LICENTIATE THESIS IN
TECHNOLOGY AND HEALTH, ERGONOMICS STOCKHOLM, SWEDEN 2017
KTH ROYAL INSTITUTE OF TECHNOLOGY SCHOOL OF TECHNOLOGY AND HEALTH www.kth.se
ISBN 978-91-7729-271-5 TRITA-REPORT 2017:2 ISSN 1653-3836 ISRN KTH/2017:2-SE
Occupational health
services in the prevention of musculoskeletal disorders
Processes, tools and organizational aspects
KRISTINA ELIASSON
Occupational health services in the prevention of
musculoskeletal disorders - Processes, tools and organizational aspects
Kristina Eliasson
Licentiate Thesis No. 2, 2017
KTH Royal Institute of Technology Technology and Health
Unit of Ergonomics
i
Academic dissertation which with permission from Kungliga Tekniska Högskolan (Royal Institute of Technology) in Stockholm is presented for public review for passing the licentiate examination on Friday 17 February 2017 at 13:15 in lecture hall 9504, School of Technology and Health, Hälsovägen
11C, Huddinge, Sweden.
TRITA-STH Report 2017:2 ISSN 1653-3836
ISRN/KTH/STH/2017:2-SE ISBN 978-91-7729-271-5
© Kristina Eliasson, 2017
Abstract
Work-related musculoskeletal disorders are associated with high costs and it is essential to prevent them before they occur. Occupational Health Services (OHS) provide expert services regarding work environment, health and rehabilitation of work related disorders. Risk assessments of the work environment can be an initial step for preventive measures, and ergonomists can be assigned by clients to assess exposures in the work environment. For such assignments different tools can be used as a support.
The aim of this thesis was to explore prerequisites, processes and practices of OHS consultants in Sweden within the domain of primary prevention of work-related musculoskeletal disorders. This was explored through the work of ergonomists in their role of assessing ergonomics risks.
The thesis is based on three papers and the research methodology was both quantitative and qualitative. Data collection includes a web questionnaire answered by 107 ergonomists, 12 semi- structured interviews and 21 inter- and 9 intra-observer reliability tests.
The results shows that ergonomics risk assessments were most commonly initiated reactively.
Furthermore, a systematic work methodology for the risk assessment process was often lacking.
Swedish ergonomists used only a few standardized tools for risk assessment. The Ergonomics provision from the Swedish Work Environment Authority, AFS-98, was widely used, but other tools based on standardized observation were used far less often. Ergonomics risks were often assessed solely by means of observation, based on ergonomists’ knowledge and experience. The results also pointed to that that the reliability was not acceptable when risk assessment was performed without any standardized tool. Furthermore, the results point towards that support from the OHS organizations is an important prerequisite for ergonomists to work with primary prevention, for example support the use of different risk assessment tools. Further, opportunities for specialization within a specific industry sector seem to facilitate ergonomic interventions. It is also important to have close relationships with clients and to make them aware about ergonomists competence.
Conclusively, this thesis identifies a numbers of areas in which OHS must develop to improve primary preventive services regarding work environment.
Keywords: Risk assessment, Ergonomists, Observation-based tools, Inter-observer reliability, Intra-observer reliability
SAMMANFATTNING
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Sammanfattning
Arbetsrelaterade muskuloskeletala besvär är förenade med höga kostnader och det är viktigt att de förebyggs. Företagshälsovården tillhandahåller experttjänster inom områden arbetsmiljö, hälsa samt rehabilitering av arbetsrelaterade sjukdomar och besvär. Riskbedömningar av arbetsmiljön kan vara ett inledande steg för olika preventiva åtgärder och ergonomer kan bli kontaktade av kunder för att bedöma exponeringar i arbetsmiljön. Vid sådana typer av uppdrag kan olika riskbedömningsverktyg användas som ett stöd för riskbedömningen.
Det övergripande syftet med avhandlingen var att undersöka förutsättningar, metodologi och processer bland svenska företagshälsovårdskonsulter för att förebygga arbetsrelaterade muskuloskeletala besvär. Detta undersöktes genom att undersöka ergonomers arbete och begränsades till deras roll gällande ergonomisk riskbedömning.
Avhandlingen baseras på två artiklar och ett konferensbidrag. Forskningsmetodologin har varit både kvalitativ och kvantitativ. Datainsamling har skett genom en webenkät som besvarades av 107 ergonomer, 12 intervjuer, samt genom 21 inter- och 9 intrabedömarreliabilitetstester.
