employees health and safety programs case study

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Success Stories

Success stories from OSHA's On-Site Consultation Program and Safety and Health Achievement Recognition Program (SHARP) recognize both the important work of On-Site Consultation and small business employers who operate exemplary safety and health programs. On-Site Consultation and SHARP are voluntary programs. To submit a request for a comprehensive consultation, see OSHA's Consultation Directory .

Authorized representatives from SHARP companies who would like to share their story of workplace safety and health may do so by working with their On-Site Consultant. To locate the On-Site Consultation program nearest you , see OSHA's Consultation Directory .

Featured Success Stories

Archived Success Stories

Onsite Consultation - couple employees in store front

Puerto Rico OSHA On-Site Consultation Program Rethinking Marketing Strategies: Getting Back to Business

PR OSHA adopted the “PR (Puerto Rico) OSHA Takes to the Street” initiative.
Also entered a MOU with the island's primary financial institution to promote consultation.

Rhode Island's Consultation Program Consultation Program Promotes Health and Safety Business Equity and Inclusion in Underserved ZIP Codes

Consultation partnered with Rhode Island Health Equity Zone (HEZ) to better integrate health equity in the Work Safer RI policies and practices.
Held two events in 2023 to provide education and information to the broader business community.

Safety Saves: Oklahoma - DOL OSHA Consultation

Oklahoma On-Site Consultation SAFE (Safe Award for Excellence) Award Recognizes Employers Best Practices

More than 360 participants attended the 2023 Oklahoma Health and Safety Conference.
There were two recipients of the 2023 SAFE Awards – Masks Builders LLC. and Builders FirstSource- Lumberyard.

Dig This Las Vegas, A Heavy Equipment Attraction Open to All Ages, Works to Earn Top Safety Designation

First attraction of its kind in Nevada to enter Pre-SHARP.
Started working with SCATS in 2019.

Montana Department of Labor and Industry Consultation Program Helps Company Pave the Way to SHARP

Initial Consultation visit was in September of 2022.
Recognized into SHARP in September of 2023.

Saint Paul Health Center Values Employees Safety

Began collaboration with Consultation in 2006.
First approved for SHARP in 2008, with most recent SHARP approval in 2022.

Wisconsin On-Site Consultation Ensures Company is Prepared for Emergency Clean Up

Company worked with Consultation since 2020
This collaboration ensured that the company's designated first responders were protected during a 2023 incident.

California On-Site Consultation Services Branch/ Combining the Voluntary Protection Program- Construction and Golden Gate Program for Even Greater Impact

83 sites are listed as Golden Gate as of February 2024.
Golden Gate is valid for on year from the date of certificate issuance.

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Injuries and Illness

Case studies in safety: a great training tool.

Updated: Nov 6, 2011

Case studies are a great safety training tool. It’s like CSI. Employees can really get involved examining the evidence and seeing why an accident occurred.

Safety case studies are fun, challenging, interactive, and a highly effective training method.

Armed with the knowledge they gain from examining the facts of real workplace accidents, workers can learn how to avoid similar incidents and injuries.

Here’s an example of such a case from BLR’s OSHA Accident Case Studies . This case is about a confined space incident.

The Incident

Two employees arrived at concrete pit at demolition site where they’d been working to salvage the bottom part of a cardboard baler imbedded in the pit. When the employees uncovered the pit, they both felt a burning sensation in their eyes.

Employee #1 climbed down into the pit to determine what might be causing their eyes to burn. He immediately climbed back out of the pit because it was hot. He decided to put a water hose into the pit to help cool it down.

The employees climbed down into the pit with the water hose. Both employees experienced chest tightness, difficulty breathing, and burning eyes. They decided to exit the pit because of the intolerable conditions.

Employee #2 climbed out first. As Employee #1 was climbing the ladder to get out, he was overcome by the fumes and fell back into the pit. He landed on his back, unconscious.

Employee #2 climbed down into the pit in an attempt to rescue employee #1, but was unable to lift him. Employee #2 exited the pit in order to get help. Unfortunately, by the time help arrived, Employee #1 had died of asphyxiation.

The accident investigation determined that employee #1 had attempted to extinguish a small cutting torch fire the day before by covering it with sand and dirt. Apparently the fire was not extinguished and smoldered overnight, which resulted in a build up of carbon monoxide inside the pit.

Try OSHA Accident Case Studies and give a boost to your safety training program with real-life case studies of actual industrial accidents from OSHA files. We have a great one on lifting. Get the details.

Discussion Questions

Once the case has been presented, some discussion questions can help kick off the analysis of the incident. For example:

What are the potential hazards of confined spaces?
What was the specific hazard in this case that cause a fatality?
Were these workers properly trained and equipped to enter a confined space?
What type of air monitoring should be done before entering a confined space?
Was this a permit-required confined space? If so, were the workers familiar with the safety requirements of the permit?
Was confined space rescue equipment readily accessible?
Training? There is no indication on the accident report that the employees were trained as authorized entrants of confined spaces. If they did receive any confined space entry training, they clearly didn’t apply what they learned. Authorized entrants are trained on the hazards of confined spaces, atmosphere testing procedures, symptoms of lack of oxygen or exposure to toxic chemicals, personal protective equipment (PPE), communication equipment, rescue retrieval equipment, etc.
Hazard warning? These employees entered the space despite experiencing "red flags," such burning eyes and unusual heat. An important part of training for confined space workers includes learning about hazards such as the symptoms of a lack of oxygen or exposure to toxic chemicals. Workers should never enter a space, and should immediately leave a space, in which they experience signs of hazardous conditions.

Even your most skeptical workers will see what can go wrong and become safety-minded employees with OSHA Accident Case Studies . They’ll learn valuable safety training lessons from real mistakes—but in classroom training meetings instead of on your shop floor. Get more info.

Permit-required? Most confined spaces require a permit before workers can enter the space. Permit-required confined spaces have the potential for hazards such as hazardous atmospheres, engulfment, entrapment, falls, heat, combustibility, etc. By reviewing a permit, entrants know they have obtained all the necessary equipment and the atmosphere has been monitored so they know the space is safe to enter.
Testing? This worker died of asphyxiation, or lack of oxygen. If the atmosphere in the pit had been tested prior to entry, this accident would not have occurred. Common monitoring practices require a check of the oxygen concentration, a check for flammable gases or vapors (especially important if welding is going to be done in the space), and finally, a check for any other toxic chemicals known to potentially be in the space. Monitoring is conducted before entering the space and periodically while workers are in the space.
Rescue procedures and equipment? The worker who collapsed back into the pit while climbing out could not be rescued because he was not wearing required rescue equipment. He should have been wearing a full-body harness attached to a retrieval line that was connected to a winch-type system that could have been used to pull the unconscious worker out of the pit. Of course, the other employee would have had to have been trained in confined space rescue procedures.

Tomorrow, we’ll introduce you to another case from OSHA Accident Case Studies, this one about a materials handling accident that resulted in a serious back injury.

Engaging Remote Employees in Their Health and Workplace Wellness Programs

Available for Download [PDF – 112 KB]

Research shows that higher levels of work related engagement contribute to improved employee and customer satisfaction, safety, and overall job performance and company profits. 1,2 Yet in 2016 more than 22% of the US workforce reported doing some or all work from home, 3 and 43% of employees worked in different locations from their employer and coworkers. 4 For some, this can create a lonely workplace. A one-size-fits-all approach does not work for any wellness program trying to attend to the needs and interests of a dispersed workforce. Wellness programs need to reach all employees—no matter where they work.

Strategies and Considerations

Well-being is the ability for individuals to address normal stresses, work productively, and realize their highest potential. 5 As companies strive to improve their workplace culture and environment to promote health and well-being, remote employees often cannot access or benefit from these changes. Therefore, it is important for employers to use additional strategies to engage remote employees in their work and health.

Use multiple channels—such as e-mail, webinars, training videos, and phone conferences—to communicate about the job, the organization, the wellness program, and other benefits.
Connect and build relationships with remote employees through regular, one-on-one conversations to check in about their job and to share information on health and wellness topics.
Flexible Work Schedule. Flexible schedules can benefit all employees, whether on-site or remote. The flexibility allows additional time for sleep and exercise, which promotes good health and creativity. 6 Employers can encourage remote workers to use flexible work schedules to address their health and well being needs—whether to exercise, meditate, volunteer, or go to a doctor’s appointment.
Create a challenge so remote employees can participate on a team and monitor physical activity through an online tracking system. This can create value and team-building for employees who are otherwise isolated from their coworkers.
Set achievable goals and rewards to help motivate remote employees to participate in health and wellness campaigns throughout the year.
Encourage remote employees to participate in walking meetings through mobile technology, which can be helpful for a company’s innovation and health. Also, encourage employees to participate in calls while standing, walking on a treadmill, or riding a stationary bike.
Use blogs and other social media to share examples of healthy living stories of remote employees and provide inspiration.
Include a wellness event when employees come together to meet for annual or quarterly events. This may include a health screening, a walk/run to raise funds for charity, and an outdoor social event.

The CDC Workplace Health Resource Center (WHRC) is a one-stop shop for organizations to find credible tools, guides, case studies, and other resources to design, develop, implement, evaluate, and sustain workplace health promotion programs. Visit https://www.cdc.gov/WHRC to find more case studies of workplace health programs in the field.

Burton WN, Schultz AB. The Association of Employee Engagement at Work with Health Risks and Presenteeism webinar. The Health Enhancement Research Organization (HERO). . https://hero-health.org/webinar/association-employee-engagement-work-health-risks-presenteeism . Accessed July 18, 2018.
Goetzel RZ, Fabius R, Fabius D, Roemer EC, Thornton N, Kelly RK, Pelletier KR. The stock performance of C. Everett Koop Award winners compared with the Standard & Poor’s 500 index. J Occup Environ Med . 2016;58(1):9-15. doi: 10.1097/JOM.0000000000000632.
Bureau of Labor Statistics. American Time Use Survey Summary webpage. https://www.bls.gov/news.release/atus.nr0.htm . Accessed July 18, 2018.
Gallup. State of the American Workplace website.]. https://www.gallup.com/workplace/238085/state-american-workplace-report-2017.aspx . Accessed July 18, 2018.
Centers for Disease Control and Prevention. Well-being Concepts webpage. . https://www.cdc.gov/hrqol/wellbeing.htm . Accessed July 18, 2018.
Oppezzo M, Schwartz DL. Give your ideas some legs: the positive effect of walking and creative thinking. J Exp Psychol Learn Mem Cogn . 2014;40(4):1142–1152.

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The impact of healthy workplaces on employee satisfaction, productivity and costs

Journal of Corporate Real Estate

ISSN : 1463-001X

Article publication date: 25 November 2021

Issue publication date: 20 February 2023

This paper aims to explore the added value of healthy workplaces for employees and organizations, in particular regarding employee satisfaction, labour productivity and facility cost.

Design/methodology/approach

The paper is based on a narrative review of journal papers and other sources covering the fields of building research, corporate real estate management, facilities management, environmental psychology and ergonomics.

The review supports the assumption of positive impacts of appropriate building characteristics on health, satisfaction and productivity. Correlations between these impacts are still underexposed. Data on cost and economic benefits of healthy workplace characteristics is limited, and mainly regard reduced sickness absence. The discussed papers indicate that investing in healthy work environments is cost-effective.

Originality/value

The findings contribute to a better understanding of the complex relationships between physical characteristics of the environment and health, satisfaction, productivity and costs. These insights can be used to assess work environments on these topics, and to identify appropriate interventions in value-adding management of buildings and facilities.

Productivity
Satisfaction
Added value

Voordt, T.v.d. and Jensen, P.A. (2023), "The impact of healthy workplaces on employee satisfaction, productivity and costs", Journal of Corporate Real Estate , Vol. 25 No. 1, pp. 29-49. https://doi.org/10.1108/JCRE-03-2021-0012

Emerald Publishing Limited

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

1. Introduction

The WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. As such, a healthy workplace can be defined as a workplace that contributes to the physical, mental and social well-being of its users. Health is the result of a complex interaction between the physiological, psychological, personal and organizational resources available to individuals and the stress placed upon them by their physical and social environment at work and home ( Clements-Croome, 2018 ). Well-being reflects one’s feelings about oneself in relation to the world, personal feelings about motivation, competence, aspirations and degree of personal control.

1.1 Impact of the physical environment on health and well-being

The past decades show a growing awareness of the impact of the physical environment on peoples’ health and well-being, both in academic research and in professional publications. This may be because of the shift from a one-sided focus on cost reduction to a more holistic and integrated value-based approach and an optimal balance between costs and benefits of interventions in buildings, facilities and services ( Jensen and Van der Voordt, 2017 ). Besides, people have become more aware of the impact of health and well-being on our quality of life and the risk of health complaints, illness or – in worst cases – burnout ( Appel-Meulenbroek et al. , 2020 ). The relationship between physical workplace characteristics and health and well-being has been explored by a variety of studies, using reviews of the literature ( Forooraghi et al. , 2020 ; Van der Voordt, 2021 ), surveys ( Cordero et al. , 2020 ), case studies ( Bauer, 2020 ) and conducting short-term experiments using mobile devices ( Nelson and Holzer, 2017 ).

It appears that in particular a poor indoor climate, noise and distraction have a negative impact on employees’ health and well-being, whereas appropriate opportunities to communicate and to concentrate and contact with nature contribute to a healthy workplace. In a survey of 2,000 office workers, occupants reported preferences for lots of natural light, access to outdoor spaces, contemplation spaces, support from colleagues and private as well as collaborative spaces, whereas the main irritants were noise in open-plan areas, lack of natural light, lack of colour, lack of greenery, lack of artwork, lack of fresh air, no personal control of temperature, lack of privacy, clutter and inflexible space ( British Council for Offices, 2018 ).

