Improvements in musculoskeletal symptoms,mental workload and mental fatigue: Effects of a multicomponent ergonomic intervention among call center workers

Abstract

BACKGROUND:

Call center workers are highly susceptible to work-related musculoskeletal disorders (WRMSDs) as well as mental stress. Nonetheless, there has been a surprising paucity in the body of the research regarding interventions among call center workers.

OBJECTIVE:

The purpose of this paper is to investigate the effectiveness of a multicomponent ergonomic intervention program on mental workload, mental fatigue and WRMSDs of call center employees.

METHOD:

A non-randomized interventional study with a single group pretest-posttest design was conducted among 84 call center workers of a private telecommunication company in the city of Tehran, Iran. At the baseline, data regarding WRMSDs prevalence, mental workload and mental fatigue were collected by means of standard Nordic, NASA-TLX and SOFI questionnaires, respectively. Then, subjects participated in a multifaceted intervention program including comprehensive office ergonomic training, work layout improvement, supervised on-site face to face visits, and provision of quality break time encompassing regular exercise program. Follow-up assessment was carried out after 6 months.

RESULTS:

After the intervention, prevalence of WMSDs in the neck (10%, P = 0.022), lower back (8.4%, P = 0.04), and knees (9.5%, P = 0.02) decreased significantly, while improvements in other body areas remained insignificant. Results also showed a significant decrease in overall score of mental demand (P = 0.000) as well as three of its subscales including performance (P = 0.02), effort (P = 0.001), and frustration (P = 0.025). Additionally, positive effect of the intervention was also observable on overall mental fatigue of call center workers (P = 0.016). As for its subscales, Lack of energy was reported to decrease meaningfully (P = 0.007) while lack of motivation did not change significantly (P = 0.240).

CONCLUSION:

Although the primary focus of many ergonomic interventions has remained to measure physical outcomes of the work place, our findings show that multicomponent interventions are indeed capable of boosting cognitive aspects of the work as well. The future studies should consider investigating such outcomes.

Keywords

WRMSDs occupational fatigue office work mental demand

1 Introduction

Computer-based customer service work, i.e. call center work, accounts for almost 3 to 4 percentage of working population, and it is one of the most rapidly growing occupations in the world [1, 2]. Call center workers spend majority of their time sitting in a workstation, which includes a computer desk and a chair, and interacting with computer and virtual customers [3, 4]. As a result, this sedentary and static nature of their work combined with simultaneous use of a communication device and computer in order to consistently answer enquiries make them susceptible to mental stress as well as work-related musculoskeletal disorders (WRMSDs) especially in the neck, shoulder and back body areas [5 –9].

WRMSDs are observed to first begin with muscles feeling fatigued and achy and then progress into a more serious condition which impairs movement of the limbs or muscles’ strength and power of the person [10]. Consequently, they impact not only the person but also the organization and the society as a whole [11]. An exemplar range of adverse outcomes includes disability of workers, absenteeism, and wasted money due to lost work time [12 –14]. According to reports about 40 percent of compensations paid to workers are associated with musculoskeletal disorders [15].

Literature provides ample evidence that the etiology of WRMSDs is multi-faceted and involves a complex interaction between personal (e.g. demographic properties and working behaviors), physical (e.g. workstation layout and awkward or static posture), and psychosocial factors (e.g. social support and rest breaks) [4 , 16–19]. Correcting postures, regular micro-exercises while working and instilling ergonomically right behaviors into employees are some of the proved practices that can make workplaces a safer place with regards to WRMSDs [15 , 20–22]. Improving workplace conditions especially refining employees’ posture not only reduces the risk of WRMSDs but there is also emerging evidence that it may have positive effects on cognitive aspects of the work including mental workload and mental fatigue [23 –26]. However, such association remains a matter of controversy, and there is a call for further investigation [27].

The results regarding effectiveness of ergonomic interventions among office workers remain inconsistent to date [17, 28]. To address such discrepancies, literature provides that holistic and multicomponent ergonomic interventions should be favored in which there is an edge compared to single item interventions [17 , 29–31]. The results of several studies among office workers have shown that the modification of workstations in line with ergonomic principles, reinforced with operative training can lead to a reduction in MSDs’ symptoms and discomfort [12 32, 33]. In their review, Juhanson and Merisaluit posited that such interventions are one of the more effective means of improving working condition [34]. Nonetheless, the general effectiveness of ergonomic interventions remains to be scrutinized by further evidence [28].

