Occupational exposure to cancer risk factors among health and social care workers in Europe: results from the Workers’ Exposure Survey

Abstract

Occupational exposure to cancer risk factors is an important avoidable cause of cancer. The European Agency for Safety and Health at Work (EU-OSHA) conducted a Workers’ Exposure Survey (WES) on cancer risk factors to increase knowledge on the prevalence and circumstances of exposure to 24 known cancer risk factors and on workplace prevention strategies in Europe. This manuscript focusses on the human health and social care work activities (HeSCare) sector, one of the largest occupational sectors in Europe. WES includes 24 402 telephone interviews from 2022 to 2023 on workers in Finland, France, Germany, Hungary, Ireland, and Spain. WES uses the Occupational Integrated Database Exposure Assessment System (OccIDEAS) where probable exposure to selected cancer risk factors during the last working week was automatically estimated based on workers’ answers to detailed sets of questions adapted to the EU context. There were 3041 workers affiliated with the HeSCare sector and almost two-thirds (65.3%) were female. A total of 29.5% of workers were probably exposed to one or more of the included cancer risk factors and 7.8% to two or more. The most common exposures among those considered were to ionizing radiation (7.4%), diesel engine exhaust emissions (6.2%), solar ultraviolet radiation (6.1%), formaldehyde (5.2%), and benzene (4.8%). The most frequent exposures estimated to occur at a high level in HeSCare were formaldehyde (2.3%) and ethylene oxide (2.0%). WES provides valuable sector-specific data about exposure to the most common cancer risk factors in occupational settings in Europe.

Introduction

Exposure to cancer risk factors at the workplace is an important European and global health issue [1]. The global burden of cancer due to 14 carcinogens was estimated to total 349 000 deaths, including 299 998 lung cancer deaths, for the year 2016 [2]. Among agents classified by the International Agency for Research on Cancer (IARC) as Group 1 carcinogens, a previous review noted that 47 were occupationally-relevant associated with 23 types of cancers and the number of established occupational carcinogens continues to increase [3–5]. Despite the importance of cancer risk factors at the workplace, there are significant knowledge gaps concerning the prevalence of exposure to cancer risk factors among workers in Europe, and worldwide.

In order to increase knowledge on the prevalence and circumstances of exposure to cancer risk factors in Europe, the European Agency for Safety and Health at Work (EU-OSHA) recently conducted a large-scale Workers’ Exposure Survey (WES) on current exposure to 24 cancer risk factors and on workplace prevention strategies using a web-based application for exposure assessment, the Occupational Integrated Database Exposure Assessment System (OccIDEAS) that was specifically adapted to the European Union (EU) work context [6–8]. WES included 24 402 total valid interview respondents representative of 98.5 million workers of six EU countries (Finland, France, Germany, Hungary, Ireland, and Spain) and is the first survey of its kind in Europe. Detailed information was captured from workers on tasks, exposure circumstances and use of protective measures to allow for estimation of probable exposure to cancer risk factors and level of exposure based on pre-defined algorithms. A total of 47.3% of workers in the overall WES were assessed to be exposed to at least one of the considered cancer risk factors in the last working week, with the most common exposures being solar ultraviolet (UV) radiation (20.8%), diesel engine exhaust emissions (DEE) (19.9%), and benzene (12.8%). Workers exposed to at least one cancer risk factor worked most often in sectors (Statistical Classification of Economic Activities in the European Community [NACE]) of manufacturing (NACE C) (14%), wholesale and retail trade (NACE G) (14%), and in human health and social work activities (NACE Q) (13%) [9].

