Development of the Chinese version of the Quick Exposure Check (CQEC)

Transcription

1 Work 48 (2014) DOI /WOR IOS Press Development of the Chinese version of the Quick Exposure Check (CQEC) Andy S.K. Cheng a, and Patrick C.W. So b a Ergonomics and Human Performance Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China b Occupational Therapy Department, Prince Margaret Hospital, Hong Kong, China Received 13 August 2012 Accepted 3 March 2013 Abstract. BACKGROUND: Work-related musculoskeletal disorders (WMSDs) are a major public health concern. There has been a strong demand from occupational safety and health agencies and operators to develop simple tools for risk assessment and management of WMSDs. The Quick Exposure Check (QEC) was designed to assess exposure to WMSDs risk factors affecting the back, shoulder/upper arm, wrist/hand, and the neck. It is a valuable observational ergonomic assessment tool, suitable for field-based assessment. OBJECTIVE: This study set out to translate, culturally adapt, and validate a Chinese version of the Quick Exposure Check (CQEC), an observational tool used to assess exposure to physical and psychosocial workplace risk factors for the development of WMSDs in different body sites. METHODS: The CQECwas translated from its original Englishversion using a forward- and back-translation approach. Content validity was examined by an expert panel and expert committee using item- and scale-level content validity indices. The intraclass correlation coefficient (ICC) was used to analyze the inter-rater reliability of the observer s assessment, with kappa statistics and percentage agreements used to estimate the test-retest reliability of the worker s assessment of individual items. RESULTS: The CQEC demonstrated an excellent scale-level content validity index (S-CVI > 0.90). The ICC lay between 0.71 and 0.97, indicating good inter-rater reliability. Test-retest reliability showed substantial agreement between the two measurement occasions for most of the items (kappa = 0.68 to 1, percentage agreement = 76 to 100%) capturing exposure to risk factors. CONCLUSIONS: The CQEC is a valid and reliable tool that can be used to calculate levels of exposure to risk factors for WMSDs. Keywords: Work-related musculoskeletal disorders, Chinese Quick Exposure Check, validation 1. Introduction Work-related musculoskeletal disorders (WMSDs) are a major public health concern. They are common and also costly, with a significant personal and socioeconomic impact in many countries [1,2]. They also Corresponding author: Andy S.K. Cheng, Ergonomics and Human Performance Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China. Tel.: ; Fax: ; andy.cheng@polyu.edu.hk. represent a major source of work-related disability [3, 4], with personal and economic costs to all stakeholders, particularly the employer and the affected worker. In recent years, because of the spread of WMSDs in various work contexts, there has been a strong demand from occupational safety and health agencies and operators to develop simple tools for risk assessment and management which can be used by nonexperts in developed and developing countries [5]. The World Health Organization (WHO) has promoted the development and implementation of practical toolkits for assessing and managing specific risks /14/$27.50 c 2014 IOS Press and the authors. All rights reserved

2 504 A.S.K. Cheng and P.C.W. So / Development of the Chinese version of the Quick Exposure Check (CQEC) to workers occupational health [6]. During the 17 th World Congress of the International Ergonomics Association (IEA) in Beijing, China, delegates from different countries agreed that to manage the risk of WMSDs arising from diverse sets of interacting hazards, a participatory ergonomics approaches should be emphasized, whereby workers themselves play a crucial role in the processes of hazard identification and risk assessment [6]. An assessment tool should not only identify physical risks, but also address the important contribution of psychosocial and workplace organizational factors to the development of WMSDs. Early detection of risk factors of WMSDs and timely intervention are believed to be the determining factors in preventing WMSDs in the workplace. Current techniques for assessing risk exposure include self-report, observational methods, and direct measurement [7]. Despite the usefulness of these methods for exposure assessment, they also have certain limitations, such as the lack of consideration for occupational safety and health practitioners needs and for workers participation [8]. In any event, a more user-friendly assessment method will better meet the needs of occupational health practitioners and therapists, who have limited time and resources at their disposal [9]. The Quick Exposure Check (QEC) was designed to assess exposure