International Journal of Industrial Ergonomics 70 (2019) 70–83

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International Journal of Industrial Ergonomics

journal homepage: www.elsevier.com/locate/ergon

Evaluation of ergonomic working conditions among standing sewing T

machine operators in Sri Lanka
T. Sakthi Nagaraja,∗, R. Jeyapaula, K. Mathiyazhaganb
a
Department of Production Engineering, National Institute of Technology, Tiruchirappalli - 620015, Tamil Nadu, India
b
Department of Mechanical Engineering, Amity School of Engineering and Technology, Amity University, Secctor 125, Noida - 201313, UP, India

ARTICLE INFO ABSTRACT

Keywords: Background: Standing Sewing Machine Operators (SSMOs) are engaged in highly repetitive operations, and work
Musculoskeletal disorders while standing during their entire working hours. This leads to discomforts and Musculoskeletal Disorders
Standing sewing machine operation (MSDs). However, there is a dearth of research in SSMOs’ working conditions.
Prolonged standing Objective: Aim of the study is to evaluate the prevalence of MSDs and related ergonomic risk factors among
REBA
SSMOs in the Sri Lankan textile industry.
Textile industry
Methods: The sample included 552 female sewing machine operators. Data were collected through self-re-
ported questionnaires which included demographic, job-related factors and Cornell Musculoskeletal Discomfort
Questionnaire [CMDQ], along with the application of validated ergonomic tools (Rapid Entire Body Assessment
[REBA] and Strain Index [SI]) to assess the ergonomic risks amongst them. The inter-rater reliability test ensured
the reliability among observers. An individual regression model was developed for each body parts to assess the
associated risk factors.
Results: The highest occurrence of musculoskeletal symptoms were in knee, foot, thigh, lower leg and lower
back of SSMOs. REBA grand score (4–11) indicated that workers’ postures were at medium, high and very high
risk levels necessitating evaluation to change. Moreover, SI indicated medium and high risk of upper extremity
disorders. Finally, regression models revealed associated risk factors with musculoskeletal symptoms among
various body parts including age, Body Mass Index (BMI), marital status, SSMO experience, job satisfaction, job
stress, daily walking distance to the boarding place/factory, interest in job rotation and satisfaction with the
design of sewing machine.
Conclusion: The findings highlighted that the prevalence of discomfort and MSDs in the lower limbs were
higher than in the upper limbs among SSMOs. The findings revealed the working conditions of SSMO and
emphasised the need for ergonomic interventions to minimise the MSDs among them.
Relevance to industry: The findings highlighted ergonomic risks among SSMOs and associated risk factors which
will help managers and researchers better understand the working conditions of SSMOs. The identified risk
factors could be considered during the implementation of standing sewing operation layouts and during the
selection and allocation of new employees.

1. Introduction cellular manufacturing concept in the garment assembly (sewing)

The textile industries are most important and dynamic contributor
to the Sri Lankan economy providing direct employment to 3,00,000
workers and indirect employment to another 6,00,000 workers. The
textile industries have a huge share in the USA and UK markets (‘Export
Development Board, 2017). A report from the Department of Census
and Statistics of Sri Lanka (2015) states that about 2,01,355 female
workers were engaged in 300–350 apparel industries throughout the
country. Most Sri Lankan apparel industries started to follow the
process to sustain themselves in a competitive market (Ratnayake et al.,
2009; Tomastik et al., 1996). A garment assembly cell consists of 12–14
multi-skilled sewing machine operators and around 20–22 workstations
in a U-shaped production cell to complete the entire process from cut
panels to packed full garment. The operators perform their task in
standing work posture to enable them to move from one machine to
another quickly. The machines are mounted on rollers with a height
adjustable stand to facilitate rapid changes in the production cell layout
during garment style changeovers and standing work respectively

∗
Corresponding author.
E-mail addresses: sakthiamie@gmail.com (T. Sakthi Nagaraj), jeyapaul@nitt.edu (R. Jeyapaul), madii1984@yahoo.com (K. Mathiyazhagan).

