Onsite Treatment to Revolutionize Employee Health Management

Workplace injuries are a constant concern among a variety of industries in the nation. Rising costs and inflation associated with medical care can also negatively impact employers as they respond to injury claims. Businesses also lose money from days of leave taken by injured employees and many additional costs can quickly add up. 

The Occupational Health and Safety Administration (OSHA) has published data suggesting that there are 2.5 injuries for every 100 construction workers in the United States. Statistics for this past year of reported injuries totalled more than 21,000 nonfatal cases caused by falls, slips, and trips. OSHA also publishes extensive safety protocols and education materials each year targeting at limiting these kinds of workplace injuries. American businesses are required to implement many forms of safety education, facilitation, and treatment for their employees. While there are a variety of tools aimed at preventing workplace injuries, they are still likely to occur and additional measures are being developed to further reduce the response time to employee claims. 

Treating Injuries Onsite

Treating injuries onsite is a newer method of response for employee injuries. Onsite clinics are equipped with the facilities, tools, and staff to effectively treat injuries that occur in a work environment. Onsite clinics allow professionals to take the necessary steps to mitigate and identify risks that could lead to accidents that pose additional risks to the company. The thought is that by having these onsite clinics available to employees, there will be improvements in the environment of safety on the job and a reduced response time to effectively treat minor injuries before they become more serious. 

Onsite Clinic Duties

• Rapid Evaluation of Injury

• The main role of an onsite clinic will be to rapidly identify and evaluate an employee’s injury. The professional report will determine the extent of the injury, cause, any trends, and lead to a diagnosis of treatment. 

• Knowledgeable Assessment of First Aid

• Many workplace injuries can be remedied by simple first aid administered by medical professionals.

• The official background and experienced staff employed by the onsite clinic will be able to translate their experience to the condition of the affected employee. 

• Recommend Treatment

• After identifying and evaluating the employee’s injury the medical staff will be able to address a diagnosis attached to treatment plans. 

• Having medically trained professionals administer diagnosis and evaluation will prevent minor injuries from getting referred to more serious and expensive practitioners. The professionals will also be able to facilitate many in house treatments that will additionally cut costs for employers and insurance lenders. 

All the nuances of treating onsite injuries without the medical professionals associated with an official clinic can add many complications to effective diagnosis and treatment of an injured employee. These complications result in exponentially higher costs harbored by the company as injury claims and workman’s compensation can be a lingering process. Last year the average worker’s compensation claim cost more than $41,000 according to the National Safety Council. With claim costs averaging such high amounts, it is vital employers and businesses across the nations develop methods to save money and adequately support their employees.

Industry Specific Customizations

By establishing a personal onsite clinic at work sites, employers will be able to customize the kind of specific care and capabilities they provide. Construction sites will be able to attribute more resources devoted toward bodily mobility injuries most commonly faced in their industry. Another feature that could be added to clinics are the ability to effectively respond to specific chemical exposures at different locations, which offers a much higher level of care and efficiency to patients.By allowing specifications to personal onsite clinics, employers will be able to save on injury costs in the future by preventing them before they happen and promptly responding when they do. 

Other Customizations

• Mobility injuries

• Bone and soft tissue treatments

• Respirator fit testing

• Medical surveillance

• Hazardous material exposure protocols

• Drug and alcohol screening

Implementing Prevention Protocols

With the breadth of knowledge and experience that will be associated with establishing an onsite clinic, employees will be able to access vital resources to treat their mental and physical well beings. It is crucial for employers who want to cut costs to not only engage in treatment and evaluation of workplace injuries, but also to invest in prevention programs that can stop injuries from ever occurring. Onsite clinics can design these prevention programs by establishing the knowledge and necessary designs to implement wellness programs that maintain a healthy and productive employee environment. 

Prevention programs will not only work to improve employee education and awareness of potential workplace injuries, but will also provide vital tools they can use to instill responsibility with employees themselves. Providing vital safety tools to employees will help them recognize safety hazards, onsite injuries, and indicators for compromised mental and physical health. 

Musculoskeletal Pain the Primary Health Risk to American Workers

Several studies exploring workplace injuries, chronic conditions, and American health has identified musculoskeletal pain as the primary risk to employees. Musculoskeletal pain can be caused by a variety of different factors, but poses risks to almost every industry in blue collar America. Scientists, and employers are working diligently to identify the root causes of the chronic illness and help industries prevent further distress. 