According to Armitage and Sprigg, there was a surprising paucity in the body of the research regarding interventions among call center workers and based on our knowledge this statement remains relevant until today [1]. Therefore, the primary purpose of this paper was to investigate the effectiveness of a multicomponent ergonomic intervention program on work-related musculoskeletal symptoms of call center employees, which targeted personal (office ergonomics training), physical (work layout improvement) and psychosocial (quality break time) aspects of the work system. Based on the existing evidence [23 , 34], It was hypothesized that such comprehensive intervention would decrease not only WRMSDs but also mental workload and mental fatigue levels of the participants. Considering the accelerating trend toward teleworking due to the pandemic, It is believed that the findings of the current study could help to build more efficient evidence-based interventions to improve working condition of not only call center agents but also other employees working in similar context including home office workers.

2 Method

2.1 Study design

This non-randomized interventional study (quasi-experimental) was conducted with a one-group pretest posttest design in a telecommunication company (MobinNet^®) in city of Tehran from March 2017 to September 2017. The participants received office ergonomics training (2×1.5 hours) and were provided with quality break time enriched by an exercise program in a period of 6 months. Data regarding their musculoskeletal disorders, mental workload and fatigue were gathered before and after the intervention. The ethics committee of the industrial engineering department, Caspian higher education institute, approved the study. Study flow diagram is presented in Fig. 1.

Fig. 1

Study profile and participant flow.

2.2 Subjects and setting

The study population were all full-time call center workers of a private telecommunication company in the city of Tehran, which were selected by census. Prior to the study informed consent of the participants was obtained. Inclusion criteria were employees who performed more than 24 hours of computer-based customer service work (4 hours a day) and didn’t have any active workers’ compensation claim involving upper body limbs. All employees sat in standard cubicles and each had their designated computer set (flat screen, keyboard and mouse) and a headset. Their job involved answering the phone and handling enquiries from the customers. There was little use of written material and majority of procedures were handled on the computer. Regarding physical layout, cubicles were all almost consistent and similar across the organization. They were U-shaped and open ended with a size of roughly 1 by 1 meter. Office furniture were hardly adjustable (i.e., none of them had arm rests), and there was not much trace of efforts by managers to upgrade workstations ergonomically.

2.3 Intervention

The multifaceted intervention program comprised four components which were suitably tailored to the needs of the community, and targeted different aspects of the work.

2.3.1 Comprehensive office ergonomic training

After the baseline assessment, two 90-minute group training sessions were held by the authors at the workplace in order to increase participants’ awareness with regard to basic office ergonomic principles. Based on authors observation, initial awareness of ergonomics seemed to be low among the employees. Basically, topics included etiology of WRMSDs and significance of work layout alterations and workplace stretching exercises to avoid WRMSDs. Additionally, subjects were taught risk self-assessment skills so that they would be able to readjust their workplace accordingly. At the end of the sessions, a concise visual pamphlet, which consisted of all the materials taught during the sessions, was given out to the attending participants.

2.3.2 Work layout improvement

As far as improving work layout was concerned, by having the top management support, noteworthy modifications were made to the physical workstation. The most important changes included making improvements to some existing chairs and replacement of non-adjustable chairs with adjustable chairs equipped with arm and head rests and provision of foot rests and standard stands for the screens.

2.3.3 Supervised on-site face to face visits

The next day after training sessions, researchers started to visit participants, while doing everyday tasks in their cubicles, and monitored how the education was translated into their everyday activities. Moreover, these personal visits sought to change participants’ behavior, if needed, by utilizing moti-vational interviewing approach. motivational interviewing is a concise, person-centered intervention devised to elevate intrinsic motivation for behavior change by understanding and reducing the client’s ambivalence [35]. Participants were approached one by one and their snapshots, if there was an inappropriate exercise, were taken while doing their usual tasks. Subsequently, the pictures were put into discussion and possible solutions were generated. After face-to-face training, Research team members revisited their mentees on a bimonthly basis. These follow-up visits were done to make sure the participant kept up with the healthy work practices and postural habits.