to work-related musculoskeletal risk factors affecting the back, shoulder/upper arm, wrist/hand, and the neck [10,11]. It involves both the observer (who completes items A to G) and the worker (items H to Q) qualitatively scoring the work task, thereby encouraging a participatory ergonomics approach to the introduction of workplace improvements. The design can also allow those being observed to contribute their own experiences, such as how stressful they perceive their working day to be. The observer and worker scores are then combined to provide an overall exposure risk profile (very high, high, moderate, and low) for the back, shoulder/upper arm, wrist/hand, and neck. For example, a score of denotes a moderate risk for the back, shoulder/arm, and wrist/hand; a score of 8 10 captures a moderate exposure risk for the neck [11]. Studies use the moderate exposure risk score as the risk threshold value to assess exposure to WMSDs risk factors for different sites of the body [12]. The QEC has been extensively evaluated and validated [8]. Research shows that the QEC is a valuable observational ergonomic assessment tool, suitable for field-based assessment of risk factor exposure for WMSDs [13,14]. However, a Chinese version has not so far been developed. Use of the English version may lead to misinterpretation of the items, particularly where workers are concerned, as most lack the English-language proficiency to read and understand the questions. The purpose of this study was therefore to translate, culturally adapt, and validate a Chinese version of the QEC (the CQEC) so as to provide Chinese users with a practical tool to assess their WSMD risk exposure. 2. Methodology 2.1. Development of the CQEC The original version was translated into the Chinese language according to the standardized guidelines proposed in 1993 by Guillemin et al. [15]. The forward translation was undertaken by a bilingual translator and the back translation by a professional translator who had never seen the QEC worksheet before Validity testing An expert panel was then formed to conduct a review of the translated version based on its relevance, representativeness, and understandability in terms of assessing exposure to WMSD risk factors. The panel consisted of seven occupational therapists, each of them have had more than 10 years of working experience in occupational safety and health. Three questionnaires were developed to guide the review of relevance, representativeness, and understandability of the translated items, respectively. Each panel member was instructed to complete each survey by rating the items using a 4-point Likert-type scale; for example, when evaluating relevance, a rating of 1 denoted not relevant, and 4 highly relevant. They were also encouraged to provide written comments to justify their evaluations if rating a single item below 3. A revised version of the CQEC was developed as a result of their feedback. Next, an expert committee comprising a consultant, two occupational therapists, an ergonomist, two occupational safety and health practitioners, and the bilingual translator, was formed to consolidate and further revise the CQEC. These members were selected because of their different professional backgrounds. Each of them had more than 15 years experience in occupational safety and health. Again, three questionnaires were devised to guide their evaluation of relevance, representativeness, and understandability, using a 4-

3 A.S.K. Cheng and P.C.W. So / Development of the Chinese version of the Quick Exposure Check (CQEC) 505 point Likert-type scale to capture responses. The expert committee members were also asked to provide written comments if rating any item below 3. A final consensus was reached through discussion, resulting in all the items on the revised version being accepted. This became the pilot version of the CQEC Pilot testing The pilot version of the CQEC was administered individually by 4 independent observers to 30 workers in various construction sites, offices, and laboratories. Each participant was asked to comment generally about any difficulties they experienced in completing the questionnaire or in understanding the purpose and meaning of any question. The expert committee then discussed these comments. A consensus was reached that more lay terms should be used to avoid confusion. The final version of the CQEC can be found in Appendix Reliability testing Reliability testing of the final version of the CQEC was conducted from the two different perspectives of workers and observers. A total of 120 workers were recruited by convenience and snowball sampling. The inclusion criteria were: (1) at least one year s experience in the current workplace; (2) sufficiently literate to read and understand simple questions; and (3) willing to follow the research protocol. All