Changes needed to reduce risk of musculoskeletal disorders.

Musculoskeletal disorders (MSDs) are the main contributor to disability levels, which are rising as populations age. Workplace hazard exposures are a major source of this problem, and current workplace risk management practices require substantial changes to tackle it more effectively. Most importantly, the current focus of risk management on "manual handling" tasks must broaden to encompass the whole job. This is necessary because a wide range of psychosocial hazards, most of which operate across the whole job rather than particular tasks, are significant contributors to risk. To ensure that risk-control actions are effective, a recurring risk management cycle that includes worker participation and addresses risk from both biomechanical and psychosocial hazards will be essential. Legislation that mandates workplace management of psychosocial hazards would be helpful. Amendment by regulatory bodies of MSD-related guidance and codes of practice so that they reflect current research evidence would also be helpful in communicating the need for change to workplace stakeholders.

Psychosocial hazards play a key role in differentiating MSD risk levels of workers in high-risk occupations.

OBJECTIVES: Workplace management practices targeting risk of musculoskeletal disorders (MSDs) fail to reflect evidence that risk is affected by psychosocial as well as physical hazards. To promote improved practices in occupations where MSD risk is highest, better information is needed on how psychosocial hazards, combined with physical hazards, affect risk of workers in these occupations. METHODS: Survey ratings of physical and psychosocial hazards by 2329 Australian workers in occupations with high MSD risk were subjected to Principal Components Analysis. Latent Profile Analysis of hazard factor scores identified different combinations of hazards to which latent subgroups of workers were typically exposed. Survey ratings of frequency and severity of musculoskeletal discomfort or pain (MSP) generated a pre-validated MSP score and its relationship with subgroup membership was analysed. Demographic variables associated with group membership were investigated using regression modelling and descriptive statistics. RESULTS: Analyses identified three physical and seven psychosocial hazard factors and three participant subgroups with differing hazard profiles. Profile group differences were greater for psychosocial than physical hazards, and MSP scores out of 60 ranged from 6.7 for the low hazard profile (29% of participants) to 17.5 for the high hazard profile (21%). Differences between occupations in hazard profiles were not large. CONCLUSIONS: Both physical and psychosocial hazards affect MSD risk of workers in high-risk occupations. In workplaces such as this large Australian sample where risk management has focused on physical hazards, actions targeting psychosocial hazards may now be the most effective way to reduce risk further.

The problem with "ergonomics injuries": What can ergonomists do?

Effects of psychosocial hazards on risk of musculoskeletal disorders (MSDs) are often very substantial, but workplace risk management practices focus largely on biomechanical hazards, as do the risk assessment methods used by ergonomists. Translation of research evidence into more effective workplace practices demands a more holistic risk management framework that encompasses both types of hazard. In this context, we evaluate the validity of different MSD risk assessment methods for different purposes, focusing particularly on requirements for routine workplace risk management. These include choice of fit-for-purpose assessment methods, prioritisation of hazards that are most affecting risk, and control actions as high as possible in the risk control hierarchy. Ergonomists could facilitate more effective workplace risk management by promoting: awareness of the need for change; improvements to guidance from OHS regulators; research on MSD-related workplace management issues; and professional development programs on this topic for ergonomists and other OHS practitioners.

Young drivers' perceptions of risk and difficulty: Day versus night.