Another frequently assessed factor is office type. A literature review by Colenberg et al. (2020) on the relationship between interior office space (layout, furniture, light, greenery, controls and noise) and employees’ physical, psychological and social well-being showed that open-plan offices, shared rooms and higher background noise are negatively related to health. Positive relationships were found between physical well-being and aspects that encourage physical activity; between physical/psychological well-being and (day)light, individual control and real/artificial greenery; and between social well-being and small shared rooms.

Other influencing factors on health and well-being are important as well, such as the context (cultural, social, economic, political), personal characteristics (age, gender, lifestyle), organizational issues (leadership, personal support) and job characteristics (work load, (mis)fit between demands and resources). The European Agency for Safety and Health at Work (2014) warns for a disbalance between high job demands and available job resources. Too little time, too much work and tight deadlines are the most widely recognized risk factors, resulting in sleep disturbance, changes in mood, fatigue, headaches and stomach irritability.

1.2 Relationship between healthy workplaces and other values

Healthy workplaces that support employees’ health and well-being can be a goal in itself, but may also have intended or unintended effects on other values, such as employee satisfaction, productivity, costs, corporate image and risk. Vice versa, values such as sustainability may contribute to health and well-being. For instance, green buildings are supposed to be healthier than non-green buildings, because of its focus on the triple P of people, planet and profit. Interrelationships between healthy workplaces and other values are much less studied. This paper aims to reduce this gap in our knowledge, and to answer two research questions: What is the relationship between healthy workplaces and employee satisfaction, productivity and costs? And which evidence is available for these relationships?

These three values turned out to be most frequently prioritized in interviews with corporate real estate and facility managers ( Van der Voordt and Jensen, 2014 ). It is hypothesized that health, satisfaction and productivity go hand in hand. Furthermore, because of the high staff costs compared to facility costs, it is hypothesized that health-supportive interventions are cost-effective. Figure 1 visualizes the key topics of this paper in blue.

Because of a limited number of available publications, it was decided to select a number of leading journals in the field and to conduct a narrative review ( Green et al. , 2006 ; Ferrari, 2015 ). In our earlier review of environmental impact factors on healthy workplaces ( Jensen and Van der Voordt, 2020 ), we checked four facilities management and corporate real estate management oriented journals in a 10-year period, covering 2008–2017: Journal of Corporate Real Estate , Corporate Real Estate Journal , Facilities and the Journal of Facilities Management . For the current paper, we extended our search to the period 2018–2021 and to other journals, based on paper citations and journal titles. We also screened the last six volumes of Applied Ergonomics , Building and Environment , Building Research and Information , Environment and Behavior , Ergonomics , Intelligent Buildings International and Journal of Environmental Psychology on the keywords workplace, health, well-being, satisfaction, productivity and cost.

All papers from the screened journals that discuss health in connection to workplace characteristics and satisfaction, productivity and/or cost were included in this review. This has resulted in a selection of 45 papers on health and satisfaction and/or productivity. Because very few scientific papers related to facility cost were found, we have included relevant industry reports and other publications. Papers that discuss the relationship between the physical environment and either health, satisfaction, productivity or cost, without discussing any interrelationships between these variables, have been excluded.

3. Findings on the added value of healthy workplaces

3.1 employee satisfaction.

Table 1 summarizes the research topics, methods and findings of eight papers that discuss relationships between physical characteristics of the built environment, health and satisfaction, ranked by year and per year in alphabetical order of the first author. Five out of eight studies investigate the impact of office type and workspaces. The other studies focus on environmental conditions, sense of coherence or green buildings. The findings show positive but also contradictory connections between office type; health and well-being; and employee satisfaction. Open-plan seems to have a negative impact, which can be partly compensated by improved environmental conditions. High density and poor acoustics affect health and satisfaction in a negative way. The green building study showed mixed results. Personal characteristics make a difference as well. Employees with high need for concentration report more distraction in all office types, except in cell, and more cognitive stress in all office types except cell and flex-offices. People suffering from claustrophobia perceive stronger effects.

3.2 Labour productivity

The findings on relationships between health and well-being and labour productivity are summarized in Table 2 . Four studies focus on office type and workplace concept (open-plan, work pattern–office type fit, high-performance hub, variety of workplaces). Five studies investigated the impact of indoor air quality (IAQ) and related issues such as thermal comfort and look-and-feel. Four studies focus on sit-stand/adjustable workstations. The other studies show a variety of research topics, i.e. the influence of a healing office design concept, wind-inducing motion of tall buildings, green buildings, workplace safety, biophilia, plants and time spent in the office. The findings show significant positive but also mixed impacts of IAQ, “green” buildings and sit–stand work on both health and productivity. Health and productivity are usually discussed separately; correlations between health and productivity were only explored in two studies. Interrelationships are affected by job demands and job stress

3.3 Satisfaction and productivity

Table 3 summarizes the findings from 17 studies on health and well-being and both satisfaction and productivity. Independent variables include office types, non-territorial workspaces, proximity, impact of break out areas, storage space, adopting the WELL criteria, indoor environmental quality (IEQ), shading conditions, sit–stand workstations and plants. Here, too, health, satisfaction and productivity are mainly discussed separately and less regarding possible correlations. In general, activity-based workplaces are perceived to have a positive impact on satisfaction, partly because of better technical qualities regarding IEQ. Searching for a workplace needs time and reduces productivity. Personal control, easiness of interaction and communication, availability of break out areas, windows, sit–stand workstations, comfort of furnishing, attractive IEQ, modern shading systems and applying to the WELL standard show to have a positive impact on both health and satisfaction, whereas distraction and lack of privacy are important predictors of productivity loss.

All presented studies on health in connection to satisfaction and/or productivity originate from Europe, USA, Australia and New Zealand.

3.4 Applied research methods to study health and satisfaction and/or productivity

The discussed papers on health and satisfaction and/or productivity show a variety of research designs and research methods ( Table 4 ). Ten studies conducted a before–after study; four studies used an experiment in a lab setting. About 80% of the presented studies used a questionnaire survey, some of them as part of a mixed-methods approach with interviews and observations, identifying healthy or unhealthy office design qualities, scores on the WELL standard and data about toxic substances in the air. Measuring physical conditions such as the heart rate or skin temperature is rather rare.

3.5 Financial costs and benefits

Clements-Croome (2018) mentions a return on investment of €5.7 for every euro invested in well-being. However, not much quantitative data was found about the financial impact of changing the spatial layout, supporting new ways of working, providing more contact with nature or the introduction of sit–stand desks. This may be because of the difficulties to quantify the results of healthy workplaces. Various papers discuss the monetary costs and benefits of health-promoting programs such as stop-smoking programs or providing sports facilities and healthier nutrition. However, these topics are not related to physical characteristics of workplaces and are beyond the scope of this paper. Table 5 summarizes the findings from 11 publications. Different research methods are used, such as literature reviews, surveys and analysis of sickness absence data (8 out of 11 studies) and costs. Some studies focus on the impact of stress, without clear links to physical characteristics. Not all project data on financial costs and benefits has been tested scientifically on reliability and validity.

4. Discussion and conclusions

The discussed studies show a huge variety in environmental characteristics that influence health and well-being, employee satisfaction and labour productivity, such as office type, proximity, density, IEQ of IAQ, furniture (ergonomics, sit–stand desks), plants and personal control. Some studies focus on specific building types such as certified green buildings, WELL-certified buildings and tall wind-excited building, specific building components such as shading systems or specific interior elements such as sit–stand desks and furniture comfort. Research methods range from questionnaire surveys to before–after studies and laboratory experiments. Measuring physical conditions such as heart rates and skin temperature is still underexposed. Remarkably, most discussed papers present findings on health and satisfaction and/or productivity without discussing correlations between health, satisfaction and productivity.

The reviewed studies indicate positive but also mixed and contradictory effects of healthy workplaces on satisfaction and productivity. Overall, a healthy IAQ, opportunities for communication, concentration and privacy, availability of break-out rooms, an attractive look-and-feel, ergonomic furniture, contact with nature and plants go hand-in-hand with higher employee satisfaction and perceived productivity. Large open-plan offices and centrally controlled air condition show a negative effect on health, satisfaction and productivity. There is some evidence that workplaces in green buildings are healthier than workplaces in conventional buildings. Adjustable workstations with sit–stand desks show to have beneficial effects for comfort and labour productivity. Practitioners should take these findings into account in their design and management activities.

What constitutes a healthy workplace is much dependent on the workstyles and the preferences of the users. The degree to which the workplace has impact on satisfaction is in particular dependent on user preferences in relation to privacy versus social contact. The impact on productivity is in particular dependent on the specific workstyle and how well the workplace supports the work activities. Involving the users in the planning process and change management during implementation is crucial.

Scientific research on monetary cost and benefits of healthy workplaces is limited. Overall, the data indicate a positive impact of healthy workplaces on the reduction of sickness absence.

Because of the impact of many interrelated variables, it is difficult to trace cause–effect relationships between characteristics of healthy work environments and support of other value dimensions. Usually, various interventions are conducted simultaneously. Furthermore, employees’ health not only depends on what the workplace does to employees, but also on what workers bring with them to the workplace.

The mixed findings make it hard to provide a sound business case for physical interventions to improve health and well-being. On the one hand, taking care of healthy work environments is a matter of moral responsibility and has in general a positive effect on employee satisfaction and labour productivity and on society as a whole. These advantages have to be balanced with the costs of interventions to provide more healthy environments. An obstacle for a more integrated, holistic business case may be that the cost of interventions and its resulting output and outcomes are not always easy to measure in a quantitative way. Another difficulty is that some outcomes might be experienced in the short term and perhaps only temporarily, while others might be sustained, reduced or only experienced in the long term. One solution is to base business cases not only on quantitative data but to take into account well-argued qualitative considerations as well. As such, we plea for a so-called value based business case or “value case”.

4.1 Suggestions for further research

Additional research is needed to get a deeper, holistic and evidence-based knowledge of the added value of healthy workplaces and interrelationships between health, satisfaction and productivity and financial impacts that integrate different research topics and research methods. A next step can be to use the research findings as input to follow-up transdisciplinary research by academics from different fields, including corporate real estate management, facilities management, human resource management, environmental psychology and work and organizational psychology. Reflections on data by an interdisciplinary team and experimenting with particular interventions may be helpful as well.

Other topics for future research are extension of this literature review with papers from other journals and databases such as Scopus and PubMed, and to conduct additional empirical research with before–after studies of particular interventions and data-collecting techniques such as workshops, group interviews, pilot projects and self-measurement of health and health-supportive behaviour, e.g. by using wearables and apps. Cost studies should not only focus on data analysis of sickness absence, but extend their scope to self-reported health risks and health conditions, to get a better understanding of what drives health costs and lost productivity ( Jinnett et al. , 2017 ). Besides, more studies are needed into the costs of particular interventions and return on investment.

A particular topic for further research is the use and experience of offices in the post Covid-19 period. Increased “infection risk mitigation” will affect the presence in the office, number of people per m 2 , need for fresh air access, etc. The Covid-19 crisis has resulted in a drastic increase in home working and this experience is likely to have profound implications for office work in the future.

employees health and safety programs case study

Key topics of this paper

Health and well-being and satisfaction (eight studies)

Health and well-being and labour productivity (20 studies)

Health and well-being, satisfaction and labour productivity (17 studies)

Applied research methods in the presented studies

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Physical work environment in an activity-based flex office: a longitudinal case study

Original Article
Open access
Published: 17 May 2024

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Viktoria Wahlström ORCID: orcid.org/0000-0002-4656-7606 1 , 5 ,
Maria Öhrn 1 ,
Mette Harder 2 ,
Therese Eskilsson 3 ,
Anncristine Fjellman-Wiklund 3 &
Anita Pettersson-Strömbäck 4

This study aimed to investigate and explore Occupational Health and Safety (OHS) management, office ergonomics, and musculoskeletal symptoms in a group of office workers relocating from cell offices to activity-based flex offices (AFOs).

The analysis was based on qualitative interview data with 77 employees and longitudinal questionnaire data from 152 employees.

Results indicate that there was a need to clarify roles and processes related to the management of OHS. Self-rated sit comfort, working posture, and availability of daylight deteriorated and symptoms in neck and shoulders increased after the relocation and seemed to be influenced by many factors, such as difficulties adjusting the workstations, the availability of suitable workplaces, and age, sex, and individual needs.

Conclusion.

Research on the long-term effects of physical work environments and management of (OHS) issues after implementing activity-based flex offices is sparse. This study demonstrates the importance of planning and organising OHS issue management when implementing an AFO, and to carefully implement office ergonomics among office workers.

Practitioner summary

Knowledge of effects on the physical work environment and management of Occupational Health and Safety (OHS) issues after implementing activity-based flex offices (AFOs) is sparse. Findings from this mixed methods longitudinal study suggests a possible need to reorganise the management of OHS issues and carefully implement office ergonomics when implementing flexible office types like AFOs.

Avoid common mistakes on your manuscript.

Introduction

In recent years there has been increased interest in flexible offices. Technological developments enable office workers to work from different locations, and it is more common to transfer to Flex Offices with Activity-based work, abbreviated as ‘AFOs’ (Rolfö 2018 ; Engelen et al. 2019 ). The main reasons for implementing AFOs are usually to stimulate communication and collaboration, and to decrease facility costs (Engelen et al. 2019 ; Haapakangas et al. 2019 ). In AFOs there are no individually assigned workstations. Instead, the choice of space is based on the current activity in terms of work task, and workers can choose a suitable workstation based on the task at hand and personal preferences. AFOs are usually designed to provide support for different types of work tasks, such as spaces for individual concentrated work, spaces for meetings and social areas, and under optimal conditions, there is always access to the right type of workstation (Hoendervanger et al. 2018 ).

