International Journal of Occupational Safety and

Ergonomics

ISSN: 1080-3548 (Print) 2376-9130 (Online) Journal homepage: https://www.tandfonline.com/loi/tose20

A low cost and efficient participatory ergonomic

intervention to reduce the burden of work-
related musculoskeletal diseases in an industrially
developing country: an experience report

João Marcos Bernardes, Carlos Ruiz-Frutos, Adriano Dias & Antônio Renato
Pereira Moro

To cite this article: João Marcos Bernardes, Carlos Ruiz-Frutos, Adriano Dias & Antônio Renato
Pereira Moro (2019): A low cost and efficient participatory ergonomic intervention to reduce
the burden of work-related musculoskeletal diseases in an industrially developing country:
an experience report, International Journal of Occupational Safety and Ergonomics, DOI:
10.1080/10803548.2019.1577045

To link to this article: https://doi.org/10.1080/10803548.2019.1577045

Accepted author version posted online: 07

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Publisher: Taylor & Francis & Central Institute for Labour Protection – National
Research Institute (CIOP-PIB)
Journal: International Journal of Occupational Safety and Ergonomics
DOI: 10.1080/10803548.2019.1577045

A low cost and efficient participatory ergonomic intervention to reduce

the burden of work-related musculoskeletal diseases in an industrially
developing country: an experience report

João Marcos Bernardesa*, Carlos Ruiz-Frutosb, Adriano Diasa, Antônio

Renato Pereira Moroc

a
Public Health Grade Program, Botucatu Medical School - São Paulo State University,
Botucatu, Brazil; bDepartment of Sociology, Social Work and Public Health,
Universidad de Huelva, Huelva, Spain; cDepartment of Physical Education, Federal
University of Santa Catarina, Florianópolis, Brazil.

*João Marcos Bernardes. Department of Public Health, Botucatu Medical School - São
Paulo State University. Prof. Mário Rubens Guimarães Montenegro Avenue, without
number. Botucatu, São Paulo, Brazil. ZIP Code: 18618-687. E-mail:
jmbernardes@fmb.unesp.br
A low cost and efficient participatory ergonomic intervention to reduce
the burden of work-related musculoskeletal diseases in an industrially
developing country: an experience report

Work-related musculoskeletal disorders (WMSDs) are the first cause of

occupational illness in Brazil and its notifications in the industrial sector has
increased progressively in the last six years. In order to prevent WMSDs,
workplace ergonomics interventions are frequently implemented worldwide. This
paper describes the implementation strategy of a participatory ergonomic
intervention conducted in the quality control department of a medium-sized
Brazilian garment company. The intervention was carried out based on the nine
steps presented by Vink, Imada and Zinck and workers’ exposure to risk factors
was investigated using the Rapid Upper Limb Assessment method. A low-tech
and low-cost solution that successfully reduced workers’ exposure to WMSDs’
risk factors was proposed, prototyped, tested and finally introduced. Participatory
ergonomic interventions can be a feasible and effective approach to reduce the
exposure to work related risk factors for WMSDs in industrially developing
countries.

Keywords: cumulative trauma disorders; ergonomics; participatory ergonomics;

developing countries; case reports.

1. Introduction
Work-related musculoskeletal disorders (WMSDs) represent a major public
health problem and economic burden to employers, workers and health insurance
systems [1]. Brazil has one of the highest rates of occupational diseases and
occupational accidents in Latin America, which are responsible for high social costs and
reduced productivity [2]. Data from the Brazilian government show not only that
WMSDs are the first cause of occupational illness in the country [3] but also that its
notifications in the industrial sector has increased progressively in the last six years [4].
In order to prevent WMSDs, workplace ergonomics interventions are frequently
implemented worldwide. In fact, the development of ergonomics in Brazil is closely
related to the Brazilian epidemic of WMSDs in the mid-1980s and early 1990s [5, 6].
However, the application of ergonomics principles differs between industrially
developing countries (IDCs), like Brazil, and industrially advanced countries [7]. The
importance of ergonomics application in IDCs as a way of improving working
conditions has been discussed in the scientific literature for most of the last four decades
[7-10]. But this discussion has not yet been translated into significant results since the
field is not well recognized, awareness regarding ergonomics’ application and its
benefits is still low in many IDCs, Brazil included [5, 11-13]. Thus, creating
ergonomics awareness should be one of the main aims of ergonomists who attempt to
improve working conditions in these countries [14, 15]. It has already been shown that
an increase in ergonomics awareness makes it possible for people to solve problems in
their work environment, which can lead to positive changes in the quality of working
life [15].
The use of participatory ergonomics interventions (PE) is one way to improve
ergonomics awareness [16-18], that has also been previously used to reduce physical
work demands and to prevent WMSDs in several studies, presenting promising results
[19-24].
PE is an increasingly utilized method of improving ergonomics aspects of work
and workplaces. It consists in the workers’ active involvement in the process to identify
risk factors in the workplace, and to select the most appropriate solutions for these risks,
supported by their supervisors and managers, in order to improve their working
conditions [25, 26]. It has been claimed that PE has some advantages compared to the
traditional ergonomics intervention, including enhanced intervention efficacy, added
problem solving capability (essential for effective assessment of the multifactorial risks
associated with WMSDs), better communication among workplace parties and better
acceptance of change by the workforce, as a result of their increased ownership of
workplace changes [21, 27].
Thanks to its characteristics, the participatory approach is cited as being the
most effective and sustainable approach in IDCs, particularly in small companies [28].
Therefore, the purpose of this paper is to present a participatory ergonomics
intervention, based on the nine steps presented by Vink, Iamada and Zinck [29],
developed in a Brazilian garment company and to evaluate the effects of this approach
in reducing exposure to work-related risk factors for WMSDs.