https://doi.org/10.1016/j.ergon.2019.01.006
Received 1 October 2018; Received in revised form 12 December 2018; Accepted 19 January 2019
0169-8141/ © 2019 Elsevier B.V. All rights reserved.
T. Sakthi Nagaraj et al.
(Jackson and Mullarkey, 2000). Though positive effects like enhanced
productivity, performance and quality are evident in cellular manu-
facturing; on the other hand, increase in ergonomic risk and MSD was
found among operators (Jonker et al., 2011; Nagaraj and Jeyapaul,
2018). MSDs are common health issues not only in the textile industry
but also in various sectors globally (Dantas and de Lima, 2015; Dianat
et al., 2015; Dianat and Salimi, 2014; Kumar et al., 2016), that sig-
nificantly affect workers performance and their quality of life (Buckle
and Jason Devereux, 2002; Kogi et al., 2003). Generally, sewing ma-
chine operators experienced high MSD prevalence due to poor work
posture throughout the working duration and highly repetitive arm/
hand motions (Dianat et al., 2015; Öztürk and Esin, 2011). Typically, a
sewing machinist assembles cut panels to make a full garment. As-
sembling includes highly repetitive actions of both hands while leaning
forward (inclined trunk and neck) for better concentration and better
visual control. In addition, operators also perform tasks like handling
cut panel bundles, threading, winding bobbins, adjusting thread tension
and cleaning the machine. This leads to MSD symptoms in the back,
neck and upper limb (Dianat et al., 2015; Öztürk and Esin, 2011;
Delleman and Dul, 2002; Lombardo et al., 2012). Moreover, working in
prolonged standing has been recognised as an occupational risk
(Balasubramanian et al., 2009; Gallagher et al., 2014; Halim and Omar,
2012), and has been associated with discomfort and MSDs of the lower
back (Coenen et al., 2017; Gallagher et al., 2014; Marshall et al., 2011;
Mendelek et al., 2011) and lower limbs (Antle and Côté, 2013; Coenen
et al., 2017; Fewster et al., 2017; Halim and Omar, 2012).
Explicit knowledge of musculoskeletal symptoms and related vari-
ables have the potential to impact on an organisation's performance and
workers' quality of life. At present, the studies to understand prevalence
of MSDs and related risk factors among Sri Lankan sewing machine
operators in sitting posture (For example, Abeysekera and Illankoon,
2016; Attanapola, 2003; Lombardo et al., 2012; Sealetsa and Thatcher,
2011) and standing posture (Nagaraj and Jeyapaul, 2018) are limited.
In the Nagaraj and Jeyapaul (2018) study, there is a lack of statistical
analysis to reveal associations between self-reported symptoms and
corresponding variables. Hence, there is a dearth of information about
MSDs prevalence and the associated risk factors for SSMOs. To fill this
research gap, this study aims to examine the working conditions of
standing sewing machine operators in cellular manufacturing and
findings help to identify potential suggestions for ergonomic interven-
tions for SSMOs. To achieve this the following objectives were.
• To evaluate the occurrence of MSDs among SSMOs using the Cornell
Musculoskeletal Discomfort Questionnaire,
• To evaluate ergonomic risk factors using the REBA and SI,
• To examine the relationship between MSDs and demographic fac-
tors, job-related characteristics, REBA scores, and SI risk levels.
2. Research methodology
2.1. Study design and methods
The study was conducted over a six-month period between February
and July 2017 in a garment manufacturing unit located in the Uva
Province of Sri Lanka. Around 1008 female sewing machine operators
were working in two shifts, and a shift was for 8 h including a half hour
Table 1
Rating (R) for frequency, severity and interference in different scales.
Frequency
0 = Never
1.5 = 1–2 times/week
3.5 = 3–4 times/week
5 = once in every day
10 = several times every day
International Journal of Industrial Ergonomics 70 (2019) 70–83
break. A sample of 552 sewing machine operators was selected based
on their working experience, past and present medical records, and
willingness to participate in the survey. Participants were volunteers
and were not paid for their contributions. A 3-h training program was
conducted for 36 Industrial Engineering (IE) officers and two IE ex-
ecutives to familiarise them about the survey methods. Each participant
was instructed about the study, and their doubts were cleared by the IE
officers and executives. Data collection was undertaken in two phases,
one, was self-reported study included combined survey sheet of de-
mographic, job-related characteristics and CMDQ, and the other was
direct observation, including REBA and SI survey sheet, of operators
during their work by IE officers.
2.2. Data collection
2.2.1. Self-reported study
A combined survey sheet was developed to record demographic,
job-related characteristics and CMDQ questionnaires. The demo-
graphics included the age, weight, height, BMI (weight/heigh2), marital
status (married or single), education level (primary school, secondary
school, diploma) and daily walking distance to the factory/boarding
point (Below 1 km, 1–2 km, 2–3 km). Many questions were based on job
and a few on lean practices. An excerpt of the questions is shown: ex-
perience as a standing sewing machine operator?, satisfaction with the
job: “At what level are you happy with the job? (low, medium, high)”,
perceived stress due to work: “Do you feel that your job is affecting your
physical and emotional wellbeing negatively? (yes/no)”, perceived
speed of tasks: “Do you feel that your job forces you to work very fast?
(yes/no)”, perceived workload: “Do you feel that you are always en-
gaged in your work? (yes/no)”, perceived physical porosity in between
work: “Do you relax in-between work? (yes/no)”, perceived job rota-
tion at work: “Are you interested in job rotation?” and regarding
workstation design: “How much are you satisfied with the design of the
standing sewing machine? (low, moderate, high)”.
The frequency, severity and interference with work of MSDs were
gathered by a CMDQ (Cornell University Ergonomics Web, 2003)
survey sheet modified with the addition of a row to obtain discomfort in
the head region. The CMDQ has three sections (frequencies, severity
and interference) and rating (R) for each section in different scales as
shown in Table 1 (According to scoring guidelines of Cornell Muscu-
loskeletal and Hand Discomfort Questionnaires). The score of frequency
(F), severity (S) and interference (I) sections were calculated by the
equation (1)
r
F (or) S (or) I =
i=1
ni Ri
(1)
Where ni is the total number of workers with specific symptoms, and
Ri is the rating of corresponding symptoms. Multiplying of the fre-
quency, severity and interference scores resulted in the overall dis-
comfort score of a worker's specific body part.
The combined survey sheet in English was translated into Tamil and
Sinhala. The translation was done by an expert committee including a
researcher (first author), two translators (Tamil and Sinhala) and three
industrial engineers. The translated combined survey sheet was vali-
dated through face validation method by two academicians and two
Severity Interference
1 = slightly uncomfortable 1 = not at all
2 = moderately uncomfortable 2 = slightly interfered
3 = very uncomfortable 3 = substantially interfered
71
T. Sakthi Nagaraj et al.
industrial engineers. It was also verified through a pilot study with 25
workers. The test-retest reliability of questionnaires was assessed with
Kappa coefficients (0.80–0.91) representing good reliability of the
questionnaires.
The self-reported study was conducted at the end of the shift on the
last working day of week. The participants were asked to specify ex-
perienced discomfort and pain or ache in the last week in different parts
of body. Moreover, the severity of the discomfort and interference with
the work were recorded through the CMDQ sheet for the corresponding
body parts. This study was extended for 1 h, and participants were as-
sisted by IE officers to fill the survey sheet.
2.2.2. Direct observational method
The direct observational method was used to record the REBA
(Hignett and McAtamney, 2000) sheet and strain index (Moore and
Garg, 1995) scoring sheet for each individual separately by the IE of-
ficers. REBA was used to examine the standing work posture of sewing
machine operators at their workstations, and the most engaging sewing
work posture was selected for analysis. REBA is a reliable (inter-rater
reliability = 62–85%) and validated observational tool to assess pos-
tural and biomechanical loading on musculoskeletal systems which
contributes to MSDs and was applied to various tasks (Hignett and
McAtamney, 2000) similar to the standing sewing machine operations.
In this method, critical work posture was selected based on more static,
perceived severity and frequency of occurrence. The posture of different
body part was observed to calculate overall REBA Grand Score which
indicated the risk level of the posture and one of the action level to
consider. REBA score was represented under three classifications as
“Group A” (neck, trunk and leg), “Group B” (wrist, lower arms and
upper arm) and the combined REBA “Grand Score”. The risk levels and
suggestions of working postures are shown in Fig. 1.
As sewing task includes highly repetitive actions and hand intensive
tasks, a separate strain index scoring sheet (The Ergonomics Center of
North Carolina, 2013) was used to observe the risk level of tasks which
lead to the distal upper extremity (DUE) musculoskeletal disorders. The
SI is a job analysis tool to identify the risk of DUE musculoskeletal
disorders. DUE includes hand, wrist, forearm and elbow. SI considers
six task variables such as duration of the task per day, efforts per
minute, posture of the hand, intensity and duration of the exertion, and
speed of the work to describe external demand for a job. Based on these
Fig. 1. REBA Grand score and corresponding action taken.
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International Journal of Industrial Ergonomics 70 (2019) 70–83
six task variables, the SI score is calculated and indicates the risk level
of the job (Moore and Garg, 1995). The SI score and corresponding risk
levels of job are shown in Fig. 2.
Trained IE officers observed the working postures and scoring of the
SI task variables. Each operator was observed for 15 min by an IE officer
to select the most occurrence and static work posture to conduct REBA
and to score SI task variables. A separate REBA sheet and SI scoring
sheet were used for each operator.
2.2.3. Reliability test
As the IE officers were familiar with English, the original version of
REBA and SI scoring sheets were used to conduct the study. The eval-
uated inter-rater reliability test (Krippendorff's alpha α = 0.81–0.89)
(Hayes and Krippendorff, 2007) for both REBA and SI scoring indicated
better reliability among IE officers. Moreover, the Chi-square test was
conducted and confirmed that REBA and SI score were significantly
associated with discomforts in the corresponding body parts and pro-
vided a good indication of the MSDs (Dianat et al., 2015; Öztürk and
Esin, 2011).
2.3. Data analysis
Data analysis was performed by SPSS software version 25.0.
Demographic and job-related factors of sewing machine operators were
reported in frequency, mean, standard deviation (SD), ranges and
percentages. The frequency and severity of discomfort and its inter-
ference with work in the last week of the sewing machine operators
were presented in frequency and percentage. The overall discomfort
score was calculated for the corresponding part of the body. The as-
sociations between study variables (demographic and job-related fac-
tors) and prevalence of musculoskeletal symptoms (frequency of dis-
comfort in last one week from CMDQ) was evaluated through
univariate ordinal logistic regression analysis (Denham, 2017). Multi-
variate ordinal logistic regression analysis was also conducted to eval-
uate the relationship between musculoskeletal symptoms and in-
dependent variables for each body part (Dianat et al., 2015). Separate
regression models were developed for each part of the body. The in-
dependent variables comprised the demographic factors (BMI, age,
educational level, marital status and daily walking distance to factory/
boarding point), job-related factors (job satisfaction, SSMO experience
T. Sakthi Nagaraj et al. International Journal of Industrial Ergonomics 70 (2019) 70–83