Resultaten visar att ergonomiska riskbedömningsuppdrag oftast initieras reaktivt av kunderna, dvs efter att anställda fått besvär. Vidare saknas ofta en systematisk metodologi för riskbedömningsprocessen. Svenska ergonomer använder endast ett fåtal standardiserade verktyg vid riskbedömning. Föreskriften Belastningsergonomi från Arbetsmiljöverket, AFS-98, användes i hög utsträckning bland svenska ergonomer men däremot var användningen av flertalet andra standardiserade observationsverktyg begränsad. Riskbedömningar utfördes oftast genom observation av arbetet och intervjuer med anställda och baserades på ergonomens erfarenhet och expertkunskap. Vidare visar resultaten att det inte är reliabelt att utföra riskbedömning utan standardiserade riskbedömningsverktyg.
Resultaten indikerar även att företagshälsovårdsorganisationen är viktig för att stötta ergonomerna att arbeta primärpreventivt, till exempel genom att stötta i användning av olika riskbedömningsverktyg. Även möjligheten att specialisera sig inom en specifik bransch förefaller främja ergonomiska interventioner. Det är också viktigt att ha en nära relation med kunderna och att uppmärksamma dem på ergonomernas kompetensområden.
Sammanfattningsvis identifierar resultaten från avhandlingen ett antal områden där företagshälsovården bör utveckla sig för att förbättra sina primärpreventiva arbetsmiljötjänster.
Nyckelord: Riskbedömning, Ergonomer, Observationsverktyg, Interbedömarreliabilitet, Intrabedömarreliabilitet
Preface
It began in 2011, when I had the privilege to become a part-time “Industrial PhD-student through a unique collaboration between Sensia Occupational Health Services and KTH Royal Institute of Technology. For a couple of years I had been working as an occupational ergonomist/registered physiotherapist (RPT) in OHS. Through the work I had seen a variety of different work environments and realized that many of these could be improved. I have always been interested in research and development and I started to think about how OHS could develop their work methods regarding primary preventive services. Through a series of coincidences, I got the opportunity to become a part of the newly founded research program “Future occupational health services – research for continuous evaluation, learning and improvement”.
In 2006, the Swedish government initiated an official investigation concerning the future competence of the OHS (SOU, 2007:91). This initiative resulted in the funding of a research program (2011-2016), “Future Occupational Health Services – research for continuous evaluation, learning and improvement”. The programme was hosted at KTH Royal Institute of Technology, in collaboration with three research institutions, Karolinska Institutet (KI), Uppsala University (UU) and the Swedish Environmental Research Institute (IVL).
The reason for starting the programme was simply that the research about Swedish OHS was scant.
Already in 2003 it was pointed out in an investigation by the government (SOU, 2004:113) that the OHS did not meet the expectations as an independent expert with competence to identify and describe relationships between the working environment, organization, productivity and health.
Furthermore, evaluations and research about benefits and effects of OHS service were lacking.
However, it was not until after the investigation in 2007 (SOU, 2007:91) that actions were taken for the OHS to be developed as its own academic field. Eventually, this led to the first Swedish professorship in OHS research and two research programmes, one at KI and one at KTH, mentioned above.
Earlier research had traditionally focused on effects of deficient working environments, such as injuries, health impairments, absence due to illness and disability. Now there was also a need for research into the effects of OHS working methods and practices. Research in the KTH programme aimed to create scientifically based knowledge that would be applicable to OHS.
The programme focused on three areas:
1. Methods and tools for effective and efficient monitoring and improvement of the work environment and health.
2. Content and driving forces of OHS services provided.
3. Methodologies for continuous follow-up and evaluation of the effectiveness and efficiency of OHS interventions and other activities in relation to desired outcome.
The overall aim of the programme was to support the development of effective and efficient OHS
PREFACE
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This thesis focuses on how the practical work in OHS is performed, with an emphasis on the work process and use of systematic methodology and tools for primary prevention of WMSDs. Increased knowledge in this area is a prerequisite to knowing how and what type of supports are needed within OHS to achieve effective and efficient services.
The studies included in this thesis are based on the practical work of OHS companies in Sweden and exemplifies the work conducted by ergonomists regarding primary preventive ergonomic assignments, for example risk assessment. It is important for me that I can contribute with research which can be practically applicable for OHS companies and promote their primary preventive services regarding work environment.
Sala, December 2016
Kristina Eliasson
List of appended papers
Paper A
Eliasson, K., Lind, C., Nyman, T. (2016). Ergonomics Risk Assessment: Tool Use and Processes.
(Manuscript).
Paper B
Eliasson, K., Palm, P., Nyman, T., Forsman, M. (2016). Inter- and Intra-Observer Reliability of Risk Assessment of Repetitive Work without an Explicit Method.