2. Methods

2.1. Setting
The intervention was conducted in the quality control department of a medium-
sized (290 employees) Brazilian garment company located in Blumenau, a 300,000
inhabitants town in the State of Santa Catarina, in the south region of Brazil.
At the time of the intervention there were eight employees working in the
quality control department, all women, with a median age of 36 years (range 18-56).
The median time as a quality control inspector was 15 years (range 1-34). Over the
previous six months, all eight workers had reported pain in the shoulder/neck region,
three of them had seen the company’s physician and were being treated with medication
and physical therapy and one of these three employees had to take a paid sick leave of
three months due to such symptom. Concerned about this situation and recognizing the
need for improvements, management brought in ergonomists to help in finding the
source of problems and possible solutions.

2.2. The participatory intervention

The intervention was carried out in a participatory way, based on the nine steps
presented by Vink, Imada and Zinck [29] with a few additions made by the
ergonomists, as described below.
2.2.1. Intervention planning (step 1)
The ergonomist and a representative from top management worked together to:
(1) define the aim of the intervention; (2) plan the intervention (based on the
participatory ergonomics framework – PEF [30]); and (3) form two working groups, as
suggested by Halpern and Dawson [31] and Koningsveld et al. [32].
The two working groups were named steering committee and ergonomics
analysis and design committee. The steering committee, would be responsible for:
providing attentiveness and support to the project; organizing time and resources needed
for the intervention; giving input and help the ergonomics analysis and design
committee to organize their activities; and acting as a go between from both committees
to upper management. The ergonomics analysis and design committee would be
responsible for identifying ergonomics inadequacies; designing and developing
solutions; implementing solutions; and evaluating solutions. While the role of the
ergonomist, as it has already been suggested [33], was firstly to initiate and then to
guide, face-to-face, the intervention process.
Workers’ involvement at this step was not possible, since they were not yet
present on the project.

2.2.2. Ergonomics training and workplace evaluation (step 2)

It was divided in two stages. First, the ergonomist trained the ergonomics
analysis and design committee’s members. This ergonomics training covered the
following topics: basic ergonomics principles; identification of workplace risk factors;
tools to perform ergonomics assessments; common practical solutions to ergonomic
problems and job redesign. The training took place over a period of 20 hours and
consisted of lectures and “hands-on” training, as proposed by Haims and Carayon [34]
and Henning et al. [35].
Secondly, the ergonomics analysis and design committee had a two weeks
period to: (1) understand and evaluate work conditions, activities and experienced
difficulties of the work situation in the quality control department; and (2) investigate
worker’s exposure to WMSDs risk factors.
Participative observation was undertaken to understand and evaluate working
conditions, activities, difficulties and their influence on worker's health. In the
participative observation, observers interacted with the workers observed to achieve a
better understanding of the work situation.
Workers’ exposure to risk factors was investigated using the Rapid Upper Limb
Assessment (RULA) method. It was decided to use this method because it was designed
to provide a rating of musculoskeletal load in tasks where workers may be exposed to
risk of neck and upper-limb disorders. Also, it is useful in comparing existing and
redesigned workstations and it may be used without the need for any equipment and,
after training in its use, it has been proved to be a quick, easy and reliable tool. It has
already been reported that even people untrained in ergonomics could accurately use
RULA method [36], that was applied through visual observation of the inspection task
by the ergonomics analysis and design committee’s members, the ergonomist only
interfered if the participants made a mistake. It should be highlighted that, participants
only used RULA after being trained in the use of this tool by the ergonomist.
At the end of this analysis, a document that summarized the results of this step
was written by the ergonomist.
From this step forward, all of the workers within the quality control department
were formally informed on the process and results of the intervention after each step. In
this manner, workers who were not part of the ergonomics analysis and design
committee were able to give input through the entire intervention.

