Neck and upper extremity musculoskeletal problems in cosmetologists caused by work-related ergonomic risk factors in Denizli,Turkey

Abstract

BACKGROUND:

Work-related musculoskeletal disorders (MSDs) of the neck and upper limbs are a common health problem among cosmetologists. Hairdressing requires bending, twisting, static postures, prolonged standing, repetitive motions, and vigorous movements of the hands and fingers. In order to determine the proper ergonomic measures, identifying the factors and hairdressing jobs that increase the risk of work-related neck and upper limb disorders is needed.

OBJECTIVE:

The objective of this study was to determine the prevalence of MSDs in the neck and upper extremities of cosmetologists and to investigate the association with ergonomic risk factors and hairdressing work.

METHODS:

The cross-sectional study was conducted on cosmetologists in Denizli, Turkey province (n = 504). Data collected through a survey included questions on sociodemographic characteristics, work organization, equipment, and hairdressing work, items on work posture, the Extended Nordic Musculoskeletal Questionnaire, and the Demand-Control-Support Questionnaire. Work posture in hairdressing was assessed using the Rapid Upper Limb Assessment (RULA).

RESULTS:

The prevalence of MSDs of the neck and upper limbs in the previous twelve months ranged from 7.7–55.8%. There was high, or very high, risk in 56.1% of work postures, and the median RULA score was 5.0 (4.0–6.0). The significant predictors of pain were work experience, gender, marital status, risk perception, awkward posture, psychological demand, and hair coloring.

CONCLUSION:

It is necessary to take control measures in hairdressing salons promptly to adopt more suitable working posture and to design workplaces ergonomically.

Keywords

Occupational health pain posture psychosocial factors workload

1 Introduction

Work-related musculoskeletal disorders of the neck and upper limbs affect the neck, shoulders, arms, wrists, hands, and fingers. These disorders are common health problems among unskilled female workers that work in manual labor-intensive occupations in the service industry [1 –5]. Symptoms of these conditions are generally characterized by pain, discomfort, awkwardness, numbness, stiffness, and/or weakness, depending on the type of condition. Work-related musculoskeletal disorders of the neck and upper limbs may be temporary if an appropriate work/rest balance is maintained. However, they can lead to permanent disability if exposure to ergonomic risk factors or poor working conditions are prolonged [4]. Chronic musculoskeletal disorders have been associated with decreased functioning and quality of life, increased sick leave application, and increased medical care costs [6]. It is generally considered that ergonomically inappropriate work design is responsible for these diseases. Ergonomic risk factors for the development of these diseases include the physical demands of the workplace (e.g., work requiring prolonged static posture, awkward posture, highly repetitive loads, and use of vibrating tools), as well as organizational and psychosocial factors (e.g., poor work-rest cycle, and shift work)[4 , 7].

Hairdressing is a high risk occupation for the development of musculoskeletal disorders (MSDs) of the neck and upper limbs because hairdressing tasks require frequent sagittal or lateral bending and twisting, static postures, prolonged standing, repetitive movements, and vigorous movements of the hands and fingers [2]. All basic hairdressing tasks performed at least 50% of the workday carry a moderate to high risk of work-related upper limb MSDs [8]. One study showed that two-thirds of cosmetologists have work posture that are at high risk for MSDs [9]. According to three health insurance companies in Germany, MSDs were the main reason for sick leave and range from 16% to 21% of the total [10]. A study from France found a significant 37.8% increase in musculoskeletal complaints among cosmetologists with at least 10 years of work experience from 2010–2016. The study showed that permanent disability (incidence rate 2/1,000), and the number of lost work days increased significantly by 16% during the study period. A total of 666,461 days were lost due to work-related MSDs [11]. Cosmetologists are also exposed to psychosocial hazards at work, such as stress, long working hours without breaks, time pressure, lack of control in organizing work, lack of support from colleagues or supervisors, lack of appreciation or rewards, conflicts, lack of professional development opportunities [12 –14]. These factors may also increase the riskof MSDs.

In previous studies, ergonomic risks and the frequency of MSDs in cosmetologists were evaluated by the presence or absence of pain. Depending on factors such as long working hours and inexperience, cosmetologists may not be able to benefit from health services adequately. In this case, chronic MSD problems are inevitable. In our study, chronic MSDs diagnosed by a doctor in cosmetologists were evaluated. The relationship between psychosocial factors and MSDs among cosmetologists is not clear. In the literature, the relationship between the level of exposure to poor working posture and pain has not been adequately addressed. There is a lack of information in the literature about pain related to MSDs in cosmetologists and smoking, physical activity, body mass index, occupational health and safety services, health insurance, all of which pose a risk for the development of neck and upper extremity MSDs.

