Evidence-based ergonomics education: Promoting risk factor awareness among office computer workers

Abstract

BACKGROUND: Work-related musculoskeletal disorders (WMSDs) related to computer work have become a serious public health concern. Literature revealed a positive association between computer use and WMSDs.

OBJECTIVE: The purpose of this evidence-based pilot project was to provide a series of evidence-based educational sessions on ergonomics to office computer workers to enhance the awareness of risk factors of WMSDs.

METHODS: Seventeen office computer workers who work for the National Board of Certification in Occupational Therapy volunteered for this project. Each participant completed a baseline and post-intervention ergonomics questionnaire and attended six educational sessions. The Rapid Office Strain Assessment and an ergonomics questionnaire were used for data collection.

RESULTS: The post-intervention data revealed that 89% of participants were able to identify a greater number of risk factors and answer more questions correctly in knowledge tests of the ergonomics questionnaire. Pre- and post-intervention comparisons showed changes in work posture and behaviors (taking rest breaks, participating in exercise, adjusting workstation) of participants.

CONCLUSIONS: The findings have implications for injury prevention in office settings and suggest that ergonomics education may yield positive knowledge and behavioral changes among computer workers.

Keywords

Musculoskeletal disorders occupational therapy prevention

1 Introduction

In the United States (US), the economic burden of work-related musculoskeletal disorders (WMSDs) is estimated to be between $45 and $54 billion annually which includes compensation costs, lost wages, and lost productivity [1]. According to the Center for Disease Control and Prevention (CDC), WMSDs are conditions that occur and/or get worse due to work-related factors such as work environment and performance of work [2]. Work-related musculoskeletal disorders have an economic influence on employers, workers, and society. According to the US Occupational Safety and Health Administration (OSHA), employers are “spending $20 billion a year on worker’s compensation costs related to ergonomic injuries and illnesses” [3, p. 106]. One of the studies that examined the cost benefit analysis of ergonomics programs revealed that improved working conditions led to higher productivity and hence reduced the number of workers required to complete the work [4].

Office computer work makes a worker prone to developing WMSDs. Rehman et al. reported that 27.4% of the computer users reported backache or discomfort [5]. According to several studies, consecutive hours of computer work, reduced frequency of rest breaks during computer work, and long duration of sustained posture during computer work have been found to be positively associated with musculoskeletal symptoms [5 –11]. Mullins stated that “office workers who use personal desktop and laptop computers for word processing or data entry are at risk for developing Cumulative Trauma Disorders” [12, p. 1], highlighting the repetitive nature of computing in computer work. According to the US OSHA, most of the injuries or illnesses related to computer workstations are of an ergonomic nature [13].

Baker and Redfern [14] stated that the focus of ergonomics is to evaluate the fit between the work environment and the worker with a goal of adapting the environment to facilitate work participation. Ergonomics has gained much attention in recent decades and is perceived as one of the viable means of controlling and preventing WMSDs. Technical (e.g., raised work surface in an office environment, redesigned conveyor belt in an automotive industry), organizational (e.g., organizing ergonomics workshops, disseminating ergonomics guides), and/or personal measures (e.g., routine physical exercise, periodic rest breaks) can be used to prevent WMSDs [15]. The interventions to prevent WMSDs include, but are not limited to, redesigning workstations, improving working conditions, modifying the way the tasks are performed, and provision of necessary equipment to safely perform the work. For these prevention measures to work, proper knowledge/awareness about how (a) the work-related factors contribute to the WMSDs, (b) to carry out the work tasks safely, and (c) to effectively use the equipment, are essential.

The view of health education as an instrument for behavioral change has been renewed over the past few decades [16]. Bohr and Barrett [17] asserted that prevention models identify behavior change as the key to continuous injury prevention throughout the literature. Numerous authors [8 , 18–22] have encouraged the use of educational strategies to prevent or reduce WMSDs and induce positive behavioral changes. According to Bohr [23] “health and safety literature stresses the importance of including education as part of any prevention program” (p. 244). Rizzo et al. [24] stated that employee education/training was frequently cited as a primary way to prevent cumulative trauma disorders in the workplace.

Ergonomics education is well documented as an evidence-based strategy to establish behavioral changes such as improvement in work posture, adherence to ergonomic principles, and safe use of workstation, among computer workers [18 , 26]. Though a variety of materials and methods about how to deliver ergonomics education have been documented in the literature, lectures, demonstrations, simulations, discussions, didactic interactions, and instructor led presentations were the frequently used methods [23 , 28], and handouts and video were the commonly used materials [20 , 29]. In some studies, authors [18, 20] used participatory education, which uses the adult learning models that allow for a high level of interaction between the participants receiving the education and the instructor, to impart ergonomics education. Researchers often used self-reporting outcome measures such as questionnaires, symptom surveys, and checklists to appraise the outcome of ergonomics education [5 , 30]. However, a few studies identified the use of different methods like videotape and photograph analysis of work behavior [31], pain mapping [22], and in-chair movement [32].