The intention of Occupational Health and Safety (OHS) in the workplace is to maintain and promote worker health and capacity, and to develop and improve the occupational setting. This is preferably performed through a process that includes a continuous loop of evaluations, planning, and the implementation of improvements (ILO 2001 ). OHS issue management likely varies depending on the country and organisation, as it is often guided by legislation, company policies and routines. When transferring to flexible offices, like AFOs, there are likely to be changes in the way OHS issues are handled if the AFO design leads to sharing facilities across departments within the organisation.

Musculoskeletal symptoms are common among office workers, prevalence is higher in females than in males (Lucas et al. 2022 ; Janwantanakul et al. 2008 ), and the prevalence of musculoskeletal symptoms also increase with age (Hoy et al. 2010 ; Mills et al. 2019 ). Preventive measures are important in avoiding the development of musculoskeletal symptoms (Hoe et al. 2018 ). Relocation to AFOs could positively affect workers due to increased variation, but it may also pose an ergonomic risk, as workers do not have individually adjusted workstations. In general, interventions to increase standing and walking among office workers have not been shown to reduce musculoskeletal symptoms (Parry et al. 2019 ), studies performed in AFOs have demonstrated a reluctance toward workplace-switching in AFOs (Hoendervanger et al. 2016 ; Haapakangas et al. 2018 ), and studies using objective measurements have seen only limited effects on occupational sitting patterns (Wahlström et al. 2019 ; Johansson et al. 2020 ). Another important ergonomic aspect of importance in office environments are visual conditions, including the lighting system, the position of computer monitors, and the visual acuity of the worker (Robertson et al. 2016 ). Under optimal conditions, workers are capable of performing tasks without straining the eyes (Osterhaus et al. 2015 ). Several visual changes can occur during human ageing, such as presbyopia, decreased contrast sensitivity, and delayed glare recovery (Peiyi 2014 ; Erdinest et al. 2021 ), therefore visual ergonomics at the workplace might affect younger and older workers differently.

Meijer et al. ( 2009 ) studied office workers who were relocated to an innovative office concept and found a decreased prevalence of upper extremity complaints at follow-up 15 months after relocation. In a qualitative study, Babapour et al. ( 2019 ) investigated consequences of desk-sharing in four organisations after relocation to AFOs and found that employees perceived that they sat less and moved more, but also noted inconveniences related to setting up and changing workstations. Berthelsen et al. ( 2018 ) found decreased ratings for workplace design regarding sit comfort and work posture among Swedish university employees after relocation to an AFO. When it comes to visual conditions for computer work in flexible office, to our knowledge, there are no studies reported in the current literature.

To achieve workplace prerequisites for good health and high productivity, it is important to establish ways of organising and managing OHS to provide workers with sustainable working environments in flexible offices. This has become even more important in the post-pandemic situation, which has trended towards a hybrid organisation of office work; i.e., remote work from home combined with work in flexible offices (Chafi et al. 2021 ; Chan et al. 2022 ). Remote work is likely to impact ergonomics and OHS management, and responsibility for the work environment may become even more complex compared to working in an AFO. To date there is limited and mixed evidence on the effects of the physical work environment, office ergonomics, and musculoskeletal disorders after relocation to AFOs, and more studies are needed (Lahtinen et al. 2015 ; Engelen et al. 2019 ; Haapakangas et al. 2023 ).

In a previous study, Öhrn et al. ( 2021 ), results showed that employees relocating from cell offices to an AFO reported reduced sit comfort and work posture after relocation, when compared to a control group that kept working in cell-based offices. To achieve a deeper understanding of office ergonomics and the management of OHS in AFOs, the overall aim of this study was to investigate and further explore the physical work environment in a group of office workers who relocated from a cell-based office to an activity-based flex office using mixed methods. The research questions were:

What are the important experiences for OHS management in an activity-based flex office (AFO)?

How are office ergonomics and musculoskeletal symptoms affected after relocation, and what seems to influence outcomes?

Materials and methods

The current study is part of an overarching research project, the Active Office Design Study (AOD), a longitudinal quasi-experimental office relocation project (Wahlström et al. 2019 , 2020 ; Öhrn et al. 2021 ). Before relocation, 91% of workers had a personal workstation and 71% worked in personal cell offices, and they relocated to either a new cell office or an AFO. In the current study, we included white-collar workers who relocated to the AFO, including workers in finance, human resources, urban planning, educational departments, and a group of politicians. In the studied organisation, managers had a delegated responsibility for the work environment of their employees.

Before the relocation managers regularly followed up on the physical work environment by, e.g., performing yearly safety inspections in the areas/corridors used by their employees. Before relocation, most employees had individual workplaces, adjustable chairs, and sit–stand tables. Ergonomists from the off-site occupational healthcare provider screened the workstation ergonomics every second year. Safety officers were assigned to represent co-workers in different departments, and to take part in developing the work environment, together with managers. Managers were mandated to implement improvements in the work environment. As part of the AOD study, an intervention program aiming to decrease sitting, increase standing and walking, and to break up prolonged sitting periods at work was developed and implemented. (Wahlström et al. 2019 , 2020 ).

After the relocation, the AFO had three floors containing open office landscapes, secluded offices, and conference rooms of various sizes. There were no assigned zones for different types of silent or more interactive work activities. The secluded offices were thought to be used whenever needed, depending on work tasks and various individual needs. After the relocation, employees had non-assigned workstations. The workstations had a standardised design, with adjustable chairs of the same model, sit–stand tables, and adjustable computer monitors. Some meeting rooms had sit–stand tables. Both sitting and standing tables were available in shared spaces. In addition, 16 shared treadmill workstations were installed in both cell offices and open office landscapes. More details are found in Supplementary Table 1 .

When planning the office design, the organisation consulted experts in workplace design, as well as ergonomists from the occupational health services. After relocation, employees were invited to join two non-mandatory ergonomic training sessions at the workplace, performed by ergonomists. After the demonstration, employees were offered a personal ergonomic consultation if they wanted them. During the planning phase, the organisation performed regular risk assessments in collaboration with union representatives.

Study design

We used a mixed methods design integrating qualitative and quantitative data (O’Cathain et al. 2008 ; Fetters et al. 2013 ). The use of mixed methods provides the possibility of a deeper understanding of the research questions, as the qualitative and quantitative datasets complement each other (Fetters et al. 2013 ; Morse and Cheek 2014 ). In the qualitative part, interviews were undertaken to explore employees’ experiences from the relocation process and the physical work environment. In the quantitative part, questionnaires were used to assess background characteristics, health, and perceived work environment. This approach provided the possibility to investigate perceptions of the physical ergonomic environment and any related behavioural changes. The study had a convergent design, meaning that qualitative and quantitative data were collected in parallel but separately, and analysis and data integration were carried out after data collection was completed (Fetters et al. 2013 ) (Fig. 1 ). We present the results using an exploratory sequential mixed methods design, where the qualitative results are considered the main findings, and the quantitative findings are used to give an additional dimension to the results, presented in a weaving pattern (Fetters et al. 2013 ; Fetters and Freshwater 2015 ).

Flow chart for data collection and data analysis in the mixed methods design.

The AOD study received ethical approval from the Regional Ethical Committee (No:2014/226 − 31). All participants signed an informed consent form with separate information and consent forms for the collection of questionnaires and interview data in the study. Data were collected between October 2014 and May 2017.

Data collection and analysis

Qualitative data collection with interviews.

Qualitative data were collected through interviews, with a total of 13 focus groups, 6 individual interviews with managers, and 7 go-along interviews (Gill et al. 2008 ; Carpiano 2009 ). Convenience sampling was used for recruitment, where all employees relocating to the AFO were invited to participate. Go-along interviews were conducted six months after relocation and focus groups at 6 and 18 months after relocation. One of the focus groups (at six months) only included managers. Due to challenges scheduling a focus group with the managers at 18 months, individual interviews with managers were carried out 24 months after the relocation (Fig. 1 ).

A semi-structured interview guide with open-ended questions covering experiences from the relocation process to specific questions about the physical work environment, ergonomics, and musculoskeletal disorders was used for all interviews (Gill et al. 2008 ) Questions about the organisation and management of OHS were included in the focus groups at 18 months and in the manager interviews. Focus groups lasted 50–90 min, involved 3–5 participants per group, and were held by two researchers. Manager interviews were also held by two researchers and lasted 30–60 min. Go-along interviews are an architectural method to capture participants’ perceptions of the built environment (Carpiano 2009 ). Each go-along interview lasted 90 min, was held by one of the researchers, and involved 2–6 participants per group. Guided by a researcher, each group visited the same six predetermined places in the office. At each place, the participants were asked to reflect on the positive and negative aspects of the space and on how well-suited it was for sitting, standing, or walking. The participants were also encouraged to suggest changes that could improve the place. The participants noted down their reflections on an architectural drawing of the office. Participants were allowed to discuss these places during the walk and, when this happened, were reminded by the researcher to note down the discussions. After walking around, the group gathered for an interview in a meeting room. Participants summarised their reflections, and a joint discussion about the work environment and ergonomics was held. The interview was recorded, and the participants’ notes were collected. All interviews were recorded and transcribed verbatim.

Qualitative content analysis

Interview data were analysed using qualitative content analysis (QCA) with an inductive approach (Graneheim and Lundman 2004 ; Elo et al. 2014 ; Graneheim et al. 2017 ). Before analysis, the first author extracted data relevant to the aim of the study from the full interviews. Three of the authors began by reading the selected transcribed excerpts. To validate the coding procedure, they collectively extracted condensed meaning units and abstracted codes from one focus group. In the next step, each researcher coded an information-dense interview. The last step was a mutual comparison and a final negotiated outcome. Data were then divided among the authors, who individually extracted codes. The resulting codes were then presented to all authors. Three of the authors analysed the data, grouping them into preliminary themes, categories, and subcategories. To further strengthen trustworthiness, preliminary results were presented and discussed with all authors on four occasions, and with other researchers involved in the AOD study on two occasions (Graneheim and Lundman 2004 ; Elo and Kyngäs 2008 ; Graneheim et al. 2017 ). Repeated reflections and feedback on the preliminary results guided further discussions and any modifications made to the analysis.

Quantitative data collection with questionnaires

All employees involved in the relocation were invited to a questionnaire 6 months before the relocation (baseline), and at 6 and 18 months after the relocation. Questionnaires were distributed via managers, with a sealable return envelope, and could be answered during work hours. In this study, we used data from baseline and 18 months follow-up. At baseline, 228 employees received the questionnaire, of which 219 (96%) responded. At 18 months, 152 out of 171 employees (89%) responded. In the current study, we analysed data from the 152 employees with questionnaire data from both points in time. Drop-out from the study was due to employee turnover ( n = 40), retirements ( n = 6), relocation to another office ( n = 4), parental leave ( n = 4), or sick leave ( n = 4).

The questionnaire included questions on background characteristics such as age, gender, and variables on health and lifestyle. Space for work material was assessed on a five-level Likert-like scale from “not enough” to “enough”. Availability of daylight and perception of lightning in the office was assessed on a five-level Likert-like scale from “good” to “bad” (Bodin Danielsson 2009 ). Perceived sit comfort and working posture was assessed on a 4-point scale Likert-like scale ranging from “very good” to “very poor”. At 18 months, a question was added to assess the perceived possibility of adapting workstations based on individual ergonomic needs, using the same 4-point scale. Perceived musculoskeletal symptoms and muscular tension during the past three months were assessed by a 5-point Likert-like scale ranging from “never” to “always”, following Wahlstrom et al. (Wahlström et al. 2004 ).

Statistical analysis

Wilcoxon-matched paired tests were used to test for changes between baseline and 18 months in questionnaire data for all workers and for subgroups. Chi-squared tests were used to test the associations of perceived possibility to adapt ergonomic settings in relation to the level of reported musculoskeletal discomfort. Statistical analyses were performed using SPSS software v.24 (IBM Corp, Armonk, NY, USA), and the significance level was set at α = 0.05.

Participants in interviews and baseline characteristics in questionnaires

In total, 77 unique participants (73% women, 27% men) aged 30–63 participated in the interviews. Of the total 77 participants, 62 were employees and 15 were managers. Among the 62 employees, 19 persons participated in more than one interview, and five of the 15 managers participated in more than one interview.

Of the respondents to the questionnaire, 67% were women, and 26% were managers. At baseline, 51% of participants rated their health as “very good” or “excellent”, while 23% reported discomfort in the neck and shoulders either “often” or “all the time” (Table 1 ).

Results from interviews and questionnaires

The qualitative results drive the presentation of the data. Where applicable, quantitative findings from questionnaires are interwoven. The qualitative analysis resulted in two themes. The first theme, reorganising Occupational Health and Safety management , includes the subthemes needing new processes and clarification of responsibilities and managers navigating the new environment . The second theme, one size does not fit all , includes the subthemes managing the body in a shared environment and challenges of different needs in the workforce. Themes, subthemes, and categories are presented in Table 2 . Further description and clarification of themes and categories are unfolded in the text.

Reorganising occupational health and safety management

In this theme, the results highlight how Occupational Health and Safety (OHS) management needed to be reorganised in the AFO, how managers strived to adapt to the new environment, and the challenges these adaptations entailed.

Needing new processes and clarification of responsibilities

In the category unclear roles, rules, responsibilities, and routines , it was described as unclear who had the overall responsibility for the work environment and who was responsible for the processes involved in making changes to the work environment. Neither managers nor employees knew how OHS management was organised or who was responsible for what. Informants described how the shared environment created the need to handle OHS in new ways, with more complex coordination of stakeholders. As an example of the ambiguities in responsibility, employees described it as unclear how to report deficiencies in the work environment, and it was also unclear who was responsible for solving the problem. Employees found this frustrating and annoying, while others expressed a sense of resignation.