Knowing that musculoskeletal problems occur while doing hair necessitated risk assessments of cosmetologists in their work conditions. In this context, posture and joint positions of the person affected during hair washing, hair cutting and combing, performing styling applications, such as using blow dryers and curling irons, and repetitive movements may lay the foundation for overuse injuries [15, 16]. Therefore, in order to apply appropriate ergonomic measures, it is necessary to identify the work-related risk factors and hairdressing activities that increase the risk of work-related MSDs in the neck and upper limbs. The novelty of this study is to examine the risk factors associated with MSDs in cosmetologists and to better understand the effect of these working conditions in this occupational group. The results of the research may enable to take appropriate preventive and rehabilitative ergonomic measures for cosmetologists in the future. The hypothesis tested is that there is a difference between work-related MSDs in the neck and upper limbs of cosmetologists and ergonomic risk factors.

2 Materials and methods

The population of this cross-sectional study consisted of cosmetologists working in Denizli province, Turkey. The sample size of the study was calculated using the Openepi software program (https://www.openepi.com/SampleSize).

The sample size calculation formula used to determine the incidence of an event in survey-type studies is as follows: $\begin{matrix} n = z_{α / 2} \times p \times q \times {D / e}^{2} \\ = {(1.96)}^{2} \times 0.5 \times (1 - 0.5) \times 1.3 / {(0.05)}^{2} \\ = 0.9604 \times 1.3 / 0.0025 \\ = 500 \end{matrix}$

Where,

n = minimum required sample size, Z_α/2= 1.96 for alpha 0.05c, p = prevalence or proportion of event, q = 1-p, D = design effect reflects the sampling design used in the survey type of study. This is 1 for simple random sampling and higher values (usually 1 to 2) for other designs such as stratified, systematic, and cluster random sampling, e = margin of error, 5% [17, 18]. With a non-response rate of 20%, the total sample size was 600.

Participants were selected by the multi-stage sampling method. In the first stage, each hair salon was treated as a cluster, and it was assumed that at least two hair salons worked in each cluster. In the second stage, the proportional stratification technique was applied. For this purpose, the districts that were geographically close to each other were reunited. Denizli was divided into 8 parts. It was aimed to reach the hair salons in equal proportion (k = 0.76) in each part they formed. In a third step, identity, address, and telephone information of registered hairdressing salons from 416 registered Denizli Cosmetologists’ Chamber were obtained. Cosmetologists located in Denizli city center (20 km radius) were included in this study. Twenty one hairdressing salons located outside the 20 km the city center radius were excluded from the study. Three hundred hair salons were selected by simple random sampling. Those working in the hairdressing salons visited between May and November 2019, and the data collection dates of the research were included in the study.

Voluntary participation was considered through verbal consent, which was obtained from the participants. The field studies of the research were conducted using a survey and an observational method. The protocols were approved by the Pamukkale College Ethics Committee for Non-Invasive Clinical Research (Number: 09, Date: 07/05/2019).

2.1 Data collection instruments

The questionnaire also included information on sociodemographic, physical, organizational, and psychosocial factors. The questionnaire consisted of 8 sections: Questions on sociodemographic characteristics, questions on work organization, equipment use and hairdressing tasks, work posture, the International Physical Activity Questionnaire Short Form (IPAQ-SF), the Swedish Control and Support of Work Questionnaire, the Extended Nordic Musculoskeletal Questionnaire, and the Rapid Upper Limb Assessment (RULA). The response options for the work posture questions were ‘always’, ‘often’, ‘sometimes’, ‘rarely’, and ‘never’. Of these options, ‘always’ and ‘frequently’ were categorized as high exposure; ‘sometimes’ and ‘rarely’ were categorized as medium exposure; and ‘never’ was categorized as low exposure. The questions from the Ergonomic Risk Assessment Checklist for Cosmetologists prepared by the European Agency for Safety and Health at Work (EU-OSHA) were used to create the survey questions.

2.2 The Extended Nordic Musculoskeletal Questionnaire (NMQ-E)

A modified, validated and standardized Nordic questionnaire developed by Kuorinka et al. (1987 s) was used [19]. Dawson et al. reconstructed this questionnaire in 2009 as the Extended Nordic Musculosceletal Questionnaire (NMQ-E) and published on its reliability [20]. The questionnaire assesses pain or discomfort occurrence in the upper limbs, spine, and lower limbs over a year, month, and day period of the interview.

