Changes in Eye Protection BehaviorFollowing an Occupational Eye Injury

by Justin L. Blackburn, PhD, Emily B. Levitan, ScD, Paul A. MacLennan, PhD, Cynthia Owsley, PhD, MSPH, and Gerald McGwin, Jr., MS, PhD

research abstractThis study investigated whether workers modify eye protection behavior following an occupational eye injury. Workers treated for work-related eye injuries were questioned regarding the use of protective eyewear for the work-month prior to their eye injuries and again 6 to 12 months later. Workers reported an increase in the proportion of work-time they used eye protection (from a median of 20% to 100%; p < .0001). The effect appeared to be driven by whether eye protection was used at the time of the injury. Most respondents (66%) indicated they were more likely to use eye protection since their injuries. Workers not using eye protection at the time of injury were more likely to use eye protection in the future. A variety of employer and employee factors may influence this change. Although many workers behaviors changed, health care providers should embrace the teachable moment when treating occupational eye injuries to encourage continued use or more appropriate forms of eye protection.

393Copyright American Association of Occupational Health Nurses, Inc.

WORKPLACE HEALTH & SAFETY VOL. 60, NO. 9, 2012393

ye injuries affect approximately 2 million Ameri- cans annually (McGwin, Xie, & Owsley, 2005). An estimated 280,000 non-fatal work-related eyeinjuries are treated each year in emergency departments nationwide (Xiang, Stallones, Chen, & Smith, 2005). Nearly 28,000 eye injuries will result in 2 or more days of missed work each year (Bureau of Labor Statistics,E

ABOUT THE AUTHORSDr. Blackburn is Research Assistant Professor, Department of Health CareOrganization & Policy; Dr. Levitan is Assistant Professor, Department of Epidemiology; Dr. MacLennan is Assistant Professor, Department of Sur- gery, Trauma and Burn Section; Dr. Owsley is Professor, Department of Ophthalmology; and Dr. McGwin is Professor, Departments of Epidemiol- ogy and Ophthalmology, University of Alabama at Birmingham.This work was supported by the EyeSight Foundation of Alabama and Re- search to Prevent Blindness, Inc.Address correspondence to Justin L. Blackburn, PhD, 1665 University Blvd., Room 330, Birmingham, AL 35294. E-mail: jblackburn@uab.edu. Received: February 28, 2012; Accepted: June 4, 2012; Posted: August 23,2012.doi:10.3928/21650799-20120816-52

2010). Preventing eye injuries, particularly occupational eye injuries, remains an area in need of further research because interventions, including the use of protective eyewear, have been underevaluated (Lipscomb, 2000). To date, only limited evidence suggests that the use of pro- tective eyewear is successful in preventing occupational eye injuries (Chen, Fong, Lin, Chang, & Chan, 2009); however, a link between the absence of protective eye- wear and occupational eye injuries requiring health care services has been shown (Fong & Taouk, 1995; Ho et al.,2008). Despite this, occupational eye injuries and lost work-time due to these injuries are considered prevent- able through the use of eye protection (Lipscomb, 2000; Prevent Blindness America, 2011).The evidence that injury is a risk factor for subse- quent injury is equivocal (Hamilton, Meeuwisse, Emery, Steele, & Shrier, 2011), but occupational eye injuries tend to reoccur among individuals and may be depen- dent on type of occupation. Previous eye injury has been

Applying Research to Practice

Workers sustaining work-related eye injuries increase their use of eye protection when resuming work. However, overall use still remains low. A perceived lack of need for eye protection among injured workers may bea barrier to increasing use. Evidence sug- gests employers safety policies may change after employees sustain eye injuries, and may improve eye protection use. Health careproviders could make use of a teachable mo- ment when treating occupational eye injuries to encourage workers use of appropriate eye protection.