2.2.3. Idea generation (step 3)

At the beginning of this step, the ergonomics analysis and design committee has
read the document written by the ergonomist at the end of the previous step. After that,
all participants (except the ergonomist) secretly voted on the most severe ergonomic
problem, according to frequency and severity, that should be prioritized for
improvement.
Next, the ergonomics analysis and design committee made an overview of
possible existing solutions to the problem previously prioritized. Subsequently, the
group held a brainstorming session, during which the committee’s members were
invited to propose, without restraint, improvements to the existing solutions and/or new
solutions to the problem. At the end of the brainstorming session, a document that
summarized the results of this step was written by the ergonomist.

2.2.4. Decision making (step 4)

The steering committee (after reading both documents previously written) and
the ergonomics analysis and design committee were discussed the
advantages/disadvantages of each ergonomics intervention previously proposed,
according to a criteria list considering: relative advantage, costs, compatibility and
complexity. Based on a consensus, the most appropriate ergonomics measure was
chosen.

2.2.5. Prototype manufacture (step 5) and prototype testing (step 6)

A prototype of the chosen ergonomics solution was manufactured and tested
during one week by an employee of the quality control department that was randomly
chosen between the non-participants of the ergonomics analysis and design committee.
After the testing period, this employee was asked to give feedback to the
ergonomics analysis and design committee. The feedback provided a concise
assessment of the intervention’s effectiveness. As proposed by Rosecrance and Cook
[19], this non-structured evaluation of the intervention consisted of the following
questions:

 Did the intervention reduce job-related discomfort, pain, or fatigue?

 Did the intervention make the task easier to perform?
 Did the change create any other problems at your workstation?

2.2.6. Solution adjusting (step 7) and solution implementation (step 8)

If necessary, the ergonomics solution would be adjusted based on the prototype
testing results and implemented into the actual workplace.

2.2.7. Intervention evaluation (step 9)

The ninth step took place 12 months after the last step to verify the effectiveness
of the intervention; therefore, the following data were compared: number of company’s
physician appointments and paid sick leaves due to musculoskeletal disorders in the
previous six months and in the twelve months following the introduction of the
ergonomics improvement.

3. Results

3.1. Intervention planning (step 1)

The aim of the intervention was defined as “to reduce the musculoskeletal
workload in the work process”.
Subsequently, the intervention’s design was planned based on the PEF. The PEF
describes the characteristics of a participatory process according to 9 dimensions, each
with two or more associated categories that define a feature of a PE initiative [30].
Table 1 describes all dimensions and respective categories of the PEF as it was applied
in this intervention.
It was also decided during the planning of the intervention that if multiple
ergonomics problems were found, each of these problems would be solved separately,
in other words, for each problem found the ergonomics intervention process would be
repeated until all problems were resolved. This decision was taken because the top
management representative was worried that, otherwise, the ergonomics intervention
would run the risk of taking too long to resolve all problems or it would waste time
solving minor problems, while the main problem was not addressed.
Finally, the two working groups were formed. The steering committee was the
first and its members were appointed by the top management representative. It was
composed by the representative from top management, one representative from the
human resources department, one representative from the health and safety department,
one representative from the finances department and the ergonomist. Following the
steering committee formation, all employees of the quality control department were
invited to a meeting where they were informed of the intervention and its objectives and
were encouraged to participate. The steering committee then directed the formation of
the ergonomics analysis and design committee, which included the department’s
supervisor, 3 employees from the quality control department, one representative from
the maintenance department and the ergonomist.

