Occupational Health Research

HITS Study (Health In Hand-Intensive Tasks and Safety)

Musculoskeletal Injury as “part of the job” Prevalence, risk factors and the importance of self-care education in hand intensive occupations in healthcare workers in Ireland.

The extent and determinants of work-related musculoskeletal disorders (WRMSDs) have been extensively researched in several occupations, however, there is little known about work-related upper limb disorders (WRULDs) in hand-intensive care occupations and healthcare workers, especially those conducting hand intensive tasks such as physiotherapists, physical therapists and sports therapists. Examples of common WRULDs are repetitive strain injury, ‘tennis elbow’ or  neck injuries.   The scarce research evidence mainly derived from American and Canadian studies suggest that there is a perception among workers performing hand intensive, repetitive tasks that injury is “part of the job”, often leading to premature retirement and career change.

The HITS study is funded by the Institution of Occupational Safety and Health (IOSH, UK) and led by Dr. Birgit Greiner (Principal Investigator) with research assistance provided by Ms. Sheilah Nolan (Study Director and PhD Student), Ms. Dervla Hogan (HITS Research Assistant and PhD Student), Ms. Denise Baker (Research Support) and Ms. Colette Cunningham (Solas Consulting).

The aim of the study is to create a reliable scientific evidence base to inform occupational health and safety strategies for effective prevention  of work-related musculoskeletal disorders (WRMSDs) in hand-intensive occupations with specific focus on health care occupations

The study objectives are:

  • To provide representative prevalence estimates of WRULDs among healthcare professionals performing hand-intensive tasks such as physiotherapists, physical therapists and sports therapists.

  • To investigate potential determinants of WRULDs in the workplace including physical/ergonomic and organisational / psychosocial workplace factors and their synergistic effects.

  • To compare health professionals with different levels of training and practice in self care of personal safety with regards WRULDs and WRULDs.

  • To assess the attitude and practice of reporting WRMSDs and determine barriers that inhibit or encourage reporting.

  • To assess levels and patterns of absenteeism and presenteeism in relation to WRMSDs and WRULDs, in a representative sample of employed physiotherapists, in physiotherapy departments of Irish hospitals.

The first stage of the study included - a systematic review of international models of good practice and codes of practice in relation to preventing upper limb musculoskeletal injury in hand-intensive occupations in healthcare. This systematic review was completed on the recognition that there is little guidance in this area. The completed review provides a resource document for Health and Safety practitioners who are looking for guidance and specific risk assessment tools for the analysis of hand-intensive tasks or upper limb disorders. The review also provides distilled criteria for the prevention of upper limb disorders in hand intensive healthcare workers that can be used for developing comprehensive guideline documents for other occupations where much still need to be done in translating the general principles for prevention of upper limb disorders.

The second stage of the study consisted of a survey with a representative sample of physical therapists and sports therapists in Ireland to determine their prevalence of WRULDs and occupational risk factors.  The findings of the study suggest that physical therapists and sports therapists are at risk of symptoms of upper limb disorders within the first five years following graduation, with multi site injuries experienced by over 40% of therapists. In relation to work risk factors, high work tempo and high quantitative demands emerged as significant risk factors. Psychosocial work resources, namely, influence at work, predictability of work and social support, input into scheduling and rest breaks were also investigated with a view to providing an orientation for the development of models of good practice to prevent upper limb disorders. It was positive to note that many therapists actively engaged in self care maintenance and how to minimise strain on their bodies, some of these strategies may in the future, provide models of good practice for effective injury prevention training.

The research team is currently investigating the prevalence of upper limb musculoskeletal injury and occupational risk factors in a representative sample of over 600 employed and self-employed physiotherapists in Ireland from various work settings including hospitals (public and private), rehabilitation centres, hospices, community services and civic society groups.

A longitudinal study on physiotherapy, physical therapy and sports therapy graduates 2011 is underway concurrently, with follow –up of graduates approximately 6-8 months after entry into employment. The aim of this study is to examine changes in their musculoskeletal health after taking up employment. 

