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Institute for Work & Health
Intervention & Intervention & Evaluation in a Evaluation in a Large Newspaper Large Newspaper
Presentation to Marconi Research
Conference at Marigold 2003
Intervention Research of Computer Use
September 13-14, 2003
By Richard P. Wells PhD andDonald C. Cole MD, MSc, FRCP(C)University of Waterloo and Institute for Work & Healthon behalf of…
STOPRSI !
Institute for Work & Health
PartnersPartners
Members of the RSI Committee:The Toronto Star: Dianne Forsyth, Dana Greenly, Jeff Hoffman,
Vivian Karnilavicius SONG: Sylvia Cowell, Ann Maguire, John Spears, Paul Willis
University of Waterloo: Dwayne Van Eerd, Richard Wells
York University: Melanie Banina, Anne Moore
The Orthopedic Therapy Clinic: Maureen Dwight, Pam Honeyman
IWH: Dorcas Beaton, Donald Cole, Sue Ferrier, Sheilah Hogg-Johnson, Carol Kennedy, Hyummi Lee, Michael Manno, Michael Polanyi, Harry Shannon, Peter Subrata, Michael Swift
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Key Findings:Key Findings:
1.1. Reduction in persons with severe/frequent painReduction in persons with severe/frequent pain2.2. RSI has been controlled but not resolved.RSI has been controlled but not resolved.
3.3. Ergonomic Policy and STOP RSI! Program Ergonomic Policy and STOP RSI! Program components are important responses.components are important responses.
4.4. Program participation by individuals associated with Program participation by individuals associated with reduction in risk factors and improvement of health reduction in risk factors and improvement of health outcomes.outcomes.
5.5. The RSI and Joint Health & Safety Committees have The RSI and Joint Health & Safety Committees have made a difference, but ongoing corporate support is made a difference, but ongoing corporate support is crucial.crucial.
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OutlineOutline
1. Nature, timeline and phases of collaborative research
2. Intervention areas and specific interventions
3. Evaluation framework
4. Exposure assessment
5. Outcomes
6. Key messages & directions
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Collaborative Research: Star-SONGCollaborative Research: Star-SONG
The Toronto Star - a large newspaper undergoing technological and organizational change.
Southern Ontario Newspaper Guild (SONG) – part of the Communication, Energy & Paper-workers union, long history of health & safety activism.
Two intertwined goals of better musculoskeletal health (particularly upper extremity WMSD) & improved business performance.
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Collaborative Research: ProcessCollaborative Research: Process
Joint development by workplace parties & research team, approved in collective bargaining, enshrined in ‘Ergonomic Policy’ and called ‘Stop RSI’ programme with goal of reduced WMSD burden.
Ongoing parallel, major moves with new equipment, work re-organization & team training, new software in different departments, attempts to contract out distribution, etc. with goal of improved business performance.
Institute for Work & Health
Overall Evaluation ProgramOverall Evaluation Program
““Teamed” GroupTeamed” Group
Status Quo Status Quo
Secondary Data LinkageSecondary Data Linkage
1996 C
ross-s
ection
al Su
rvey (Ph
ase 199
6 Cro
ss-sectio
nal S
urvey (P
hase
I)I) 1997 In
tens
ive S
tud
ies (Ph
ase II)
1997 In
tens
ive S
tud
ies (Ph
ase II)
Qualitative Documentation & AnalysisQualitative Documentation & Analysis
Workplace SurveillanceWorkplace Surveillance
Extensive Repeat ExposureExtensive Repeat ExposureMeasurement (subset of n=44)Measurement (subset of n=44)For physical ExposuresFor physical Exposures
20
01
Cro
ss-s
ectio
nal S
urv
ey
20
01
Cro
ss-s
ectio
nal S
urv
ey
1998
1998
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SurveysSurveys
1996: Cross-sectional Survey
(descriptive, analytic)
…provided workforce coverage
1997: Suite of Intensive Studies
(multiple methods including in-depth interviews, focus groups, surface EMG and additional questionnaire measures)
…deepened understanding2001: Cross-sectional Survey (individually linked)
(descriptive, analytic)
…measurement of change
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Evaluation Framework: (i)Evaluation Framework: (i)
Means Intermediate Outcomes Longer Term Outcomes
Strategies Activity Area Objectives Metric Objectives Metric
Policy Formulation of
Ergonomic
Policy
Employees/managers
aware of policy &
contents
Interviews Policy used to guide
actions
Document analysis
Human
Resources
Definition of
employer &
employeeresponsibilities
Each aware of theirresponsibilities
Interviews &
document review
Each fulfilling theirresponsibilities
Joint committees
Document review
Questionnaire
“Stop RSI”*
training
Entire office
workforce
has been part of
training
% trained by
department
Part of orientation
of new staff
Changes in
Knowledge
attitudes
& practices
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Evaluation FrameworkEvaluation Framework
Means Intermediate Outcomes Longer Term Outcomes
Strategies Activity Area Objectives Metric Objectives Metric
Human
Resources
Knowledge of
WMSD† risk
factors (incl.