Fig. 2. Strain Index and corresponding risk level of job.

in years, job stress, perceived speed of work, workload, physical por- Table 3
osity, interest in job rotation and satisfaction with the design of Job-related variables of standing sewing operators.
standing sewing machines) and three REBA scores as well as strain Variables (n = 552) n (%)
index of job. The odds ratios (ORs), p-value and 95% confidence in-
tervals (CIs) were calculated from the ordinal logistic regression Job Satisfaction
models. The statistically significant level, p < 0.05 was considered for Low 158 (28.6)
Moderate 252 (45.7)
all statistical tests.
High 142 (25.7)
Job Stress
3. Results Low 169 (30.6)
Moderate 252 (45.7)
High 131 (23.7)
3.1. Demographic and job-related factors
Working very fast
Yes 474 (85.9)
The demographic and job-related factors of the participants are No 78 (14.1)
represented in Table 2 and Table 3, respectively. Participants’ ages Workload- Always engaged with work
Yes 508 (92.0)
ranged from 18 to 36 years (mean = 25.04; SD = 3.8), with around
No 44 (8.0)
55% participants being educated to the primary school level. Around Physical porosity- relaxing in-between work
80% participants were married and had an average BMI of 21.3 kg/m2 Yes 37 (6.7)
(range = 15.6–30.6 kg/m2; SD = 2.7). Most participants (68%) walked No 515 (93.3)
1 km or less to reach the factory/boarding place, whereas, a few (18%) Interest in job rotation
Yes 401 (72.6)
participants walked two-three kilometres. Only 26% of workers were
No 151 (27.4)
Satisfy with the design of standing sewing machine
Low 120 (21.7)
Table 2 Moderate 250 (45.3)
Demographic variables of standing sewing operators. High 182 (33.0)

