Effectiveness of participatory ergonomic interventions on health outcomes: A systematic review
Introduction
Participatory ergonomic (PE) interventions or programmes are often used to reduce work related musculoskeletal disorders (MSD) in workplaces (Hagberg et al., 1995; National Research Council, 2001). They grew out of quality circle experiences in Japan (Nagamachi, 1995) and participatory workplace design processes in Northern Europe (Elden, 1986) and North America (Liker et al., 1995) during the 1980s. Unions (Bryson, 2004; Canadian Auto Workers, 2004), health and safety sectoral agencies (Archer and Courville, 1998), and health and safety associations (Occupational Health & Safety Agency for Healthcare in British Columbia, 2005) have actively promoted PE approaches. Wells et al. (2004) and researchers from the Centre for Research Expertise on the prevention of Musculoskeletal Disorders and Disability (CRE-MSD) in Canada have advocated the use of a blueprint specifically developed to guide PE interventions. In addition, multi-stakeholder initiatives have promoted PE approaches as in the recent Occupational Health and Safety Council of Ontario proposal to explore ergonomic strategies to reduce the number of MSD claims submitted by Ontario workers (Pulp and Paper Health and Safety Association, 2004).
Wilson and Haines (1997) defined PE as ‘the involvement of people in planning and controlling a significant amount of their own work activities, with sufficient knowledge and power to influence both processes and outcomes in order to achieve desirable goals’. Kuorinka (1997) defined PE as ‘practical ergonomics with participation of the necessary actors in problem solving’. A characteristic feature of PE is the formation of an ergonomics ‘team’ typically made up of employees or their representatives, managers, ergonomists, health and safety personnel, and research experts. Once formed, teams typically undergo training by an expert (usually an ergonomist) to become familiar with ergonomic principles (Wells et al., 2004). With a foundation of ergonomic concepts and methods in place, the group uses its newly developed knowledge to make improvements in their workplace (Haims and Carayon, 1998; Halpern and Dawson, 1997; Reynolds et al., 1994; Noro and Imada, 1991). By working together to improve workplace conditions through participation, communication, and group problem solving, a PE intervention can positively impact on workers’ health (Haims and Carayon, 1998; Haines et al., 2002; Laitinen et al., 1997a, Laitinen et al., 1997b; Nagamachi, 1995; Simon and Leik, 1999). Ideally, the PE approach encourages workers to be involved in controlling their own work activities, consequently decreasing work organization or psychosocial risk factors (Bongers et al., 2002; Westgaard, 1999; Wilson and Haines, 1997).
In the scientific literature, evaluation studies often focus on particular aspects of PE. We can conceive of a number of steps along a pathway by which PE might improve both employee health and productivity (see Fig. 1).
Process evaluation of PE implementation is important for understanding how changes are brought about. Qualitative and quantitative literature on PE processes examining the implementation of PE interventions is available (Kuorinka et al., 1994; Rice et al., 2002). Similarly a literature exists on the effectiveness of PE in reducing exposures or risk factors for MSD i.e., exposure change evaluations. For example, a randomized controlled trial by Straker and colleagues (2004) demonstrated reductions in a variety of important indicators of biomechanical exposure. Such changes in exposure are important to overall judgments of the effectiveness of PE (Cole et al., 2003). Adequate details about PE processes and biomechanical exposure reduction are needed to better evaluate improvements in health outcomes (Cole et al., 2003). A nascent formal economic evaluation literature on the efficiency of workplace interventions in achieving changes in both employee health and production outcomes is also developing (Dul, 2004). Economic evaluations may address the relative cost–benefit of implementing PE in different kinds of workplaces.
Important narrative reviews have reflected upon implementing and evaluating PE interventions (Haims and Carayon, 1998; Haines et al., 2002; Haslam, 2002; Hignett et al., 2005; St-Vincent et al., 2000). The prerequisites and benefits of implementing successful PE programs have also been described (Nagamachi, 1995; Wilson and Haines, 1997). Hignett's narrative review provided an excellent summary of the strengths of PE with examples from a range of industries, including health care, military, manufacturing, production and processing, services, construction and transport. However, we could not find a systematic evaluation of the quality, quantity and consistency of evidence of effectiveness of PE in improving health outcomes, similar to Hignett's (2003) examination of strategies to reduce patient handling MSD.
We therefore sought to conduct a systematic literature review to assess the quality of available scientific evidence with two objectives: (1) to synthesize evidence on the effectiveness of workplace-based PE interventions in improving health outcomes, in order to assist practitioners and policy makers; and (2) to provide an assessment of the methodological strengths and weaknesses which characterize the studies of PE interventions with health outcome evaluations, in order to provide guidance for future research and evaluation. In proceeding with these objectives we actively engaged the participation of stakeholders in the genesis and conduct of this review to ensure our research question responded to stakeholders’ needs and interests.
Section snippets
Literature search
Six electronic databases were searched from their inception until July 2004: Medline, Excerpta Medica database (EMBASE), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Canadian Centre for Occupational Health and Safety (CCINFO web), Safety Science and Risk, and Ergonomic Abstracts. The terms used in the search were customized for each database, so that the databases’ controlled vocabulary was used whenever possible (see Appendix A for search terms). The search was limited to
Literature search and selection of relevant studies
Of the 442 non-duplicate citations (see Fig. 3), 23 studies met our relevance criteria. The remaining 419 studies were not relevant to our review objectives i.e. 43% did not describe an intervention; 44% were not ergonomic; 43% were not judged to be participatory; 47% did not include health outcomes; and 23% were not peer reviewed. Although these studies often reported on interesting frameworks, experiences, cases or aspects of ergonomics, they could not help us answer our question regarding PE
Evidence of effectiveness
This review systematically sought evidence on the effectiveness of PE interventions in improving health outcomes by following a conceptual framework that examined process implementation, changes in exposures, and effects on health outcomes. Participatory ergonomics interventions relatively consistently led to improvements in MSD-related symptoms, MSD injuries or claims, and MSD sick leave or lost workdays. The positive effects spanned a wide range of workplace settings in many countries. These
Conclusions
Eleven of the 12 medium or higher quality studies reported a positive effect on health outcomes associated with PE interventions. However, the heterogeneity in research methods and reporting across the studies led the review team to assign an appraisal of partial to moderate evidence that PE interventions are effective in improving different health outcomes. The main reason for not finding full support for PE is the low number of methodologically sound studies currently available in the
Acknowledgments
This project was sponsored by the Institute for Work & Health, an independent not-for-profit research organization. The Institute receives ongoing support and received direct funding for this review from the Ontario Workplace Safety & Insurance Board. We would like to acknowledge assistance of our colleagues Dee Kramer, Doreen Day, and Dan Shannon for their help in conducting this review. We thank other colleagues from the Institute, the Centre for Research Expertise in Prevention of
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