Health interventions are essential to minimise the risks to employees in the workplace. Siân Edwards outlines the importance of manual handling training and how an effective programme can help to promote and improve health at work.
If workplace health interventions are to be effective then they need careful planning and should at least be informed by theory if not firmly grounded in it. Behaviour-change theories and thinking of health as a resource for living rather than an end in itself are both helpful in health promotion and protection in individual, group and organisational settings (Noblet and Rodwell, 2010). Workplace health promotion and protection should be in response to actual need and should involve the workers.
Defining the problem
Manual handling can be defined as “the use of force by a person to lift, lower, push, pull, carry, move, hold or restrain something” (Carrivick et al, 2005).
Verbeek et al (2011) defined manual material handling as: “A variety of techniques related to moving inanimate or animate objects from one place or level to another, using muscular force with or without assistive devices.”
Around one-third of reportable accidents each year relate to manual handling, with back pain and other musculoskeletal injuries and conditions being commonly linked with manual handling (Health and Safety Executive (HSE), 2004; Verbeek et al, 2011; Swain et al, 2003; Carrivick et al, 2005). The HSE recommends risk assessment (including the principles of avoid, assess, reduce), training, and good manual handling technique to reduce risk from manual handling.
Although manual handling cannot be designed out of some occupations, the belief has grown that training people in good technique will protect them from strain and reduce risk of back pain or other injury as a result of manual handling by teaching the individual to reduce the strain on their back. It is recognised that manual handling training and provision of manual handling aids are the major interventions that are used to help prevent back pain and manual handling injuries.
Model for behaviour change in workplace health promotion
Despite that, a systematic review by Verbeek et al (2011) found moderate evidence that manual handling training and provision of “assistive devices” has little effect on reports of back pain, disability or absence and they conclude that manual handling training alone is not an effective intervention.
Dwyer and Lotz (2003) stated that: “Recognising the importance of proper manual material handling is a critical step in the job improvement process.” They focus on the risk assessment of manual handling tasks and recommend the hierarchy of controls with engineering controls the preferred option in ergonomics as with other areas of health and safety in the workplace.
The second level of the hierarchy is administrative control, while the third level is modification of work practices, which includes helping individuals to modify their work practices through knowledge of safer techniques and through participation in identifying work solutions.
As part of the occupational health involvement in this project, the risk assessments were reviewed to identify safe ways of moving items including use of fork-lift trucks, pallet trucks, scissor lifts, trolleys, etc. And this combination of e-learning and practical manual handling training sought to reduce risks further by enabling individuals to understand the risks to health and employ risk reducing techniques such as safer manual handling and use of assistive aids.
Throughout the development and delivery of the manual handling training, the occupational health professionals sought to help the company recognise the need for a broader approach to risk reduction and improving practice with regards to manual handling.
At the start of the project to deliver the manual handling training it was not clear if or how the training was to be evaluated. In a practical sense the company was able to offer evidence that something was being done about the concerns about manual handling by commissioning the training.
However, that would not evaluate how well the training meets its objectives or if there will be any other benefits (or indeed problems) not anticipated at the start of the project. Randall and Nielsen (2010) discussed how evaluation should be careful to measure effectiveness against stated objectives while also taking account of other side-effects.
Designing the training
Levels of intervention
Engineering controls/eliminating need for manual handling tasks (eg keeping tasks at waist height through arrangement of stock, use of trolleys, tables, etc).
Consideration of the environment and different learning styles were taken into account when designing both the e-learning and practical aspects of the training. Understanding employees’ attitudes and beliefs also helped the design of a specific course to be effective in the specific business. Issues such as trust (do employees trust the motives of the company? Does the employee feel valued and included in the organisation? Do the employees believe that the intervention will help to improve their work environment and their health?) and other beliefs can affect how the employees engage with the programme, which will then determine how effective the programme can be at reducing accidents and injuries and improving health at work.
Participatory ergonomics is the inclusion of workers in the assessment of risks and the planning, implementation and evaluation of improvements (Haslam, 2002). Although it did not set out to be, this Haslam case study became a form of participatory ergonomics.
Carrivick et al (2005) evaluated the use of participatory ergonomics to reduce manual handling injuries and offered the critique that, as many other interventions have failed, further study is required to determine the true value of the participatory approach.
Health professionals should understand the role of individuals in health behaviour if they are to intervene effectively and then evaluate those interventions.
Rimer (2010) noted that individuals are “the essential unit” in health education and health behaviour theory and that all other settings, including work settings, are composed of individuals.
