institute for work & health intervention & evaluation in a large newspaper presentation to...

Institute for Work & Health

Intervention & Intervention & Evaluation in a Evaluation in a Large Newspaper Large Newspaper

Presentation to Marconi Research

Conference at Marigold 2003

Intervention Research of Computer Use

September 13-14, 2003

By Richard P. Wells PhD andDonald C. Cole MD, MSc, FRCP(C)University of Waterloo and Institute for Work & Healthon behalf of…

STOPRSI !


PartnersPartners

Members of the RSI Committee:The Toronto Star: Dianne Forsyth, Dana Greenly, Jeff Hoffman,

Vivian Karnilavicius SONG: Sylvia Cowell, Ann Maguire, John Spears, Paul Willis

University of Waterloo: Dwayne Van Eerd, Richard Wells

York University: Melanie Banina, Anne Moore

The Orthopedic Therapy Clinic: Maureen Dwight, Pam Honeyman

IWH: Dorcas Beaton, Donald Cole, Sue Ferrier, Sheilah Hogg-Johnson, Carol Kennedy, Hyummi Lee, Michael Manno, Michael Polanyi, Harry Shannon, Peter Subrata, Michael Swift


Key Findings:Key Findings:

1.1. Reduction in persons with severe/frequent painReduction in persons with severe/frequent pain2.2. RSI has been controlled but not resolved.RSI has been controlled but not resolved.

3.3. Ergonomic Policy and STOP RSI! Program Ergonomic Policy and STOP RSI! Program components are important responses.components are important responses.

4.4. Program participation by individuals associated with Program participation by individuals associated with reduction in risk factors and improvement of health reduction in risk factors and improvement of health outcomes.outcomes.

5.5. The RSI and Joint Health & Safety Committees have The RSI and Joint Health & Safety Committees have made a difference, but ongoing corporate support is made a difference, but ongoing corporate support is crucial.crucial.


OutlineOutline

1. Nature, timeline and phases of collaborative research

2. Intervention areas and specific interventions

3. Evaluation framework

4. Exposure assessment

5. Outcomes

6. Key messages & directions


Collaborative Research: Star-SONGCollaborative Research: Star-SONG

The Toronto Star - a large newspaper undergoing technological and organizational change.

Southern Ontario Newspaper Guild (SONG) – part of the Communication, Energy & Paper-workers union, long history of health & safety activism.

Two intertwined goals of better musculoskeletal health (particularly upper extremity WMSD) & improved business performance.


Collaborative Research: ProcessCollaborative Research: Process

Joint development by workplace parties & research team, approved in collective bargaining, enshrined in ‘Ergonomic Policy’ and called ‘Stop RSI’ programme with goal of reduced WMSD burden.

Ongoing parallel, major moves with new equipment, work re-organization & team training, new software in different departments, attempts to contract out distribution, etc. with goal of improved business performance.


Overall Evaluation ProgramOverall Evaluation Program

““Teamed” GroupTeamed” Group

Status Quo Status Quo

Secondary Data LinkageSecondary Data Linkage

1996 C

ross-s

ection

al Su

rvey (Ph

ase 199

6 Cro

ss-sectio

nal S

urvey (P

hase

I)I) 1997 In

tens

ive S

tud

ies (Ph

ase II)

1997 In

tens

ive S

tud

ies (Ph

ase II)

Qualitative Documentation & AnalysisQualitative Documentation & Analysis

Workplace SurveillanceWorkplace Surveillance

Extensive Repeat ExposureExtensive Repeat ExposureMeasurement (subset of n=44)Measurement (subset of n=44)For physical ExposuresFor physical Exposures

20

01

Cro

ss-s

ectio

nal S

urv

ey

20

01

Cro

ss-s

ectio

nal S

urv

ey

1998

1998


SurveysSurveys

1996: Cross-sectional Survey

(descriptive, analytic)

…provided workforce coverage

1997: Suite of Intensive Studies

(multiple methods including in-depth interviews, focus groups, surface EMG and additional questionnaire measures)

…deepened understanding2001: Cross-sectional Survey (individually linked)

(descriptive, analytic)

…measurement of change


Evaluation Framework: (i)Evaluation Framework: (i)

Means Intermediate Outcomes Longer Term Outcomes

Strategies Activity Area Objectives Metric Objectives Metric

Policy Formulation of

Ergonomic

Policy

Employees/managers

aware of policy &

contents

Interviews Policy used to guide

actions

Document analysis

Human

Resources

Definition of

employer &

employeeresponsibilities

Each aware of theirresponsibilities

Interviews &

document review

Each fulfilling theirresponsibilities

Joint committees

Document review

Questionnaire

“Stop RSI”*

training

Entire office

workforce

has been part of

training

% trained by

department

Part of orientation

of new staff

Changes in

Knowledge

attitudes

& practices


Evaluation FrameworkEvaluation Framework


Strategies Activity Area Objectives Metric Objectives Metric

Human

Resources

Knowledge of

WMSD† risk

factors (incl.