Inexperienced drivers have a higher crash risk than others, particularly at night when drivers of all ages are at increased risk, but there has been little if any research on day-night differences in drivers' perceptions of risk and difficulty. Also, previous research on determinants of risk and difficulty ratings has focused largely on effects of vehicle speed, and researchers have identified a need to look more broadly at how ratings are affected by the complexity of depicted road-traffic situations. This study addressed those issues, using an exploratory approach entailing both quantitative and qualitative analyses. The 62 participants (28 females, 34 males) were grouped according to level of driving experience and age (16-30 years). Determinants of ratings were investigated using 6 day-night pairs of video clips at 6 different locations, plus 2 night-only clips at 2 other locations (14 clips in all). Depicted driving situations varied naturalistically in complexity as well as speed. They were presented in random orders twice to each participant, who used a slider to rate each clip continuously, once for risk and once for difficulty in balanced order. Consistent with previous evidence, there were no significant differences in ratings between participant groups. Ratings of risk and difficulty were highly correlated, as expected, but Rasch analysis confirmed that they reflected empirically different constructs. Ratings were significantly higher for night than day. They also differed significantly between locations, with vehicle speed not being their main determinant. Further, there were significant differences between locations in the relationship between risk and difficulty ratings, suggesting that participants' interpretations of 'risk' and 'difficulty' varied between locations. Qualitative analysis of rating patterns in relation to video clip content utilised constructs drawn from information theory and research on human information processing. It was concluded that more systematic research is required to investigate effects on ratings of variables determining the amount of information drivers must process, such as numbers and types of other road users and the predictability of their actions, road types and configurations, visibility conditions, particularly day versus night - as well as effects of vehicle speed which determines the required rate of processing.

Parent perceptions of participation in a parent-mediated communication-focussed intervention with their young child with autism spectrum disorder.

LAY ABSTRACT: Paediatric Autism Communication Therapy is an intervention for young children with autism spectrum disorder that focuses on parent-child communication. In Paediatric Autism Communication Therapy, the therapist and parent watch videos of the parent and child playing together. The therapist coaches the parent to carefully observe the child's communication and to interact with their child in a more sensitive and responsive way. Parents are encouraged to use the strategies with their child at home. Paediatric Autism Communication Therapy has been shown to lead to long-term improvements in parent-child communication and family quality of life. This study aimed to explore parents' perceptions of their participation in Paediatric Autism Communication Therapy. Interviews were carried out by an independent researcher with 18 parents. Parents discussed the learning processes they went through when working with Paediatric Autism Communication Therapy therapists and carrying out home practice. Some parents described initial doubts about the approach and hesitations about being videoed and analysing video material. In time, most parents came to really value the therapy and their relationship with the therapist. They reported positive changes in their interaction and relationship with their child and improvements to their child's communication and interaction. Some also highlighted poignant realisations and emotional challenges associated with taking part in this post-diagnosis therapy. Practical difficulties were also emphasised, including the time commitment, accessibility of therapy venues and difficulties in occupying the child during therapist-parent discussion. Implications for the clinical practice of parent-mediated interventions are discussed.

The APHIRM toolkit: an evidence-based system for workplace MSD risk management.

Musculoskeletal disorders (MSDs) continue as one of the largest occupational health and safety problems worldwide. One reason for this situation is that current workplace risk management practices fail to meet some important evidence-based requirements for effective reduction of MSD risk. In particular: they largely fail to address risk arising from psychosocial hazards; do not allow sufficient participation by workers; and often fail to control risk at its sources.To address these deficiencies, A Participative Hazard Identification and Risk Management (APHIRM) toolkit has been formulated in accordance with both a framework developed by the World Health Organisation and implementation science principles. It comprises a set of online tools that include automated data analysis and reporting modules, and procedures to guide users through the five stages of the conventional risk management cycle. Importantly, it assesses both hazard and risk levels for groups of people doing a particular job, focusing on the job overall rather than only on tasks deemed to be hazardous. Its intended users are workplace managers and consultants responsible for occupational health and safety, with active participation from workers also. Resultant risk control interventions are customized to address the main physical and psychosocial hazards identified for the target job, and repetitions of the risk management cycle enables ongoing evaluation of outcomes in terms of both hazard and risk levels.

Barriers to more effective prevention of work-related musculoskeletal and mental health disorders.

Work-related psychosocial hazards have substantial effects on risks of both musculoskeletal and mental health disorders (MSDs, MHDs). Recent Australian research on workplace risk management practices in 19 work organisations found that risks from work-related psychosocial hazards were poorly managed. This study identified factors impeding better management of MSD and MHD risks within those organisations. METHOD: Interviews were conducted with staff from residential aged care and logistics/transport organisations in Australia. Transcripts were analysed using a worker-centred systems framework. RESULTS AND CONCLUSIONS: Many barriers to more effective risk management were identified. Most fundamentally, few people knew of the need to manage MSD risk arising from work-related psychosocial hazards, and OHS-related skills of key managers were often reported as inadequate, particularly concerning management of risk from psychosocial hazards. Also, funding and staffing levels were often reported as problematic, and OHS issues were seen as lower priority than accreditation and commercial requirements.