2.3.4 Provision of quality break time encompassing regular exercise program

Prior to the study an agreement with the key stakeholders of the company was achieved to provide the employees with an additional rest break opportunity, halfway through their work shift. However, it was up to employees to find the right opportunity, so it would not impact customer attendance and overall work flow of the system. During training sessions, the length of the exercise program was put into the discussion with the relevant parties, and it was agreed to be 10 minutes. Regarding the content of the program, participants were advised to perform a set of stretching and joint mobilization exercises, targeting whole body including upper body and lower body, once a day when they felt their muscles were tense or fatigued. This exercise program was essentially devised in parallel with the procedure of another study, but nevertheless it was slightly tailored to the needs of the population [36]. Additionally, a log was given to each participant to be ticked every day when the exercise was performed, and later, it was monitored regularly by the supervisors and the researchers on a weekly and bimonthly basis, respectively.

2.4 Outcome measures

Outcomes of the study were measured at the 6-month time point after the baseline assessment. Prevalence of the WMSDs was the primary focus of the study, and it was evaluated by the Persian version of the standardized Nordic questionnaire of musculoskeletal symptoms [37, 38]. The respondents were asked to report the occurrence of musculoskeletal symptoms in 6-month time period in 9 regions of their body including the neck, shoulders, upper back, elbows, low back, wrist/hands, hips/thighs, knees and ankles/feet.

Fatigue and mental workload were the secondary outcomes of the study. Swedish Occupational fatigue inventory (SOFI-20) was used to assess mental fatigue of employees [39]. Its dimensions are Lack of energy, Physical exertion, Physical discomfort, Lack of motivation and Sleepiness. We chose only two dimensions of this scale since the other dimensions were out of the scope of this study. Lack of energy (items: worn out, spent, drained, overworked) is a general dimension of the fatigue phenomenon capturing its mental or physical aspects. Lack of motivation (items: lack of concern, passive, indifferent, uninterested), on the other hand, is a primarily mental dimension of fatigue referring to how detached and uninvolved the person is with his job. Rating of the scale is on a Likert scale ranging from 0 (never had this felling) to 20 (had this feeling to a very high degree). Reliability and validity of this scale are reported satisfactory in Persian population [40].

The NASA-TLX questionnaire is stated to be the most reliable and valid instrument to assess mental workload subjectively [41]. It is a multidimensional instrument which comprises six subscales including mental demand (MD), physical demand (PD), temporal demand (TD), frustration (FR), effort (EF), and performance (PE) [42]. These subscales were combined to create an overall NASA-TLX workload score (scaled to 0 = low, 100 = high). Mohammadi et al. translated this scale into Persian and its reliability and validity were reported to be acceptable [43].

2.5 Data analysis

Data were analyzed using SPSS software package. Normality of the variables was investigated by means of Shapiro-Wilk test. Since the distribution of the variables was not normal, non-parametric tests were used to analyze the data. To compare pre and post-intervention prevalence of musculoskeletal disorders, McNemar test was utilized. In a similar vein, Wilcoxon sign test was applied to analyze subjects’ perceived mental fatigue and mental workload before and after the intervention. The P value was set at α≤0.05 for statistical significance.

3 Results

Demographic characteristics of the call center workers are presented in Table 1. The age mean of the participants was 28.1±3.69 years, and majority of them were females (76%). According to the table, the average BMI was 24.2 (±3.69), which places it within the normal (fit) range. For education, 59 (70%) of the call center workers were graduates, while the rest (30%) were holding a Diploma. Additionally, 67 (80%) of them had a job tenure of less than 3 years.