(Accepted for publication in Applied Ergonomics)
Paper C
Eliasson, K., Lind, C., & Nyman, T. (2015). Facilitators for the Implementation of Ergonomic Interventions. Proceedings from the NES 2015 Nordic Ergonomics Society 47th Annual Conference, K. I. Fostervold, et al., Editors. 2015, NEHF (Norwegian society for Ergonomics and Human Factors): Lillehammer, Norway.
LIST OF ABBREVIATIONS ANS GLOSSARY OF TERMS
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List of abbreviations and glossary of terms
Client Refers to e.g. different industries or different companies in various sectors that are clients of OHS companies.
OBRAT Observation-based risk assessment tool.
OHS Occupational health services. Companies that provide services in the domains of the work environment, health promotion and
rehabilitation.
OHSM Systematic occupational health and safety management. Involves different activities that in a systematic manner involve inventory, analysis and measures to prevent various types of risk within a company.
Risk assessment A series of logical steps to enable, in a systematic way, identification, analysis and evaluation of risks.
SWEA Swedish Work Environment Authority Standardized risk
assessment tools
Tools that are used in a systematic methodology, as in assessing different risk factors, e.g. OBRAT.
Systematic methodology
A work methodology that includes a series of logical steps in which different facts are collected and analysed and often evaluated.
Proactive Taking the initiative by making things happen or by preparing for possible future problems.
Prevention Includes a wide range of activities (interventions) which are aimed at reducing risk or threats to health.
Primary prevention Aims to prevent disease or injury before it occurs.
Secondary prevention Aims to reduce the impact of a disease or injury that has already occurred.
WMSD Work-related musculoskeletal disorders are pain, injuries and disorders in the human musculoskeletal system.
Table of contents
Abstract i
Sammanfattning ii
Preface iii
List of appended papers v
List of abbreviations and glossary of terms vi
Table of contents vii
1 Background 1
1.1 Work environment and risk assessments 1
1.2 Occupational health services in Sweden 3
1.3 Work-related musculoskeletal disorders and prevention 4
1.4 Primary prevention and occupational health services 5
1.5 Ergonomists within occupational health services 7
1.6 Ergonomic risk assessment - a tool in primary prevention? 8
2 Aim 10
3 Method 11
3.1 Research design 11
3.2 Data collection methods 12
3.3 Data analysis 14
3.4 Preconceptions of the author 17
3.5 Ethical considerations 17
4 Summary of results 18
4.1 Paper A - Ergonomic Risk Assessment: Tool Use and Process 18 4.2 Paper B - Inter- and Intra-Observer Reliability of Risk Assessment of Repetitive
Work without an Explicit Method 19
4.3 Paper C - Facilitators for the Implementation of Ergonomic Interventions 20
CONTENTS
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5 Discussion 21
5.1 Results discussion 21
5.2 Methodological discussion 24
5.3 General reflections 26
6 Conclusions and further research 27
6.1 Practical implications 27
6.2 Further research 27
7 Acknowledgments 28
8 References 29
1.2 Occupational health services in Sweden
The industrialisation contributed to the development of the Swedish OHS. During the mid-1800s new work-related health and safety problems arose. This resulted in a need for medical care adjacent to workplaces (Josefsson & Kindenberg, 2004). Initially, the focus was on health care and treatment. The modern OHS, which included both technical and medical expertise, originated from the mid-1960s. Somewhat later, psychosocial and ergonomics competence was also included and the OHS began to focus on preventing work-related ill health. During the 1980s, the OHS sector in Sweden expanded rapidly and about 75% of the employees had access to OHS. Between the years 1986 and 1992, the government provided indirect funding to OHS companies. At the beginning of the 1990s, the collective agreement regulating OHS between the employers and the union was terminated. According to the former collective agreement, all employers were obliged to provide OHS; after the termination it was not mandatory for an employer to have a contract with OHS and the access to OHS varies between industry sectors and size of companies. However, “the employer shall be responsible for the availability of the occupational health services which the working conditions require” (the Swedish Work Environment Act, chapter 3, § 2c) (AML, 2015). All these events led to a decline of the Swedish OHS during the late 20th century. Today approximately 65%
of Swedish employees have access to OHS through their employer (Företagshälsor, 2016). This can be compared to France, the Netherlands, Finland, Belgium and Luxembourg where 75–100% of employees have access to OHS (Hämäläinen, Husman, Räsänen, Westerholm, & Rantanen, 2001).
According to Axelsdotter Hök (2009), it also seems that there has been a shift in requested services from the Swedish OHS. Focus has shifted from prevention of work environmental risk factors towards rehabilitation and health promotion.