Statistics suggest that every 1 in 2 American employees experience some form of chronic musculoskeletal complications, supported by surveys sampling more than 252 million citizens.The industries with the highest risk of complications include software businesses, utility management, retail, transportation, hospitality, construction, manufacturing, healthcare, education, and more. These industries require employees to be sitting or standing for long periods of time, and sometimes also require heavy lifting that can pose risk to their musculoskeletal stability. Leading experts relate the hard manual labor and sedentary position of the body over long periods of time as some of the main causes of this specific injury. 

What is the Musculoskeletal System

The musculoskeletal system includes the bones, muscles, ligaments, joints, connective tissues, cartilage, and tendons. This system gives our human bodies structure and supports movement of the limbs. The MSK system is vital to a person’s mobility and can change with them over time. The overall endocrine system is stimulated by exercise and interacted with via biochemical signaling passed through other organs in the body. 

5 Main Functions of the MSK System

• Movement: The skeletal system pulls on bones causing movement at the joints. Facial skeletal muscles pull on soft tissues resulting in facial expressions. All the movement is caused by the respiratory system introducing oxygen into the blood supporting the systems, enabling the muscles to breathe.

• Support: Muscles in the system support the internal organs, but are prone to weaknesses with age or injury. Prolonged weakness to the system's muscles can result in organ displacement.

• Protection: Skeletal muscles protect vital organs and cushion exterior physical impacts taken by the body. 

• Heat Generation: Heat is a waste product of body metabolism which is maintained by keeping an internal body temperature of 98.6 degrees Fahrenheit. Shivering is a major control of the MSK system to regulate the body temperature and generate heat when the internal body temperatures fall below optimal levels. 

• Blood Circulation: Cardiac muscles pump the heart and control the body’s blood circulation to vital organs and other areas of the body. 

“Ergonomic injuries” are those that affect the MKS system. These injuries are the result of overuse, improper use, or exterior inflictions to the muscles, tendons, ligaments, or hard structures. Symptoms of MKS injuries include but are not limited to the inability to effectively use limbs or muscles to complete tasks, soreness, bruising, muscle tears, and bone fractures. These symptoms often accompany the hazards associated with sitting and working at a desk, impacting the employee over long periods. The study also analyzed the resulting economic expenditure associated with MSK-related injuries and discovered its national costs have more than doubled over the last decade. 

Associated Costs of Musculoskeletal Injuries

The cost to treat MSK is one of the third largest industries in the United States healthcare system, totaling more than $600 billion annually.Associated costs to treat MSK injuries include medical appointments, expert referrals, and leave from work. The injuries also have to be treated with various medications, physical therapy, and work limitations after being diagnosed. These costs fall predominantly on the employee who ends up having to take the excess leave from employment and source the kind of treatments that best fit their situation. Employers also take the brunt of any MSK injury costs by involving their insurances and liability officials. 

The Hinge study also acknowledged that the driving factor behind increasing costs is the undeniable connection between MSK and mental health treatments, as affected employees often use double the average worker’s sick days.  The average worker misses more than 8 days of work, while employees experiencing symptoms of MSK complications often miss upwards of 13 average days annually to deal with their treatment and mental health. The sheer absence of millions of workers for extended durations of time throughout the annual work year alone costs businesses and the greater US economy millions of dollars.

Impacts of New MSK Understanding 

The impacts of MSK are affecting many aspects of employee health and welfare in the United States, as medical costs and health inequities continue to increase. Access to MSK-associated healthcare, medicines, and affordable treatments have continued to drive up prices, far surpassing the economic costs shared by employers to treat other ailments like heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion). It is no surprise that medical costs, insurance, and access to treatments have all become a much larger burden on the lower and middle working class of America.

The nuances of MSK and its lack of study have also prevented many employer insurance companies from effectively covering their employee’s risk of MSK exposure and rehabilitation. The lack of understanding has only recently resulted in studies highlighting the close relation to employee mental health welfare. Chronic pain can often intensify mental challenges resulting in increased anxiety and depression, worsening the MSK symptoms. Many health insurances fail to fill the gap in social and behavioral support needed to recuperate from mental health symptoms associated with the effects of chronic MSK in the workplace. 