work

organization &

physical)

Employees/ managers

aware of such factors

and attempting to deal with them

Interviews

Observations

during joint committees

Document review

Managers

incorporating

consideration of in

Work design &

operations decision

making

Interviews

Participation in joint

committees

Questionnaire

Team Work

Team training Consideration of work

organization and

physical WMSD risk

factors in training

Document review

Interviews

Ongoing training and

new team structures

incorporate WMSD

risk factor

considerations

Document review

Interviews




Strategies Activity Area

Objectives Metric Objectives Metric

Team Work

Team formation

&

implementation

Multi-skilling

Increased variety

iImproved

productivity

Interviews

Number

of tasks & % time

Variation in

surface EMG

Improved: Synchronization of tasks, handling of deadlines & workflow

ditto

Equipment

and

Environ-ment

New spatial

layout of

workstation

Allow adequate space for work and improves

contact between team members

Observation

Interview

Workflow

improvement &

increased teamwork

Interviews

New adjustable

workstations

Improved ‘ergonomic

design’ of workstations

Workstation

dimensions,

Observational

data on

postures, EMG

Purchasing policies

revised

Interviews

Ergonomic

assessment data,

Questionnaire




Strategies Activity Area

Objectives Metric Objectives Metric

Information

Systems

New software Improved workflows

& productivity

Interviews

Observations

Productivity data

in departments

New software designs

incorporate WMSD

considerations

Interviews with

system staff

Questionnaire

Productivity data in

departments

Human resource

(HR)

information

systems

Improve ongoing

surveillance of WMSD

risk factors (ergonomic

assessments) and

reporting

Data from

relevant HR data bases to joint

committees

Reduce overall risk

factors and severity of

WMSD

Decline in WMSD severity on injury

reports

Regular

ergonomic

assessments


Assessment MethodsAssessment Methods

Methodologies include: Interviews Questionnaires and diaries Observation and video Measures of EMG, postures, dimensions Site administrative data Compensation system, health care system records

linkage


Assessment: Workstations (1)Assessment: Workstations (1)

Wrist, neck and shoulder postures and dimensions of VDT location on workstation taken, EMG: Spring/Summer 1999 Winter 2000

(excluding circulation) Spring/Summer 2000

(41 participants)

45 Participants (31 female, 14 male) 45 Participants (31 female, 14 male) (40/41 new workstations, 3/41> 1 (40/41 new workstations, 3/41> 1 workstations, adjustable keyboard tray workstations, adjustable keyboard tray 36/41)36/41)

Did the installation Did the installation of new workstations of new workstations improve the postures improve the postures adopted?adopted?


Assessment: Muscle Activity (i)Assessment: Muscle Activity (i)

How to assess muscle activity in a workplace setting?Muscle activity in a naturalistic setting is determined by: tasks

performed, workload, workstation, equipment, technique, task/time organization

Electromyographic signals bilaterally from:Extensor Carpi Ulnaris Brevis (ECRB),Trapezius, recorded using portable EMG system with simultaneous video recording

On/off states of 7 tasks identified while viewing video and simultaneously recorded on computer (Observer Pro 4.0, Noldus Technology, Netherlands): Keying, mousing, phone, deskwork, sitting/standing, at/away from desk, other.


Assessment: Muscle Activity (ii)Assessment: Muscle Activity (ii)

Two hours of work (on 2 days (am and pm) pre, during, and after interventions).

30 minute segment analysed; work at desk over-sampled 33 Participants: Newspaper advertising and finance employees,

Clerical, administration, sales, customer accounts and call centre,10 male/ 23 female


Assessment: Muscle Activity(iii)Assessment: Muscle Activity(iii)

Extracting mousing task EMG from working EMG

0

10

20

30

40

50

0 1 2 3 4 5 6Time (min)

-10

0

10

20

30

40

50

0 1 2 3 4 5 6 7 8 9 10Time (min)

EM

G (

% M

VC

)

Mousing On

0

10

20

30

40

50

0 1 2 3

Time (min)

Mousing Off


Assessment: Muscle ActivityAssessment: Muscle Activity

0

5

10

15

20

R.ECRB R. Traps L. ECRB L. Traps

Gap

tim

e (s

ec/m

in)

