Raising awareness of hand-arm vibration syndrome (HAVS) using posters

Abstract

BACKGROUND:

Hand-arm vibration syndrome (HAVS) is caused by prolonged occupational exposure to hand-transmitted vibration. Although HAVS is preventable, disease awareness and prevention knowledge are lacking in high-risk workplaces; this may contribute to under-diagnosis, delays in seeking care, and poor health outcomes. Posters may be used to increase awareness in the workplace.

OBJECTIVE:

To conduct a pilot survey in workers with HAVS about poster use in their workplaces, their recommendations for poster campaigns and training programs, and their evaluation of HAVS awareness and prevention posters.

METHODS:

All eligible HAVS patients in the Occupational Health Clinic at St. Michael’s Hospital, in Toronto, Canada, were asked to complete a questionnaire on workplace poster use and to evaluate a set of HAVS posters.

RESULTS:

Fifty workers participated; almost all were males, aged 50 and older, working in construction. Most indicated having non-HAVS specific awareness posters in their workplaces. There was a positive evaluation of the design, content, and potential usefulness of the posters. The poster depicting finger blanching stood out most. The poster depicting anti-vibration gloves rated highest for relatability and effectiveness at conveying disease importance.

CONCLUSIONS:

Participants supported the proposed use of industry-specific HAVS awareness posters in their workplaces. Future research should evaluate the effectiveness of these posters in the workplace.

Keywords

Occupational diseases prevention health and safety training workplace

1 Introduction

Hand-arm vibration syndrome (HAVS) is an occupational disease caused by regular exposure to vibration from hand-held power tools or vibrating work surfaces [1]. HAVS is a complex condition that manifests in the nervous, vascular, and musculoskeletal systems [2 –4]. Affected workers present with a range of symptoms including blanching, paresthesia, numbness, tactile sensitivity, loss of functional dexterity, joint stiffness, reduced grip strength and pain in the fingers, hands, elbows and/or shoulders. Vasospastic manifestations in the feet [5, 6] and hearing loss [7] have also been associated with vibration exposure. The permanent damage caused by HAVS can diminish quality of life by limiting functional abilities required for everyday tasks, vocational opportunities, and self-perception [2, 8]. Financial pressure, resignation, and stoicism are only some of the factors that drive workers to continue in their jobs despite experiencing HAVS symptoms [9]. This works to the detriment of their health, since symptoms cause workers to assume poor hand-arm posture, and exert excessive grip and push forces, all factors that affect the transmission of hand-arm vibration [10 –12]. Furthermore, due to the progressive nature of HAVS, continued exposure to vibration can worsen disease outcomes.

The prevalence of HAVS amongst workers exposed to hand-arm vibration varies from 6–100%, with a mean of 50% [13]. The latency period also shows considerable variation; however, a mean of 18 years (range 1–41 years) has been reported [14]. Due to their lacking awareness of the seriousness and irreversibility of the disease, on average, workers have been reported to delay seeking general medical attention for 3 years and assessment by an occupational health specialist for 9 years [15]. The literature reveals that HAVS is substantially under recognized in Canada and workers at risk do not have a good understanding of primary, secondary and tertiary prevention measures [16, 17]. This is especially problematic since advanced disease may result in irreversible damage and impairment.

The implementation of preventive measures in the workplace can improve occupational health outcomes by eliminating or minimizing hazardous exposures. The hierarchy of controls systematically prioritizes possible strategies that can be implemented to manage workplace hazards and risks [10]. Vibration exposure can be controlled by implementing principles of this hierarchy in several ways. Examples include, but are not limited to, modifying processes to eliminate the use of vibration, selecting lower vibration producing tools, performing regular tool maintenance, scheduling break periods throughout extended periods of continuous vibration exposure, implementing awareness and training programs to address good work practice and disease awareness, as well as providing personal protective equipment such as anti-vibration gloves [12, 18].

Given the under-recognition of HAVS and the need for improved prevention, posters could be used as part of an awareness and training program. Posters can be an effective way to communicate information and prompt change in behaviour or attitude [19]. They are widely used in health promotion campaigns, particularly those promoting hand hygiene, vaccinations, stair use, and smoking cessation. However, there is a dearth of literature addressing the use of health and safety awareness posters in the workplace and their effectiveness at improving safety practice.