In an environment like this, it becomes even more important to be clear. We cannot act as individual islands anymore. It requires more cooperation, better structure, and professionalism. (Manager, interview 5)

The category a need for restructured safety inspections describes the changed prerequisites for carrying out safety inspections. Before relocation, regular safety inspections were held by managers and safety officers in each department. Eighteen months after relocation to the new premises, no safety inspection had been held, and it was still unclear who was responsible for initiating and leading the development of new routines. Informants discussed the challenge in finding new ways to carry out safety inspections, both concerning which stakeholders should be represented, and how to create updated routines and protocols.

“Safety representatives ought to be independent from organisational divisions. The safety representative should represent the whole workplace, regardless of who is sitting where.” (Employee, Focus group 12, 18 months)

In the category digital solutions are needed for the flex office to be used as intended , informants explained that the perception of the office’s functionality depended on work tasks and to what extent digitalised work processes were implemented in departments. Employees working with non-digitalised work processes did not perceive the AFO to be supportive. As an example, employees who mainly worked with papers and binders described how they spent more time packing, unpacking, and carrying work materials. Regarding the possibility of storing work material, some perceived the available cabinets to be sufficient, while others found them to be too small. The use of the cabinets seemed to work well for employees who mainly worked in digitalised processes, while employees working with paper and binders were more critical of the cabinets’ storage capacity.

“I work with mail and paper and registration. My desk is full of papers. I cannot keep moving around. I feel rootless, a little stressed, I have to find a place for my papers.” (Employee, Focus group 3, 6 months) “I usually work with digital processes and have been forced to become even more digital. It works really well.” (Employee, Focus group 6, 6 months)

Questionnaire data showed that 80% of participants reported having enough space for work material at baseline. This decreased to 38% at follow-up (Table 3 ).

Managers navigating the new environment

In the category new strategies come without guidance , managers described how the AFO imposed difficulties when it came to handling their subordinates’ work environment issues. After relocation they found it more complicated to help their subordinates with workplace adaptations, as there were no clear guidelines or policies to follow. They tried to support their subordinates and to solve problems as they went along, but due to the shared premises across departmental boundaries, combined with a lack of clear processes and responsibilities, managers perceived that there were limited opportunities to act, leading to frustration among both managers and their subordinates. Managers received some support from human resource departments when they needed help on individual cases, but often they had to come up with solutions themselves.

“My picture is that individuals with special needs are dealt with case-to-case. It’s done in a positive spirit.” (Manager interview 4)

In the category imbalance between responsibility and mandates , managers described it as more complicated to take responsibility for their subordinates´ work environment, due to an imbalance between their responsibilities and their mandate to address issues with the workplace environment. They describe situations where they wanted to make adaptations for a subordinate but did not receive any response from top management regarding their inquiries on how they could and should proceed. This led to difficult situations for managers, since they had a responsibility to adapt the work environment according to their subordinates´ needs, but at the same time, they had limited mandates to decide on changes in the shared environment. This imbalance created worse conditions for managers, especially among first-line managers.

One size does not fit all

This theme explores how the physical work environment, both upsides and challenges, was perceived after relocation to the AFO. Results also describe how the AFO was perceived in relation to a variation of needs.

Managing the body in a shared environment

In the subcategory individual preferences for temperature and lighting , the indoor environment was reported to be satisfying overall with very good air quality. On the other hand, premises were also described as cold, and informants explained that they often felt cold and used more clothing to keep warm. Temperature differed within the office, and small rooms were perceived as warmer. The office area was perceived as bright, and access to daylight was perceived to be satisfactory, especially on the top floor. Lighting was perceived as unevenly distributed, where some places were perceived as ‘dark’ (desk booths), and participants desired individual desk lights at workstations. The automated lighting was perceived as problematic. It was difficult to understand how to use the light switches, and when turning on a light switch, several areas of the office were affected.

“The indoor air is fantastic here!” (Employee, Focus group 5, 6 months) “And then these light switches, you can’t find them, and you don’t know which button to press. And then, suddenly, you turn the light off…” (Employee, Go-along interview 5, 6 months) “…everything works well except that the light is uneven…as I am getting old and need a lot of light.” (Employee, Go-along interview 6 months)

In the questionnaires, access to daylight was rated lower after relocation ( p < 0.001). The perceptions of lighting quality showed no change after relocation for the whole group ( p = 0.119), but employees ≥40 years ( p = 0.031) of age reported worse lighting after relocation, while employees 20–39 years did not ( p = 0.397) (Table 3 ).

In the category time, space, and equipment as barriers for good ergonomics , employees described the ergonomic conditions as being generally good, with great possibilities for variation between sitting, standing, and walking. At the same time, they perceived office ergonomics to be deteriorated and less of a priority than before, and there were some concerns expressed about what the ergonomic consequences might be in the long run. Some thought it was difficult and time-consuming to adjust the chairs and often they choose not to. Instead, they chose to stand up while working, use another chair, or sit at the front edge of the chair. There were also employees who reported that they always took the time to set up their workstation; i.e., due to previous experience with poor ergonomics or problems with musculoskeletal symptoms.

”It takes time to adjust the chair, it’s hard. And you twist and twist and they are hard, and it probably takes 20 minutes. And I must look at the instruction manual every time…” (Employee, Focus group 11, 18 months) “I always adjust my workstation. I try to be aware of this because I have problems (musculoskeletal symptoms)” (Employee, Focus group 11, 18 months) “It’s difficult, I can only encourage them to stand up and try to vary their work posture. But from what I hear, many do not have the patience to adjust the workstations. You make some small adjustments, raise and lower the desk a little, move the monitor arm a little, but I’m not sure how much you can really customise it to your own needs”. (Manager interview 6)

Overcrowding and lack of workstations also affected office ergonomics, and informants explained that they did not always find an ergonomically suitable workstation and were forced to work on a sofa, or in the breakroom or other shared spaces, without any possibility of adjusting their chair or table or connecting the laptop to an external monitor. For example, sitting on the sofa working on a laptop led to forward bending of the neck. Other obstacles mentioned were that the technical settings on the computer could be spoiled when switching workstations if the computer had not been docked. This made employees remain at the same workstation instead of switching.

“… you only use the sofas if there’s no other workstation available.” (Employee, Go-along interview 2, 6 months)

Ratings for sit comfort and work posture decreased significantly after relocation. This decrease seemed to be driven by older employees, persons with neck- and shoulder symptoms at baseline, and women (Table 4 and Supplementary Table 2 ).

In the category, pain and how to handle the new environment , some employees report that they had more problems with headaches and back, neck, and shoulder discomfort or pain after relocation. They believed that the increase was due to difficulties adjusting the workstation. Their symptoms were triggered when the current workstation was not adjusted correctly, or when working mainly on a laptop. Informants also mentioned that they tended to sit closer to the laptop screen when doing high-concentration work.

Employees report different strategies for managing discomfort and pain in the new office. Some used the treadmills in the office to relieve back pain, while others appreciated the daily digital prompts for exercise programs. Other informants, however, felt exposed when using the exercise program in the open office environment. To achieve good ergonomic conditions and avoid discomfort and pain, individual responsibility and self-care were mentioned as being more important in the new office environment. To achieve a sustainable situation, some employees claimed a personal room or described leaving their things at the same workstation to ‘keep’ the workstation for the whole day.

“I’ve got more problems with my neck, shoulders, back, and everywhere. I’m sitting badly. I’ve had problems before and then my chair and table were adjusted to my needs. Now it’s hard to adjust all the settings every morning…” (Employee, Focus group 6, 6 months)

“…instead, I have become more selfish and pick a quiet workplace or a room of my own as quickly as I can, and don’t bother to change during the day.” (Employee, Focus group 11, 18 months)

The questionnaires showed a significant increase in reported neck and shoulder discomfort between baseline and 18 months ( p < 0.007) in the whole group (Supplementary Table 3 ). Subgroup analysis revealed that the increase in reported neck and shoulder pain seemed to be driven by younger employees; employees that reported to never, seldom, or sometimes experience neck and shoulder symptoms at baseline; and by women (Table 4 ). Those who reported musculoskeletal discomfort and muscular tension at 18 months after relocation also reported fewer possibilities to adjust their workstation ergonomically compared to those who did not (Supplementary Table 4 ).

Challenges of different needs in the workforce

In the category, various needs and preferences depending on work tasks , employees described that the type of work tasks affected the extent to which they took advantage of the new office. Employees who mainly worked on stationary screen-based work found no incentives to change workplaces during the day. In contrast, those attending many meetings needed to find new workstations between meetings, which could be a challenge, due to crowdedness. Employees with high-concentration work tasks complained that they spent time finding secluded rooms or a quiet place so they could concentrate. The possibility of arriving early at the office to secure a suitable workstation was described as a problem, as it was not possible for everyone to arrive early.

In the category various needs depending on cognitive and physical disabilities , there was a critique that individual adaptation needs were not mapped and considered sufficiently before relocation. It was emphasised that this should have been considered already during the planning phase, to be able to account for and accommodate the premises for various needs. Furthermore, it was perceived as difficult—for both employees and managers—to decide when an individual adaptation was needed, and in what cases the individual could handle their individual adaptation in the shared office environment without a targeted adaptation.

Employees perceived it to be more complicated to obtain individual ergonomic aids in the new office environment after the relocation. The reasons for this could be that they did not receive any response from management, or that they simply did not know how to go about requesting an adaptation. Some also felt hesitant about expressing their needs due to concerns about feeling singled out or stigmatised; for example, if a personal room was desired. Furthermore, it was described as easier to ask for equipment and support for physical problems than for psychological issues. Another barrier that was mentioned in the interviews was that it could be burdensome to carry around physical aids (e.g., chairs, armrests, mice, etc.) and that it took time to install them.

“The basic mistake is the insufficient mapping of needs (depending on various work tasks)…The needs vary. I think that a mix of activity-based and cell offices had been better. But the perfect office does not exist…” (Employee, Focus group 10, 18 months) ”It has to be equal for everybody, but we are all different.” (Employee, Focus group 7, 6 months)

The aim of this study was to investigate the physical work environment in an organisation after relocation from a cell office to an AFO using a mixed-methods design.

We found a need for clarified roles and updated processes to handle OHS management. We also found that managers perceived it to be more complicated to help their subordinates with work environmental issues, indicating a need to clarify how managers should handle individual accommodations for employees. Our results regarding OHS management may have been reinforced by the shortcomings of the office design, with crowdedness and perceived challenges finding suitable workstations for concentrated work. The crowdedness itself is an indicator of the lack of holistic OHS management, as no one had the overarching responsibility for the number of employees located in the building. Babapour et al. ( 2019 ) also found it important to establish continuous, proactive, and inclusive processes for customising AFOs after relocation to address work environmental problems, and highlight the need to pay close attention to OHS managerial processes in organisations once AFOs are implemented. Our results also illuminate the importance of establishing new ways of organising OHS management. In the post-pandemic situation, when hybrid work is more common, this complexity might increase further. Organisations need to find ways to manage OHS to avoid the possible negative aspects of working from home and blurry lines in work environment responsibility.

Both qualitative and quantitative data revealed that ergonomics and musculoskeletal symptoms after relocation to ABW were negatively affected. Quantitative data suggest that this was driven by young female employees with low or no symptoms at baseline. The qualitative data revealed that desk sharing in AFOs could challenge ergonomics due to the time it takes to set up the workstation, the knowledge of how to adapt the workstation, and the availability of the right space and equipment. In line with our results, Berthelsen et al. ( 2018 ) also reported decreased sitting comfort and working postures after relocation to a flex office, and another Swedish study (Babapour Chafi and Rolfö 2019 ) found that limited time and knowledge could be a barrier to proper ergonomics in flex offices. A recent cross-sectional study found no differences in pain prevalence in most body areas when comparing workers in AFOs and cell offices, but workers in AFOs reported significantly more pain in the right hand, wrist, and fingers, and authors discuss that this might be explained by the daily use of different workspaces and work equipment (Argus and Paasuke 2021 ). In line with our results, Kim et al. ( 2016 ) found the shortage of available desks on busy days and the need to provide easy-to-adjust chairs and desks to be important from an ergonomic perspective in AFOs. Contrasting our results, Meijer et al. ( 2009 ) found decreased musculoskeletal symptoms after relocation from shared cell offices to an innovative office with desk sharing. In their study, the furniture before relocation was not adjustable and employees were not informed about how to properly adjust them, while more ergonomic furniture was purchased for the new office. These differences might explain the different findings of Meijer et al. ( 2009 ). Robertson et al. ( 2008 ) also found positive effects on the prevalence of musculoskeletal discomfort after relocation to AFOs, especially in the group of workers who participated in the development of the workspace design and in a two-hour ergonomic training session. Therefore, it is likely to be of the utmost importance that organisations implementing flexible office environments make sure their employees have good knowledge of why and how to set up their workplace (Sanaeinasab et al. 2018 ). In our study, employees were offered a non-mandatory ergonomic training session and an individual ergonomic consultation if they wanted them. Unfortunately, we have no data on the attendance rate for the training session, but they were rarely mentioned in the interviews, which leads us to believe that attendance was low. The implemented intervention during the study period, aiming to decrease sitting and increase physical activity, showed no changes in sitting time or in the temporal patterns of sitting at work, but there was an increase in time spent walking and in moderate-to-vigorous physical activity in the group relocating to the flex office (Wahlström et al. 2019 ). Thus, the reported changes in perceived sit comfort, working posture, and musculoskeletal pain were likely unaffected by any changes in the temporal patterns of sitting or standing. If any, the effect on ergonomics from the intervention should be a mitigating effect on physical activity, as it is associated with fewer musculoskeletal symptoms.