Variables (n = 552)

Age Mean (SD) 25.04 (3.8)

Range 18–36
fully satisfied with their jobs and 70% of operators were working under
BMI
Mean (SD) 21.3 (2.7)
stress. Most of the operators were always engaged with their work
Range 15.6–30.6 (92%) with less physical porosity (93%). They also worked very fast
Education n (%) (86%) to perform assigned tasks. Only 27% operators were not inter-
Primary school 303 (54.9) ested in job rotation, and 67% operators were not fully satisfied with
Secondary school 174 (31.5)
the design of sewing machines. Pearson correlation coefficient in-
Diploma 75 (13.6)
Marital Status n (%) dicated that independent variables do not show perfect collinearity
Married 441 (79.9) (Denham, 2017).
Unmarried 111 (20.1)
Walking Distance to Boarding place n (%)
3.2. REBA assessment of working posture
Below 1 km 376 (68.1)
1–2 km 76 (13.8)
2–3 km 100 (18.1) Table 4 shows the percentage of operators with REBA scores for
SSMO Experience n (%) corresponding body parts. Neck score for the operators was 1 (47.3%),
Below 1 Year 276 (50.0) indicated that the operators' neck was flexed forward between 10° - 20°.
1–2 Year 184 (33.3)
Most operators’ trunk score was 2 (67.4%), revealed that operators
2–3 Year 92 (16.7)
needed to lean forward between 0° - 20°. The leg score of operators was

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T. Sakthi Nagaraj et al. International Journal of Industrial Ergonomics 70 (2019) 70–83

Table 4
Percentage of operators with REBA score for corresponding body parts.
Score Neck Trunk Leg Upper Arm Lower Arm Wrist Score A Score B Grand Score

1 261 (47.3) 315 (57.1) 287 (52.0) 123 (22.3)

2 168 (30.4) 372 (67.4) 214 (38.8) 299 (54.2) 237 (42.9) 265 (48.0) 258 (46.7) 262 (47.5)
3 123 (22.3) 180 (32.6) 338 (61.2) 141 (25.5)
4 112 (20.3) 294 (53.3) 167 (30.3) 505 (91.5)
5
6
7
8 37 (6.7)
9
10
≥ 11 10 (1.8)

3 (61.2%), as most operators stood on one leg with the other at a 30° -
60° angle. Most lower arm (57.1%) and wrist (52%) score for operators
were 1, indicated that the lower arm was at a 60° - 100° angle while that
of the wrist was at a ± 15° angle. According to the REBA grand score
(4–7), almost all operators (91.5%) were at medium risk based on their
working posture. Hence, further investigations were needed to change
in their working postures. The typical working posture of SSMO is il-
lustrated in Fig. 3.
3.3. Risk level of distal upper extremity disorders among the operators
Half the participants (52.5%) were at strain index risk level of 3–7
and few (6.5%) at SI ≥ 7, indicated that they faced the risk of distal
upper extremity disorders, the only consolation being that 40.9% op-
erators were at a probable safe risk level (SI ≤ 3).
body parts that should be considered for ergonomic interventions. It
was observed that most operators experienced greater discomfort in the
lower limbs. Among the lower limbs, the foot (left-13.9%, right-10.7%)
and knee (left-10.3%, right-6.3%) were more critical than the thigh
(left-4.6%, right-6.8%) and lower leg (left-6.8%, right-4.8%). It was
observed that the left lower body parts suffered more than the right
except the thigh. Concerning the upper body parts; lower back (6.2%),
neck (4.2%) and right shoulder (3.6%) were identified as being more
critical than other upper body parts. Body parts on the right suffered
more discomfort than the left side including the shoulder (right-
3.6% > left-2.6%), wrist (right-3.0% > left-2.5%), upper arm (right-
2.9% > left-2.1%) and forearm (right-1.8% > left-1.2%). It was re-
vealed that the foot was the most critical part (13.9%) and hip/buttocks
(0.0%) was the least critical for ergonomic interventions amongst
SSMOs.

3.4. Musculoskeletal symptoms among operators
The first part of Table 5 represents the prevalence of MSDs in the
various body parts of the operators. Around 81% of operators felt dis-
comfort at least once a day. The second and third part of Table 5 re-
presents the severity and interference with work. Most of the operators
reported moderate to very uncomfortable (73%) discomfort interfered
with their work (69%), and these were more prevalent in the lower
body.
Table 6 represents the discomfort score for the corresponding body
parts of operators. The body parts were ranked, based on overall dis-
comfort scores. The overall discomfort score indicated the most critical
3.5. Casual relationship between musculoskeletal symptoms and
independent variables
The logistic regression models of both univariate and multivariate
context revealed a significant association between musculoskeletal
symptoms and independent variables in different body parts as shown
in Appendices A, B, C and D respectively. Multivariate logistic regres-
sion models indicated that age, operators BMI, marital status, daily
walking distance to factory/boarding point, years of experience as a
standing sewing machine operator, satisfaction with job, job stress,
interest in job rotation and satisfaction with the design of sewing ma-
chines were significantly related to discomforts of different body parts.

Fig. 3. The typical working posture of standing sewing operators.