Table 1
Demographic characteristics of the participants

Variable (Mean±SD) or %

Age (yrs) 28.1±3.69

BMI 24.2±2.6

Gender

Male 20 (24%)

Female 64 (76%)

Education

BSc 59 (70%)

Diploma 25 (30%)

Job tenure

More than 3 years 17 (20%)

Less than 3 years 67 (80%)

Variable	(Mean±SD) or %
Age (yrs)	28.1±3.69
BMI	24.2±2.6
Gender
Male	20 (24%)
Female	64 (76%)
Education
BSc	59 (70%)
Diploma	25 (30%)
Job tenure
More than 3 years	17 (20%)
Less than 3 years	67 (80%)

Prevalence of musculoskeletal discomfort before and after the intervention is reported in Table 2. The neck (42.9%), knees (34.5%) and upper back (33.3%) were the most experienced symptoms in the baseline of the study which is typical for call center workers. As indicated by McNemar analysis, after implementing workplace improvements, there was a significant reduction in the prevalence of symptoms in the neck (10%, P = 0.022), lower back (8.4%, P = 0.04), and knees (9.5%, P = 0.02). As for the shoulders and upper back although there was an observable reduction in the reported symptoms (4.8%, P = 0.344, and –7.1 %, P = 0.15 respectively), it was not significant.

Table 2

Prevalence rate of musculoskeletal symptoms in the body areas before and after the intervention (N = 84)

Body regions	Before intervention		After intervention		Change	P-value ^a
	Yes (%)	No (%)	Yes (%)	No (%)
Neck	36 (42.9%)	48 (57.1%)	27 (32.1%)	57 (67.9%)	–10.8%	0.022^*
Shoulder	26 (31%)	58 (69%)	22 (26.2%)	62 (73.8%)	–4.8%	0.344
Elbow	6 (7.1%)	78 (92.9%)	6 (7.1%)	78 (92.9%)	0	1.00
Hand/Wrist	23 (27.4%)	61 (72.6%)	21 (25%)	63 (75%)	–2.4%	0.50
Upper back	28 (33.3%)	56 (66.7%)	22 (26.2%)	62 (73.8%)	–7.1%	0.15
Lower back	25 (29.8%)	59 (70.2%)	18 (21.4%)	66 (78.6%)	–8.4%	0.04^*
Thighs	8 (9.5%)	76 (90.5%)	9 (10.7%)	75 (89.3)	1.2%	1.00
Knees	29 (34.5%)	55 (65.5%)	21 (25%)	63 (75%)	–9.5%	0.02^*
Feet/Ankles	23 (27.4%)	61 (72.6%)	19 (22.6%)	65 (77.4%)	–4.8%	0.22

^aMcNemar analysis was conducted. ^* The P value was set at α≤0.05 for statistical significance.

NASA-TLX subscales and its overall score are presented in Table 3. Prior to the intervention, the overall score was reported to be 59.2 (66.7) which is considered to be exceedingly high [44]. This high level of mental workload, as it is presented in the table, was mainly due to temporal (70 (70)), and mental demands (65 (95)) of the job. While the two main attributes of mental workload did not change meaningfully, multifaceted intervention proved to significantly decrease overall mental demand of the job (P = 0.000) which was due to the meaningful reduction of other subscales, including performance (P = 0.02), effort (P = 0.001), and frustration (P = 0.025).

Table 3

Scores of NASA-TLX questionnaire and its dimensions before and after intervention (n = 84)

Dimensions	Before intervention	After intervention	Z	P-value ^a
	Median (range, mean, sd)	Median (range, mean, sd)
Overall score	59.2 (66.7, 59.6, 10.8)	57.5 (45.8, 57.4, 9.1)	–3.528	0.000^**
Mental demand	65 (95, 65.3, 16.3)	65 (65, 65.5, 12.5)	–0.968	0.333
Physical demand	50 (45, 45.9, 11.4)	50 (55, 46.5, 13.5)	–0.223	0.823
Temporal demand	70 (70, 71.3, 12.1)	70 (70, 70, 12.9)	–1.315	0.188
Performance	60 (90, 57.1, 15.9)	50 (80, 53.6, 18.3)	–2.333	0.020^*
Effort	60 (90, 59.2, 14.5)	50 (90, 53.8, 15)	–3.271	0.001^**
Frustration	60 (80, 59, 13)	60 (90, 55.1, 18.3)	–2.247	0.025^*

^a Wilcoxon signed rank test was conducted. ^* P≤0.05, ^** P≤0.01.