workers completed the CQEC anonymously and voluntarily. After filling in the CQEC assessment form, each was given a return envelope containing the second (identical) form and asked to complete and return this days after the first. Each CQEC assessment form was given a code in order to track who had responded. The research team also checked the completion date of the second questionnaire in order to ensure at least 10 days had elapsed between surveys. From the observers perspective, we used the approach adopted by the original authors [8]. Four final-year occupational therapy students viewed video recordings of 15 static and dynamic work tasks (combinations of high repetition and low force, and low repetition with high force, for both seated and standing postures) from different occupations including healthcare professions, assistants, and manual workers. These tasks had different demands, ranging from sedentary to very heavy as classified by the Physical Demand Characteristics of Work [16]. All four students had been thoroughly trained in how to use the CQEC to evaluate exposure to risk factors for WMSDs Approach to data analysis Validity analysis Content validity was assessed using the content validity index (CVI) [17]. The item-level content validity index (I-CVI) was computed as the number of experts giving a rating of either 3 or 4 to an item divided by the total number of experts; that is, the proportion in agreement on the relevance, representativeness, and understandability. The scale-level content validity index (S-CVI) was computed by calculating the average I-CVI across items. For a scale to be judged as having excellent content validity, it must comprise items withi-cvisof0.78orhigherandans-cviof0.90or higher [17] Reliability testing The intra-class correlation coefficient (ICC) was used to analyze the inter-rater reliability of the observer s assessment. Kappa statistics and percentage agreement were used to estimate the test-retest reliability of the worker s assessment on individual items of the CQEC. The interpretation of kappa values was as follows; 0.20 poor, fair, moderate, substantial, and almost perfect agreement [18]. All statistical analyses were carried out using SPSS version 18.0 for Windows. The significance level was set at p< Results 3.1. Content validity Observers assessment items All members of the panel agreed that the observers assessment items (A to G) were highly relevant and representative. However, in terms of the understandability of item A (I-CVI = 0.43), four members pointed out that it would be better to describe the response categories more clearly on the assessment form so that the observers would understand the meaning of the terms almost neutral, moderately flexed or twisted, and excessively flexed or twisted without referring to the user guide. The definition of these terms was therefore added in parentheses after each response category. Furthermore, the majority of the members commented that the weight unit used in items H and J should be changed to pounds instead of kilograms as the former is more commonly used in Hong Kong. The expert committee yielded an I-CVI score of 1 for the relevance and representativeness of item A to

4 506 A.S.K. Cheng and P.C.W. So / Development of the Chinese version of the Quick Exposure Check (CQEC) Table 1 Ratings of content validity by expert panel and committee Item I-CVI of relevance I-CVI of representativeness I-CVI of understandability A 1 (1) 1 (1) 0.43 (1) B 1 (1) 1 (1) 1 (1) C 1 (1) 1 (1) 1 (1) D 1 (1) 1 (1) 1 (1) E 1 (1) 1 (1) 1 (1) F 1 (1) 1 (1) 1 (1) G 1 (1) 1 (1) 1 (0.43) H 1 (1) 1 (1) 0.43 (1) J 1 (1) 1 (1) 1 (1) K 1 (1) 1 (1) 0.43 (1) L 0.43 (0.71) 0.57 (0.71) 0.71 (1) M 0.57 (1) 0.57 (1) 1 (1) N 1(1) 0.86(1) 1(1) P 0.71 (1) 0.71 (1) 1 (1) Q 1(1) 0.86(1) 1(1) S-CVI = 0.91 (0.98) S-CVI = 0.90 (0.98) S-CVI = 0.87 (0.96) I-CVI = item-level content validity index, S-CVI = scale-level content validity index; Numbers in parentheses indicate the CVIs assigned by the expert committee. Table 2 Inter-rater reliability of four independent observers PDC Work task ICC # 95% CI Sedentary Blood taking Stomach endoscopy Wound care Removal of stitches Light Mop sweeping Mop wringing Pushing and pulling linen trolley Packaging of medical groceries Medium Offloading of linen Lifting of cleansing tool Cart operation Heavy Patient transfer from bed to chair Transfer of hospital bed Very heavy Lifting of medical equipment at waist level Lifting of medical equipment at chest level Physical Demand Classification; # Intra-class Coefficient Reliability. G, indicating excellent content validity. However, the I- CVI for the understandability of item G was only The same argument was made by the expert committee as regards the meaning of bent or twisted. As a result, the descriptive term neck angle greater than 20 