The two main schools of thought for behaviour-change theories are stages of change and continuum-based theories. Stages of change theories may be familiar to anyone who has tried to promote smoking cessation.
Haslam (2002) considered the lessons that could be learnt from health promotion theories and models when deciding on ergonomic interventions.
Haslam noted: “There appears to be at least some support in the scientific literature for the idea that health and safety interventions in the workplace could usefully extrapolate from theoretical models of health-related behaviour.”
Haslam cited Urlings et al (1990) who said that workplace interventions should tackle attitudes of both managers and employees. Of particular relevance to the case study considering manual handling training, Haslam also cited DeJoy (1996) who applied a health belief model to “self-protective behaviour at work”. His model was based on four areas:
- hazard appraisal;
- initiation; and
It applies similar principles to other versions of the health belief model:
- threat-related beliefs (perception of severity and likelihood of negative health effect);
- self-efficacy (perceived ability to make the behaviour change);
- response efficacy (perceived effect of the behaviour change in reducing the risk of the negative health effect); and
- facilitating conditions and safety climate (benefits and costs of making the change).
DeJoy suggested targeting the different areas to effect “self-protective” behaviour change taking account of the specific situation factors within the specific workplace.
Health belief model
This attempts to explain individual health behaviour and behaviour change based on:
In this case study, consideration was given to the individuals’ beliefs and perceptions about the risks from manual handling, such as how likely they thought it might be that they get injured and how severe they perceived the implications of injury to be.
The individuals’ evaluation of the behaviour change was also addressed and attempts made to empower them to see the benefits of making the change as outweighing the costs (eg the cost of giving up old ideas and ways of working).
Finally, the manual handling training increased the external cues to action through the business attempting to change culture through risk assessment and training.
In 2010, Carpenter conducted a meta-analysis looking at the effectiveness of four variables within the health belief model in predicting behaviour and found that benefits and barriers were the strongest predictors of behaviour. In the case study, the manual handling training highlighted the benefits of making the behaviour change (ie reduced risk of injury, being partners in improving health, safety and welfare at work, more efficient work) at the same time as identifying some barriers to behaviour change (ie disquiet about the motives of management in carrying out the training, overcrowding in production areas leading to some risky manual handling operations).
Swain et al (2003) identified three areas in research evidence that might explain the gap between theory and practice (or why people do not use the knowledge they gain to change the way they do things), which were: cognitive structure; metacognitive processes; and situational factors.
Although Swain et al’s study was concerned specifically with student nurses the principles could be useful elsewhere. Taking manual handling training out of the classroom and into the actual workplace and practically helping workers to apply theory to practice helped to improve the effectiveness of the training as well as to tackle some incorrect beliefs and enable all staff to apply good knowledge in order to reduce the risk of injury.
The provision of lifting and handling aids does not guarantee that they will actually be used and that is something to be monitored in the future for this case study.
Swain et al found that a middle-ground approach emerged in their case, which used a balanced risk assessment approach to balance nurse safety and patient safety in manual handling.
This case study also identified a need to balance employee safety and the need to “get the job done”, which could affect the way that employees use the knowledge they gain through this training and whether or not that will actually result in any behaviour change when it comes to manual handling tasks.
Swain et al (2003) critiqued their own research, noting that the data was limited in nature; however, it did match other research findings to offer some common ground.
In discussing how to effect change in practice they highlighted individual willingness to change, senior staff commitment, the most effective people to effect that change (in their case a particular grade of nurses) and the key group to target (in their case the auxiliary staff who had the biggest role in setting the social norms of the work areas).
By using these areas to foster willingness to change, commitment to change and using key employees to target key groups the training in this case study may improve its effectiveness. In fact, since the delivery of the training the company has identified champions for change in a bid to overhaul the whole approach to health and safety in the workplace.
In 2007, the National Institute for Health and Clinical Excellence (NICE) published guidance on behaviour change in communities including workplaces.
The advice summarises the points raised so far and outlines principles for promoting health through behaviour change:
- planning interventions and programmes;
- assessing social context;
- education and training;
- individual-level interventions and programmes;
- community-level interventions and programmes;
- population-level interventions and programmes;
- evaluating effectiveness; and
- assessing cost effectiveness.
To summarise, interventions that are underpinned by theory and evidence are more effective than interventions without such a framework. Planning and evaluation of interventions are as important as the implementation, and workers and management should be involved at all stages.
Using the theories of behaviour change discussed here should allow the design of an effective workplace health intervention for manual handling that takes a holistic approach and includes a manual handling programme as part of a wider work to improve and promote health in the workplace.