Table 4 illustrates the results pertaining to mental fatigue and its two dimensions. At the baseline, overall score of mental fatigue was 66.25 (78.13) which was significantly above the midpoint. As for its dimensions, lack of energy (68.75 (81.25)) was higher than lack of motivation (64.37 (85)), and both were relatively high. After the intervention, overall mental fatigue was reported to be 63.75 (71.25) which was significantly lower than the base line (P = 0.016). Furthermore, lack of energy was assessed to be 66.25 (80) which showed a meaningful reduction compared to baseline (P = 0.007). However, despite the observable reduction for lack of motivation, it wasn’t scientifically significant (P = 0.240).

Table 4

Score of mental fatigue and its dimensions before and after the intervention

Dimensions	Before intervention	After intervention	Z	P-value ^a
	Median (range, mean, sd)	Median (range, mean, sd)
Overall score	66.3 (78.1, 66.4, 15.5)	63.7 (71.2, 63, 15.5)	–2.417	0.016^*
Lack of energy	68.8 (81.3, 68.3, 18.6)	66.3 (80, 65, 18.1)	–2.695	0.007^**
Lack of motivation	64.4 (85, 64.5, 20)	61.9 (76.3, 61.1, 17.3)	–1.176	0.240

^aWilcoxon signed rank test was conducted. ^* P≤0.05, ^** P≤0.01.

4 Discussion

This study was carried out to determine the effectiveness of a multicomponent ergonomic intervention among 84 call center workers of a telecom company. In brief, the intervention including comprehensive ergonomic training (formal and on-site), work layout improvement and quality break time involving regular exercises reduced the prevalence of WRMSDs and improved mental aspects of the work system by reducing overall mental demand and mental fatigue of employees.

Based on the primary results, prevalence of WRMSs in the body regions of neck, lower back and knees at the follow-up was assessed to be significantly lower compared to baseline, especially in the neck region which was reduced by more than 10%. Such finding is in line with other studies [12 , 45]. Kamalikhah et al. studied the effectiveness of different interventions, and they found that both ergonomic intervention (i.e. work layout modifications) and educational intervention (i.e. ergonomic training) can separately affect people’s posture which results in significant reduction in MSDs. In another study among office workers, Sjorgen et al. showed that performing workplace exercises can reduce headache and neck symptoms while it does not affect the prevalence of shoulder symptoms [46]. Similarly, a study among VDT workers showed that workplace exercises including range of motion, stretching and eye-relaxation reduces whole body discomfort and postural adjustment (in-chair movements), implicating the relationship between posture and workplace exercises [47]. These findings demonstrate that a proper workstation, which is modified and used in line with ergonomic principles, and carrying regular exercises during work can reduce WRMSD symptoms. Moreover, in parallel with the literature, we acknowledged it is equally important to make sure that employees have understood the true necessity of such practices (by using proper methods e.g. motivational interviewing), and diligently exercise them, since they are the main actors of the change [48, 49].

Our findings also suggested that the intervention program reduced mental workload and consequently mental fatigue of the participants. Regarding NASA-TLX results, it was interesting that three dimensions of the scale including performance (obstacles), effort and frustration along with the overall score were reported to be less after the intervention, while other dimensions (mental demand, physical demand and temporal demand) remained without significant change. After the improvements and mainly due to alleviated burden of adverse body postures and musculoskeletal discomfort. employees perceived they performed their tasks with less obstacles and put less effort into their job, and as a result experienced less frustration. However, the content of their job remained unchanged, thus mental, physical and temporal demands of their tasks did not change significantly. Our finding is in harmony with a narrow body of literature supporting the relationship between posture and exercise, and mental demands of a job [23, 50]. Although there are few studies questioning the association of physical alteration of the work and mental demands [27].

In a similar vein, the results of SOFI scale also showed that the overall score of mental fatigue reduced at the follow-up, since it is a natural byproduct of mental load [51]. As for dimensions, the results show that although the working condition regarding “lack of energy” item improved, “lack of motivation” remained steady. That is to say, while the improvements helped them maintain higher levels of energy during the work, they were not more motivated as regards their job. Similarly, Lacaze showed that providing quality break time enriched with stretching and joint mobilization not only reduced call center worker’s musculoskeletal disorders but also decreased their mental fatigue [36]. It should be noted, there is a paucity in the literature concerning the relationship between occupational exercises and mental fatigue, and currently, there are not many studies with which we compare the results. Thus, the findings of this study should be interpreted with caution, until further evidence reinforces such relationship.

