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Analytic Hierarchy Process to Rate Risk Factors

Associated with WMSDs in General Physicians

Article in Journal of Health Management · May 2015

DOI: 10.1177/0972063415575813

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Article

Analytic Hierarchy Process to Rate Journal of Health Management

17(2) 241–247
Risk Factors Associated with WMSDs © 2015 Indian Institute of
Health Management Research
in General Physicians SAGE Publications
sagepub.in/home.nav
DOI: 10.1177/0972063415575813
http://jhm.sagepub.com

Sanjib Kumar Das1

Suman Mukhopadhyay1
Maddulety Koilakuntla2

Abstract
Work-related musculoskeletal disorders (WMSDs) is a generic term used to describe symptoms caused
or aggravated by work and characterized by discomfort, impairment, disability or persistent pain in
joints, muscles, tendons and other soft tissues with or without physical manifestations. Musculoskeletal
disorders are a major reason for the loss of work efficiency, which is related to type of occupation or
activity. Scientific studies have attributed several factors for the precipitation of WMSDs. In this article,
the identified risk factors for WMSDs in general physicians (GP) have been categorized into physical and
psychosocial factors and the article also views the analytic hierarchy process (AHP) as a tool to quantify
the physical and psychosocial risk factors that have been established as being associated with WMSDs
by assessing priority weights. Hence, the authors have attempted to use the factor weights through the
AHP analysis, based on the knowledge and experience of experts to act as a decision-support system
that would undoubtedly help the GP to increase the preventive strategies and proactively reduce the
contribution of risk factors for the precipitation of WMSDs successfully leading to its attenuation.

Keywords
Work-related musculoskeletal disorders (WMSDs), analytic hierarchy process (AHP), general physicians
(GP), psychosocial, physical risk factors

Introduction
The phrase ‘work-related musculoskeletal disorders’ (WMSDs) was first coined in 1971, in a report on
Australian telegraph operators (Tittiranonda et al. 1999). Therein, complaints were described as ‘occupa-
tional cramps’ or ‘occupational myalgias’. Previously labelled as repetitive motion disorders, cumulative

1
Ergonomics and Human factors Engineering, National Institute of Industrial Engineering (NITIE), Mumbai.
2
Operations Management, National Institute of Industrial Engineering (NITIE), Mumbai.

Corresponding author:
Sanjib Kumar Das, Doctoral Scholar, Ergonomics and Human factors Engineering, National Institute of Industrial Engineering
(NITIE), Mumbai 400 087, Maharashtra.
Email: sanjib_bpt@yahoo.co.in

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242 Journal of Health Management 17(2)

trauma disorders or overuse syndromes, WMSDs became a generic nomenclature associated with numer-
ous occupations (Abbas et al. 1998; Lincoln et al. 2000; Nordstrom et al. 1998; Tittiranonda et al. 1999),
and the incidence has been increasing (Abbas et al. 1998; Nordstrom et al. 1998). Generally, fatigue and
discomfort initiate the injury development process, and under certain conditions the symptoms persist, pos-
sibly resulting in damage to the musculoskeletal structures causing impairment and disability (Hagberg
et al. 1995).
Emerging reports have begun to show that musculoskeletal complaints are increasingly becoming
important occupational concerns for workers all over the world (Li et al. 2004). Studies have revealed
that the health-care professionals are vulnerable to musculoskeletal disorders during the course of their
work routine (Bork 1996; Russo et al. 2002; Szeto et al. 2009). Musculoskeletal complaints affect a wide
variety of workers in the health-care industry and appear to be a particularly imperative problem for
physicians (Smith et al. 2005, 2006). Physical workplace tasks of these practitioners include regular
walking from ward to ward, constant bending over the bed while physically examining patients (Smith
et al. 2006a, 2006b), prolonged sitting in outpatient clinics to meet the work demands, which may be
associated with considerable physical stress resulting in many complaints relating to the musculoskeletal
system (Long et al. 2011).
Prolonged posture, demands of the job, patients expectations, interruptions, practice administration,
work–home interface and social life, dealing with death and dying and medical responsibilities for
friends and relatives, all these precipitate in copious amounts of strain and stress among physicians
(Sutherland 1995). Since physicians are lifesavers, if they come under stress, their efficiency is reduced,
directly affecting the lives of a large number of people who they treat (Sharma 2005).
WMSDs require workers to generate low levels of muscle force and adopt awkward postures or static
postures for prolonged periods during the performance of their duties. Furthermore, individual and
psychosocial factors may also contribute to the development of WMSDs (Bongers et al. 1993; Hagberg
et al. 1995; National Research Council 2002; NIOSH 1997; Szeto et al. 2009). Few studies have attempted
to associate physical and psychosocial factors with WMSDs in medical practitioners. The physical and
psychosocial factors that have been established as being associated with WMSDs have been screened
after a rigorous review of the literature to fit as the risk factors for the precipitation of WMSDs in general
physicians (GP) for this article. The derived factors include prolonged static postures (Bernard 1997),
repetitive tasks (Bernard 1997), prolonged periods of exposure to a given task (Bernard 1997; MacDonald
2004), awkward posture (NIOSH 1997), job satisfaction (Bongers et al. 1993), time and work demands
(Bernard 1997; Bongers et al. 1993), organizational culture (Bongers et al. 1993) and occupation or
work-related stress (Devereux et al. 2002).
There may be various methods for multi-criteria decision-making such as data envelopment analysis,
analytic hierarchy process (AHP) and fuzzy technique (Koilakuntla et al. 2012), but in the present study
the authors have considered AHP as a tool to quantify the physical and psychosocial factor’s prioritiza-
tion that precipitates WMSDs in GP. Saaty (1994, 1996) developed AHP, which is helpful in complex
problems and is widely used as multi-criteria decision-making techniques well suited to decisions involv-
ing ranking and prioritizing alternatives, and in quantifying opinions, which are based on personal expe-
rience and knowledge, and to develop a consistent decision-making process as occurs in the medical and
health-care scenario (Kaplan & Shaw 2004; Liberatore & Nydick 2008). Both qualitative and quantita-
tive data can be analyzed efficiently through AHP (Cebeci & Ruan 2007). The overall aim of the present
study was to carry out a survey of expert views and analyze the set of responses in order to prioritize the
physical and psychosocial risk factors that have been established as being associated with WMSDs, so
as to develop a better understanding of the aetiology of precipitation of WMSDs in GP.

