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. 2025 Apr 14;25:1393. doi: 10.1186/s12889-025-22564-z

Development of National profile for occupational safety and health services in Iran (IRANOSH): a mixed-method study focusing on input and process indicators

Narmin Hassanzadeh-Rangi 1,2, Bayan Hosseini 3, Yeganeh Akhtari 4, Yahya Khosravi 1,2,5,6,✉
PMCID: PMC11995502  PMID: 40229830

Abstract

Background

This study introduces a protocol for developing anational profile for occupational safety and health services (NPOSH), tailored for Iran (IRANOSH). Itfocuses on basic information, structure, programs, and human resources, highlighting challenges and practicesin the context of OSH services.

Methods

Forty-six NPOSH indicators were identified through content analysis of literature and categorized into ten domains and six types. The NPOSH framework was customized for Iran (IRANOSH) following an initial focus group discussion. Quantitative data were collected by 2,317 occupational health inspectors from820,846 workplaces across Iran, including3,734,249 workers. The quantitative and qualitative indicators were further discussed in a second focus group.

Results

Quantitative findings show the target population for occupational safety and health (OSH) services was estimated to be 34% of the country’s population. Small workplaces comprised 98% of all workplaces including 40% of workers. Access to OSH structures indicates one OSH center per 154 workers and 33 workplaces, one OSH engineeringcompany per 12,447 workers and 2,736 workplaces, and one OSH medical examination center per 3,404 workers and 748 workplaces. Access to OSH human resources involves one OSH inspector for every 354 workplaces and 1,612 workers and one occupational medicine specialist for every 3,270 workplaces and 14,877 workers.Qualitative findings show that thekey OSH programs in Iran include targeted inspections, occupational medical examinations, and monitoring of occupational exposures focusing on difficult and hazardous occupations in medium to large workplaces. Small workplaces present the most significant challenge and priority. A pronounced shortage of human resources hampers service provision, making developing OSH services for these settings a top priority.

Conclusions

Implementing an OSH self-assessment system through trade unions is proposed to bridge OSH service gaps. Additionally, expanding the PHC system to incorporate OSH structures within public organizations is essential for improving service delivery. Customizing the NPOSH framework for other countries with various health system contexts is recommended. Updating this study and comparing current findings with other data sources will help validate the current findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-22564-z.

Keywords: Human resources, Iran, Occupational safety and health services, National profile, Program, Structure

Introduction

Globally, there were 2.9 million deaths attributed to work, comprising 2.58 million from work-related diseases and 0.32 million from occupational injuries. While fatalities from occupational injuries have decreased, work-related diseases with long latency periods are on the rise. In 2019, the disability-adjusted life years (DALY) related to work were estimated at 180 million, resulting in an economic loss of 5.8% of global GDP [1]. Occupational exposures often underestimated as a contributor to the burden of diseases, received renewed attention [2–4], For example, in June 2022, a group of 25 scientists from eight countries met at the International Agency for Research on Cancer (IARC) in Lyon, France, to finalize their evaluation of the carcinogenicity of occupational exposure as a firefighter, an upgrade from its previous status in 2007 as “possibly carcinogenic to humans” (Group 2B) [5].

Despite legal support, and integration of occupational safety and health (OSH) into the primary health care (PHC) system, national programs, inspection systems, and occupational examinations in many countries, there is still a lack of coherent information on the status of OSH services [6, 7]. Limited studies on the systematic assessment of occupational exposures have been conducted in developed and developing countries with the majority of studies being cross-sectional [8, 9].Due to the lack of targeted studies in this field, the provision of an OSH country profile for research and executive planning has been neglected and under-considered in the decision-making system of countries. An OSH country profile is a tool used to describe OSH conditions, monitor progress in health status over time, develop evidence-based policies, and evaluate the effectiveness of programs and actions in a country [10, 11]. The World Health Organization (WHO) and ILO jointly support the development of national action plans, OSH profiles, and other workplace initiatives [12]. ILO has requested all countries to prepare and regularly update the OSH country profile in the Occupational Safety and Health Recommendation 2006 (No. 197) [13]. A review of documents reveals that only a few countries such as Germany, Finland, Singapore, Thailand, Turkey, and Pakistan have prepared a traditional version of OSH profiles. A review of the OSH profiles in Thailand, Finland, Germany, Singapore, Pakistan, and Turkey reveals common features among these profiles, including the governance structure, laws and regulations, legislative systems, human resources, OSH officials, and OSH indicators. However, each country also has its unique features. For instance, Thailand’s OSH profile includes OSH inspection, campaigns to improve educational levels, an OSH information network and system, and international cooperation. In Finland, compensation issues related to work-related health problems or future priorities are also addressed. The German OSH profile provides recommendations for development, while the Singapore OSH profile suggests methods and tools for implementing a professional strategy. The Turkish OSH profile includes institutions, regular and ongoing activities, and more [14–17]. Due to the lack of studies in this field, OSH profile indicators are not very clear. Therefore, there is a need for a study to develop an integrated framework for the OSH country profile as a platform for the integrated policy of OSH services in the health systems of countries. This study presents a framework for the national profile for occupational safety and health (NPOSH) customized for Iran (IRANOSH). This study part focuses on basic information, structure, programs, and human resources in the context of OSH services, highlighting challenges and practices.