work
organization &
physical)
Employees/ managers
aware of such factors
and attempting to deal with them
Interviews
Observations
during joint committees
Document review
Managers
incorporating
consideration of in
Work design &
operations decision
making
Interviews
Participation in joint
committees
Questionnaire
Team Work
Team training Consideration of work
organization and
physical WMSD risk
factors in training
Document review
Interviews
Ongoing training and
new team structures
incorporate WMSD
risk factor
considerations
Document review
Interviews
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Evaluation FrameworkEvaluation Framework
Means Intermediate Outcomes Longer Term Outcomes
Strategies Activity Area
Objectives Metric Objectives Metric
Team Work
Team formation
&
implementation
Multi-skilling
Increased variety
iImproved
productivity
Interviews
Number
of tasks & % time
Variation in
surface EMG
Improved: Synchronization of tasks, handling of deadlines & workflow
ditto
Equipment
and
Environ-ment
New spatial
layout of
workstation
Allow adequate space for work and improves
contact between team members
Observation
Interview
Workflow
improvement &
increased teamwork
Interviews
New adjustable
workstations
Improved ‘ergonomic
design’ of workstations
Workstation
dimensions,
Observational
data on
postures, EMG
Purchasing policies
revised
Interviews
Ergonomic
assessment data,
Questionnaire
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Evaluation FrameworkEvaluation Framework
Means Intermediate Outcomes Longer Term Outcomes
Strategies Activity Area
Objectives Metric Objectives Metric
Information
Systems
New software Improved workflows
& productivity
Interviews
Observations
Productivity data
in departments
New software designs
incorporate WMSD
considerations
Interviews with
system staff
Questionnaire
Productivity data in
departments
Human resource
(HR)
information
systems
Improve ongoing
surveillance of WMSD
risk factors (ergonomic
assessments) and
reporting
Data from
relevant HR data bases to joint
committees
Reduce overall risk
factors and severity of
WMSD
Decline in WMSD severity on injury
reports
Regular
ergonomic
assessments
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Assessment MethodsAssessment Methods
Methodologies include: Interviews Questionnaires and diaries Observation and video Measures of EMG, postures, dimensions Site administrative data Compensation system, health care system records
linkage
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Assessment: Workstations (1)Assessment: Workstations (1)
Wrist, neck and shoulder postures and dimensions of VDT location on workstation taken, EMG: Spring/Summer 1999 Winter 2000
(excluding circulation) Spring/Summer 2000
(41 participants)
45 Participants (31 female, 14 male) 45 Participants (31 female, 14 male) (40/41 new workstations, 3/41> 1 (40/41 new workstations, 3/41> 1 workstations, adjustable keyboard tray workstations, adjustable keyboard tray 36/41)36/41)
Did the installation Did the installation of new workstations of new workstations improve the postures improve the postures adopted?adopted?
