Interventions to prevent injuries in construction workers

Henk F van der Molen; Prativa Basnet; Peter LT Hoonakker; Marika M Lehtola; Jorma Lappalainen; Monique HW Frings‐Dresen; Roger Haslam; Jos H Verbeek

doi:10.1002/14651858.CD006251.pub4

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Figure 1

PRISMA Study flow diagram (* numbers of 2017 update)

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Analysis 1.1

Comparison 1 Introduction of regulation (ITS), Outcome 1 Level.

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Analysis 1.2

Comparison 1 Introduction of regulation (ITS), Outcome 2 Slope.

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Analysis 2.1

Comparison 2 Inspections (ITS), Outcome 1 Level: non‐fatal injuries.

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Analysis 2.2

Comparison 2 Inspections (ITS), Outcome 2 Slope: non‐fatal injuries.

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Analysis 3.1

Comparison 3 Training (ITS, CBA), Outcome 1 Level: non‐fatal injuries.

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Analysis 3.2

Comparison 3 Training (ITS, CBA), Outcome 2 Slope: non‐fatal injuries.

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Analysis 3.3

Comparison 3 Training (ITS, CBA), Outcome 3 Non‐fatal Injuries (CBA).

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Analysis 4.1

Comparison 4 Subsidy for scaffolding (CBA), Outcome 1 Injuries from falls to a lower level.

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Analysis 5.1

Comparison 5 Safety campaign (ITS), Outcome 1 Level: non‐fatal injuries.

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Analysis 5.2

Comparison 5 Safety campaign (ITS), Outcome 2 Slope: non‐fatal injuries.

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Analysis 6.1

Comparison 6 Drug‐free workplace programme (ITS), Outcome 1 Level: non‐fatal injuries.

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Analysis 6.2

Comparison 6 Drug‐free workplace programme (ITS), Outcome 2 Slope: non‐fatal injuries.

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Summary of findings for the main comparison. Summary of findings: introduction of regulations

Regulations versus no regulations for reducing injuries in the construction industry
Patient or population: workers in various occupations Settings: construction Industry Intervention: legislation Comparison: no legislation
Outcomes	Impact ^a (95% CI)	No. of studies	Quality of the evidence (GRADE)
Fatal injuries Change in level	Effect size −0.13 (−1.51 to 1.25)	5 ITS	⊕⊝⊝⊝ Very low^b
Fatal injuries Change in slope	Effect size −0.20 (−0.64 to 0.23)	5 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in level	Effect size −0.44 (−3.70 to 2.83)	5 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in slope	Effect size 0.14 (−0.26 to 0.54)	5 ITS	⊕⊝⊝⊝ Very low^b
CI: confidence interval;ITS: interrupted time series. GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aEffect size can be interpreted as follows: < 0.2: small effect, 0.2‐0.8 moderate effect, > 0.8: large effect; negative sign means decrease in injuries. ^bObservational studies start with low‐quality evidence; we downgraded 2 levels: 1 for risk of bias and 1 for heterogeneity.

Summary of findings for the main comparison. Summary of findings: introduction of regulations

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Summary of findings 2. Summary of findings: safety campaign

Safety campaign versus no campaign for reducing injuries in construction industry
Patient or population: workers in various occupations Settings: construction Industry Intervention: safety campaign Comparison: no campaign
Outcomes	Impact^a (95% CI)	No. of studies	Quality of the evidence (GRADE)
Fatal injuries	No available data
Non‐fatal injuries Change in level (company)	Effect size −1.82 (−2.90 to 0.74)	1 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in slope (company)	Effect size −1.30 (−1.79 to −0.81)	1 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in level (regional)	Effect size 0.47 (−0.04 to 0.98)	1 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in slope (regional)	Effect size 0.46 (0.36 to 0.56)	1 ITS	⊕⊝⊝⊝ Very low^b
CI: confidence interval;ITS: interrupted time series. GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aEffect size can be interpreted as follows: < 0.2: small effect, 0.2‐0.8 moderate effect, > 0.8: Large effect; negative sign means decrease in injuries. ^b Observational studies start with low‐quality evidence; we downgraded 2 levels: 1 for risk of bias, 1 for imprecision (1 study).