This paper presents a descriptive account of findings from the first sectoral analysis of the WES among respondents in the human health and social work activities sector (NACE Q: HeSCare sector) [10]. The HeSCare sector is an essential sector and one of the largest in Europe providing employment to 11% of the total work force including over 21.6 million people [11]. Employment levels in the HeSCare sector have been steadily increasing over the past 10 years in the EU [12]. It includes three divisions: human health activities (NACEQ-86: Healthcare), residential care activities (NACEQ-87: Residential work), and social work activities without accommodation (NACEQ-88: Social work). It provides jobs in formal care settings such as hospitals, nursing and care homes, or medical practices, and also includes workers who provide care to individuals in their own homes. Workers in the HeSCare sector are exposed to a variety of work-related risk factors including carcinogens, which may often be overlooked as an important setting of exposure [6, 8].

Methods

WES is a cross-sectional telephone survey conducted from September 2022 to February 2023. A detailed description of the overall survey methodology is described elsewhere [7], as are findings of a prior feasibility study [13]. Briefly, this survey included workers from nearly all sectors of economic activity (covering both employees and self-employed, and excluding people working for private households), aged 15 years or more, residing and employed in the country of the study and speaking the main national language. The survey estimated worker exposure to 24 cancer risk factors relevant in the EU working context, that is, industrial chemicals, physical risk factors, process-generated substances and mixtures during the last working week (reference interview period) organized under the NACE statistical classification [7, 8]. Details on the selected cancer risks factors and criteria for inclusion in the survey are provided elsewhere [14–16]. All cancer risk factors were IARC classified Group 1 or 2A agents, already included in OccIDEAS, with relevant occupational exposures in the EU. Demographic and employment-related data was also captured.

The sampling strategy for the study was based on random digit dialling of mobile phones, oversampling occupations with expected exposure to the included cancer risk factors. Interviews were conducted by trained interviewers in the main national language of each country using a standardized questionnaire and lasted on average 16 minutes. Overall response rates varied and ranged from 7% in Ireland providing complete interviews up to 22% in Finland. Participant refusal ranged from 34% in both Finland and Spain to 54% in Ireland.

Exposure probability (categorized as ‘no’, ‘possible’, or ‘probable’) and semi-quantitative level of exposure (categorized as ‘low’, ‘medium’, or ‘high’ for those probably exposed) to the cancer risk factors included in the survey were automatically estimated for each worker using OccIDEAS, a previously tested web-based application using specific pre-defined exposure algorithms [17–20]. The underlying automatic exposure assessment uses input data from questionnaire responses by workers on job context and work tasks during the last working week, and are based on evidence from the published scientific literature including, where relevant, exposure measurements, and expert knowledge from occupational epidemiologists and hygienists in the six participating countries, who adapted the original Australian survey, questions, and exposure assessment algorithms to the EU work context and existing chemical legislation [7, 21]. Questions on protective measures were also harmonized throughout the survey. A detailed translation procedure was undertaken to translate the survey to all the main national languages of survey countries. The survey methodology was pilot tested from March to May 2022 [22].

Exposure assigned to each respondent takes into account reported use of preventive and control measures during the performance of specific tasks, for example, existence of ventilation systems or respiratory protection to derive final assessments. In terms of level of exposure, three categories (low, medium, high) were defined that relate with approximate EU occupational exposure limits (OELs) as follows: probable exposure, low level: exposure greater than the general community and < 10% of the OEL; probable exposure, medium level: exposure from 10% to 80% of the OEL; and probable exposure, high level: exposure near the OEL. When exposure to a cancer risk factor occurred through different tasks for a given respondent, the highest exposure level was assigned.

Statistical analyses were performed using R statistical software version 4.1.2 [23]. Unweighted survey data are provided for descriptive information regarding respondent characteristics, whereas survey findings regarding occupational exposures, circumstances of exposure, and prevention measures are presented as weighted data, accounting for socio-demographic structure, the total working population of each included country, and ownership of multiple mobile phones [7]. For group comparisons, Chi-squared tests were used for categorical variables and Student’s t-tests for continuous variables. Statistical significance was determined using a 5% significance level.

WES was conducted in accordance with applicable European laws, regulations, and guidelines for protection of natural persons with regard to the processing of personal data (Regulation (EU) 2018/1725).

