that would reduce the strain on the back. Another possible explan ation is that the risk of back pain is not directly related to incorrect lifting techniques but to other work-related factors inherent in the studied populations (e.g. psychosocial strain or other non-neutral postures without MMH), which are not captured with the MMH training and advice. Then it is probably better to concentrate on measures that reduce the load on the back, other than lifting techniques, such as lifting aids and lighter loads to lift [9].

To meet these criticisms Cochrane Work continuously develop their reviews so that they really contain and synthesize the best available evidence. Cochrane Work provides both individual and general guidance to its authors. Individual guidance takes the shape of occasional video meetings or authors coming to stay at the editorial base. For general guidance, Cochrane has developed a range of tools including: software, online learning modules, methodological standards, Cochrane Handbook, Style Manual and pre-submission checklists for both protocols and reviews. In addition to these, Cochrane Work also participates in methods development. For example, Cochrane Work has taken strides in incorporating evidence produced with different study designs. The randomized controlled trial (RCT) is of course the gold standard design with the least bias. It would be great if all reviews could be restricted to RCTs only, such as in the blunt needles review [3]. Unfortunately, there are circumstances in occupational safety and health where the RCT design is difficult to implement in practice. In such cases, it may still be possible to conduct controlled before–after (CBA) studies and achieve relevant results. One example of making good use of such evidence is the hearing protection review [6]. In injury prevention even the CBA design may be problematic. Here, Cochrane Work has successfully used evidence from interrupted time-series studies. Cochrane Work has also surveyed how and why Cochrane reviews include and make use of nonrandomized study evidence, based on which they developed guidance [10].

Another way in which Cochrane Work tries to improve the uptake of evidence is by dissemination. Cochrane Work advertises its publications in their newsletter, it hosts monthly webinars, it posts actively on social media (Twitter, Facebook, LinkedIn) and records podcasts. All of these can be accessed through the group’s website.

The evidence that Cochrane reviews offer could be used more actively in occupational safety and health policy and recommendations. Evidence can bring more transparency and show effectiveness and efficiency in political decision making. However, it is good to remember that evidence-based policy is not the same as policy-based evidence. In the beginning of this year (2017), the EU Commission has published a communication in order to modernize the EU Occupational Safety and Health Legislation and Policy. The review of the EU OSH legislation fits within the Commission’s ongoing work on a European Pillar of Social Rights, which aims to adapt EU legislation to changing work patterns and society. The Commission will work with Member States and social partners to remove or update outdated rules within the next 2 years. The aim is to simplify and reduce administrative burden, while maintaining workers’ protection. This modernization should also support better enforcement on the ground. Cochrane reviews offer a reliable source of evidence for decision makers on which to build their opinions.

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