The Autism Family Experience Questionnaire (AFEQ): An Ecologically-Valid, Parent-Nominated Measure of Family Experience, Quality of Life and Prioritised Outcomes for Early Intervention.

There is a lack of measures that reflect the intervention priorities of parents of children with autism spectrum disorder (ASD) and that assess the impact of interventions on family experience and quality of life. The Autism Family Experience Questionnaire (AFEQ) was developed through focus groups and online consultation with parents, and reflected parental priorities. It was then administered to the parents of children enrolled in the Pre-school Autism Communication Trial and its 6-year follow-up study. The AFEQ showed good convergent validity with well-established measures of child adaptive functioning, parental mental health and parental wellbeing. It was sensitive to change in response to a parent-mediated intervention for young children with autism, showing treatment effect at treatment endpoint which increased at six-year follow-up.

Driving Task: How Older Drivers' On-Road Driving Performance Relates to Abilities, Perceptions, and Restrictions.

This study examined a cohort of 227 older drivers and investigated the relationship between performance on the electronic Driver Observation Schedule (eDOS) driving task and: (1) driver characteristics; (2) functional abilities; (3) perceptions of driving comfort and abilities; and (4) self-reported driving restrictions. Participants (male: 70%; age: M = 81.53 years, SD = 3.37 years) completed a series of functional ability measures and scales on perceived driving comfort, abilities, and driving restrictions from the Year 2 Candrive/Ozcandrive assessment protocol, along with an eDOS driving task. Observations of participants' driving behaviours during the driving task were recorded for intersection negotiation, lane-changing, merging, low-speed maneuvers, and maneuver-free driving. eDOS driving task scores were high (M = 94.74; SD = 5.70) and significantly related to participants' perceived driving abilities, reported frequency of driving in challenging situations, and number of driving restrictions. Future analyses will explore potential changes in driving task scores over time.

Requirements for more effective prevention of work-related musculoskeletal disorders.

BACKGROUND: Exposures to occupational hazards substantially increase workers' risk of developing musculoskeletal disorders (MSDs) and can exacerbate pre-existing disorders. The effects on MSD risk of the physical requirements of work performance are well recognised, but there is now ample evidence that work-related psychosocial hazards can also have substantial effects; further, some hazards may be additive or interactive. This evidence is not reflected in current workplace risk management practices. DISCUSSION: Barriers to more effective workplace management of MSD risk include: the widespread belief that risk arises largely or entirely from physical hazard exposures; regulatory and guidance documents targeting MSDs, most of which reflect this belief; risk assessment tools that focus narrowly on subsets of mainly physical hazards and yet generate outputs in the form of MSD risk indicators; and the conventional occupational health and safety (OHS) risk management paradigm, which is ill-suited to manage MSD risk. It is argued that improved workplace management of MSD risk requires a systems-based management framework and more holistic risk assessment and control procedures that address risk from all types of hazard together rather than in isolation from each other, and that support participation by workers themselves. New MSD risk management tools are needed to meet these requirements. Further, successful implementation of such changes is likely to require some restructuring of workplace responsibilities for MSD risk management. Line managers and supervisors often play key roles in generating hazards, both physical and psychosocial, so there is a need for their more active participation, along with OHS personnel and workers themselves, in routine risk assessment and control procedures. MSDs are one of our largest OHS problems, but workplace risk management procedures do not reflect current evidence concerning their work-related causes. Inadequate attention is given to assessing and controlling risk from psychosocial hazards, and the conventional risk management paradigm focuses too narrowly on risk from individual hazards rather than promoting the more holistic approach needed to manage the combined effects of all relevant hazards. Achievement of such changes requires new MSD risk management tools and better integration of the roles of OHS personnel with those of line managers.