Results

Among the overall WES sample of 24 402 workers, 3041 (12.5%) were working in the HeSCare sector, with the majority in the healthcare division (n = 2478, 81.5%), followed by residential care then social work (Table 1). The majority of HeSCare respondents were from Germany followed by Finland, Hungary, France, Spain, and Ireland. The job categories, as defined by WES, reported in the HeSCare sector included predominantly health workers (91.3%), with laboratory workers/chemists, food workers, office workers, and cleaners representing a smaller percentage (Table S1). The specific work tasks most often reported in the sector included sterilizing equipment (18.8%) and driving or maintaining vehicles as part of work (18.2%), followed by cleaning hands, working outside during the day, medical radiation, and working in a pathology or a gross anatomy laboratory (Table S1). Workers in residential care and social work reported more often driving or maintaining vehicles as well as working outside than in healthcare work.

Table 1.

Characteristics of HeSCare sector workers included in the study overall and by division, unweighted data

	Total health and social care sector	Healthcare division	Residential care division	Social work division
n	3041	2478	329	234
Age (%)
≤24 years	2.5	1.7	7.0	5.6
25–34 years	20.7	21.1	17.0	21.4
35–44 years	26.1	26.5	27.4	20.1
45–54 years	28.7	29.1	24.9	29.9
55–64 years	19.5	19.2	20.7	20.9
65+ years	2.4	2.4	2.7	2.1
Missing/other	0.1	0.0	0.3	0.0
Sex (%)
Male	34.5	38.7	17.3	14.5
Female	65.3	61.2	82.7	85.1
Missing/other	0.2	0.1	0.0	0.4
Country (%)
Germany	34.2	38.1	19.5	13.7
Finland	24.0	17.8	44.1	62.0
Hungary	15.9	16.6	14.3	11.1
France	11.5	12.3	10.6	3.8
Spain	8.3	8.9	6.7	3.8
Ireland	6.1	6.3	4.8	5.6
Country of birth (%)
Reporting country	87.1	87.3	83.3	89.7
Another EU state	5.4	5.4	6.7	4.3
Outside EU	7.5	7.3	10.0	6.0
Contract type (%)
Unlimited	75.1	74.2	79.4	79.0
Limited	8.6	7.4	15.0	12.7
Self employed	15.3	17.7	3.3	7.0
Missing/other	1.0	0.7	2.3	1.3
Company size (number of workers) (%)
1	7.1	6.8	4.0	14.1
2–9	26.3	25.8	24.3	34.2
10–49	35.6	32.3	59.6	37.7
50–249	20.9	23.3	10.6	9.8
≥250	9.3	11.0	0.6	3.8
Do not know/refused	0.8	0.8	0.9	0.4
Working hours (per week) (%)
≤20	4.6	4.2	5.5	7.3
21–30	14.9	15.1	13.7	14.1
31–40	61.3	59.8	66.0	71.4
41–50	13.4	14.8	10.0	4.3
>50	3.4	3.6	2.4	2.6
Do not know/refused	2.4	2.5	2.4	0.3

Approximately two-thirds of workers in the HeSCare sector were female (65.3%), increasing to 85.1% for the social work division. Most of the workers in the sector were born in the reporting country (87.1%), with the remainder born in another EU member state or outside of the EU. A total of 75.1% of workers were employed with a contract of unlimited duration, 15.3% were self-employed, and 8.6% were employed with a contract of limited duration. By sex, there was a tendency for a higher proportion of female workers with a contract of unlimited duration (HeSCare: 76.0%) compared with male workers with a similar contract type (HeSCare: 67.2%). There was also a higher proportion of male workers who were self-employed (HeSCare: 22.2%) than self-employed female workers (HeSCare: 11.1%). The majority of workers were working in small companies ranging from 2 to 9, 10 to 49, or 50 to 249 workers, with social workers tending to work more often alone or in companies of smaller size. The majority of workers in HeSCare (61.3%) were working between 31 and 40 hours per week with a mean (SD) of 37.7 (9.3). By division, workers working 31–40 hours per week ranged from 59.8% in healthcare to 71.4% in social work.