74
 T. Sakthi Nagaraj et al.

Table 5
Prevalence of MSDs among operators for corresponding body parts.
Body Parts Frequency of discomfort in last week Severity of discomfort Discomfort interfered with work

Never 1-2 times 3-4 times Once every day Several times every Slightly Moderately Very Uncomfortable Not at all Slightly Substantially
day Uncomfortable Uncomfortable Interfered interfered

Head 110 (19.9) 70 (12.7) 146 (26.4) 173 (31.3) 53 (9.6) 172 (38.9) 194 (43.9) 76 (17.2) 152 (34.4) 156 (35.3) 134 (30.3)
Neck 101 (18.3) 102 (18.5) 112 (20.3) 120 (21.7) 117 (21.2) 102 (22.6) 156 (34.6) 193 (42.8) 104 (23.1) 178 (39.5) 169 (37.5)
Shoulder Left 104 (18.8) 89 (16.1) 122 (22.1) 124 (22.5) 113 (20.5) 212 (47.3) 182 (40.6) 54 (12.1) 182 (40.6) 174 (38.8) 92 (20.5)
Right 96 (17.4) 70 (12.7) 129 (23.4) 130 (23.6) 127 (23.0) 139 (30.5) 192 (42.1) 125 (27.4) 166 (36.4) 169 (37.1) 121 (26.5)
Upper Back 126 (22.8) 77 (13.9) 116 (21.0) 126 (22.8) 107 (19.4) 198 (46.5) 145 (34.0) 83 (19.5) 216 (50.7) 131 (30.8) 79 (18.5)
Upper Arm Left 124 (22.5) 92 (16.7) 135 (24.5) 112 (20.3) 89 (16.1) 196 (45.8) 161 (37.6) 71 (16.6) 191 (44.6) 154 (44.6) 83 (19.4)
Right 106 (19.2) 81 (14.7) 129 (23.4) 129 (23.4) 107 (19.4) 150 (33.6) 189 (42.4) 107 (24.0) 180 (40.4) 175 (39.2) 91 (20.4)

75
Lower Back 72 (13.0) 56 (10.1) 117 (21.2) 143 (25.9) 164 (29.7) 78 (16.3) 156 (32.5) 246 (51.3) 98 (20.4) 214 (44.6) 168 (35.0)
Forearm Left 162 (29.3) 136 (24.6) 149 (27.0) 55 (10.0) 50 (9.1) 189 (48.5) 171 (43.8) 30 (7.7) 167 (42.8) 138 (35.4) 85 (21.8)
Right 137 (24.8) 128 (23.2) 142 (25.7) 76 (13.8) 69 (12.5) 160 (38.6) 190 (45.8) 65 (15.7) 164 (39.5) 164 (39.5) 87 (21.0)
Wrist Left 126 (22.8) 129 (23.4) 148 (26.8) 73 (13.2) 76 (13.8) 161 (37.8) 156 (36.6) 109 (25.6) 117 (27.5) 146 (34.3) 163 (38.3)
Right 116 (21.0) 119 (21.6) 136 (24.6) 93 (16.8) 88 (15.9) 149 (34.2) 169 (38.8) 118 (27.1) 101 (23.2) 157 (36.0) 178 (40.8)
Hip/Buttocks 392 (71.0) 114 (20.7) 39 (7.1) 5 (0.9) 2 (0.4) 126 (78.8) 29 (18.1) 5 (3.1) 155 (96.9) 5 (0.0) 0 (0.0)
Thigh Left 92 (16.7) 76 (13.8) 116 (21.0) 139 (25.2) 129 (23.4) 63 (13.7) 168 (36.5) 229 (49.8) 156 (33.9) 178 (38.7) 126 (27.4)
Right 61 (11.1) 36 (6.5) 113 (20.5) 176 (31.9) 166 (30.1) 49 (10.0) 178 (36.3) 264 (53.8) 131 (26.7) 197 (40.1) 163 (33.2)
Knee Left 29 (5.3) 29 (5.3) 96 (17.4) 172 (31.2) 226 (40.9) 52 (9.9) 176 (33.7) 295 (56.4) 58 (11.1) 168 (32.1.) 297 (56.8)
Right 76 (13.8) 55 (10.0) 126 (22.8) 159 (28.8) 136 (24.6) 73 (15.3) 157 (33.0) 246 (51.7) 67 (14.1) 179 (37.6) 230 (48.3)
Lower Leg Left 51 (9.2) 68 (12.3) 91 (16.5) 130 (23.6) 212 (38.4) 101 (20.2) 129 (25.7) 271 (54.1) 181 (36.1) 172 (34.3) 148 (29.5)
Right 79 (14.3) 106 (19.2) 96 (17.4) 132 (23.9) 139 (25.2) 104 (22.0) 116 (24.5) 253 (53.5) 163 (34.5) 189 (40.0) 121 (25.6)
Foot Left 12 (2.2) 28 (5.1) 69 (12.5) 108 (19.6) 335 (60.7) 32 (5.9) 191 (35.4) 317 (58.7) 61 (11.3) 207 (38.3) 272 (50.4)
Right 28 (5.1) 46 (8.3) 84 (15.2) 98 (17.8) 296 (53.6) 58 (11.1) 182 (34.7) 284 (54.2) 107 (20.4) 189 (36.1) 228 (43.5)
Average n (%) 105 (19) 81 (15) 115 (21) 118 (21) 133 (24) 122 (27) 161 (36) 164 (37) 139 (31) 164 (37) 145 (32)
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T. Sakthi Nagaraj et al. International Journal of Industrial Ergonomics 70 (2019) 70–83

Table 6
Ranking of different body parts based on a total discomfort score.
Body Parts Frequency Score Severity Score Interference Score Total discomfort Score Total discomfort Score (%) Rank

