Running head: HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 1

Assessing Heat-Related Knowledge, Perceptions, and Needs

among Emergency Oil Spill Cleanup Responders

A dissertation submitted to the Graduate School of the University of Cincinnati in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

In the Department of Health Promotion and Education

Of the College of Education, Criminal Justice, and Human Services

September 26, 2017

by

Brenda L. Jacklitsch

M.S. Texas A&M University, 2007

B.S. Texas A&M University, 2003

Committee Chair: Keith A. King, Ph.D., MCHES

Committee Members: Rebecca A. Vidourek, Ph.D., CHES

Ashley L. Merianos, Ph.D., CHES

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 2

ABSTRACT

AN ABSTRACT OF THE DISSERTATION FOR THE DOCTOR OF PHILOSOPHY

DEGREE IN HEALTH PROMOTION AND EDUCATION, PRESENTED ON SEPTEMBER

26, 2017 AT THE UNIVERSITY OF CINCINNATI, CINCINNATI, OH

TITLE: Assessing Heat-Related Knowledge, Perceptions, and Needs among Emergency Oil Spill

Cleanup Responders

DOCTORAL COMMITTEE MEMBERS: Dr. Keith A. King (chair), Dr. Rebecca A. Vidourek, and Dr. Ashley L. Merianos

This dissertation consists of two studies. Study one examined the heat-related knowledge, perceived severity, self-efficacy, and barriers among oil spill cleanup responders. Study two examined the heat-related training and educational material needs among oil spill cleanup responders.

Study One Abstract

Background: Occupational exposure to heat and hot environments can result in illness, injury, and death among workers, particularly those in outdoor environments such as emergency oil spill cleanup responders. Purpose: This study assessed heat-related knowledge, perceptions, and barriers among emergency oil spill cleanup responders. Methods: A total of 65 emergency oil spill cleanup responders completed an online survey which examined occupational heat stress during oil spill cleanup activities. Results: Of the respondents, most had 25 or more years’ experience (52.4%), worked for companies with 19 or fewer employees (53.5%), were not classified as safety and health professionals (67.7%), had a Bachelor’s degree or higher (73.3%), HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 3

and worked in the northern or central regions (50.8%) of the United States. While most respondents were knowledgeable of heat stress, the items in which respondents were least knowledgeable were: identifying the difference between heat exhaustion and heat stroke (12.5% responded correctly), the appropriate use of salt tablets (62.5% responded correctly), the effects of air conditioning on acclimatization (70.3% responded correctly), and previous heat-related illness (HRI) as a risk factor (73.4% responded correctly). For knowledge of heat stress, there was a significant difference in the employment classification scores for non-safety and health professionals (M = 5.70, SD = 1.081) and safety and health professionals (M = 6.62, SD = 1.024); t = -3.257, p = .002). Respondents reported that they tended to perceive that heat stress can be severe (M = 4.45, SD = 0.711) and that HRI’s may affect workers (M = 4.03, SD = 0.712).

Regarding self-efficacy, most respondents felt confident in contacting emergency medical services for HRI (M = 4.45, SD = 0.589), recognizing signs and symptoms of HRI (M = 4.27, SD

= 0.623), and knowing what to do if a coworker became ill (M = 4.06, SD = 1.037). Discussion:

The difference in heat stress knowledge between those with professional safety and health experience and those without experience is confirmatory, but not surprising. Oil spill cleanup responders are at high risk for HRI, injury, and death and those responsible for their training need to be knowledgeable about all the aspects of occupational heat stress. More research is needed to determine further information about knowledge, perceptions, self-efficacy, and barriers at the non-safety and health professional, worker level.

Study Two Abstract

Background: Heat-related illness, injury, and death among emergency oil spill cleanup responders can be prevented through training and educational materials. Purpose: This study HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 4

assessed heat-related training and educational materials currently used and desired by oil spill cleanup responders. Methods: A needs assessment was completed by 65 emergency oil spill cleanup responders regarding their occupational heat-related experiences and training needs.

Results: Oil spill cleanup responders reported participating on average in 37.52 (SD = 92.249) oil spill cleanup activities per year. Most reported experiencing additional heat-related illness (HRI) risk factors, such as, high temperatures (> 80°F [71.9%], > 90°F [67.2%], > 100°F [56.3%]) and humidity (85.9%), and wearing personal protective equipment (PPE) and clothing ensembles

(96.9%), respirators (71.9%), and personal flotation devices (78.1%). Many reported experiencing symptoms of HRI (profuse sweating [41.5%], headache [40.0%], weakness

[27.7%], decreased urine output [26.2%], high body temperatures [26.2%]), and 11% reported experiencing heat exhaustion. While multiple prevention controls were reported, only one in four

(26.2%) reported using an acclimatization plan. The most common training and education received included just-in-time training (68.9%) and printed materials (50.8%). The most desirable future training and education products were smartphone or tablet applications (61.0%), printed materials (51.2%), and online training (46.3%). Discussion: Findings from this study may be beneficial to safety and health professionals and health educators, particularly those interested in developing heat stress training and educational materials for oil spill cleanup responders.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 5

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 6

Acknowledgements

I would like to express my gratitude to Dr. Keith King for his years of guidance and encouragement as I made my way through this long, twisting road of coursework and dissertation. Even with my skeptical nature, he was always able to ease my mind when research did not always go as planned. In addition, I would like to thank Dr. Rebecca Vidourek and Dr.

Ashley Merianos who provided valuable insight and motivation throughout the process.

To my colleagues from outside academia, I would like to say a special thank you. Many of you assisted with making contacts, providing review, and simple reassurance: Tim Bauerle,

Christine Branch, Sherry Berrer, David Caruso, Tom Cunningham, Barb Dames, Lisa Delaney,

Chad Dowell, Scott Earnest, Behzad Esmaili, Cherie Estill, Eric Esswein, Renee Funk, John

Gibbins, Rebecca Guerin, Ryan Hill, Laura Hodson, Naomi Hudson, Joselito Ignacio, Max

Kiefer, Edward Leblanc, T.J. Lentz, Jennifer Lincoln, Kathleen MacMahon, Lauralynn

McKernan, Todd Niemeier, Pranav Rane, Dale Sandler, Kelly Schnapp, Paul Schulte, Jill

Shugart, Tristan Victoroff, Jon Williams, and Kristin Yeoman.

Finally, I would like to thank my family, who always encouraged my goals. Especially my husband, Gino, who saw the stresses of graduate school, work, and new motherhood take their toll on me; but who still loved me and took on more than his share so I could keep going.

And to my “PhD babies”, you always gave me a reason to smile. You taught me that life is bigger than a single moment of academic or career frustration. And you provided me a new reason to keep my life well-balanced, so that I can always take in the small, joy-filled moments. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 7

Table of Contents

Abstract ...... 2 Study One Abstract ...... 2 Study Two Abstract ...... 3 Acknowledgements ...... 6 List of Tables ...... 9

Study One: Heat-Related Knowledge, Perceived Severity, Self-efficacy, and Barriers among Emergency Oil Spill Cleanup Responders ...... 10 Introduction ...... 11 Study Purpose ...... 16 Methods...... 18 Participants ...... 18 Instrumentation ...... 18 Procedures ...... 19 Data Analysis ...... 20 Results ...... 21 Demographics and Work Information ...... 21 Heat Stress Knowledge ...... 21 Perceived Severity of Heat Stress ...... 22 Self-Efficacy Related to Recognizing HRI and Performing First Aid ...... 22 Perceived Barriers to Hydration and Rest Breaks ...... 23 Discussion ...... 23 Knowledge of Heat Stress ...... 23 Years of Experience ...... 24 Company Size ...... 25 Safety and Health Professionals...... 25 Education ...... 26 Climate Regions ...... 26 Conclusions and Recommendations ...... 27 HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 8

Limitations ...... 28 References ...... 29 Tables ...... 34

Study Two: Heat-Related Training and Educational Material Needs among Emergency Oil Spill Cleanup Responders...... 44 Introduction ...... 45 Study Purpose ...... 50 Methods...... 51 Participants ...... 51 Instrumentation ...... 52 Procedures ...... 53 Data Analysis ...... 53 Results ...... 54 Demographics and Work Information ...... 54 Previous Heat-Related Experiences ...... 55 Work Activities and Heat Prevention Controls ...... 55 Current Heat Stress Training ...... 56 Desirable Future Heat Stress Training ...... 56 Discussion ...... 56 Heat-Related Experiences ...... 56 Current and Desired Training ...... 57 Opportunities for Public Health Educators ...... 58 Conclusions and Recommendations ...... 59 Limitations ...... 60 References ...... 61 Tables ...... 65

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 9

List of Tables

Study One List of Table: Heat-related Knowledge, Perceived Severity, Self-efficacy, and Barriers among Emergency Oil Spill Cleanup Responders Table 1: Demographics ...... 34 Table 2: Employment Information...... 35 Table 3: Heat Stress Knowledge ...... 36 Table 4: Knowledge of Heat Stress Based on Demographic Variables ...... 37 Table 5: Heat Stress-related Perceived Severity ...... 38 Table 6: Perceived Severity of Heat Stress Based on Demographic Variables ...... 39 Table 7: Heat Stress-related Self-efficacy ...... 40 Table 8: Self-Efficacy in Relation to Recognizing HRI and Performing First Aid Based on Demographic Variables ...... 41 Table 9: Heat Stress-Related Barriers ...... 42 Table 10: Perceived Barriers to Hydration and Rest Breaks Based on Demographic Variables ...... 43