The objectives of the study were to obtain feedback from workers affected by HAVS with respect to 1) current poster use in their workplace, 2) recommendations for poster use and training programs in workplaces and 3) their evaluation of a series of HAVS posters.

2 Patients and methods

2.1 Research ethics

Study approval was granted by the St. Michael’s Hospital Research Ethics Board.

2.2 Study group

All eligible patients attending the Occupational Health Clinic at St Michael’s Hospital during the study period (July to October 2016) were invited to participate in the study, until a sample of 50 was achieved (51 approached to obtain 50 participants). Eligible participants were workers being assessed for HAVS and proficient in English.

2.3 Study conduct

The receptionist in the Occupational Health Clinic identified eligible participants using the appointment schedule and provided them a study package, comprised of the Letter of Information and questionnaire, upon their arrival to the clinic for their appointment. Patients were asked to complete a 5-page questionnaire while viewing the HAVS posters. Participation was voluntary and in no way affected subsequent clinical investigation or treatment. Implied consent was inferred upon the submission of a completed questionnaire into the collection box. Returned questionnaires did not contain any individually identifying information.

2.4 Posters

A series of 6 posters promoting HAVS awareness and prevention were developed by the Centre for Research Expertise in Occupational Disease (CREOD) in collaboration with Workplace Safety and Prevention Services (WSPS). These posters were based on a similar set of workplace posters developed to raise awareness about occupational skin disease (http://app.wsps.ca/Poster/PosterDesigner.php). The posters addressed the following themes: prevention, early detection, use of personal protective equipment, hygiene, exposure avoidance and exposure control. The pictures in the background depicted the use of vibrating tools in various industry sectors.

2.5 Questionnaire

A self-reported questionnaire was used to collect the following data: socio-demographic characteristics (i.e. sex, age, job sector), current exposure to health and safety posters at work (i.e. are there posters related to awareness and prevention of HAVS in your workplace?), preferred format(s) for health and safety training (i.e. posters, talks, hand-outs, on-line, videos, training sessions), opinion on the usefulness of workplace posters (i.e. in general, in participants own workplace), and preferred characteristics for a workplace poster campaign (i.e. ideal location for display, frequency of rotation, content customization to the industry/organization).

The evaluation of 6 HAVS posters was structured in three parts: 1) dichotomous styled questions about participants’ overall impressions of the poster set, 2) an open ended question for participants to explain which poster stood out to them from the set and 3) rating-type questions about participants’ impressions of the posters individually, according to the following three criteria: “How clear is the message on this?”; “How easy is it to understand the picture related to the message on the poster?”; and “How effective is this poster in making you think about the importance of HAVS”. A 7-point Likert Scale ranging from 1 (not clear) to 7 (very clear) was used.

2.6 Data analysis

Data were analyzed using Microsoft Excel. Descriptive statistics including proportions and percentages were computed. In the case of missing item responses, proportions were calculated excluding the subject(s) who did not respond. Qualitative data in the form of free-text responses were reported without detailed qualitative analysis, as they were a minimal component of the predominantly quantitative research design.

3 Results

3.1 Demographics

The study population consisted of 49 males and 1 female. Of the participants, 56% (N = 28) were aged 50 or older. A wide range of industries were represented in the sample. The majority of participants reported working in the construction (51%) and mining (22%) industries. Others came from the manufacturing, service, chemical, steel, transportation, forestry and pulp and paper industries.

3.2 Current use of workplace posters

Eighty-two percent (N = 40/49) of participants reported having general health and safety posters in their own workplaces. Only 15% (N = 7/48) recalled having posters which addressed awareness and prevention for HAVS. The data did not suggest a greater tendency for HAVS posters usage in any particular industry.

3.3 Recommended use of posters and training programs

Nearly all the participants (N = 47/49, 96%) agreed that workplace posters are an effective method to communicate information in a training program. More respondents indicated that information about occupational diseases and prevention should be delivered through video-based learning (70%), training sessions (70%) and talks (66%) compared to hand-outs (36%) and on-line communications (22%).

There was a high level of agreement (N = 45/48, 94%) among participants that posters and other educational materials should address industry-specific information. The lunch area was selected as the optimal location for poster display (84%), followed by work area (48%), locker room (42%), and washroom (32%). Free-text responses suggested trailers, offices, meeting rooms, health and safety boards, time-card clocks and machinery/equipment as other prominent locations where posters might be displayed.