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Assessment: Muscle Activity (i)Assessment: Muscle Activity (i)
How to assess muscle activity in a workplace setting?Muscle activity in a naturalistic setting is determined by: tasks
performed, workload, workstation, equipment, technique, task/time organization
Electromyographic signals bilaterally from:Extensor Carpi Ulnaris Brevis (ECRB),Trapezius, recorded using portable EMG system with simultaneous video recording
On/off states of 7 tasks identified while viewing video and simultaneously recorded on computer (Observer Pro 4.0, Noldus Technology, Netherlands): Keying, mousing, phone, deskwork, sitting/standing, at/away from desk, other.
Institute for Work & Health
Assessment: Muscle Activity (ii)Assessment: Muscle Activity (ii)
Two hours of work (on 2 days (am and pm) pre, during, and after interventions).
30 minute segment analysed; work at desk over-sampled 33 Participants: Newspaper advertising and finance employees,
Clerical, administration, sales, customer accounts and call centre,10 male/ 23 female
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Assessment: Muscle Activity(iii)Assessment: Muscle Activity(iii)
Extracting mousing task EMG from working EMG
0
10
20
30
40
50
0 1 2 3 4 5 6Time (min)
-10
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9 10Time (min)
EM
G (
% M
VC
)
Mousing On
0
10
20
30
40
50
0 1 2 3
Time (min)
Mousing Off
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Assessment: Muscle ActivityAssessment: Muscle Activity
0
5
10
15
20
R.ECRB R. Traps L. ECRB L. Traps
Gap
tim
e (s
ec/m
in)
Keyoff
Keyon
0
0.5
1
1.5
2
2.5
3
Rt ECRB Rt Traps Lt ECRB Lt Traps
Stat
ic E
MG
(%
MV
C)
keyoff
keyon
*
*
*
*
Low static is better
High gaps is better
Institute for Work & Health
Assessment: Muscle ActivityAssessment: Muscle Activity
0
1
2
3
4
5
Rt ECRB Rt Traps Lt ECRB Lt Traps
Stat
ic E
MG
(%
MV
C)
mouse off
mouse on
*
*
Institute for Work & Health
Assessment: Muscle ActivityAssessment: Muscle Activity
0
0.5
1
1.5
2
R.ECRB R. Traps L. ECRB L. Traps
Stat
ic E
MG
(% M
VC
)
Phoneoff
Phoneon
Holding Handset (in right hand)
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Intermediate OutcomesIntermediate Outcomes
Shorter term outcomes such as reductions in exposures, that are thought to precede improvements in longer term outcomes such as pain levels and lagging indicators such as injury or lost time from work…
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Process Indicators: EducationProcess Indicators: Education
1998 STOP RSI! training sessions in all departments – 58% reported on 2001 survey
RSI training as part of orientation – 11% of 2001 survey respondents
90% of 2001 survey respondents felt that The Toronto Star STOP RSI! program had completely to moderately “ensured that all employees are informed about RSI”
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Intermediate Outcomes: Education Intermediate Outcomes: Education
Perceived Cause 1996 Survey Respondents
2001 Survey Respondents
Poorly designed workstations 68% 78%
Working without breaks 40% 52%
Excessive workload 27% 40%
Lack of training 37% 23%
Awareness of Causes of RSIAwareness of Causes of RSI
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Process Indicators: Equipment/ WorkspaceProcess Indicators: Equipment/ Workspace
Input by RSI Committee during purchasing process
Over 2000 Ergonomic Reports/ Workstation Assessments completed by over 20 trained assessors (56% (459) of 2001 survey respondents)
Among a smaller group, the research team measured workstation dimensions and conducted postural assessments.