Study Two List of Tables: Heat-Related Training and Educational Material Needs among Emergency Oil Spill Cleanup Responders Table 1: Demographics ...... 65 Table 2: Employment Information...... 66 Table 3: Previous Heat-related Experiences during Oil Spill Response Activities ...... 67 Table 4: Previously Experienced Symptoms of Heat-related Illness during Oil Spill Response Activities ...... 68 Table 5: Previously Experienced Heat-related Illness and Injuries during Oil Spill Response Activities ...... 69 Table 6: Percentage of Time Doing Particular Activities during the Shift ...... 70 Table 7: Previously Work-provided Heat Prevention Controls during Oil Spill Response Activities ...... 71 Table 8: Heat Stress Training and Educational Materials ...... 72 Table 9: Current Heat Stress Training Received Based on Demographic Variables ...... 73 Table 10: Desired Heat Stress Training Based on Demographic Variables ...... 74

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 10

Study One: Heat-Related Knowledge, Perceived Severity, Self-efficacy, and Barriers

among Emergency Oil Spill Cleanup Responders

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 11

Introduction

Heat stress can result in occupational illnesses and injuries during situations where the total heat load (environmental and metabolic) exceeds the abilities of the body to maintain the heat balance. Heat balance is the equilibrium between body heat production and environmental gain, and the heat loss to the environment. Heat can be transferred to the environment by convection

(e.g., breeze, fan), evaporation (e.g., sweat evaporating), conduction (e.g., contact with a cool object), and behavioral mechanisms (e.g., leave the area, remove clothing, drink water) (National

Institute for Occupational Safety and Health [NIOSH, 2016]; Taylor, Kondo, & Kenny, 2008).

Heat-related illnesses (HRIs) include heat stroke, heat exhaustion, rhabdomyolysis, heat cramps, heat syncope, and heat rash. These illnesses can vary in severity, with heatstroke potentially resulting in death. Heat-related occupational injuries may also occur from sweaty palms, fogged- up safety glasses, dizziness, or reduced brain function responsible for reasoning ability (NIOSH,

2016). Other heat injuries, such as burns, may occur as a result of contact with hot surfaces, steam, or fire.

Despite efforts at heat stress prevention, heat-related death, illnesses, and injuries continue to occur in workplaces. To address the hazards of heat stress, NIOSH (2016) published the Criteria for a Recommended Standard: Occupational Exposure to Heat and Hot Environments. This publication assessed the potential safety and health hazards encountered in hot environments, regardless of the workplace, and recommended a standard to protect workers from those hazards.

Recommendations included: using limits related to the calculation of environmental temperature and metabolic heat; medical monitoring programs; training programs; and heat controls, such as engineering or work practice controls (NIOSH, 2016). HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 12

The incidence of heat-related illnesses in the United States has not been well-documented by surveillance systems specific to occupational injury and illness (NIOSH, 2016). Because heat- related illnesses are often not recognized, and only illnesses involving days away from work are reported, the actual number of occupational heat-related illnesses and deaths is not known.

Additionally, estimates of the number of workers exposed to heat are not available. Workers exposed to extreme heat or work in hot environments, either indoors or outdoors, or even those engaged in strenuous physical activities, may be at risk for heat-related illness.

Many risk factors can contribute to heat stress and some are more difficult to address than others. Risk factors associated with heat-related illness may be environmental or individual.

Environmental factors occur in the workplace setting, while individual risk factors can be present and affect each worker with individual variation (NIOSH, 2016).

Environmental factors that put workers at additional risk for heat-related illnesses and injuries include: high temperatures and humidity; direct sun exposure or indoor radiant heat sources; and limited air movement (NIOSH, 2016). High environmental temperatures can increase the heat load of workers. While environments with high humidity, inhibit the evaporation of sweat, reducing the heat transfer from the body, and thereby increasing internal body temperature causing a possible heat-related illness (NIOSH, 2016; Taylor et al., 2008).

Radiant heat sources can be classified as artificial (e.g., ovens and furnaces) or natural (i.e., sun).

Air movement affects evaporative heat loss and convective heat exchange (NIOSH, 2016). When there is limited air movement, the heat loss from sweat evaporating may be reduced. In the case of convective heat exchange, air movement across the skin removes heat. The presence of appropriate ventilation, fans, air conditioning, or a natural breeze can all increase air movement and aid in cooling workers. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 13

Individual risk factors can include: not drinking enough fluids; physical exertion, personal protective equipment (PPE) and clothing; physical condition and health problems; medications; pregnancy; lack of acclimatization; and advanced age (NIOSH, 2016). In hot environments, often the primary way heat is transferred to the environment is through evaporative heat loss, or the vaporization of sweat from the skin. Sweating results in significant dehydration, which leads to heat strain, therefore adequate rehydration is necessary in order to replace the water lost to the environment and to reduce the risk of heat-related illness (NIOSH,

2016). With physical exertion, the heat produced by muscles during exercise must be dissipated if a heat balance is to be maintained. The heat load from metabolism is therefore widely variable, and working in a hot environment poses the greatest challenge to normal thermoregulation, especially during long periods of intense work (Åstrand, 2003; Parsons, 2003). PPE and clothing serve as a barrier between the skin and the environment to protect against normal environmental elements of moisture, abrasion, and provide further protection against hazardous chemical agents. Because of the protective nature of the material and construction of the ensembles, the rate and amount of heat exchange between the skin and the ambient air will be altered (NIOSH,

2016). In addition, the metabolic energy required to wear and work in the PPE and clothing produces a greater amount of heat than would occur without the impermeable clothing adding to the heat burden (Centers for Disease Control and Prevention [CDC, 2014]; NIOSH, 2016).

During exposure to hot environments, physically fit individuals have a reduced incidence of heat-related illnesses (Tipton, Pandolf, Sawka, Werner, & Taylor, 2008). However, having high body fat, obesity, and certain diseases can place workers at additional risk for heat-related illnesses (NIOSH, 2016). Drugs prescribed for therapeutic purposes can interfere with thermoregulation (Department of Defense [DOD], 2003; Khagali & Hayes, 1983). Almost any HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 14

drug that affects central nervous system activity, cardiovascular reserve (e.g., beta blockers), or body hydration could potentially affect heat tolerance (NIOSH, 2016). Acclimatization consists of the physiological changes that occur in response to a succession of days of exposure to environmental heat stress and reduce the strain caused by the heat stress of the environment; and enable a person to work with greater effectiveness and with less chance of heat injury (NIOSH,

2016). When workers are not acclimatized they may readily show signs of heat stress when exposed to hot environments, and have difficulty replacing all of the water lost in sweat (DOD,

2003; NIOSH, 2016). If an individual has had a previous incident resulting in a heat-related illness, then they may be more susceptible in additional instances of working in hot environments (Armstrong, De Luca, & Hubbard, 1990; Leithead & Lind, 1964).

Although there is much research in the professional literature on the topic of heat stress, there are still numerous gaps and opportunities to more thoroughly understand this issue, particularly when examining worker populations in high risk industries, such as many outdoor worker professions. From previous incidents of large-scale oil spills, it has been documented that heat stress is a current problem for emergency oil spill cleanup responders (King & Gibbins, 2011;

Michaels & Howard, 2012; NIOSH, 2016). During the Deepwater Horizon oil spill response there were 978 heat stress incidents reported (Michaels & Howard, 2012). Such workers are placed in stressful situations, where there is great demand for a task to be completed quickly, resulting in physically strenuous activity. In addition, these workers are often wearing personal protective equipment (e.g., Tyvek coveralls, boots, gloves) to protect themselves from the oil and chemicals used during cleanup, thereby, creating additional heat stress by altering the rate and amount of heat exchange between the skin and environment (NIOSH, 2016). Moreover, many oil spill cleanup companies are considered small businesses. Small businesses tend to have a variety HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 15

of factors negatively affecting their overall occupational safety and health, including: a lack of resources; greater time demands on managers; poor manager attitudes about safety; and fewer employees to engage in activities such as safety committees (De Kok, 2005; Hasle & Limborg,

2006; Lentz & Wenzl, 2006; Parker et al., 2007; Sinclair & Cunningham, 2014). Small businesses are also burdened with higher injury and fatality rates than larger businesses

(Buckley, Sestito, & Hunting, 2008; Mendeloff, 2006; Page, 2009; Sinclair & Cunningham,

2014). Due to this difference in injury and fatality rates, there is ongoing interest in how to modify or eliminate associated factors and create safer work environments for the large workforce found in small businesses.

Preventing heat stress by implementing controls, such as providing hydration and rest breaks, may also lack efficiency among emergency oil spill cleanup responders. Workers may experience barriers that prevent them from taking the breaks that their body needs to cool down.

Even if heat-related illnesses are present among workers, there are first aid steps that can be taken to reduce the severity and prevent death. However, workers must feel that they are capable of both identifying a heat-related illness and implementing the appropriate first aid. A lack of appropriate knowledge may affect all of these factors, putting emergency oil spill cleanup workers who are already at high risk, even further in harm’s way.