In total, 29.5% of HeSCare workers were probably exposed to at least one cancer risk factor during the same working week, with males having a greater prevalence of exposure than females (35.7% vs. 26.1%, P < .001). A total of 21.7% of workers were assessed to be exposed to only one of the studied cancer risk factors and 7.8% were exposed to two or more cancer risk factors. In the healthcare division, findings were similar with 28.0% probably exposed to at least one cancer risk factor (34.3% males vs. 24.3% females, P < .001), with 20.6% exposed to only one of the studied cancer risk factors and 7.4% to two or more.

Prevalence of exposure was defined as the proportion of respondents assessed as being exposed to at least one of the included carcinogens in their current job during the last working week, regardless of frequency, duration, or level of exposure. The most common carcinogen exposure in the HeSCare sector, among those included in WES, was ionizing radiation with 7.4% of workers probably exposed (Fig. 1; Table S2). DEE emissions and solar UV radiation were also more common exposures with 6.2% and 6.1% of workers exposed respectively, followed by formaldehyde, benzene, ethylene oxide, respirable crystalline silica (RCS), and artificial UV radiation. The most frequent exposures estimated to occur at a high level in HeSCare were formaldehyde (2.3%) and ethylene oxide (2.0%) and at a medium level solar UV radiation (3.7%) and RCS (1.4%). The remainder of exposures were categorized as predominantly occurring at a low level. The most common combination of exposures co-occurring during the same working week in the HeSCare sector included DEE emissions and solar UV radiation, ethylene oxide and formaldehyde, and ionizing radiation and artificial UV radiation. Differences in overall exposure by sex were small but statistically significant for most cancer risk factors, with males more often probably exposed than females for ionizing radiation, DEE emissions, solar UV radiation, formaldehyde, and RCS.

Figure 1.

Proportion of workers probably exposed to cancer risk factors included in WES, by level of exposure (% of all workers in the sector) in the HeSCare sector. Weighted data. Cancer risk factors with at least 30 exposed workers overall are considered here.

Findings were generally similar in the healthcare division to those in the HeSCare sector overall (Fig. 2; Table S3). The most common exposures in the healthcare division were ionizing radiation, formaldehyde, and DEE emissions. The most common exposures in the residential care division were solar UV radiation (14.7%) and DEE emissions (9.1%), whereas in social work, they were solar UV radiation (19.5%), benzene (19.3%), and DEE emissions (18.0%).

Figure 2.

Proportion of workers probably exposed to cancer risk factors included in WES, by level of exposure (% of all workers in the sector) in the healthcare division. Weighted data. Cancer risk factors with at least 30 exposed workers overall are considered here.

Work circumstances that led to probable exposure in the HeSCare sector to ionizing radiation included working with or near machines that used X-rays for purely diagnostic purposes, driving or maintaining vehicles for DEE emissions, working outside during the day in a vehicle with the window down for solar UV radiation, working in a gross anatomy laboratory for formaldehyde, fuelling a vehicle with petrol for benzene, sterilization usage for ethylene oxide (including 55.2% at a high exposure level), and manufacturing crowns, false teeth or bridges for RCS (Table 2). For formaldehyde exposure, using formaldehyde or formalin for sterilization and handling specimens/waste preserved in formaldehyde had a greater proportion exposed at a higher level (29.1% and 12.5%, respectively).

Table 2.