Today the Swedish OHS operates on the free market and the Swedish Work Environment Act describes and defines the function of OHS as follows:
“The OHS company is an independent expert resource in the domains of the work environment and rehabilitation. OHS shall in particular work for the prevention and elimination of health risks at workplaces, and shall have the competence to identify and describe connections between the working environment, organization, productivity and health” (the Swedish Work Environment Act, chapter 3, § 2c) (AML, 2015).
The Swedish OHS are among the least regulated OHS in Europe (Hämäläinen et al., 2001)
The most common organization of OHS is “private external OHS”. They are privately owned and have contracts with several clients who pay for ordered services, often per hour or alternative per service assignment. A handful of large OHS corporations with OHS units nationwide are the main actors in the Swedish OHS market. Another, much less common, organization of OHS is the “in- house OHS”, which is an internal OHS unit/department incorporated into a larger company/industry, municipality or county council.
The Swedish OHS market employs about 4000 people. Nurses comprise about a third of the OHS employees, followed by behavioral scientists, physicians, ergonomists, work environment engineers, administrators and others (Svenska Företagshälsor, 2016).
BACKGROUND
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Schmidt, Gunnarsson, Dellve, & Antonsson (2016), has claimed that the OHS do not fulfil their function as impartial OHSM experts. Clients do not use them as an expert resource to prevent occupational health and safety risk. Instead, the services often are focused on individual issues such as rehabilitation, curative services and wellness activities (Schmidt & Sjöström, 2015). Hence, according to the law, the OHS overall objective to be an expert within work environment correlations and to offer primary preventive service is not fulfilled.
1.3 Work-related musculoskeletal disorders and prevention
Health hazards resulting in WMSD are a major problem worldwide, entailing expenses and suffering for society, employers and the affected individual (Breivik, Eisenberg, & O’Brien, 2013;
Cimmino, Ferrone, & Cutolo, 2011). Work-related musculoskeletal disorders is one of the most common causes to ill-health relating to the work environment (Arbetsmiljöverket, 2014; Punnett, 2014). Exposures in the work environment that affect these tissues are biomechanical exposure, such as awkward postures, repetitive work, forceful exertions, static loads and vibrations, but also work-related psychosocial and organizational factors (Bovenzi, 2006; da Costa & Vieira, 2010; Lang, Ochsmann, Kraus, & Lang, 2012). WMSD can be acute – for example, acute back pain in connection with lifting activities when a heavy load leads to a sudden failure in both the structure and function of the locomotor system (Luttman et al., 2003). However, usually it takes several years to develop WMSD because they are the result of a long-term load (Cimmino et al., 2011; Luttman et al., 2003). The long incubation period and other contributing factors (such as lifestyle factors) might lead to WMSD not being prevented in time.
To prevent WMSD, it is most important to have balance between the load at work and the capacity of the working person. This can be done by the work design adapting the working conditions to the worker or by developing the capacity of the workers through training and vocational adjustment.
However, preventive measures should strive for the adaption of the working conditions (Luttman et al., 2003). Changes in the work design can involve job rotation, job enlargement and enrichment, team work, as well as changes in the workplace design and the development of tools and equipment to better fit the worker.
Primary prevention aims at preventing the onset of injuries and disorders in a healthy working population (Driessen et al., 2010). This includes successful and effective work methodology to improve work environment and to reduce sick leave, such as workplace interventions, organizational interventions and multidisciplinary interventions (Arnetz, Sjogren, Rydehn, & Meisel, 2003; de Boer, van Beek, Durinck, Verbeek, & van Dijk, 2004; Goine, Knutsson, Marklund, &
Karlsson, 2004; Jensen, Bergstrom, Ljungquist, & Bodin, 2005; Karsh, Moro, & Smith, 2001; Rivilis et al., 2008; Silverstein & Clark, 2004). “Multiple component intervention” is one of the most effective types of intervention to controlling WMSD (Karsh et al. 2001, Silverstein et al. 2004).
“Multiple component intervention” refers to some combination of organizational changes (e.g.
work rotation), technical changes (e.g. new tools, new workstation) and individual changes (e.g.
training, education) (Karsh et al. 2001). Another important factor for successful WMSD interventions is a participative approach, meaning that the intervention takes place in cooperation with managers and employees (Karsh et al. 2001, Rivilis et al. 2008).
1.4 Primary prevention and occupational health services
All these primary preventive activities described in the previous section are within the expertise of OHS. However, instead of primary preventive activities, research reveals that OHS focus on individual rehabilitation after occurrences of WMSD (Axelsdotter Hök & Tege, 2009).