The health belief model is a theory containing constructs (i.e., perceived severity, perceived barriers, and self-efficacy) that may provide some explanation as to why a heat stress prevention plan, which often relies heavily on training and controls, may not work well within a certain population. This model asserts that health-related behavior is determined by whether individuals:

(a) perceive themselves to be susceptible to a particular problem; (b) see this problem as a serious one; (c) are convinced that treatment or prevention activities are effective yet not overly HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 16

costly in terms of effort; and (d) receive a prompt or cue to take action (Rosenstock, 1966). A comprehensive review of the literature did not reveal the use of the health belief model in occupational settings related to heat, but one study did describe its use in relation to heat waves.

The researchers sought to determine the predictors of perceived risk using a heat wave scenario and identify the health belief model constructs that could predict adaptive behaviors during a heat wave (Akompab et al., 2013). For a hypothetical example related to occupational heat stress, one might say that a worker may choose to adhere to a heat stress prevention program if he: (a) sees a coworker die from heat stroke; (b) sees first aid steps taken when a coworker displayed signs of heat exhaustion and did not die; (c) sees how easy it is to access water and take a rest break as needed; and (d) had been instructed during heat stress training about a variety of steps to prevent heat-related illnesses. By applying this model, training and educational materials can be modified to provide a more useful and utilized heat stress prevention plan for emergency oil spill cleanup responders.

Study Purpose

The present study aimed to more thoroughly inform researchers and those in the field about emergency oil spill cleanup responders’ perceptions and self-efficacy related to their work in hot environments and exposure to heat stress, which are important when planning future heat stress preventions plans. Therefore, the purpose of the present study was to assess heat-related knowledge, perceptions, and needs among emergency oil spill cleanup responders. Exposure to heat stress in an occupational environment, risk factors for heat-related illnesses, and possible preventive steps often create a complex world of possibilities that may either be protective or detrimental to workers, such as, emergency oil spill cleanup responders. In order to gain increased understanding of such factors, constructs from the health belief model were used for HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 17

this pilot study. Constructs included perceived barriers (to taking hydration and rest breaks), perceived severity (of heat stress itself), and self-efficacy (in relation to identifying heat-related illness and using first aid). This worker population is at high risk for heat-related illness and may benefit from targeted and desired training.

The present study examined the following research questions:

(1) How knowledgeable are emergency oil spill cleanup responders in regards to heat stress

(e.g., HRI, risk factors, first aid, and prevention)?

(2) To what extent does heat stress knowledge among emergency oil spill cleanup responders

differ based on number of years of experience, company size, employment classification,

highest education achieved, and current climate region?

(3) Does the perceived severity of heat stress in an emergency oil spill response situation

among emergency oil spill cleanup responders differ based on number of years of

experience, company size, employment classification, highest education achieved, and

current climate region?

(4) Does the self-efficacy of emergency oil spill cleanup responders in relation to (a)

recognizing a heat-related illness and (b) performing appropriate first aid differ based on

number of years of experience, company size, employment classification, highest

education achieved, and current climate region?

(5) Do perceived barriers to how often emergency oil spill cleanup responders choose to take

a hydration or rest break differ based on number of years of experience, company size,

employment classification, highest education achieved, and current climate region? HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 18

Methods

Participants

A purposive convenience sample of oil spill cleanup responders in the United States was obtained through utilization of stakeholder networks and via an online directory of oil spill cleanup contractors (cleanupoil.com). Based on the unknown population of oil spill cleanup responders targeted, a pilot study sample of 440 potential participating companies was requested to participate, with 65 participants completing surveys. Participants were oil spill cleanup responders. Responders had to be at least 18 years of age. Participation was voluntary and confidential, and no incentives were offered.

Instrumentation

An online survey was developed to assess participants’ knowledge, perceptions, needs, and attitudes in regards to heat stress. While other heat-related survey instruments were reviewed, the questions found were not always suitable for the targeted audience of oil spill cleanup responders of this project. A panel of experts was used to establish face and content validity. The panel consisted of NIOSH subject matter experts familiar with emergency oil spill cleanup activities and heat stress. In addition, the panel included health survey researchers who had extensive expertise in survey design, health behavior, and the health belief model.

SurveyMonkey was used to host the online survey. The survey was divided into eight sections (i.e., employment information, heat experiences, knowledge, perceived severity, self- efficacy regarding heat-related illnesses and first aid, perceived barriers to hydration and rest breaks, attitudes and desires related to training and educational materials, and demographics).

The Employment Information section consisted of five items which requested participants to report their occupational role (safety and health professional, employer, or HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 19

worker); years of employment in the oil spill cleanup industry; state within which they currently worked; whether they respond to oil spill cleanups in other states/countries; and size of company.

The Heat-Related Experiences at Work section requested participants to report the number of oil spill cleanups in a year; shift length; number of breaks during a shift and whether they experienced a list of heat-related situations. There was also a question which requested participants to report the level of activities that a shift might consist of, as a way to estimate the level of physical exertion experienced. The section ended with a checkbox list of possible heat stress preventive initiatives a workplace may have in place.

The Knowledge of Heat Stress section consisted of eight items. Participants were requested to answer each item by checking “True,” “False,” or “Unsure.” Statements chosen for this section were common topics and concepts that should be addressed in a quality occupational heat stress training program. Participants received one point for each correct answer, resulting in a potential range of 0 to 8.

A series of 5-point Likert scales were used to measure Perceived Severity of heat stress;

Self-Efficacy related to identifying a heat-related illness and effectively responding with first aid; and Perceived Barriers to taking hydration and rest breaks during oil spill cleanup activities (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree; except when reverse order coding was necessary). Statements were based on previously used heat-related survey instruments as well as items identified in the professional literature. The Demographics section consisted of items assessing age, sex, level of education and race/ethnicity.

Procedures

As aforementioned, a purposive convenience sample of United States oil spill cleanup companies (N = 440) was obtained through stakeholder networks and an online directory of oil HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 20

spill cleanup contractors (cleanupoil.com). Oil spill cleanup companies were invited to participate in the survey. The company contacts were instructed that survey participants needed to be individuals who respond to emergency oil spill cleanup activities. Contacts were sent a cover letter describing the purpose and the link to the online survey, via email. Following the initial cover letter, three follow-up contacts were made to those who had not as yet completed the survey. The survey remained open online for a two month period, and all survey reminders had been sent.

Upon clicking the survey link, participants arrived at the welcome page which provided them with the purpose of the survey, assurance that responses were confidential and that participation was voluntary. Electronic consent was required to continue to the survey. Surveys took on average 10 to 15 minutes to complete. Confidentiality was preserved, as the survey did not request participants’ names, email address, or IP address. All data was stored in a password- protected computer. In addition, there were no personal identifiers collected in the survey.

Surveys in which the majority of questions were left unanswered were eliminated from the study.

Data Analysis

Data was exported from SurveyMonkey into Microsoft Excel spreadsheets and recoded, as necessary. All data was analyzed using the IBM Statistical Package for the Social Sciences

(SPSS) statistical software package (Version 24). Frequencies, ranges, and percentages were used to describe demographics, employment information, and knowledge levels. Means and standard deviations were used to describe heat stress-related perceived severity, self-efficacy, and barriers. Due to being a pilot study and the small sample size, the independent variables were dichotomized into the following categories: number of years of experience (24 years or less; 25 years or more), company size (1-19 individuals; 20 or more individuals), employment HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 21

classification (non-safety and health professional; safety and health professional), highest education achieved (Associate’s degree or less; Bachelor’s degree or higher), and current climate region (north/central; south/west). Subscale scores were computed for each of the dependent variables: heat stress knowledge, perceived severity, perceived self-efficacy, and perceived barriers. T-tests were used to determine whether heat stress knowledge, perceived severity, self- efficacy, and perceived barriers differed significantly based on demographic variables (number of years of experience, company size, employment classification, highest education achieved, and current climate region).

Results

Demographics and Work Information

A total of 65 emergency oil spill cleanup responders participated in the survey. Of these participants, the mean years of experience was 22.3 years (SD = 13.568); with 52.4% reporting

25 or more years and 47.6% reporting 24 or fewer years (Table 1). Company size varied with

53.5% having 19 or fewer employees and 46.5% having 20 or more employees. Approximately one in three (32.3%) reported that they were safety and health professionals, while two in three

(67.7%) reported that they were not safety and health professionals (Table 2). Regarding education, most (73.3%) had a Bachelor’s degree or higher whereas 26.7% had an Associate’s degree or lower. Half (50.8%) reported working in the northern or central region of the US and half (49.2%) reported working in the southern or western region of the US. For further breakdown of demographics and employment information, see Table 1 and Table 2.

Heat Stress Knowledge

Nearly all respondents correctly responded to knowledge statements related to symptoms of dehydration (98.4% percent correct), high humidity as a risk factor (96.8%), medications as a HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 22

risk factor (95.3%), and recognizing that heat stroke is a medical emergency (92.2%) (Table 3).

Items that had the lowest percent of respondents answering correctly were identifying the difference between heat exhaustion and heat stroke (12.5% percent correct), the appropriate use of salt tablets (62.5%), the effects of air conditioning on acclimatization (70.3%), and previous

HRI as a risk factor (73.4). Results revealed that safety and health professionals had a significantly higher heat stress knowledge score. For knowledge of heat stress, there was a significant difference in the employment classification scores as safety and health professionals

(M = 6.62, SD = 1.024) were significantly more knowledgeable than non-safety and health professionals (M = 5.70, SD = 1.081, t = 3.257, p = .002) (Table 4). Knowledge of heat stress did not differ significantly based on number of years of experience, company size, highest education achieved, and current climate region in which individuals worked.