Circumstances of exposure to cancer risk factors included in WES in the HeSCare sector overall and by level of exposure, weighted data

Exposure circumstances	% of exposed workers performing task
	Total (any exposure level)	Level of exposure
		Low	Medium	High
Ionizing radiation
Working with or near machines that used X-rays for purely diagnostic purposes	55.9	42.2	12.0	1.7
Working with radioisotopes or caring for patients who received radioisotopes	37.1	23.2	10.1	3.8
Working with or near machines that used X-rays for interventional radiography	26.3	16.3	9.0	1.0
Administering radiotherapy, such as brachytherapy	17.5	8.8	6.6	2.1
Diesel engine exhaust emissions
Driving, maintaining, or travelling in diesel-powered vehicles	99.9	89.6	9.0	1.3
Solar UV radiation
Working outside during the day in a vehicle with the windows down at least 1 hour/day	42.2	17.9	24.3	0.0
Working outside during the day in the open	39.4	2.7	34.8	1.9
Working with or near reflective surfaces	36.5	9.5	24.8	2.2
Working outside during the day under partial shade at least 1 hour/day	23.4	12.1	11.2	0.1
Formaldehyde
Working in a gross anatomy laboratory	37.9	13.0	20.3	4.6
Using formaldehyde or formalin for sterilization	36.7	0.6	7.0	29.1
Handling formaldehyde, specimens preserved in formaldehyde solution (formalin) or waste containing formaldehyde	29.3	4.7	12.1	12.5
Benzene
Fuelling a vehicle with petrol	89.1	87.4	0.0	1.7
Ethylene oxide
Using ethylene oxide gas for sterilization	66.6	2.4	9.0	55.2
Respirable crystalline silica
Manufacturing crowns, false teeth or bridges	75.1	0.2	54.1	20.8
Artificial UV radiation
–	–	–	–	–

Findings for exposure circumstances are presented where there are at least 30 respondents at any level of exposure reporting the particular task.

For exposure to ionizing radiation, the use of protective measures was common across exposure circumstances (Table 3). Use of radio-protective shields ranged from 77.9% for administering radiotherapy, such as brachytherapy to 85.0% for working with or near machines that used X-rays for purely diagnostic purposes. For solar UV radiation, use of protective measures was generally common across most exposure circumstances, with the exception of working with or near reflective surfaces where 58.6% did not report use of any of the protection measures asked. Wearing clothing that covered most of the body ranged from 81.5% to 99.7% by exposure circumstance, whereas wearing sunglasses, sunscreen, or a hat was less commonly reported. For formaldehyde, use of a laboratory fume hood was most commonly reported when handling specimens/waste preserved in formaldehyde, while those working in a gross anatomy laboratory or using formaldehyde for sterilization most commonly reported presence of general ventilation system. A total of 64.5% of workers exposed to ethylene oxide gas for sterilization reported use of some protection measure, most commonly general or local ventilation systems. For RCS, 95.9% of respondents reported use of some protection measure, most commonly local ventilation or work in an enclosed box or system.

Table 3.

Self-reported specific personal protective practices according exposure circumstance in the HeSCare sector for exposure to (a) ionizing radiation, (b) solar UV radiation, (c) formaldehyde, (d) ethylene oxide, and (e) respirable crystalline silica, weighted data

a) Ionizing radiation
Exposure circumstances	Protection measures
	Radio-protective shields (%)	Radio-protective garments (%)	Working at 2 meters or more from the radiation source (%)	None of the protection measures asked (%)
Working with or near machines that used X-rays for purely diagnostic purposes	85.0	67.0	7.6	3.0
Working with radioisotopes or caring for patients who received radioisotopes	83.6	86.5	N/A	5.8
Working with or near machines that used X-rays for interventional radiography	84.6	87.4	N/A	1.5
Administering radiotherapy, such as brachytherapy	77.9	85.5	N/A	12.1

b) Solar UV radiation
Exposure circumstances	Protection measures
	Wearing sunglasses (%)	Wearing clothing that covered most of your body (%)	Wearing sunscreen (%)	Wearing a hat or other sun protection head cover (%)	None of the protection measures asked (%)
Working outside during the day under partial shade at least 1 hour/day	24.6	81.5	12.5	32.5	8.4
Working outside during the day in the open	14.9	99.7	9.9	25.4	0.2
Working with or near reflective surfaces	41.4	N/A	N/A	N/A	58.6
Working outside during the day in a vehicle with the windows down at least 1 hour/day	48.3	93.5	12.5	N/A	6.2