Nevertheless, a primary preventive perspective is more cost effective and affects more people. The proactive initiative for implementation of, for example primary preventive measures, is the responsibility of the employer (client) (SWEA, 2001). Research has shown that organizations with a proactive OHSM report higher profits and fewer accidents; furthermore, they have significantly more positive safety climate perceptions which are associated with better self-reported physical and mental health (Haslam, O’Hara, Kazi, Twumasi, & Haslam, 2016). Since the OHS would have the competence to know what measures are needed for primary prevention (AML, 2015), they also would have the ability to take a role as a proactive partner towards their clients which have a less developed OHSM and actively support them to prevent WMSD.
The research about how OHS use a systematic work methodology for services that aims to be primary preventive is very limited (Eliasson, 2016). Table 1 presents three studies which describe primary preventive work methodologies used by OHS. Menckel, Hagberg, Engkvist, & Wigaeus Hjelm (1997)described feedback models used by occupational physiotherapists to prevent back injuries in health care. The models tested were feedback to work groups and supervisor, and feedback solely to supervisors. Both models generated a considerable number of accident- prevention proposals and the work method was perceived as favourable (Menckel et al., 1997). In a case study, Godderis, Vanhaecht, Masschelein, Sermeus, & Veulemans (2004) described, developed and evaluated a methodology for OHS companies to work preventively with chemical risks. The model could be transferred to other work environmental risks and the methodology was evaluated to be promising. Another primary preventive work method for OHS, described by Mattila & Kivi (1991), is called job load and hazard analysis and is a risk assessment methodology. This methodology was considered to be good and effective by both the OHS company and its client (Mattila & Kivi, 1991).
BACKGROUND 6
Table 1.Primary preventive work methods used by OHS companies. AimStudy designMethodsStudy populationImportant findings The Prevention of Back Injuries inSwedish Health Care –a Comparison between Two Models for Action-Oriented Feedback. (Menckel et al., 1997) Evaluate two different models for action-oriented feedback to prevent back injuries.
Case studyForms, written reports, interviews with physiotherapists.
11 physiotherapists, 5 OHS units. 122 cases. The action-oriented feedback methodology was regarded favourably, especially feedback to both supervisor and entire work group. Prevention Pathways: Application of the Critical Path Methodology in Occupational Health Services. (Godderis et al., 2004)
Develop, implement and evaluate a work methodology for OHS to work preventively. In this case, regarding chemical risks.
Case studyInvolvement of a multidisciplinary team (action research) A multidisciplinary team from an OHS company in Belgium. The team consisted of a hygienist, safety engineer, nurse, physician and client company.
The PP-methodology was considered a promising methodology to improve the OHS services regarding preventive work environment service. Hazard Screening and Proposals for Prevention by OccupationalHealthService:An Experiment with Job Load and Hazard Analysis at a Finnish Construction Company. (Mattila & Kivi, 1991)
Evaluate the effectiveness of a systematic tool for risk assessment (job load and hazard analysis) and whether it could be a work methodology for OHS to work more preventively.
Case study, Action research
Interviews, comparison between OHS programme before and after the implemented work methodology.
Large construction company, over 2000 employees. OHS company.
The method worked well as a central component of preventive occupational health care.
1.5 Ergonomists within occupational health services
The International Ergonomics Association (IEA) defines ergonomics as:
Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance(IEA, 2016).
Furthermore the IEA describes the role of ergonomics practitioners as follows:
Practitioners of ergonomics and ergonomists contribute to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people(IEA, 2016).
The ergonomics discipline is broad and there are several domains of specialization, such as physical ergonomics, cognitive ergonomics and organizational ergonomics. Ergonomists’
backgrounds may vary widely, from technical or medical disciplines (Piegorsch et al., 2006). In Sweden, ergonomists employed in OHS usually have a background as a registered physiotherapist (RPT) with additional education in physical ergonomics. The role is often complex and the work in OHS can include, for example, treating patients, rehabilitation, health examinations, risk assessments, education (Laring, Neumann, Nagdee, Wells, & Theberge, 2007). The title “ergonomist” is, in Sweden, unprotected, this means that anyone can use the title. However, the Swedish Association of Physiotherapists can promulgate RPT´s the title
“specialist in ergonomics”. The process includes an application and special requirements regarding for example education, research and practical experience of ergonomics (Fysioterapeuterna, 2014). Furthermore, in Europe, ergonomists can apply for the protected title “European Ergonomist”, the minimum requirements are three years of education at university level, whereof at least one is dedicated to ergonomics. Furthermore, at least three years of practical experience and continuous development within the discipline are required.