found predictive of subsequent eye injury among steel- workers (Schoemaker, Barreto, Swerdlow, Higgins, & Carpenter, 2000), carpenters (Lipscomb, Dement, Mc- Dougall, & Kalat, 1999), military personnel (Ward & Gorie, 1991), and workers in general (de la Hunty & Sprivulis, 1994).Prevention of occupational eye injuries should take a multifaceted approach, including education, enforce- ment, and environmental interventions. When eye injury occurs, a unique opportunity exists to improve workers understanding of the factors that lead to injury occur- rence and what is done after an eye injury to prevent reoccurrence. The extent to which an injury event can trigger a change in behavior has not been well estab- lished, and no evidence currently exists regarding oc- cupational eye injuries. Identifying the factors that influence safety-related behavior change (or fail to in- cite change) after an eye injury can improve eye injury prevention efforts. For example, health care provider contact following injury may be an opportunity to capi- talize on the teachable moment. The teachable moment has been used by health care providers to encourage sev- eral health behaviors (e.g., tobacco cessation, seatbelt and helmet use, and reductions in dangerous driving, binge drinking, and violence) (Cummings, Francescutti, Predy, & Cummings, 2006; Ekeh, Hamilton, Demko, & McCarthy, 2008; Gittelman, Pomerantz, Fitzgerald, & Williams, 2008; Horn, Dino, Hamilton, & Noerachman- to, 2007; Johnston, Rivara, Droesch, Dunn, & Copass,2002; Mangus, Simons, Jacobson, Streib, & Gomez,2004; Neuner et al., 2009).The primary aim of this study was to evaluate whether an eye injury is an event that can change in- dividuals habits regarding wearing eye protection. Although other forms of occupational eye injury pre- vention exist and should be emphasized, the use of eye protection ultimately falls to the individual and requires minimal effort. Thus, the results of this study could be used to explore whether health care provider-based in- terventions may prevent occupational eye injuries. A

cohort of workers with treated occupational eye injuries were asked to quantify their eye protection habits prior to, at the time of, and during a period of 6 to 12 months following an eye injury.

METHOdSThe study protocol was approved by the Institutional Review Board at the University of Alabama at Birming- ham.

Sample DesignThe sample for this cohort study included workers19 years and older seeking care at a dedicated eye emer- gency department for eye injuries sustained during work activities from August 2008 through September 2010. The emergency department serves primarily individu- als in a single county, but is the only 24-hour eye emer- gency department in the state. The emergency department evaluates approximately 400 individuals per month, with36% representing all categories of injury. Between Au- gust 2008 and September 2010, a total of 198 individuals completed a baseline questionnaire following 201 work- related eye injuries; they were re-contacted between Sep- tember 2009 and December 2010 for administration of the follow-up questionnaire.Study participants were identified through daily review of health records from the previous day to de- termine injury-related emergency department visits re- sulting from occupational activities. Eye injuries were broadly defined as any condition resulting from trauma to the eye or ocular adnexa, which included extraocular muscles and the eyelids. Such injuries were identified through the interpretation of the treating ophthalmolo- gists notes as well as the billing diagnosis using the In- ternational Classification of Diseases, Ninth Revision, Clinical Modification (Centers for Disease Control and Prevention, n.d.) and included codes 802.6 and 802.7 (orbital floor fractures); 870.0 to 870.9 (open wounds of the ocular adnexa); 871.0 to 871.9 (open wounds of the eyeball); 918.0 to 918.9 (superficial wound of the eye and adnexa); 921.0 to 921.9 (contusion of the eye and adnexa); 930.0 to 930.9 (foreign body on the exter- nal eye); 940.0 to 940.9 (burn confined to the eye and adnexa); 941.02 to 941.52 (burn involving the eye with other parts of the face, head, and neck); 950.0 to 950.9 (injury to the optic nerve and pathways); and 951.0,951.1, and 951.3 (injury to the oculomotor, trochlear, and abducens nerves). In some situations, other diag- noses were included if other information from the oph- thalmologists notes indicated an injury was likely, such as keratitis (370), other disorders of the eye (379), con- junctiva (372), and iris and ciliary body (364). Work status during the time of the injury was determined by reviewing the ophthalmologists and the nurses notes, identifying whether workers compensation was filed, and contacting the worker directly.