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Feedback InformationFeedback Information
Analyses of xxxxx when performing keyboarding tasks. Measure Sept 17/99 May 3/00 Preferred Range Interpretation
Head Tilt Angle 5 (up) 11 (up) 0-20 (down) Needs Improvement Gaze Angle 20 (down) 1 (down) 0-30 (down) Within Preferred Range Head Rotation 20 11 (right) 15 (left) - 15 (right) Within Preferred Range Glare Yes No No Within Preferred Range Right Shoulder Abduction 30 22 0-20 * Within Preferred Range* Left Shoulder Abduction 25 20 0-20 * Within Preferred Range Right Shoulder Flexion 30 22 0-20 * Within Preferred Range* Left Shoulder Flexion 30 20 0-20 * Within Preferred Range Inner Elbow Angle (right) 115 115 80 - 120 Within Preferred Range Inner Elbow Angle (left) 115 120 80 - 120 Within Preferred Range Supported Right Elbow No Yes Yes Within Preferred Range Supported Left Elbow Yes Yes Yes Within Preferred Range Supported Right Wrist No Yes Yes-when not typing Within Preferred Range Supported Left Wrist No Yes Yes-when not typing Within Preferred Range Right Wrist Extension 15 27 0-30 Within Preferred Range Left Wrist Extension 5 0 0-30 Within Preferred Range Rt Wrist Ulnar Deviation 15 6 0-20 (ulnar) Within Preferred Range Lt Wrist Ulnar Deviation 15 0 0-20 (ulnar) Within Preferred Range * - If arms are supported on armrests, shoulder flexion and abduction measures that exceed the preferred range represent minimal increases in risk of injury.
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Feedback ExampleFeedback Example
The figures below are a visual representation of your posture on the dates indicated, as well as a preferred posture when using the computer. The first figure is the view from the side, while the second figure is a top view. The black box represents your monitor position relative to your body. The contrasting color scheme in the figures is used so that the arms will stand out, not to indicate a potential location of risk.
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Feedback DiagramsFeedback Diagrams
The figures below are a visual representation of your posture on the dates indicated, as well as a preferred posture when using the computer. The first figure is the view from the side, while the second figure is a top view. The black box represents your monitor position relative to your body. The contrasting color scheme in the figures is used so that the arms will stand out, not to indicate a potential location of risk.
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Feedback DiagramsFeedback Diagrams
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Feedback DiagramsFeedback Diagrams
The figures below are a visual representation of your posture on the dates indicated, as well as a preferred posture when using the computer. The first figure is the view from the side, while the second figure is a top view. The black box represents your monitor position relative to your body. The contrasting color scheme in the figures is used so that the arms will stand out, not to indicate a potential location of risk.
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Intermediate Outcomes : Workstation Intermediate Outcomes : Workstation Dimension Change over TimeDimension Change over Time
Gaze Angle vs Monitor height
-20
0
20
40
60
80
0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0
Monitor Height (cm from floor)
Gaz
e A
ng
le (
deg
)
1999 w2000 S2000 S2001
Gaze Angle vs Monitor HeightGaze Angle vs Monitor Height
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Intermediate Outcomes : Workstation Intermediate Outcomes : Workstation Dimension Change over TimeDimension Change over Time
Mouse Location (fore/aft vs side/side)
-30
-20
-10
0
10
20
30
40
50
60
70
-60 -40 -20 0 20 40 60 80
Mouse side/side (cm from j key)
Mo
use
fo
re/a
ft (
cm f
rom
tab
le
edg
e)
1999 w2000 S2000 S2001
Mouse Position
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Intermediate OutcomesIntermediate Outcomes : Equipment/ : Equipment/ Workspace (ii)Workspace (ii)
Piece of Equipment
1996 Survey Respondents
2001 Survey Respondents
Keyboard 56% 72%
Mouse 17% 61%
Monitor/Screen 72% 71%
Proportion Proportion insideinside preferred location (from questionnaire) preferred location (from questionnaire)
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Intermediate Outcomes : Change in Working Intermediate Outcomes : Change in Working Postures over Time Postures over Time
MeasureMeasure Preferred Preferred RangeRange
Summer Summer 19991999
Winter Winter 20002000
Summer Summer 20002000
Right Shoulder Right Shoulder Abduction (°)Abduction (°)
0-200-20 * * 5757 6666 3636
Left Shoulder Left Shoulder Abduction (°)Abduction (°)
0-200-20 * * 6767 7474 4545
Right Shoulder Right Shoulder Flexion (°)Flexion (°)
0-200-20 * * 4747 4747 6060
Left Shoulder Left Shoulder Flexion (°)Flexion (°)
0-200-20 * * 4545 5050 6262
Supported Right Supported Right (%)(%)
Yes**Yes** 4141 7979 6868
Supported Left (%)Supported Left (%) Yes**Yes** 3939 8787 7979
* If arms are supported on armrests, shoulder flexion and abduction measures that exceed the preferred range represent minimal increases in risk of injury.