There was no appreciable difference in participants’ preferences to display a set of posters simultaneously (49%) or to implement a rotation schedule for poster presentation (51%). When asked to select the optimal duration for poster display prior to rotation, the majority of participants opted for once a month (44%), followed by once per week (33%), every 3 months (19%) and longer than 3 months (4%). Nearly all participants (94%) agreed that poster implementation in their own workplaces would be useful.

3.4 Evaluation of HAVS poster series

All participants agreed that the posters were easy to read, 94% (N = 47/50) agreed that the posters attracted their attention, and 96% (N = 47/49) agreed that the poster content was clear and easy to understand.

Forty-four participants (88%) indicated that a particular poster(s) stood out to them. The total number of posters selected as standing out (N = 62) exceeds the number of participants since 12 of the 44 participants who completed this question, selected more than 1 poster for their answer. The posters selected most were poster 1, featuring a hand with finger blanching, affected by HAVS (N = 20/62, 32%), and poster 4, featuring a pair of anti-vibration gloves (N = 12/62, 19%) (Fig. 1). Poster 1 was identified by workers across all sectors whereas the other choices varied by sector (Fig. 2). The graph in Fig. 2 describes the number of times each poster was selected as standing out by construction workers and other sector workers.

Fig. 1

HAVS posters. 1) vibration white finger (diseased hand); 2) grinder; 3) hand examination (early detection); 4) anti-vibration gloves; 5) jackhammer; 6) rock drill.

Fig. 2

Graph comparing the poster selection of construction and other sector workers.

Posters were evaluated on three criteria: message clarity, ease of understanding the relationship between the image and the message, and effectiveness at making the viewer think about the importance of HAVS. Scores were given on a 7-point scale ranging from “not clear” (1) to “very clear” (7). A score of 5 or above was analyzed as a positive rating. Poster scores are presented in Table 1. Again, poster 1 scored the highest while posters 2 and 3 scored the lowest.

Table 1

Evaluation of specific posters

Poster	Message Clarity N (%)	Picture to Message Relatability N (%)	Effectiveness at Conveying Importance of HAVS N (%)
1	42/49 (86)	40/49 (82)	40/49 (82)
2	38/50 (76)	38/50 (76)	36/50 (72)
3	34/50 (68)	34/48 (71)	31/50 (62)
4	41/50 (82)	43/50 (86)	42/50 (84)
5	39/49 (80)	41/49 (84)	38/48 (80)
6	41/49 (84)	41/49 (84)	39/49 (80)

Note: only positive scores (i.e. 5, 6, or 7) were reported in the table (N = number of positive scores/total number of responses)

4 Discussion

To the authors’ knowledge, this study is the first to evaluate HAVS patients’ feedback on the use of posters to improve awareness of HAVS as well as the hazard of hand-arm vibration exposure, to promote prevention practices in the workplace. While the poster depicting a hand with finger blanching scored the highest across the evaluation criteria, nearly all the participants agreed that the 6 posters were readable, attention grabbing, and clear.

The proposed use of HAVS awareness posters in the workplace is a promising intervention since posters have been rated by young workers as one of the top three methods of safety training along with safety videos and lectures [21]. Furthermore, message recall from posters has been found to exceed that from other means of communication such as flyers and the company intranet [22]. Despite this, health and safety posters that address HAVS awareness and prevention are uncommon in the workplace.

There is a large body of research concerning the use and effectiveness of health promotion posters, such as those designed to improve nutritional knowledge and physical activity, as well as health and safety posters designed to improve infection prevention and control practices. However, to-date, there is only one published study on the prevention of HAVS through education [17]. This deficit should be addressed given that treatment options are limited and the vibration-induced damage is irreversible.

Signage tends to be prevalent in the workplace. Therefore, it is important that educational posters be displayed in high-traffic areas that are visible to workers. Our findings indicate that the lunch area is the optimal location for posters to be displayed (84%). However, the wide range of responses with respect to the optimal location for poster display and poster rotation schedule support the importance of tailoring a poster campaign to the individual workplace and its characteristics. A one-size-fits-all strategy for educational campaigns should be avoided, especially when catering to workers in heavy industries like mining and construction where remote jobs are common [21 , 24].