Summary of findings 2. Summary of findings: safety campaign

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Summary of findings 3. Summary of findings: drug‐free campaign programme

Drug‐free workplace programme versus no programme for reducing the risk of occupational injuries
Patient or population: employees of the companies with Washington Drug‐Free Workplace (WDFW) Program Settings: various construction companies Intervention: drug‐free campaign programme Comparison: non‐WDFW programme
Outcomes	Impact^a (95% CI)	No. of studies	Quality of the evidence (GRADE)
Fatal injuries	No available data
Non‐fatal injuries Change in level	Effect size −6.78 (‐10.01 to −3.55)	1 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in slope	Effect size −1.76 (−3.11 to −0.41)	1 ITS	⊕⊝⊝⊝ Very low^b
CI: confidence interval;ITS: interrupted time series. GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aEffect size can be interpreted as follows: < 0.2: small effect, 0.2‐0.8 moderate effect, > 0.8: large effect; negative sign means decrease in injuries. ^b Observational studies start with low‐quality evidence; we downgraded 2 levels: 1 for risk of bias and 1 for imprecision (1 study) and upgraded with 1 for large effect size.

Summary of findings 3. Summary of findings: drug‐free campaign programme

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Summary of findings 4. Summary of findings: training

Training versus no training for reducing work‐related injuries
Patient or population: workers in the construction industry Settings: union members in the USA and construction workers in railway construction project Intervention: OSHA outreach training; safety and health training for railway workers Comparison: no training
Outcomes	Impact^a (95% CI)	No. of studies	Quality of the evidence (GRADE)
Fatal injuries	No available data
Non‐fatal injuries	OR 0.87 (0.72 to 1.06 )	1 CBA study	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in level	Effect size 0.10 (−1.74 to 1.94)	1 ITS	⊕⊝⊝⊝ Very low^b
Non‐fatal injuries Change in slope	Effect size −0.43 (−0.96 to 0.10)	1 ITS	⊕⊝⊝⊝ Very low^b
CI: confidence interval;OR: odds ratio; ITS: interrupted time series. GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aEffect size can be interpreted as follows: < 0.2: small effect, 0.2‐0.8 moderate effect, > 0.8: large effect; negative sign means decrease in injuries. ^b Observational studies start with low‐quality evidence; we downgraded 2 levels: 1 for risk of bias and 1 for imprecision (1 study).

Summary of findings 4. Summary of findings: training

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Summary of findings 5. Summary of findings: inspection

Inspection versus no inspection of construction site
Patient or population: workers of reconstruction site Settings: reconstruction site after earthquake Intervention: accidents in building site Comparison: no inspection
Outcomes	Impact^a (95% CI)	No of Studies	Quality of the evidence (GRADE)
Fatal injuries	No available data
Non‐fatal injuries Change in level	Effect size 0.07 (−2.83 to 2.97)	1 ITS	⊕⊕⊝⊝ Very low^b
Non‐fatal injuries Change in slope	Effect size 0.63 (−0.35 to 1.61)	1 ITS	⊕⊕⊝⊝ Very low^b
CI: confidence interval;ITS: interrupted time series. GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aEffect size can be interpreted as follows: < 0.2: small effect, 0.2‐0.8 moderate effect, > 0.8: large effect; negative sign means decrease in injuries. ^b Observational studies start with low‐quality evidence; we downgraded with two levels: 1 for risk of bias and 1 for imprecision (1 study).

Summary of findings 5. Summary of findings: inspection

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Summary of findings 6. Summary of findings (Subsidy for Scaffolding)

Subsidy for scaffolding versus no subsidy for injuries due to falls to a lower level
Patient or population: population working in construction companies Settings: construction company Intervention:subsidy for scaffolds Comparison: no subsidy for scaffolds
Outcomes	Impact (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
Fatal injuries	No available data
At baseline	RR 3.89 (2.32 to 6.52)	(1 CBA Study)	⊕⊝⊝⊝ Very low^a
At follow‐up (2 years)	RR 0.93 (0.30 to 2.91)	(1 CBA Study)	⊕⊝⊝⊝ Very low^a
CBA: controlled before‐after; CI: confidence interval; RR: risk ratio. GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^a Observational studies start with low‐quality evidence; we downgraded 2 levels: 1 for risk of bias, 1 for imprecision (1 study).