c) Formaldehyde
Exposure circumstances	Protection measures
	Local exhaust ventilation or on-tool extraction (%)	Lab fume hood, a fume cupboard, a multiple slot hood, or a ventilated bench (%)	General ventilation system (%)	Rubber face mask fitted with a particle/vapour filter or cartridge (%)	Powered air-purifying respirator (PAPR) (%)	Air-supplied respirator or SCBA (self-contained breathing apparatus) (%)	None of the protection measures asked (%)
Working in a gross anatomy lab	34.4	N/A	65.4	2.7	8.0	2.4	13.7
Using formaldehyde or formalin for sterilization	19.7	N/A	65.0	3.1	13.2	0.0	18.8
Handling formaldehyde, specimens preserved in formaldehyde solution (formalin) or waste containing formaldehyde	N/A	63.0	N/A	5.5	5.2	18.2	27.3

d) Ethylene oxide
Exposure circumstances	Protection measures
	Use of local exhaust ventilation or on-tool extraction (%)	Use of general ventilation system (%)	Use of rubber face mask fitted with a particle/vapour filter or cartridge (%)	Use of a powered air-purifying respirator (PAPR) (%)	Use of an air-supplied respirator or SCBA (self-contained breathing apparatus) (%)	Specimens or waste in sealed containers when not in use (%)	None of the protection measures asked (%)
Using ethylene oxide gas for sterilization	31.6	63.1	4.0	9.5	6.5	15.2	35.5

e) Respirable crystalline silica
Exposure circumstances	Protection measures
	Enclosed box or system (%)	Use of local exhaust ventilation or on-tool extraction (%)	Use of rubber face mask fitted with a particle/vapour filter or cartridge (%)	None of the protection measures asked (%)
Manufacturing crowns, false teeth/bridges	72.0	83.8	2.8	4.1

Findings for personal protective practices are presented where there are at least 30 respondents at any level of exposure reporting the particular exposure circumstance. N/A denotes that the question was not asked to the workers in the survey in the given circumstance of exposure.

Discussion

This study presents the prevalence of exposure to major occupational cancer risk factors among workers of six EU member states in HeSCare, a key sector of economic activity in Europe. Overall, 29.5% of workers in HeSCare were assessed as being exposed during the last working week to at least one cancer risk factor considered in the survey, with exposures being somewhat more common among male (35.7%) than female workers (26.1%). A total of 7.8% of workers overall were exposed to multiple cancer risk factors (two or more), with an overall higher prevalence among male than female workers (10.5% vs. 6.4%, respectively). Exposure to specific cancer risk factors ranged from 2.5% for artificial UV radiation to 7.4% for ionizing radiation in HeSCare. The most frequent exposures estimated to occur at a high level were formaldehyde (2.3%) and ethylene oxide (2.0%), and at a medium level solar UV radiation (3.7%) and RCS (1.4%).

In comparison, findings from the overall WES sample, including workers from all sectors of economic activity, reported a higher prevalence of exposure to at least one cancer risk factor in the last working week of 47.3% compared to 29.5% of workers in the HeSCare sector reported here [6, 8]. Workers in the overall WES sample also had a higher prevalence of exposure to two or more cancer risk factors, at 26.1% compared with 7.8% here. The most common exposures with any level of exposure in the overall WES were solar UV radiation (20.8%) and DEE emissions (19.9%), whereas RCS and wood dust had greater proportions of workers probably exposed at a high level in the overall WES.