2.3 Rapid Upper Limb Assessment (RULA)

The Rapid Upper Limb Assessment (RULA) worksheet was developed by McAtamney and Nigel Corlett to measure potential risk exposure by assessing posture, strength, and muscle activity. The RULA scale, which consists of a single page, is divided into Sections A and B. Section A includes arm and wrist analyzes, and Section B includes neck, trunk, and leg analyzes. On the scale, the postures of the body parts in the different task areas were evaluated according to their angular range of motion. The result shows a single score that determines the risk classification for MSDs. Scores between 1 and 7 on the scale can be divided into 4 risk levels for neck and upper limb disorders. Accordingly, scores of 1-2 are classified as acceptable risk (action level 1, no action needed), 3-4 as low risk (action level 2, changes may be needed), 5-6 as moderate risk (action level 3, further investigation, make changes soon), and 7 and above as very high risk (action level 4, make changes now). RULA is calculated for the most difficult and longest lasting postures in each service after a pre-observation and pre-interview with the employee [21].

2.4 Application of the RULA method

Phase 1: Each participant was asked to fill out a questionnaire designed to identify MSDs among cosmetologists, which took about 15 minutes.

Phase 2: The participants were not allowed to take pictures or videos. Therefore, flexion and extension movements, static and repetitive movements were observed directly at the workstation. All observations were made by the same person. Verbal consent was obtained from each participant to be observed during tasks without explaining the purpose of the observation. Before starting the observation period, the participant was asked to clarify their dominant extremity. RULA was calculated for the participant’s dominant extremity. Participants were observed by the researcher at the workplace for a minimum-maximum of 5–20 minutes during each task.

Phase 3: In this phase, the postures to be evaluated were selected for each tasks. These selections were based on: 1) the most difficult postures and work tasks (based on initial observation); 2) the posture sustained for the longest period of time; or 3) the posture where the highest force loads occur.

Phase 4: A single page worksheet was used to evaluate required body posture, force, and repetition. Based on the evaluations, scores were entered (with pen and paper) for each body region in section A (arm and wrist), and section B (neck and trunk). Each body segment was evaluated in the sagittal plane. If a posture cannot be represented in this way (e.g., abduction leaning, or raising), one more point added to the score. After the data for each region was collected and scored, a single score that represents the level of MSD risk was generated. Evaluation of each posture took about 2 minutes. In this study, we calculated 622 RULA values for nine different hairdressing tasks (drying, styling, washing hair, cutting, blow drying, hair coloring, make-up, manicure/pedicure, eyebrow shaping).

2.5 The Demand-Control-Support Questionnaire (DCSQ)

The questionnaire is from the control-demand model developed by Karasek and Theorell [22, 23] to explain work stress. A support dimension was added to the scale by Johnson and Hall [24]. Studies have shown that the scales based on the demand-control-social-support model are valid and reliable in explaining work stress [25 –27]. The DCSQ consists of the following 3 subscales: psychological demands (5 items), decision latitude (6 items), and social support (6 items). Decision latitude includes decision authority (2 items) and discretion (4 items). For the psychological demand and decision latitude subscales, each item of the questionnaire is rated on a scale from 1 (often) to 4 (never). The response categories of the social support subscale are also rated using a four-point Likert scale ranging from 1 (strongly agree) to 4 (strongly disagree) [26]. According to this scale, workers with jobs characterized by psychosocial factors such as high demands (e.g., having to work too much and too fast), low decision-making latitude, and low social support are at increased risk for poor psychological well-being and mental health [28, 29].

2.6 International Physical Activity Questionnaire Short Form (IPAQ-SF)

Physical activity was assessed by means of the International Physical Activity Questionnaire Short Form (IPAQ-SF). The short form is used to determine the intensity level of four activities of a person over for a previous 7 days: vigorous physical activity, moderate intensity activity, walking and sitting. The sum of durations (minutes) and frequencies (days) of walking, moderate activity, and vigorous activity is used to calculate the total score. The energy required for the activities is calculated by means of MET-minute score. Continuous data can be categorized as inactive, minimally active, very active [10].

2.7 Variables

The prevalence of MSDs in the neck and upper limbs was the dependent variable in this study (i.e., the presence of pain or discomfort in any part of the upper limbs with neck, shoulders, elbows, hands, and wrists in the past twelve months). Physical factors such as awkward working posture, equipment (adjusting the working height, using a vibrating hand-tool, and hanging hair dryer around the neck), organizational factors (daily working time, overtime, number of customers per day, regular break, working on appointment, number of employees, and job rotation) and psychosocial factors were independent variables in this study. Sociodemographic factors were confounding variables. These variables were age, gender, education level, income level, marital status, health insurance, work experience, history of MSDs of neck and upper limb, smoking, physical activity, body mass index, training on occupational hazards.