Head 2011 788 866 1372322488 2.6 13

Neck 2315 993 967 2222934765 4.2 9
Shoulder Left 2310.5 738 806 1374350094 2.6 13
Right 2476.5 898 867 1928118699 3.6 10
Upper Back 2221.5 737 715 1170630533 2.2 15
Upper Arm Left 2060.5 731 748 1126656674 2.1 16
Right 2288 849 803 1559837136 2.9 12
Lower Back 2848.5 1128 1030 3309501240 6.2 6
Forearm Left 1500.5 621 698 650403729 1.2 18
Right 1759 735 753 973527345 1.8 17
Wrist Left 1836.5 800 898 1319341600 2.5 14
Right 1999.5 841 949 1595818946 3.0 11
Hip/Buttocks 352.5 199 165 11574337 0.0 19
Thigh Left 2505 1086 890 2421182700 4.6 8
Right 2989.5 1197 1014 3628529541 6.8 4
Knee Left 3499.5 1289 1285 5796449318 10.9 2
Right 2678.5 1125 1115 3359843438 6.3 5
Lower Leg Left 3190.5 1172 969 3623348754 6.8 4
Right 2545 1095 904 2519244600 4.8 7
Foot Left 4173.5 1365 1291 7354604303 13.9 1
Right 3813 1274 1169 5678723778 10.7 3

However, the educational level, perceived speed of work, workload,
and physical porosity of operators were not associated with any mus-
culoskeletal symptoms.
4. Discussions
The study's findings helped to understand the working conditions of
SSMO with respect to the MSDs prevalence and related risk factors in
the lean environmental textile industry. The occurrence of muscu-
loskeletal symptoms among SSMO was found to be very high, where
highly affected body parts included the knee, foot, thigh, lower back,
lower leg and neck, respectively. The most significant result of the study
was that around 81% of operators felt MSD symptoms at least once or
twice a week. About 25% of operators experienced such symptoms
many times a day. Higher discomfort was related to the lower limbs,
whereas among upper body parts, maximum discomfort was in the
lower back, which agreed with earlier studies (Capodaglio, 2017;
Coenen et al., 2017; Fewster et al., 2017; Tissot et al., 2009; Widanarko
et al., 2015). Most operators experienced discomfort severity from
moderate (36%) to very uncomfortable (37%) which interfered with
their work (69%). Higher discomfort was felt in the right of the upper
body and left of the lower limbs due to the body being balanced on the
left leg and most activities being performed by the right hand.
Though there is no similar study for standing sewing operations, the
present study's findings can rely on earlier studies of MSDs among sit-
ting sewing machine workers and standing workers of some other tasks.
The prevalence of musculoskeletal symptoms was high in the upper
body among sitting sewing operators (Dianat et al., 2015; Öztürk and
Esin, 2011; Kaergaard and Andersen, 2000). Prolonged standing for
different tasks leads to high MSDs in the lower limbs and lower back but
not in other upper body parts (Balasubramanian et al., 2009;
Capodaglio, 2017; Coenen et al., 2017). However, the present study
highlighted the high occurrence of musculoskeletal symptoms in both the
lower and upper bodies of SSMOs, which agreed with an earlier study
(Nagaraj and Jeyapaul, 2018). This was due to the highly repetitive
actions of the upper limbs and due to prolonged standing together.
Multiple logistic regression models indicated a significant relation-
ship between variables (demographics, job characteristics, postures and
strain index) and musculoskeletal symptoms among different body
parts. Most variables were associated with the existence of MSD
symptoms at least in one body part. Regarding individual risk factors,
age was a significant risk factor for the knee, lower leg and foot
symptoms with an odds ratio (OR) around 1.1 to 1.2. Previous studies
reported that age was significantly related to knee symptoms among
sitting sewing operators (Dianat and Salimi, 2014; Öztürk and Esin,
2011; Dianat et al., 2015), whereas the present study reveals that age
was significantly related not only to the knee but also to the lower leg
and feet among SSMOs. This study also revealed the BMI was positively
associated with lower and upper body symptoms (OR = 1.1–1.8) and
agreed with similar studies in the literature (Dianat et al., 2015; Gell
et al., 2011; Kaergaard and Andersen, 2000). In the present study,
marital status, daily walking distance to boarding place/factory and
work experience had a significant relationship with musculoskeletal
symptoms in the lower limbs. Married operators had higher symptoms
(OR = 2.0–2.2) than unmarried operators due to being involved in
household work also. Increase in daily walking distance to the boarding
place/factory developed musculoskeletal symptoms (OR = 1.4–49).
Increased work experience as a SSMO developed musculoskeletal
symptoms (OR = 0.6–5.2) in the knee and foot whereas earlier studies
reported that neck and shoulder symptoms were associated with work
experience in sitting posture (Dianat et al., 2015; Öztürk and Esin,
2011). These findings highlight the necessity for deliberation of in-
dividual factors such as the age, BMI, marital status, daily walking
distance to boarding place/factory and work experience in future
analysis of MSDs among SSMO.
The findings revealed that decrease in job satisfaction led to upper
limb symptoms (OR = 1.2–9.4), but not in sitting sewing operations
(Dianat et al., 2015; Dianat and Salimi, 2014). Job satisfaction was
significantly associated with the time available to complete a task and
pauses (Saurin and Ferreira, 2009). In the present study, workers had
limited time to complete a task to maintain smooth material flow and to
cope with other operators whereas sitting sewing operators had enough
buffer inventory and time for completing tasks and pauses. Increase in
stress levels led to musculoskeletal symptoms in the upper limbs and
foot (OR = 1.5–2.6) among SSMO whereas earlier studies considered
work pressure and reported that significant relationship with various