Methods

This study employed a mixed-methods approach with a multi-perspective approach. We conducted cross-sectional research with a triangulation approach using a literature review, qualitative study, and quantitative study, as illustrated in Fig. 1.

Fig. 1.

Fig. 1

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Study protocol for the development of IRANOSH

Developing NPOSH

In the initial phase, a literature search was conducted to identify publications related to the topic. Three bibliographic databases were searched including Google Scholar, PubMed, and Science Direct as well as websites of organizations such as WHO, ILO, Occupational Safety and Health Administration, and Health and Safety Executive from 2008 to 2018. The search query included keywords such as ‘occupational health’ OR ‘occupational hygiene’ OR ‘industrial health’ OR ‘industrial hygiene’ OR ‘occupational safety’ OR ‘health at work’ OR ‘safety at work’ OR ‘health and safety’ OR ‘occupational medicine’ OR ‘industrial medicine’ OR ‘occupational disease’ OR ‘occupational disorder’ OR ‘occupational exposure’ AND ‘indices’ OR ‘indicators’ OR ‘profile’ OR ‘action plan’ OR ‘plan’ OR ‘program’ OR ‘program’ OR ‘service’ OR ‘system’ OR ‘surveillance’. We followed PRISMA guidelines and quality ratings for document selection. We scanned 112 documents and reviewed 31 in detail. These documents included international laws and regulations, WHO and ILO documents, country profiles, relevant articles, and national surveys.

To analyze the included documents, we used the content analysis method [18] allowing us to extract NPOSH indicators from open coding, NPOSH domains from axial coding, and NPOSH types through selective coding based on WHO health system monitoring and evaluation indicators [19]. Thematic analysis was used, wherein NPOSHindicators were extracted through open coding of themes and domains from axial coding. Subsequently, indicators and domains were categorized based on the WHO’s health system monitoring and evaluation indicators [19].

IRANOSH study

Based on data availability, a preliminary face-to-face focus group discussion was facilitated by the Ministry of Health and Medical Education (MOHME) involving 10 OSH experts. The discussion was conducted with informed consent and lasted approximately three hours, during which the NPOSH indicators were customized for Iran (IRANOSH). Quantitative data to developIRANOSH (nationalized version of NPOSH) was collected from the MOHME portal based on an inspection checklist (Table 1).

Table 1.

Summary content of the inspection checklist and MOHME portal

Section Summary content
General and geographical workplace specifications Name of industry (or service), location, type of ownership, type of industry, category of activity or occupations, type of product or service, type of industry, number of employees by sex, and work shift
Occupational health services Type of occupational health organization, type of health care workers, occupational examination, exposure assessment, training, and consulting services
Health facilities and equipment Access to healthy drinking water, sink, dressing room, bathroom, kitchen, dining hall, sewage and waste treatment system, first aid, eye wash, safety shower, personal protective equipment
Exposures Chemicals, noise, vibration, ionizing and non-ionizing radiation, lighting, heat stress, biological agents, ergonomic and mechanical risk factors
Control measures Engineering, administrative, procedural, and personal protective measures
Risk estimation The risk level of the workplace, harmful occupations
Recommendations Corrective and preventive advice for improvement
Anomaly reports General and occupational disease cases, health legal notices, referral to court
Inspection and health center information Demographics of inspector and supervisors, date, signatures, health system center, city, province
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From March 2019 to March 2020, 2,317 occupational health inspectors recorded data for 820,846 workplaces with 3,734,249 workers. Workplace selection was performed through stratified sampling. The sample of workplaces was taken from all 62 health networks across the country in proportion to the number of workplaces.In addition, worker and workplace data from the Iranian Statistics Center (ISC) on 23,813,045 workers and 1,997,261 workplaces from the 2017 census and updates until 2020 [20] were used. Descriptive statistics were applied to analyze the quantitative data using EXCEL software.

