Recipe for health

A paper describing a project to tackle musculoskeletal injury in a large
bakery made Joe Patton, nursing adviser with Rank Hovis McDougall, a highly
commended runner-up in this year’s Roche Diagnostics Occupational Health Award.  By Joe Patton

This paper describes the result of a three-year occupational health project,
designed to reduce musculoskeletal injury in a large bread making bakery. The
bakery is capable of producing 10,000 loaves every hour, meeting the 10
million-a-day demand from British supermarkets and comer shops. To achieve this
level of production, a healthy workforce is essential.

The current thinking behind the role of occupational health in workplace
health promotion is cited by HSE1 and the RCN2,3. One way of promoting health
is to ask a simple yet fundamental question, "What is it about work that
makes employees sick?" The next step is to do something about the answer.

Ill health at the bakery was previously managed by reacting to data
collected on absenteeism in terms of days off, which did little to actually
promote health. But with this method, sickness recurred and one-time healthy
employees began to develop avoidable illness.

In order to address the causes of ill health it was felt that data
collection needed to be more detailed – describing and quantifying the reasons
given for illness. Bakery employees returning from sickness would often of
submit a self certificate that lacked a recognised medical diagnosis and would
read "felt sick" or "had a bad back". Against this background
a form was designed to record non-diagnostic reasons for sickness, separating
public health issues from essential occupational health information.

Within the food industry people are not allowed at work if products are at
risk of bacteriological contamination. Setting this group aside, illnesses
caused or aggravated by work formed the basis of an occupational health
promotion initiative which is described here.

Musculoskeletal illness

In 1997 a workforce of 623 reported an average of 76 episodes of sickness
every month. An analysis of the reasons given revealed that musculoskeletal
problems accounted for 33 per cent of all absences. This matched the expected
rate for episodes of absence due to musculoskeletal causes for workers involved
with manual handling operations in the food and drink industry4.

Within the setting of a large bread production unit, the weight of loads is
not the most significant factor in the cause of musculoskeletal injuries.
Sustained or repeated spinal flexion or hazardous postures present a risk of
injury to the musculoskeletal system. Then there are activities that risk
musculoskeletal injury. These include twisting the trunk, bending the back,
reaching above shoulder height or awkward positions of the legs and feet which
affects the body’s stability.

The risk of musculoskeletal injury extends beyond posture, too. The
environment will decide how well a person can work and personal fitness can
also reduce the risk of injury. Musculoskeletal problems may be related to home
or leisure activities5.

To make this distinction, a suitable assessment tool was required; one that
appreciated the fact that work and leisure activities can produce similar
symptoms. Such a tool was the Nordic Musculoskeletal Questionnaire. This
questionnaire distanced itself from using diagnostic labels and asked about
pain, discomfort or numbness arising in nine body areas: the neck, shoulders,
upper back, lower back, elbows, wrist and hands, thighs, knees and ankles6. In
order to define any relationship to occupational factors, the severity of
symptoms are analysed alongside activities at work and during leisure time7.

The questionnaire was piloted on six bakery employees and minor changes were
made to improve the layout of questions. By the end of 1997, 132 employees
representing despatch (n=52), engineering (n -3 1), hygiene (n=33) and office
staff (n=16) had been circulated with the questionnaire; 81 were returned, a
response rate of 61 per cent.

Of those who responded, the average age was 37, most were male and 34 of the
81 smoked. Some 20 employees attributed their condition solely to work
activities that involved distribution, maintenance and cleaning tasks. The
remaining respondents (n – 6 1) inferred their condition was caused by a
combination of lifestyle and work activities.

Specific interventions

Those who attributed their condition solely to work were singled out as a
study group. All were male whose average age was 46 years and the majority (70 per
cent) smoked cigarettes. During 1997 the study group had accumulated a total of
26 episodes of ill health, resulting in 286 days absence from work.

Each member of the study group received a functional assessment of fitness
and a health interview. Although they knew what part of their body had been
affected by muscular pain, most did not attribute their condition to a
particular event, suggesting they were victims of cumulative strain. Gentle
questioning established whether any lack of job satisfaction was influencing
their motivation to attend work. It was clear, however, that absence only
occurred when pain prevented them from earning a living.

Emphasis was placed on the fact that smoking might increase the risk of
musculoskeletal injury and delay the healing of an injury. The side-effects of
reduced blood flow with a depleted oxygen content were described. Those who
wished to stop smoking, were helped to do so.

Following the health interviews, workplace observations were made which
revealed widespread bad practice in manual handling operations. No obvious
preparation was made in the work environment and, as a result, people were not
making tasks safer and easier for themselves. Aids to make tasks easier were
either not used, or were used incorrectly.

To improve the situation it was clear that changes in behaviour were
required. Each employee would need to take greater responsibility for their own

The Prochaska and Di Clemente model of care

The conceptual framework being applied to the 20 people in this study8 was
originally devised to treat addictive behaviours. It is based on a belief that
people can be educated to change any behaviour that risks illness. This
involves six stages of change:

Pre contemplation: this sets the scene for people who would otherwise
not consider making changes. In the context of this study an analysis of
sickness absence placed a high priority to reducing musculoskeletal illness.
The population group, identified from the Nordic assessment tool, attributed
their musculoskeletal condition solely to work activity. Health interviews and
observations of work practice then identified the need to take greater
responsibility for self care.