Solutions recommended by the Hinge report and other health professionals suggest filling the gaps in coverage by addressing issues with physical recovery, behavioral support, and medical services. Remote care and support are ultimately important in treating the patient’s physical self-care and mental health. With digital accessibility at an all-time high, connecting patients to health professionals is easier than ever, and acquiring the kind of frequent care needed to recover from MSK complications entirely. 

Testing Workers Safety Gear

Many industries across the United States require workers to abide by certain safety standards set by the Occupational Health and Safety Administration (OSHA), often including basic safety gear. There are multiple different sets of safety gear that are differentiated based on the line of work employees are undertaking. These standards were developed to prevent serious injury and reduce the risk of any incidents while on an active job site. 

The kind of gear and duration of use is constantly modified to better fit the needs of employees and their environment. OSHA and other committees set out to test the gear to understand how they respond to real world situations, and if they comply with the American National Standards Institute (ANSI).

Types of Protective Gear

There are many different types of protective safety gear utilized by the general workforce in the United States. The purpose of utilizing safety gear while at work is to minimize workplace injuries, protect employee health, and promote healthy work environments. The most common gear observed in the field include, but are not limited to:

• Gloves

• Respirator

• Helmet

• Hearing protection

• Hard hat

• Goggles

• Eye protection

• Face shield

• Ear plugs

These types of protective wear otherwise known as PPE (personal protective equipment) were continuously developed in response to dangerous work environments where employees are interacting with chemical, radiological, physical, electrical, mechanical, and other unique hazards. The different types of PPE is completely dependent on the type of work being conducted and the risk to the employee. 

All PPE used in a work environment should also be maintained and clean in a reliable fashion to ensure its performance will be effective. All workplaces should have a system in place to source safely designed and constructed equipment that fits the employees comfortably and to encourage their use in the workplace. If the PPE does not fit properly workers are less likely to consistently choose to utilize them, increasing the risk of engaging in dangerous or exposed activities. Like all workplace duties, the use of specific PPE must be trained and there are a multitude of different online and in person resources available. Specific criteria included in the worker training programs requires users to understand wearing PPE:

• When it is necessary to source PPE.

• The type of PPE necessary.

• How to properly wear, remove, and adjust equipment.

• The limitations and effectiveness of certain PPE.

• The proper care, maintenance, lifespan, and disposal procedures for the PPE.

Testing PPE Effectiveness

Many different committees surrounding PPE have developed their own unique tests applicable to types of equipment to assess their usefulness and construction when used in the workplace. All PPE advertised by OSHA pass the ANSI standards, however there are additional tests done to ensure their application is necessary and effective in real world simulations. 

Many of the tests completed by committees are to study the way PPE responds when in motion. These tests are vital because they simulate real world situations when workers are climbing, walking on a site, or in motion in the event of an accident. Plenty of tests are run during the construction process of PPE to ensure their stability and durability in the face of exposure or collision. 

The most important tests that PPE is run through include their effectiveness when under different kinds of stresses. Most employers have working conditions that deal with at least one of these conditions, if not all of them. Some employees undergo working conditions that replicate all five tests on the same job. 

5 General Tests:

1. Ascent

2. Descent

3. Load bearing

4. Load bearing under stress

5. Friction

When ascending PPE needs to protect the worker from overhead dangers like spills, falls, and miscellaneous contusions. On the descent tests, PPE is analyzed in scenarios that replicate falls and rapid downward altitude changes. The descent test is incredibly vital in types of constructive work that involves large amounts of climbing and transporting materials from different levels. The load bearing test seeks to establish the stability of different PPE when a worker or equipment is suspended in place. Labs simulate load bearing under stress by adding swinging or momentum into the PPE test trial. The final test for PPE before deciding its credibility among employers is a friction test, establishing the durability of the equipment when moved between levels at high speeds. The friction test replicates the event of a fall or dropped item on a work site and can be applied to many different forms of PPE. 

Applications for PPE Tests

Many of the tests can be applied to the various PPE used by the industry, and having more than one test is an effective way at determining its durability in a real world environment. These tests not only put workers at ease knowing the equipment they use is in fact safe and effective, but also the employers. Industry leaders want the assurance that the kind of PPE they invest in for their companies is safe, effective, and actually prevents workplace injuries. The other caveat that comes from these tests is changes in the standardizations published by overhead administrations like OSHA and ANSI. If a certain PPE is found to be more or less effective than previously assumed, the standards advertised to employers may have to be entirely modified. These tests also provide clarity into the specific uses individual PPE should be used for, creating more uniform standards and expectations of certain industries. 

