8

Standards for Communicating with and Educating End Users

Key Messages from Individual Speakers¹

• A bedrock principle at OSHA is that employers have the ultimate responsibility to communicate with and educate their workers because they are the ones who both choose and purchase PPE and study the policies and regulations pertaining to PPE. (Levinson)
• If the goal is to protect members of the public, new products could be investigated, including those that do not require fit testing and medical clearance for proper use, are more comfortable to wear, and are intuitive to use. (Coefield)
• Employers could be incentivized to provide PPE, proper training, and accommodations. If proper PPE and the services of community health workers could be made available to employers at low cost, workers would have access to proper PPE and training provided from trusted communicators from their community. (Guild)
• There is a gap in robust, consistent education programs, delivered by trusted sources, on why PPE is important, and how to don and doff it properly, as well as proper fit testing and medical evaluations. (Guild, Royal)

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¹ The following list of key messages is the rapporteurs’ summary of points made by the individual speakers identified, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect a consensus among workshop participants.

• Given the diversity of the health care workforce, equity is important in the distribution and availability of PPE along with training and education from trusted sources. (Royal)

The last stop in the supply chain is the end user, and the final session in the series following the components of the supply chain focused on the standards pertaining to communicating with and educating those who use personal protective equipment (PPE) and personal protective technology (PPT). The panel examined how standards and guidance can be different for and have different effects on workers in occupational settings versus members of the general public. In remarks to introduce the session, Amrita John, critical care and infectious disease physician at University Hospitals Cleveland Medical Center, pointed out that the National Strategy for a Resilient Public Health Supply Chain Task Force² noted a need for technological advances, including developing training apps, to aid in PPE use and education. The task force also raised the need for collaboration and coordination with employers to protect workers. Carolyn Sheridan, founder and executive director of the Ag Health and Safety Alliance, added that equity issues play a critical role in ensuring that underserved populations have affordable and accessible PPE and understand how to use it properly to keep them safe.

THE RESPONSIBILITY OF EMPLOYERS, GOVERNMENT, AND THE MEDICAL COMMUNITY

Andrew Levinson, director for the Directorate of Standards and Guidance at the Occupational Safety and Health Administration (OSHA), said that OSHA communicates with both employers and workers, with each requiring a different focus and each presenting with their own set of challenges. However, he added, a bedrock principle at OSHA is that employers have the ultimate responsibility to communicate with and educate their workers because they are the ones who choose the PPE, purchase the PPE, and study the policies and regulations pertaining to PPE. Moreover, employers are OSHA’s main communication and education target because that is where the agency’s responsibility lies given its regulatory and enforcement mandates.

During the COVID-19 pandemic, said Levinson, there were real challenges as the science was evolving as to whether droplet or airborne transmission was responsible for spreading the SARS-CoV-2 virus and which mode of transmission was of greatest concern and in which settings. One

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² Additional information is available at https://aspr.hhs.gov/newsroom/Pages/SupplyChain-9Mar2022.aspx (accessed May 2, 2023).

complicating factor was that the approach to communicating about PPE changes if transmission is occurring via droplets or aerosol. For example, comparing the ASTM F2100 standard for surgical masks (ASTM, 2023) to the new ASTM F3502 standard for barrier face coverings (ASTM, 2022), ASTM F2100 has more variability in filtration and makes no attempt to address fit because it is concerned with droplet-transmissible diseases and not a disease transmitted by aerosol. “All of these things complicate the way that you explain to people why they are wearing certain PPE and how to use it effectively,” said Levinson. Levinson also said that coordinating agency recommendations created significant complications with communication and education efforts around PPE. He said that a review of the literature shows there is tremendous variability in the filtering capacity of surgical masks that meet the Food and Drug Administration’s (FDA’s) 510(k) approval process and that also satisfy the ASTM F2100 standard.

Another challenge during the pandemic was the strong desire for there to be one U.S. government voice on COVID-19 recommendations. Getting alignment among OSHA, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the National Institute of Occupational Safety and Health (NIOSH) took time, said Levinson. In addition, the medical, epidemiological, industrial hygiene, and occupational safety and health communities looked at and communicated about these issues in fundamentally different ways. “There are some institutional biases in the way that people approach problem solving,” said Levinson, “and that dramatically affected the communication and recommendation efforts.”