Keyoff

Keyon

0

0.5

1

1.5

2

2.5

3

Rt ECRB Rt Traps Lt ECRB Lt Traps

Stat

ic E

MG

(%

MV

C)

keyoff

keyon

*

*

*

*

Low static is better

High gaps is better



0

1

2

3

4

5

Rt ECRB Rt Traps Lt ECRB Lt Traps

Stat

ic E

MG

(%

MV

C)

mouse off

mouse on

*

*



0

0.5

1

1.5

2

R.ECRB R. Traps L. ECRB L. Traps

Stat

ic E

MG

(% M

VC

)

Phoneoff

Phoneon

Holding Handset (in right hand)


Intermediate OutcomesIntermediate Outcomes

Shorter term outcomes such as reductions in exposures, that are thought to precede improvements in longer term outcomes such as pain levels and lagging indicators such as injury or lost time from work…


Process Indicators: EducationProcess Indicators: Education

1998 STOP RSI! training sessions in all departments – 58% reported on 2001 survey

RSI training as part of orientation – 11% of 2001 survey respondents

90% of 2001 survey respondents felt that The Toronto Star STOP RSI! program had completely to moderately “ensured that all employees are informed about RSI”


Intermediate Outcomes: Education Intermediate Outcomes: Education

Perceived Cause 1996 Survey Respondents

2001 Survey Respondents

Poorly designed workstations 68% 78%

Working without breaks 40% 52%

Excessive workload 27% 40%

Lack of training 37% 23%

Awareness of Causes of RSIAwareness of Causes of RSI


Process Indicators: Equipment/ WorkspaceProcess Indicators: Equipment/ Workspace

Input by RSI Committee during purchasing process

Over 2000 Ergonomic Reports/ Workstation Assessments completed by over 20 trained assessors (56% (459) of 2001 survey respondents)

Among a smaller group, the research team measured workstation dimensions and conducted postural assessments.


Feedback InformationFeedback Information

Analyses of xxxxx when performing keyboarding tasks. Measure Sept 17/99 May 3/00 Preferred Range Interpretation

Head Tilt Angle 5 (up) 11 (up) 0-20 (down) Needs Improvement Gaze Angle 20 (down) 1 (down) 0-30 (down) Within Preferred Range Head Rotation 20 11 (right) 15 (left) - 15 (right) Within Preferred Range Glare Yes No No Within Preferred Range Right Shoulder Abduction 30 22 0-20 * Within Preferred Range* Left Shoulder Abduction 25 20 0-20 * Within Preferred Range Right Shoulder Flexion 30 22 0-20 * Within Preferred Range* Left Shoulder Flexion 30 20 0-20 * Within Preferred Range Inner Elbow Angle (right) 115 115 80 - 120 Within Preferred Range Inner Elbow Angle (left) 115 120 80 - 120 Within Preferred Range Supported Right Elbow No Yes Yes Within Preferred Range Supported Left Elbow Yes Yes Yes Within Preferred Range Supported Right Wrist No Yes Yes-when not typing Within Preferred Range Supported Left Wrist No Yes Yes-when not typing Within Preferred Range Right Wrist Extension 15 27 0-30 Within Preferred Range Left Wrist Extension 5 0 0-30 Within Preferred Range Rt Wrist Ulnar Deviation 15 6 0-20 (ulnar) Within Preferred Range Lt Wrist Ulnar Deviation 15 0 0-20 (ulnar) Within Preferred Range * - If arms are supported on armrests, shoulder flexion and abduction measures that exceed the preferred range represent minimal increases in risk of injury.


Feedback ExampleFeedback Example

The figures below are a visual representation of your posture on the dates indicated, as well as a preferred posture when using the computer. The first figure is the view from the side, while the second figure is a top view. The black box represents your monitor position relative to your body. The contrasting color scheme in the figures is used so that the arms will stand out, not to indicate a potential location of risk.


Feedback DiagramsFeedback Diagrams



Intermediate Outcomes : Workstation Intermediate Outcomes : Workstation Dimension Change over TimeDimension Change over Time

Gaze Angle vs Monitor height

-20

0

20

40

60

80

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0

Monitor Height (cm from floor)

Gaz

e A

ng

le (

deg

)

1999 w2000 S2000 S2001

Gaze Angle vs Monitor HeightGaze Angle vs Monitor Height


Intermediate Outcomes : Workstation Intermediate Outcomes : Workstation Dimension Change over TimeDimension Change over Time

Mouse Location (fore/aft vs side/side)

-30

-20

-10

0

10

20

30

40

50

60

70

-60 -40 -20 0 20 40 60 80

Mouse side/side (cm from j key)