We also found that older employees reported the lighting to be less satisfactory after relocation. These results illuminate the need to take various needs into account when designing visual ergonomics in the office (Peiyi 2014 ; Erdinest et al. 2021 ). The choice of lighting design and control strategies for lighting depends on different factors, such as the number of workers who use the surface, the visual tasks to be performed, and the visual abilities of occupants; e.g., age or other conditions affecting vision (Osterhaus et al. 2015 ). Before relocation, all cell offices were located along the façade, with direct access to windows and daylight. After relocation, the full depth of the building was utilised for workstations, which led to less availability of daylight and limited access to windows. Based on information in the interviews, we found that the reasons for this deterioration could also be due to perceived difficulties in handling the light switches, which might have caused insufficient and unevenly distributed indirect lighting. Visual comfort has been shown to impact productivity, health, and overall comfort among office workers (Peiyi 2014 ; Robertson et al. 2016 ; Candido et al. 2019 ). Our results exemplify the importance of providing good visual ergonomics via a lighting design with sufficient indirect lighting and the availability for direct lighting where needed, especially for older workers (Osterhaus et al. 2015 ). To our knowledge, there are no previous longitudinal studies investigating the effects of visual comfort in AFOs, and further studies are needed.

Furthermore, we found that the AFO did not match the prerequisites with the variety of work tasks performed within the organisation. This affected the extent to which employees perceived how they could benefit from the AFO. Employees in the AFO with concentration-demanding work tasks complained about the time spent searching for a suitable secluded workstation. This could potentially affect productivity, since work tasks and a high degree of workspace switching have been shown to be positively associated with productivity and well-being in AFOs (Seddigh et al. 2014 ; Haapakangas et al. 2019 ). Previous results from the AOD study (Öhrn et al. 2021 ) also indicate that flexible and interactive work tasks are more appropriate in AFOs compared to individual high-concentration tasks, and a recent Finnish study (Haapakangas et al. 2022 ) found that both task-related (related to interactive needs, concentration demands, and managerial position) and person-related factors (age, sex, work ability, and satisfaction with ergonomics) influenced the use of the office and the perception of the person–environmental fit of the AFOs.

Our results highlight the importance of planning and accounting for workers’ individual accommodation needs when relocating to AFOs. In the current study, both managers and employees described various challenges in handling individual workplace adaptations after relocation. The finding that employees with musculoskeletal discomfort reported fewer possibilities to adjust their workstations ergonomically in the AFO is important, since workplace adaptations and workplace support seem to be of great importance in allowing people with disabilities to participate in the workforce (Anand and Sevak 2017 ). Research on the need and use of work accommodation in terms of adaptations and adjustments to work support is limited, especially in relation to different office types, and to our knowledge, there are no studies regarding workplace adaptations in AFOs. However, studies have shown that the most-needed workplace adaptations are modifications to and accommodations in the work environment and work tasks; for example, scheduling flexibility and accessible workstations (Jetha et al. 2021 ). A recent paper highlights the need to offer an inclusive environment for all employees and describes the development of a post-occupancy method to evaluate inclusion, diversity, equity, and accessibility in the built environment (Zallio and Clarkson 2022 ). When implementing AFOs, we suggest that a thorough analysis of work tasks and individual needs should be performed in the planning phase, to be able to design the premises in the best possible way for all employees.

Methodological considerations

The strengths of this study are its long-term follow-up, the rich qualitative data, and the high response rates on questionnaires providing complementary data and a possibility for a deeper understanding of the sociocultural context and the real-world environment for workers and managers (Gjerland et al. 2019 ). When using mixed methods, the researcher will end up with a more comprehensive and complete understanding of the problem and potential solutions (Vedel et al. 2018 ). The qualitative data offers information on how participants interpret and explain their thinking and behaviours when handling, i.e., workplace ergonomics, and thereby offers clues as to possible preventive actions. The use of qualitative content analysis is suitable for studies with an exploratory purpose and repeated discussions among the authors, and when combined with presentations and reflections from other researchers involved in the AOD study it also strengthens the trustworthiness of the study (Priest et al. 2002 ). This offered the possibility to identify how the combination of a poor office design combined with management failure to prepare employees for the transfer to AFOs seemed to lead to a deterioration in employees’ ergonomic situations and increased musculoskeletal symptoms after relocation. Relocating to an activity-based office does not just involve a change in office design, but implies a whole new way of working, and the individual adaptation to the organisational change is likely to differ between employees. Therefore, a strength in our study is the long-term follow up which has given employees the opportunity to adapt to the new work situation.

Weaknesses that merit mentioning are that the study was conducted within a single organisation in Sweden and that the current study includes no formal control group. As organisations differ substantially in terms of work environment legislation, OHS management, and how the AFO implementation process is performed, the transferability of our findings might be limited. In this study, simultaneous activities and processes—such as the programme for promoting physical activity and the sizing issues, leading to crowdedness—could affect the results. By providing detailed descriptions of the context, study design, participants, analysis process, and by using quotations from study participants, we have facilitated the reader’s ability to interpret the transferability of the results (Nielsen and Randall 2013 ). In the interviews, the informants were men and women, and managers and non-managers of various ages, which could be assumed to be a representative sample. However, the representation of informants could be biased, as employees who have strong opinions, both positive and negative, might be more prone to sign up for participation when invited to interview. However, data from the interviews showed a large variation, which suggested that the results capture a wide range of experiences, opinions, and feelings that both workers and managers had in relation to the AFO. In sum, we believe that the results could be applicable not only to organisations in Nordic countries but also in a wider international context.

In the future, hybrid work is expected to increase (Hopkins and Bardoel 2023 ), and our study brings forward important aspects of work environment issues in relation to flexible work environments. Ergonomic concerns as a risk of remote work have been highlighted before, and the International Labor Organisation points out that training and awareness initiatives for both employees and managers are needed to handle the potential risks of remote work (ILO 2017 ; Chafi et al. 2021 ). Even though the legislation might differ between different national contexts, OHS management is likely to become more individualised. We argue that when working in AFOs or remotely, there is a shift towards increased individual responsibility for occupational health risks, which means that employees need to be equipped with both knowledge and adequate tools.

Practical implications

To create a sustainable work environment and a healthy workforce, employers must take preventive measures when designing the office. Further, to settle OHS issues, organisations must engage in continuous dialogue between concerned stakeholders, with the aim of clarifying areas of responsibility and processes related to the flexible work environment. A practical implication of our study is also that ergonomics still matters, and we suggest that ergonomic training for all employees should be mandatory if working in an AFO with desk sharing. Our results also highlight the importance of equipping the office with furniture and equipment that are easy to use and robust enough to withstand repeated changes in settings.

Conclusions

The implementation of AFOs based on activity-based work is a complex process. Our findings indicate a need to reorganise and clarify roles and processes for OHS management when implementing an AFO. We also found office ergonomics and musculoskeletal symptoms to be negatively affected after relocation. These effects were influenced by a combination of factors, such as difficulties adjusting the workstations, a lack of suitable workstation due to crowdedness, age, sex, and a variety of needs relevant to different groups as well as individuals. Long-term health effects after implementing AFOs are understudied, and there is an urgent need for more longitudinal studies in larger samples to increase knowledge and support organisations and policymakers in successfully handling the complex process of implementing AFOs.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author only upon reasonable request. Data are located in controlled access data storage at Umeå University.

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Acknowledgements

We thank all study participants and Örnsköldsvik Municipality for their cooperation. We also thank Maria Nordin, Lisbeth Slunga Järvholm, and Christina Bodin Danielsson for reflecting on our preliminary results.

This work was funded by AFA Insurance (grant number 140308, 2014) and Region Västerbotten. The funders had no role or influence over the study design, data collection, analysis, interpretation of the data, or the decision to publish the results.

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Published: 10 May 2024

Translating global evidence into local implementation through technical assistance: a realist evaluation of the Bloomberg philanthropies initiative for global Road safety

Rachel Neill ORCID: orcid.org/0000-0002-1110-5479 1 ,
Angélica López Hernández 1 ,
Adam D. Koon 1 &
Abdulgafoor M. Bachani 1

Globalization and Health volume 20 , Article number: 42 ( 2024 ) Cite this article

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Traffic-related crashes are a leading cause of premature death and disability. The safe systems approach is an evidence-informed set of innovations to reduce traffic-related injuries and deaths. First developed in Sweden, global health actors are adapting the model to improve road safety in low- and middle-income countries via technical assistance (TA) programs; however, there is little evidence on road safety TA across contexts. This study investigated how, why, and under what conditions technical assistance influenced evidence-informed road safety in Accra (Ghana), Bogotá (Colombia), and Mumbai (India), using a case study of the Bloomberg Philanthropies Initiative for Global Road Safety (BIGRS).

We conducted a realist evaluation with a multiple case study design to construct a program theory. Key informant interviews were conducted with 68 government officials, program staff, and other stakeholders. Documents were utilized to trace the evolution of the program. We used a retroductive analysis approach, drawing on the diffusion of innovation theory and guided by the context-mechanism-outcome approach to realist evaluation.

TA can improve road safety capabilities and increase the uptake of evidence-informed interventions. Hands-on capacity building tailored to specific implementation needs improved implementers’ understanding of new approaches. BIGRS generated novel, city-specific analytics that shifted the focus toward vulnerable road users. BIGRS and city officials launched pilots that brought evidence-informed approaches. This built confidence by demonstrating successful implementation and allowing government officials to gauge public perception. But pilots had to scale within existing city and national contexts. City champions, governance structures, existing political prioritization, and socio-cultural norms influenced scale-up.

The program theory emphasizes the interaction of trust, credibility, champions and their authority, governance structures, political prioritization, and the implement-ability of international evidence in creating the conditions for road safety change. BIGRS continues to be a vehicle for improving road safety at scale and developing coalitions that assist governments in fulfilling their role as stewards of population well-being. Our findings improve understanding of the complex role of TA in translating evidence-informed interventions to country-level implementation and emphasize the importance of context-sensitive TA to increase impact.

Road traffic crashes are the leading cause of death for persons aged 5–29 years age [ 1 ], and the 12th leading cause of deaths overall [ 2 ]. Road traffic mortality is three times higher in low-income countries than high-income countries (HICs), despite low-income countries having less than 1% of global motor vehicles [ 2 ]. Over half of traffic-related deaths are vulnerable road users (e.g., pedestrians, cyclists, and motorcyclists) [ 2 ].

Attention to road safety has grown, supported by evidence on the severity of the problem and solutions [ 3 ]. Successive ‘Decades of Action for Road Safety’ have raised awareness, and new institutions have improved policy cohesion and civil society mobilization [ 3 ]. The global road safety community has also cohered around a consensus-based solution – the safe system approach – developed in Sweden and increasingly applied globally. The safe system approach is a human-centered, proactive approach that shifts the focus of road safety from preventing crashes and improving road user behavior to preventing deaths and injuries while accounting for human error [ 4 ]. Despite global momentum, there is limited implementation of the safe system approach in low- and middle-income countries (LMICs) [ 3 , 5 , 6 ]. Global road safety programs emphasize the adaptation of the safe systems model to LMICs [ 5 , 7 ], even though the implementation context in LMICs varies significantly [ 8 ].

The role of technical assistance

Technical assistance (TA) is one way to increase the uptake of the safe system approach and other evidence-informed interventions. TA is a capacity-building process to design and/or improve the quality, effectiveness, and efficiency of programs and policies, [ 9 ]. Multi-country TA programs seek to translate the safe system approach to LMICs to reduce traffic-related injuries and mortality. The Bloomberg Philanthropies Initiative for Global Road Safety (BIGRS) is one of the largest and longest-standing multi-country road safety TA programs. This analysis concerns BIGRS Phase II, which provided a common package of TA interventions to ten LMIC city governments from 2014 to 2019. By the end of Phase II, cities differed considerably on the scale and scope of implementation.

BIGRS’ differential experiences across LMIC cities present an empirical case study on the feasibility of adapting common technical approaches across divergent contexts and the TA’s role. How much influence does TA have? What is the role of context in shaping TA providers’ and recipients’ agency?

A diverse body of scholarship concerns these questions and can guide empirical inquiry. Diffusion of innovation theory describes the process of transferring an evidence-informed intervention from one setting to another [ 10 , 11 ] and has been used to explore TA effectiveness [ 9 ]. Diffusion of innovation theory focuses on intervention characteristics, intervention adaptation, and how adaptation influences adoption and fidelity [ 10 , 11 , 12 ]. Greenhalgh’s Determinants of Diffusion, Dissemination, and Implementation of Innovations in Health Service Delivery and Organization Conceptual Model builds on diffusion of innovation theory by mapping considerations that influence the uptake of innovations. These include credibility, personal relationships, effective communication,translation of the innovation to meet end-users needs, and support to adopters [ 12 ]. More broadly, social science theories consider the role of structural context (e.g., laws, social norms, and governance) and pragmatic implementation contexts (e.g., individuals, relationships, and organizational cultures) in determining adaptation, and implementation [ 13 ]. These literature bring different perspectives to explain change through the interaction of interventions, actors, and context.

However, there is limited application of this literature to understand TA, especially road safety TA. A growing body of case studies describes what works and does not work for improving road safety in LMICs [ 14 , 15 , 16 ]. Limited research emphasizes political will, intervention tailoring, human and financial resources for dissemination [ 17 ], the best practice exchange [ 18 ], technology transfer [ 19 ], and the power of multi-sectoral coalitions [ 20 ] to translate road safety evidence into practice. However, despite the existence of several multi-million-dollar road safety TA and funding programs [ 21 , 22 , 23 , 24 , 25 ], we did not identify any evidence on the role of TA in supporting or inhibiting road safety improvements – a key evidence gap.