An early study estimated that approximately 32 million workers, or 23% of those employed in the EU, were exposed to at least one cancer risk factor (including IARC Group 1 and 2A agents as well as some Group 2B agents) in occupational settings, with workers on average simultaneously exposed to 1.3 carcinogenic agents at a time [24]. For workers in medical, dental, and other health service industries more specifically, it was estimated there were 730 000 exposed workers among 8 200 000 employed [24]. Estimates were based upon national labour force data and estimates of exposure prevalence from Finland and the USA refined by national experts. In Costa Rica, it was estimated there were 16 035 exposed workers among 43 320 employed in the medical, dental, and other health service sector with DEE emissions among the most prevalent [25]. More recently in Canada, it was estimated there were 468 000 workers in the healthcare and social assistance industry exposed to cancer risk factors among 1 716 000 employed, with night shift work, antineoplastic agents, and ionizing radiation being the most common [26].

Findings from the Australian Work Exposures Study (AWES), performed in 2011–2012 based on the total working population with exposure estimated using OccIDEAS, reported that 38% of 1879 total worker respondents were probably exposed to cancer risk factors in their current job with 31% exposed to multiple cancer risk factors [17]. In AWES, there were 38 included IARC Group 1 or 2A agents, compared with the 24 covered by WES. The most frequent exposure was solar UV radiation (34.8% males, 6.2% females) followed by DEE emissions (28.8% males, 5.7% females). Health professionals in AWES were among the most common occupational groups estimated to be occupationally exposed to ionizing radiation among both male and female workers, whereas female health professionals and health support workers were among the most common occupational groups exposed to formaldehyde and ethylene oxide.

In the New Zealand carcinogens survey, conducted in 2021, including over 50 IARC Group 1 or 2A carcinogens, it was reported that 57.5% were probably exposed to at least one cancer risk factor in their current job, including 28.0% at a high level [27]. Males were also more likely to be exposed (67.1%) than females (46.8%) to at least one carcinogen in the survey overall, as well as to multiple carcinogens. In industry-specific analysis, 54.9% of 603 workers in the healthcare and social assistance industry were exposed to at least one carcinogen, with an average number of exposures of 1.9. The most frequent exposures in healthcare and social assistance were benzene (23.6%), solar UV radiation (18.5%), and shiftwork (17.5%). Although shift work was not examined here, the WES infrastructure is flexible and could be expanded to include other cancer or health risk factors of interest [6, 8, 15].

Common co-exposures in HeSCare included DEE emissions and solar UV radiation. This was also common in the overall WES sample; followed by benzene and DEE emissions; and benzene and solar UV radiation [6]. However, exposure to multiple cancer risk factors may not necessarily have occurred at the same time (the assessment period of WES was the last working week) or through the same work process. In the New Zealand survey, DEE emissions and solar UV radiation were also common co-exposures [27].

A main strength of the present study was the use of a specific task-based worker questionnaire and the OccIDEAS tool to determine individual exposure probability to cancer risk factors. The workers were asked to report a range of common tasks they carried out during the last working week, on the basis of their actual occupation, and exposure assessments were based on the information collected. Therefore, there may be less potential for misclassification bias than where exposure is attributed solely from self-report or from where exposures are assigned to job titles without consideration of performance of specific tasks [20, 28]. The specific task-based approach also allowed the detailed investigation of use or availability of control measures in the workplace, and therefore suggest potential areas for greater worker protection.

However, exposure assessment to cancer risk factors here needs to be interpreted in light of the pre-defined cancer risk factors considered in WES, which is likely an underestimation of cancer risks faced by workers. There are other known and suspected carcinogens not covered by WES [3]. Indeed, a limitation in this particular sector is that HeSCare workers may be occupationally exposed to hazardous medicinal products, for example, some of which are known human carcinogens, such as some antineoplastic drugs used for chemotherapy which may accidentally expose workers along the drug life cycle in a facility, from production to patient administration [29, 30], and for which often best practices for safe management in the workplace may not be in place [31, 32].