Data CollectionA brief questionnaire was mailed to all patients meeting age requirements for whom the injury wasTable 1Respondents Versus Non-respondents demographicsRespondents(N = 77)

Non-respondents(N = 124) pAge (years) .3890

< 2510 (13.0%)22 (17.7%)

254546 (59.7%)71 (57.3%)

466521 (27.3%)28 (22.6%)

> 66Sex0 (0.0%)3 (2.4%)

.2094

Male62 (80.5%)108 (87.1%)

Female15 (19.5%)16 (12.9%)

Race/ethnicity.0144

White69 (89.6%)90 (72.6%)

African American6 (7.8%)28 (22.6%)

OtherMajor occupational groupa2 (2.6%)6 (4.8%)

.0545

Precision production, craft, and repair42 (54.5%)71 (57.3%)

Machine operators, assemblers, and inspectors9 (11.7%)24 (19.4%)

Service, except private household4 (5.2%)13 (10.5%)

Handlers, equipment cleaners, helpers, and laborers7 (9.1%)8 (6.4%)

Professional, technical and related7 (9.1%)4 (3.2%)

Other8 (10.4%)4 (3.2%)

Job experience (years).6315

< 113 (16.9%)20 (16.1%)

1534 (44.2%)63 (50.8%)

> 530 (38.9%)41 (33.1%)

Size of employer.8637

Self-employed11 (14.3%)14 (11.3%)

210 workers19 (24.6%)28 (22.6%)

1150 workers23 (29.9%)46 (37.1%)

> 51 workers23 (29.9%)34 (27.4%)

Unknown1 (1.3%)2 (1.6%)

Used eye protection during eye injury40 (52.0%)60 (48.4%).6235

Note. aFor those with multiple occupations, the job with the most hours worked was used.

clearly work-related or it was unknown whether the in- jury occurred at work. The initial questionnaire assessed eye protection use and other work-related exposure in- formation and was estimated to take approximately 20 minutes to complete. Questions were intuitive and based on questionnaires previously used to assess similar oc- cupational exposures (McGwin, Taylor, MacLennan, & Rue, 2005). Demographic data, including occupation- al characteristics, were collected at baseline from the workers responses. Occupation was classified based on

the Bureau of Labor Statistics Occupational Classifica- tion System.Approximately 6 months to 1 year following the in- jury, responding workers were contacted again by tele- phone and asked a brief set of questions about current eye protection habits, likelihood of eye protection use given the previous injury, current use of eye protection during tasks similar to when the eye injury occurred, and changes to employer requirements regarding pro- tective eyewear. The period between questioning variedTable 2All Primary and Secondary International Classification of Diseases, NinthRevision, Clinical Modification (ICd-9-CM) diagnoses Among Respondents

ICD-9-CM CodeDescriptionFrequency (%)

930Foreign body on external eye27 (26.7)

918Superficial injury of eye and adnexa24 (23.7)

370Keratitis13 (12.9)

379Other disorders of eye8 (7.9)

940Burn confined to eye and adnexa7 (6.9)

372Disorders of conjunctiva5 (5.0)

921Contusion of eye and adnexa5 (5.0)

871Open wound of eyeball2 (2.0)

OtherAll other diagnoses codes10 (9.9)

Table 3Comparison of the Median Work-Time Wearing Eye Protection Before and After Injury Among Those With Complete Information (N = 77), Stratified by Protective Eyewear Use during Injury and Job Experience

Median Use, Prior toInjury (% of Work-Time)Median Use, AfterInjury (% of Work-Time)pa

Protective eyewear use during eye injury

Wearing during injury (N = 40)100100.2314

Not wearing during injury (N = 37)03< .0001

Job experience at current job (years)

< 115100.2188

1512100.0015

> 525100.0290

Total (N = 77)20100< .0001

Note. aWilcoxon signed rank test.

based on the researchers ability to re-contact the initial respondents. Participants reporting no change or less likely to use eye protection since their eye injuries were asked to describe why their behaviors had not changed.

Statistical AnalysisFor each individual, the usual frequency of eye pro- tection was calculated as the proportion of time using eye protection while at work. The numerator was the amount of time respondents used eye protection during the past work-month (in minutes), derived from questions asking about the frequency and duration of use (i.e., On how many days did you wear eye protection? and When you wore eye protection, for how long did you wear it?). The denominator was the total minutes worked in the previous month. This proportion was calculated for the period dur- ing the work-month prior to injury and the work-month6 to 12 months after injury. To account for data skewed

toward proportions of 0 and 100%, the Wilcoxon signed rank test was used to test the null hypothesis that an eye injury did not change the usual frequency of eye protec- tion use. If respondents changed jobs or were no longer employed, their data were excluded from analysis.