Additionally, a qualitative study was conducted through secondfocus group discussions, building on the quantitative findings of the previous phase.The aim was to prioritize challenges, identify areas for future research, and propose interventions, with a particular focus on the structure, organization, and OSH programs. Thesecond focus group discussions consisted of 24 senior experts from different backgrounds, including OSH experts (n = 8), managers from MOHME (n = 4), and other representatives (OSH inspector, occupational medicine specialist, Behgar, Behvarz, employer, and worker) from the country’s OSH system (n = 12).Four online focus groups were conducted via Adobe Connect and Skyroom, each lasting approximately two hours. MOHME facilitated the meetings. The sessions began with a presentation of the quantitative findings from the previous stage, followed by a discussion on the current and desirable state of the country’s OSH system. They concluded with semi-structured questions addressing the challenges and strategies related to OSH services in Iran. With the consent of the participants, the interviews were recorded and transcribed. The informed consent form clarified the confidentiality of participants’ identities and confirmed their awareness that the meetings were being recorded, transcribed, and accessible through executive reports or publications. The thematic analysis method was employed to analyze the transcriptions. This involved reviewing the texts multiple times in both a holistic and detailed manner to identify each segment that conveyed a specific meaning, which was then categorized into meaning units and organized into themes.

Trustworthiness of findings

The triangulation approach was used in the data gathering (literature review, focus group, inspection, and national data) and data analysis (descriptivestatistics and thematic analysis). In addition, data saturation, returning findings to experts to receive feedback, and checking peer review for the trustworthiness offindings [21].

Findings

NPOSH framework

Forty-six operational indicators related to NPOSH were identified and categorized into 10 domains: baseline information, structure and organization, human resources, financing, programs, service coverage and sustainability, intervention coverage, occupational exposures and risk factors, workers’ health status, and disease and economic burden. The indicators and domains were classified into six typesfrom an input-process-output perspective. Table S1 (see Additional file 1) presents types, domains, and indicators of the NPOSH framework, extracted from document review and experts’ perspectives. Sample indicator specification of the NPOSH framework is illustrated in Table S2 (see Additional file 1).

IRANOSH profile

Based on data availability and expert opinions, IRANOSH was customized into 44 indicators across 9 domains and 6 types: (1) input (including basic information), (2) process (including structure, plan and program, and human resource), (3) output(including service coverage and intervention coverage, (4) outcome (including risk factors), (5) result (including workers’ health status), and (6) impact (including the burden of disease (Table 2). This part of the study focuses on input and process indicators, including basic information, structure, programs, and human resourcesin the context of OSH services (Tables S2-S6, Supplementary Material).

Table 2.

Types, domains, and indicators of the National profile for occupational safety and health services (NPOSH) customized for Iran (IRANOSH)

Type Domain Indicators
1. Input 1. Basic information 1. Country Population
2. Population by economic activity
3. Active population in terms of employment
4. Workers categorized by main economic activity (ISIC)
5. Workers categorized by occupational group (ISCO)
6. Workers by place of residence
7. Workers by Gender
8. Workers by type of workplace ownership
9. Workers categorized by type of workplace
10. Workplaces categorized by economic activity
11. Workplaces categorized by population size
2. Process 2. Structure 12. Occupational safety and health (OSH) structure at the workplace
13. OSH companies
14. Occupational medicine center
15. General practitioner’s office with occupational medicine license
16. Occupational examination center at the workplace
3. Plan and programs 17. OSH targeted inspections
18. Occupational examinations
19. Measurement of harmful factors
20. Control of harmful factors in high-risk workplaces
21. Health for specific occupations
22. Difficult and hazardous occupations
23. Basic health services for governmental employees
24. Regulation and guidelines making
25. OSH services registry and sustainability
4. Human resources 26. OSH inspectors
27. Workplace OSH experts
28. Behgar (workplace primary healthcare worker)
29. Behvarz (rural primary healthcare worker)
30. Authorized general practitioners for occupational examination
31. Occupational medicine specialist
3. Output 5. Service coverage 32. OSH Inspection
33. Measurement of harmful factors at the workplace
34. Occupational medical examinations
35. Services sustainability
6. Intervention coverage 36. Access to healthcare facilities
37. Increasing the workers’ knowledge
38. Proper utilization of personal protective equipment
39. Controlling harmful factors in the workplace
4. Outcome 7. Risk factors 40. Workplace including risk of harmful factors
41. Workers at risk of occupational exposure
5. Result 8. Workers’ health status 42. Lifestyle and common diseases
43. Occupational diseases and injuries
6. Impact 9. Burden of disease 44. Burden of occupational diseases and injuries
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Input indicators: OSH basic information

According to ISC 2020 statistics (Fig. 2), the country’s population was approximately 80 million people, of which around 60 million (74%) lived in urban areas and around 20 million (25%) lived in rural areas. Around 40% of the country’s population were economically active, of which 80% were employed. Furthermore, 53% of the economically inactive population were housewives and 29% were students.

Fig. 2.

Fig. 2

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Input indicators of IRANOSH 2020: basic information of population (%)

According to Fig. 3, out of approximately 24 million workers in the country, 49% were active in the service sector, 32% in the industry sector, and 19% in the agriculture sector.

Fig. 3.

Fig. 3

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Input indicators of IRANOSH 2020: basic information -workers categorized by main economic activity

Additionally, out of the 24 million workers, approximately 80% of jobs were related to industrial, service, specialist, operator, simple worker, and technician occupations, and around 20% were related to agricultural, administrative, managerial, and other job groups (Fig. 4).

