Results

A response rate of 71% (55 of 78) was obtained for the first questionnaire and 76% (72 of 95) for the second questionnaire. The response rate for the first questionnaire was 79% (33 of 42) for the government departments and 57% (17 of 30) for industry. Five of six university participants completed the first questionnaire. For the second questionnaire the response rate for industry was 80% (32 of 40), for the government departments 71% (35 of 49), and for the universities five of six responded. The response rate for the Ministry of Health for the second questionnaire was 66% (21 of 32).

The first questionnaire asked all respondents to identify broad priority areas for occupational health research, the findings of which were used to formulate the second questionnaire. The results from the second questionnaire are shown in tables 1-5. The mean scores for each of the five main research topic areas are shown in table 1, with the percentage of participants scoring this topic area as their highest priority and the overall ranking for each topic area based on the mean scores. The topic area with the highest overall ranking was occupational health problems for specific groups and industries. Ministry of Health participants gave incidence and prevalence of work related diseases as their highest priority, whereas industry participants gave the highest priority to health problems associated with industrial development. Evaluation of occupational health services was given a low priority overall. Priorities assigned to specific areas of concern within each of the broad research topic areas are shown in tables 2-5.

Within the broad topic area “occupational health problems for specific occupational health groups and industries” the Ministry of Health participants identified healthcare workers as the top priority (table 2), compared with plantation workers for participants from industry. This is perhaps to be expected, as Ministry of Health personnel might rightly have a major interest in the biggest occupational group in their Ministry. Overall for all participants the occupational group ranked to be the most important was construction workers followed by pesticide sprayers. Of the occupational groups ranked, those considered to be least important and not given the top priority by any of the participants included hotel, restaurant, and administrative workers.

Table 3 lists the ranking of specific occupational health problems for research. The main area of concern for both the industry and government participants was chemical poisoning and injuries from accidents at work. The lower priority areas for research were psychological disorders and work related back problems. Musculoskeletal problems and repetitive strain injuries were considered to be more important by industry than the Ministry of Health.

Table 4 shows the relative importance of specific clinical occupational health areas for research. Occupational asthma was considered to be the most important by the Ministry of Health whereas the industry participants ranked asthma as fifth of the seven clinical areas. For the industry group research into mechanical injuries was the main priority with 47% of these participants ranking injuries as the top priority. Suicide and depression and occupational cancer were considered to be less important.

Respondents working in industry perceived health problems associated with industrial development as the most important area for research (table 1). For all participants the highest priority under this broad topic area was community health effects from industrial pollution (table 5). Community health effects from industrialisation were of particular concern to the Ministry of Health with 43% ranking this as the topic priority. This may reflect the frequency of such issues being raised to the occupational health and safety professionals working in industry. Some participants thought that more guidance was needed on planning environmental impact studies with particular reference to study design, sampling techniques, exposure modelling, and criteria for judging the impact on health.

Discussion

The Delphi technique has several advantages in reaching consensus. It allows each participant to have an equal say in decision making, and avoids undue influence by assertive people or organisations that can be encountered in decision making by committee.

The technique also has several limitations.

• In common with other methods in which questionnaires are administered, it requires adequate time, a good standard of written communication, and high participant motivation.

• The views obtained depend in part on the selection of participants. For occupational health research priorities, participants should be representative of all relevant sections of the workforce, government, and employers. In this study, the number of participants was limited by practical considerations of time and cost. The industry participants had a predominance of representation from multinational organisations and the agricultural industry. The reason for this was that in Malaysia, many occupational health and safety professionals are employed by these sectors of industry.

• A possible source of observer bias is that the investigators may subconsciously influence responses in the way in which questions are stated, or by omission of topics they themselves do not perceive as important. We do not think that this occurred to any great extent in this study as several different occupational health professionals with divergent backgrounds and representatives of the Ministry of Health, Malaysia, were involved in devising, reviewing, and testing the questionnaires before they were finalised.