Mo

use

fo

re/a

ft (

cm f

rom

tab

le

edg

e)

1999 w2000 S2000 S2001

Mouse Position


Intermediate OutcomesIntermediate Outcomes : Equipment/ : Equipment/ Workspace (ii)Workspace (ii)

Piece of Equipment



Keyboard 56% 72%

Mouse 17% 61%

Monitor/Screen 72% 71%

Proportion Proportion insideinside preferred location (from questionnaire) preferred location (from questionnaire)


Intermediate Outcomes : Change in Working Intermediate Outcomes : Change in Working Postures over Time Postures over Time

MeasureMeasure Preferred Preferred RangeRange

Summer Summer 19991999

Winter Winter 20002000

Summer Summer 20002000

Right Shoulder Right Shoulder Abduction (°)Abduction (°)

0-200-20 * * 5757 6666 3636

Left Shoulder Left Shoulder Abduction (°)Abduction (°)

0-200-20 * * 6767 7474 4545

Right Shoulder Right Shoulder Flexion (°)Flexion (°)

0-200-20 * * 4747 4747 6060

Left Shoulder Left Shoulder Flexion (°)Flexion (°)

0-200-20 * * 4545 5050 6262

Supported Right Supported Right (%)(%)

Yes**Yes** 4141 7979 6868

Supported Left (%)Supported Left (%) Yes**Yes** 3939 8787 7979

* If arms are supported on armrests, shoulder flexion and abduction measures that exceed the preferred range represent minimal increases in risk of injury.

** Wrist Support optimum when not typing

Shoulder Posture; Percentage within Preferred RangeShoulder Posture; Percentage within Preferred Range


Intermediate Outcomes : Summary of Intermediate Outcomes : Summary of Equipment/ Workspace/Work Postures Equipment/ Workspace/Work Postures

Detailed dimension and posture measures From 1999 to 2001, changes among group of

employees (mostly Advertising):

reduced extreme mouse positions (horizontal and vertical)

monitor heights higher but fewer extreme head tilts

fewer monitors displaced to the side and less head rotation


Intermediate Outcomes: Intermediate Outcomes: Job Changes (i)Job Changes (i)

Over past 3 years among 2001 respondents Different job title/description (32%)

Different tasks in same job (37%)

Broader job scope (29%)

Increased job responsibility (47%)

Changes in immediate supervisor (42%) or co-workers (45%)


Intermediate Outcomes: Intermediate Outcomes: Job Changes (ii)Job Changes (ii)

Increased use of computer (27%) and addition of mouse (36%)

Among users, increased mean hours of use of keyboard (extra 40 min.) and mouse (extra 56 min.) between 1996 & 2001

Time sitting >2 hours continuously, increased by 9% to 33% of 2001 respondents

Both keyboard use and time sitting were RSI risk factors in 1996


Longer Term OutcomesLonger Term Outcomes

Among the entire workforce period prevalence of more severe pain (NIOSH case) decreased; 205/1007 or 20% in 1996 127/813 or 16% in 2001 difference p<0.01

NIOSH case: those who have experienced moderate or severe pain and discomfort either once per month or longer than a week over the past year and had no trauma to the area.


Longer Term Outcomes: Symptom Level Longer Term Outcomes: Symptom Level Transitions in 1996-2001 CohortTransitions in 1996-2001 Cohort

From:1996 Symptom

Level

To: 2001 Symptom Level

1 2 3 Totals

non-case (1)Stable97 (23.0%)

Incident53 (12.6%)

Incident13 (3.1%)

163(38.6%)

mild (2)Resolved42 (10.0%)

Ongoing93 (22.0%)

Worsened21 (5.0%)

156(37.0%)

more severe or frequent (3)

Resolved12 (2.8%)

Improved54 (12.8%)

Chronic37 ( 8.8%)

103(24.4%)

Totals151

(35.8%) 200 (47.4%) 71 (16.8%) 422 (100%)


Longer Term Outcomes: Changes in Longer Term Outcomes: Changes in RSI 1996-2001(ii)RSI 1996-2001(ii)

Fewer wrist/hand (- 6%), more shoulder (+7%) and neck (+12%)

Majority in 2001 aggravated by work

(yes, 57%; to some extent, 34%)

Persistent problems with work function: Work-DASH (Disability of Arm, Shoulder & Hand) 1996 mean 6.3/100, SD 14.9; 2001 mean7.8, SD15.3 (no significant difference)

Among those with painAmong those with pain


Longer Term Outcomes: Trends in Musculoskeletal Longer Term Outcomes: Trends in Musculoskeletal Related Drug CostsRelated Drug Costs