76
T. Sakthi Nagaraj et al.
body parts of sitting sewing operators (Dianat et al., 2015; Öztürk and
Esin, 2011). Work pressure is desirable to complete a task on time
whereas work stress is not. Moreover, work stress leads to headaches,
unmotivated, tears, aggression, fatigue, irritability and depression
(Michie, 2002). In this study, around 80% operators had headaches
which interfered with 65% of operators’ work and was further evidence
of the presence of job stress among SSMOs. Operators interested in job
rotation had lesser symptoms than those who lacked this interest
(OR = 1.1–25). Moreover, decrease in satisfaction with the sewing
machine design developed musculoskeletal symptoms with the
OR = 0.5–3.7. No such association was reported among sitting sewing
operators. These findings provide evidence that both physical and
psychological work factors are related to increased risk of MSDs among
standing sewing machine operators which was in agreement with stu-
dies among sitting sewing operators (Dianat et al., 2015; Öztürk and
Esin, 2011).
Sewing operators working posture was a vital factor related to
musculoskeletal symptoms in a sitting posture (Dianat et al., 2015;
Öztürk and Esin, 2011). The results of the multiple logistic regression
revealed that an increase in working posture risk levels significantly
related to increased musculoskeletal symptoms in different body parts
of SSMOs which was in agreement with other standing operations
(Capodaglio, 2017). This study's REBA grand score indicated that
91.5% of operators were at medium risk and the remaining at high
(6.7%) and very high (1.8%) risk levels which highlighted the need to
evaluate and change operators' work posture to avoid permanent dis-
orders.
The findings of the study revealed that the increase in job strain was
significantly related to increased upper body symptoms (OR = 1.6–32)
among SSMOs. Around 60% of operators were at increased risk of upper
extremity musculoskeletal disorders due to the high frequency of re-
petitive actions, less porosity and awkward hand posture of standing
sewing operations. This finding highlights the need for further ergo-
nomic development to reduce risk of upper extremity disorders and
consideration of SI during ergonomic assessments among SSMOs.
Some general guidelines provided by literature to reduce discomfort
among standing workers: standing only for 1 h with stretching exercise
77
International Journal of Industrial Ergonomics 70 (2019) 70–83
every 30 min for joints (ankles and hip) (Lin et al., 2012), and Coenen
et al. (2017) suggested a safe exposure limit of 40 min of uninterrupted
standing to eliminate low back symptoms and recommended provision
for laying down or sitting in the rest area during breaks. Providing anti-
fatigue mats was recommended to reduce the discomforts due to pro-
longed standing (Coenen et al., 2017). Moreover, Balasubramanian
et al. (2009) recommended the dynamic standing to reduce the risk of
lower extremity disorders.
5. Conclusions
The research improves the understanding about the prevalence of
MSDs and associated ergonomic risk factors which helps for developing
procedures to ensure improved ergonomic working conditions of
SSMOs in the lean environmental textile industry. Since the higher
prevalence of MSDs in both upper and lower body parts among SSMOs
indicate a necessity for pay more attention to enhance their quality of
life. The higher prevalence of MSDs can be reduced by providing anti-
fatigue mats, provision for sitting and laying down in rest area during
breaks, stretching exercises and effective job rotation. Moreover, the
study helps managers to consider associated ergonomic risk factors
while implementation of standing sewing operation layouts and selec-
tion and/or allocation of employees to prevent ergonomics risks. Hence,
the study helps to guide MSD prevention efforts for standing sewing
machine operators in Sri Lanka.
The present study has few limitations, particularly, operators had
only three-year experience in standing sewing machine operations.
Also, limitations related to the reliability and validity of collected data
could lead to recollection bias (where operators may forget data and
bias among the observer and participants). The data were collected
from an industry and the results related to the particular industry which
may differ for other industry. The study can be further extended to
consider organisational and environmental (noise, humidity and light)
factors as confounders. Further research is needed to investigate the
significant impacts of anti-fatigue mats among SSMOs’ discomforts.
Moreover, an empirical study from various garment industries can also
provide the most reliable significant ergonomic risk factors of SSMOs.
 Appendix

Appendix A
Univariate and Multivariate logistic regression analyses of factors related with head, neck, upper back and shoulder symptoms

Variables Head symptoms Neck symptoms Upper back symptoms Shoulder left symptoms Shoulder right symptoms
T. Sakthi Nagaraj et al.

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Age
BMI 1.1 (0.05–0.16) 1.1 (0.01–0.13)
Education Primary school ® 1 1
Secondary school 1 (−0.3–0.36) 0.8 (−0.6–1.5)
Diploma 0.6 (-0.9–-0.02) 0.6 (-1.0–-0.1)
Marital Status Unmarried ®
Married
Daily walking distance Below 1 km ®
1–2 km
2–3 km
SMO Experience Below 1 Year ®
1–2 Year
2–3 Year
Job Satisfaction High ® 1 1 1 1 1 1
Moderate 1 (0.08–0.7) 1.2 (−0.2–0.6) 2.1 (0.36–1.1) 2.8 (0.6–1.4) 2 (0.32–1.1) 2.8 (0.61–1.4)
Low 2.9 (0.65–1.5) 2 (0.1–1.2) 3.5 (0.84–1.7) 4.5 (0.9–2.1) 3.3 (0.8–1.6) 4.7 (0.98–2.1)
Job Stress Low ® 1 1 1 1 1
Moderate 1.1 (−0.2–0.47) 1.4 (−0.03–0.7) 1.5 (0.06–0.8) 1.4 (0.02–0.7) 1.6 (0.12–0.9)