This article describes a 6-week evidence-based pilot project on ergonomics education in an office setting. The project was designed to explore whether the ergonomics education was an effective intervention to promote awareness of risk factors associated with WMSDs among office computer workers, as identified in the literature. A Critically Appraised Topic (CAT) portfolio was developed with 25 articles comprising quantitative and qualitative studies obtained from several databases and journals (Table 1), to design the intervention. The underlying assumption of the project was that increased knowledge of risk factors associated with WMSDs will encourage participants to engage in safe work behavior and computing patterns, thereby reducing the incidence of WMSDs [18].

2 Methodology

This project was approved by Chatham University Institutional Review Board.

2.1 Sample

The participants were recruited on a voluntary basis through an email invitation requesting participation. Seventeen participants (two males and 15 females) who work for the National Board for Certification in Occupational Therapy Inc. (NBCOT) volunteered for this project. A written informed consent was obtained from all participants. Inclusion criteria included participants between the age ranges of 18 –65 years who used a computer at least five hours per day. Those who received ergonomics education or intervention in the past six months were excluded from this project. One participant participated in this project remotely from his/her home office. All other participants worked in the same location, however, represented different departments such as customer service, information technology, credentialing, and competency services.

2.2 Data collection

The primary author collected the data utilizing a self-designed and piloted ergonomics questionnaire and the Rapid Office Strain Assessment (ROSA), which is a picture-based posture checklist that quantifies the risk factors in an office work environment [33]. All participants completed the ergonomics questionnaire described in full below. The questionnaire was used to record participants’ demographic information and work behaviors, as well as participants’ knowledge of risk factors through knowledge tests. The primary author completed the ROSA throughout the project. Data were collected at baseline (prior to intervention) and post-intervention. Pre-tests were completed after preliminary orientation and post-tests were completed in the final educational session.

2.3 Evidence-based intervention

Intervention included a preliminary orientation session and six educational sessions. All participants participated in all educational sessions that were delivered through individual and group sessions. Each session lasted approximately 30 minutes. The modes of information delivery included PowerPoint lectures, group discussion, demonstrations, and video.

The intervention was implemented for six weeks. The following describes the six week protocol used after the administration of the pre-test questionnaire and the ROSA. The content of the educational modules is discussed below with reference to each week.

First week – General overview of biomechanics of upper body and risk factors associated with computer work [27]. A twenty-five minute PowerPoint presentation was followed by five minutes of group discussion.

Second week – A PowerPoint presentation focusing on work posture and workstation analysis [14] was delivered. The ergonomic safety guidelines proposed by the US OSHA in relation to computer work was incorporated into this presentation [13].

Third week – The participants were assigned to three groups. These small groups participated in group education sessions. The primary author demonstrated appropriate posture and effective use of office chair and accessories in relation to office computer work [26]. After the demonstration, the instructor asked one of the participants to work in the workstation and encouraged other participants to comment on the user’s posture, suitability of the office chair to that user, and strategies to improve the workstation to enable function and comfort of the user. At the end of the session, participants were provided with an ergonomic workstation checklist developed by the author based on OSHA ergonomic guidelines. Participants were advised to complete the checklist evaluating their own workstation.

Fourth week – A PowerPoint presentation focusing on the importance of stretching, exercises, and rest breaks while engaging in computer work [8, 32] was delivered. This presentation was followed by five minutes of group discussion.

Fifth week – A Biz library video on computer workstation safety [34] was shown to the participants followed by a discussion. The primary author acted as a facilitator of the discussion and encouraged the participants to identify risk factors demonstrated by the characters in a series of pictures [28]. The duration of the video was 18 minutes, which was followed by a 12 minute discussion.

Sixth week – In the final week of the intervention, the primary author engaged in individual workstation observation of all participants. The primary author offered customized suggestions to improve work posture, work behavior, and workstation design based on the input received through the ergonomic workstation checklist that was completed by each participant during the third week of the intervention. The primary author also clarified questions or concerns of the participants [22, 35]. The post-tests were administered using the same outcome measures that were used for pre-intervention data collection.

Table 2 presents an overview of the implementation phase as well as the content covered in the educational sessions. All participants who attended on-site sessions received the electronic version of the PowerPoint presentation via email after each educational session. The primary author emailed the narrated PowerPoint versions of lectures and handouts to those participants who were unable to attend the educational sessions on-site. On two occasions, weekly educational sessions were re-delivered to one participant because an on-site participant who missed the scheduled session requested it. A sign-in sheet was used to record attendance of participants at the on-site sessions. To ensure confidentiality all email communications were sent to the group as a blind copy.