Problems with the supply chain also affected agency recommendations and communication. Levinson noted the tension between relying solely on health-based information when recommending PPE and considering the feasibility of those recommendations being followed. For example, NIOSH does not consider the feasibility of implementing its recommended exposure limits (RELs) pertaining to chemical exposure, resulting in more conservative exposure levels, whereas OSHA’s permissible exposure limits (PELs) often allow higher chemical exposure levels because considering the feasibility of implementing any recommendations is required by law. Making recommendations that were not feasible given the limited supplies of PPE could lead to public frustration or trigger a surge for limited PPE that would exacerbate shortages. Levinson continued that supply chain issues, the ongoing confusion about KN95 respirators, other countries’ respirator standards, the discovery of counterfeit KN95 respirators, and discovering that many KN95 respirators were delivered with ear loops rather than head straps created other complications for OSHA, NIOSH, and FDA as these agencies were trying to calibrate their recommendations in the changing landscape.

At the start of the pandemic, OSHA took a compliance assistance approach, recognizing that people were trying to understand and deal with an evolving and emerging situation. Over time, OSHA shifted to more of an enforcement approach, but as Levinson explained, focusing on voluntary guidance versus regulatory requirements during an emergency does not always involve a clear and simple communication effort. The initial stages of the pandemic also saw countless recommendations on how to make masks at home. OSHA does not consider homemade masks to be PPE under its standards because such devices were not designed or manufactured to a standard and thus do not provide a known minimum level of protection.

One challenge that arose during the pandemic related to OSHA’s Respiratory Protection Standard is that the standard does allow employers to prohibit voluntary use of respirators by workers as respirators sometimes can become hazards themselves. The agency’s emergency standard, said Levinson, shifted the balance of power to allow workers to voluntarily use PPE. OSHA recognized there are some individual risk factors beyond occupational risk that may cause a worker to voluntarily wear PPE. For example, either the personal medical condition of the worker or a family member with whom they are in close contact with could cause an individual to seek a higher level of protection due to the potential for severe outcomes if they became infected. As for COVID-19, there are still ongoing challenges. Levinson cited the lack of good guidance on extended use and the lack of science regarding how to appropriately clean PPE that is normally disposable (e.g., filtering facepiece respirators) between uses.

Going forward, OSHA is increasing its communication efforts, including the use of videos to provide detailed information on aspects of respiratory protection programs. A particular focus is on the importance of fit and leakage as critical factors in reducing airborne transmission of the disease. Toward that end, OSHA is engaged in more detailed compliance assistance work on how facial hair affects fit and how to teach people to conduct fit testing on their own. “We saw a shortage of people being able to conduct fit tests as a major barrier to good respirator use, particularly as you saw respirators extend out into nursing homes and other kind of extended care settings where they did not typically use respiratory protection,” he said.

OSHA is also focusing on PPE selection, particularly between N95^®3 respirators and the more expensive, disposable P100 respirators typically used for welding. One challenge here is that health care has always wanted the cheapest and most disposable PPE possible for infection con-

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³ N95 is a certification mark of the U.S. Department of Health and Human Services (HHS) and is registered in the United States and several international jurisdictions.

trol purposes. This has driven manufacturers to produce PPE that meets the bare minimum. “As long as the standards allow the bare minimum, those responsible for purchasing in the health care community will keep selecting the cheapest PPE possible,” said Levinson. He noted in closing that elevating the baseline requirements for PPE provided to health care workers will require a change in the standards to prohibit some of the cheaper devices from being used in those settings.

COMMUNICATING WITH AND EDUCATING THE PUBLIC

Sarah Coefield, air quality specialist with the Missoula City-County Health Department, said that as an air quality specialist, her focus for the most part will be on wildfire smoke and wildfire smoke exposure. The best option for protecting oneself from wildfire smoke is a filtering facepiece respirator, she said, but these are not made with the general public in mind. “They are not comfortable, they are hot, they can cause heat stress,” said Coefield. As a result, the general public is likely to use a respirator incorrectly.

Another barrier to public use of respirators is that instructions and guidance around how to use respirators focus on workers and assumes there will be fit testing and medical clearance, said Coefield. However, members of the general public are unlikely to get fit tested or see their primary care providers to learn how to use a respirator. As a result, if the goal is to protect members of the public, new products are needed that do not require fit testing and medical clearance for proper use and are more comfortable to wear. In her opinion, such a device needs to be intuitive to use because most members of the public expect to use a product without reading detailed instructions. “We need to be aware . . . how the public takes in guidance . . . [and] that they do not like technical language,” said Coefield.

