Prevalence, Severity, and Risk Factors

of Work-Related Musculoskeletal Disorders

Among Stevedores in a Philippine Break-Bulk
Port Terminal

Keneth Sedilla(&) and Aura Matias

Department of Industrial Engineering and Operations Research,

University of the Philippines Diliman, Quezon City, Philippines
keneth.sedilla@gmail.com,
{kbsedilla,acmatias}@up.edu.ph

Abstract. While it plays a vital role in a country’s economic development, port

operations host a wide spectrum of health problems and work-related diseases.
This study aimed at determining the prevalence, severity, and significant risk
factors that contribute to the occurrence of work-related musculoskeletal dis-
orders among stevedores in a Philippine break-bulk port terminal. The steve-
dores were asked to identify the work-related musculoskeletal symptoms they
had experienced over the last three months. In this cross-sectional study, the
results showed that self-reported prevalence and severity of work-related mus-
culoskeletal symptoms were significantly higher in the upper and lower back,
shoulder, and forearm regions. Some of the identified risk factors associated
with the severity of musculoskeletal symptoms are age, work experience,
number of working days per week, vessel work assignment, type of steel
commodity, level of job satisfaction, and perceived job security among others,
suggesting that the etiology of this condition is multifaceted.

Keywords: Human factors
Work-related musculoskeletal disorders

Break-bulk port terminal
Stevedoring operations
Stevedores

1 Introduction

Musculoskeletal disorder (MSD) is also known as repetitive strain injury, repetitive

motion injury, cumulative trauma disorder, occupational overuse syndrome, muscu-
loskeletal injury, and sprain and strain [1–3]. These terms are based on the idea that
injuries in the muscles, tendons, ligaments or any musculoskeletal regions are caused or
made more severe by intense repeated, or sustained use, or by insufficient recovery
from exertions, motions of the body, vibration, or cold [1]. Moreover, there are some
clarifications to be aware of regarding the use of the terms “disorder” and “injury”.
An injury occurs when there is a mechanical disruption of tissues while a disorder
occurs even without disruption of tissues. The onset of a disorder may be gradual while
injury is sudden [1].Also, we note that musculoskeletal disorders are not always nec-
essarily work-related, because the disorder may be due to other aspects of daily life,

© Springer International Publishing AG 2018

L.E. Freund and W. Cellary (eds.), Advances in The Human Side of Service Engineering,
Advances in Intelligent Systems and Computing 601, DOI 10.1007/978-3-319-60486-2_9
 Prevalence, Severity, and Risk Factors 91

including, for example, sports activities and frequently repeated household activities
such as gardening. MSDs are work-related when they are significantly contributed to or
exacerbated by work-related factors such as work postures, work shifts and so on [4].
Musculoskeletal symptoms are often intermittent and episodic, especially in the early
stages [5]. They may develop over weeks, months or years [1, 5–7]. Musculoskeletal
disorders arise from several simultaneously contributing factors and hence are multi-
factorial in origin [1, 5, 8–11]. Musculoskeletal disorders affect all workplaces [8].
With its substantial health and economic implications [12], musculoskeletal disorders
have received increasing attention across different industries [8].
Any major port terminal is an important working environment for the local economy
and the world market [13]. Such facilities are situated on a coastline where vessels can
dock and transfer passengers to or from land. One of its primary functions is to efficiently
manage the loading and/or unloading of goods or commodities to or from cargo vessels
[14]. Lift-on/lift-off operations are the most common type of cargo vessel operations,
where a vessel crane or mobile crane is used to transfer the cargoes from the ship’s lower
decks through deck hatches to the port’s apron and/or vice versa. Break-bulk port ter-
minals accommodate wide varieties of break-bulk cargoes. Such cargoes are loaded into
ships as individual pieces or are unitized on pallets, in bundles, and not containerized.
While playing a vital role in a country’s economic development, port operations also
contribute to a wide spectrum of worker health problems and work-related diseases.
Globally, there are 2.34 million work-related deaths per year; around 86% are due to
work-related diseases, while others are accident-related [13]. Workers involved in port
operations such as stevedores or dockworkers carry out a set of tasks, which, if not
properly designed and managed, may result to a wide variety of musculoskeletal disorders
[15]. There had been a few studies looking into understanding the possible causes of MSD
among port workers. Of the 6 related studies, 3 are focusing on port equipment/machinery
operators [16–18]. In addition, there is some literature focusing on the prevalence of
occupational risks among dockworkers in container port terminals [19–21].