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Das, Mukhopadhyay and Koilakuntla 243

Research Methodology
The study involves collection of primary data and analysis and interpretation for meaningful conclusion.
In this study, the authors have considered the expert opinion method for pairwise comparison, for
computing weightages of eight selected physical and psychosocial risk factors, which are a part of
AHP (Table 1). The ‘Five Expert’ method envisages consultation with five experts of which three are
working in the government sector and the other two as private general practitioners. All the five
experts involved in the study had a minimum experience of 15 years in clinical practice. The author
only explained the procedure of pairwise comparison to the experts and acted as an observer during
the collection of data.
The weightages were computed with the help of the experts by comparing each pair of the factor and
ranking them on a scale by comparing factor (a) ‘i’ and ‘j’ (where i is assumed to be at least as important
as j), given a value aij as follows: factor i and j are of equal importance, factor i is weakly more important
than j, factor i is strongly more important than j, factor i is very strongly more important that j and factor
i is absolutely more important than j. The values of the scale are shown in Table 2.
Next, normalization has been done, that is, dividing each cell value of the column by the sums of
the columns, and average across rows to get the relative weights of each factor. This resulted in
Table 4.

Table 1. Physical and Psychosocial Factors that Have Been Established as Being Associated with WMSDs

Risk Factors Abbreviations

Prolonged static postures psp
Repetitive tasks rt
Prolonged exposure to a given task pet
Awkward posture ap
Job satisfaction js
Time and work demands twd
Organizational culture oc
Work related stress wrs
Source: Authors.

Table 2. Scale with the Values of aij

Factor i less important than j ½

Factor i and j are equally important 1
Factor i weakly more important than j 2
Factor i strongly more important than j 3
Factor i very strongly more important than j 4
Factor i absolutely more important than j 5
Source: Authors.

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244 Journal of Health Management 17(2)

Results and Discussion

After pairwise comparison (Table 3), normalization and calculations of weightages of physical and
psychosocial factors (Table 4), screened to fit as the risk factors for the precipitation of WMSDs in GP,
and results are derived in percentages. Amongst the physical factors, prolonged periods of exposure to a
given task showed the highest value (21.7254 per cent) followed by prolonged static postures
(21.0103 per cent), awkward posture (19.7015 per cent) and repetitive tasks (16.9902 per cent). Amongst
the psychosocial factors, time and work demands showed the fifth ranking with the value of
5.47881 per cent followed by organizational culture (5.21027 per cent), occupation or work-related
stress (4.97641 per cent) and job satisfaction with the lowest value (4.90707 per cent).
According to Rural Health Statistics in India (2011), the number of registered medical practitioners is
8,40,130. Despite this number of physicians, the doctor/population ratio now stands at a staggering
1:1,800 (Deo 2013). The shortage of physicians creates enormous work demands on the beleaguered
practitioners, who are already a potential high-risk group for WMSDs because of their occupational