degrees was added in parentheses after the question Workers assessment items In the panel review, the I-CVI of relevance, representativeness, and understandability for these items ranged from 0.43 to 1. Four of 7 members thought that item L, related to the visual demand of the task, was irrelevant to WMSDs. However, the others pointed out that the level of visual demand could significantly influence neck flexion angle and that neck posture is strongly associated with neck disorder since the angle of gaze has a significant effect on the loading of the cervical spine [19,20]. After discussion, a consensus was reached that this item should be retained. Otherwise, the majority of the members thought that the translated items were highly relevant, representative, and understandable. Most of the comments related to the wording of questions and the definition of specific terms, such as vibrating tools in item N. The expert committee mainly scored items H to Q with an I-CVI of 1 for relevance, representativeness, and understandability, indicating excellent content validity. Despite disagreements over individual items, the S-CVI assigned to the whole scale by both expert panels were higher than 0.90, indicating the overall scale

5 A.S.K. Cheng and P.C.W. So / Development of the Chinese version of the Quick Exposure Check (CQEC) 507 Table 3 Demographic characteristics of the workers (n = 94) Gender (%) Male: 57.84%, Female: 42.16% Mean age (SD) (7.46) Education level (%) Primary: 1.49% Secondary: 95.29% Tertiary: 3.22% Mean work experience in years (SD) 7.12 (6.19) Mean work experience in current post in years (SD) 5.34 (7.36) Physical Demand Classification of occupation (%) Sedentary: 15.84% Light: 34.16% Medium:38.31% Heavy: 10.34% Very Heavy: 1.35% Table 4 Test-retest reliability of CQEC worker s items (n = 94) Raw agreement % Kappa value 95% CI p-value Item H Item J Item K Item L Item M Item N Item P Item Q had been successfully culturally adapted and possessed excellent content validity in terms of relevance, representativeness, and understandability (see Table 1) Inter-rater reliability of observers assessment As noted above, 4 raters viewed video recordings of 15 work tasks with different physical demand characteristics. The ICC (2,1) for these assessments lay between 0.71 and If the criterion of 0.75 is adopted to indicate good reliability [21], the results demonstrated good inter-rater reliability among the four observers regardless of the different demand characteristics of the work tasks (Table 2) Test-retest reliability of workers assessment A total of 120 workers completed and returned the first CQEC assessment form, of whom 94 sent back the second form. This resulted in a response rate of 78.3%. The descriptive characteristics of the return sample are shown in Table 3. Most of them operated mostly at the light and medium levels of a physically-demanding job. The mean work experience in current post was 5.34 years. Other than items K, P, and Q, the percentage agreement between first and second assessment ranged from % and the kappa values fell within the range 0.68 to 1. These results demonstrated substantial agreement among workers on the exposure factors between the two assessment occasions (Table 4). 4. Discussion Identification of exposure to risk factors for WMSDs in the workplace has become one of the main duties of occupational safety and health practitioners as well as the healthcare professionals involved in providing therapy to workers with WMSDs. The CQEC is straightforward to use and applicable to a wide range of work tasks. It can normally be completed within 10 minutes. The primary purpose of this study was to translate, culturally adapt, and validate the CQEC so as to provide a practical tool to assess exposure to risk for WMSDs in Hong Kong. The validity and reliability testing of the proposed measure is an important aspect of this process. Based on these results, we found that our translated version can be considered as a valid and reliable observational ergonomic assessment tool to be used in Hong Kong. However, subsequent modification of the items may be required to further improve its clarity. Items P and Q showed moderate test-retest reliability compared to the other items. They address the psychosocial risk factors at work and require workers to give their subjective perceptions of their work situation. Inconsistencies in the scoring may result from the imperfect nature of human judgment rather than because the items themselves are unreliable or invalid. In addition, if a worker feels that he or she needs to impress or please the investigator, the information collected may not be an accurate representation of the actual job demands. Nevertheless, there is room for fur-