Siân Edwards is an occupational health adviser and is the current regional director at the Association of Occupational Health Nurse Practitioners (UK). Tel: 07986 699986.
Carpenter CJ (2010). “A meta-analysis of the effectiveness of health belief model variables in predicting behaviour”. Health Communication vol.25, no.8, pp.661-669.
Carrivick PJW, Lee AH, Yau KKW, Stevenson MR (2005). “Evaluating the effectiveness of a participatory ergonomics approach in reducing the risk and severity of injuries from manual handling”. Ergonomics, vol.48, no.8, 22 June 2005, pp.907-914.
DeJoy DM (1996). “Theoretical models of health behaviour and workplace self-protective behaviour”. Journal of Safety Research; vol.27, pp.61-72.
Dwyer W, Lotz C (2003). “An ergonomic win-win for manual material handling”. Occupational Hazards; vol.65, no.9, p.108.
Haslam RA (2002). “Targeting ergonomics interventions – learning from health promotion”. Applied Ergonomics; vol.33, pp.241-249.
Harrison JA, Mullen PD, Green LW (1992). “A meta-analysis of studies of the health belief model with adults”. Health Education Research: Theory and Practice; vol.7, no.1, pp.107-116.
Health and Safety Executive (2004). “Getting to grips manual handling: a short guide”. HSE Books – www.hse.gov.uk/pubns/indg143.pdf
NICE (2007). “Behaviour change: quick reference guide”. London: National Institute for Health and Clinical Excellence.
Noblet AJ, Rodwell JJ (2010). “Workplace health promotion”. In Leka S, Houdmont J (eds) Occupational Health Psychology Chichester: Wiley-Blackwell.
Randall R, Nielsen K (2010). “Interventions to promote well-being at work”. In Leka S, Houdmont J (eds) Occupational Health Psychology. Chichester: Wiley-Blackwell.
Rimer K (2008). “Models of individual health behaviour”. In Glanz K, Rimer BK, Viswanath K (eds) Health Behaviour and Health Education: Theory, Research and Practice. Fourth edition. San Francisco: John Wiley & Sons.
Swain J, Pufahl E, Williamson GR (2003). “Do they practise what we teach? A survey of manual handling practice amongst student nurses”. Journal of Clinical Nursing; 12, pp.297-306.
Urlings IJM, Nijboer ID, Dul J (1990). “A method for changing the attitudes and behaviour of management and employees to stimulate the implementation of ergonomic improvement”. Ergonomics; vol.33, pp.629-637.
Verbeek JH, Martimo KP, Karppinen J, Kuijer PPFM, Viikari-Juntura E, Takala EP (2011). “Manual material handling advice and assistive devices for preventing and treating back pain in workers”. Cochrane Database of Systematic Reviews 2011, Issue 6.
This case study shows how occupational health helped to improve the impact of a manual handling training intervention after a company had launched the programme without proper assessment of the problem or adequate planning.
Company A is a medium-sized manufacturing company making medical equipment.
It employs around 200 staff, of which around 100 work in manufacturing and production across two sites.
One site focuses on making metal components while the other site focuses on assembly.
The manual handling tasks are varied and range from lifting 300 6kg units through eight different stations on a night shift, through carrying 30kg bundles of 3m-long copper tubing to changing 18kg vice parts inside a milling machine and loading a 200kg completed unit onto a crate for shipping.
Staff involved in manual handling include production, logistics, IT and sales staff.
Company A was advised that it needed to improve the management of risks from manual handling and, as a result, decided to implement some manual handling training.
The company approached a respected OH specialist to develop an e-learning package for all staff on manual handling, and the author was invited to carry out the training sessions for all production staff and employees with regular manual handling as part of their role after they had completed the online module.
In preparing for the practical sessions the author joined all those involved in developing the training in visiting both sites to understand the processes and tasks involved in order to tailor the training to the specific company, departments and people involved.
The e-learning module included: the risks from manual handling; the importance of self-care including diet, exercise and general fitness; and techniques for safe handling using the TILE (task, individual, load, environment) model.
The practical sessions were then designed to take groups of up to 15 employees through a revision of what they had learnt in the module and then talk through some practical examples in their workplaces.
The practical sessions then moved into the workplace to apply theory to practice with some worked examples.
The sessions were deliberately designed to mix employees from different areas who were able to look at each other’s tasks with fresh eyes and offer suggestions about how to eliminate tasks or carry them out in a safer manner.
The information gathered during the practical sessions (which included the night-shift sessions) was then fed back to management as part of the ongoing programme to overhaul health and safety within the company.