Table 3. Pair-wise Comparison Values

psp rt ppe ap js t&w oc owrs

psp 1 2 1 1 4 3 3 4
rt 0.5 1 1 1 3 3 3 4
ppe 1 1 1 1 4 4 5 5
ap 1 1 1 1 4 4 3 4
js 0.25 0.33 0.25 0.25 1 1 0.5 1
t&w 0.33 0.33 0.25 0.25 1 1 1 1
oc 0.33 0.33 0.2 0.33 0.5 1 1 1
owrs 0.25 0.25 0.2 0.25 1 1 1 1
Column sum 4.66 6.24 4.9 5.08 18.5 18 17.5 21
Source: Authors.

Table 4. Normalization and Calculations of Weightages of Factors

100
psp rt ppe ap js t&w oc owrs Average Per Cent
psp 0.214592 0.32051 0.20408 0.19685 0.21622 0.16667 0.17143 0.19048 0.2101 21.0103
rt 0.107296 0.16026 0.20408 0.19685 0.16216 0.16667 0.17143 0.19048 0.1699 16.9902
ppe 0.214592 0.16026 0.20408 0.19685 0.21622 0.22222 0.28571 0.2381 0.21725 21.7254
ap 0.214592 0.16026 0.20408 0.19685 0.21622 0.22222 0.17143 0.19048 0.19702 19.7015
js 0.053648 0.05288 0.05102 0.04921 0.05405 0.05556 0.02857 0.04762 0.04907 4.90707
t&w 0.070815 0.05288 0.05102 0.04921 0.05405 0.05556 0.05714 0.04762 0.05479 5.47881
oc 0.070815 0.05288 0.04082 0.06496 0.02703 0.05556 0.05714 0.04762 0.0521 5.21027
owrs 0.053648 0.04006 0.04082 0.04921 0.05405 0.05556 0.05714 0.04762 0.04976 4.97641
Source: Authors.

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Das, Mukhopadhyay and Koilakuntla 245

demands which range from sitting continuously for hours in the outpatient department (Umehara et al.
2007), that is, which includes both ppe and psp, rated as the primary risk factors in our results. Maintaining
awkward static postures, cramped positions for prolonged periods, long working hours coupled with
heavy workload (Morse et al. 2010) relevant to ap that follows the primary risk factors in our hierarchi-
cal findings. Other than these physical risk factors, other potential contributing risk factors for the devel-
opment of WMSDs are psychosocial factors such as time pressure, high work load, high responsibility,
poor social support from colleagues and superiors, little autonomy, high perceived work stress and low
job satisfaction (Bongers et al. 1993) that are identical to the factors of our study that has been rated in
the following hierarchical pattern: t&w, oc, owrs and js.
The judgments that have been supported by Five Expert Choice in this article allowed reliable com-
parison in evaluating the physical and psychosocial risk factors and estimating the probabilities of occur-
rence of WMSDs in physicianss. The results here with the approach of the AHP model offered the
advantage of decomposing a complex system into a hierarchical structure, allowing lucid evaluation of
dangers that precipitate WMSDs in GPs. The possibility of managing these conflicting risk factors with
this decision-making process is anticipated to form realistic measures in preventing musculoskeletal
disorders in the near future.

Future Research Scope

Since musculoskeletal disorders are a major reason for the loss of work efficiency, future emphasis can
be given on recommending suitable remedial solutions for attenuation of the WMSDs in GP (Das and
Mukhopadhyay 2014). The study can also be repeated to quantify the risk factors for WMSDs in other
group of health-care professionals with an increased size of experts.
The study has some limitation such as the analysis relies on the output of a scientific tool AHP without
cross-validation due to time constraints. However, future studies may overcome this dilemma. More
factual data can be collected, incorporated and compared for validating the outcome of the study.

Ergonomic Implications and Conclusion

This article presents a novel risk factor-based approach using the AHP method and Expert Choice,
which is one of the superlative techniques for multi-criteria decision-making. This risk evaluation
would increase the effectiveness of preventive measures to be undertaken and a basis for further research
on contributing factors subsequently can be used in long-term follow-up studies as well as intervention
effectiveness studies. This article may help ergonomists and GPs to give better tools to set priorities in
the prevention of WMSDs and job redesign.

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