Final conclusions on the prevalence of upper limb musculoskeletal injury and occupational risk factors  in physical therapists, sports therapists and physiotherapists; the development of realistic strategies and suitable assessment tools specific to hand intensive occupations; the importance of early detection and surveillance of WRULDs in those performing hand intensive tasks and the development of a Health and Safety Self Care Training programme for healthcare workers performing hand intensive tasks  will be drawn after completion of study.

The smoking ban in work places has been one of the major public health interventions in Ireland in the past years that gained international attention. Tobacco control remains one of the major research foci of the Department of Epidemiology and Public Health. Researchers examine the sustained effect of the ban on health, smoking behaviour and ‘smoking careers’ as well as smoking risk perceptions among Bar workers, General Practitioners and the General Population. The project is funded by the Health Research Board and led by Dr Birgit Greiner (Principal Investigator) with colleagues Ms Bernie Mullally and Ms Sarah Meaney. Ms Mullally, who is currently pursuing a PhD, led the third phase of the Bar Workers Study with the help of research assistants Ms Sarah Meaney and Ms Nicola Gwillym. They continue to document the health impact of the legislative ban two years after its introduction. The findings concerning the impact of the ban on respiratory health and smoking behaviour of bar workers are of international interest as policy makers in several European countries have considered the introduction of a legislative smoking ban. Future work within this project will use qualitative interviews with bar workers and others to learn more about the ‘smoking careers’ in the context of the smoking ban.

The research team is also investigating whether the general population has become more aware of the health risks associated with active and passive smoking over the past few years. Ms Mullally recently coordinated a survey conducted by TNS/MRBI among a nationally representative sample of the general population (n=1,000). The results on risk perception of smoking in this sample will be compared with results of a similar survey among the general population conducted in 1999 (Power et al., 2004) to determine changes in risk perception over time. Questions include class and sex differences in risk perception of smoking in relation to other risks (e.g. road traffic accidents).

Data collection on a follow-up sample of 131 General Practitioners from the Cork and Kerry region was co-ordinated by Ms Sarah Meaney. Ms Meaney and Ms Mullally were supported in this data collection by Ms Nicola Gwillym, Ms Shabana Khalid and Ms Eilish Dolan. Data was previously collected in 1999 by Professor Ivan Perry and colleagues (Power et al.,2004) and this data will serve as an expert groups opinion for comparisons with the general population. In addition to this repeated sample researchers also recruited an additional sample of 117 newly qualified General Practitioners. These were recruited in order to account for changes in age and sex distributions throughout general practice since 1999.

It can be assumed that the general public and especially general practitioners are aware of most but not of all health risks associated with smoking and passive smoking. An insight into smoking risk perceptions may provide valuable information for smoking cessation advice in the future and inform public health practice to ensure that risks of smoking are cogently and accurately communicated to all sectors in society. Furthermore the results will help public health policy makers understand the consequences of this tobacco control measure on existing health inequalities. Currently Ms Meaney is comparing the accuracy of both general practitioners’ and the general population’s risk perceptions of smoking by making a direct comparison between the outcomes on both smokers’ and non-smokers’ health.

Dr Birgit Greiner investigates specific systematic prevalence and consumption changes in the general population before and after implementation of the ban. She is using data of a monthly phone survey with data collected under the auspices of the Office of Tobacco Control. Research results were presented at national and international conferences such as the World Tobacco Conference in Washington, the European Tobacco or Health Conference in Basel, the Asian Pacific Conference on Tobacco or Health in Taipei and the Society for Social Medicine UK & Ireland.