05000

1000015000

200002500030000350004000045000

Cost

s/Qua

rter

All Kinds NSAIDS OPIATE AGONISTS


Longer Term Outcomes: Analyzing linkages in Longer Term Outcomes: Analyzing linkages in 1996-2001 cohort1996-2001 cohort

Reported Program Participation:• Training• Workstation Asst. • New equipment

Reported WorkChanges:• Computer-related• Job-related

∆ Health Outcome:• Pain intensity (all)• Disability Work-DASH &QuickDASH

(sub-set)

∆ Potential Risk Factors:• Biomechanical• Psychosocial

∆ Potential Risk Factors:• Biomechanical• Psychosocial

Confounders/ Effect Modifiers(age, seniority, gender) accounted for

Confounders/ Effect Modifiers(age, seniority, gender) accounted for

(n=433)(n=433)


Longer Term Outcomes : Predictors of changes Longer Term Outcomes : Predictors of changes in risk factorsin risk factors

Of biomechanical risk factors multiple kinds of new equipment with likelihood

of worse telephone setup (p=0.005) broader responsibility & scope in job with

physical effort (p=0.098) Of psychosocial risk factors

having a workstation assessment (p=0.062), participation in Stop RSI training (p=0.007), & broader responsibility & scope in job (p=0.032) with decision latitude


Longer Term Outcomes : Predictors of changes Longer Term Outcomes : Predictors of changes in health outcomesin health outcomes

In pain intensity supervisor awareness & concern associated with pain

(p=0.161) keyboard time with pain (p=0.125)

In upper extremity related disability management support for RSI (p=0.006) & frequency

of workers taking part in decisions (p=0.082) with disability (QuickDASH)

physical effort (p=0.119) & decision latitude (p=0.121) with work disability (Work-DASH)


Longer Term Outcomes: Longer Term Outcomes: 2001 Survey Respondents’ Assessment2001 Survey Respondents’ Assessment

The STOP RSI! program “promoted continuous improvement in the technology and management practices to control exposure to workplace risk factors that can cause RSI” - 85% completely to moderately agreed

Toronto Star management were supportive in dealing with RSI - 74% agree or strongly agree (vs. 64% in 1996)

Immediate supervisor was aware and concerned - 57% (unchanged from 1996)


Future Directions: 2001 Survey Future Directions: 2001 Survey Respondents’ Suggestions Respondents’ Suggestions Equipment:

mouse wrist rests and longer cords monitors should be placed at an appropriate distance

and height, adjustable to height of person Workspaces:

all workstations should be assessed/set up for each new employee during 1st week at work and regularly thereafter

working at workstation other than one's own usually uncomfortable - cannot adjust

Social Supports: awareness sessions with [RSI] “victims” for immediate supervisors


Future Directions: Ongoing Tensions Future Directions: Ongoing Tensions Relevant to RSIRelevant to RSI Proportion of respondents who disagree that

“I can take breaks when I want to” unchanged from 1997 to 2001 (28%)

“…productivity is really important here. You have to be always available on your phone. And all their incentives …[are] based on how much you’re producing.” - manager


Ongoing Workplace Directions:Ongoing Workplace Directions:

RSI/JH&S committees are continuing training, ergonomic assessments, purchasing guidelines and therapy initiatives

Struggling with: strengthening management practices supportive of

dealing with RSI, particularly at the supervisory level need to persuade organizational leaders to move

“upstream” to influence decisions on new technology, organization of work and design of jobs, as per Ergonomic Policy


Key Findings:Key Findings:

1.1. Reduction in persons with severe/frequent painReduction in persons with severe/frequent pain2.2. RSI has been controlled but not resolved.RSI has been controlled but not resolved.

3.3. Ergonomic Policy and STOP RSI! Program Ergonomic Policy and STOP RSI! Program components are important responses.components are important responses.

4.4. Program participation by individuals associated with Program participation by individuals associated with reduction in risk factors and improvement of health reduction in risk factors and improvement of health outcomes.outcomes.

5.5. The RSI and Joint Health & Safety Committees have The RSI and Joint Health & Safety Committees have made a difference, but ongoing corporate support is made a difference, but ongoing corporate support is crucial.crucial.


Ongoing Research:Ongoing Research:

Changes in exposure Company surveillance review Path modeling for changes in cohort Integrating the quantitative and qualitative

components


Supported by: Supported by:

NIOSH/NIH R010H03708-02 Centre for VDT & Health Research Toronto Star Southern Ontario Newspaper Guild IWH and indirectly, the Ontario WSIB

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