The application and certification is associated with a fee. In Sweden, 40 ergonomists are registered European Ergonomists (CREE, 2016).
In recent years, there has been a growing focus on ergonomists work and their consultative role (Laring et al., 2007; Wells, Neumann, Nagdee, & Theberge, 2013; Whysall, Haslam, &
Haslam, 2004). Furthermore, some of the ergonomics research emphasizes the importance of how ergonomists should “navigate” within the client organization and how to make the client aware of the ergonomics issues (Berlin, 2011; Broberg & Hermund, 2004; Ege, 2006; Theberge
& Neumann, 2010). However, the ergonomists’ role and work are not only affected by the organization and management of the client company in which the ergonomists provide their service, but are also affected to a high degree by the OHS organization in which the ergonomists are employed – and the research is scarce in this area.
BACKGROUND
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1.6 Ergonomic risk assessment - a tool in primary prevention?
As described above, multiple component interventions are an effective way to prevent WMSD (Karsh et al., 2001, Rivilis et al., 2008). Since WMSD can be affected by different work environmental factors (biomechanical, environmental, psychosocial and organizational) an intervention should be preceded by a thorough mapping/risk assessment. A systematic methodology for OHS has shown to be a good basis for preventing health hazards (Mattila &
Kivi, 1991). The ergonomic risk assessments include assessment of the exposure of ergonomic risk factors. The risk assessment of WMSD can involve different standardized tools, such as direct technical measurements tools, which includes inclinometry, heart rate monitors and electromyography (David, 2005; Neumann, 2007). However, observational-based risk assessment tools (OBRATs) are often mentioned to be useful due to the fact that they are time-efficient, flexible and considered less costly compared with technical measurement tools (Chiasson, Imbeau, Aubry, & Delisle, 2012; David, 2005; David, 2005). This makes them suitable for OHS ergonomists since assignments often are restricted in time by the client.
There are several OBRATs reported in the literature (David, 2005; Neumann, 2007; Takala et al., 2010). An overview of a number of OBRATs and what sort of exposure and outcome they are developed for is presented in Table 2. To conduct a qualitative risk assessment/exposure assessment, use of several specific tools may be required. This means that ergonomists must have knowledge of a range of tools and the situations for which they are applicable.
OBRATs are structured in a manner such that one can rather easily conclude whether the elevated risk level found is due to the duration, force, repetition of the work task or other exposures. This may simplify the prioritizing process for ergonomists when determining which exposures should be targeted in an intervention. The standardized approach in OBRATs makes these tools also suitable for use in evaluation of risk reduction measures taken at a workplace which should be of interest to both the OHS providing the service and the client receiving the service. The use of OBRATs is described in few studies (Dempsey, McGorry, &
Maynard, 2005; Diego-Mas, Poveda-Bautista, & Garzon-Leal, 2015; Pascual & Naqvi, 2008;
Wells et al., 2013), and information concerning use among ergonomists with a background as physioterapists is even more limited. Studies of tools used by Swedish ergonomists have included a small number of respondents, about twenty (Laring et al., 2007; Sturesson, 2006), or a respondent rate of less than twenty percent (Sturesson, 2006). However, these studies indicate that the Ergonomics provision AFS-98 from the SWEA (SWEA, 1998) was widely used, as well as methods that were developed within the respondents’ own organizations.
As previously described, there is published research about ergonomists’ practice and their work with standardized tools. However, there is not much research regarding whether and how OHS- companies work with systematic methodology for primary preventive services, and
information is scarce about how the OHS organization affects the work of their consultants (e.g. ergonomists).
BACKGROUND 9
.Overview of observational methods for risk assessment of physical load at work. More comprehensive presentations and links tothe methods are avail ort (Palm, Eliasson, Lindberg, & Hägg, 2014) Screening toolsMainly for repetitive workMainly for awkward posturesMainly for manual handling QECWashington state ergonomic checklist
HARMKIM IIIOCRAStrain IndexHALRULAREBAKIM IIKIM INIOSHlifting equationRAMP ullYesNoNoNoNoNoNoNoNoYesNoNoYes iftsYesYesNoNoNoNoNoPartlyYesNoYesYesYes YesYes tionYesYesYesYesYesYesYesPartlyNoNoNoNoYes uresYesYesYesYesYesYesNoYesYesYesYesYesYes tion ofYesNoYesYesYesYesYesYesYesYesYesYesYes YesYesYesPartlyPartlyNoNoYesYesNoNoNoYes ristYesYesYesYesYesYesYesYesYesNoNoNoYes YesYesNoYesNoNoNoYesYesYesYesYesYes NoYesNoNoNoNoNoNoYesYesPartlyNoYes e n/ dose YesYesYesYesYesNoNoNoYesYesYesYes
AIM
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2 Aim
The aim of this thesis was to explore prerequisites, processes and practices of Occupational Health Services consultants in Sweden within the domain of primary prevention of work-related musculoskeletal disorders.