RESUlTSDuring the enrollment period, between August 2008 and September 2010, an attempt was made to contact in- dividuals with 1,101 potentially work-related eye injuries identified through the emergency department. Of those,724 (66%) were confirmed to be work-related, of which46 (6%) of the individuals refused to participate, 477 (66%) could not be contacted, and 201 (28%) responded. A total of 77 (38.3%) individuals responded to the second questionnaire and had information on eye protection use prior to their eye injury as well as during the period after eye injury. An additional 23 (11.4%) respondents wereTable 4likelihood and Frequency of Wearing Eye Protection Since Eye Injury in General and When Performing the Same Task as When Injured

Eye Protection UseAt work, since injury

Not Wearing During Injury(N = 37)

Wearing During Injury(N = 40)

Total(N = 77)More likely 27 (73.0%) 24 (60.0%) 51 (66.2%) No change in likelihood 9 (24.3%) 16 (40.0%) 25 (32.5%) Less likely 1 (2.7%) 0 (0.0%) 1 (1.3%) When performing same task as when

successfully re-contacted, but were unemployed or had changed jobs and thus were excluded. Age, sex, and race/ ethnicity comparisons between the 77 respondents and the 124 non-respondents yielded similar results, with the exception of African Americans being underrepresented in the study group (p = .0144) (Table 1). The most com- mon age group was 25 to 45 years (59.7%); most respon- dents were male (80.5%) and White (89.6%). Precision production, craft, and repair were the most commonly represented major occupational groups (54.5%), using the Bureau of Labor Statistics system. Most respondents had held their jobs between 1 and 5 years (44.2%) with an employer size of either 11 to 50 employees (29.9%) or more than 51 employees (29.9%). More than half of the respondents (52.0%) indicated they were wearing eye protection at the time of the eye injury. The most common injuries observed among respondents involved corneal foreign bodies (26.7%) and corneal abrasions (23.7%) (Table 2).The median proportion of work-time spent wear- ing protection prior to injury among respondents was20% (Table 3). In the period after eye injury, the median proportion of work-time spent using eye protection in- creased to 100% (p < .0001). This change was modified by whether eye protection was recorded as being worn at the time of eye injury. Those wearing eye protection at the time of eye injury reported nearly universal use, with a median proportion of 100%. No change in time between before and after injury was found for this group. Respondents stating they were not wearing eye protec- tion during the eye injury were unlikely to usually wear eye protection during work, with a median proportion of work-time of 0%. The proportion of work-time using eye protection among this group increased to 3%, a statisti- cally significant (p < .0001) finding. Job experience had a slight effect on the proportion of work-time for which

Table 5Reasons Given for Not Changing Eye Protection Habits Among Those Not More likely to Use Protective Eyewear Following Their Eye Injury N (%) Already in the habit of wearing 18 (69.2) No perceived need 5 (19.2) Interferes with job 2 (7.7) Do not like wearing 1 (3.9)

eye protection was used, such that the median proportion prior to the eye injury was 15% for less than 1 year, 12% for 1 to 5 years, and 25% for 5 years or more. The median proportion of work-time eye protection use following in- jury for each category of job experience was 100%; 1 to5 years (p = .0015) and 5 years or more (p = .0290) were statistically significant.Overall, respondents self-reported they were more likely to wear eye protection following the injury (66.2%);32.5% indicated no change in their eye protection habits (Table 4). Most respondents indicated they currently al- ways wore eye protection when performing tasks similar to those when they sustained their eye injuries (Table 4). A stronger likelihood of always wearing eye protection for a similar task was observed among those who were using eye protection during their eye injuries (87.5%) versus those who were not (56.8%). Regardless of eye protection status at the time of injury, 25 respondents in- dicated they did not make any changes and 1 respondent was less likely to wear eye protection after the injury;the primary reason given was that they were already in the habit of wearing eye protection (69.2%), followed by no perceived need for eye protection (19.2%) (Table 5). Employer eye protection policy changes initiated since the injury to introduce eye protection requirements or in- crease enforcement of existing requirements were report- ed by 25 respondents (32.4%). Employer policy changes did not differ for respondents based on their eye protec- tion use during the eye injury.