Perceived Severity of Heat Stress

Respondents reported they perceived that heat stress can be severe, such as leading to death (M = 4.45, SD = 0.711) and that HRI’s may affect workers as the jobs are hot and hard (M

= 4.03, SD = 0.712) (Table 5). Perceived severity of heat stress did not differ based on number of years of experience, company size, whether or not employees were safety and health professionals, highest education achieved, and current climate region in which individuals worked (Table 6).

Self-Efficacy Related to Recognizing HRI and Performing First Aid

In general, most respondents felt confident in contacting emergency medical services for

HRI (M = 4.45, SD = 0.589), recognizing signs and symptoms of HRI (M = 4.27, SD = 0.623), and knowing what to do if a coworker became ill (M = 4.06, SD = 1.037) (Table 7). Self-efficacy did not differ based on number of years of experience, company size, whether or not employees HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 23

were safety and health professionals highest education achieved, and current climate region in which individuals worked (Table 8).

Perceived Barriers to Hydration and Rest Breaks

The majority of respondents felt that there were few barriers to taking rest and hydration breaks (Table 9). Perceived barriers did not differ significantly based on number of years of experience, company size, whether or not employees were safety and health professionals, highest education achieved, and current climate region in which individuals worked. (Table 10).

Discussion

Knowledge of Heat Stress

This study found that while most participants were knowledgeable regarding heat stress, the item least understood was identifying the difference between heat exhaustion and heat stroke.

Occupational heat stress experts anecdotally concur with this area being an area for needed improvement. The low level of knowledge regarding the differences between heat exhaustion and heat stroke may be due to insufficient and unclear classification and differentiation between not only these two types of HRI, but the two classifications of heat stroke. Widely unrecognized in public health, there are actually two classifications of heat stroke: classic and exertional heat stroke (NIOSH, 2016). The characteristics of the individual (age and health status), type of activity (sedentary versus strenuous exertion), and symptoms (sweating versus dry skin) vary between the classic and exertional classifications (DOD, 2003). Some of the commonly heard public health messaging focuses only on classic heat stroke, despite workers being at higher risk for exertional heat stroke.

A lack of knowledge about how acclimatization basics, might lead to a lack of acclimatization being implemented in any heat stress prevention plans. Acclimatization consists HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 24

of the physiological changes that occur in response to a succession of days of exposure to environmental heat stress and reduce the strain caused by the heat stress of the environment; and enable a person to work with greater effectiveness and with less chance of heat injury (NIOSH,

2016). When workers are not acclimatized they may readily show signs of heat stress when exposed to hot environments, and have difficulty replacing all of the water lost in sweat (DOD,

2003; NIOSH, 2016). Arbury et al. (2014) presented cases of heat-related illness or death among workers, in which most of the employers had no program to prevent heat-related illness, or the program was deficient. Acclimatization was the program element most commonly absent and clearly associated with worker death.

An increase in salt intake is probably not justified, unless recommended by a physician, as the average United States diet contains a relatively high salt content, more than 3,440 mg per day

(U.S. Department of Health and Human Services & U.S. Department of Agriculture, 2015).

Additionally, salt tablets can irritate the stomach and should not be used; instead, salt losses are best replaced by the ingestion of normal salted foods or fluids over many hours (DOD, 2003). Increased clarity and understanding of these areas is warranted among employees in the field.

Years of Experience

It is often reasonable to assume that with increased years of experience, knowledge increases. However, in this study no significant difference was noted. This may be related to other factors, such as, that most respondents perceived heat stress as severe and could affect responders at their worksites. If something is a known danger, then a person may be more knowledgeable about the risks and how to prevent becoming ill or injured and more motivated to take action to prevent a detrimental outcome (Rosenstock, 1960). This acknowledgement about HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 25

the perceived severity of heat stress and the increased knowledge, could also affect self-efficacy and the perception of barriers.

Company Size

Interestingly, knowledge, perceived severity, perceived self-efficacy, and perceived barriers did not differ significantly based on company size. Oftentimes, small businesses are most susceptible to workplace illness and injury, as they tend to have limited resources, greater time demands on managers, poor manager attitudes about safety, and fewer employees to engage in activities such as safety committees (De Kok, 2005; Hasle & Limborg, 2006; Lentz & Wenzl,

2006; Parker et al., 2007; Sinclair & Cunningham, 2014). As definitions of small businesses by size can vary, it may be that not enough of the smallest businesses participated for a significant difference to be realized. A larger sampling of small businesses is recommended in future studies.

Safety and Health Professionals

Not surprisingly, safety and health professionals were significantly more knowledgeable than non-safety and health professionals regarding heat stress knowledge. Such a finding may be due to the increased amount of workplace training and education they receive regarding workplace safety in general, and heat stress specifically. However, perceived severity, perceived self-efficacy, and perceived barriers did not differ significantly based on employment classification. The findings indicated that both types of employees recognized the severity of heat stress, felt confident in addressing the issue, and perceived there to be few barriers. While overall knowledge differed, it appears that all employees recognize that heat stress is an important and critical issue in workplace safety. Additionally, this pilot sample did not include some of the most often cited vulnerable populations of workers (e.g., small businesses, HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 26

immigrant, young, and/or temporary workers) (NIOSH & ASSE, 2015). Future studies are therefore needed to examine whether knowledge and attitudes differ based on such variables.

Education

Nearly three-fourths of respondents had a Bachelor’s degree or higher which may have impacted the overall knowledge score of heat stress. Studies have shown that those with higher education are able to think more critically, problem solve, and understand while retaining important information (Gyekye & Salminen, 2009). This study failed to show any significant differences based on education. Therefore, it may well be the case, that companies overall education level does not impact knowledge and attitudes of heat stress, but rather on-the-job training and education at the workplace may have more of a profound impact on oil spill cleanup responders.

Climate Regions

Climate region was hypothesized to have an impact on knowledge attitudes. Previous studies have shown that those working in certain regions of the United States experience more heat-related illness and fatalities (Hyatt, Lemke, & Kjellstrom, 2010; Schulte, Bhattacharya,

Butler, Chun, Jacklitsch, Jacobs, et al., 2016) The present study indicated that knowledge, perceived severity, perceived self-efficacy, and perceived barriers did not differ based on the climate region in which individuals worked. Perhaps, respondents had experienced similar incidents of heat stress and such incidents were not dependent on climate region. Due to the limited sample size, this study dichotomized climate region into two different regions, and therefore the extremes in any climatic differences may have been muddied by including states with more moderate or varying temperatures. Follow up studies which are larger in scope and HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 27

use the nine NOAA climate regions, as was originally planned in this study, may show different results (Karl & Koss, 1984; NOAA, 2017).

Conclusions and Recommendations

This study provides some insight into heat-related knowledge and perceptions among oil spill cleanup responders. While acknowledging the small sample size of this pilot study, it can still be inferred that oil spill cleanup responders who are considered safety and health professionals are quite knowledgeable about heat stress and more knowledgeable than those in the industry without this designation. For those with or without this professional designation, other constructs such as perceived severity of heat stress, self-efficacy related to recognition of

HRI and performing first aid, and perceived barriers to hydration and rest breaks all seem to be present, leading to the potential effectiveness of heat stress prevention plan being put in place or currently in use. While all the constructs are in place, for training and a prevention plan to be well received, more emphasis on some heat stress basics are needed to efficiently increase general knowledge and ensure the correct information is being presented at the workplace.

Additionally, despite intervention efforts to prevent heat-related deaths and illnesses, such deaths and illnesses continue to plague workplaces. An abundance of research-based knowledge is available, but safety and health professionals, employers, and educators must know where to obtain information and guidance, how to implement evidence-based practices into workplaces, and how to most effectively educate employees. Extreme environmental heat combined with the metabolic heat of person working can result in illness, injury, and death.

Knowledge about heat stress, perceiving the level of danger, recognizing HRI and performing first aid, and removing barriers to taking needed rest and hydration breaks are all important elements for a safer work environment for employees. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 28

The findings from this study may be beneficial to safety and health professionals and health educators, particularly those interested in assisting oil spill cleanup responders regarding their knowledge and perceptions in handling heat stress while on the job. More emphasis on certain knowledge-related issues is needed, such as acclimatization, use of salt tablets, and differentiating between heat exhaustion and heat stroke. More research is needed to determine further information about knowledge, perceptions, self-efficacy, and barriers at the non-safety and health professional worker level. Workers, particularly those with limited educational backgrounds, and additional vulnerabilities (e.g., immigrant, young, and/or those working for small businesses) may have more deficiencies and variability related to knowledge, perceptions, and barriers of occupational heat stress.

Limitations

The limitations of this study should be noted. First, the present study was a pilot study consisting of a small sample size. Therefore, results may not be generalizable to all populations.

Second, as this was an unmonitored, online survey, knowledge items may have been searched for online before answering. Third, some individuals may have answered in a socially desirable manner. Fourth, dichotomizing the variables may have affected findings by diluting the extremes. Future studies are needed which specifically recruit workers with different backgrounds and vulnerabilities (e.g., immigrant, young, and/or those working for small businesses).