Summary of findings 6. Summary of findings (Subsidy for Scaffolding)

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Table 1. Characteristics of excluded before‐after and retrospective studies

Study ID	Methods	Participants	Interventions	Outcome per 100 person‐years
Altayeb 1992	Before‐after study	Construction workers (31 companies, no control group)	Drug testing programmes issued from 1985 to 1988 in USA	Number of injuries: before: 11.2; after: 9.1; absolute change: 2.1
Darragh 2004	Before‐after study	Residential construction workers (97 companies, no control group)	Safety education and training programme, issued in 1997 in USA (also booklet, focused inspection and financial incentives were used)	Number of injuries: before: 17.4; after: 14.7; absolute change: 2.7 Number of LWDI: before: 5.8; after: 3.5; absolute change: 2.3 Number of LWDI and medical cost: before: 3.8; after: 2.2; absolute change: 1.6
Evanoff 2016	Before‐after study	1018 apprentice carpenters in residential construction (no control group)	Educational intervention: training utilised hands‐on, participatory training methods preferred by the learners to address the safety gaps in the curriculum, including ladder use, leading edge work, truss setting, and use of scaffolding and personal fall arrest. Rolled out in USA in 2007	Number of self‐reported falls: before 18.2; after: 14.5; absolute change 3.7
Gerber 2002	Before‐after study	Construction workers (49 companies, no control group)	Drug‐testing programmes issued from 1985 to 1999 in USA	Number of injuries: before: 8.9; after: 4.4; absolute change: 4.5
HSA 2006	Before‐after study (not enough data points)	Construction workers (142,100 in 1999 to 206,000 in 2004)	Construction regulations for safe work environments issued in 2001 in Ireland	Number of injuries: in 1999: 0.4; in 2004: 0.7; absolute change: 0.3 Number of fatal injuries per 1,000,000 person‐years: in 1999: 113; in 2004: 73; absolute change: 40
Johnson 2002	Before‐after study	Carpenters and drywall tapers from variety of ethnic backgrounds (5 administrators plus 50 workers, no control group)	A job safety programme (toolbox, training, stress management techniques) issued in 1998 in USA	Number of injuries: before: 26.8; after: 12.9; absolute change: 13.9 Number of lost days: before: 23.5; after: 2.4; absolute change: 21.1
Kim 2016	Retrospective cohort study	1298 patients who suffered work‐related fall injuries.	Preventive effects of safety helmets: emergency‐department based occupational injury database with work‐related injury patients who visited 10 emergency departments between July 2010 and October 2012 in Korea. Surveillance database was used to evaluate the extent to which safety helmets have an effect on reducing the risk of traumatic brain injury resulting from work related fall injuries by comparing the effect across different heights.	Usage of helmets: 45% work‐related fall injured patients were wearing safety helmets. Intracranial injury was high at 8.7% in the no safety helmet group and 4.6% in the safety helmet group. There was significant preventive effects of safety helmet on intracranial injury when the height of fall was less than 4 m. OR 0.42 (95% CI 0.24 to 0.73)
Marcucci 2010	Before‐after study	Electricians in Ontario, Canada	Multifaceted electrical burn prevention programme (starting in 2004) consisting of education, facilitation: survey to understand the multimeter problem, best practice review, technical research awareness raise behavioural change through proper safety precautions influence product design new product design and stimulate market place	No denominator reported Non‐fatal injuries, i.e. electrical burns through multimeters Before (1998 to 2005): 26 electrical burn injuries caused by multimeters After (2006 to 2008): 0 electrical burn injuries caused by multimeters
Nelson 1997	Retrospective cohort study	Construction workers (784 employers, control group of 8301 employers)	Washington State fall protection standard, violation during 1991 to 1992 in USA	Number of fall injuries: before intervention group: 1.8; before control group: 1.0; after intervention group: 1.4; after control group: 1.0; absolute change difference between intervention and control group: 0.4
Ohdo 2014	Before‐after study	—	Amended occupational safety and health regulations in Japan in 2009: installation of mid‐rails, lower bars and other similar structures to prevent falls from the space between a guardrail and the work platform erected on scaffolds	Scaffold‐related fall accidents: Decrease over years 1552 (2007), 1227 (2008), 828 (2009), 718 (2010), 871 (2011)
Salminen 2008	Before‐after study	Company 1: 172 drivers/electricity workers Company 2: 179 drivers/electricity workers	Company 1: 3, 45‐60 min group discussions Company 2: 1‐day course in anticipatory driving	Company 1 Number of work‐related road injuries: before: 10.5; after: 2.9; absolute change: 7.6 Number of other occupational injuries: before: 42.4; after: 48.8; absolute change: 6.4 Company 2 Number of work‐related road injuries: before: 2.2; after: 3.4; absolute change: 1.2 Number of other occupational injuries: before: 23.5; after: 28.5; absolute change: 5.0
Williams 2010	Before–after study	Latino day labourers in USA	Training safety and health awareness of 1 day based on active learning and problem solving through peer trainers. Training materials adapted from OSHA curriculum and pilot	No denominator reported Non‐fatal injuries leading to stop with work Any serious injury last 6 months: before: 21% (N = 64); after: 24% (N = 16) At least 2 serious injuries last 6 months: before: 16% (N = 36); after: 1.5% (N = 1)
CI: confidence interval;LWDI: lost work day injuries; OR: odds ratio; OSHA: Occupational Safety and Health Administration.