Guidance for both PPE for workers and the public could be better harmonized. “We have found that in a given wildfire smoke event, you may be getting conflicting advice on if you should use a respirator or should not use a respirator, depending on who is speaking,” said Coefield. “That kind of recommendation needs to be harmonized across all levels of government.” For example, the recommendation would be for someone to wear a respirator if going outside during a wildfire event and to consider using a good-fitting, legitimate KN95 respirator for their children, given that NIOSH Approved^®4 respirators do not come in children’s sizes. However, she acknowledged, the odds of getting a good seal with a KN95 respirator on a child are not great.

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⁴ NIOSH Approved is a certification mark of the U.S. Department of Health and Human Services (HHS) and is registered in the United States and several international jurisdictions.

Aside from the difficulty providing guidance to the public for PPE that was not designed for use by the general public, Coefield said another difficulty with communication and guidance is convincing people of the need to take action in the face of a hazard. With wildfire smoke, for example, people have become desensitized to it, discounting the fact that it is dangerous and not acting to protect themselves. There is also the added difficulty of sociocultural and behavioral issues underlying if someone will use a given type of PPE. During the COVID-19 pandemic, this issue arose in communities or settings where wearing a mask was not socially acceptable. “We need to figure out how to best communicate when we need to take all of these considerations into our calculations of how we design guidance that is meaningful, can get to people where they are, and help them take out these technologies and use them appropriately,” said Coefield.

Concluding her remarks, Coefield said that communication cannot be narrowly focused on workers, and it cannot assume that training for PPE use will be available. As a result, guidance must be easy to understand, with as few words as possible, to help people purchase something and use it correctly without needing to seek outside help. Members of the public, she said, should not have to figure things out on their own to protect their own health and that of their family members.

COMMUNICATING WITH FARM WORKERS

Alexis Guild, director of health policy and programs for Farmworker Justice, noted that agriculture is among the most hazardous occupations in the United States. Farmworkers, she said, are routinely exposed to pesticides and increasingly, in many parts of the United States, wildfire smoke. She also explained that while there are many reasons farmworkers lack adequate access to PPE, despite the many hazards they face, a primary reason is their lack of workplace protections and their lack of control over their working conditions.

Guild said there are few regulations in agriculture. For example, the Environmental Protection Agency (EPA), not OSHA, regulates pesticide exposure, limiting the scope of enforcement activities. There is no national regulation to protect workers from heat or wildfire smoke, despite the increasing frequency of extreme heat and wildfire events. As a result, farmworkers rely on their employers to provide PPE. “We cannot assume that workers are being provided with PPE, especially if there is no requirement for employers to do so,” said Guild.

In fact, she said, during the height of the COVID-19 pandemic, many farmworkers lacked adequate access to masks and other PPE to prevent

transmission in the workplace. Employers’ provision of PPE and implementation of protective measures varied from farm to farm, she added, especially in states without any regulations in place. Similarly, during the most recent wildfire season, she heard stories of workers who were not told of impending fires or increasingly hazardous air quality and were not provided with N95 respirators for their protection. “We all saw photos of workers in the fields with only bandannas to protect themselves while the skies were lit up in orange due to the wildfire smoke,” said Guild. “Unfortunately, this was not an uncommon sight.”

Even when farmworkers have access to PPE, they may be reluctant to use it, said Guild. PPE can exacerbate heat stress, for example, which is a major issue faced by farm workers because of the more frequent and intense heat waves happening throughout the country. With no national regulation on heat stress, workers may not necessarily be able to take breaks during periods of extreme heat. Farmworkers may also choose not to wear PPE because it can slow them down or make them more susceptible to heat-related illness. Farmworkers, she noted, do not have sick leave and often work on piece rate, where the amount they earn is based on their productivity.

Other social determinants of health, including immigration status, lack of health insurance, and lack of transportation, may deter workers from requesting or using PPE because it may negatively affect their work, which may lead to lost wages or perhaps employer retaliation. “We must consider these challenges when developing standards and strategies to promote PPE adoption among farmworkers specifically,” said Guild.

Absent regulations, employers could be incentivized to provide PPE, proper training, and accommodations. Guild said that making sufficient supplies of proper PPE to protect workers from hazards available to employers at low cost and to workers for free is important. “Workers should not have to pay for PPE to protect themselves from workplace hazards,” she said. In addition, trusted communicators could provide information and training about PPE. “Given the sometimes precarious relationship between workers and employers, it would be most effective to have communicators who are from the community, such as clinicians, health care providers, and community health workers,” said Guild.