It was the work of the professionals who are employed as ergonomists by OHS in Sweden that was in focus of the research in this thesis.
The thesis focuses on the following specific research questions;
When are OHS ergonomists involved in ergonomics assignments?
When and how are observation based risk assessment tools used by Swedish ergonomists?
How reliable are risk assessments performed by ergonomists without the use of any standardized observational method?
What organizational prerequisites within OHS companies facilitate involvement in work environment assignments?
3 Method
The following section presents the various data collection methods and analysis used in the research. Furthermore, reflexions regarding the author’s preconceptions and ethical considerations related to respective papers are presented.
3.1 Research design
The goal with this research has been to reach a deeper knowledge about the practice in OHS companies within the domain of primary preventive services, and for this various research methods have been used. Several methods were used in this thesis: survey, interviews, and inter- and intra-observer reliability testing. Use of multiple methods (triangulation), can help to achieve a deeper understanding and therefore a combination of both qualitative and quantitative research methodologies were used.
The first study (resulting in Paper A and C) aimed to explore the prerequisites which affected the ergonomists work and also to deepen understanding about the ergonomists’ work processes for risk assessment, a descriptive research design with an exploratory approach was used. This means that the research aimed to answer to the questions what (descriptive) and why (explanatory). In Paper A, both quantitative and qualitative methodology was used. The mixed methodology was chosen to get both a broad description regarding the use of OBRATs among Swedish ergonomist in general – for this, the questionnaire was the obvious choice. Furthermore, to explore the risk assessment process, interviews were considered to be an appropriate method since they gave an opportunity to gather in-depth information.
The research in the second study (resulted in Paper B) was conducted to evaluate the reliability of ergonomists’ risk assessment without the support of any standardized risk assessment tool.
Research aimed at test reliability (and also validity) in different tools is important when it comes to preventing WMSD; reliable tools are a precondition for selecting different measures.
Table 3 shows an overview of the research design of the included papers.
METHOD
12
Table 3. Description of the design of the papers.
Paper A Paper B Paper C
Title Ergonomic Risk Assessment:
Tool Use and Processes
Inter- and Intra-Observer Reliability of Risk Assessment of Repetitive Work
without an Explicit Method
Facilitators for the Implementation
of Ergonomic Interventions
Publication type
Journal article Journal article Conference paper
Research methodology
quantitative and qualitative quantitative qualitative
Methods Web-based questionnaire Semi-structured interviews
Inter- and intra-observer reliability testing
Semi-structured interviews
Research questions in respective paper
What are Swedish ergonomists’ knowledge and use of OBRATs, as well as OBRATs’ important immanent features?
Explore the processes of assignments that include ergonomic risk assessment.
How reliable are expert based risk assessments?
What factors within the OHS- companies facilitate ergonomic interventions?
(From a Swedish context)
Respondents Survey answered by 107 ergonomists
Response rate: 43%
Interviews with 12 ergonomists
Inter-observer
reliability: 21 ergonomists intra-observer
reliability: 9 ergonomists
Interviews with 12 ergonomists
3.2 Data collection methods
The methods used for data collection in the three papers included in this thesis are described below. The data for Papers A and C were collected during 2012 and for Paper B during 2014–
2015.
3.2.1 Survey (Paper A)
To explore the use of OBRATs among Swedish ergonomists, a web-based questionnaire was conducted (Appendix A). To reach as many ergonomists as possible, the survey was attached in a periodical e-newsletter sent to all members (598, year 2012) of the Ergonomic Section of the Swedish Association of Physiotherapists. The distribution of the questionnaire was handled entirely by the Swedish Association of Physiotherapists. In total, 251 ergonomists opened the newsletter, of which 107 completed the survey (43%).
The questions included the ergonomists’ knowledge about and use of different OBRATs, and what qualities they considered important in them. The questionnaire was inspired of a similar survey by Dempsey et al. (2005). It contained an introductory part with questions about gender, age and work experience, followed by questions about 17 different OBRATs. Ergonomics
students, several of whom were employed at OHS, answered a pilot version of the study. After the feedback the questionnaire was slightly revised before distribution.
