Ergonomics Hazards and Musculoskeletal Disorders Among Workers of health Care Facilities

The present study was conducted to determine occupational health and safety hazards with special focus on ergonomic hazards among healthcare facility (HCF) workers. A structured questionnaire survey was conducted among 200 workers in five HCFs of Lahore, Pakistan. Among the reported ergonomic hazards, muscle aches/ sprains (76.5%), elbow/ wrist/ neck pain (56.0%), body posture issues (56.0%), excessive stretching of muscles (67.5%) and bending/ twisting at work (55.5%) were commonly encountered. Biological hazards included incidences of cuts/wounds/ lacerations (69.0%), contact with specimens (56.0%), exposure to airborne diseases (64.0%) and other infections (72.0%) inspite of the fact that majority (90.0%) were aware of procedures where needle stick injuries are most likely to occur and knowledgeable on occupational infections. Physical hazards included slips/trips/falls (65.0%), high noise levels (64.0%) and chemical spills (54.0%). A significant percentage of workers experienced psychosocial hazards including work related stress (77.0%) and some form of psychosocial or physical abuse (68.5%). Despite workers awareness about occupational health hazards and implementation of control measures by HCF to mitigate hazards (especially biological) prevalence of hazards was reported. Hence, there is a need to improve working standards and conditions to reduce the occurrence of ergonomic and psychosocial hazards. Current World Environment Journal Website: www.cwejournal.org ISSN: 0973-4929, Vol. 13, No. (2) 2018, Pg. 251-258

introduction Healthcare is, directly or indirectly, associated with the provision of health facilities to individuals.The healthcare facilities (HCF) involve a broad range of workforce such as physicians, nurses, experts, clinical research/ laboratory personnel, social and administrative workers 1 .Health care services around the world employ over 59 million personnel who are daily exposed to a variety of health and safety hazards.Healthcare, an important sector of the U.S. economy provides employment to over 8 million U.S. healthcare workers (HCW), including pharmacy and nursing workers, physicians, operative room staffs, environmental facilities employees, personnel in examination laboratories, veterinary care staffs and those involved in shipping and receiving patients, who are potentially exposed to dangerous drugs as well as diverse hazards 2 .
Common hazards experienced by HCW include biological, ergonomics, physical and psychosocial hazards.Biological hazards comprise needle stick injuries, exposure and susceptibility to infections such as tuberculosis, hepatitis and HIV/ AIDS occurring through direct and indirect body contact.Physical hazards include slips trips and falls, exposure to noise and chemicals such as glutaraldehyde, ethylene oxide and drugs.While violence, stress and anxiety due to work constitute psychosocial hazards 3 .
Work related musculoskeletal disorders (WMSDs) are most often experienced by medical professionals with surgeons being the most susceptible, followed by nurses and physiotherapists 4 .Ergonomic hazards including problems related to backbone, neckline, shoulder and knees are common complaints among medical, dental and nursing professionals 5 .
The HCW face high ergonomic risks and therefore have greater potential for musculoskeletal issues along with other work associated injuries.According to an estimate, more than 5000 injuries among HCW have been reported annually.These are mainly attributed to manual handling of patients and excessive workloads.Moreover, awkward or static postures during treatment of patients result in stresses and strains which is another cause of such problems 6 .According to an estimate, one third of all cases of sick leave among health care employees are due to musculoskeletal disorders (MSDs).Even in developed countries, MSDs among HCW are generally under reported 4 .The MSDs affect body movements, cause wounds or dys functions of nerves, tendons, muscles, cartilagebone, spinal discs and joints.These disorders comprise soreness, connective tissue damage, pain in back, hernia, problems of shoulder and knee tears 7 .According to National Institute for Occupational Safety and Health (NIOSH), numerous studies indicated direct relationship between physical work and occupational related MSDs.Several aspects that are related with MSD include constant body posture, persistent sitting positions, continuous movement, unnecessary use of force and prolonged standing 8 .
Many programs on psychosocial nature of humans, physical work and medical facilities related to the prevention and effective management of MSDs have been conducted by NIOSH and OSHA 9 .
Keeping in view the significance of OH&S, the current study aimed to determine various occupational hazards, especially ergonomic hazards, faced by different types of HCW, assess the level of awareness among workers regarding occupational hazards and to identify control measures provided by the employers as well as those adopted by the workers to mitigate and minimize the prevalent occupational hazards.

Materials and Methods
A descriptive cross-sectional study was conducted among 200 health care workers employed at five government and private HCFs in Lahore, Pakistan.The respondents included doctors, nurses, laboratory attendants, pharmacists, x-ray technicians and hospital sanitary workers.The total population of HCW of selected hospitals is over 3,000.An online calculator 10 was used to determine the sample size of study group, keeping margin of error less than 7%, and confidence level 86% .The calculated sample size was 200 HCW.