Fig. 4.

Fig. 4

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Input indicators of IRANOSH 2020: basic information - workers categorized by occupational group (%)

Figure 5 reveals that out of approximately 24 million workers in the country, 86% (approximately 20 million people) were active in the private sector and 14% (around 3.5 million people) were active in the executive and public sector. The findings showed that out of the 24 million working people in the country, 82% are men and 18% are women. Of these workers, approximately 73% were urban and 27% were rural.

Fig. 5.

Fig. 5

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Input indicators of IRANOSH 2020: basic information -workers categorized by gender, type of workplace ownership and place of residence (%)

Figure 6 also shows that workers in workplaces with an employee size of less than 20 constitute 39%, and workers in home workshops 2%.

Fig. 6.

Fig. 6

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Input indicators of IRANOSH 2020): basic information -workers employed in workplaces categorized by employee size (%)

According to Fig. 7, the quantitative findings of this study showed that out of all existing workplaces, those involving food and wholesale services, car and household appliance services, personal services, food services, and drinking and health-related services make up about 90%, while the remaining 10% were related to other major economic activities.

Fig. 7.

Fig. 7

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Input indicators of IRANOSH 2020: basic information -workplaces categorized by economic activity (%)

Figure 8 reveals that workplaces with fewer than 20 workers make up 90%, while workplaces with a population of 500 workers or more make up 0.1%. Small workplaces (under 20 workers and home workshops) accounted for 98% (including 40% of workers), and other medium and large workplaces together accounted for 2% of the workplaces in the country.

Fig. 8.

Fig. 8

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Input indicators of IRANOSH 2020: basic information -workplaces categorized by employee size (%)

Process indicators: OSH structure

Figure 9 shows thataccess to OSH services includes one OSH center at the workplace for every 154 workers and 33 workplaces. Approximately 95% of workplaces lack OSHstructure at the workplace, and only 5% have OSH structures including OSH committees (55%), worker health houses (23%), health stations (20%), and occupational health centers (2%). Workplaces with fewer than 25 workers are not required to establish an OSH committee.

Fig. 9.

Fig. 9

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Process indicators of IRANOSH 2020: structure– type of OSH structure at the workplace

Many experts emphasize that since most private sector employees work in small workplaces, and workplaces with lessthan 20 employees are not required to establish OSH structures or hire occupational health professionals, the entire burden of monitoring occupational exposures in small workplaces is imposed on occupational health inspectors. Some experts acknowledged that due to the number of workplaces and exposure diversity, inspectors have not succeeded in identifying exposures. They believed that even prioritizing inspections and classifying workplaces categorized 1, 2, and 3 risk groups have not addressed these supervisory deficiencies. Other experts believe that activating a self-assessment system by trad union officers for occupational health in small workplaces could partially compensate for deficiencies in service coverage and supervision in the private sector. For rural workers, the responsibility of monitoring exposures assigned to rural healthcare workers has been hindered by their lack of specialized training and multiple roles. All experts emphasize the importance of improving the OSH service delivery system and monitoring exposures in small workplaces. Some experts suggest that conducting research in this domain, leveraging global experiences with a national perspective, could provide valuable insights.

Figures 10 and 11 show that access to OSH services includes one OSH company for every 12,447 workers and 2,736 workplaces. Experts believe that OSH service companies are the most specialized organizations that provide occupational exposure assessment services. Although these companies have provided a quantitative assessment of job exposures, there are criticisms of the performance of these companies.Some experts emphasize the issues with how these companies measure exposure and argue that environmental assessments of harmful factors in workshops cannot be fully applied to occupational exposures. As a result, these measurements cannot be effectively incorporated into occupational medical exams or used as a basis for planning and assessing control measures.Access to OSH services includes one occupational examination center for every 3,404 workers and 748 workplaces.Experts consider the importance of linking occupational medical examinations to occupational exposure assessments. Some experts believe the examinations are not commensurate with exposures, and others noted a lack of guidelines based on occupational groups. Experts recommended stratifying service delivery, with exposure assessments by OSH specialists, followed by clinical and paraclinical examinations by trained general practitioners and referring suspected work-related cases to specialists. Redesigning the occupational examination and monitoring system was identified as a priority in focus group discussion.

Fig. 10.

Fig. 10

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Process indicators of IRANOSH 2020: structure - workplaces’ access to the OSH services (workplaces per one center / company)

Fig. 11.