dISCUSSIONThe experience of an eye injury appears to provide an impetus to produce changes in the use of eye protec- tion persisting for months after the injury. The observed proportion of work-time spent wearing eye protection was highly skewed, suggesting many workers either nev- er use eye protection or use it during the entire work shift. Thus, the change in median work-time spent using eye protection was driven in part by workers increasing their use to 100% of their work-time. The precise reasons for this change require additional investigation, as maintain- ing eye protection habits may be related to a variety of factors, including the work environment or the individu- als themselves. Specific factors such as employer policy, worker age, and comfort and fit of protective eyewear have previously been identified as predicting eye protec- tion use (Lombardi, Verma, Brennan, & Perry, 2009). Several other factors may influence the use of eye pro- tection, including fear of irreversible vision loss, pain, temporary disability, costs associated with treatment, and attitudes toward the perceived need for eye protection.Eye injuries, despite often being minor, are costly in terms of health care expenses, missed workdays, and potential disability (Islam, Doyle, Velilla, Martin, & Ducatman, 2000; Welch, Hunting, & Mawudeku, 2001). Although this study found that an eye injury may lead to increased use of eye protection among some work- ers, it does not diminish the need for primary prevention. Rather, the results are only generalizable to workers able to return to work following an eye injury and thus given a second chance to prevent a more serious eye injury. Additional opportunities to encourage more appropriate or correct use of eye protection could exist in the clini- cal setting through counseling and education following an eye injury. Although an increase in the use of pro- tective eyewear was observed among those not wearing eyewear during injury, the rate of use among this group remains relatively low. It is presumed that ophthalmolo- gists treating individuals in the emergency department do provide some counseling or encouragement to wear eye protection in the future, using the teachable moment, but a structured intervention was not in place during the study period. Such an intervention may capitalize on workers willingness to change following an injury and result in greater and more appropriate use of eye protection.Few prospective studies have investigated behavior changes following an injury. Seatbelt use after a motor vehicle collision has been shown to increase from 54% to 85% a year following the crash (Passman, McGwin, Taylor, & Rue, 2001). Among children hospitalized for