2 Methods
2.1 Sampling Frame
This cross-sectional study was conducted in the largest break-bulk cargo terminal
within the Port District Office of Manila/Northern Luzon [22].
There are 561 stevedoresunder the port’s accredited stevedoring agencies. Gener-
ally, the stevedores’ work assignment varies depending on the number and type of
vessels at berth. Thus, to increase the objectivity of the results of the association of risk
factors to the symptoms of work-related musculoskeletal disorders, purposive sampling
was used. In order to qualify as a respondent in this study, the stevedore must be
previously assigned to steel vessels more frequently than other types of commodities
such as logs, lumber, bagged cargo, and general cargo. Based on the port’s stevedoring
database, steel has the highest annual cargo throughput. In addition, the stevedores who
had any history of major musculoskeletal trauma regardless of whether it was
work-related or not were excluded in the study. Based onthe selection criteria, fifty-two
percent of the stevedores (290) were qualified to participate in the study.
92 K. Sedilla and A. Matias

2.2 Data Collection

Preliminary interviews and worksite observations were conducted prior to the
deployment of the employee survey questionnaires. Questionnaires with self-reported
musculoskeletal symptoms were used in conducting surveillance of work-related
musculoskeletal disorders. The questionnaires include stevedores’ individual attributes
such as age, sex, marital status, highest educational attainment, body mass index, etc.
Further, there are sets of questions pertaining to work-related factors such as work
characteristics and psychosocial factors.
In addition, the stevedores were asked to identify the work-related musculoskeletal
symptoms (pain, tingling sensation, etc.) they had experienced over the last three
months using the body discomfort chart. Subsequently, the frequency and intensity of
each musculoskeletal symptom per body region (neck, shoulder, upper back, lower
back, forearm, etc.) were also identified.

2.3 Statistical Analysis

In determining the significant predictors of the symptoms of work-related muscu-
loskeletal disorders, ordinal logistic regression models for the body regions with the
highest prevalence rates were generated using IBM SPSS statistics software (version
24). All the individual and work-related factors were included in the regression models
so that the effect of their interactions to the severity of work-related musculoskeletal
symptoms per body region is considered. In this study, there are eleven (11) individual
factors and fifteen (15) work-related factors linked to the severity of symptoms of
work-related musculoskeletal disorders.

3 Results

3.1 Sample Demographics

Two hundred ninety stevedores participated in the study. All the respondents were male,
aged 19 to 56 years old. The stevedores’ average height and weight are 161.59 cm and
63.50 kg respectively. A majority of the respondents were married (81%). Moreover,
eighty percent (80%) of the stevedores are high school graduates. Approximately
three-fourths (72%) of the stevedores do not exercise regularly and/or perform very light
physical activities intermittently. The average weekly consumption of alcoholic drinks
is 3.08 alcohol units. Moreover, seventy seven percent of the respondents are smokers.
On the average, a stevedore consumes 3.61 cigarettes per day.
The stevedores work an average of 11.56 (SD 0.26) hours per shift. The respon-
dents’ average working days per week is 3.43. Forty-six percent of the stevedores were
assigned to steel billets more frequently than wire rods and coils. A little more than half
(53%) was frequently assigned to work ondock/quayside. In regards to the type of shift
in which stevedores were assigned to, the results showed that the frequency for day
shift and night shift is nearly equal. In relation to psychosocial factors, almost half
(44.48%) of the stevedores are slightly dissatisfied with their job while 39.66% gave a
 Prevalence, Severity, and Risk Factors 93

satisfactory rating for their job satisfaction. Most of the stevedores (53.45%) seldom
experienced conflicts at work. Moreover, 53.79% of the respondents receive little
support from their co-employees. Of the 290 stevedores, 126 (43.35%) stated that they
are receiving little support from the management. More than half (53.79%) of the
stevedores have experienced low level of decisional latitude at work while 182 of the
total respondents stated that they had low of perceived job security.