Community health workers in particular can inform workers in formats and languages accessible to them. Guild cited examples including in-person trainings, low-literacy materials such as comic books or photo novellas, and even apps such as WhatsApp, which is broadly used in farmworker populations. Since community health workers often work for community-based organizations, Guild said funding for such organizations would help support these efforts.

COMMUNICATING WITH HEALTH CARE SERVICE WORKERS

Elizabeth Royal, assistant director of health care workforce strategy in the health care division of the Service Employees International Union (SEIU), noted that the rollout of PPE and training for essential workers, particularly those working in health care, in the initial stages of the pandemic was challenging. “We did not know much for a relatively long time, and folks risked their lives to keep us safe, to heal us, to keep our country moving,” said Royal. “They went to work every single day not really knowing what they were walking into.” In short, it was a traumatic time for health care service workers.

Unfortunately, said Royal, essential health care workers contracted COVID-19 and died in disproportionate numbers over the first year of the pandemic. Supplies of PPE were tight, and emergency departments ran out of small-size N95 respirators, forcing workers to use ill-fitting equipment that left them vulnerable to getting sick. Since then, the supply has improved, and for the most part, workers have access to PPE with fewer instances of hoarding, though this is still a problem for PPE that provides high-quality respiratory protection.

Reiterating Guild’s message, Royal said there is a need for robust, consistent education programs, delivered by trusted sources, on why PPE is important, and how to don and doff it properly, as well as proper fit testing and medical evaluations. “These are often required for certain settings but not for all, and there is not often an enforcement mechanism that is reliable if they are not happening,” said Royal. This is important now given the high rate of turnover in health care settings, including nursing homes. Using management training funds is often a good way of ensuring that workers are equipped to protect themselves.

Royal said it is important to ensure a wide variety of sizes and comfortable PPE are available so workers can make good choices about what is best for them but still offers good protection. Equity in the distribution and availability of PPE is important given the diverse health care workforce. She also called for addressing the trend for workers to move to surgical masks or nothing at all when they would be better protected with better PPE.

In planning for the next surge in usage, Royal said there is an absolute need for a broad infectious disease standard that covers all health care settings, as well as the forthcoming COVID-19 permanent safety standard from OSHA that covers a wide variety of health care settings. She also called for transparency, enforcement, and accountability for employers. “Every health care work setting must have robust health care hazard plans and real penalties for noncompliance,” said Royal.

Going forward, Royal said infectious disease control could be thought of in broader settings, such as patient homes. Royal noted that there are about 3.3 million home care workers, and many do not have access to any standardized training, education, or high-quality PPE. These home care workers, who care for some of the most vulnerable populations in the United States, are largely paid through Medicaid, earn low wages, and are not formally connected to the rest of the health care system. Today, nobody ensures that home care workers have PPE to keep themselves and their clients safe. Often, a union would make sure its members had PPE kits and educational sessions, but many workers are without union representation and have nothing.

In conclusion, Royal said that health care workers cannot rely on employers to do the right thing. “We need to help workers protect themselves on the job. We need real enforcement mechanisms and penalties for noncompliance, and we need to make sure workers have all the information they need from trusted sources, training, and access to quality PPE they need to do their job safely,” said Royal.

DISCUSSION

Sheridan opened the discussion with the observation that the lack of good communication during the COVID-19 pandemic caused divides in communities, health care facilities, and families. She also noted that as a health care provider, she values and understands information coming from NIOSH and OSHA. However, many individuals and communities do not even know what NIOSH and OSHA are, let alone trust the advice coming from them.

Guild, when asked to discuss some of the work her organization has done, said that Farmworker Justice works with community-based organizations around the country using train-the-trainer models that enable community health workers (such as promotores or promotores de salud) to work directly with farmworkers. Often, community health workers are former farmworkers or family members of farmworkers. Training includes subjects such as pesticide safety, COVID-19 safety, and dairy worker safety. Information is provided in various languages, including Spanish and Indigenous languages, and in low-literacy accessible formats. However, she said, education does little good if employers are not providing environments that allow workers to protect themselves and are not providing PPE and encouraging its use. Addressing that problem will require thinking about the broader regulatory environment.

John asked the panelists for their ideas on how health care workers can help educate and communicate with workers about using PPE and protecting themselves. Royal said there needs to be a great deal of cul-

tural competence and wide range of language abilities. Nurses, she said, are considered the most trusted voices in health care, so involving them would be a good idea. Public health nurses, in particular, can be effective sources of information on a wide range of issues relevant to health. What is most important is having a trusted source, someone who is not seen as having an underlying agenda, to deliver the information.