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 29

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Tables

Table 1: Demographics n % Age 18-29 3 5.8 30-39 8 15.4 40-49 16 30.8 50-59 25 48.1 60+ 0 0.0

Sex Male 51 86.4 Female 8 13.6

Highest Level of Education Some high school 1 1.7 High school diploma 0 0.0 GED 0 0.0 Trade/vocational school 2 3.3 Some college 9 15.0 Associate’s degree 3 5.0 Bachelor’s degree 24 40.0 Graduate or professional 20 33.3 Other 1 1.7

Race/Ethnicity African American/Black 1 1.7 Asian/Pacific Islander 1 1.7 Caucasian 56 93.3 Hispanic/Latino 1 1.7 American Indian/Alaska 0 0.0 Native Other 1 1.7 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 35

Table 2: Employment Information n % Employment Classification Safety and health professional 21 32.3 Employer 18 27.7 Supervisor 19 29.2 Employee/worker 4 6.2 Scientific support/consultant 3 4.6

Company Size 1-9 11 25.6 10-19 12 27.9 20-49 13 30.2 50-99 7 16.3 100+ 0 0.0

Years of Experience 24 years or less 30 47.6 25 years or more 33 52.4 Mean 22.25 Range 1 – 69

Current Climate Region Alaska 5 7.7 Central 6 9.2 East North Central 2 3.1 Northeast 11 16.9 Northwest 7 10.8 South 15 23.1 Southeast 11 16.9 Southwest 3 4.6 West 3 4.6 West North Central 2 3.1 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 36

Table 3: Heat Stress Knowledge Knowledge Correct Responses n % Dark, infrequent urination may mean I am dehydrated. 63 98.4 High humidity is a risk factor for heat stress. 61 96.8 Some medications may affect tolerance to the heat. 61 95.3 Heat stroke is not always a medical emergency. 59 92.2 Having a previous heat-related illness puts you at higher risk for another 47 73.4 heat-related illness. Taking a break in the air conditioning will ruin your acclimatization. 45 70.3 Salt tablets are an effective way to restore electrolytes lost during 40 62.5 sweating. The difference between heat exhaustion and heat stroke is there is no 8 12.5 sweating with heat stroke. Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 37

Table 4: Knowledge of Heat Stress Based on Demographic Variables M SD t p Number of Years’ Experience 24 years or less 6.00 1.195 0.105 .917 25 years or more 5.97 1.075

Company Size 1-19 6.09 1.083 1.044 .303 20+ 5.68 1.416

Employment Classification Non-safety and health professional 5.70 1.081 -3.257 .002 Safety and health professional 6.62 1.024

Highest Education Achieved Some high school through associate’s 5.56 1.315 -1.811 .075 degree Bachelor’s degree or higher 6.16 1.055

Current Climate Region North/Central 6.00 1.061 0.000 1.000 South/West 6.00 1.238 Note: N = 65; Means based on knowledge score with potential range of 0 to 8.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 38

Table 5: Heat Stress-related Perceived Severity Perceived Severity M SD Heat stroke can lead to death. 4.45 0.711 Other oil spill cleanup workers may suffer from a heat-related illness 4.03 0.712 because it is a hot, hard job. As long as I am still sweating, I am ok. 3.69 0.871 I am concerned about becoming ill from working in a hot 3.67 1.085 environment because heat-related illnesses can be dangerous. I have mentioned to my supervisor that it may be too hot to finish a 3.09 1.035 task. Note: N = 65; Means based on a five-point Likert scale (1 = strongly disagree; 5 = strongly agree) (reverse order for item “As long as I am still sweating, I am ok.”).

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 39

Table 6: Perceived Severity of Heat Stress Based on Demographic Variables M SD t p Number of Years’ Experience 24 years or less 18.62 2.884 -0.884 .380 25 years or more 19.21 2.382

Company Size 1-19 19.17 2.640 -0.047 .963 20+ 19.21 2.394

Employment Classification Non-safety and health professional 18.70 2.633 -1.065 .291 Safety and health professional 19.43 2.461

Highest Education Achieved Some high school through associate’s 18.50 2.608 -0.951 .345 degree Bachelor’s degree or higher 19.20 2.511

Current Climate Region North/Central 18.94 2.621 0.006 .995 South/West 18.94 2.581 Note: N = 65; Means based on a Perceived Severity score with a potential range of 5 to 25.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 40

Table 7: Heat Stress-related Self-efficacy Self-efficacy M SD I feel confident in contacting emergency medical services for a heat- 4.45 0.589 related illness. I feel confident I can recognize the signs and symptoms of heat- 4.27 0.623 related illnesses. If a coworker became ill because of the heat, I worry I won’t know 4.06 1.037 what to do. I feel confident administering first aid for heat-related fainting and 3.84 1.072 heat cramps. I feel confident in distinguishing between heat exhaustion and heat 3.80 1.057 stroke. Note: N = 65; Means based on a five-point Likert scale (1 = strongly disagree; 5 = strongly agree) (reverse order for item “If a coworker became ill because of the heat, I worry I won’t know what to do.”).

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 41

Table 8: Self-Efficacy in Relation to Recognizing HRI and Performing First Aid Based on Demographic Variables M SD t p Number of Years’ Experience 24 years or less 20.69 2.880 0.543 .589 25 years or more 20.27 3.135

Company Size 1-19 20.00 3.162 -0.167 .541 20+ 20.58 2.854

Employment Classification Non-safety and health professional 20.23 3.146 -0.727 .470 Safety and health professional 20.81 2.600

Highest Education Achieved Some high school through associate’s 20.19 3.082 -0.592 .556 degree Bachelor’s degree or higher 20.70 2.962

Current Climate Region North/Central 20.27 2.730 -0.412 .682 South/West 20.58 3.243 Note: N = 65; Means based on a Self-Efficacy score with a potential range of 5 to 25.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 42

Table 9: Heat Stress-Related Barriers Barriers M SD Taking a break to rest will make me look weak in front of coworkers. 4.33 0.672 Access to water is too far away. 4.25 0.695 I do not like the taste of water. 4.24 0.756 I’m never sure how much I should drink. 4.16 0.601 My PPE is too burdensome to remove or put back on, so I try not to 4.16 0.700 take breaks. My supervisor regularly encourages me to take a break. 4.08 0.768 I’m never sure how long to rest. 4.02 0.751 I get too busy to take breaks. 3.75 0.967 Note: N = 65; Means based on a five-point Likert scale (1 = strongly disagree; 5 = strongly agree) for item “My supervisor regularly encourages me to take a break.” (Reverse order for other items).

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 43

Table 10: Perceived Barriers to Hydration and Rest Breaks Based on Demographic Variables M SD t p Number of Years’ Experience 24 years or less 32.03 4.547 -1.767 0.082 25 years or more 33.84 3.418

Company Size 1-19 33.13 3.415 -0.907 0.370 20+ 34.11 3.526

Employment Classification Non-safety and health professional 33.38 4.042 1.115 0.269 Safety and health professional 32.19 3.894

Highest Education Achieved Some high school through associate’s 32.94 3.872 -0.129 0.898 degree Bachelor’s degree or higher 33.09 4.213

Current Climate Region North/Central 33.25 3.943 0.533 0.596 South/West 32.71 4.108 Note: N = 65; Means based on a Barrier score with potential range from 8 to 40.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 44

Study Two: Heat-Related Training and Educational Material Needs

among Emergency Oil Spill Cleanup Responders HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 45

Introduction

Heat stress is a problem in many occupations, as it can result in illnesses and injuries during situations where the total heat load (environmental and metabolic) exceeds the abilities of the body to maintain the heat balance (National Institute for Occupational Safety and Health

[NIOSH], 2016). Heat balance occurs when there is equilibrium between body heat production and environmental gain, and the heat loss to the environment. When heat balance is not maintained, heat-related illnesses (HRI) and injuries can occur. Heat-related illnesses include heat stroke, heat exhaustion, rhabdomyolysis, heat cramps, heat syncope, and heat rash.

Occupational heat-related injuries may occur from sweaty palms, fogged-up safety glasses, and dizziness, or reduced brain function responsible for reasoning ability (NIOSH, 2016).

According to 2010 data from the Bureau of Labor Statistics (BLS, 2011) there were 4,190 annual cases of illness and injury from environmental heat exposure, resulting in one or more days of lost work among private industry and state and local workers. During that same time period, the BLS reported that 40 workers (from construction, agriculture, mining, professional and business services, and manufacturing) died from exposure to environmental heat. In addition, the National Fire Protection Association (NFPA) reported 2,890 cases of “thermal stress” in 2008, but this category included both frostbite and heat exhaustion as per their definition (NIOSH, 2010). In California, there are heat-specific workplace regulations, however, heat-related illnesses and deaths still occur particularily in agricultural workers who are at additional risk (e.g., extreme conditions, lack of knowledge, poverty, seasonality, low level of education, and other vulnerabilities related to migratory status) (Stoecklin-Marois, Hennessy-

Burt, Mitchell, & Schenker, 2013). A Centers for Disease Control and Prevention (CDC) report identified 423 worker deaths among United States (U.S.) agricultural industries (16% were crop HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 46

workers) and nonagricultural industries during 1992–2006 (Luginbuhl, Castillo, & Loringer,

2008). Luginbuhl et al. (2008) reported the heat-related average annual death rate for the crop workers was 0.39 per 100,000 workers, compared with 0.02 for all U.S. civilian workers.

Many risk factors can contribute to heat stress, and may be environmental or individual.