Table 1. Characteristics of excluded before‐after and retrospective studies

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Table 2. Results from re‐analysis of the ITS studies; non‐standardised data

Study	Pre‐int level (SD)	Change level (SE)	Pre‐int slope (SE)	Change slope (SE)	Autocorrelation
Fatal injuries/1 million person‐years
Derr 2001	45.80 (3.42)	8.16 (2.18)	−1.97 (0.51)	0.28 (0.67)	−0.64
Suruda 2002	14.01 (2.09)	−2.18 (1.17)	−1.10 (0.23)	0.76 (0.31)	−0.37
Beal 2007	73.60 (15.31)	4.21 (6.61)	−4.52 (0.84)	2.79 (1.23)	0.22
Choe 2016	40.2 (4.92)	−9.05 (5.19)	1.96 (1.22)	−6.34 (1.60)	−0.74
Farina 2013	4.94 (0.37)	−0.38 (0.38)	−0.10 (0.08)	−0.29 (0.12)	0.17
Non‐fatal injuries/100 person‐years
Spangenberg 2002	3.34 (2.06)	−3.75 (1.13)	2.17 (0.43)	−2.67 (0.52)	−0.82
Lipscomb 2003	3.50 (0.49)	0.39 (0.57)	−0.70 (0.35)	0.47 (0.35)	−0.08
Wickizer 2004: intervention	27.80 (1.40)	−4.62 (2.43)	−0.79 (0.98)	0.13 (1.01)	−0.70
Wickizer 2004: control	28.06 (2.35)	2.93 (0.61)	−2.25 (0.24)	2.01 (0.25)	−1.25
Wickizer 2004: int‐con	−0.26 (1.12)	−7.59 (1.85)	−1.50 (0.75)	−1.97 (0.77)	−0.83
Miscetti 2008	10.92 (1.44)	0.11 (2.13)	−0.94 (0.62)	0.90 (0.72)	0.46
Bena 2009	23.6 (4.58)	0.46 (4.33)	−0.57 (0.98)	−1.97 (1.22)	−0.14
Aires 2010_Austria	8.10 (2.08)	1.33 (0.86)	−1.44 (0.27)	1.22 (0.29)	−0.13
Aires 2010_Belgium	9.20 (0.87)	1.08 (0.52)	−0.50 (0.17)	−0.11 (0.17)	−0.40
Aires 2010_Germany	10.28 (0.73)	1.13 (0.45)	−0.57 (0.20)	−0.01 (0.20)	−0.63
Choe 2016	43.58 (3.47)	−21.78(1.71)	−0.76 (0.4)	−2.07(0.53)	−0.88
Non‐fatal injuries/million m³construction volume
Laitinen 2010: intervention	792.29 (195.12)	105.15 (50.18)	‐86.75 (9.12)	87.39 (10.18)	−0.35
Laitinen 2010: control	372.1 (21.57)	17.58 (23.54)	−3.43 (4.35)	3.52 (5.09)	0.06
Laitinen 2010: int‐con	420.14 (187.75)	87.57 (49.28)	‐84.11 (8.97)	85.43 (9.96)	−0.46
Pre‐int: pre‐intervention; SD: standard deviation; SE: standard error.