** Wrist Support optimum when not typing
Shoulder Posture; Percentage within Preferred RangeShoulder Posture; Percentage within Preferred Range
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Intermediate Outcomes : Summary of Intermediate Outcomes : Summary of Equipment/ Workspace/Work Postures Equipment/ Workspace/Work Postures
Detailed dimension and posture measures From 1999 to 2001, changes among group of
employees (mostly Advertising):
reduced extreme mouse positions (horizontal and vertical)
monitor heights higher but fewer extreme head tilts
fewer monitors displaced to the side and less head rotation
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Intermediate Outcomes: Intermediate Outcomes: Job Changes (i)Job Changes (i)
Over past 3 years among 2001 respondents Different job title/description (32%)
Different tasks in same job (37%)
Broader job scope (29%)
Increased job responsibility (47%)
Changes in immediate supervisor (42%) or co-workers (45%)
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Intermediate Outcomes: Intermediate Outcomes: Job Changes (ii)Job Changes (ii)
Increased use of computer (27%) and addition of mouse (36%)
Among users, increased mean hours of use of keyboard (extra 40 min.) and mouse (extra 56 min.) between 1996 & 2001
Time sitting >2 hours continuously, increased by 9% to 33% of 2001 respondents
Both keyboard use and time sitting were RSI risk factors in 1996
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Longer Term OutcomesLonger Term Outcomes
Among the entire workforce period prevalence of more severe pain (NIOSH case) decreased; 205/1007 or 20% in 1996 127/813 or 16% in 2001 difference p<0.01
NIOSH case: those who have experienced moderate or severe pain and discomfort either once per month or longer than a week over the past year and had no trauma to the area.
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Longer Term Outcomes: Symptom Level Longer Term Outcomes: Symptom Level Transitions in 1996-2001 CohortTransitions in 1996-2001 Cohort
From:1996 Symptom
Level
To: 2001 Symptom Level
1 2 3 Totals
non-case (1)Stable97 (23.0%)
Incident53 (12.6%)
Incident13 (3.1%)
163(38.6%)
mild (2)Resolved42 (10.0%)
Ongoing93 (22.0%)
Worsened21 (5.0%)
156(37.0%)
more severe or frequent (3)
Resolved12 (2.8%)
Improved54 (12.8%)
Chronic37 ( 8.8%)
103(24.4%)
Totals151
(35.8%) 200 (47.4%) 71 (16.8%) 422 (100%)
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Longer Term Outcomes: Changes in Longer Term Outcomes: Changes in RSI 1996-2001(ii)RSI 1996-2001(ii)
Fewer wrist/hand (- 6%), more shoulder (+7%) and neck (+12%)
Majority in 2001 aggravated by work
(yes, 57%; to some extent, 34%)
Persistent problems with work function: Work-DASH (Disability of Arm, Shoulder & Hand) 1996 mean 6.3/100, SD 14.9; 2001 mean7.8, SD15.3 (no significant difference)
Among those with painAmong those with pain
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Longer Term Outcomes: Trends in Musculoskeletal Longer Term Outcomes: Trends in Musculoskeletal Related Drug CostsRelated Drug Costs
05000
1000015000
200002500030000350004000045000
Cost
s/Qua
rter
All Kinds NSAIDS OPIATE AGONISTS
Institute for Work & Health
Longer Term Outcomes: Analyzing linkages in Longer Term Outcomes: Analyzing linkages in 1996-2001 cohort1996-2001 cohort
Reported Program Participation:• Training• Workstation Asst. • New equipment
Reported WorkChanges:• Computer-related• Job-related
∆ Health Outcome:• Pain intensity (all)• Disability Work-DASH &QuickDASH
(sub-set)
∆ Potential Risk Factors:• Biomechanical• Psychosocial
∆ Potential Risk Factors:• Biomechanical• Psychosocial
Confounders/ Effect Modifiers(age, seniority, gender) accounted for
Confounders/ Effect Modifiers(age, seniority, gender) accounted for
(n=433)(n=433)
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Longer Term Outcomes : Predictors of changes Longer Term Outcomes : Predictors of changes in risk factorsin risk factors
Of biomechanical risk factors multiple kinds of new equipment with likelihood
of worse telephone setup (p=0.005) broader responsibility & scope in job with
physical effort (p=0.098) Of psychosocial risk factors