Study objective

This study aims to improve understanding of if, how, why, and under what conditions TA programs strengthen evidence-informed road safety programs in LMICs. We do this via a realist evaluation with a multiple case study design of BIGRS’ implementation, comparing how common TA interventions interacted with contextual factors to produce differential observable outcomes in Accra, Bogotá, and Mumbai. These findings are distilled into a program theory that provides insight into how ‘global’ approaches are translated to country-level implementation and can be used to guide TA’s design and implementation.

Realist evaluation connects theories of ‘how the world works’ with ‘how a program works’ to explain how interventions trigger mechanisms in different contexts [ 26 ]. We used a realist evaluation methodology [ 27 ] to identify how, why, and under what conditions TA can strengthen evidence-informed road safety, with a multiple case study design to improve understanding of how BIGRS worked in diverse contexts [ 28 , 29 ] [ 26 ]. This methodology was selected to identify the underlying mechanisms driving the program’s differential outcomes in different contexts [ 27 ].

Realist evaluation

Programs are theories about how something works. They are embedded into open systems and adaptively interact with the context. Intervention outcomes result from engagement between program actors and contexts [ 27 ]. An intervention-context-mechanism-outcome pattern (ICMO) represents this [ 27 ] (Table 1 ).

We adhered to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMSES) II reporting guidelines for realist evaluation to guide design, data collection, and analysis [ 26 ], provided in Additional File 1 . The study protocol is in Additional File 2 .

Study setting

Bloomberg Philanthropies’ BIGRS Phase Two was implemented in Accra, Addis Ababa, Bandung, Bangkok, Bogotá, Fortaleza, Mumbai, Ho Chi Min, Sao Paulo, and Shanghai from 2014 to 2019 and is the focus of this study. BIGRS is currently in its third phase and has scaled up to 27 cities and two states across Latin America, sub-Saharan Africa, and Asia.

Cities applied for BIGRS-supported TA by submitting a proposal that demonstrated their commitment to and plans for road safety. This is important because it meant that cities demonstrated a common commitment and desired TA, at least in theory. Funding for interventions (e.g., re-designing an intersection or mass media campaigns) came from city governments.

BIGRS’ TA came with a technical agenda – aligned to the safe system approach – on how road safety should be improved. BIGRS’ scope was tailored to city needs within pre-existing parameters and excluding funding for capital construction. To provide TA, BIGRS seconded staff into leading road safety agencies to build institutional capacity for change. Embedded staff supported BIGRS interventions, provided direct TA to city counterparts, and often, provided cross-cutting support to city officials. In addition, seven international partner organizations managed technical activities. Partners and embedded staff were aligned to technical areas and often worked with different counterparts (e.g., an enforcement partner working with the police, an infrastructure partner working with an engineering unit).

Case design and sampling

A multiple case study design was utilized; see Additional file 3 for details. Only cities continuing into BIGRS Phase Three were eligible for selection to ensure access to informants. We purposefully selected three cities – Accra, Ghana; Bogotá, Colombia; and Mumbai, India – with different baseline characteristics described in Table 2 .

Data collection

Key informant interviews (KIIs) were our primary data source, and documents were secondary. Program documents were used to build an initial program theory, develop the interview guides, and follow ‘hunches’ about how an intervention worked in a context [ 35 , 36 ]. We also snowballed documents from interviews to confirm and triangulate interview findings.

Key informant interviews

We used a theoretical sampling approach to select informants based on their ICMO potential [ 27 ]. We iteratively sampled informants until saturation – when interviews provided no new insights [ 37 ]. Table 3 describes the KII sample. Road safety governance models influenced the balance of KII types. Road safety governance in Accra and Mumbai is more diffused than Bogotá, which had fewer government informants. KIIs also varied across cities due to differential access to informants. To overcome this disadvantage, we triangulated findings with the document review.

Interviews were conducted from January 2020 to November 2022 by two members of the research team with doctoral-level training in qualitative methods. Participants were contacted via email and invited to a one-hour interview on barriers and enablers to BIGRS and mechanisms associated with program outcomes. Interviews in Mumbai were conducted via Zoom. Interviews in Bogotá and Accra were conducted in-person and on Zoom.

A realist approach to interviewing was used to build an iterative understanding of how the program worked, test our interpretations, and seek alternative explanations (Additional file 3 ). Interviews were recorded and transcribed with permission. Fifty-one interviews were conducted in English, recorded, and transcribed. Seventeen interviews were conducted in Spanish by a native speaker, recorded, transcribed, and translated into English by a certified translator.

Data collection and analysis were done iteratively using a process of retroduction [ 35 , 36 , 38 ] (Fig. 1 ).

Iterative analysis process

As is common in this literature [ 39 ], BIGRS’ theory of change (TOC) was used as the initial program theory (IPT). Following guidance on realist evaluation analysis [ 38 ], we iteratively identified ICMOs and compared them to the IPT and broader literature to develop the program theory. This included an initial thematic coding of the data, a second round of theory refinement coding where themes were split into ICMOs, triangulation of findings from the documents and interviews, and comparison of the findings with existing theory to deepen our understanding of plausible mechanisms. Additional file 3 describes this process in more detail. We conducted this analysis in NVivo12.

Regular discussions were held across the research team to define and iterate on the codebook, discuss emergent themes, and review ICMO configurations. Memos were developed in Microsoft Word and documented ICMO iterations. Draft findings were shared with a subset of the participants for feedback and validation before program theory finalization.

In 2014, BIGRS initiated a common TA program in Accra, Bogotá, and Mumbai. TA interventions, individuals providing and receiving TA, the city context, and the national-level road safety context influenced implementation. Table 4 outlines interventions and outcomes. Interventions are grouped under two outcomes: (1) improved road safety capabilities (via capacity building and data) and (2) increased the uptake of evidence-informed road safety interventions (via infrastructure, enforcement, and policy support).

We present one example per case that demonstrates how different interventions worked together to achieve different outcomes in case study cities. Interventions (i), mechanisms (m), contexts (c), and outcomes (o) are denoted in the text. Reference to KII data is provided as M# for Mumbai, B# for Bogotá, A# for Accra, and G# for KIs working across multiple cities.

Transforming junctions on Mumbai’s congested streets

When BIGRS began, Mumbai’s road safety officials used high-level figures on traffic fatalities supplemented with national or state-level statistics to guide road safety decision making (c) . The city-specific data required to target road safety interventions was buried in paper-based police records of variable quality (c) . A government official in Mumbai describes:

" That is [a] very big [problem] because we are not like other countries, we are not getting the data correctly.” – M17

In response, BIGRS’ TA first sought to improve surveillance data. An embedded surveillance coordinator partnered with the police to catalog and analyze city surveillance data and package it in new annual city road safety reports (i) [ 40 ]. Infrastructure assessments (i) further demonstrated how specific road junctions contributed to injuries and mortality (o). BIGRS staff described the change in data availability:

“[Before] there were no reports at all […]. Now I have […] a 40-page report that talks about who the road users are, […] a list of high-risk junctions and corridors […], a map that details the hotspots where crashes are occurring […] which vehicle is causing maximum crashes, […] the time of the day, the month of the year, the day of the week.” – M8

New data demonstrated that half of traffic-related crash victims were pedestrians, which was further reported by local city media [ 41 , 42 ]. Providing granular, city-specific data shifted the focus (m) of government towards pedestrian safety (M8, M12, M17). The same BIGRS staff member described:

“The government didn't know that so many pedestrians were dying in crashes. These reports help bring that to light. And when that came to light, they started taking a more serious approach.” – M8

The emphasis on pedestrians was echoed by city government officials, who agreed that the data was illuminating (M12, M17). But the city also required solutions for this perception shift to lead to concrete action. The same government official describes the challenges (c) :

“We lack the best instrument in the old system to make the road elevated, or a road underpass is very difficult because the traffic on that high main road. […] That is very critical because it we are really facing problems.” – M17

BIGRS provided the safe system approach as a solution– but how would it work in Mumbai? This question was a central concern in all cities, especially in densely populated Mumbai, where participants described the street as a ‘contested space’ (M9, M2, M21) (c) . Implementing the safe system approach in Mumbai required a complex adaptation process (G5, M2, M9, G6, M7) (i) . A BIGRS infrastructure partner described:

“We’re constantly trying to balance Global Best Practices versus what can be done in an Indian city while pushing boundaries to be able to think outside the box. […] it's helpful to show International Best Practices, but also at the same time, balancing it out with what’s actually possible in Indian cities.” – M9

Implement-ability was top of mind for city government officials taking risks by trying a new approach (c) . BIGRS staff had to recognize those risks and work collaboratively with city government counterparts to understand how international approaches could work within local realities (B15, M13) (c) . A BIGRS staff member described this:

“[When you introduce international examples], there are a lot of questions and pushback saying, ‘how could this be done [here]? That was also instructive to us. How do you deal with such situations?” – M13

Short-term demonstration projects – for example, temporarily changing traffic flow using cones and other local, low-cost materials (i) – allowed city government counterparts to see the safe system approach in action on their street in a low-risk context, demonstrating that a new approach was possible (B15, M11, G7, M9, B7, M17). A city official describes:

“People are generally not aware of the things [happening outside India], [but] the problems are same. […] That can be taken only if you can show them the models […] because firsthand information from those people is much more important.” – M17

Seeing the possibility of change was perceived to shift the focus of road safety towards vulnerable road users and especially pedestrians (M18B, B15, M11, G7, M9, M15, M18, M17, M2, G2, M9, M7, M14, M8) (m) . It also created a ‘how-to’ moment, enabling city government counterparts to internalize both the concept and implementation feasibility (m). A city official describes what he learned:

“[I learned] new technical things, that might be there's been a certain technical change in junction design or in the road design. […] we were not able to do that thing nicely already […] We were able to grab that opportunity properly.” – M18

Once city government counterparts understood the potential of the safe system approach (o) , BIGRS TA worked with city officials to use the data and select specific junctions for re-design (i) . Data was critical because it helped target infrastructure improvement to junctions with an outsized number of crashes. A BIGRS staff described:

“Now [Mumbai city government are] not just randomly doing the interventions. They're very focused on where crashes are occurring, who the victims are, who the perpetrators are, and how to ensure that these crashes don't occur at all.” – M8

Once the mechanism for change was triggered, transforming junctions started with a pilot (i). Pilots ensured that the safe systems approach was feasible and appropriately adapted to the context, that its impact on different road users was understood and planned for, and that the re-design successfully reduced crashes [ 43 , 44 , 45 ]. Pilots also allowed the city government to understand public sentiment about the changes (c) [ 43 ] . If the public was supportive, this reduced the risk to city officials trying a new approach (m) . The city government counterpart’s confidence in new approaches grew (m). This was further reinforced by data showing that infrastructure redesign positively impacted traffic flow [ 43 ]. A pilot’s success was described as leading to exponential growth in implementation (M21, M1) [ 44 , 46 , 47 ]. A BIGRS partner described:

“If you see our work, it has exponentially grown in impact. […] From that one [pilot] corridor, we […] build a relationship and trust […] and so we got a chance to do design in the intersection. Then you try it with temporary sort of barricades and then it became a big thing. And then one thing just kept leading to another to another.” – M21

As implementation took off, BIGRS engaged local media to spread awareness about the junction transformations (i) (M11). After seeing firsthand what could be accomplished, the city government also committed to improving high-risk intersections in the city. However, despite growing momentum and support from both city government and city engineers to transform individual junctions, the bottom-up pilot approach presented practical scale and sustainability challenges despite this government commitment (M9, M13, documents) (c). A BIGRs partner described:

“It's a challenge at times, when the city does not have the funds allocated in that year. If you do manage a successful pilot and the city takes on doing it, then it's great because they can be scaled up. But in many cases […] pilots are sort of left as just that.” – M9

BIGRS partners described city government approvals as challenges preventing scale. In contrast, city government participants urged respect for government processes and timelines, which they saw as paramount to success (c). In managing these processes, city officials also took on significant work to enable each infrastructure re-design (M12, M18) – a contribution that often went unacknowledged (c).

Comparison of Mumbai’s infrastructure experience with other BIGRS cities

The Mumbai infrastructure example is illustrative of common dynamics. In Bogotá, capacity building was similarly perceived as successful when it used hands-on components specifically relevant to the participants (B15, G2, B9, B7, B14), and when facilitators used a coaching model that emphasized the participant’s experience (B15, B5, B9, G2).

Accra’s and Bogotá’s infrastructure TA were also targeted at bottom-up approaches (G6, A9, A5, A6, A8, M9) and guided by city-specific data (i ), but with limited scale. In Accra, BIGRS focused on low- or no-cost interventions (e.g, changing signal times for pedestrian crosswalks, widening pedestrian medians (i) ) (A5, A6, A8) because the city did not control the infrastructure budget and could not budget for new interventions. BIGRS also worked with the city to re-design the infamously dangerous Lapaz intersection to improve pedestrian safety, which was funded directly by BIGRS via a small grants program (i) [ 48 ]. In Bogotá, tactical urbanism demonstrated speed-calming measures, and feedback from road users was gathered (i) (B2). However, despite promising pilots, the lack of BIGRS’ ability to influence upstream changes to road procurement tenders and design guidelines limited the scale of infrastructure outcomes in each city.

Enforcing road safety legislation in Accra

In Accra, road safety legislation existed but needed to be enforced (c). In the words of a national road safety agency staff , “there’s no real commitment in solving some of these things.” (A17). BIGRS’ enforcement interventions started with relationship building (i). A BIGRS partner describes:

“How important it is to have this relationship with the high-level police officers. Because we cannot just go to a city or road police agency and say that this is what we want to do.” – A22

Trainings on the safe systems approach (i) and evidence-based enforcement operations were enabled by leadership support from the Superintendent of Police (A4) and the Mayor of Accra who championed road safety and several BIGRS initiatives (A4, A6, A3, A5, A8, A1, program documents) [ 48 , 49 ] (c) .