2.8 Statistical analysis

SPSS version 17.0 was used for data analysis. Descriptive values were expressed by numbers, medians, percentages (25th and 75th percentiles). Normality analysis of numerical data was performed using the Kolmogorov-Smirnov test. The Mann Whitney U test was used to compare binary groups. The chi-square test and Fisher’s exact test were used to determine the relationship between categorical independent and dependent variables. Binary logistic regression analysis (Backward LR) was used to determine the predictors of pain and discomfort. In this study, variables with a p-value of less than 0.05 in the bivariate analysis were included in the multivariable logistic regression analysis model to control for the effect of confounding factors. Model fit was tested for goodness of fit using the Hosmer and Lemeshow test. This showed a p-value = 0.44 for model 1 and a p-value = 0.73 for model 2, while a p-value of less than 0.05 were considered statistically significant for all analyses.

3 Results

3.1 Socio-demographic characteristics of the study participants

In this study, 224 hairdressing salons were visited. Out of 600 cosmetologists, 504 were reached (response rate 84.0%). The median age of the participants was 25.0 (19.0–33.0), while 72.8% of them were female and 27.2% of them were male. The body mass index (BMI) of the participants was as follows: 11.1% of the participants were underweight, 56.6% of the participants were normal weight, 23.7% of the participants were overweight, 8.6% of the participants were obese, 55.7% of the participants were smokers, 42.9% did not smoke and 1.4% had quit smoking (Table 1). Fifty one of the 224 (22.8%) hairdressing salons visited were receiving occupational health and safety services.

Table 1
Sociodemographic characteristics of cosmetologists (n = 504)

Variables Numbers Percentage (%)

Age (years) ≤18 years 116 23.1

19–29 206 41.0

≥30 years 180 35.9

Gender Female 367 72.8

Male 137 27.2

Education Primary school 65 13.1

Middle school 225 44.6

High school 192 38.1

Higher education 21 4.2

Income More than income 55 11.5

Income is equal to expenses 294 61.4

Less than income 130 27.1

Marital status Married 201 40.0

Single 270 53.7

Divorced / widowed / separated 32 6.3

Health insurance Yes 378 77.1

No 112 22.9

Work experience (years) <10 229 46.5

≥10 264 53.5

History of MSDs* of neck and upper limb Yes 169 33.5

No 335 66.5

Have you received physical therapy and rehabilitation in the last one year? Yes 23 4.6

No 481 95.4

BMI** Underweight 53 11.1

Normal 270 56.6

Overweight 113 23.7

Obese 41 8.6

Smoking Yes 280 55.7

No/left 223 44.3

Physical activity Inactive 234 54.7

Minimally active 133 31.1

Very active 61 14.3

Do you perceive the job as risky Yes 173 34.9

No 322 65.1

Have you received any training on occupational hazards? Yes 307 61.3

No 194 38.7

Variables		Numbers	Percentage (%)
Age (years)	≤18 years	116	23.1
	19–29	206	41.0
	≥30 years	180	35.9
Gender	Female	367	72.8
	Male	137	27.2
Education	Primary school	65	13.1
	Middle school	225	44.6
	High school	192	38.1
	Higher education	21	4.2
Income	More than income	55	11.5
	Income is equal to expenses	294	61.4
	Less than income	130	27.1
Marital status	Married	201	40.0
	Single	270	53.7
	Divorced / widowed / separated	32	6.3
Health insurance	Yes	378	77.1
	No	112	22.9
Work experience (years)	<10	229	46.5
	≥10	264	53.5
History of MSDs* of neck and upper limb	Yes	169	33.5
	No	335	66.5
Have you received physical therapy and rehabilitation in the last one year?	Yes	23	4.6
	No	481	95.4
BMI**	Underweight	53	11.1
	Normal	270	56.6
	Overweight	113	23.7
	Obese	41	8.6
Smoking	Yes	280	55.7
	No/left	223	44.3
Physical activity	Inactive	234	54.7
	Minimally active	133	31.1
	Very active	61	14.3
Do you perceive the job as risky	Yes	173	34.9
	No	322	65.1
Have you received any training on occupational hazards?	Yes	307	61.3
	No	194	38.7

*Musculoskeletal disorders. **Body mass index.

3.2 Self-report of work-related musculoskeletal disorders of the neck and upper limbs in cosmetologists

The result of the study showed that 55.8–7.7% of cosmetologists suffered from work-related MSDs of the neck and upper limbs in the past 1 year. The body region about which participants complained the most of pain and discomfort was the neck (55.6%) (Table 2). Of the participants enrolled, 33.5% reported having musculoskeletal conditions related to the neck and upper MSDs diagnosed by a physician (Table 1). The most common neck and upper extremity MSDs were cervical disc herniation / cervical kyphosis (n = 128), osteoarthritis (n = 30), posture disorder (n = 20), carpal tunnel syndrome (n = 20) and tennis elbow (n = 7).