Environmental factors occur in the workplace setting and affect all employees, while individual risk factors affect each worker with individual variation. Environmental factors that place workers at elevated risk for heat-related illnesses and injuries include: high temperatures and humidity, direct sun exposure or indoor radiant heat sources, and limited air movement (NIOSH,

2016). Individual risk factors can include: not drinking enough fluids, physical exertion, personal protective equipment (PPE) and clothing, physical condition and health problems, medications, pregnancy, lack of acclimatization, and advanced age (NIOSH, 2016).

In an effort to address the continuing heat-related deaths, illnesses, and injuries in workplaces, NIOSH (2016) published the Criteria for a Recommended Standard: Occupational

Exposure to Heat and Hot Environments. This publication assessed the potential safety and health hazards encountered in hot environments, regardless of the workplace, and recommended a standard to protect workers from those hazards. In most cases, specific jobs and/or tasks involving exposure to heat and high temperatures can be predicted in advance. Safety and health professionals and employers can lower the risk of heat stress by following the recommendations in this NIOSH criteria document and incorporate them into their own workplace heat stress prevention plan. Key elements presented in the document will likely need to be addressed in most workplaces, but as needs and workplace environments vary, some modifications are likely needed for individual occupations. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 47

One element of the NIOSH 2016 document is the use of occupational exposure limits.

The total heat exposure (metabolic and environmental) for all workers, should be controlled so that unprotected healthy workers are not exposed to heat greater than the appropriate recommended alert limit (RAL) for unacclimatized workers or recommended exposure limit

(REL) for acclimatized workers (NIOSH, 2016). According to NIOSH (2016), workers who are wearing personal protective equipment (PPE) or clothing that increases their heat exposure may need additional modifications to be protected from heat stress. The appropriate RAL or REL can be selected from the NIOSH criteria document, by a safety and health professional using the Wet

Bulb Globe Thermometer (WBGT) method. If environmental heat measurements exceed the applicable RAL or REL, then work conditions should be modified. In addition, according to

NIOSH (2016), each worker’s metabolic heat must be estimated to determine whether the total heat exposure exceeds the applicable RAL or REL. Metabolic heat rates should be determined per task and include all activities and all scheduled and nonscheduled rest periods (NIOSH,

2016). While using these occupational exposure limits in hot environments would be ideal, for businesses that do not have safety and health professionals, establishing the required information can be daunting.

In addition to occupational exposure limits, NIOSH (2016) recommends a medical monitoring program be instituted for all workers (acclimatized or not) who are or may be exposed to heat stress above the RAL. This medical monitoring program is intended to prevent adverse health outcomes and to identify early signs or symptoms of heat-related illness. All prospective workers should be considered unacclimatized for the preplacement evaluation, which at minimum should include: work and medical history; physical examination; assessment of the use of therapeutic drugs, over-the-counter medications, supplements, alcohol, or caffeine; HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 48

assessment of obesity; and assessment of the worker's ability to wear or use any required protective clothing and equipment (NIOSH, 2016). Periodic medical evaluations should be made available at least annually to all workers who may be exposed to heat stress exceeding the RAL.

Training programs should be implemented for all workers, and their supervisors, who work in areas where there is reasonable likelihood of heat injury or illness (NIOSH, 2016;

Occupational Safety and Health Administration [OSHA], n.d.). Training should include information on heat stress hazards, predisposing factors, signs and symptoms, and first aid

(NIOSH, 2016). Heat stroke in particular should be thoroughly discussed, because the characteristics of the individual (age and health status), type of activity (sedentary versus strenuous exertion), and symptoms (sweating versus dry skin) vary between the classic and exertional classifications; and the end result if not treated quickly and appropriately is often death (DOD, 2003). It may also be pertinent to offer periodic refresher training, especially regarding symptoms; as some of the commonly heard public health messaging focuses on classic heat stroke, and workers because of the high level of physical activity are at higher risk for exertional heat stroke (Armstrong et al., 2007; DOD, 2003; Navy Environmental Health Center

[NEHC], 2007).

In addition, suitable precautions for working in hot areas and workers’ responsibilities for following appropriate work practices and control procedures, should be regularly reviewed

(NIOSH, 2016). This should include instructions to immediately report to their supervisor any signs or symptoms of heat-related illness they or a coworker are experiencing. Training should cover the effects of therapeutic drugs, over-the-counter medications, alcohol, or caffeine that may reduce heat tolerance and increase the risk of illness. NIOSH recommends that the proper use of PPE and clothing should also be explained or demonstrated, and workers should be HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 49

included in discussions regarding cultural attitudes toward heat stress. For example, some workers might incorrectly believe that an individual can be “hardened” against the requirement for fluids when exposed to heat by deliberately becoming dehydrated before work on a regular basis (NIOSH, 2016). These myths and misinformation regarding heat stress need to be discarded and replaced with easily digestible facts to prevent injury or illness (Schwarz, Newman

& Leach, 2016).

Finally, heat stress can be often be reduced by implementing engineering controls to modify metabolic heat production or heat exchange through convection, radiation, or evaporation; or work practice controls (NIOSH, 2016). Engineering controls might include those that aim to increase air velocity; reflective or heat-absorbing shielding or barriers; and reduction of steam leaks, wet floors, or humidity. Work practice controls may include: (a) limiting time in the heat and/or increasing recovery time in a cool area; (b) reducing the metabolic demands of the job (e.g., mechanization, use of special tools, or increasing the number of workers per task);

(c) instituting a heat acclimatization plan and increasing physical fitness; (d) implementing a buddy system to watch for early signs and symptoms of heat intolerance; (e) providing adequate amounts of cool, potable water near the work area and encouraging all workers to drink (i.e., 1 cup [8 oz.] of water or other fluids every 15–20 minutes); and (f) in certain situations, requiring workers to conduct self-monitoring, and creating a work group (comprising workers, a qualified healthcare provider, and a safety manager) to make decisions on self-monitoring options and standard operating procedures (NIOSH, 2016). In addition, if the weather service forecasts that a heat wave is likely to occur in the following days then a heat alert program should be implemented. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 50

A lack of training and appropriate preventive controls may elevate emergency oil spill cleanup responders’ risk for heat stress. A comprehensive review of the literature failed to identify any published study which identified the training and educational needs of emergency oil spill cleanup responders. Heat stress is well-documented as a major problem for emergency oil spill responders during large-scale oil spills (King & Gibbins, 2011; Michaels & Howard,

2012; NIOSH, 2016). There were 978 heat stress incidents reported during the Deep Water

Horizon oil spill response (Michaels & Howard, 2012). The physically strenuous activities these workers were tasked with were amplified by the stressful situation and the demand to quickly complete the cleanup. Many emergency oil spill responders also work long shifts while wearing personal protective equipment (e.g., Tyvek coveralls, boots, gloves) to protect themselves from the oil and chemicals used during cleanup, creating additional heat stress (NIOSH, 2016). In addition, often these oil spill cleanup companies are small businesses, facing a lack of resources, greater time demands on managers, poor manager attitudes about safety, and fewer employees to engage in activities such as safety committees (De Kok, 2005; Hasle & Limborg, 2006; Lentz &

Wenzl, 2006; Parker et al., 2007; Sinclair & Cunningham, 2014). As safety and health does not always take priority, small businesses are also burdened with higher injury and fatality rates than larger businesses (Buckley, Sestito, & Hunting, 2008; Mendeloff, 2006; Page, 2009; Sinclair &

Cunningham, 2014).

Study Purpose

The present study was conducted as a means to inform researchers, employers, and employees about emergency oil spill cleanup responders’ training and education needs related to heat stress. Findings from the study may help provide much needed insights on prevention strategies and education for this at-risk population. Exposure to heat stress in an occupational HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 51

environment, risk factors for heat-related illnesses, and possible preventive steps often create a complex world of possibilities that may be either protective or detrimental to workers, such as, oil spill cleanup responders. In this study, the training and educational needs of emergency oil spill cleanup responders were assessed. This worker population is high risk for heat-related illness and may benefit from better-targeted and desirable training and educational opportunities.

This pilot study examined the following research questions:

(1) What is the current heat stress training provided to emergency oil spill cleanup

responders in various regions of the country?

(2) Do type and duration of heat stress training in emergency oil spill cleanup response

situations differ based on emergency oil spill responders’ number of years of experience,

company size, employment classification, highest education achieved, and current

climate region?

(3) What heat stress supplementary educational products are currently utilized by emergency

oil spill responders?

(4) What heat stress supplementary educational products do emergency oil spill responders

desire for use in an emergency oil spill cleanup response situations?

Methods

Participants

A purposive convenience sample of oil spill cleanup responders in the United States was obtained through utilization of stakeholder networks, and via an online directory of oil spill cleanup contractors (cleanupoil.com). A pilot study sample of 440 potential participating companies was requested to participate, with 65 participants completing surveys. Participants HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 52

were oil spill cleanup responders. Responders had to be at least 18 years of age. Participation was voluntary and no incentives were offered.

Instrumentation

An online survey was developed to assess participants’ associated training and educational materials needs and desires. A panel of experts was used to establish face and content validity. The panel consisted of NIOSH subject matter experts familiar with emergency oil spill cleanup activities and heat stress. In addition, the panel included survey design and health education research professors from the University of Cincinnati. SurveyMonkey was used to host the online survey.