Questionnaire survey
Data were collected using quantitative methods via a structured questionnaire.The questionnaire forms were completed onsite with face to face communication with the respondents.Each questionnaire form took on an average about 10 minutes to complete.The questionnaire was adapted from US Center for Disease Control (CDC), NIOSH as well as hazards reported in literature 2,11,12 .The questionnaire included section on demographic information, smoking status, education status, type of health care facility, duration of work and work experience with respect to hazards.The questionnaire comprised four more sections that addressed ergonomic, biological, physical and psychosocial hazards respectively commonly faced by HCW in the work environment.Moreover, questions on awareness of workers regarding occupational hazards and safety practices as well as control measures in place by the employers to mitigate the potential hazards in the HCFs, were also asked.The survey did not address pre-existing screening of musculoskeletal disorders.

Consent
In accordance with the guidelines for conducting such research, consent was obtained from the respondents prior to filling of questionnaire.Onsite surveys were conducted with the permission from the administration of each surveyed facility.

results
The results of the survey showed prevalence of various hazards among HCWs including ergonomic, biological, physical and psychosocial.According to the demographic data (Table 1), majority of the HCWs were females (72.5%).Respondents comprised majorly nurses (37.5%) and doctors (32.5%).Fifty-seven percent respondents belonged to government while 43.0 % were employed in private sector HCFs.Most of the workers (54.5%) had work experience of fewer than 5 years.The range of working hours varied from 6-10 hours, seven days a week.A number of respondents (43.5%) also worked overtime and 36.5% were doing job in multiple health care facilities.Generally, characteristics such as working overtime, work in multiple facilities or in multiple shifts is reportedly associated with higher risks of injuries and susceptibility to ergonomic hazards 18,22 .A study conducted among registered nurses and care aides working at full time and part-time work showed that those involved in full time work shifts had higher risks of work related injuries and fractures than those working on a part time basis 23 .Several risk factors such as heavy and prolonged physical activity, increased stress and work demand as well as high body mass index (BMI) are also linked with work related MSDs among workers 17,19 .
In the present study, biological hazards reported included experience of cuts/wounds/ lacerations (69.0%), direct contact with specimens (56.0%), and experience of airborne diseases (64.0%) and other infections (72.0%).Although majority of the workers (90.0%) were aware of procedures where needle stick injuries are most likely to occur and were knowledgeable on occupational infections and most likely sources of occupational infection as well of the fact that occupational cross infection after clinical procedure could be prevented by effective hand washing (89.5%).Other studies also support exposure to biological hazards such as injuries due to needles and cuts, direct contact with infectious materials and cuts/wounds due to needles and sharp objects among HCWs despite having received training in handling sharp objects and infectious material 24,25 .
As regards protective measures, majority of the respondents had received different kinds of vaccinations including BCG, Hepatitis A and B vaccinations as well as HIV screening examination.All the facilities had proper control measures to mitigate and reduce the prevalence of biological hazards (Table 5).These included training on the proper use of machinery and equipment, universal precautions and hand washing, provision of safety education, safety tools, a set of personal protective equipment and a separate area for the disposal of medical waste.
With respect to physical hazards, slips/trips/falls (65.0%), high noise levels (64.0%) chemical spills (54.0%) and exposure to x-rays (51.5%) was the most prevalent risks experienced by workers.A study conducted among Zambian HCWs also found exposure to high noise levels, skin contact with chemicals and pesticides as important issues 23 .
The present study also shows workers coming across psychosocial hazards including work related stress (77.0%) and some form of psychosocial or physical abuse (68.5%).Work related stress can be associated with factors such as working overtime, work in multiple health facilities, assault from coworkers and some forms of psychosocial hazards.The prevalence of psychosocial and physical abuse is a reflection of poor work ethics and work control in these health facilities.A study conducted among the HCWs of southern India indicated the prevalence of psychosocial hazards in the form of lack of promotions, non-availability of amenities; high workload and poor grievance report and address system 11 .
The survey showed that majority (85.5%) of the workers was aware of occupational hazards and their categories as most of the surveyed respondents comprised doctors and registered nurses.Major sources of knowledge and awareness were postemployment workshops (44.5%), professional workshops (32.5%) and post-employment learning in ward (15.5%).

Conclusion
The chronic back pain, neck/wrist/ shoulder pain, fracture/body injury, problems in body posture, stretching of muscles.Bivariate correlation was determined.The applied tests were ANOVA one-way and Pearson's chi-square test.

Table 2
summarizes reported OH&S problems faced by HCW.Ergonomic hazards included muscle aches/ muscle sprains, carpel tunnel syndrome, chronic back pain, elbow/wrist/ hamstring/neck pain, problem of body posture, excessive stretching of muscles, bending/ twisting as well as lifting heavy loads multiple times at work.Biological hazards included experience of cuts/wounds/lacerations, airborne infections, body contact with retroviral patients and specimens, and exposure to blood borne specimens.Physical hazards included trips/falls, exposure to x-rays, high noise level and chemical spills, and experience of skin burn.Psychosocial hazards