Table 2
Frequency of pain and discomfort in the past twelve months in the body regions reported by cosmetologists (n = 504)

Pain

Yes No

Numbers Percentage (%) Numbers Percentage (%)

At least one body region 377 75.0 126 25.0

Neck 280 55.8 222 44.2

Upper back 249 49.6 253 50,4

Shoulder 169 33.6 334 66.4

Elbow 39 7.8 464 92.2

Hand and wrist 180 35.9 322 64.1

	Pain
At least one body region	377	75.0	126	25.0
Neck	280	55.8	222	44.2
Upper back	249	49.6	253	50,4
Shoulder	169	33.6	334	66.4
Elbow	39	7.8	464	92.2
Hand and wrist	180	35.9	322	64.1

3.3 Work posture, organizational and psychosocial factors in cosmetologists

According to the results of the study, 16.2% of cosmetologists had a daily working time of more than 12 hours, and 55.2% of them did not take regular breaks during work (Table 3). The result of the study showed that 84.0% of the participants stood for a long time during hairdressing work and 59.9% of them performed repetitive movements. The distribution of cosmetologists’ work postures is shown in Table 4. The median value for psychological demand was 15.4 (14.0–17.0), and the median value for decision latitude was 21 (20.0–22.0). The median score for social support was 23 (22.0–24.0) (Table 5).

Table 3
Distribution of the organizational factors of cosmetologists (n = 504)

Variables Numbers Percentage (%)

Daily working time 12 hours≥ 392 83.8

12 hours< 76 16.2

Overtime Very often 323 66.7

Rarely 161 33.3

Number of customers per day 10 customers> 74 19.8

10 customers≤ 299 80.2

Regular break Yes 224 44.8

No 276 55.2

Working on appointment Yes 395 82.6

No 83 17.4

Number of employees 1 59 11.9

2-3 249 50.3

4≤ 187 37.8

Job rotation Yes 429 86.0

No 70 14.0

Adjusting the working height Yes 485 97.2

No 14 2.8

Using a vibrating hand-tool Yes 136 27.2

No 364 72.8

Hanging hair dryer around the neck Yes 334 67.6

No 160 32.4

Variables		Numbers	Percentage (%)
Daily working time	12 hours≥	392	83.8
	12 hours<	76	16.2
Overtime	Very often	323	66.7
	Rarely	161	33.3
Number of customers per day	10 customers>	74	19.8
	10 customers≤	299	80.2
Regular break	Yes	224	44.8
	No	276	55.2
Working on appointment	Yes	395	82.6
	No	83	17.4
Number of employees	1	59	11.9
	2-3	249	50.3
	4≤	187	37.8
Job rotation	Yes	429	86.0
	No	70	14.0
Adjusting the working height	Yes	485	97.2
	No	14	2.8
Using a vibrating hand-tool	Yes	136	27.2
	No	364	72.8
Hanging hair dryer around the neck	Yes	334	67.6
	No	160	32.4

Table 4

Distribution of cosmetologists’ work postures by exposure level (n = 504)

Variables	Exposure level
	High	Medium	Low
	Numbers (%)	Numbers (%)	Numbers (%)
Working standing up for long periods time	421 (84.0)	75 (15.0)	5 (1.0)
Working in the same position	247 (49.4)	216 (43.2)	37 (7.4)
Working with head bent	248 (49.8)	217 (43.6)	33 (6.6)
Working by bending to the side	90 (18.1)	301 (60.6)	106 (21.3)
Working with arms above shoulder	100 (20.1)	304 (61.2)	93 (18.7)
Working with elbows above chest level	128 (25.9)	291 (58.8)	76 (15.4)
Rotating wrists	196 (39.7)	250 (50.6)	48 (9.7)
Repetitive motions	300 (59.9)	185 (36.9)	16 (3.2)
Reaching	62 (12.5)	222 (44.8)	212 (42.7)

Table 5

Distribution of the psychosocial factors of cosmetologists (n = 504)

Sub scales	Median	25th percentile–75th percentile
Psychological demand	15.4	14.0–17.0
Decision latitude	21.0	20.0–22.0
Skill discretion	14.0	13.0–15.0
Decision authority	7.0	6.0–8.0
Social support	23.0	22.0–24.0

3.4 RULA score for hairdressing

The results of the study showed that 56.1% of all observed work postures were high, or very high risk, and the median RULA score was 5.0 (4.0–6.0). The three tasks with the highest RULA scores were make-up (median = 6.0), manicure/pedicure (median = 6.0), and eyebrow shaping (median = 6.0) (Table 5).