3.2 Prevalence of Work-Related Musculoskeletal Disorders Among

Stevedores
Table 1 presents the prevalence of work-related musculoskeletal symptoms on various
body regions among the stevedores. The body regions with high prevalence of
self-reported work-related musculoskeletal symptoms are the upper (60%) and lower
back (58%), shoulder (64%), and forearm (62%).

Table 1. Prevalence of symptoms of work-related musculoskeletal disorders per body region.

Body region No. of stevedores (Percent)
Neck 69 (24%)
Shoulder 187 (64%)
Upper back 175 (60%)
Lower back 169 (58%)
Forearm 180 (62%)
Hand/Wrist 88 (30%)
Hip/Buttocks 65 (22%)
Thigh 56 (19%)
Lower leg 41 (14%)
Ankle/Foot 27 (9%)

3.3 Severity of Work-Related Musculoskeletal Disorders Among

Stevedores
Table 2 presents the summary of the severity of the symptoms of work-related mus-
culoskeletal disorders per body region. Based on the results, the upper and lower back,
shoulder, and forearm region has the higher percentage of stevedores experiencing
medium to high severity of work-related musculoskeletal symptoms.

3.4 Risk Factors of Work-Related Musculoskeletal Disorders (Shoulder)

Work experience in a break-bulk port terminal (expressed in yrs.) has a strong positive
association with the severity of the work-related musculoskeletal symptoms. The odds
ratio (OR) indicates that stevedores with more years of work experience are 2.53 times
more likely to experience high severity than those with no/less experience working in
break-bulk port terminal. Further, the regression model shows that a unit increase in
94 K. Sedilla and A. Matias

Table 2. Severity of all the symptoms of work-related musculoskeletal disorders per body
region (average rating of all musculoskeletal symptoms per body region)
Body region No. of stevedores (Percent)
Low Medium High
Neck 230 (79.31%) 52 (19.93%) 8 (2.76%)
Shoulder 161 (55.52%) 99 (34.14%) 30 (10.34%)
Upper back 150 (51.72%) 118 (40.69%) 22 (7.59%)
Lower back 132 (45.52%) 133 (45.58%) 25 (8.62%)
Forearm 186 (64.14%) 76 (26.21%) 28 (9.66%)
Hand/Wrist 208 (71.72%) 73 (25.17%) 9 (3.10%)
Hip/Buttocks 236 (81.38%) 43 (14.83%) 11 (3.79%)
Thigh 259 (89.31%) 26 (8.97%) 5 (1.72%)
Lower leg 252 (86.90%) 31 (10.69%) 7 (2.41%)
Ankle/Foot 277 (95.52%) 13 (4.48%) 0 (0%)

stevedore’s age (expressed in yrs.) is associated with a twenty-percent increase in the

odds of having high severity. The results also shows that weekly consumption of
alcoholic drinks has a positive association with work-related musculoskeletal
symptoms.
With regard to psychosocial factors, the ordinal logistic regression model indicates
that stevedores who were completely dissatisfied with their job (as compared to those
who have a very high job satisfaction) had 185.50 times higher odds of reporting high
severity of musculoskeletal. Likewise, stevedores who felt that they have no assurance
of keeping their job had 105.69 higher odds of having high severity level of shoulder
work-related musculoskeletal symptoms. The identification of stevedores’ vessel work
assignment as a shoulder MSD risk factor was an interesting finding of the study, and
one that incurred a high odds ratio (OR: 66.05). Moreover, the type of steel commodity
specifically the steel billets is also a significant work-related risk factor with odds ratio
of 18.97. With regard to stevedores’ average working days per week, there is 3.22
higher odds of experiencing high severity of musculoskeletal symptoms for every
one-day increase in a stevedore’s average working days per week.