2.4 Outcome measures

The primary author designed the questionnaire utilizing evidence-based ergonomic guidelines, outcome measures, and ergonomic texts. The ergonomics questionnaire consisted of three sections with closed ended questions. Section A recorded the participants work behavior, musculoskeletal symptoms, and brief demographic information. Sections B and C recorded the participant’s knowledge of risk factors associated with WMSDs. The risk factors provided under section B include awkward postures, bending, excessive work, force of movement, glare, job strain, lifting, monotonous tasks, pace of work, prolonged posture, repetition, and vibration. Section C presented ten dichotomous true/false items (Table 3). The purpose of the questionnaire was to measure the differences in the knowledge of risk factors associated with WMSDs and work behavior before and after the intervention. In section A, items 1 – 2 recorded the duration of computer use; items 3 – 7 recorded participants work behavior on a 4 point scale (Never = 1; Often = 4); and the final item recorded the area(s) of pain or discomfort. Section B was scored based on the number of risk factors identified by each participant. Similarly, section C was scored based on the number of correct responses. A draft of the completed ergonomics questionnaire was given to six occupational therapists who have more than five years of experience in the field of ergonomics. The experts were asked to review the questionnaire and provide feedback. The feedback from individual reviewers was collated and necessary changes were made to questionnaire’s layout and response options. The primary author piloted the questionnaire with five computer workers outside this project’s setting to ensure that instructions were comprehensible. During the post-test administration, items one (hours of computer use at work), two (hours of computer use outside work), and eight (painful body regions) under Section A were omitted as those items did not measure either a change in behavior or the knowledge of risk factor.

The Rapid Office Strain Assessment (ROSA) is a picture-based posture checklist on which the author recorded the participants’ observed postures for ten minutes while working at their workstation. The ROSA grouped the risk factors into three sections: chair, monitor and telephone, and keyboard and mouse. Inter- and intra-observer reliability of the ROSA have been reported to be 0.88 and 0.91, respectively [32].

3 Results

Tables 4 and 5 present participants’ demographics and computer use patterns, respectively. Forty seven percent of participants were more than 51 years of age. The hours of computer use on any given day ranged from six to more than 12 hours, while the average hours of computer use was 8.94 hours (SD 1.82 hours).

Comparison between baseline and post-intervention data indicated a change in participants’ behaviors. Change was noted in participants’ behaviors in terms of frequency of taking rest breaks, engaging in stretching exercise while working with computers, adjusting their office chair to suit their anthropometry and workstation, and rearranging the workstation after the intervention. Figures 1–4 present the comparison of participants’ behaviors prior to and post-intervention. After the intervention, seven participants reported a change in the frequency of rest breaks taken and all participants reported a change in the frequency of participation in stretching exercises. Similarly, post-intervention data revealed that 11 participants adjusted their office chair and/or re-arranged their workstation.

Following the intervention, 15 participants were able to identify a greater number of risk factors associated with WMSDs as evidenced by their responses in sections B and C of the ergonomics questionnaire. Ten out of 12 risk factors listed under section B were identified by 89% of the participants post-intervention (Fig. 5). Of interest, the majority of participants identified awkward and prolonged postures as risk factors associated with WMSDs prior to the intervention. However, as evident in the pre-intervention ROSA scores, this awareness did not reflect in participants’ work behaviors prior to the intervention. Pre-test and post-test comparisons revealed that among 17 participants, only five participants were aware of all risk factors listed under section B of the ergonomics questionnaire prior to the intervention. As per the post-intervention data, the remaining 12 participants’ demonstrated increased awareness of risk factors associated with WMSDs as they identified a greater number of risk factors. Of interest, one participant identified only three of the 12 risk factors listed, prior to the intervention. However, the same participant identified nine risk factors post-intervention. In section C, interestingly, two participants scored less than their pre-intervention score. Both participants answered one question incorrectly, they answered it correctly prior to the intervention. In the responses of five other participants, there were no differences in the number of correct responses prior to and post-intervention.

Five participants failed to identify pace of work as a risk factor, while two participants failed to identify vibration and force of movement as risk factors associated with WMSDs. Similarly, 89% of the participants answered six of the ten items correctly in Section C of the questionnaire, post-intervention. The questions that were related to sitting posture (item 2) and typing speed (item 8) were answered incorrectly by six and eight participants, respectively. Figure 6 shows the average percentage of scores received by participants’ in the knowledge tests on the ergonomics questionnaire, prior to and post-intervention.