6 508 A.S.K. Cheng and P.C.W. So / Development of the Chinese version of the Quick Exposure Check (CQEC) ther improvement in the response categories for both items. Item P asks about difficulty in keeping up with the work; that is, time pressure. A worker s sense of being under time pressure or behind schedule in his/her assigned work duties may be different at different times. For example, for shift workers, workload could vary greatly between shifts. Likewise, item Q is related to work stress. Workers perception of this may be subject to periodic changes in workload. Workers may therefore be unable to provide conclusive information about time pressure and work stress using only three or four exposure categories. While there was a free space for the workers to add supplementary information if they rated item P as often or item Q as medium or high, most respondents left this blank. Since time pressure and perceived work stress are identified as important factors in the development of WMSDs [22 24], we recommend quantifying these questions. For example, workers could be asked about their difficulty in keeping up with work during the last month, their overall perception of work stress, or simply their perception of the worst-case scenario. Item K asks the workers to estimate the maximum force level exerted by one hand. This can be very different if assistive tools are available or the load transfer takes place at a different posture or height level. As this estimation was very subjective, the workers may have found it difficult to provide a consistent response across the first and second assessments. This may be why the test-retest reliability of this item was only moderate. However, in the original QEC, the worker s response is based on their perceptions of the load, not the actual weight [8]. Therefore, the reported weight of load or force exerted by the worker may be over or below the actual task demand. The observer should take note of this. Item L is related to visual demand at work. It has two response categories: low (almost no need to read the fine details), and high (need to read some fine details). The description of both response options was somewhat ambiguous. The definition of fine details and the duration of viewing both need further elaboration. Furthermore, there is an important assumption underlying this question, namely that workers respond to increased visual demand by increasing the neck flexion angle, thereby causing undue stress on the neck muscles resulting in the development of WMSDs. However, workers may not actually need to flex their neck to view fine details. For example, they can read the fine details of a written report by placing it on a book stand or a document holder. Therefore, further improvement in the clarity of the response categories for this item is also needed. 5. Conclusions Based on the results of this study, the CQEC is a valid and reliable tool that can be used to rate workers exposure to WMSD risk factors. It provides occupational safety and health practitioners and other healthcare professionals with a quick observational tool to distinguish a range of the most important risk factors in the workplace. Most importantly, it brings together the observer and the worker to make the assessment, thereby encouraging participatory ergonomics. It forms a basis for communication between different parties who are interested in preventing the occurrence of WMSDs and minimizing their impact in the workplace. However, of the CQEC requires further revision and refinement based on its application in the workplace and in the light of future epidemiological research. Acknowledgements The authors are grateful to Dr Guangyan Li for allowing them to translate the QEC into Chinese and adapt it culturally for use in Hong Kong. The authors would also like to thank all the experts for their valuable comments on developing the CCQEC, the workers who took part in the test-retest reliability testing, and the occupational therapy students who undertook the inter-rater reliability testing. References [1] Szeto GPY, Lam P. Work-related musculoskeletal disorders in urban bus drivers of Hong Kong. J Occup Rehabil. 2007; 17: [2] Yu WZ, Yu ITS, Wang XR, Li ZM, Wan S, Qiu H, et al. Effectiveness of participatory training for prevention of musculoskeletal disorders: A randomized controlled trial. Int Arch Occup Environ Health. 2012; DOI /s [3] Williams RM, Westmorland M. Perspectives on workplace disability management: A review of the literature. Work. 2002; 19: [4] Iles RA, Wyatt M, Pransky G. Multi-faceted case management: reducing compensation costs of musculoskeletal work injuries in Australia. J Occup Rehabil. 2012; DOI /s

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8 510 A.S.K. Cheng and P.C.W. So / Development of the Chinese version of the Quick Exposure Check (CQEC) Appendix 1: Final version of the Chinese Quick Exposure Check (CQEC) )