Developing a comprehensive approach to risk management of musculoskeletal disorders in non-nursing health care sector employees.

This study of selected jobs in the health care sector explored a range of physical and psychosocial factors to identify those that most strongly predicted work-related musculoskeletal disorders (WMSD) risk. A self-report survey was used to collect data on physical and psychosocial risk factors from employees in three health care organisations in Victoria, Australia. Multivariate analyses demonstrated the importance of both psychosocial and physical hazards in predicting WMSD risk and provides evidence for risk management of WMSDs to incorporate a more comprehensive and integrated approach. Use of a risk management toolkit is recommended to address WMSD risk in the workplace.

Findings from the Candrive/Ozcandrive study: Low mileage older drivers, crash risk and reduced fitness to drive.

Previous research has found that only older drivers with low annual driving mileages had a heightened crash risk relative to other age groups. These drivers tend to drive mainly in urban areas, where the prevalence of complex traffic situations increases crash risk. However it might also be that some drivers may have reduced their driving due to perceived or actual declines in driving fitness. This paper uses Canadian and Australian data from the Candrive/Ozcandrive older driver study to investigate the association between annual driving distances and a set of driving-related factors, including fitness to drive. All drivers in the Candrive/Ozcandrive older driver cohort study were allocated to one of three groups according to their self-reported annual driving distances: <5001km; >5000 and <15,000km; and 15,000km or greater. Relationships between these driving-distance categories and: (a) self-reported crash data; (b) various Year 1 'fitness to drive' performance measures; and (c) self-perceptions of driving ability and of comfort while driving, were determined. Results confirmed the previously reported association between low mileage and heightened crash risk. Further, low mileage drivers performed relatively poorly on a wide range of performance measures, perceived their own driving ability as lower, and reported lower comfort levels when driving in challenging situations, compared to the higher mileage drivers. In most instances, these differences were statistically significant. The paper provides further evidence that the so-called 'older driver problem' is most pertinent to low mileage drivers, and that this is due in part to low mileage drivers tending to have reduced fitness to drive. This higher risk group represented a fairly small proportion of the sample in this study.

The Relationship between Older Drivers' Performance on the Driving Observation Schedule (eDOS) and Cognitive Performance.

RESEARCH QUESTION/OBJECTIVE: The Driving Observation Schedule (eDOS) was developed for use in the Candrive/Ozcandrive five-year prospective study of older drivers to observe the driving behavior of older drivers and monitor changes in driving behaviors over time. The aim of this study is to describe participants' driving performance during the eDOS driving task and investigate the association between driving performance and cognitive measures. METHODS: A subset of Ozcandrive participants (n = 144, 104 male [72%], 40 female [28%], Mean age = 81.49 years, SD = 3.58 years, Range: 76 - 96 years) completed the eDOS driving task. Participants drove to their selected destinations (up to 4 locations), with observations of driving behaviors (both inappropriate and appropriate) recorded for specific driving maneuvers: intersection negotiation, lane-changing, merging, low speed maneuvers and maneuver-free driving. Driving behaviors (e.g. signalling, speed regulation, gap acceptance, lane position, 'critical errors') were scored by a trained observer and participants received an overall eDOS driving task score (Maximum = 100 points). Participants also completed a series of cognitive assessments as part of the Year 2 Candrive/Ozcandrive assessment protocols. RESULTS: The overall eDOS driving task score was very high (M = 95.77; SD = 5.15; Range = 65.63 - 100). Detailed analyses of participants' driving behavior revealed a high level of appropriate driving behavior (96%, n = 5,935 maneuvers), with few errors (4%, n = 252 maneuvers). While most participants' performance on the cognitive assessments was high, some scores were below the criteria for cogntive impairment (BIC) according to conventional benchmarks: (MoCA: M = 26.56, SD = 2.12, Range = 19 - 30, % BIC = 28%; MMSE: M = 29.10, SD = 1.01, Range = 26-30, %BIC = 0%; Trails B: M = 111.66, SD = 43.53, Range = 50 - 301, %BIC = 6%). There was no significant relationship observed between participants' overall eDOS driving task scores and age (r (144) = -0.17, p > 0.05), and performance on various cognitive assessments including: MoCA (r (144) = 0.07, p > 0.1), MMSE (r (144) = 0.03, p > 0.5), Trail Making Test B (r (144) = 0.09, p > 0.1). IMPLICATIONS: Preliminary analyses of the eDOS driving task revealed a high level of appropriate driving behavior among Ozcandrive older drivers. Despite some participants' cognitive performance suggesting impairment, participants' overall eDOS driving task scores were not significantly related to cognitive performance. This finding is consistent with previous research suggesting some older drivers are able to compensate well for age-related cognitive impairment.