Fig. 11

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Process indicators of IRANOSH 2020: structure–workers’ access to the OSH services (workers per one center / company)

Process indicators: OSH programs

Experts believe numerous OSH programs have been defined, including targeted inspections, occupational examinations, measurement and control of harmful factors, difficult and hazardous occupations, basic health services for governmental employees, health for specific occupations, regulations, and guidelinesmaking, and OSH servicesregistry and sustainability systems. Experts acknowledged that OSH programs focused on exposure assessment rather than exposure control.Programs of health forspecific occupations include carpet weavers, agricultural workers, waste management workers, and hospital safety and health. While affirming functioning, experts consider their efficiency and effectiveness ambiguous and subject to managerial preferences. The difficult and hazardous occupations program based on labor law has received criticism due to conflicting interests and a lack of a coherent evaluation system.Efforts have been made to develop guidelines covering government employees’ OSH within the basic service package, though they have not yet been implemented. Most experts were satisfied with guideline development like exposure limits, industry guides, and COVID-19 protocols, suggesting more specialized documents could be developed with medical universities. Some noted the lack of operational guidelines for legal provisions like supervision of equipment and personal protective equipment.

Occupational health inspections and occupational medical examinationservices are registered in a specific OSH informatic system, named SAMEH (Environmental and Occupational Health Center System, in Persian), and a public health informatic system, named SIB (Integrated Health System, in Persian). Experts pointed out the lack of registration systems for programs like difficult and hazardous occupations, exposure assessment, service provider accreditation, and information systems for laws and guidelines. Integration of registration systems across OSH inspection, exposure assessment, occupational medical examinations, and OSH surveillance was suggested, as well as integration with other health monitoring systems including cancer registriesand occupational cohort studies.

Process indicators: human resources

Figures 12 and 13 show the access of workplaces and workers to human resources providing occupational safety and health services. Access to OSH services includes one Behvarz (rural primary healthcare worker) for every 39 rural workplaces and 178 rural workers.Experts have recognizedthat integrating the country’s OSH services into PHC has improved rural workers’ access to trained Behvarzs in the field of OSH services. Access to OSH services also includes one workplace OSH expert for every 61 workplaces and 278 workers. Experts consider the success of this indicator to be relative, as it is linked to the legal capacity building of Article 93 of Iran’s Labor Law, which requires all workplaces with more than 25 workers to employ an OSH expert. Furthermore, access to OSH services includes one Behgar (workplace primary healthcare worker) for every 173 workplaces and 787 workers.Experts believe that Behgars who focus on PHC services at workplaces, canhelp address the lack of OSH human resourcesand improve workers’ health. Access to OSH services also involves one OSH inspector for every 354 workplaces and 1,612 workers. Most experts agree that the number of occupational health inspectors in the country is insufficient considering the volume of services and programs.Inspectionsareconsidered a crucial service in the OSH governance monitoring system, as the indicator of access to inspection services impacts the coverage of OSH services in workplaces and the monitoring of occupational exposures.Additionally, access to OSH services includes one authorized general practitioner for occupational examinations for every 970 workplaces and 4,414 workers.There is also one occupational medicine specialist for every 3,270 workplaces and 14,877 workers. Experts note that while access to general authorized practitioners for occupational examinations is low, it is better than access to occupational medicine specialists, as general physicians are more widely available across the country compared to specialists in occupational medicine.

Fig. 12.

Fig. 12

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Process indicators of IRANOSH 2020: human resources–workplaces’ access to the OSH care workers (workplaces per one care worker)

Fig. 13.

Fig. 13

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Process indicators of IRANOSH 2020: human resources–workers’ access to the OSH care workers (workers per one care worker)

Discussion

The IRANOSH quantitative analysis indicated that the target population of the OSH services was estimated to be around 34% of the country’s population with about 41% of workplaces and 15% of workers under the direct coverage of OSH services. According to the IRANOSH qualitative analysis, one of the reasons for not achieving the desired coverage is the lack of OSH inspectors and the underdeveloped infrastructure of the OSH systems. In Iran, a targeted inspection plan has been designed and implemented by categorizing workplaces (grades 1 to 3) based on occupational exposures. This allows for occupational health inspections to be carried out on workplaces with more dangerous exposures, including carcinogenic exposures [22]. All employed workers, self-employed workers, part-time employed workers, housewives, and students who are engaged in some kind of occupational exposure should be prioritized in the country’s research programs.

The IRANOSH quantitative analysis revealed that the priority of executive and research interventions should be based on the demographic distribution pattern of the workers and workplaces. Out of approximately 24 million workers, the majority were in the service sector (49%). The IRANOSH qualitative analysis suggested that the lack of attention to exposure in the service and agriculture sectors is due to underestimating exposure risks in these sectors compared to industry, and the lack of professional health organizations in the service and agriculture sectors. One reason to focus more on the exposure of the agricultural sector is that it is often a family business, with the entire family, including vulnerable groups like children and sometimes pregnant women exposed to occupational hazards. Reviving previous programs like Bagha (carpet weavers’ health plan) and agricultural work health, with a tripartite perspective and inter-sectoral cooperation and community-oriented initiative, is necessary for the full implementation of these regulations. Several studies have emphasized the risks and the need to pay more attention to OSH in agricultural workplaces [23–25] and services [22] as both an executive and research priority [23, 26].