3.5 Ergonomic risk factors associated with work-related MSDs of the neck and upper limbs

According to multivariate logistic regression analysis 1, working in the same position [OR = 2.69, 95% CI 1.07, 6.77] and working with the head bent [OR = 2.78, 95% CI 1.05, 7.33] were ergonomic risk factors significantly associated with work-related MSDs of the neck and upper limbs (Table 7). According to multivariate logistic regression analysis 2, psychological demand [OR = 1.15, 95% CI 1.04, 1.27], hair coloring [OR = 3.69, 95% CI 1.68, 8.10] were hairdressing tasks that increased the risk of work-related MSDs in the neck and upper limbs (Table 8).

Table 6
RULA, risk level, and action levels of hairdressing

Risk level Risk value Action level

Tasks Low / moderate High / very high Median (25th percentile – 75th percentile)

Drying 70 (74.5) 24 (25.6) 4.0 (3.0–5.0) 2

Styling 41 (67.2) 20 (32.8) 4.0 (3.0–5.0) 2

Washing hair 28 (35.9) 50 (64.1) 5.0 (3.7–6.0) 3

Cutting 23 (36.5) 40 (63.5) 5.0 (4.0–6.0) 3

Blow drying 53 (49.0) 55 (50.9) 5.0 (4.0–6.0) 3

Hair coloring 36 (44.5) 45 (54.6) 5.0 (4.0–6.0) 3

Make-up 6 (31.6) 13 (78.4) 6.0 (4.0–6.0) 3

Manicure/pedicure 8 (25.8) 23 (74.2) 6.0 (4.0–7.0) 3

Eyebrow shaping 8 (9.2) 79 (90.8) 6.0 (5.0–7,0) 3

TOTAL 273 (43.9) 349 (56.1) 5.0 (4.0–6.0) 3

	Risk level	Risk value	Action level
Drying	70 (74.5)	24 (25.6)	4.0 (3.0–5.0)	2
Styling	41 (67.2)	20 (32.8)	4.0 (3.0–5.0)	2
Washing hair	28 (35.9)	50 (64.1)	5.0 (3.7–6.0)	3
Cutting	23 (36.5)	40 (63.5)	5.0 (4.0–6.0)	3
Blow drying	53 (49.0)	55 (50.9)	5.0 (4.0–6.0)	3
Hair coloring	36 (44.5)	45 (54.6)	5.0 (4.0–6.0)	3
Make-up	6 (31.6)	13 (78.4)	6.0 (4.0–6.0)	3
Manicure/pedicure	8 (25.8)	23 (74.2)	6.0 (4.0–7.0)	3
Eyebrow shaping	8 (9.2)	79 (90.8)	6.0 (5.0–7,0)	3
TOTAL	273 (43.9)	349 (56.1)	5.0 (4.0–6.0)	3

Table 7

Ergonomic risk factors associated with work-related MSDs of the neck and upper limbs in cosmetologists – multivariable logistic regression model 1

Variable	Odds ratio	95% Confidence interval	p
Sex
Male (ref.)	–	–	<0.001
Female	2.69	[1.62, 4.46]
Do you perceive the job as risky?
No (ref)	–	–
Yes	2.37	[1.34, 4.18]	0.003
Work experience (years)
<10 (ref)	–	–
≥10	1.67	1.03, 2.72.	0.037
Working in the same position
Low (ref)	–	–
Moderate	1.30	[0.54, 3.11]	0.549
High	2.69	[1.07, 6.77]	0.035
Working with head bent
Low (ref)	–	–
Moderate	1.65	[0.66, 4.15]	0.281
High	2.78	[1.05, 7.33]	0.039

Table 8

Ergonomic risk factors associated with work-related MSDs of the neck and upper limbs in cosmetologists – multivariable logistic regression model 2

Variable	Odds ratio	95% Confidence interval	p
Sex
Male (ref.)	–	–
Female	4.23	[2.03, 8.80]	<0.001
Marital status
Single (ref)	–	–
The married	1.78	[1.08, 2.95]	0.024
Divorced / widowed / separated	2.09	[0.67, 6.49]	0.198
Do you perceive the job as risky
No (ref)	–	–
Yes	2.54	[1.46, 4.42]	0.001
Psychological demand	–	–
	1.15	[1.04, 1.27]	0.003
Hair coloring
No (ref)	–	–
Yes	3.69	[1.68, 8.10]	0.001
Make-up
No (ref)	–	–
Yes	0.94	[0.54, 0.26]	1.108

4 Discussion

There was a difference between work-related MSDs in the neck and upper limbs of cosmetologists and exposure to ergonomic risk factors among cosmetologists. Hence, the H1 hypothesis was accepted.