What is New With OSHA in 2023?

Each year occupational safety administrators seek to make changes that effectively keep employees safe while working. The Occupational Safety and Health Administration is a government agency working to ensure safety by setting and enforcing standards applicable to the United States Department of Labor.

Last year there were more than 2.5 million workplace injuries reported to administrators across the United States. These injuries more-or-less fit into categories involving overexertion, falls, object impacts, and bodily reactions to awkward postures. OSHA constantly makes reforms to their rules as needed in various industries. Their mission includes evolving with current events and addressing potential areas where any safety risks could occur. The changes with the new rules OSHA is proposing for 2023 will seek to better prevent these injuries and many others in the workforce. 

Who is OSHA?

OSHA began regulating workplace safety after the Occupational Safety and Health Act was passed in 1970. The origins of the administration arose after massive public outcries against rising injuries and death rates at work. Congress created the Occupational Safety and Health Administration to ensure safe and healthful workplace conditions existed for workers in all industries. The administration works to create and enforce specific safety standards by providing training, outreach, education, and assistance. 

Each year the administration receives a budget to effectively provide the resources needed to regulate workplace safety around the country. Originally this budget was utilized to develop the enforcement strategies best fit for businesses, but has gradually evolved into targeting more of those high-hazard industries that have continued ongoing workplace injuries. The current enforcement strategy aids in identifying the specific sites where high injury rates occur, and offers critical resources directly to the highest problem areas within labor departments. One of the most important proponents of OSHA’s enforcement plans is their education and outreach protocols that play vital roles dealing with health and safety. 

OSHA has invested heavily into its websites, educational materials, and resource distribution across the United States. More than 23 million users are present on the OSHA website each year, with more than 300,000 annual downloads of its advisor software systems. The administration has continued to branch out creating various web pages for individual employees, businesses, industry partners, and foraging counterparts in Europe and beyond. 

New Rules for 2023

This year OSHA has made some big changes in reforming many previously existing regulations to better fit the evolving industries in the United States. Here are 5 important changes that you should know about including record keeping, Lockout-Tagout changes, silica exposure, updated HazCom classifications, and shipping requirements. 

1. Recordkeeping Proposed Rule

OSHA published a new rule which would revise electronic injury and illness reporting requirements in US workplaces. Key impacts will include:

• Expanding reporting requirements to ensure companies with more than 100 employees are able to electronically submit all of their OSHA information, whereas previously they were only required to submit a single form’s data. 

• OSHA plans to publish the data collected from the electronic submissions on a public database after removing individual identifiers. Immediately this portion of the proposed ruling has garnered concerns about the likelihood and effectiveness of completely removing personal information from the data prior to being released to the public. 

• The new ruling will also provide exclusions for establishments with 250 or more employees from having to electronically submit their Form 300A information annually to OSHA. 

2. Lockout-Tagout (LOCO) Updates

LOCO is OSHA’s control of hazardous energy standards, initially established in 1989. This regulation has largely remained unchanged since its establishment although OSHA is finally modernizing it to match industry standards utilizing computer based safety softwares. 

• Most hazard controls in national industries recognize and incorporate many different computer based safety softwares. 

• A request for information (RFI) assessed the strengths and limitations of such software when controlling hazardous energy. 

• The RFI determined the current regulations in LOTO, which specifies control current devices are unsuitable for energy isolating devices, must be changed in response to recent technological advancements. Modern technologies may have improved the safety and control of such circuit type devices, and OSHA has responded by preparing to update the LOTO standard and compliance implications for employers. 

3. Silica Exposure Considerations

Silica dust particles are incredibly small and can become trapped in the lung tissue of a person who is exposed, leading to inflammation and scarring that can affect their respiratory tracts. The minute particles can reduce the lung’s capacity to take in oxygen causing a condition classified as silicosis. Silicosis can result in permanent lung damage as it is a progressive, debilitating, and sometimes fatal disease. 