The period of time covered by the data collection for each worker in the study of the past working week is relatively short and may not be fully representative of exposures encountered by workers over a longer period. Additionally, the survey was largely conducted over fall and winter months, from September 2022 to February 2023, and as such estimation of exposure to cancer risk factors that may be influenced by seasonal patterns in exposure circumstances or protective measure use, such as solar UV radiation, for example, may be impacted here. Information on job duration or task frequency was also not captured. Exposure assessments were based on self-reports, which could potentially be influenced by social desirability constraints (e.g. underreporting or overreporting some tasks or behaviours including use of protective equipment at work), leading to some information bias. However, the survey referred to practices during the previous working week which may limit the potential for recall bias given the short time frame for recall. There was also no information captured regarding appropriate use of protective measures or of their maintenance. The survey was conducted during the COVID-19 pandemic time period, which may have also impacted performance of specific tasks and exposure circumstances captured in the HeSCare sector. In particular, typical patterns of usage of ventilation systems, respiratory personal protective equipment, or filtering facepieces may have been be altered, although the extent to which this may impact specific exposure circumstances here, or use or reporting of specific personal protective practices relevant to exposure estimation here is unclear.

Although more than 3000 WES survey respondents were classified as HeSCare workers, the available sample size remains limited to further investigate exposure to cancer risk factors and estimated levels of exposure at the division level (particularly in residential care or social work) or among individual survey countries. The HeSCare sector is large and diverse which also limits our ability to make inferences regarding specific occupations in the sector or to make comparisons between specific included occupations. Response rates were low, as has been observed in other European studies over time, despite application of a variety of measures including call strategy patterns and fieldwork monitoring here [7, 33]. Survey weights were applied in analysis in order to account for representativeness of respondents according to socio-demographic features and the working population of the included study countries.

The findings of this study provide information regarding exposure to carcinogenic agents in EU workplaces and in particular here in the sector of HeSCare. Additionally, results show that exposures may also occur in combination and point towards some sex differences in exposure. By providing granular information on current work practices and identifying specific exposure circumstances, results offer novel information to inform the development and adoption of more targeted, task-specific preventive measures and support occupational cancer prevention in Europe.

Supplementary data

Supplementary data are available at EURPUB online.

Conflict of interest: The authors declare no conflicts of interest.

Funding

The WES was funded by the European Agency for Safety and Health at Work (EU-OSHA). M.C.T. is funded by a Ramón y Cajal fellowship (RYC-2017-01892) from the Spanish Ministry of Science, Innovation and Universities and co-funded by the European Social Fund. ISGlobal is a member of the CERCA Programme, Generalitat de Catalunya. We acknowledge support from the Spanish Ministry of Science and Innovation through the ‘Centro de Excelencia Severo Ochoa 2019-2023’ Program (CEX2018-000806-S), and support from the Generalitat de Catalunya through the CERCA Program.

Data availability

The full WES questionnaire and dataset are available for research purposes at: https://doi.org/10.7802/2818.

Ethics statement

This article has been produced based on the results of a study that was commissioned by the European Agency for Safety and Health at work (EU-OSHA). The WES was conducted in accordance with applicable laws, regulations, and guidelines in Europe for protection of natural persons with regard to the processing of personal data (Regulation (EU) 2018/1725).

Disclaimer

This article, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect the views of EU-OSHA.

Key Points.

• Occupational exposure to cancer risk factors is an important avoidable cause of cancer.

• There are significant knowledge gaps concerning the current prevalence of occupational exposure to cancer risk factors among workers in Europe.

• We present findings from the first sectoral analysis of the European Agency for Safety and Health at Work (EU-OSHA) Workers’ Exposure Survey on cancer risk factors (WES) among workers in the human health and social work activities sector.

• Information regarding the prevalence of exposure to specific cancer risk factors and level of exposure is provided, as well as circumstances of exposure and preventive measures as reported by workers.

• Findings provide novel information to inform occupational cancer prevention in Europe.