Reinforcing outpatient medical student learning using brief computer tutorials: the Patient-Teacher-Tutorial sequence.

BACKGROUND: At present, what students read after an outpatient encounter is largely left up to them. Our objective was to evaluate the education efficacy of a clinical education model in which the student moves through a sequence that includes immediately reinforcing their learning using a specifically designed computer tutorial. METHODS: Prior to a 14-day Pediatric Emergency rotation, medical students completed pre-tests for two common pediatric topics: Oral Rehydration Solutions (ORS) and Fever Without Source (FWS). After encountering a patient with either FWS or a patient needing ORS, the student logged into a computer that randomly assigned them to either a) completing a relevant computer tutorial (e.g. FWS patient + FWS tutorial = "in sequence") or b) completing the non-relevant tutorial (e.g. FWS patient + ORS tutorial = "out of sequence"). At the end of their rotation, they were tested again on both topics. Our main outcome was post-test scores on a given tutorial topic, contrasted by whether done in- or out-of-sequence. RESULTS: Ninety-two students completed the study protocol with 41 in the 'in sequence' group. Pre-test scores did not differ significantly. Overall, doing a computer tutorial in sequence resulted in significantly greater post-test scores (z-score 1.1 (SD 0.70) in sequence vs. 0.52 (1.1) out-of-sequence; 95% CI for difference +0.16, +0.93). Students spent longer on the tutorials when they were done in sequence (12.1 min (SD 7.3) vs. 10.5 (6.5)) though the difference was not statistically significant (95% CI diff: -1.2 min, +4.5). CONCLUSIONS: Outpatient learning frameworks could be structured to take best advantage of the heightened learning potential created by patient encounters. We propose the Patient-Teacher-Tutorial sequence as a framework for organizing learning in outpatient clinical settings.

Occupational health and safety in Australia.

The focus of OHS in Australia is on workplace-based prevention rather than individual health care. Over the past decade, workers' compensation data have shown continuous improvement in work-related deaths, serious injuries and diseases. Injuries from work-related vehicle incidents are the leading cause of fatalities. There is a high incidence of on-road incidents in light vehicles; this problem is under-recognised, and better incidence data are required to support more effective interventions. Rates of many long-latency diseases such as cancers are underestimated, and again more reliable information is needed, particularly on work-related exposures to carcinogens. Disease-related deaths are largely confined to older workers. Musculoskeletal injuries and disorders are the most frequent and costly OHS problem, constituting a large majority of non-fatal injuries and diseases. There is growing recognition that their risk management should be more evidence based, integrating assessment and control of psychosocial and 'manual handling' hazards. A high rate of population ageing is increasing risk of chronic diseases, including musculoskeletal disorders, which is helping to raise awareness of the importance of protecting and promoting workforce health. Strategies to achieve this have been developed but implementation is at an early stage.

A Study of Young Offenders' Perceptions of Health and Health Care Services in Custody and in the Community.

The level of unmet health needs in young offenders has been raised as a concern in recent research with this population. There is a lack of research examining the views of young offenders on health issues and the services available to them. This article summarizes a qualitative study conducted in four young offender institutions in the United Kingdom with young people expressing their attitudes toward aspects of health and the provision of health care services. While there were gaps in their knowledge, the young people were well informed of the services they could access. They also identified barriers to accessing these services and the effect that being in custody could have on their health. Many of the young people thought that the services provided in custody addressed their health needs more successfully than community-based services. Implications for user-informed service delivery to meet their health needs are discussed.