having a workstation assessment (p=0.062), participation in Stop RSI training (p=0.007), & broader responsibility & scope in job (p=0.032) with decision latitude
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Longer Term Outcomes : Predictors of changes Longer Term Outcomes : Predictors of changes in health outcomesin health outcomes
In pain intensity supervisor awareness & concern associated with pain
(p=0.161) keyboard time with pain (p=0.125)
In upper extremity related disability management support for RSI (p=0.006) & frequency
of workers taking part in decisions (p=0.082) with disability (QuickDASH)
physical effort (p=0.119) & decision latitude (p=0.121) with work disability (Work-DASH)
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Longer Term Outcomes: Longer Term Outcomes: 2001 Survey Respondents’ Assessment2001 Survey Respondents’ Assessment
The STOP RSI! program “promoted continuous improvement in the technology and management practices to control exposure to workplace risk factors that can cause RSI” - 85% completely to moderately agreed
Toronto Star management were supportive in dealing with RSI - 74% agree or strongly agree (vs. 64% in 1996)
Immediate supervisor was aware and concerned - 57% (unchanged from 1996)
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Future Directions: 2001 Survey Future Directions: 2001 Survey Respondents’ Suggestions Respondents’ Suggestions Equipment:
mouse wrist rests and longer cords monitors should be placed at an appropriate distance
and height, adjustable to height of person Workspaces:
all workstations should be assessed/set up for each new employee during 1st week at work and regularly thereafter
working at workstation other than one's own usually uncomfortable - cannot adjust
Social Supports: awareness sessions with [RSI] “victims” for immediate supervisors
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Future Directions: Ongoing Tensions Future Directions: Ongoing Tensions Relevant to RSIRelevant to RSI Proportion of respondents who disagree that
“I can take breaks when I want to” unchanged from 1997 to 2001 (28%)
“…productivity is really important here. You have to be always available on your phone. And all their incentives …[are] based on how much you’re producing.” - manager
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Ongoing Workplace Directions:Ongoing Workplace Directions:
RSI/JH&S committees are continuing training, ergonomic assessments, purchasing guidelines and therapy initiatives
Struggling with: strengthening management practices supportive of
dealing with RSI, particularly at the supervisory level need to persuade organizational leaders to move
“upstream” to influence decisions on new technology, organization of work and design of jobs, as per Ergonomic Policy
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Key Findings:Key Findings:
1.1. Reduction in persons with severe/frequent painReduction in persons with severe/frequent pain2.2. RSI has been controlled but not resolved.RSI has been controlled but not resolved.
3.3. Ergonomic Policy and STOP RSI! Program Ergonomic Policy and STOP RSI! Program components are important responses.components are important responses.
4.4. Program participation by individuals associated with Program participation by individuals associated with reduction in risk factors and improvement of health reduction in risk factors and improvement of health outcomes.outcomes.
5.5. The RSI and Joint Health & Safety Committees have The RSI and Joint Health & Safety Committees have made a difference, but ongoing corporate support is made a difference, but ongoing corporate support is crucial.crucial.
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Ongoing Research:Ongoing Research:
Changes in exposure Company surveillance review Path modeling for changes in cohort Integrating the quantitative and qualitative
components
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Supported by: Supported by:
NIOSH/NIH R010H03708-02 Centre for VDT & Health Research Toronto Star Southern Ontario Newspaper Guild IWH and indirectly, the Ontario WSIB