However, translating training into implementation quickly stalled because the police force required equipment and certification for implementing enforcement operations (c) (A1, A4, A6, program documents) . BIGRS’ partners then donated new drink-driving and speed enforcement equipment under the condition that the city utilized the equipment to conduct enforcement pilots (i) . These donations were accompanied by training and certification processes (A1, A4, A25, program documents) (c) .

While the lack of equipment could be directly addressed by BIGRS, the disconnect between city-level enforcement efforts and Ghana’s centralized policing structure could not be so easily overcome. City police did not have the authority to conduct enforcement operations (c) , so in exchange for the donated equipment, the police formed a dedicated tri-partite pilot task force with the authority to use the donated equipment in a series of roadside speed and drink-driving enforcement operations (i) .

New training and improved accuracy of the equipment were perceived to reduce conflict between police and citizens during enforcement and improved transparency in the enforcement operations (A1, A4, A25, program documents), reducing the perception of risk of public blowback (m). A high-ranking police officer describes the perceived increase in acceptability from the public:

“they don’t complain, they go to the court […] because you’ve told us that the device arefor enforcement operations (A4, A25) limiting further […] the very latest speed device, speed detection devices [equipment] because we’ve told the whole world about it.” – A25

The collective intervention – piloting the enforcement approach, supported by training and in tandem with appropriate equipment – was also received positively by the police. A senior police officer described a shift in focus towards ensuring road safety (m):

“What I’ve realised is, what a positive impact on our capability to be able to ensure road safety. [..]. With the devices, we can go to the route when they see us, all cars, cars you know approaching the robot, reduce their speed and that has really resulted in a lot of improvement.” – A25

However, while the pilot taskforce did conduct enforcement operations, a series of upstream barriers prevented the taskforce from scaling up. Most practically, the police force still lacked dedicated vehicles for enforcement operations (A4, A25) limiting further implementation. More broadly, the social and political context (A1, A4) (c) remained unconducive to enforcement. A BIGRS staff describes:

“During [the enforcement pilot], we did a special round of data collection for speed, and the data showed that there was a reduction in speed. However, the moment could not be sustained. Some of the feedback they got from the police was that [the] police could not boldly or fearlessly enforce.” – A1

Another challenge was that the required authority to change enforcement practices was vested in national agencies instead of the city government, limiting the ability of city police to institutionalize new enforcement operations (A4, program documents) (c). Finally, the transfer of police was described as a challenge to sustaining enforcement interventions (A4, A2, program documents) (c). A BIGRS partner described:

“We can work with person, everything agreed, and then just before we roll out, he's been transferred or there's a rotation, and we have to change everything.” — A22

Comparison of Accra’s enforcement experience with other BIGRS cities

Across the enforcement TA provided in the three cities, building trust with senior police officers was repeatedly emphasized (A4, B4, M16, G7, G10). Using former senior police officers from other countries was seen as key to building that neccessary trust (B4, M16, G7, G10) (c).

Like Bogotá, Accra’s enforcement interventions took place within broader city road safety prioritization (c), and BIGRS donations ensured police had the right equipment (i) , leading to increased enforcement (B8, G12, A4, A1, A22, A25) (o) . However, Bogotá’s enforcement was described as widespread and sustained (B8, G12), while in Accra, enforcement operations remained limited (o). The authority of the police to conduct enforcement was the key difference (c).

In contrast, India was moving towards an automated speed enforcement model, which contrasted with the model proposed by BIGRS (c) . Although automated and roadside enforcement co-exist (and they did in Bogotá), BIGRS’ roadside enforcement model did not align to the broader policy agenda in Mumbai and was not implemented.

Reducing city-wide speed limits in Bogotá – an example of policy change

Before BIGRS, improved mobility had been the focus of several consecutive city administrations (c) . A BIGRS partner described the favorable baseline environment:

“Bogotá has been concerned about road safety for a long time. [Bogotá] already had a Road Safety Directorate; […] there was already a direction with a super great team. It was easy to work in Bogotá because institutionally, they were already armed.” – B13

During Phase II, a new Secretary of Mobility with a public health background further elevated road safety in city administration (c) which was perceived as critical to the city's subsequent policy change (B1, B11, B12, B13, B14, B15, B16). A city official explained:

“ It is about setting priorities. So, we [the secretariat], from the first day, said the priority is road safety, and we will do everything possible to make it so.” – Bogotá 2

Alongside a change in government, BIGRS also hired new embedded staff, some who were former members of city government, all who were local to Bogotá, and all who were passionately committed to improving road safety (c) (B12). However, support for road safety did not immediately translate to speed. Instead, city officials were interested in reducing drunk driving and were explicitly resistant to tackling speed ( c) . This was due both to concerns that reducing speed would increase traffic and also a perceived lack of concern from the population over speed (G12, G5, B8, B12). A BIGRS staff recalled:

“Even when communicating to [the] Mayor, he had the issue of road safety in his heart the main thing he communicated and did not want to do. ‘Do not slow down on arterial roads’” – B12

However, BIGRS’ analyses of city data (i) identified that speed was a serious concern on arterial roads at night (B8, B12, G5, G8). A BIGRS partner in Bogotá described:

“The first thing I did was share with the Police the data that clearly showed that most of the deaths occurred at night or early in the morning when most roads were empty.” – B8

This was further demonstrated by a modeling study (i) showing both the relationship between speed and the crash rate and that the change in speed limits would not impact average travel times. This study was important evidence, which was only possible because the city’s existing speed detection infrastructure provided the modeling data (B12) (c).

The presentation of this novel information to city officials was perceived to shift the focus of city officials by demonstrating that speeding was prevalent at night when roads were empty, and that reducing speed wouldn’t worsen traffic (m) . City officials used this data to select five arterial road corridors with high speeds, crashes, and deaths to pilot a reduced speed limit of 50 km per hour (kmph) (o and i) .

The speed reduction pilot required close collaboration between the Secretariat of Mobility and the police to conduct nighttime enforcement (c). However, the police lacked necessary nighttime radar equipment (c) (B8, G12), a gap subsequently filled by BIGRS’ donations (i) . TA was provided for the police to use the equipment and to conduct safe nighttime operations (i), increasing enforcement campaigns in the pilot speed management corridors (o). A BIGRS staff described:

“ [It] was clear when you make enforcement operations visible, like speed enforcement down that avenue. In a matter of months, we already saw a reduction [in speed].” – G12

The new roadside enforcement was complemented by automated speed detection cameras ( c) ; however, the public was skeptical of the speed cameras' threatening the pilot’s success (c). Public messaging campaigns were therefore developed using city data to demonstrate the rationale behind the speed reduction and enforcement ( i ). A BIGRS staff described:

“Legitimacy has to do with road users' acceptance of this type of control. […] What decisions were made? Make visible the places where photodetection cameras are installed. They were published on the website of the Ministry of Mobility, and there was a strong media drive to make these cameras visible and associate the cameras with the issue of life-saving cameras.” –B8

BIGRS also provided monitoring and evaluation support (i) which quickly demonstrating the pilot’s effectiveness (o). A BIGRS staff described:

“In a matter of months, I already saw a reduction [in deaths]. That gave the Secretary of Mobility the confidence, trust like, ‘OK, like this is working, we are reducing deaths where we are not messing up traffic. Let's do it.’” – G12

A city official recalled the importance of the pilots:

“Yes, yes, yes, that was very well done. The expressive power of those corridors, of the first ones” – B14

Because of the positive pilot results, the city increased the number of corridors with lowered speed limits (o). The results of the pilot were also shared with the public, reinforcing the message that the speed reduction corridors were lifesaving interventions (G12, G5) (i) and further reducing the perception of risk in lowering the speed limit by building public support (m). As the pilot gained increased support, city counterparts used the data to develop a technical document justifying the lowered speed limits to Bogotá’s city council. A BIGRS staff described:

“To be able to argue before the City Council, it was necessary to argue with objective judgment elements […] Why did they decide to slow down? Not because it occurred to us. No, the speed was lowered because this technical document allows us to support making that decision.” – B8

Aided by the pilot’s success and with the support built through public messaging campaigns, the city council maintained the 50 km/h speed limit on the pilot corridors (o). However, the city council initially did not have the authority to change city-wide speed limits permanently (c), preventing scale-up until a window of opportunity opened in 2020. During the 2020 COVID-19 pandemic, a state of emergency was declared, giving temporary executive authority to the Mayor (c) . Although the Secretary of Mobility (the champion of the pilot) had changed, their successor became a new champion. They successfully argued that the speed limit reduction was preventing traffic crashes, thereby reducing non-COVID-19 health emergencies and freeing up healthcare capacity during the pandemic. This allowed the Mayor to extend the speed reductions city-wide in alignment with the WHO’s advised 50 km/h (o).

Reflecting on Bogotá’s experience with BIGRS, a city official described how BIGRS’ comprehensive TA approach was important in supporting the city’s road safety vision:

“We wanted to build how this systemic vision of approaching the problem. And then Bloomberg supported us with communications, technical, infrastructure, traffic calming, and enforcement issues.” – B2

City officials and BIGRS staff alike credited city leadership for continuously supporting road safety throughout several administrations and for giving political support to technical staff who brought changes to the city (c). One government official commented:

“ Everyone, I think, without exception, has supported this work. I believe that the first requirement to choose a city is that there is willingness. What has been in Bogotá, really, is the political will of the leaders to carry it out. Without it, you do nothing .” – B14

Comparison of Bogotá’s policy experience with other BIGRS cities

The scale of change in Bogotá’s road safety programming stands apart from the other case studies. Second to this was Accra; the city government formed a new road safety council and developed the city's first Pedestrian Action Plan (o). Like Bogotá, BIGRS in Accra leveraged city prioritization for road safety and provided city-specific evidence (i), which focused city stakeholders’ efforts on the importance of pedestrian safety (A8, A1, A5, A3, program documents). Also, like Bogotá, the Mayor was a champion who lent convening power to the development of Accra’s action plan (4, A6, A3, A5, A8, A1, program documents) (c) . The Accra Pedestrian Action Plan was further perceived to improve coordination of different road stakeholders towards a common goal (A8, A1, A5, A3, A6, program documents).

In Mumbai, in contrast, BIGRS staff and partners described a lack of an individual champion with the authority to advance road safety policy and planning at the city level as a key challenge (M10, M11, M12, M13, M14, M15, M21).

Revised program theory

The revised program theory for BIGRS should be considered an initial attempt to synthesize across both positive cases (where outcomes were observed) and negative cases (where outcomes were limited by specific factors) to distill a set of higher-level statements about how BIGRS works at the city level and the contexts that enable or constrain its success.

The first program theory is improved road safety capabilities, focused on capacity and data use interventions described by BIGRS staff and partners as precursors to implementation in each case study city.

Program theory for improved road safety capabilities:

Providing TA to increase capacity and data use (i), if delivered via trusted and credible TA providers who provide hands-on coaching support tailored to city needs and with counterparts interested in engaging with road safety, can strengthen road safety capabilities (o) because it shifts the focus of city officials towards evidence-informed approaches and creates a how-to moment to improve road safety through the safe system approach (m). This outcome is enabled by city prioritization of road safety (c) and can be disrupted if city government officials change (c) .

The second program theory is increasing the uptake of evidence-informed implementation of road safety interventions. In this theory, capacity building and data now comprise the necessary context that supports the interventions, and BIGRS and city officials are characterized as working together to implement.

Program theory for increasing the uptake of evidence-informed implementation of road safety interventions:

If trusted and credible TA providers, working with and through city champions (c), undertake a successful pilot (i), guided by city-specific data that targets interventions (c) , and with facilitation of city implementation via dedicated equipment, training and other supportive resources (i) , then this can increase the uptake of evidence-informed road safety interventions (o). This occurs because a pilot builds confidence that the safe systems approach is feasible in a specific road context (m) , and it reduces the perception of risk in adopting a new approach (m) by allowing city officials to gauge public sentiment. The scale and sustainability of the outcome(s) are determined by the city’s existing prioritization of road safety, the authority of the individuals and road safety agencies targeted in the intervention, and existing socio-cultural norms (c) . It can be disrupted if city government officials change (c) .

BIGRS’ interventions sought to accelerate cities’ adoption of the safe system approach. What united city officials were two questions – will it work here, and how? To answer those questions, TA needed to go beyond recommending that a safe system approach would work, to demonstrating how it could work, to prove that it worked (without provoking negative reactions from the public).

How did TA work?

TA provider credibility and ability to navigate the city context were important. This was demonstrated by embedded staff who continuously connected the evidence-base and resources of international partners with the tacit knowledge and goals of city agencies. By playing a dual ‘insider-outsider’ role, embedded staff worked to create a favorable context for interventions and made interventions a better fit for the context. This describes the role of boundary-spanners who bridge insider and outsider roles to facilitate the adoption of an intervention [ 12 ].

How TA was provided was also essential. TA providers needed to understand the context and work effectively within it, not against it. Capacity-building activities needed to follow a coaching model, amplifying the existing knowledge, needs, and priorities of decision-makers. Interventions needed to be immediately relevant to the context, or TA providers risked losing credibility. BIGRS embedded staff and partners based full-time in the city again had the advantage here. This finding aligns with calls for TA to be context-sensitive [ 50 , 51 ] and aligns with the characteristics of successful change agents [ 12 ].

Why did TA work (or not work)?

The mechanism ‘shifting the focus’ was about data. Aligning with diffusion of innovation theory, data framed a ‘felt need’ for change [ 52 ] in all cities to different degrees. Bogotá was an early adopter; new data was presented within the context of political commitment to road safety, and pre-existing automated enforcement infrastructure enabled BIGRS to develop data-driven machine learning models to predict the results of the speed enforcement pilot. In Mumbai, in comparision, most of BIGRS’ Phase II activities focused on building city data capabilities to catalyze this shift in focus. ‘Shifting the focus’ was further enhanced by city officials’ ability to establish fora for governing the use of data to support policy decisions, consistent with international norms [ 53 ].