3.2.1 Interviews (Papers A and C)
To complement the questionnaire in Paper A with deeper understanding about the process regarding risk assessment and the practical use of risk assessment methods, interviews with 12 ergonomists were conducted. The samples of ergonomist were strategic, and they all worked in OHS and represented both in-house and privately owned OHS and had experience of ergonomic risk assessment. Five of the recruited ergonomists were part of a network group involved in a project developing a new OBRAT (Lind, Rose, Franzon, & Nord-Nilsson, 2014). Through these ergonomists, different OHS with units spread in several regions were identified and additional seven ergonomists were asked to participate in the study. All ergonomists were RPTs and worked as ergonomists in eight different OHS. Three ergonomists were employed by the same in-house OHS department in a global industrial manufacturing company, working in different production plants. The other nine ergonomists were employed in privately owned OHS situated in seven different regions in the southern and central parts of Sweden.
The interviews were semi-structured and followed an interview guide (Appendix B). In the first part of the interview, the ergonomists were asked to describe one or several ergonomic assignment projects in which they had been involved. The broad initial question was intended to
“open up” the ergonomists to talk freely about important assignments. Furthermore, each ergonomist was asked about how the assignment was initiated, methods used for ergonomic risk assessment and about how feedback to the client was given and whether assignments were evaluated. A pilot interview was conducted with two ergonomists, which resulted in slightly modification with more questions emphasizing the assignment process. The majority of the interviews were performed by the author of this thesis. Because of the ergonomists’ geographical spread most interviews were conducted as telephone interviews, with a length from 45 to 60 minutes. The interviews were audio-recorded and transcribed verbatim.
3.2.1 Inter- and intra-observer reliability test (Paper B)
Paper B aimed to evaluate the inter- and intra-observer reliability of ergonomic risk assessment based on the ergonomists’ own experience and without the support of any standardized risk assessment tool. Twenty-one OHS-employed ergonomists were recruited to the study, all of whom had at least one year of experience as an OHS ergonomist.
The risk assessment procedure consisted of the ergonomists watching video recordings of ten different work tasks. They were given complementary information about each work task such as duration of work task during the work day, break schedules, weights of handled goods, other physical factors, and ratings of discomfort on Borg’s CR10-scale (Borg, 1998), work demands and control. The video-recorded work task covered different types of repetitive work from different job sectors: grocery store work, meat cutting, industrial assembly, cleaning, post sorting and hairdressing. To provide as natural an observational view of the worker as possible, each work task was recorded with two to four video cameras. The different views were synchronized into one video consisting of multiple frames with a close-up on hand and wrist movement.
METHOD
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The collected data consisted of the risk assessment protocol from each work task (Appendix C).
At the protocol, the ergonomist rated the risk for WMSD. Risk was rated using a three-stage scale: high risk (red), moderate risk (yellow) and low risk (green), and it was rated for eight specific body regions: neck, lower back, right and left shoulders, arms/elbows, and wrists/hands, as well as for the global risk. Nine ergonomist performed the risk assessment procedure a second time and the protocols from the first and second assessments were used for calculation of intra- observer reliability.
3.3 Data analysis
3.3.1 Paper A
The questionnaire in Paper A was analysed descriptively using SPPS Statistics 22. The data were presented in numbers and percentages. The qualitative analysis of the interviews was more comprehensive. The approach for the analysis was content analysis with an inductive approach, meaning that it was not based on a previous theory (Elo & Kyngaes, 2008). The focus was on the manifest content (Graneheim & Lundman, 2004), which means that the analysis focuses on the visible and obvious components of the text.
The content analysis was performed by the author of this thesis, and the process contained the following steps:
The author:
1. Listened to the interviews and transcribed the text. Three interviews were transcribed by another person. During the transcription, reflections and interpretations began.
2. Created an overall picture of the content of the interviews. The goal of this step was to delve into the different interviews and get to know the material. This step included both listening and reading the interviews several times.
3. Highlighted words and sentences related to the research questions, both on paper and in the computer.
4. Condensed the text. In this step, the sentences, called meaning units (Graneheim & Lundman, 2004) were condensed and reduced into a brief summary format (Thomas, 2006). The condensed texts were abstracted and labelled with a code. The abstraction emphasized that the meaning of the text was interpreted on a higher logical level (Graneheim & Lundman, 2004).
This step was done by copying highlighted meaning units from the transcribed documents into a table created in Word. The meanings were condensed and given a code.
5. Clustered the codes into different subcategories and further, three main categories were formulated. The categories constituted the manifest content of the interviews.
6. Formulated an overall theme. Finally, based on the aim of Paper A, an overall theme (Graneheim & Lundman, 2004) was formulated – “Process of ergonomic assessment assignments” – of which the three main categories represent different stages in the process.
The analysis process is illustrated in Table 4.