In a recent study of nursing education interventions, KuKanich et al. argued that poster campaigns tend to yield short-term improvements only and their effectiveness is maximized when posters are rotated [24]. Although our results do not indicate any strong preference to display posters all at once or to rotate them one at a time, and no gold standard rotational period is known, participants favoured once per month (44%) and once per week (33%) when asked how often posters should be changed if displayed one at a time. These results are consistent with the British Safety Council’s recommendation that posters be displayed for a maximum of 10 working days as well as the findings from a workplace study of steelworkers that preferred biweekly poster rotations [25, 26].

A year-long hand hygiene poster campaign delivered to healthcare workers involved in direct and non-direct patient contact is one of many cases where poster use led to a significant increase in compliance with infection prevention practices [27]. A similar beneficial outcome was reported in a multi-center study of accounting firms, where a health promotion poster campaign promoting stair use led to a significant increase in this physical activity [28].

In general, interventions should be framed in a way to appeal to viewers’ interests and be perceived as high priority [27]. Furthermore, there is evidence to suggest that women are influenced by knowledge-based messages and men by messages that provoke emotional responses like disgust [29, 30]. Rothman and Salovey argue in favour of messages that promote behaviour in terms of its benefit to the individual [31]. Kerr et al. found that male and female poster message preferences differed when the posters were displayed in a mall and train station [32]. Seeing how poster appeal differs by audience and location indicates how characteristics of successful poster campaigns are contextual.

Poster 3, showing a preventive skin examination, with the negatively framed caption: “It can get worse. Speak to your doctor.” stood out least from the set. In contrast, poster 1, showing finger blanching, with the positively framed caption: “Your hands are important. Protect them.” stood out most. Likewise, the anti-vibration glove poster (poster 4), which also featured a positively-framed caption, received the highest score in two out of the three scoring criteria. These results are consistent with those from a study of coal miners, where negatively framed messages were found to be less effective than positive and neutral messages at promoting the use of voluntary hearing protection [32]. While posters generating fear may succeed by attracting audience attention, there is controversy over whether they are counterproductive, by causing a viewer to experience stress that leads to avoidant and inattentive behaviour [19]. Self and Rogers add that the effectiveness of fear appeal messages depends on the extent to which the audience is convinced that they can cope with the danger, while Akl et al. speculate that the effects from message framing, being the positive or negative description of an item, are condition dependent [34, 35].

The main limitations of this study include a relatively small study size (N = 50) and the lack of a comparison group. Given that the participants are workers who have actively sought medical care for their condition, they may not be representative of all workers with HAVS or all those exposed to hand-arm vibration. Furthermore, it is possible that this sample may have had a greater interest in HAVS awareness and prevention than the population of workers at risk of HAVS because of their experiences with the disease.

Since almost all the participants were men (98%), from the construction sector (61%), it remains to be determined if their opinions represent those of other demographic groups (e.g., non-construction workers, women and non-English speaking workers). However, given that women are a minority in some sectors associated with vibration exposure, we suspect that the lack of female input is unlikely to be a major limitation of this feasibility study.

5 Conclusion

HAVS is an under recognized occupational illness and there is insufficient attention given to the identification and control of exposure to hand-arm vibration in the workplace. This is especially the case given the fact that a recent meta-analysis indicated that workers with hand-arm vibration exposure have a 4-5 fold increased risk of developing the vascular and neurological components of HAVS [36]. Therefore increased prevention efforts are needed for HAVS and these could include awareness posters. Our study, the first to provide HAVS patients’ feedback, provides useful information about the design and use of such posters. Future research will involve piloting the HAVS posters in the workplace so that their effectiveness at increasing disease awareness and use of preventive practices can be evaluated. Given the tendency for workers to overlook the early non-specific symptoms of HAVS and their attribution to their work, as well as the limited treatment options for the disease, primary and secondary prevention, are promising approaches to reducing the incidence of HAVS [37].

Conflict of interest

The authors declare no conflict of interest relating to the material presented in this article. Ms. Budd received student support from the Centre for Research Expertise in Occupational Disease (CREOD), funded by the Ontario Ministry of Labour.

Funding

This research was funded by The Centre for Research Expertise in Occupational Disease (CREOD).

Footnotes

Acknowledgments

We gratefully acknowledge Dr. Ron House for reviewing this manuscript and sharing his expertise on HAVS. We would also like to thank the participants for their contributions to this study.

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