The IRANOSH quantitative analysis showed that the majority of the working population was in the private sector. However, only a small percentage are directly covered by OSH inspection systems. The reason for not reaching the desired coverage is the lack of OSH inspectors. Previous studies have also highlighted this shortcoming and the need to target inspection [22]. A large portion of private sector workers are covered by trade union laws, and activating the OSH self-assessment system of trade unions can partially compensate for the shortcomings of service coverage and supervision in this sector. In recent years, focusing more on OSH in small workplaces has been an important priority of past studies [23, 27–31]. On the other hand, a small part of the workers are employed in governmental and publicsectors. However, the lack of integration of these services with the PHC system has hindered the full utilization of the OSH units in the public sector. Establishing the OSH system in line with the responsibility of public and governmental organizations has improved OSH indicators [32].

The qualitative analysis indicated that working women have been largely neglected in the country’s implementation and research programs, which primarily focus on industrial activities. It is essential to consider the physiological, psychological, and social differences between male and female workers in evaluating and controlling occupational exposures, as confirmed byfindingsof previousstudies [32, 33].

Furthermore, the IRANOSH quantitative analysis revealed that workers in small workplaces often have limited access to OSH services, making it crucial to prioritize them in interventions and research programs [34]. Previous studies emphasized the importance of addressing occupational exposures in smallworkplaces due to the nature of work and the vulnerability of the workers [35–37]. Based on qualitative findings, at each provincial health network, there is a regional health system through which PHC services are provided following a hierarchy down to health bases in cities and health houses in rural areas, with supervising inspectors in urban areas and healthcare workers in rural areas.The PHC system is one of the most successful health service delivery systems in the world [6, 38–41].Workplace OSHstructures have provided a platform for progressing the PHC system to almost all workers in workplaces with more than 20 employees.The PHC and OSH systemsin Iranhave proven to be effective in various fields, including the COVID-19 pandemic [31, 34].

According to quantitative findings, almost allworkplaces with more than 25 workers have at least one OSH structure and almost all small workplaces with less than 25 workers lack any OSH structure at the workplace. The most common OSH structure is the workplace OSH Committee. OSH Committee is an executive structure including representatives from workers, employers, and OSH graduated experts. This committee conducts at least one meeting monthly and is responsible for OSH interventions at the workplace. According to regulations, the responsibility for providing primary care and OHS services lies with health stations for workplaces with 20–50 workers, worker health houses for workplaces with 50–500 workers, and occupational health centers for workplaces with 500 or more employees [6, 22, 29].

According to qualitative findings, during COVID-19, health protocols were developed and implemented by workplace OSH structures. Medium and large workplaces with OSHstructures performed well in adhering to these protocols [31, 34].Large organizations and workplaces with access to OSH specialists and structures performed better in preventing COVID-19 compared to smaller workplaces [30].The pandemic assessed countries’ responses, health systems, and OSH organizations in workplaces worldwide [42].

The health, safety, and environment (HSE) units of governmental and public organizations have an impact on OSH indicators [32, 43].These HSE units operate independently from the PHC system in providing OSH services. MOHME has developed a guideline for basic health services for government employees, necessitated by the pandemic, leading to successful inter-sectoral collaborations [31, 34].

Most private sector employees work in small workplaces, where exposure recording, and supervision are conducted by inspectors due to a lack of OSH experts and structures. Previous studies highlighted the occupational health challenges in small workplaces [27, 29]. A targeted inspection system, prioritizing higher-risk workplaces, has addressed supervisory deficiencies in medium and large workplaces [22]. However, small workplaces may not be prioritized due to the workplace grading mechanisms and inspectors’ inability to accurately identify exposures during short inspections. Epidemiological studies have shown that these small business workers are exposed to high occupational exposures [8, 44, 45].

According to the current findings, workplace exposure assessmentprovided byOSH companies needs quantitative and qualitative improvement. They are the most specialized organizations providing occupational exposure assessment services to evaluate difficult and hazardous occupations as per regulations. While providing quantitative exposure assessments, criticisms exist regarding the quantity and quality of workplace exposure assessments conducted by OSH companies. Workplace exposure measurements cannot be generalized to occupational exposures or suitably used in occupational medical examinations or for specific control interventions. Annualexposure measurements instead of exposure control services are another deficiency. Previous studies identified the lack of OSH services in small workplaces as a challenge and intervention priority [27, 33].