The project identified that the most important perceived area for future occupational health research in Malaysia was occupational health problems for specific groups and industries. Of these, the highest priority was given to construction workers. This would be expected to cover research into the type, extent, and cause of injuries, illnesses, and accidents, within the construction industry. Participants from industry also ranked plantation workers as another important group of workers for further research. The areas of research suggested for this group included the extent of work related injuries and diseases, hazard prevention and control strategies, and health surveillance needs. These research areas seem to be common regardless of the occupational group identified as those warranting top priority—for example, healthcare workers for those from the Ministry of Health, construction workers and plantation workers from participants from industry.

Participants from the Ministry of Health ranked the incidence and prevalence of occupational diseases as the most important area for research. Under this heading, occupational asthma was highlighted. Research into this area could include development of suitable reporting systems for occupational and work related lung diseases including occupational asthma. As a follow up to this exercise, a reporting system for occupational lung diseases, skin diseases, and poisonings was developed by the Ministry of Health, Malaysia.10 This was publicised through several training seminars involving hospital clinicians, occupational physicians, and other health and safety personnel—all of whom will have a major role in the identification and reporting of occupational diseases. A benefit of this Delphi exercise was that it led to concrete proposals for improving the notification system for occupational diseases in Malaysia. Another benefit was that criteria for diagnosis of occupational lung diseases and occupational skin diseases in Malaysia were proposed, debated, agreed, and published.11 12 These were based on data and criteria from several publications,13 modified and adapted to be relevant for the clinical conditions common in Malaysia. Specialists in respiratory medicine, dermatology, and occupational health in Malaysia were involved in discussions on the criteria and conditions to be included.

For the 11 specific topics identified from the first questionnaire outside the broad topic areas, there was agreement between industry and Ministry of Health participants on the top priority. This was the need to assess and develop “knowledge, training, and instruments in the prevention of occupational ill health”. Updating training and knowledge for occupational health professionals, especially doctors and nurses, was highlighted by many participants. The broad areas suggested for information, instruction, and training included workplace risk assessment, the principles, basis, and procedures for pre-employment screening, indications and techniques for occupational health surveillance, and control technology.

Comparisons can be made between the findings in this study and the views on priorities in occupational health research in developed countries—for example, Finland, the United Kingdom, and The Netherlands. In the early 1970s, a stated priority for occupational health in Finland was to improve the quality and quantity of research output.14 By the early 1980s, the priority had shifted towards evaluating the effectiveness of research activities and assessment of the relevance of research programmes. In the early 1990s, the emphasis was on examining the practical and societal impact of research, and directing research efforts towards the most important problems within occupational health and safety. Harrington 19945 in a Delphi project on occupational health in the United Kingdom, included only physicians based in academic institutions and industry as study participants. The first priority for research was identified to be the natural history of certain work related disorders, the most important being musculoskeletal disorders associated with the back and upper limbs. Van der Beek et al19976 in the Netherlands used supplementary methods as well as the Delphi technique. Some of the opinions were obtained from interviews and workshops. Comparison of the findings from these studies indicates that evaluation of occupational health research has a low priority in Malaysia, a medium priority in the United Kingdom, and a high priority in the Netherlands. These differences may be due entirely to the way in which the questions were phrased, or the way in which the different Delphi studies were done, or may reflect a true difference between participants in the different countries in their research priorities. It is possible that the countries are at different stages along a route that has already been experienced in Finland. Malaysia may be at the beginning of this process as its provisions for occupational health are in their infancy. Hence evaluation of research activity was given a low priority at this stage by most participants, in comparison with higher priority being given to basic issues such as criteria for recognising occupational diseases, the true extent of occupational ill health, and the occupational health and safety concerns of specific occupational groups such as construction workers, plantation workers, and healthcare staff.

Conclusions

A high perceived priority is only one important factor in determining future research. Rantanen,14 when discussing strategic planning in occupational health research highlighted the issue of relevance in the setting of priorities. Assessment of relevance in any research strategy should take into consideration the capacity to solve prioritised perceived problems. These perceived problems in occupational health would vary according to the climate, political and cultural settings, and the stage of economic development of different countries. Although the experience in developed countries could provide lessons for developing countries, the focus on research areas and occupational health solutions for any country should be geared to the conditions and facilities in that country.

Having identified the priority areas in occupational health in Malaysia, the next logical step would be to identify resources for implementing the research. It will also be reasonable to review these research priorities periodically as views change and new issues emerge requiring research in occupational health.