Acknowledgements: The researchers thank Ms Nicola Gwillym, Ms Shabana Khalid and Ms Eilish Dolan for their help with interviews. They especially thank the bar staff and General Practitioners who participated in the interviews. For further information on this research contact Dr Birgit Greiner, Email: b.greiner@ucc.ie

Dr Birgit Greiner and Ms Vera Mc Carthy are collaborating with Dr Ellen Rosskam, Visiting Professor, University of Massachusetts, Lowell, Work Environment Department, USA and Dr Stephen L. Smith Brunel University School of Business, London, UK,  and the International Transport Workers’ Federation in London on a research project on stress and fatigue in airline workers.

The area of Occupational Health has been a research field in expansion within the Department of Epidemiology and Public Health in UCC.

A few research projects have been completed in the past and many more are being developed exploring diverse aspects of health and wellbeing at work:

Work-related musculoskeletal disorders in Hand Intensive Healthcare Occupations

by Dervla Hogan (PhD candidate)

H&S Officer’s Role, Safety Climate and H&S Performance - an International Study

by Sara Leitão (PhD candidate)

An Ageing Workforce:  Unlocking the Issues in the Winter of our Lives

by Vera Mc Carthy (Research assistant and PhD candidate)

Work-related musculoskeletal disorders in Hand Intensive Healthcare Occupations 

by Dervla Hogan (PhD candidate)

Dervla’s PhD is in the area of Occupational Health and focuses on work-related musculoskeletal disorders (WRMSDs) in Hand Intensive Healthcare Occupations. The data been used for this PhD comes from the HITS Study which was funded by the Institution of Occupational Safety & Health (IOSH). 

The main rationale for this research is the high prevalence of work-related musculoskeletal disorders (WRMSDs). 24.7% of European workers reported that the work they do affects their health by the development of backache, with 22.8% reporting muscular pains which they felt were caused by work. The associated figures within the health and social work sector were higher than the overall figures with 26.3% reporting backache and 24.3% reporting muscular pains associated with work tasks.

Whilst much research has been completed in relation to the prevention and/or reduction of WRMSDs in health care workers, previous research has primarily related to back injury and discomfort due to patient handling and/or manual handling tasks and focused solely on employed health care workers. This research broadens this investigation further than just employed health care workers by including self employed health care workers. Research including self employed workers is sparse. The main focus of previous research including self employed workers as been the link between different psychosocial risk factors and general health of the employed versus the self employed worker.

The health care workers in this research are chartered physiotherapists, physical therapists and athletic therapists in Ireland. Previous international research on physiotherapists and physical therapists has only included employed therapists and primarily investigated the impact of physical risk factors and not psychosocial risk factors. 

Therefore, the overarching aim of this research is to develop a scientific evidence base to assist in the prevention of work-related musculoskeletal disorders (WRMSDs) by investigating the effectiveness of current risk reduction strategies and the synergistic effects of potential determinants of WRMSDs in both employed and self employed health care workers, specifically chartered physiotherapists, physical therapists and athletic therapists. 

H&S Officer’s Role, Safety Climate and H&S Performance - an International Study

by Sara Leitao (PhD candidate)

This project argues that the Health and Safety Officers (HSOs), as professionals, suffer from diverse pressures and demands that have an impact on their Health and wellbeing prompted essentially by the lack of a defined role and/or status.

It is, generally, acknowledged that work plays a pivotal role in the maintenance of, not only physical health, but also psychological well-being. However, the frontline professionals in promoting such conditions – the Health and Safety Officers – are often not recognized for their role. In fact, this is still a job without a clear role definition across Europe or even, in some countries, at national level as it is the case in Ireland. 

Although the role of this professional is vaguely defined in different jurisdictions, it still lacks a specific job description that defines in detail his/her responsibilities, tasks and level of authority. Thus, to compare the different situations of Ireland, Portugal and UK, as it will carried out in the current study, becomes interesting.

Work environment and demands have changed with the progress in technology and modernity of organizations and, as required with this shift, Occupational Health and Safety (OHS) practice has added new issues of psychosocial hazards at work.