OSHA developed two standards for respiratory silica, one for general industries like construction and one for maritime. Those 2016 standards established exposure action levels reducing the acceptable amount of total daily exposure, installing exposure control measures, and implementing medical surveillance programs to monitor employee health. The established regulations also required businesses and recordkeepers to maintain written documentation of the ongoing exposure control plans and maintain the OSHA standards. 

Other chemical exposure regulations like those that deal with lead, cadmium, and formaldehyde also yield an additional medical removal provision that the former silica regulations lacked. The medical provision required employers to monitor certain airborne exposure indicators or those found in blood concentrations, removing the employee from the contact area once exposure levels are reached. The United States Court of Appeals concluded that OSHA failed to explain its decision to remove the medical provisions from the 2016 silica regulations and remanded the rule for additional consideration of the implications. 

• OSHA is planning to revisit the silica rules and to implement a medical provision installing surveillance programs and removal procedures. 

• Employers that are subjected to the silica rules must ensure they have effective workplace inspection and hygiene standards, efficient incident management strategies, and the ability to promptly record medical removal cases. 

4. Regulatory Activities in Regards to Heat Exposure

The United States Department of Labor reported that hazardous heat exposure resulted in an average of 35 fatalities and 2,700 annual cases in industries across the nation. These injuries also resulted in multiple days away from work during the length of injury. 

• Heat exposure injuries may be incorrectly diagnosed or underreported due to failures when documenting at what point the heat exposure caused or contributed to the official cause of death and injury. This is especially true when the victim ultimately succumbs to some other life threatening condition such as a heart attack or stroke, which may have direct correlations with the onset of heat exposure injuries. 

• OSHA will initiate work on a heat exposure index standard. 

• New emphasis on indoor and outdoor heat related hazards.

5. HazCom Proposed Rule

Proposed updates to existing HazCom standards to align with the United Nations Globally Harmonized System of Classification and Chemical Labeling. 

• Classifications for flammable gasses, aerosols, and desensitized explosives.

• Additional requirements for various sized shipping containers. 

• Specific requirements for bulk shipments. 

• Required classifications of hazards under normal use including those that result in chemical reactions and other physical changes. 

More Plans For OSHA

As OSHA continues to evolve to better fit modern industries there are likely to be many more reforms down the road. The administration will continue to focus on reducing injuries, illnesses, and fatalities in all traditional industries while also looking ahead toward future challenges. Future safety violations may surround new chemicals or other workplace hazards in the growing service sector industries. OSHA regulations must also adapt to many more hybrid workplaces utilizing virtual assistance and AI technologies to either replace or assist the bulk of their employees. 

Proposed New Rules for Workplace Protection Against Wildfire Smoke

Not much is known about the true effects wildfire smoke has on outdoor workers, yet many regions are considering installing new rules to protect workers against associated workplace health hazards. Wildfires generate copious amounts of smoke into the atmosphere which can linger and spread far distances affecting many diverse workplace industries, and those that must work outdoors are directly at risk. Certain complications affecting respiratory and cardiovascular systems are known to be caused directly from smoke inhalation, and protections in the new rules will seek to provide for those ailments. 

Many different components have contributed to the new rules and certain regions have been in discussions for multiple years over the specific regulations to be imposed. Lawmakers have been diligently working with environmentalists, scientists, medical professionals, public involvement, and those predominantly affected to develop succinct rules that can protect those at risk. Certain areas more severely affected by climate change, drought, and dry conditions will continue to increase frequency of wildfires posing additional risks for industries and any employee conducting business outdoors. 

Effects of Smoke Exposure

Smoke exposure can invoke a variety of different complications to the human body, particularly affecting the respiratory and cardiovascular systems of those exposed. Wildfire smoke is different from cigarettes or exhaust due to the variety of different gas combinations and particulate matter. The mix of gasses and fine particulates form from burning vegetation, structures, or other materials. Studies suggest breathing in wildfire smoke can have instantaneous effects on anytype of individual, regardless of health. 

Immediate Symptoms

• Coughing

• Breathing difficulties 

• Stingy eyes

• Dry throat

• Runny nose

• Irritated sinuses

• Wheezing and shortness of breath

• Chest pain

• Headache

• Asthma attacks

• Tiredness

• Accelerated heartbeat

Immediate side effects from smoke inhalation can rapidly degrade a person’s ability to effectively work, travel, or participate in outdoor activities. These symptoms can continue to persist for extended periods of time, even when a person removes themselves from the source of the smoke.