Basic work information questions asked whether participants were a safety and health professional, employer, or worker; years of employment in the oil spill cleanup industry; within which state they currently work; and size of company. The heat-related experiences while at work section requested responders to report the number of oil spill cleanups in a year; shift length; number of breaks during a shift; and included a list of heat-related experiences. There was also a question about the level of activities that a shift might consist of, as a way to better estimate the level of physical exertion experienced. The section ended with a checkbox list of possible heat stress preventive initiatives a workplace may have in place. Responders were requested to check all that apply.

A series of 5-point Likert scales were used for a list of statements relating to training and whether it is (1) sufficient, or there is (2) a desire for additional training (1 =strongly disagree, 2

=disagree, 3 =neutral, 4 =agree, 5 = strongly agree”; except when reverse order coding was necessary). Items in the table are elements recommended by the NIOSH 2016 heat guidance HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 53

document. There were also questions about the format of the received training and educational materials and the desire for certain formats.

Participants responded to demographics questions that included age, sex, level of education, and race/ethnicity.

Procedures

Oil spill cleanup companies across the U.S. were requested to participate (N = 440). The company contacts were instructed that survey participants needed to be those who respond to emergency oil spill cleanup activities. Contacts were sent a cover letter describing the purpose and the link to the online survey, via email. The survey remained open online for a two-month period of time.

Survey participants arrived at the welcome page after they clicked the link for the survey, and were provided the purpose of the survey, assurance that responses were confidential and that participation was voluntary. Electronic consent was required to continue to the survey questions.

Surveys could be completed in approximately 15 minutes.

Confidentiality was preserved, as the survey did not request participants’ names, email address, or IP address. No personal identifiers were collected. Surveys in which the majority of questions were left unanswered were eliminated from the study.

Data Analysis

Data was exported from SurveyMonkey into Microsoft Excel spreadsheets and recoded, as necessary. All data was analyzed using the IBM Statistical Package for the Social Sciences

(SPSS) statistical software package (Version 24). Frequencies, ranges, and percentages were used to describe demographics, employment information, previous heat-related experiences (i.e., symptoms, illnesses/injuries), activities, heat prevention controls, training and educational HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 54

materials, and knowledge levels. Means and standard deviations were used to describe heat stress-related training and educational materials received, and training and educational materials desired. Due to this being a pilot study and the small sample size, the independent variables were dichotomized into the following categories: number of years of experience (24 years or less; 25 years or more), company size (1 to 19; 20 or more), employment classification (non-safety and health professional; safety and health professional), highest education achieved (Associate’s degree or less; Bachelor’s degree or higher), and current climate region (north/central; south/west). T-tests were used to determine whether training received and training desired differed based on demographic variables (number of years of experience, company size, employment classification, highest education achieved, current climate region).

Results

Demographics and Work Information

A total of 65 emergency oil spill responders participated in the survey. Of these participants, the mean years of experience was 22.25 years (SD = 13.568); with 52.4% working

25 or more years and 47.6% working 24 or fewer years (Table 1). Company size varied with

53.5% having 19 or fewer employees and 46.5% having 20 or more employees. Participants were classified as either being safety and health professionals (32.3%) or non-safety and health professionals (67.7%) (Table 2). Regarding highest education achieved, 73.3% had a Bachelor’s degree or higher and 26.7% had an Associates’ degree or less. Concerning climate region in which individuals worked, 50.8% reported working in the northern or central regions and 49.2% reported working in the southern or western regions of the United States. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 55

Previous Heat-Related Experiences

On average, respondents reported participating in 37.52 oil spill cleanup activities per year (SD = 92.249), with the average length of the shift being 11.55 hours (SD = 5.855). During shifts, most reported taking either 2-3 breaks (44.6%) or 4-5 breaks (32.3%) (Table 3).

Respondents reported experiencing high temperatures (> 80°F [71.9%], > 90°F [67.2%], > 100°F

[56.3%]), high humidity (85.9%), wearing PPE ensembles (96.9%), wearing a respirator

(71.9%), and wearing a personal flotation device (78.1%). Nearly one quarter or more respondents reported experiencing the following HRI symptoms during oil spill response activities: profuse sweating (41.5%), headache (40.0%), weakness (27.7%), decreased urine output (26.2%), high body temperature and/or flushed skin (26.2%), and dark urine (24.6%)

(Table 4). The most commonly reported HRI and injuries reported were heat exhaustion (10.8%), heat cramps (6.2%), heat rash (6.2%), and accidents related to fogged up glasses (6.2%) (Table

5).

Work Activities and Heat Prevention Controls

Light, moderate, and heavy activities most often were reported to each occupy approximately 25% of the shift (Table 6). Very heavy activities were reported to take up 25% or less of the shift. Respondents reported that the following work-provided heat prevention controls were most often used: access to drinking water (96.9%), heat stress training (89.2%), buddy system (81.5%), weather monitoring (80.0%), shaded or cooled area for rest breaks (78.5%), work/rest schedules (72.3%), preplacement medical evaluation (67.7%), and annual medical evaluation (67.7%) (Table 7). Mandatory “stop work” rules were reported by 50.8% of respondents. The least often work-provided heat prevention controls were water-cooled or air- cooled garments/vest (36.9%) and acclimatization plan (26.2%). HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 56

Current Heat Stress Training

Respondents were asked about what current heat stress training and educational materials they received (Table 8). Training received varied with most receiving just-in-time training

(68.9%) and printed materials (50.8%). A series of t-tests revealed that current heat stress training did not differ significantly based on number of years of experience, company size, employment classification, highest education achieved, and current climate region (Table 9).

Desirable Future Heat Stress Training

Respondents were also asked what future heat stress training and educational materials they desired (Table 8). Many were interested in a smart phone or tablet application (61.0%), printed materials (51.2%), and online training (46.3%). A series of t-tests revealed that desired heat stress training did not differ significantly based on number of years of experience, company size, employment classification, highest education achieved, and current climate region (Table

10).

Discussion

Heat-Related Experiences

Overall many of the respondents had work-related experience in the heat. Long shifts, in high temperatures and humidity, while wearing various PPE can make heat stress a likely experience. These risk factors have been well documented as attributing to the overall heat burden of individual workers, and too often result in HRI and injury (NIOSH, 2016). While most reported taking multiple breaks during a shift, many also reported experiencing common symptoms of HRI, therefore the breaks may not have been frequent enough or an adequate amount of time for the body to cool. Exertion is a contributing risk factor for heat-related illness

(NIOSH, 2016), and with nearly 25% of their shift consisting of heavy work activities, this may HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 57

also indicate that more recovery time and/or hydration is needed. Along with the symptoms, the reported HRI and injuries are concerning, and are a possible indicator that additional training and education may be warranted for such a hot and dangerous work environment.

As many respondents had work experience, results indicated that many heat prevention controls were used at the worksite. While mandatory “stop work” rules only existed in about half of the respondents’ worksites, this is not necessarily surprising. Often oil spill cleanup activities need to be completed in a timely manner (i.e., long shifts), despite weather conditions (King &

Gibbins, 2011). While water-cooled and air-cooled garments/vests were not often used, this may be attributed to the added cost, which for many small businesses can be deemed unnecessary

(Sinclair & Cunningham, 2014). The lack of an acclimatization plan being utilized for such a high percentage of participants was disappointing, and indicates an opportunity for improving the heat stress prevention plan at many of these companies. Acclimatization consists of the physiological changes that occur in response to a succession of days of exposure to environmental heat stress; and enable a person to work with greater effectiveness and with less chance of HRI or injury (NIOSH, 2016). When workers are not acclimatized they may readily show signs of heat stress when exposed to hot environments, and have difficulty replacing all of the water lost in sweat (DOD, 2003; NIOSH, 2016). Acclimatization has previously been identified as the program element most commonly absent and clearly associated with worker deaths when examining a series of HRI cases and associated heat prevention plans (Arbury et al.

2014).

Current and Desired Training

While a larger, more diverse, and more robust sample could have identified potential variations in training and education needs, this pilot study provided some interesting results. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 58

Just-in-time training and printed materials were most often available at the companies for presenting information on heat stress. Such materials are commonly made available when there is an emergency situation resulting in little time to train but some quickly obtained, effective training is necessary (Kirsch, Circh, Bissell, & Goldfeder, 2016). Many of the respondents were also interested in future heat stress trainings that could be made available in digital form, such as, smartphone or tablet applications and online training. This may be of growing interest, as more companies and individuals adopt use of portable electronic devises for worksites (Bezerra, Bock,

Candelon, Chai, Choi, Corwin, Digrande, Gulshan, Michael, & Varas, 2015). Half of respondents were also interested in additional printed materials, likely because these are easy to distribute to workers during training and can easily serve as a reminder for some of the most important heat stress information (e.g., symptoms of HRI and first aid).

Several demographic variables were examined to determine whether training and educational needs and desires differed based on such variables. However, no significant differences were found. While years of experience, company size, safety and health professional status, education, and climate region seemed to make no difference in this pilot study, follow-up, larger scale studies are needed to determine whether similar results are revealed.

Opportunities for Public Health Educators

Public health educators play an important role in the planning, implementing, and evaluating of health programs as well as the dissemination of health promotion information.