The HSOs have shown the ability to reshape and adapt to the new demands of this field readjusting their functions and responsibilities to the needs of workers and organizations. Such adaptations lead to an extension of the professional role and tasks raising new challenges in the job contributing to further confusion on the HSOs work and position as well as an undefined autonomy of this professional. As evidenced in previous research, the lack of structured role can result in unclear and high demands, role ambiguity and lack of control of the HSOs (with pressures from management and hostility from workers).

Finally, another aspect to be explored in this project will be Safety Climate. Research has shown that the Safety Climate within an organization (“Employees shared perceptions (…) on the true priority of Safety at work”) influences safety behaviour, performance and safety-related outcomes. One of the main hypotheses of this research is that safety climate has an impact on the H&S Officer’s job conditions and, ultimately, his wellbeing.

In sum, this project aims to increase recognition of the HSOs activity across EU and contribute to knowledge sharing across the countries, developing models of good practice.

An Ageing Workforce:  Unlocking the Issues in the Winter of our Lives

By Vera Mc Carthy (Research assistant and PhD candidate)

The burden of occupational related diseases and disabilities is a major public health issue.  This is compounded by our ageing population and ailing health care services.  Vera’s PhD work aims to highlight the working conditions of older workers in Ireland by investigating a link between their work life and their physiological and psychological well being. 

The data being used for this PhD work comes from three main sources, two cross-sectional studies and one case-control study.

Vera’s interest in examining work type and functional limitations/disability in older age resulted in the publication of a paper entitled “Has your work worked you too hard?  Physically demanding work and disability in a sample of the older Irish Population” in the Irish Journal of Medical Science (DOI 10.1007/s11845-012-0824-7 - http://www.ncbi.nlm.nih.gov/pubmed/22528252).  This work, carried out with colleagues in the Department of Epidemiology and Public Health, UCC looked at not only paid workers, but also unpaid workers (household labour).  The findings showed that physically demanding work was related to functional limitations and activities of daily living disability in older age. 

Psychosocial work characteristics are another area of Vera’s PhD work.  Along with colleagues in UCC she investigated job characteristics such as job strain, job demands and job control and their association with cardiovascular risk factors.  The data used for this part of her PhD work was from a case-control study.  This research looked at younger (<50 years ) and older (≥50 years) workers investigating the association between job strain and the occurrence of a coronary event.  This piece of work will soon be published.

The rest of Vera’s PhD work will focus on data from a large cross-sectional study which was carried out by the Department of Epidemiology and Public Health in 2010-2011 on 50+ year olds.

Musculoskeletal Injury as “Part of the Job" (2,223kB)Abstract

The purpose of this study was to determine the prevalence of work-related upper limb disorders (WRULDs) in hand-intensive health care occupations, specifically in Irish chartered physiotherapists, physical and athletics therapists and to identify work risk factors and best practice strategies for the prevention of WRULDs.


Two questionnaire studies were conducted: A cross-sectional study with 347 employed and self-employed therapists and a follow-up study with 74 students at baseline in their final year of training with follow-up 12 months after graduation (n=22) to investigate early career onset of WRULDs.


Musculoskeletal symptoms were high with 82.5% of experienced therapists reporting symptoms in at least one upper limb body part during the past year and a 25.7% annual prevalence of incapacitating symptoms. Upper limb symptoms to the shoulders, neck and thumbs accounted for most of the 12 month prevalence. Neck, shoulder and wrist symptoms accounted for most of the incapacitating symptoms. 37.5% reported at least one clinical diagnosis.

Work risk factors with significant associations to UL health included perceived physical effort during manual therapy, work organisation - specifically lack of sufficient breaks and input into scheduling, and psychosocial factors including social support, predictability of work and influence at work. Analyses accounted for demographics, physical work load, lifestyle factors and mental health. Therapists with injury prevention training and with risk assessments completed in their workplace had a lower rate of UL symptoms. One year incidence rate for new symptoms in graduates was 40% with 15 newly developed incidence cases, mainly in thumbs and neck.

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