3.5 Risk Factors of Work-Related Musculoskeletal Disorders (Forearm)

The ordinal logistic regression model implies that there is an 8% increase in the
probability of experiencing high severity of symptoms for every additional year in a
stevedore’s age. The stevedores’ weekly consumption of alcoholic drinks has a positive
association with the severity level of musculoskeletal disorders. This indicates that a
20% increase in the probability of having high severity of symptoms of MSD for a unit
increase in stevedore’s alcoholic drinks consumption per week.
The results show that stevedores who are working inside the vessel hatch (as
compared to those who are working on-dock) have 12.79 times higher odds of expe-
riencing high severity of MSD symptoms. Moreover, the regression model specifies
that for every one day increase in stevedores’ average working days per week, there is
 Prevalence, Severity, and Risk Factors 95

3.23 higher odds of having high severity of work-related musculoskeletal symptoms.

The psychosocial factors associated with the severity level of work-related muscu-
loskeletal disorders are job satisfaction and perceived job security. Apparently, the
results are nearly similar with the shoulder region in which the values of odds ratio are
also high. The regression model states that stevedores who were completely dissatisfied
in their job (as compared to those who have a very high job satisfaction) had 10.69
times higher odds of showing high severity of MSD. With regard to perceived job
security, the findings show that those who felt that they have no assurance of keeping
their job in the port terminal for a period of time had 4.11 higher odds of having high
severity level of musculoskeletal symptoms (Tables 3).

Table 3. Ordinal logistic regression model for risk factors associated with the severity of
musculoskeletal symptoms in the shoulder region (only significant factors are shown below)
Factors Coefficient P value Odds ratio (95% CI)
Age 0.184 0.000* 1.20 (1.10–1.31)
Yrs. in break-bulk port 0.928 0.004* 2.53 (1.34–4.77)
Alcoholic drinks consumption 0.381 0.001* 1.46 (1.17–1.83)
Average days/week 1.169 0.002* 3.22 (1.52–6.82)
Vessel work assignment
Quayside (Ref.) – – 1.00
Vessel hatch 4.190 0.000* 66.05 (15.73–277.35)
Steel commodity
Coils (Ref.) – – 1.00
Wire rods 0.830 0.343 2.29 (0.41–12.78)
Steel billets 2.943 0.000* 18.97 (4.20–85.64)
Job satisfaction
Very satisfied (Ref.) – 1.00
Satisfied −0.856 0.411 0.43 (0.06–3.27)
Slightly dissatisfied 2.802 0.008* 16.49 (2.09–129.72)
Dissatisfied 5.223 0.001* 185.50 (9.43–3649.37)
Job security
High – 1.00
Medium −0.042 0.965 0.96 (0.15–6.25)
Low 2.054 0.041* 7.80 (1.08–56.03)
None 4.660 0.001* 105.69 (7.14–1564.30)

3.6 Risk Factors of Work-Related Musculoskeletal Disorders

(Upper Back)
Table 5 shows the results of the ordinal logistic regression model for the respondents’
upper back region. Among the individual attributes, age is a significant risk factor for
upper back MSD. The model specifies that there is a 10% increase in the probability of
experiencing high severity of work-related musculoskeletal disorders for an additional
96 K. Sedilla and A. Matias

Table 4. Ordinal logistic regression model for risk factors associated with the severity of
musculoskeletal symptoms in the forearm region (only significant factors are shown below)
Factors Coefficient P value Odds ratio (95% CI)
Age 0.072 0.015* 1.08 (1.01–1.14)
Alcoholic drinks consumption 0.183 0.032* 1.20 (1.02–1.42)
Average days/week 1.174 0.000* 3.23 (1.79–5.85)
Vessel work assignment
Quayside (Ref.) – – 1.00
Vessel hatch 2.549 0.000* 12.79 (4.51–36.25)
Job satisfaction
Very satisfied (Ref.) 1.00
Satisfied −1.379 0.096 0.25 (0.05–1.28)
Slightly dissatisfied 0.471 0.546 1.60 (0.35–7.40)
Dissatisfied 2.370 0.038* 10.69 (1.14–100.27)
Job security
High – 1.00
Medium −0.109 0.881 0.90 (0.22–3.74)
Low 0.659 0.373 1.93 (0.45–8.24)
None 1.413 0.016* 4.11 (0.66–25.46)

year in stevedores’ age. In addition, weekly consumption of alcoholic drinks and

cigarette smoking are also significant predictors for the severity of the symptoms of
work-related musculoskeletal disorders.