But ‘shifting the focus’ was also directly facilitated by BIGRS, making it the most uncertain mechanism. An alternative conceptualization is that BIGRS ‘shifted the focus’ by dedicating resources to specific interventions, informed by its data, which the city endorsed.

The second mechanism, creating a ‘how-to moment’, comes from diffusion of innovation’s knowledge phase [ 52 ]. Adopters must understand how an innovation works, especially if the innovation is complex [ 52 ]. Pilots allowed officials to see change in action, built confidence, and reduced the risk of stakeholder discontent from changing the road environment [ 12 , 52 ]. BIGRS also had an advantage; infrastructure re-design and enforcement are trial-able approaches with quickly observable outcomes which supports innovation adoption [ 10 , 12 ].

Under what conditions did TA work (or not work)?

Moving from the first program theory outcome (‘strengthened road safety capabilities’) to the second (‘increasing evidence-informed interventions’) required more than triggering individual-level mechanisms. To change implementation, individual-level mechanisms had to translate into institutional actions by city officials– e.g., approving pilots, allocating resources, and implementing interventions. It was here that context was critical.

City champions were key to enabling change. Champions are important in diffusion of innovation theory [ 12 ] and were critical here. However, following structure-agent theory, city champions could only change areas within their control [ 54 ] and their agency varied. Comparing Bogotá and Accra is instructive. Bogotá had considerable latitude to change road safety practices, while Accra’s pilot task force failed to scale due to limited institutional and normative authority to enforce legislation. Officials in road safety agencies lamented this alongside BIGRS staff, suggesting that the interventions were compatible with the context [ 52 ] but that the city's agency was constrained.

Structural, or outer, contexts therefore determined the feasibility of converting individual and city level mechanisms into outcomes. Diffusion of innovation theory considers that innovation may not be ‘compatible’ with the context or that the system may not be ‘ready’ for change, which was important in these cases. But more important, however, was how the innovation was introduced, who introduced it, the city's priorities, and city’s authority to adopt the innovation. This points to a critical consideration – if the dissemination approach of how the innovation is introduced is incompatible with structural context, adoption will be slow or unsuccessful (even if the innovation itself fits the context).

Boundary spanning – crossing boundaries to negotiate interactions and translate knowledge from different settings [ 55 ] – is one way to bridge the gap between proposed solutions and local contexts. A 2017 multi-county nutrition project found that boundary spanning was feasible and useful to navigate context-specific challenges [ 56 ]. Our study suggests that boundary spanning – if those doing the boundary spanning are deeply embedded within the local context – could be a useful model for delivering TA. Engaging boundary spanners from the beginning to work with city government officials to design TA programs around local problems and priorities, rather than providing both with a model from elsewhere to adapt, is a practical way to design more context-sensitive TA and surface local innovations [ 13 ].

Strengths and limitations

The goal of this study was to learn from implementation experience and develop a program theory. We did not quantitatively measure outcomes, a limitation. To improve trustworthiness, we triangulated findings across cities and data sources. However, outcomes were mainly validated with informants due to a lack of access to documents across BIGRS partners, creating some uncertainty. Another limitation was the overrepresentation of BIGRS staff and partners in our sample as compared to government officials and other city stakeholders. The reasons for this were both practical – e.g., scheduling interviews over Zoom, governance differences across cities – and representative of broader findings – government official turnover limited available informants. Finally, several authors (but not the first author) were involved in BIGRS’ implementation, which required continual bracketing when analyzing the data.

Our multiple case study design was a strength, enabling ICMO comparison across cities, reducing uncertainty, and increasing confidence. Iterative data collection and validation of the program theory with participants further reduced uncertainty because we could discuss uncertainties with participants and dig deeper. We also verified our interpretations with documents.

We identified broadly applicable insights into the role of TA in strengthening evidence-informed road safety in LMICs and distilled these into a program theory, contributing to knowledge on multisectoral TA programs in global health. Our study is the first we know of to empirically analyze the role of TA in influencing road safety in LMICs. BIGRS’ program theory emphasizes the interaction of trust, credibility, champions and their authority, governance structures, political prioritization, and the implement-ability of evidence in creating the conditions for road safety change. Designing context-specific TA appropriate for structural contexts is critical. If decision makers prioritize road safety, TA can accompany local leaders in adapting international approaches to local realities. In this way, we see cross-country multisectoral projects as important opportunities to improve population health.

Availability of data and materials

Data generated and analyzed during this study are included in this article. Key informants were assured that the raw transcripts would not be shared.

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Acknowledgements

The authors wish to acknowledge Dr. Jeremy Shiffman, Dr. Svea Closser, and Dr. Nukhba Zia of the Johns Hopkins University Bloomberg School of Public Health who provided comments on an earlier version of this manuscript. The authors also thank Sylviane Ratte, Director, Road Safety Program and Sara Whitehead, Consultant, Public Health and Preventive Medicine, Road Safety Program, at Vital Strategies who provided valuable comments on this research and support in contacting key informants. The authors also wish to thank Alma H. Ramírez of Teasa Translate for providing translation and transcription services for the study. Finally, the authors wish to thank the study participants who generously provided their time and valuable insights.

This project was supported by Bloomberg Philanthropies through the Bloomberg Philanthropies Initiative for Global Road Safety (Grant No. 111882). The funders were not involved in this study or development of this manuscript.

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RN, ALH, AK, and AB designed this study. RN and ALH collected and analyzed the data. RN wrote the first draft of the manuscript. RN, ALH, AK, and AB provided critical revisions to the manuscript. All authors approved the final version for publication.

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Correspondence to Rachel Neill .

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This study was exempted as non-human subject research by the Johns Hopkins University Bloomberg School of Public Health Institutional Review Board (No: IRB00013713). We received oral informed consent from all participants.

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Neill, R., Hernández, A.L., Koon, A.D. et al. Translating global evidence into local implementation through technical assistance: a realist evaluation of the Bloomberg philanthropies initiative for global Road safety. Global Health 20 , 42 (2024). https://doi.org/10.1186/s12992-024-01041-z

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Received : 20 December 2023

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Published : 10 May 2024

DOI : https://doi.org/10.1186/s12992-024-01041-z

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Employer Case Study

From stressed to secure: transforming financial well-being at work.

A major telecommunications organization faced a challenge: their widely diverse employee population was stressed due to money strains, especially given the turbulent economic conditions. They needed a financial well-being program that would meet each employee’s unique needs and positively change behaviors around money without selling products or services.

After reevaluating their EAP and benefits, the client discovered they didn’t offer a benefit that would help employees manage financial health.

MSA’s Solution

MSA created an unbiased, holistic financial well-being solution, providing personalized coaching that’s rooted in behavioral change, a digital platform, and guided and self-help resources. They also offer many on-site trainings, events, and webinars for locations across the country.

The Results

With the support of C-Suite champions and MSA’s Customer Success Management team, program efforts have been outstanding:

14.3% utilization across all program features*
45% increase in financial well-being scores*
94 Net Promoter Score (NPS) for employees working with a coach*
21% increase in work productivity*
$1,900+ decrease in debt*
50+ point improvement in credit score*
2% of salary increase in retirement contribution*

The Details

MSA Client: Major Telecommunications Organization
Employees: 70,000+
Main Office: Bellevue, WA
Locations: 6,400+

Challenge #1: Accessibility

Many locations and different work schedules made arranging benefit communications difficult.

Solution: MSA’s robust benefits communication guide and calendar solved the problem of what, who, and when.

Challenge #2: Benefit Integration

This client’s ideal partner would be able to integrate their benefit with other existing company benefits.

Solution: MSA’s program integrates an employer’s benefits package, boosting utilization of benefits like 401k, student loans, etc.

Challenge #3: On-site Events

This client’s many locations needed a more robust on-site education package.

Solution: MSA’s program allows for adding as many educational events as needed. MSA happily supports 20 events per year for this client.

The Feedback

Here’s what a major telecommunications employee and MSA member had to say:

“[My Money Coach] was great! He set clear expectations during the call, committed to those expectations, and wasted no time to dive right into educating me about strategies. I enjoyed the experience, and I have faith that I’ll be able to follow the practical steps he provided.”

To learn more about the MSA financial well-being solution and how you can help your workforce, call 800-984-6811.

* My Secure Advantage, Inc., 2023. Average based on MSA member self-reported data, when working with a coach on this specific issue, from 1/1/22 – 12/31/22.

Testimonial provided by member of MSA. They did not receive compensation of any kind for their statement.

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Employers & Sponsors

Governor Newsom Unveils Revised State Budget, Prioritizing Balanced Solutions for a Leaner, More Efficient Government

Published: May 10, 2024

The Budget Proposal — Covering Two Years — Cuts Spending, Makes Government Leaner, and Preserves Core Services Without New Taxes on Hardworking Californians

Watch Governor Newsom’s May Revise presentation here

WHAT YOU NEED TO KNOW: The Governor’s revised budget proposal closes both this year’s remaining $27.6 billion budget shortfall and next year’s projected $28.4 billion deficit while preserving many key services that Californians rely on — including education, housing, health care, and food assistance.

SACRAMENTO – Governor Gavin Newsom today released a May Revision proposal for the 2024-25 fiscal year that ensures the budget is balanced over the next two fiscal years by tightening the state’s belt and stabilizing spending following the tumultuous COVID-19 pandemic, all while preserving key ongoing investments.

Under the Governor’s proposal, the state is projected to achieve a positive operating reserve balance not only in this budget year but also in the next. This “budget year, plus one” proposal is designed to bring longer-term stability to state finances without delay and create an operating surplus in the 2025-26 budget year.

In the years leading up to this May Revision, the Newsom Administration recognized the threats of an uncertain stock market and federal tax deadline delays – setting aside $38 billion in reserves that could be utilized for shortfalls. That has put California in a strong position to maintain fiscal stability.

“Even when revenues were booming, we were preparing for possible downturns by investing in reserves and paying down debts – that’s put us in a position to close budget gaps while protecting core services that Californians depend on. Without raising taxes on Californians, we’re delivering a balanced budget over two years that continues the progress we’ve fought so hard to achieve, from getting folks off the streets to addressing the climate crisis to keeping our communities safe.” – Governor Gavin Newsom

Below are the key takeaways from Governor Newsom’s proposed budget:

A BALANCED BUDGET OVER TWO YEARS. The Governor is solving two years of budget problems in a single budget, tightening the state’s belt to get the budget back to normal after the tumultuous years of the COVID-19 pandemic. By addressing the shortfall for this budget year — and next year — the Governor is eliminating the 2024-25 deficit and eliminating a projected deficit for the 2025-26 budget year that is $27.6 billion (after taking an early budget action) and $28.4 billion respectively.

CUTTING SPENDING, MAKING GOVERNMENT LEANER. Governor Newsom’s revised balanced state budget cuts one-time spending by $19.1 billion and ongoing spending by $13.7 billion through 2025-26. This includes a nearly 8% cut to state operations and a targeted elimination of 10,000 unfilled state positions, improving government efficiency and reducing non-essential spending — without raising taxes on individuals or proposing state worker furloughs. The budget makes California government more efficient, leaner, and modern — saving costs by streamlining procurement, cutting bureaucratic red tape, and reducing redundancies.

PRESERVING CORE SERVICES & SAFETY NETS. The budget maintains service levels for key housing, food, health care, and other assistance programs that Californians rely on while addressing the deficit by pausing the expansion of certain programs and decreasing numerous recent one-time and ongoing investments.

NO NEW TAXES & MORE RAINY DAY SAVINGS. Governor Newsom is balancing the budget by getting state spending under control — cutting costs, not proposing new taxes on hardworking Californians and small businesses — and reducing the reliance on the state’s “Rainy Day” reserves this year.

HOW WE GOT HERE: California’s budget shortfall is rooted in two separate but related developments over the past two years.

First, the state’s revenue, heavily reliant on personal income taxes including capital gains, surged in 2021 due to a robust stock market but plummeted in 2022 following a market downturn. While the market bounced back by late 2023, the state continued to collect less tax revenue than projected in part due to something called “capital loss carryover,” which allows losses from previous years to reduce how much an individual is taxed.
Second, the IRS extended the tax filing deadline for most California taxpayers in 2023 following severe winter storms, delaying the revelation of reduced tax receipts. When these receipts were able to eventually be processed, they were 22% below expectations. Without the filing delay, the revenue drop would have been incorporated into last year’s budget and the shortfall this year would be significantly smaller.

CALIFORNIA’S ECONOMY REMAINS STRONG: The Governor’s revised balanced budget sets the state up for continued economic success. California’s economy remains the 5th largest economy in the world and for the first time in years, the state’s population is increasing and tourism spending recently experienced a record high. California is #1 in the nation for new business starts , #1 for access to venture capital funding , and the #1 state for manufacturing , high-tech , and agriculture .

Additional details on the May Revise proposal can be found in this fact sheet and at www.ebudget.ca.gov .

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Translating global evidence into local implementation through technical assistance: a realist evaluation of the Bloomberg philanthropies initiative for global Road safety

The role of technical assistance

Study objective

Study setting

Case design and sampling

Data collection

Key informant interviews

Transforming junctions on Mumbai’s congested streets

Comparison of Mumbai’s infrastructure experience with other BIGRS cities

Enforcing road safety legislation in Accra

Comparison of Accra’s enforcement experience with other BIGRS cities

Reducing city-wide speed limits in Bogotá – an example of policy change

Comparison of Bogotá’s policy experience with other BIGRS cities

Revised program theory

How did TA work?

Why did TA work (or not work)?

Under what conditions did TA work (or not work)?

Strengths and limitations