Coefield commented that one challenge regarding health care workers as sources of information is that much of the medical community has not received training on how to use PPE or education on air pollution as a health hazard. “We need to make sure that that training takes place for our medical professionals, so that when they are put on the spot, they are ready for it and have the resources that they need,” said Coefield. Levinson said that when OSHA is developing guidance, it approaches it in a generic way so that while aimed at workers, it can benefit the general public, too. In particular, OSHA is creating videos to illustrate how best to use PPE and make sure it fits properly.

John asked the panelists for suggestions for how end users can improve their own agency and advocate for themselves. Levinson replied that OSHA conducts many whistleblower investigations raised by workers, and it experienced a surge of complaints during the pandemic. He noted that the current regulations give employers the right to deny voluntary use of respiratory protection. One place where OSHA has more pull in terms of requiring respiratory protection is when workers are dealing with an established hazard. He and John both noted that this is a personal rights and liberty issue.

Coefield pointed out that only three states—California, Washington, and Oregon—have taken steps to protect outdoor workers from wildfire smoke exposure. Even though enforcement of those rules is shaky, she said, at least it is a start, and the rules say that employers must provide respirators for workers when the air quality hits a certain level. Given that no other states offer this protection, Coefield said this is a place where standards could help at the national level. Guild noted that the regulations in California, Washington, and Oregon are complex and there is little information about the regulations for workers. “When these regulations are in place, it is important that there are ways and efforts to educate workers about their rights, and to have them understand this is what the standard says, and this is what is required by your employer,” said Guild.

As for wildfire smoke protection, a member of the public attending the workshop wondered if developing a new standard that would certify respiratory protection devices performing at less than 95 percent efficiency could be part of the solution. This participant noted that there is a gap in solutions for people concerned about their respiratory health

but who might not need a respirator capable of 95 percent filtration. The consumer could then do a risk analysis and use this more accessible respiratory protection device based on what a given hazard requires, at least until it is clear a higher level of protection is needed.

Another workshop participant wondered if, absent consistent regulations and enforcement of worker protection in health care, industry could develop a comprehensive worker protection standard covering PPE and other controls. Industry may not be able to directly enforce a standard, but compliance could be tied to licensing, insurance, and accreditation. A health care worker protection standard committee could also provide an infrastructure to evaluate and promote improvements to PPE.

Responding to a question about train-the-trainer models, Guild said this approach is effective. OSHA emphasizes train-the-trainer models through its Susan Harwood Training Grant Program.⁵ This program funds organizations to provide training directly to workers on various health and safety topics. She explained that the reason this approach is so effective is that the worker-trainers can use a popular education format to inform their colleagues and can do so in a variety of formats and at a variety of locations. Guild noted that training can occur outside of the workplace to meet workers where they are and that the trainings are effective when accompanied by resources in accessible languages and formats.

John followed up by asking if there are training models designed to work outside of medicine or health care. Sheridan replied that her organization is working on training college students to reach the next generation of agricultural workers. Coefield noted that what is important with any big outreach effort is to broaden the group of people who can become trusted sources of information and help with communication by reaching people where they are in their communities. Also important is providing people at the local level with good, culturally appropriate resources they can use and information on how to use those resources correctly. The challenge, said Coefield, is finding local champions and giving them the needed tools and materials.

Levinson said that OSHA has worked with nontraditional partners such as church groups involved in advocacy for certain Latina/o worker communities with immigration status issues. One factor for success is tailoring the information to the hazard and finding trusted sources in the community who can talk about that hazard. A good option generically, said Levinson, is to find third-party surrogates to amplify the message at hand.

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⁵ Additional information available at https://www.osha.gov/harwoodgrants (accessed May 2, 2023).

A workshop participant asked the panelists if there is a role pharmacies could play in improving access to fit testing and educational information. Levinson said he does not see pharmacies as a viable option for offering fit testing because it requires training, practice, and often equipment. He noted that the American Industrial Hygiene Association (AIHA) and the American Society of Safety Professionals (ASSP) work with local community providers who are trained safety professionals. One option might be to partner with local fire departments who could bring in a local industrial hygiene provider to do fit testing at a fire station. Sheridan added that she has had some pharmacy technicians and pharmacists who have asked about understanding fit testing.