Contemplation: once the need to take greater responsibility for self
care has registered, people then require further information to help their
thinking; In January 1998 this process began with an injury analysis. The
analysis was designed to explain the health risks associated with manual
handling followed by a description of the damage that people were doing to
themselves as a result of poor handling techniques.

Preparation: when the perceived benefits of change outweigh the
desire to continue with present behaviour, people are motivated to seek and
accept extra knowledge or skills to support such a move. In February 1998 this
was delivered by manual handling retraining. The risk of personal injury was
reduced by demonstrating and practising the correct technique for activities
that involved lifting, carrying, pushing or pulling.

Making Change: the early days of change require positive decisions to
do things differently. Support through practical help provides the necessary
encouragement to make those changes work. From February 1998 job specific
guidance was given to make the working environment safer with instruction on
the correct use of equipment that would make tasks easier. In March 1998,
manual handling risk assessments were updated with improved controls that aimed
to further reduce the likelihood of musculoskeletal injury.

Maintaining Change: when new habits become established, the person is
seen as moving out of the change process and into a long term safer lifestyle.
Maintaining this required vigilance and support, so in May 1998 health
surveillance interviews checked what progress had been made and during the
following two months a programme of flexibility exercises was organised. People
were reminded how to prepare their body for activity and how to relax

Relapsing: when a person is unable to maintain change, old habits
return. This is because the change is no longer perceived to be worthwhile, a
feature that Prochaska and Di Clementi consider to be expected. Throughout this
study individuals received constant vigilance and support to prevent a relapse.
Observations of work practice ensured that correct techniques were becoming
common place. "Lifting and Carrying" wall posters were displayed,
self care leaflets issued and constant reminders given about the action to take
in the event of musculoskeletal injury. Ultimately it became less difficult for
people to maintain the changes that had occurred.

Measures of effectiveness: without measures of effectiveness there is
no way of knowing whether occupational healthcare is leading to improvements.
In this project three measures of effectiveness were taken. First, members of
the study group were invited to express an opinion. Second, their absence was
used to calculate a financial cost of musculoskeletal illnesses to the
business. Third, sickness data for all bakery workers measured the effect of
the initiative among the total workforce.

A total of 16 study group members (80 per cent) responded to a request for
their opinion about the project. Professionally, the most important outcome was
a unanimous statement of having less musculoskeletal pain and a greater sense
of well-being. They commented on the ease of using the correct technique for
manual handling and the need to improve their working environment.

In 1997 the 20 members of the study group had reported a combined total of
26 musculoskeletal illness that had been solely attributed to work. This
resulted in 209 days absence, costing the business around £15,000. By March
1999 episodes of musculoskeletal illness had reduced to 13, resulting in 107
days absence at a cost of about £9,000. This constitutes a relative risk
reduction of 50 per cent and a financial saving of £6,000.

Finally, the number of musculoskeletal absences among all bakery workers had
accounted for 33 per cent of illness. By March 1998 this decreased to under 30
per cent but other reasons for sickness increased. Fortunately, this situation
was not reflected in subsequent months. By March 1999 musculoskeletal illness
reduced to 22 per cent.


Sickness data enabled occupational healthcare to be prioritised towards the
reduction of musculoskeletal illness. The Nordic questionnaire proved a
valuable tool to identify bakery workers who had not reported a recognised
medical diagnosis, but suffered with problems that were solely attributed to
work. Observations of work practice identified that faults in technique were
the cause of many injuries and the change from being an "injury
victim" to a "healthy worker" occurred through education that
led to safer behaviour.

While the project has succeeded in reducing the recurrence of
musculoskeletal problems, further work is required to reduce the incidence of
musculoskeletal injury. Data seems to suggest that within bakery settings, the
occupational group with most "work specific" musculoskeletal problems
are male smokers aged over 40. Further research will be required to check the
reliability of this suggestion, which can then form the basis of a more
proactive approach to promoting musculoskeletal health at work.


1 Developing an occupational health strategy for Great Britain, (1998),
Health & Safety Executive

2 The OH nurse – towards professional practice, (1991), Royal College of

3 The Occupational Health Nurse: opportunities for developing professional
practice, (1993), Royal College of Nursing

4 A recipe for safety: health and safety in the food and drink industries,
(1999), Health & Safety Executive

5 Deakin et al, The use of the Nordic Questionnaire in an industrial
setting: a case study, (1994), Applied Ergonomics, Vol 25 pp182-185

6 Kuorinka, I, Standardised Nordic Questionnaire for analysis of
musculoskeletal symptoms, (1987), Applied Ergonomics, Vol 18, pp233-237

7 Dickinson, C E et al, Questionnaire development: an examination of the
Nordic Musculoskeletal Questionnaire, (1992), Applied Ergonomics, Vol 23,

8 Prochaska J and Di Clementi C, Model of care – in search of helping people
change: application to addictive behaviours, (1992), American Psychologist,
September 1992, pp1102-1113

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