According to the results of this study, 7.7–55.8% of cosmetologists suffered from work-related MSDs in the neck and upper extremities. This finding is consistent with the results of the studies by Kozak et al. [2] (range 5–60%), Mussi and Gouveia [13] (49%), De Smet et al. [12] (41%), Mahdavi et al. [9] (range 4.1–52%), Khandan et al. [30] (range 14.9–50.9%), Tsigonia et al. [14] (range 35–58%), Ercan et al. (range 4.5–48.5%) [16]. In all this result was higher than that of Bradshaw et al. (range 7–37%) [31] and Mishra and Sarkar (range 16.4–38.8%) [32]. This study found that cosmetologists complain of pain and discomfort especially in the neck region. Mahdavi et al. [9] (52%), Khandan et al. [30] (50.9%), Ercan et al. [16] (48.5%) Tsigonia et al. [14] (58%) found similar results to the present study. Mussi and Gouveia found a small difference between the frequency of neck pain and the frequency of shoulder pain (49% shoulder pain, 47% neck pain) [13]. The results of the study showed that cosmetologists were the least likely to complain of elbow pain compared to other body parts. This was similar to the studies by Bradshaw et al. [31] (7%), Mahdavi et al. [9] (4.1%), Mishra and Sarkar (16.4%) [32]. In contrast to our results, Khandan et al. showed that cosmetologists were the least likely to complain of upper back pain compared to other body parts [30].

The differences between the results of the studies could be due to the demographic structure, different samples, number of samples, data collection instruments, societies’ demand for hairdressing services, workload, work organization, suitable ergonomic workplace, and hairdressing equipment. Although there are differences in the prevalence of work-related neck and upper extremity MSDs among cosmetologists, it is clear that they are at risk for work-related MSDs. The similarity between the prevalence found in studies conducted in previous years and our study indicates that this risk has not decreased over the years. However, the diagnosis of chronic MSD by a doctor to one out of every three employees necessitates the urgent development of occupational health and safety services in this occupational group. The neck and upper extremity areas of cosmetologists who apply to a health institution with pain should be especially examined. Furthermore, these people should be carefully evaluated in terms of occupational diseases and a comprehensive treatment approach should be applied [16].

The result of this study showed that female cosmetologists were 4 times more likely to suffer from pain and discomfort than male participants. Previous studies have shown that female gender is considered a risk factor for work-related MSDs in the neck and upper extremities [33 –35]. This finding may be related to biological, psychosocial, and cultural factors as well as working conditions. Gender-specific biological characteristics influence the functions of tendons, ligaments, and tolerance to biomechanical loading [35]. Another possible reason that women are more prone to pain and discomfort is that they are exposed to different cumulative risk factors at work and at home, which is due to the type of housework performed by women [36]. Repetitive and monotonous hairdressing work, which involves frequent use of the upper limbs, is mostly performed by women. In Turkish cosmetology, manicure, pedicure, eyebrow correction, makeup and other hairdressing work are almost always performed by women. However, in the study conducted by Ercan et al., no statistically significant difference was found between male and female cosmetologists in terms of RULA scores. This may be due to the small number of female employees represented in this study. Research results show that female cosmetologists have priority in terms of preventive and rehabilitative services for neck and upper extremity MSDs. In addition, as it can be understood from these findings, future studies should focus on the causes of gender differences in terms of the risk of MSDs in cosmetologists.

This study showed that psychological demand was a risk factor that increased the likelihood of MSDs in cosmetologists. This result was consistent with that of other studies [12 –14]. There is a positive correlation between exposure to physical risk factors and psychosocial risk [37]. Psychosocial risk factors are thought to interact with physical risk factors to increase the risk of MSDs. When job demands are at their highest, increased stress can trigger biochemical and physiological responses that lead to muscle tension [4, 37]. In a study conducted by Çelikkalp et al., the work stress scores of the teachers were found to have a positive and significant correlation with MSD scores [38].

In this study, persistent poor work posture (working with head bent, working in the same position) was shown to be a predictor of work-related MSDs in the neck and upper limbs. Previous studies have also shown that unnatural posture is associated with MSDs [12–14 , 39]. One possible explanation could be that muscles cannot perform their functions effectively when they are in an awkward posture. Working with different parts of the body (e.g., joints, limbs, back) in flexed, extended, or bent positions rather than in a straight or neutral position entails awkward positions that increase the effort and muscular strength a worker must exert to complete a task. When muscles are strained, this leads to compression of tendons, nerves, and blood vessels, reducing blood supply to muscle tendons, which in turn causes MSDs [36]. In the study conducted by Çelikkalp et al. [38], the time spent sitting at a desk, time spent working in a standing position, time devoted to housework, shoe preference, work stress and life satisfaction were determined as effective predictors of musculoskeletal complaints.