bicycle-related injuries, only modest gains in helmet use were observed after discharge, with 75% continuing to ride without protective headwear (Nakayma, Pasieka, & Gardner, 1990). Regarding eye injuries, evidence from cross-sectional studies has indicated that previous eye injury is predictive of current use of protective eyewear among squash and female lacrosse players (Eime, Finch, Owen, & McCarty, 2005; Waicus & Smith, 2002). De- spite the differences that may exist in readiness to change behavior among the populations previously studied, the effects are consistent with the findings of this study.A high proportion of respondents were wearing eye protection at the time of their injury. The Bureau of Labor Statistics (2010) has previously reported that 60% of oc- cupational eye injuries occur among workers not wear- ing eye protection. Approximately half of the participants in this study, including those responding only to the first questionnaire, self-reported wearing eye protection dur- ing the injury. This group of respondents did not indicate a decline in eye protection use after the injury, despite equipment failure in preventing eye injury. Thus, the mo- tivation to wear eye protection was seemingly not dimin- ished as worker behaviors were maintained. However, it is unclear from the collected information whether the most appropriate eye protection was used, and whether improper use may have contributed to injury. Nor is it clear to what extent eye protection may have mitigated the severity of eye injury. Primary prevention efforts should not only be aimed at promoting universal use of eye protection, but also be focused on educating indi- viduals about appropriate types of protective eyewear. Although the findings of this study suggest individuals are likely to increase their overall use of eye protection following an eye injury with no intervention, clinician- based counseling to promote not only use, but appropriate use, of protective eyewear could be effective.In an occupational setting, behavior changes regard- ing protective eyewear are not only the workers respon- sibility. Approximately one third of the respondents in this study indicated their employers had initiated policy changes since the eye injury. Employer policies have pre- viously been identified as an effective means to prevent occupational eye injuries (Lipscomb, 2000; Lombardi et al., 2009). Most employers have eye protection require- ments, and are required by federal law to provide eye pro- tection when reasonably appropriate. The observed pro- portion of workers stating their employers enacted policy changes could indicate that eye injuries not only prompt behavior change among workers, but also can trigger policy changes or increased vigilance of existing policies by employers. Differentiating whether workers them- selves change their own behaviors or whether employ- ers dictate change is difficult. Both employer-initiated and worker-initiated changes are important in preventing occupational eye injuries. Opportunities exist to encour- age employers to improve eye injury prevention prior to an eye injury by addressing the associated human capital and economic costs, as well as presenting known modifi- able risk factors.The results of this study are preliminary work on eyeprotection use following occupational eye injuries among a relatively small sample of injured workers and must be interpreted in light of these limitations. One fourth of the workers responding were unemployed or had changed jobs and were excluded. In one case, this job change was directly related to the eye injury, which prevented the re- spondent from returning to work. Therefore, the results should only be interpreted for injured workers who were able to return to work. Other than whether the injury was directly responsible, no other information about job changes was collected. For example, whether workers left their jobs based on realization of injury risk could be an important avenue of future research. As such, the results of this study should be interpreted in light of this limita- tion. In addition to those responses that were excluded, half of the cohort was lost before answering the second questionnaire. As a potential source of selection bias, no differences between respondents and non-respondents regarding age and gender were found. However, if Af- rican Americans, who were underrepresented, are less likely to modify their behavior following an injury, the results could be biased upward. Evidence has suggested African Americans may be less likely to wear eye protec- tion at work (Forrest, Cali, & Cavill, 2008), but nothing suggested a differential effect by race or ethnicity among the limited studies of behavioral changes following injury (Eime et al., 2005; Passman et al., 2001; Waicus & Smith,2002). The extent to which contact with respondents dur- ing the initial survey following their eye injury influenced their behavior is not clear, but cannot be ignored. Respon- dents were informed after the initial questionnaire that they would be contacted again, but the nature of the ques- tions was not specified and no educational information was presented. Questions were designed to collect objec- tive information about eye protection habits. Similarly, the extent to which respondents experienced interventions directed toward improving eye protection use, whether as part of the work site or other exogenous sources, is un- known but could have influenced study results. It is pos- sible that staff treating workers provided counseling on eye protection, but no standard or structured intervention was in place at the hospital. It is possible that perceptions regarding the risk of injury may fade from the time of the injury; thus, reporting of eye protection use could differ depending on time since injury or initial survey, which varied from 6 months to 1 year. Any bias would likely favor the null hypothesis, in that it is more likely risk per- ception would fade over time. Regarding the proportion of work-time using eye protection, no observable differ- ences were found between the responses collected 6 to 8 months after the initial questionnaire and those collected greater than 9 months later (p = .85). Self-report data are always subject to recall bias or overestimation, as shown in a previous study of occupational exposures (Eime et al., 2005), but it is not known how bias or overestimation might affect reporting of eye protection. Additionally, the fear of retribution from employers or loss of workers compensation benefits could have influenced workers to overreport the use of eye protection. It was made clear prior to the interview that the results were confidential

and strictly for research purposes. It is possible that work- ers with these concerns would choose not to participate in the study, thus affecting the generalizability rather than the internal validity of the study. As respondents were compared to their own baseline, it is unlikely that either recall or overestimation would differ between pre-injury and post-injury periods for a given individual.

IMPlICATIONS FOR PRACTICEThis study highlights changes in workers safety behavior following eye injury. The results suggest that workers who previously did not wear eye protection may be ready to change safety behaviors. It is clear that pre- ventive behaviors prior to eye injury are preferable, but health care providers can use the teachable moment after an eye injury to encourage the use of eye protection or ed- ucate workers about appropriate types of eye protection given the nature of workers occupations. Understanding specific factors that drive the observed increase in eye protection use following an eye injury can enhance pri- mary prevention efforts. Employer policy and perceived need for eye protection appear to be significant factors. Although beyond the scope of this study, future research should investigate the extent to which workers with eye injuries can influence the eye protection habits of non- injured coworkers. Other opportunities to evaluate effec- tive interventions to prevent occupational eye injuries can build on the new knowledge presented here.

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