Table 1. Description of the participatory intervention using the Participatory

Ergonomics Framework
Dimension Categories
Permanence Temporary
Involvement Representative
Level of influence Department, work group
Decision-making Group consultation
Mix of participants Operators, supervisors, middle
management, internal and external
specialists, senior management
Requirements Voluntary
Focus Designing or specifying equipment or
tasks
Remit Problem identification, solution
 generation, solution evaluation, solution
implementation, process maintenance

3.2. Ergonomics training and workplace evaluation (step 2)

According to the work situation analysis the following problems were present at
the quality control department: sustained shoulder postures with greater than 60° of
flexion and abduction; prolonged standing and perceived lack of job control.
The awkward sustained shoulder postures were related to the use of an
apparatus, called inspection arch, to place garments while they were inspected.
These inspection arches, which had 80 cm of height, were attached to
workbenches (95 cm height, 50 cm width and 150 cm length), this workstation layout
(Figure 1) forced the static maintenance of shoulder postures with greater than 60° of
flexion and abduction throughout the entire inspection process (mean work cycle time
of 90 seconds).
Figure 1. Workstation before the intervention
To apply the RULA method the inspection task was divided in three actions:
garment placement in the inspection arch, garment inspection and garment removal
from the inspection arch. Two of these actions, garment placement and removal,
presented a score of 3, which, according to the RULA method, means that changes may
be required to these operations. The inspection action, however, presented a score of 6,
which means that changes to this operation are required soon.
Regarding the prolonged standing, workers had no chair or stool available and
had to stand during their entire work day (almost 9 hours). However, due to the
combined height of the workbenches and the inspection arches, even if chairs or stools
were made available, workers would not be able to use them while performing the
inspection task.
Finally, the work pace of 60 garment per 2 hours was externally defined (by
management), which resulted in the perceived lack of job control.

3.3. Idea generation (step 3)

The ergonomics analysis and design committee reached a unanimous decision
that the sustained shoulder postures with greater than 60° of flexion and abduction were
the most severe and frequent ergonomics problem in the quality control department and
should be the first problem addressed by the ergonomics intervention.
Subsequently, the ergonomics analysis and design committee held a
brainstorming session and the following solutions were proposed:

 Adopt an exercise program, including stretching and warm-ups, during

structured work-rest periods;
 Adopt electric adjustable height workbenches and attach inspection arches;
 Design and adopt inspection arches with adjustable height;
 Eliminate inspection arches and adopt manual adjustable height with angled top
workbenches.

3.4. Decision making (step 4)

During the meeting where the ergonomics solutions were discussed by the
steering committee and the ergonomics analysis and design committee. It was decided
that the inspection arches would be eliminated and manual adjustable height
workbenches with angled top would be adopted.

3.5. Prototype manufacture (step 5)

A prototype workbench was built in the maintenance department by the
company’s mechanic; it had a 15° angled top, height of 80 cm at the lower edge and 100
cm in the highest edge (with possibility of increasing both heights up to 15 cm), width
of 80 cm and length of 150 cm (Figure 2).
Figure 2. Workstation after the intervention

3.6. Prototype testing (step 6)

During the testing period it could be observed that worker’s posture during the
garment inspection process with the new workbench did not require the static
maintenance of inadequate shoulder postures any longer. Thus, the ergonomics analysis
and design committee applied the RULA method once more. The results showed that
the garment inspection action, which presented a score of 6 in the previous analysis,
now presented a score of 3 while the other two actions, garment placement in the
inspection arch and garment removal from the inspection arch, which presented a score
of 3 in the previous analysis, were now totally eliminated (Table 2).

Table 2. Results of the RULA method before and after the intervention
Action Before intervention After intervention
Garment inspection 6 3
Garment placement in the inspection arch 3 Action eliminated
Garment removal from the inspection arch 3 Action eliminated

Also, the feedback provided by the employee, when answering the three
questions made by the ergonomics analysis and design committee, during the interview
to evaluate the intervention was positive: the intervention reduced the symptoms of
shoulder/neck discomfort/pain; it made the inspection task easier; and it did not create
any problems.

3.7. Solution adjusting (step 7) and solution implementation (step 8)

In view of the results obtained in the last step, the ergonomics analysis and
design committee decided that there was no need to make any adjustments to the new
workbench and introduced it into the workplace.

3.8. Intervention evaluation (step 9)

Initially in this step the ergonomics analysis and design committee compared the
number of company’s physician appointments and paid sick leaves due to
musculoskeletal disorders in the previous six months and the twelve months following
the introduction of the ergonomics improvement, through the analysis of the records
from the company on-site medical clinic and the human resources department. The
analysis of this data showed that none of the quality control department workers had an
appointment with the company’s physician nor any of them took paid sick leaves due to
musculoskeletal disorders in the twelve months following the introduction of the new
workbenches.
Since the workers did not need to put and to remove the garments from the
inspection arches two times anymore (garments must be inspected on the right and
wrong sides), it was also decided to evaluate if the work cycle time had been reduced
with the introduction of the new workbenches. The results showed that the mean work
cycle time, which was of 90 seconds when using the inspection arches, had been
reduced to 50 seconds with the use of the new workbenches. Thus, since mean work
cycle time was reduced and there was no increase in the work pace, a situation was
created that enabled workers to take voluntary rest pauses or reduce the speed of work,
whenever they felt it was needed.
These results were presented to the steering committee, which approved the new
workbenches and agreed with the ergonomics analysis and design committee’s decision
that they did not need any further improvements.