Ergonomic risk assessment methods have an important place in determining the causes of work-related occupational diseases. These methods can be grouped under the main headings of unloading related methods, observation/survey-based methods and computational biomechanical measures [40].

In this study, we performed risk assessment with both observation (RULA method) and survey method (Nordic Musculoskeletal Questionnaire). The results of the two methods were consistent with each other.

The results of the posture assessment of cosmetologists conducted by RULA showed that 56.1% of working postures were high or very high risk. The level of ergonomic risk in hairdressers was moderate according to the RULA score standard. This result is similar to the studies of Mahdavi et al. [9] (REBA method, high or very high risk 34.4–46%), Khandan et al. [25] (LUBA method, high risk 44.1%), Ercan et al. (RULA method, high risk 48.9%, 5.36±1.22). In the study by Martolia et al. [41], in which they used the workplace ergonomic risk assessment (WERA) risk analysis, the risk level of 80% of the cosmetologists was found to be moderate (WERA score [33, 40]. In a different study conducted by Şahin and Vapur [40] on cosmetologists in Turkey, the results of both RULA and REBA risk analysis were mostly found to be moderate. According to the results of the RULA method, most hairdressing tasks had a medium risk (action level 3) for MSDs in the neck and upper limbs, with hair coloring, eyebrow shaping, manicure/pedicure, and make-up being the highest risk for MSDs in the neck and upper limbs among hairdressing tasks. Multivariate logistic regression analysis showed that cosmetologists whose job was to color hair had a three times higher risk of disease than those who did not. In a study by Mahdavi et al., makeup application was a risk for shoulder and back pain, and hair coloring was a risk for neck pain [9]. The results of the present study indicate that it is necessary to take control measures and adopt a more appropriate working posture. Although different risk assessment tools have been used in studies conducted in this context, the common opinion in the literature is that cosmetologists mostly have a moderate and/or high ergonomic risk level. In this study, no significant difference was found between social determinants of health such as health insurance, income status, education level, and pain related to neck and upper extremity disorders. However, it is striking that one out of every five cosmetologists do not have health insurance. Health insecurity may prevent cosmetologists from applying to health services, causing simple musculoskeletal pain to turn into chronic and difficult-to-treat MSDs. Although more than half of the cosmetologists in the study reported neck and upper extremity pain and one third reported a chronic neck and upper extremity disorder, very few (4.6%) received rehabilitation services in the last 1 year. According to our findings, the majority of the profession consists of youngpeople.

Young workers may be more likely to perceive occupational risks as low and ignore work-related health problems. Two-thirds of the employees in the study do not consider their profession as dangerous, and one-third of them state that they have not received training on occupational hazards. Only one-fifth of the cosmetologists participating in the research received occupational health and safety services from a professional center. Although there is no relationship between these social variables and musculoskeletal pain, the findings are important in terms of revealing the working conditions of the hairdressing industry.

Our findings show that musculoskeletal system problems in cosmetologists will be an important occupational health problem in the future, with rapid intervention.

4.1 Limitations

Survey data were based on statements. Some participants may have avoided disclosing their illnesses at work. Asking about previous symptoms may have caused recall bias. Also, if the goal of the observation was not explained during the observation and the probability was low, then an unexpected bias may have occurred depending on the awareness of the worker.

5 Conclusions

This study has shown that cosmetologists suffered from work-related MSDs in the neck and upper body regions at a high rate in the last twelve months. The most common body regions were the neck, followed by the upper back, hand or wrist, shoulder, and elbow. Multivariate analysis revealed that the significant predictors of the occurrence of work-related MSDs in the neck and upper body among cosmetologists included gender (female), awkward posture, mentally challenged, and/or dyed hair. Most hairdressing jobs posed a moderate risk of work-related MSDs to the neck and upper extremities.

The results of the present study indicate that it is necessary to take control measures, adopt more suitable working postures, and design workplaces ergonomically as soon as possible. Qualified and continuous ergonomic and postural awareness training containing risk factors and prevention methods regarding work-related MSDs should be provided. The design of the workplace, the layout of tools and equipment in hair salons should be in a way that provides comfortable work posture. Engineering measures are required for high risk hairdressing tasks. Considering the prevalence of chronic MSDs in cosmetologists, rehabilitation services for these diseases should be integrated into existing occupational health and safety services. Future studies on cosmetologists should therefore be randomized controlled trials on how to ensure healthy working conditions.

Ethical approval

The research was conducted after obtaining ethical approval from the Pamukkale College Ethics Committee for Non-Invasive Clinical Research (Number: 09, Date: 07/05/2019).

Informed consent

Verbal informed consent was obtained from all participants.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors would like to thank Ali KITIS, M.D., for contributions to the research and all cosmetologists who agreed to participate in this study.

Funding

The authors report no funding.

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