Falls from height are a leading cause of serious occupational injury and fatality globally.1–7 In 2013 alone, falls from height accounted for 36.9% of total occupational fatalities in the USA, 31% in the UK and 12% in Australia.1 In the South African construction industry, falls from height constituted the second highest cause of permanent disability and the third highest cause of fatality between January 2020 and December 2021.8 Work at heights is thus considered a hazardous or high-risk activity. Work at heights is defined as ‘work in any place where, if precautions are not taken, a person could fall a distance liable to cause personal injury’.9 A person is working at height if they: (1) work above ground/floor level, (2) could fall from an edge, through an opening or fragile surface or (3) could fall from ground level into an opening in a floor or a hole in the ground.10

The International Labour Organisation (ILO) Constitution sets forth the principle that employers have a duty to protect workers from sickness, disease and injury arising from their employment.11 Most countries have a system of laws, regulations and policies that govern health and safety in the workplace, and many have specific regulations for work at heights. In South Africa, the Construction Regulations of the Occupational Health and Safety Act, 199312 requires a medical certificate of fitness for all persons who work at heights.

Worker fitness relates to the individual’s capacity to work without risk to their own or others’ health and safety.13 14 Serra et al14 describe worker fitness as a multidimensional14–17 and dynamic concept, incorporating: (1) the worker’s physical and mental capacity, (2) the worker’s risk in relation to their job demands and the work environment and (3) ethical, economic and legal considerations. Evidence suggests that worker fitness plays a key role in preventing occupational accidents in high-risk occupations.1 16 18–22 The risk factors for falls from height can be classified as technical, organisational and human.23 Human risk factors include safety attitude of workers (or low risk awareness),6 23–28 psychological fitness (especially fear and anxiety),27 29–37 physical and mental capacities1 38 39 and drugs and alcohol use.26 40

Despite the integral role of fitness assessments in occupational health services and the evidence supporting worker fitness as a preventative measure for accidents in high-risk occupations, an initial search of the literature, produced very little information on the assessment of fitness to work at heights. Indeed, we found a paucity of peer-reviewed evidence on fitness to work in general.14 16 21 Available literature14 41–44 mostly addresses baseline pre-employment medical examinations in a variety of industrial settings. We also found some industry-specific guidelines for assessing fitness to work in various high-risk occupations including mining,45 driving,46 aviation41 and firefighting.47 None of these articles specifically address fitness to work at heights. The literature furthermore raises ethical, economic and legal concerns around fit-for-work examinations,14–16 with several authors cautioning that work fitness assessments should not discriminate against or exclude individuals from work they could perform safely and productively. For this reason, the current practice in many countries restricts work fitness testing to job-specific examinations.16

In South Africa, the approach for assessing fitness to work at heights is currently left to the discretion of the examining occupational health practitioner.48 These examinations typically take the form of a baseline medical examination, which may not be sufficiently job-specific and may therefore be viewed as discriminatory.49

A conspicuous discomfort and even conflict thus emerges between the legal and moral duty of employers and occupational health practitioners, on the one hand, to ensure workers are fit and safe to perform high-risk duties, and on the other hand, to avoid unfairly discriminating against or limiting employment opportunities for these individuals. This conflict needs to be carefully and decisively addressed at the level of the fit-for-work assessment and certification process.

The objective of this scoping review is to identify and map the current evidence base around the assessment of fitness to work at heights. More specifically, the review question is: ‘What evidence is available on the assessment of fitness to work at heights?’

As far as the authors are aware, this will be the first systematic synthesis of evidence on the assessment of fitness to work at heights. The evidence obtained in this scoping review will be utilised to develop an interdisciplinary consensus statement for assessing fitness to work at heights in the South African construction industry.

An initial search of PROSPERO and the Cochrane Database of Systematic Reviews did not produce any systematic reviews relating to fitness to work at heights and no scoping reviews on this topic were found on Open Science Framework, Figshare or BMJ Open. Two systematic reviews addressing fitness to work in general were however found. The first, a 2007 review by Serra et al,14 examines criteria and methods employed by occupational doctors when evaluating fitness for duty. Criteria identified in this study include the determination of the worker’s capacity and risk in relation to their job demands and work environment together with ethical, economic and legal considerations. The study found poor clarity around the decision-making process used when judging fitness to work. It concludes that evidence-based guidelines are needed to assess fitness for work. The second study is a 2016 Cochrane review by Schaafsma et al16 that evaluates the effectiveness of pre-employment examinations of job applicants in preventing occupational injury, disease and sick leave compared with no intervention or alternative intervention. This study concludes that (1) health examinations that focus on health risks of particular jobs may be effective, (2) adequately dealing with potential health risks by changing work tasks or physical fitness training may be effective, (3) not allowing people to work in certain jobs may have effects on their health and financial well-being and (4) further research is needed on findings (1), (2) and (3).

Both the above systematic reviews indicate value in fitness to work assessments for high-risk occupations. However, both also highlight the need for further research. This scoping review addresses this need for further research by mapping the evidence base in a specific high-risk work activity, namely work at heights.