Analysis of the ROSA scores identified notable differences in participants’ posture and work behaviors as evidenced through low ROSA scores post-intervention (Fig. 7). Post-intervention data revealed decreased ROSA scores for 15 (88%) participants, compared to pre-intervention scores. The authors of the ROSA stated that research has shown a positive correlation between increased ROSA scores and musculoskeletal discomfort (MSD) [33]. Hence, a reduction in ROSA scores suggests that there would be a reduction in MSD secondary to improved work posture and work behavior.

4 Discussion

This project was designed and implemented with the impetus of reducing the incidence of WMSDs in office computer workers by promoting their awareness of risk factors associated with WMSDs. This project was carried out at a single site due to convenience and management support. The educational sessions were delivered in the conference room of the organization.

Since the ergonomics questionnaire used for data collection presented dichotomous items to test the knowledge of risk factors associated with WMSDs, the possibility of a participant randomly choosing the correct answer cannot be ruled out as the probability of choosing the correct response was 50%. The participants who volunteered for the project belonged to different departments and worked in similar workstations and offices, which offered more control in completing ROSA. One participant who participated in the project from the home office was requested to email pictures of the workstation to complete ROSA, as ROSA can also be completed using pictures [33].

As stated earlier, the participants who were unable to attend on-site sessions and the remote participant received the narrated PowerPoint version of the educational sessions. A reminder email was sent to these participants, after three days of the initial email, to encourage them to watch the narrated version. The participants who received the narrated version were asked to send the primary author a one sentence summary of one thing they learned from the presentation before the final week of the intervention to ensure that they watched the narrated version. Though the author received the summaries, the possibility of these participants failing to watch the narrated version in its entirety cannot be ruled out.

The outcomes of this educational intervention shows that the intervention had some positive effect on participants awareness of risk factors associated with WMSDs. This was evident in participants’ responses to knowledge tests, engagement in safe work behaviors, and reduced ROSA scores post-intervention. Though this project did not have a control group for comparison, the findings of this project were consistent with the findings in the literature [19 , 28].

Similar to the findings in the literature [5, 9], this project revealed a positive relationship between the duration of computer use and musculoskeletal discomfort. All participants in this project used computers more than five hours a day and reported some form of musculoskeletal discomfort. Further, several studies in the literature [16 , 25] cite behavioral change as an outcome of educational intervention. The outcomes of this project confirm the same, as more than half of the participants reported behavioral changes after the intervention. In addition, ergonomics education was reported to have a positive influence on worker’s posture [18, 23]. This was confirmed in this project through low ROSA scores post-intervention.

In summary, the findings from this project show some positive knowledge and behavioral changes among participants, supporting the use of ergonomics education with office computer workers.

5 Conclusion

Though the results imply a positive outcome, caution must be exercised before generalizing these findings due to the low sample size, which eventually prevented meaningful statistical analysis. This project sets the stage for future, more in-depth studies. Based on the current findings and available evidence, OT practitioners may advocate for injury prevention through ergonomics education for employees in office work settings. As computer use becomes an integral part of life, it is advisable for OT practitioners to include “computer use” as a variable in their functional assessments.

Some of the major limitations of this project include small sample size, lopsided sample with more women, and a lack of comparison group. These limitations limit the generalization of the findings. Further, only articles published in English were synthesized for evidence. During intervention implementation, some participants received their educational information via narrated PowerPoint. These participants lacked the opportunity to discuss what they had learned with other participants and with the author to supplement or clarify presented information. This may have influenced participants’ comprehension of the presented materials and hence the outcomes. Next, two participants in this project were occupational therapists (OTs) by profession. Their background knowledge in biomechanics and ergonomics might have influenced their performance in knowledge tests as these topics are typically covered in an OT curriculum. Eliminating OTs from participating in this intervention could have minimized this limitation.

More research would help health practitioners to determine the effectiveness of ergonomics education as a strategy to promote WMSD risk factor awareness and expected behavioral changes such as taking frequent rest breaks, following proper body mechanics, and participating in flexibility exercises to reduce incidence of WMSDs. Future research should expand on the targeted population to include software engineers, computer operators, and laptop/personal digital assistant users as this population is ever growing. The methodology can also be modified to test the retention of knowledge for extended periods of time such as 3 months, 6 months, and one-year intervals. Further, web-based ergonomics education and on-site ergonomics education can be compared, as educational interventions can be delivered to a larger population through a web-based platform.

Conflict of interest

None to report.

Footnotes

Acknowledgments

Authors would like to express their gratitude to Paul Grace, President/CEO, NBCOT, Micheal Sonne, Author of ROSA, Dr. Karen Jacobs, Occupational Therapy Scholar, and all participants who volunteered for this project.

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