Table 5. Ordinal logistic regression model for risk factors associated with the severity of
musculoskeletal symptoms in the upper back region (only significant factors are shown below)
Factors Coefficient P value Odds ratio (95% CI)
Age 0.099 0.000* 1.10 (1.06–1.15)
Cigarette consumption 0.055 0.014* 9.47 (8.80–10.20)
Alcoholic drinks consumption 0.069 0.028* 1.07 (0.94–1.21)
Vessel work assignment
Quayside (Ref.) – – 1.00
Vessel hatch 1.202 0.001* 3.33 (1.61–6.87)

Vessel work assignment is still a useful predictor for predicting high severity of
symptoms of upper back MSD. Stevedores who are working inside the vessel hatch
(as compared to those who are working on-dock) have 3.33 times higher odds of
experiencing high severity of work-related musculoskeletal symptoms. Based on the
results, there are no psychosocial factors identified as significant risk factors for the
symptoms of upper back MSD.
 Prevalence, Severity, and Risk Factors 97

3.7 Risk Factors of Work-Related Musculoskeletal Disorders

(Lower Back)
The results of the ordinal logistic regression model for the respondents’ lower back
region is quite similar with the upper back region. Vessel work assignment is still
associated with high severity of symptoms of upper back MSD. Stevedores who are
working inside the vessel hatch (as compared to those who are working on-dock) have
5.15 times higher odds of experiencing high severity of WMSD symptoms.
Age is a significant risk factor for lower back MSD. The model specifies that there
is a 12% increase in the probability of experiencing high severity for an additional year
in a stevedore’s age. Moreover, weekly consumption of alcoholic drinks and cigarette
smoking are also significant predictors for work-related musculoskeletal symptoms
(Table 6).

Table 6. Ordinal logistic regression model for risk factors associated with the severity of
musculoskeletal symptoms in the lower back region (only significant factors are shown below)
Factors Coefficient P value Odds ratio (95% CI)
Age 0.116 0.000* 1.12 (1.07–1.18)
Cigarette consumption 0.077 0.046* 9.26 (8.60–10.00)
Alcoholic drinks consumption 0.040 0.003* 1.04 (0.92–1.18)
Vessel work assignment
Quayside (Ref.) – – 1.00
Vessel hatch 1.640 0.000* 5.15 (2.41–11.02)

4 Discussion

Table 7 shows the summary of significant risk factors of work-related musculoskeletal

disorders per body region. The occurrences of work-related musculoskeletal symptoms
in the upper and lower back, shoulder, and forearm region can be associated with the
nature of manual handling activities performed by the stevedores during vessel loading
and unloading operations. These activities include securing and manual adjustment of
slings to lifting gears, reaching and/or hoisting for proper positioning of cargoes upon
landing, and releasing of cargo (hooking/unhooking) from the lifting gears.
Table 7. Summary of significant risk factors of work-related musculoskeletal disorders
Significant factors Shoulder Forearm Upper back Lower back
Age U U U U
Yrs. in break-bulk port U
Cigarette smoking U U
Alcoholic drinks consumption U U U U
Average days/week U U
Vessel work assignment U U U U
Steel commodity U
Job satisfaction U U
Job security U U
98 K. Sedilla and A. Matias