5 Conclusion

The contribution of this study is to the body of the literature suggesting a multicomponent ergonomic intervention can help bring significant improvements to the work systems and the employees. Findings showed although the primary focus of many interventions has remained to improve physical aspects of the work place, multicomponent interventions are indeed capable of boosting cognitive aspects of the work as well. Future studies should aim at investigating such outcomes by utilizing more robust study designs (e.g. true experimental designs). Furthermore, while the findings of our study can be generalized to other similar contexts of working like office work and telework to some extent, there will be a need for future studies to investigate and replicate the results within these contexts.

5.1 Limitations and strengths of the study

First, the major limitations of the current study were lacking a control group, and non-randomized nature of the study. Since we were asked to design the intervention for whole the employees, it was not feasible to allocate a portion of population to a controlled arm or randomizing the population. That is why a census was agreed to be the best choice. Additionally, as all employees were working and spending all their time in a same working area, in case of having a controlled arm, the information could have been easily shared, producing contamination issues. Accordingly, the results of this study should be interpreted by caution. Second, all the outcomes of the study were evaluated by self-report measures although using valid and reliable instruments alleviated this limitation. Third, we did not assess the effectiveness of the office ergonomic training after the sessions at the baseline. However, the on-site face to face ergonomic training was a measure to not only check such effectiveness but also to address misunderstandings or correct bad behaviors. Fourth, data analysis of the results was carried out by means of non-parametric test; Although such analysis was chosen because of non-normality of the variables, literature recommends interpreting the significancy of results with careful considerations [52]. Finally, a 6-month window to measure outcomes of the intervention seems limited, and true impact should be assessed in a longer time frame.

In spite of all abovementioned limitations, our study possessed some major strengths which are discussed here. First, the main strength was that the intervention was designed to be multifaceted, employing different strategies (personal, physical and psychosocial) to improve the working experience of people. Such an approach was undertaken because of existing literature questioning the effectiveness of single solution interventions [17, 53]. Second, full participation was indeed an advantage of this study. Although the awareness of ergonomics principles was low at baseline, by having full commitment of the management and full participation of employees throughout the study, we could have an effective intervention. Last but not least, multi-outcome evaluation was carried out to assess the effectiveness of the intervention including physical and mental aspects of the job. Such evaluations can give a broader picture of how interventions can impact work systems.

Footnotes

Acknowledgment

The current paper is a part of the thesis titled “The Effect of Ergonomic Interventions on Occupational Performance, Mental Workload, Fatigue and Musculoskeletal Disorders” which was carried out in partial fulfillment of the requirements for the Master of Science degree in industrial safety engineering at the Caspian Higher Education Institute.

The authors wish to thank the MobinNet^® call center management for facilitating the possibility of this study. The authors would also like to thank the participating call center workers, and their supervisors for their willingness to cooperate in this research.

Conflict of interest

No conflict of interest has been declared by the authors.

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Improvements in musculoskeletal symptoms,mental workload and mental fatigue: Effects of a multicomponent ergonomic intervention among call center workers

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSION:

Keywords

1 Introduction

2 Method

2.1 Study design

2.3 Intervention

2.3.1 Comprehensive office ergonomic training

2.3.2 Work layout improvement

2.3.3 Supervised on-site face to face visits

2.3.4 Provision of quality break time encompassing regular exercise program

2.4 Outcome measures

2.5 Data analysis

3 Results

Table 1 Demographic characteristics of the participants Variable (Mean±SD) or % Age (yrs) 28.1±3.69 BMI 24.2±2.6 Gender Male 20 (24%) Female 64 (76%) Education BSc 59 (70%) Diploma 25 (30%) Job tenure More than 3 years 17 (20%) Less than 3 years 67 (80%)

5 Conclusion

5.1 Limitations and strengths of the study

Footnotes

Acknowledgment

Conflict of interest

References

Table 1
Demographic characteristics of the participants

Variable (Mean±SD) or %

Age (yrs) 28.1±3.69

BMI 24.2±2.6

Gender

Male 20 (24%)

Female 64 (76%)

Education

BSc 59 (70%)

Diploma 25 (30%)

Job tenure

More than 3 years 17 (20%)

Less than 3 years 67 (80%)