Table 2. Results from re‐analysis of the ITS studies; non‐standardised data

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Comparison 1. Introduction of regulation (ITS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Level Show forest plot	9		Effect Size (Random, 95% CI)	‐0.33 [‐2.08, 1.41]

1.1 Fatal injuries	5		Effect Size (Random, 95% CI)	‐0.13 [‐1.51, 1.25]
1.2 Non‐fatal injuries	5		Effect Size (Random, 95% CI)	‐0.44 [‐3.70, 2.83]
2 Slope Show forest plot	9		Effect Size (Random, 95% CI)	‐0.03 [‐0.30, 0.24]

2.1 Fatal injuries	5		Effect Size (Random, 95% CI)	‐0.20 [‐0.64, 0.23]
2.2 Non‐fatal injuries	5		Effect Size (Random, 95% CI)	0.14 [‐0.26, 0.54]

Comparison 1. Introduction of regulation (ITS)

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Comparison 2. Inspections (ITS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Level: non‐fatal injuries Show forest plot	1		Effect Size (Random, 95% CI)	0.07 [‐2.83, 2.97]

2 Slope: non‐fatal injuries Show forest plot	1		Effect Size (Random, 95% CI)	0.63 [‐0.35, 1.61]

Comparison 2. Inspections (ITS)

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Comparison 3. Training (ITS, CBA)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Level: non‐fatal injuries Show forest plot	1		Effect Size (Random, 95% CI)	0.1 [‐1.74, 1.94]

2 Slope: non‐fatal injuries Show forest plot	1		Effect Size (Random, 95% CI)	‐0.43 [‐0.96, 0.10]

3 Non‐fatal Injuries (CBA) Show forest plot	1		Odds Ratio (Fixed, 95% CI)	0.87 [0.72, 1.06]

Comparison 3. Training (ITS, CBA)

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Comparison 4. Subsidy for scaffolding (CBA)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Injuries from falls to a lower level Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Baseline	1	58019	Risk Ratio (M‐H, Fixed, 95% CI)	3.89 [2.32, 6.52]
1.2 At 2 years follow‐up	1	44619	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.30, 2.91]

Comparison 4. Subsidy for scaffolding (CBA)

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Comparison 5. Safety campaign (ITS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Level: non‐fatal injuries Show forest plot	2		Effect Size (Random, 95% CI)	Totals not selected

1.1 At company level	1		Effect Size (Random, 95% CI)	0.0 [0.0, 0.0]
1.2 At regional level	1		Effect Size (Random, 95% CI)	0.0 [0.0, 0.0]
2 Slope: non‐fatal injuries Show forest plot	2		Effect Size (Random, 95% CI)	Totals not selected

2.1 At company level	1		Effect Size (Random, 95% CI)	0.0 [0.0, 0.0]
2.2 At regional level	1		Effect Size (Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Safety campaign (ITS)

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Comparison 6. Drug‐free workplace programme (ITS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Level: non‐fatal injuries Show forest plot	1		Effect Size (Random, 95% CI)	‐6.78 [‐10.01, ‐3.55]

2 Slope: non‐fatal injuries Show forest plot	1		Effect Size (Random, 95% CI)	‐1.76 [‐3.11, ‐0.41]

Comparison 6. Drug‐free workplace programme (ITS)

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