However, when specifically examining the field of occupational safety and health, the role of health educators may be under-utilized or perhaps in some cases, particularly in small businesses, nonexistent. There are ample opportunities for health educators working at health departments and health agencies to provide assistance to the workplaces in their community. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 59

Sinclair, Cunningham, and Schulte (2013) used the diffusion of innovations and social exchange theory to identify steps specific to building relationships with small businesses which resulted in a model highlighting the important role of intermediaries and how they can deliver occupational safety and health information and engage small businesses. Intermediaries may include trade associations, chambers of commerce, health departments, health providers, training and education organizations, and government agencies (Sinclair et al., 2013). Health educators can act as intermediaries and assist in delivering heat training and education to these small businesses, addressing their specific educational needs and desires.

Conclusions and Recommendations

This study provided insights into the heat-related training and educational needs of emergency oil spill cleanup responders. The findings from this pilot study showed that more training on acclimatization and implementing an acclimatization plan is needed. As responders continue to experience symptoms of HRI, there are likely ways to strengthen current heat stress prevention plans and further opportunities to increase workers’ ability to physically cool down and avoid HRI and injury. While current trainings, such as the commonly held just-in-time trainings can likely be modified and improved to include items like acclimatization; it is also important to address the desires of a changing workforce to meet new needs and desires related to faster, at-hand options.

Additionally, despite an abundance of available research-based knowledge, heat-related deaths and illnesses continue in workplaces. By understanding the needs of particular occupational populations, safety and health professionals, employers, and educators can create more effective information and guidance for implementation into workplaces, and experience improved success at properly educating and training workers. There are opportunities for health HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 60

educators to collaborate with organizations and agencies to focus on occupational safety and health research, specifically to assess gaps in heat stress training and education in various industries and small businesses. The dangers of extreme environmental heat combined with the metabolic heat of the person working, such as during an oil spill cleanup effort, can result in illness, injury, and death. Appropriate training and education will provide for a safer work environment and more effectively protect worker safety and health.

The findings from this study may be beneficial to safety and health professionals and health educators, particularly those interested in developing heat stress training and educational materials for oil spill cleanup responders. As these companies become more digitalized, providing online training and educational applications about heat stress will be a growing area of opportunity for occupational safety and health professionals and health educators. Future studies should further examine workers, particularly those with limited educational backgrounds, and additional vulnerabilities (e.g., immigrant, young, and/or those working for small businesses), who may have specific needs related to training and educational materials.

Limitations

This pilot study contained the following limitations. First, the small sample size may limit the generalizability of the overall findings. Follow-up studies that are larger in scale are needed. Second, some respondents may have answered in a socially desirable manner. Third, since this study employed an online survey, the potential for limitations in recall exist. Future studies are needed that specifically recruit workers with different backgrounds and potential vulnerabilities to determine if heat stress training and educational needs differ. HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 61

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Tables

Table 1: Demographics n % Age 18-29 3 5.8 30-39 8 15.4 40-49 16 30.8 50-59 25 48.1 60+ 0 0.0

Sex Male 51 86.4 Female 8 13.6

Highest Level of Education Some high school 1 1.7 High school diploma 0 0.0 GED 0 0.0 Trade/vocational school 2 3.3 Some college 9 15.0 Associate’s degree 3 5.0 Bachelor’s degree 24 40.0 Graduate or professional 20 33.3 Other 1 1.7

Race/Ethnicity African American/Black 1 1.7 Asian/Pacific Islander 1 1.7 Caucasian 56 93.3 Hispanic/Latino 1 1.7 American Indian/Alaska 0 0.0 Native Other 1 1.7 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 66

Table 2: Employment Information n % Employment Classification Safety and health professional 21 32.3 Employer 18 27.7 Supervisor 19 29.2 Employee/worker 4 6.2 Scientific support/consultant 3 4.6

Company Size 1-9 11 25.6 10-19 12 27.9 20-49 13 30.2 50-99 7 16.3 100+ 0 0.0

Years of Experience 24 years or less 30 47.6 25 years or more 33 52.4 Mean 22.25 Range 1 – 69

Current Climate Region Alaska 5 7.7 Central 6 9.2 East North Central 2 3.1 Northeast 11 16.9 Northwest 7 10.8 South 15 23.1 Southeast 11 16.9 Southwest 3 4.6 West 3 4.6 West North Central 2 3.1 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 67

Table 3: Previous Heat-related Experiences during Oil Spill Response Activities n % Average Cleanups Per Year Mean 37.52 Min 1 Max 625

Average Shift Length (hours) Mean 11.55 Min 4 Max 48

Number of Breaks Per Shift 1 8 12.3 2-3 29 44.6 4-5 21 32.3 6 or more 7 10.8

Heat Experiences Temperatures > 80°F 46 71.9 Temperatures > 90°F 43 67.2 Temperatures > 100°F 36 56.3 High humidity 55 85.9 Wearing PPE ensembles 62 96.9 Wearing a respirator 46 71.9 Wearing a PFD/life jacket 50 78.1 Other heat-related hazard 12 18.8 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 68

Table 4: Previously Experienced Symptoms of Heat-related Illness during Oil Spill Response Activities Symptoms n % Profuse sweating 27 41.5 Headache 26 40.0 Weakness 18 27.7 Decreased urine output 17 26.2 High body temperature and/or 17 26.2 flushed skin Dark urine 16 24.6 Dizziness 14 21.5 Irritability 12 18.5 Heat rash 11 16.9 Cramps 8 12.3 Nausea 7 10.8 Confusion 3 4.6 Vomiting 3 4.6 Fainting 1 1.5 Seizures 0 0.0 Other 3 4.6 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 69

Table 5: Previously Experienced Heat-related Illness and Injuries during Oil Spill Response Activities n % Heat-related Illness Heat exhaustion 7 10.8 Heat cramps 4 6.2 Heat rash 4 6.2 Heat syncope 2 3.1 Heat stroke 1 1.5 Rhabdomyolysis 1 1.5 Other 1 1.5

Heat-related Injuries Accident related to fogged up 4 6.2 glasses Burns from hot equipment 2 3.1 Falls from dizziness 0 0.0 Other 1 1.5 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 70

Table 6: Percentage of Time Doing Particular Activities during the Shift n (%) Type of Activity 0% 25% 50% 75% 100% Light activities (sit/stand, slow 15 (23.1) 28 (43.1) 11 (16.9) 9 (13.8) 2 (3.1) walk, inspecting visually)

Moderate activities (walking, 8 (12.5) 32 (50.0) 16 (25.0) 4 (6.3) 4 (6.3) surveying environment, working with hands and arms)

Heavy activities (handling lighter 21 (32.8) 31 (48.4) 10 (15.6) 2 (3.1) 0 equipment, physically active)

Very heavy activities (handling 40 (63.5) 16 (25.4) 4 (6.3) 3 (4.8) 0 heavy equipment, very physically active doing strenuous work) Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 71

Table 7: Previously Work-provided Heat Prevention Controls during Oil Spill Response Activities Prevention Controls n % Access to drinking water 63 96.9 Training on heat stress 58 89.2 Buddy system 53 81.5 Weather monitoring 52 80 Shaded or cooled area for rest 51 78.5 breaks Work/rest schedules 47 72.3 Preplacement medical 44 67.7 evaluation Annual medical evaluation 41 63.1 Mandatory “stop work” rules 33 50.8 Water-cooled or air-cooled 24 36.9 garments/vests Acclimatization plan 17 26.2 Other 9 13.8 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 72

Table 8: Heat Stress Training and Educational Materials Training/Materials Received Desired n % n % Just-in-Time 42 68.9 10 24.4 training Printed materials 31 50.8 21 51.2 Posters 28 45.9 13 31.7 Online training 27 44.3 19 46.3 Smart phone or 25 41 25 61.0 tablet app Half-day training 20 32.8 11 26.8 with instructor All-day training 15 24.6 6 14.6 with instructor Other 8 13.1 3 7.3 Note: N = 65; Percents refer to valid percents; Missing values excluded.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 73

Table 9: Current Heat Stress Training Received Based on Demographic Variables M SD t p Number of Years’ Experience 24 years or less 3.46 1.710 1.073 .288 25 years or more 3.00 1.612

Company Size 1-19 2.71 1.454 -0.451 .655 20+ 2.95 1.810

Employment Classification Non-safety and health professional 3.14 1.601 -0.484 .630 Safety and health professional 3.37 1.862

Highest Education Achieved Some high school through associate’s 3.13 1.500 -0.206 .837 degree Bachelor’s degree or higher 3.23 1.764

Current Climate Region North/Central 3.26 1.731 0.211 .833 South/West 3.17 1.642 Note: N = 65; Means based on current heat stress training score with potential range of 0 to 8.

HEAT-RELATED KNOWLEDGE, PERCEPTIONS, AND NEEDS 74

Table 10: Desired Heat Stress Training Based on Demographic Variables M SD t p Number of Years’ Experience 24 years or less 2.55 2.089 -0.223 .825 25 years or more 2.68 1.635

Company Size 1-19 2.33 1.397 -0.356 .725 20+ 2.55 1.635

Employment Classification Non-safety and health professional 2.71 1.802 0.411 .683 Safety and health professional 2.46 1.898

Highest Education Achieved Some high school through associate’s 2.60 1.838 -0.068 .946 degree Bachelor’s degree or higher 2.65 1.836

Current Climate Region North/Central 3.16 2.141 1.764 .086 South/West 2.18 1.368 Note: N = 65; Means based on desired heat stress training score with potential range of 0 to 8.