The difficulties when assessing smoke inhalation risks in regards to wildlife smoke is the percentage of pollutant particulate matter. Health effects when dealing with air particulates can range from relatively minor symptoms to more serious long term health effects. The fine particulates are respiratory irritants that can cause persistent coughing, phlegm build up, difficulty breathing, and impacts to the entire respiratory system. These particulates can decrease the body’s ability to effectively remove foreign materials from the lungs, leading to excess bacteria and viral infections. Even people without underlying conditions can experience reduced respiratory activity including lung irritation and pulmonary inflammation. 

Long term exposure to wildfire smoke inhalation has relatively little known data to conclusively make assessments, however studies involving prolonged exposure to severe conditions over several days and weeks suggest a cumulatively negative effect on the lung’s capacity to provide clean oxygen to the body. Difficulties in assessing the effects of wildfire exposures is due to the lack of detailed studies on the general public's reaction to those conditions compared to the studies conducted on wildland firefighters directly in the pathway of dangerous smoke conditions. Gaps in the knowledge also fail to accurately depict the status of persistent health conditions in the wildlife offseason for workers. 

Protections From Wildfire Smoke

The most effective way to prevent wildfire smoke inhalation health effects is by limiting a person’s direct exposure to the elements. The Center for Disease Control has published a variety of tips for the public to avoid developing health complications in the height of wildlife season. 

1. Observe local air quality conditions

1. News and health networks will release warnings and condition updates when there is a wildfire in your area. Take safety precautions by limiting your exposure to the outdoors when under advisory. 

2. Evaluate health guidelines if they are available to your area.

3. Stay indoors and keep indoor air as clean as possible. 

1. Keeping inside air sealed from outside pollutants is almost as important as staying inside. 

4. Use an air filter

1. Air filters will help remove potential harmful particulates from the air you are breathing.

5. Do not rely on dust masks for protection

1. Comfort and dust masks will not protect you from smoke as they are only designed to stop large materials like sawdust. 

2. A typical N95 used for covid will provide some protection if you must be exposed to the elements. 

Proposed rulings for regional safety precautions for employers are based on the Air Quality Index (AQI) tool used by the Environmental Protection Agency to measure air quality. The AQI utilizes a rating system to quantify the probability of danger to the respiratory system and anyone outdoors. The rules outline necessary protections for when the AQI denotes dangerous particulate conditions in the air quality. 

AQI Rules - Rating spans 0 to 500 or higher

0 to 69

1. Air quality is satisfactory and no risk to outdoor exposure. 

1. 69 to 100

1. Air quality is acceptable but may pose certain risks to sensitive individuals or those with underlying conditions. 

2. Wildfire smoke response plan and recommended emergency response measures for workers experiencing any associated symptoms. 

2. 101 to 300

1. Some members of the public may begin to experience health complications and respiratory symptoms, while those with underlying conditions may react more severely. 

2. Provide respiratory protections 

3. Feasible working conditions with necessary precautions 

3. 301 to 500

1. Respirator use for affected workers

2. At least N95 masks for every employee

3. Full workplace respiratory protection program

4. Higher than the AQI

1. An N95 does not offer satisfactory protections, and more advanced respirators are required. 

Wildlife Risks for 2023

With summer shortly beginning across the United States what are the predicted risks for wildfires?

Areas in the western United States prone to severe wildfires include dry regions with adequate amounts of vegetation like California, Washington, and Colorado. The threat between April and June will be very low, but gradually increase with summer temperatures and lack of moisture. 

The peak wildlife season is expected to last between August and September, with some areas to remain under advisory until late November. The 2022 season observed more than 7 billion acres of land burned by wildfires and although 2023 has seen more moisture in certain areas then previously recorded, that statistic will likely remain the same if dry conditions prevail later in the year. 

The Northwest and Rockies observed a dryer than average winter, which means those regions will face a higher risk of wildfires as the snowpack melts quickly with the onset of summer temperatures. Some forecasters are placing the start of severe wildfires season as early as June in some of these at risk areas. Forecasters also released warnings that although many states are unaffected by the direct outburst of severe wildfires, the spread of smoke across the nation can continue to pose long lasting effects and should be taken seriously.