Illness representations in patients with multimorbid long-term conditions: qualitative study.

Most research on illness representations explores how patients view single conditions, but many patients report more than one long-term condition (known as multimorbidity). It is not known how multimorbidity impacts on patient illness representations. This exploratory qualitative study examined patients' representations of multimorbid long-term conditions and sought to assess how models of illness representation might need modification in the presence of multimorbidity. We explored two major issues: (1) the impact of multimorbidity on patient representations of their individual conditions and (2) the representation of multimorbidity itself. Twenty eight adults with at least two long-term conditions (mean of 4) were interviewed. The presence of multimorbidity impacted on patient illness representations in relation to the dimensions of identity, perceived cause, coherence and consequences. Representations of multimorbidity itself concerned representations of the burden of medication and perceived priorities among conditions and synergies and antagonisms between conditions and their management. The results have implications for the measurement of multimorbidity (through scales such as the Illness Perception Questionnaire) and the use of illness representations in the design and delivery of interventions to improve health behaviour and outcomes of patients with multiple long-term conditions.

Conceptual framework for development of a toolkit for prevention of work-related musculoskeletal disorders.

The World Health Organisation (WHO) network of Collaborating Centres in Occupational Health aims to promote the development, implementation use of "toolkits" for workplace use in reducing the risk of injuries and disease. As a major partner within this network, the International Ergonomics Association is committed to developing a toolkit to reduce the risk of musculoskeletal disorders. This paper outlines the kind of conceptual framework required to support this work.

Design of occupational therapy on-road test routes and related validity issues.

BACKGROUND/AIM: Specialist Occupational Therapy Driver Assessors and driver licensing authorities require on-road assessment procedures that are both valid and reliable. Assessment validity may be influenced by both test route characteristics and driver characteristics. To address these issues, this study aimed to evaluate the characteristics of test routes used by Occupational Therapy Driver Assessors (including associated driving manoeuvres and traffic conditions) and to explore Occupational Therapy Driver Assessor views relating to on-road assessment procedures. METHODS: In-depth interviews of 22 Occupational Therapy Driver Assessors were conducted; seven of the routes examined were in rural or regional locations. Supplementary information was obtained by observation of routes and review of Occupational Therapy Driver Assessors' route documentation. RESULTS: All Occupational Therapy Driver Assessors reported using a standard test route for clients seeking an open (i.e. not geographically restricted) licence. Compliance with professional guidelines reassessment procedures was very high for test items designated as compulsory, but more variable for those designated only as desirable. Differences between rural/regional vs. urban routes were noted, with those in rural/regional areas being less cognitively demanding. CONCLUSIONS: This study highlighted variation in route complexity between urban and rural locations. Whereas compliance with current professional guidelines for compulsory route items was very high, more detailed specification of standard route requirements is needed to improve the construct and content validity of assessments.

What is the relationship between diabetes and depression? a qualitative meta-synthesis of patient experience of co-morbidity.

AIMS: To develop an explanatory framework concerning patient experience of diabetes and depression and the relationship between these disorders; to better understand how interventions and health services should be delivered for this group of patients. METHODS: The study used meta-synthesis. Published qualitative studies were identified using a structured search, and themes synthesized across studies to develop a new explanatory framework. RESULTS: Searches of three databases identified 5506 papers, and 22 were included. Diagnosis of diabetes and the impact of symptoms on functioning were associated with varied psychological reactions, not all of which are negative, and the concept of 'depression' only captures aspects of the experience. Similarly, the relationship between diabetes and relationships with professionals and family were variable, with relationships serving as both a buffer of the effects of diabetes and potentially as a cause of further difficulties for patients. Depression and other psychological states were significant barriers to effective coping. Definition of 'self' emerged as a key potential moderator of the relationship between depression and diabetes. CONCLUSIONS: The variability in psychological reactions to diabetes suggested three key clinical implications, reflecting increasing levels of complexity for practitioners.