Age is one of the major risk factors for prevalent regional pain [23]. It is a sig-
nificant predictor of work-related musculoskeletal symptoms for the body regions with
high prevalence rates. Stevedores who reported drinking alcoholic drinks were more
likely to experience symptoms of work-related musculoskeletal disorders. Possible
explanation for this relationship is difficult to surmise as few, if any; other studies have
looked at alcohol as predictor of musculoskeletal disorders. However, the relationship
with cigarette smoking was more specific, with it being a strong predictor for upper and
lower back region. Tobacco is as a risk factor in several studies, suggesting a probable
biological relationship with musculoskeletal disorders [24].
Work experience (expressed in yrs.) contributes to the occurrence of work-related
musculoskeletal disorders for the shoulder region. The results showed that an increase
in work experience of stevedores, leads to an increase in probability of experiencing
high severity of shoulder pain as compared to those with less experience working in
break-bulk port. This finding can be associated to the nature of tasks performed by the
stevedores on a regular basis, which require overhead reaching and hoisting of heavy
lifting gears. The identification of vessel work assignment as a significant risk factor for
all the body regions is an interesting finding of the study. The stevedores who are
working inside the vessel hatch (as compared to quayside/on-dock) had higher odds of
showing high severity of musculoskeletal symptoms. This result may be associated
with the stevedores’ exposure to postural load, forceful exertions and handlings,
non-neutral or awkward postures (e.g. bending, twisting) while working inside the
vessel hatch. In addition, mobility inside the vessel hatch is more restricted than
quayside because of the various cargoes stowed inside. In addition, the stevedores
on-board are also in-charge of assessing the conditions of all steel cargoes on board
(stowed inside the vessel hatch) before the start of discharging/loading operations.
Moreover, the type of steel commodity specifically, steel billets appeared to be a
predictor of musculoskeletal symptoms in the shoulder region. Handling steel billets is
more physically demanding compared to other steel commodities because the required
lifting gears for steel billets are chain slings with hook, wire sling, and or belt slings,
which are heavier than other lifting gears. In addition, hooking and unhooking of these
gears entails forceful exertion that may contribute to the development of work-related
musculoskeletal disorders. The number of working days per week is a significant risk
factor for work-related musculoskeletal symptoms in the shoulder and forearm region.
The results showed that for a unit increase (expressed in days) in the average number of
working days per week, there is a 3.22 and 3.23 higher odds of experiencing high
severity of shoulder and forearm pain respectively.
Psychosocial factors appear to play a role in the occurrences of musculoskeletal
symptoms in the shoulder and forearm region. This is consistent with the emerging
evidence from various literatures. In this study, the most effective predictors in most of
the body parts are job dissatisfaction and perceived job security. The results showed
that stevedores who were dissatisfied in their job had higher odds of showing high
severity of work-related musculoskeletal symptoms in the shoulder region. Likewise,
those who felt that they have no assurance of keeping their job had higher odds of
having high severity level of symptoms of MSD. This finding can be associated with
the respondents’ type of employment in the port terminal. All of them are under the
company’s stevedoring agencies and employed on a contractual basis. Majority of the
 Prevalence, Severity, and Risk Factors 99

stevedores mentioned that they are always worried about the future of their job
employment in the port terminal. In addition, most of them are anxious in losing their
job because they are the breadwinners of their family. Low job satisfaction can lead to
poor performance at work, eventually leading to occurrence of musculoskeletal dis-
orders [25]. In several studies, psychosocial factors, such as low job satisfaction, high
job strain, and low level of perceived job security, have been reported to increase the
occurrence of work-related MSDs.

5 Conclusion

In conclusion, the results of this study showed that the prevalence of work-related
musculoskeletal disorders among stevedores is significantly higher in the upper
extremities. It was determined that age, work experience in break-bulk port terminal,
cigarette smoking, alcoholic drinks consumption, vessel work assignment, type of steel
commodity assigned to, average number of days of work per week, level of job
satisfaction, and perceived job security are the significant predictors amongst the risk
factors considered in the study. The variety of these factors suggests that the etiology of
this condition is both complex and multifaceted.
The magnitude of the reported period prevalence and severity level of work-related
musculoskeletal disorders justifies the application of further research to determine other
possiblerisk factors associated with the occurrences of MSDs among port workers. This
study contributes to the existing body of literatures that in one way or another provide
bases in the formulation of policies and intervention programs in port industry - par-
ticularly on stevedoring operations in a break-bulk port terminal.

Acknowledgement. The authors would like to acknowledge the funding support from the
Engineering Research and Development for Technology (ERDT), Department of Science and
Technology (DOST), Philippines. Special thanks to Jairus Gogorza, Bryan Gayagoy, Kenneth
Soldevilla, James Lomeda, Bannie Alcantara, and Michelle Estrada for their significant contri-
bution in data collection.

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