4. Discussion
The work situation analysis before the ergonomic intervention revealed that the
most severe and frequent ergonomics problem in the quality control department was the
static maintenance of shoulder postures with greater than 60° of flexion and abduction
due to the use of an apparatus to place garments while they were inspected. Static work
and greater than 60° flexion and/or abduction of the shoulders are considered to be high
risk for the development or exacerbation of WMSDs; in fact there is epidemiologic
evidence for a relationship between repeated or sustained shoulder postures with greater
than 60° of flexion or abduction and shoulder WMSDs [37].
As a result of the ergonomics intervention, two actions performed by the
workers during the inspection task which required greater than 60° of shoulder flexion
and abduction (RULA score of 3) were totally eliminated. Another action, which
required this same awkward posture to be statically maintained (RULA score of 6) was
modified so that workers could perform it with the shoulders in a relaxed, neutral
posture. These results are consistent with previous studies, which have also shown that
PE interventions led to reductions in risk factors for WMSDs [20, 23].
The analysis of the records from the company on-site medical clinic and the
human resources department has also shown that none of the quality control department
workers had an appointment with the company’s physician nor any of them took paid
sick leaves due to musculoskeletal disorders in the nine months following the
introduction of the new workbenches. Instead, in the six months before the ergonomics
intervention three workers from the quality control department had seen the company’s
physician and were being treated with medication and physical therapy due to shoulder
and/or neck pain complains and one of these three employees had to take a paid sick
leave of three months due to such symptoms. These results support the conclusions of a
systematic review that there is partial to moderate evidence that PE interventions have a
positive impact on: musculoskeletal symptoms, reducing injuries and workers’
compensation claims, and reducing lost days from work or sickness absence [22].
In addition to these results, the mean work cycle time was reduced from 90 to 50
seconds with the implementation of the new workbenches. This finding is in accordance
with the results from various studies that demonstrated gains in productivity following a
PE intervention [38, 39].
The success of the intervention presented in this experience report may be
explained by the presence of the following elements: use of a stepwise approach; strong
management support; direct workers’ participation; establishment of a steering group
with responsibilities; conduct a broad analysis of the occupational tasks; check the
effects, including side effects, in an early stage; a positive cost-benefit ratio. All of these
factors have been suggested as being essential for the successful design of ergonomics
intervention projects [32].
Even though the risks as well as the solution presented in this paper might have
been quite obvious at first glance for any properly trained ergonomist, it has already
been suggested that early successes of PE interventions that address relatively simple
problems, which can be solved relatively quickly, can foster organizational learning,
what will empower the organization to solve more challenging issues later [35].
Methodologically this experience report has some drawbacks such as the limited
number of subjects and the lack of a randomized control group, which limit the
conclusions that can be drawn regarding the intervention’s impact on the reduction of
WMSDs’ symptoms. However, Roquelaure [40] points out that randomized controlled
multidimensional intervention trials are not always feasible in the occupational setting.
According to the author, often, only less rigorous interventions can be adapted to the
specific socioeconomic and psychosocial contexts of a company, particularly if the
implemented changes are to be sustained, which is exactly the case here. It should also
be highlighted that, since this is a case study, it describes the implementation of a
participatory ergonomics intervention and its results in a single Brazilian garment
company, thus it may only be suggestive of what would happen in similar
circumstances. Further researches would be needed to determine if our results can be
generalized to other companies.

5. Conclusions
This paper describes the implementation strategy of a participatory ergonomic
intervention and demonstrates how it was successful in: determining ergonomic
inadequacies; finding a solution that was judged to be feasible by all stakeholders
involved; and introducing this solution, that reduced workers exposure to
musculoskeletal’ risk factors, in a Brazilian garment company. As a result from this
intervention, a low-tech and low-cost solution that successfully reduced workers’
exposure to WMSDs’ risk factors was proposed, prototyped, tested and finally
introduced in the workplace. Thus, the experience report presented here extends the
literature on the efforts to reduce the burden of WMSDs in IDCs by demonstrating that
participatory ergonomic interventions can be a feasible and effective approach to reduce
the exposure to work related risk factors for WMSDs and increase the awareness of
workers and management to ergonomic issues.

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