Another OSH structure providing occupational health services is the authorized occupational medical examination centers. These centers are established to outsource services to the private sector and obtain operating licenses from the regional health system. They include occupational medicine centers, a general practitioner’s office with an occupational medicine license, and an occupational examination center at the workplace.While occupational examination centersfacilitate early diagnosis, criticisms exist regarding licensing and supervision processes leading to quantitative and qualitative deficiencies. The number of these centers is insufficient due to a shortage of occupational medicine physicians and obstacles in issuing licenses to general practitioners. Results from previous studies show that such limitations do not exist in developed countries like Italy [46], Germany [47], the United Kingdom [48], and the United States [49]. A study in the United States examined the qualifications of physicians practicing occupational medicine. The findings showed that 60% had occupational medicine certifications, and 68% had completed specialty board programs in other specialties [49].

In addition, limited authorized centers and high private-sector costs have hindered access to occupational medical examinations for underprivileged workplaces, especially small ones.A gradedreferral system for occupational medical examinations is proposed to address deficiencies. It involves (1) initial assessment of exposures by OSH experts or companies, (2) occupational medical examinations by trained practitioners based on the exposure assessment, (3) referral of suspected cases to occupational medicine physicians, (4) specialized medical examinations for diagnosed cases referred to the surveillance system, and (5) provision of therapeutic interventions, rehabilitation, and workplace corrections.

Redesigning the structures and procedures of occupational medical examinations aiming to achieve a surveillance system is essential. Establishing such surveillance systems has been a priority emphasized in previous studies [50] and the national health systems of countries such as Italy [46], Germany [47], and the United Kingdom [48] with emphasis on optimizing collaboration between specialists and improving mechanisms for occupational medical examinationsand healthcare services.

In Iran, human resources providing occupational safety and health services include OSH inspectors, workplace OSH experts, Behgar (workplace primary healthcare worker), Behvarz (rural primary healthcare worker), authorized general practitioners for occupational examination, and occupational medicine specialists. The findings indicate that Iran, like other countries, faces a shortage of human resources to provide OHS services.The lack of OSH professionals has been declared a global challenge by the WHO [51].The findings showed that while Iran has more OSH inspectors than the International Labor Organization’s recommendation of one inspector per 10,000 workers [52], the country has also implemented a trained OSH Behvarzs program. These Behvarzs serve as the primary service providers in rural workplaces, helping to address the shortage of inspectors and enhance workers’ health in those areas. Additionally, with Behgar’s initiative as a provider of PHC services in workplaces, Iran could somewhat overcome the lack of occupational health experts, especially in small workplaces. In Iran, access to OSH services includes one workplace OSH expert for every 61 workplaces and 278 workers. In England, only 7% of small and medium-sized workshops with less than 250 employees employed occupational health advisors, and 10% employed full-time or part-time occupational health nurses. In European countries, the ratio of occupational health nurses to workers varies from 1 to 500 to 1 to 5,000 workers [48]. Iran is facing a severe lack of access to authorized general practitioners (one for every 970 workplaces and 4,414 workers) and occupational medicine specialists (one for every 3,270 workplaces and 14,877 workers) for occupational examinations. In England, only 12% of workers have access to medical services and there are five occupational medicine specialists available per 100,000 workers [48].

Recommendation

The study proposes several practical initiatives based on both quantitative and qualitative findings. These include:

  • Enhancing current OSH services by adapting the existing IRANOSH framework for integration into national health systems.

  • Extending the PHC system to small workplaces and public organizations.

  • Revising guidelines to ensure that OSH companies’ services are focused on control-based exposure assessment.

  • Expanding OSH companies’ exposure assessment and control services to small workplaces through revising relevant guidelines.

  • Establishing an OSH self-monitoring and self-care system, involving active participation from trade unions, guilds, and small businesses.

  • Integrating HSE units in governmental organizations with the PHC network.

  • Considering the physiological, psychological, and social differences between male and female workers in evaluating and controlling occupational exposures.

  • Access to occupational examination centers needs quantitative and qualitative improvement.

  • Revising regulations governing OSH service providers and occupational medical examination centers, with a focus on controlling harmful factors and ensuring maximum coverage, especially in small workplaces.

  • Implementing regulations for OSH education, alongside the establishment of OSH training centers prioritizing small workplaces.

  • Improving the quality of OSH registration systems and participatory monitoring of occupational exposures in small and rural workplaces.

  • Revising the inspection system to increase coverage of small workplaces, and delegating exposure assessment tasks to the OSH committee.

  • Enhancing OSH services in small and rural workplaces.

  • Activating a self-assessment system for OSH services with a community-based approach could compensate for service coverage deficiencies in the private sector.

  • Integrating exposure assessment services with inspection systems, occupational examinations, interventions for difficult and hazardous occupations, and other exposure controls.

  • Redesigning operational and supervisory mechanisms for service delivery by OSH companies, including procedures, quality control systems, and supervisory systems.

  • Conducting master of occupational health courses for practitioners and implementing referral systems from authorized general practitioners to occupational medicine specialists to compensate for the lack of access to occupational medicine specialists.

Further research required

The study proposes several future research directions based on quantitative and qualitative findings. These include:

  • Redesigning the operational system for monitoring exposures and defining all operators and operations within a management process.

  • Preparating the OSH image of the country and planning to cover the entire active population of the country with a focus on service sectors, agriculture, small workplaces, self-employed workers, and part-time employed workers.

  • Customizing the NPOSH framework for other countrieswith various health system contexts would enhance the credibility of the findings for researchers and practitioners in promoting OSH services globally.

  • Updating this study and comparing current findings with other data sources will help validate the current findings.

Conclusion

The study outlines a protocol for the development of the NPOSH framework and tailors it for Iran (IRANOSH). A total of 44 IRANOSH indicators were identified and categorized into nine domains and six types. The IRANOSH quantitative indicators revealed thatmost workplaces have fewer than 20 workers. Small workplaces including those with fewer than 20 workers and home-based workshops, accounted for about 98% of all workplaces. The development of OSH services for small and agricultural workplaces was identified as a significant challenge and priority in Iran. The implementation of the OSH self-assessment system by trade unions could help address the gap in service coverage in small workplaces. Extending the PHC system to include OSH structures in public and governmental organizations could facilitate the advancement of OSH services.

The most important OSH programs in Iran include targeted inspections, occupational medical examinations, harmful factors monitoring and controlling, regulations and guidelines, and service registration and sustainability systems. The most important measure in the context of OSH plans and programs is revisingcountry OSH services based on the IRANOSH framework developed in this study and ensuring their sustainability through an integrated system synchronized with other PHC systems.

Based on inspection data, almost allworkplaces with more than 25 workers have at least one OSH structure and almost all small workplaces with less than 25 workers lack any OSH structure at the workplace.Workplace OSHstructures have provided a platform for progressing the PHC system to almost all workers in workplaces with more than 25 employees.The development of OSH services for small and agricultural workplaces was identified as a significant challenge and priority in Iran. The implementation of the OSH self-assessment system by trade unions could help address the gap in service coverage in small workplaces. Extending the PHC system to include OSH structures in public and governmental organizations could facilitate the advancement of OSH services. The most crucial intervention in the context of the OSH structure is extending the PHC system, including the OSHstructure, to guilds and governmental and public bodies.

The findings indicate that Iran, like other countries, faces a shortage of human resources to provide OHS services. Iran could somewhat overcome the lack of OSH human resources by Behvarzs (rural primary healthcare workers) for rural workplaces, Behgars (workplace primary healthcare workers) for small workplaces, and authorized general practitioners for occupational medical examinations.

The NPOSH framework and its indicators, as outlined in this study can be adapted for use in other countries. Since the information sources of the IRANOSH study were limited to the Iranian context, customizing the NPOSH framework for other countries with various health system contexts is recommended. Updating this study and comparing current findings with other data sources will help validate the current findings.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (22.9KB, docx)

Acknowledgements

This research was supported academically by the research deputy of the MOHME and Alborz University of Medical Sciences as part of the national program for establishing an occupational exposure registration system. We acknowledge the participation of occupational health experts from the MOHME’s center and the OSH experts and faculty members of the regional health systems. The authors are grateful for the constructive comments of Prof. Kazem Zendehdel and Prof. Ali Asghar Farshad.

Abbreviations

COVID-19

Coronavirus Disease 2019

HSE

Health, Safety, and Environment

ILO

International Labor Organization

IRANOSH

National Profile for Occupational Safety and Health Services in Iran

MOHME

Ministry of Health and Medical Education

NIOSH

National Institute for Occupational Safety and Health

NPOSH

National Profile for Occupational Safety and Health

OSH

Occupational Safety and Health

OSHA

Occupational Safety and Health Administration

PHC

Primary Health Care

WHO

World Health Organization

Author contributions

N. H.R., Y. Kh., and B. H. designed the study. N. H.R., Y. A., and Y. Kh. collected data. N. H.R. and Y. Kh. analyzed the data. N. H.R., Y. A., B. H., and Y. Kh drafted the manuscript. N. H.R., Y. Kh., and B. H. edited the manuscript, All authors reviewed the manuscript.

Funding

This work was supported academically by the Alborz University of Medical Sciences (IR.ABZUMS.REC.1400.033).

Data availability

All data generated or analyzed during this study are included in the text / additional file of this published article.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the Alborz University of Medical Sciences (IR.ABZUMS.REC.1400.033). All participants provided informed consent to participate in the study. The Helsinki Declaration rules were followed during research.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Disclaimer

The views expressed in this work are those of the authors and do not necessarily reflect the organizations with which they are affiliated or their sponsoring institutions or agencies. Where authors are identified as personnel of the International Agency for Research on Cancer / World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policies, or views of the International Agency for Research on Cancer / World Health Organization.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Supplementary Material 1 (22.9KB, docx)

Data Availability Statement

All data generated or analyzed during this study are included in the text / additional file of this published article.

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