78
High 2 (0.3–1.1) 2.3 (0.42–1.2) 1.8 (0.1–1.1) 2.2 (0.39–1.2) 1.8 (0.11–1.1)
Working very fast No ® 1 1
Yes 1.9 (0.2–1.1) 1.7 (0.08–0.9)
Workload- Always engaged with work No ® 1
Yes 3.2 (0.6–1.7)
Physical porosity- Relaxing in work Yes ® 1 1
No 3.5 (0.6–1.9) 1.9 (0.07–1.3)
Interest in job rotation Yes ® 1 1 1 1
No 4.1 (1.1–1.8) 4.1 (0.89–0.19) 2.4 (0.53–1.2) 2.2 (0.46–1.1)
Satisfaction-Sewing machine design High ® 1 1 1
Moderate 0.6 (-0.9–-0.2) 0.7 (-0.8–-0.1) 0.8 (−0.5–0.2)
Low 2.1 (0.33–1.2) 2.4 (0.43–1.3) 3.2 (0.7–1.6)
REBA Score A 2-3 ® 1 1 1 1 1 1 1 1
4–7 2.2 (0.5–1.1) 2.1 (0.4–1.1) 2 (0.39–0.98) 1.9 (0.3–0.97) 1.9 (0.32–0.9) 1.8 (0.26–0.9) 2 (0.40–1.0) 2 (0.37–1.0)
REBA Score B 1® 1 1 1 1 1 1 1 1
2–3 2.2 (0.39–1.2) 2.4 (0.45–1.3) 2 (0.32–1.1) 1.7 (0.1–0.98) 1.8 (0.2–0.98) 2.1 (0.3–1.2) 1.9 (0.25–1.0) 2.3 (0.39–1.2)
4–7 8.4 (1.7–2.6) 7.2 (1.5–2.5) 4.2 (1.0–1.9) 3.6 (0.8–1.76) 3.3 (0.8–1.6) 3.1 (0.7–1.6) 3.6 (0.85–1.7) 3.4 (0.76–1.7)
REBA Grand Score 4-7 ® 1 1 1 1 1
8–10 4.8 (0.94–2.2) 3.3 (0.49–1.9) 5.8 (1.1–2.4) 5.6 (1.1–2.4) 3.9 (0.61–2.1)
≥11 3.3 (0.05–2.3) 0.6 (−1.8–0.1) 7.2 (0.74–3.2) 11(1.1–3.8) 3.6 (−0.3–2.9)
Strain Index 1-3 ® 1 1 1 1 1 1 1 1 1 1
4–6 1.2 (−0.13–0.5) 1.3 (−0.04–0.6) 1.8 (0.3–0.9) 1.8 (.26–0.9) 2.9 (0.76–1.4) 3.1 (0.78–1.5) 3.2 (0.83–1.5) 3.7 (0.96–1.6) 2.8 (0.73–1.4) 3.2 (0.82–1.5)
≥7 5.4 (1.0–2.4) 5.2 (0.90–2.4) 48 (2.9–4.9) 32 (2.4–4.6) 8.2 (1.4–2.8) 7 (1.2–2.7) 11 (1.8–3.2) 11 (1.6–3.2) 13 (1.9–3.3) 11 (1.6–3.3)

p < 0.05 – Highlighted in bold font (95% confidence level).

® - First category is considered as reference category for multinomial logistic regression analysis.
OR- Odd Ratio at 95% confident interval (CI).
International Journal of Industrial Ergonomics 70 (2019) 70–83
 Appendix B
Univariate and Multivariate logistic regression analyses of factors related with upper arm, forearm and wrist symptoms

Variables Left - Upper arm symptoms Right - Upper arm symptoms Left - Forearm symptoms Right - Forearm symptoms Left - Wrist symptoms Right - Wrist symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate
T. Sakthi Nagaraj et al.

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Age
BMI 1.1 1.1(.01–0.1) 1.1 1.1
(.06–0.2) (.02–0.1) (.01–0.1)
®
Education Primary school
Secondary
school
Diploma
Marital Status Unmarried ®
Married
Daily walking distance Below 1 km ®
1–2 km
2–3 km
SMO Experience Below 1 Year ®
1–2 Year
2–3 Year
Job Satisfaction High ® 1 1 1 1 1 1 1 1 1 1 1
Moderate 1.6 1.98 1.6 2.2 1.1 1.2 1.3 (-.1–0.7) 1.6 2.7 2.4 1.2 (0.4–−.2)
(0.1–0.86) (0.3–1.1) (0.1–0.9) (0.4–1.2) (−0.3–.5) (−0.3–.6) (.07–0.9) (0.6–1.4) (0.4–1.3)
Low 2.6 2.4 2.5 2.9 2.7 1.9 2.7 (0.6–1.4) 2.2 9.4 3.7 2.4
(0.56–1.4) (0.3–1.43) (0.5–1.3) (0.5–1.6) (0.6–1.4) (.08–1.1) (0.2–1.3) (1.8–2.7) (0.7–1.9) (0.5–1.3)
Low ® 1 1 1 1 1 1 1 1 1 1 1 1

79
Job Stress Moderate 1.6 1.69 1.4 1.5 1.5 1.5 1.1 (-.2–0.5) 1.1 (-.3–0.5) 1.5 1.1 0.9 (-.5–0.3) 0.9 (-.5–0.2)
(0.1–0.78) (0.2–0.9) (−0.1–1) (.04–0.8) (.08–0.8) (.04–0.8) (0.1–0.8) (−0.4–.5)
High 1.9 1.8 1.9 1.9 2.8 2.6 2.4 (0.5–1.3) 2.1 4.7 2.6 2.8 (.6–1.5) 2.5
(0.24–1.1) (0.12–1.1) (.2–1.03) (0.2–1.1) (0.6–1.5) (0.5–1.4) (0.3–1.2) (1.1–2.0) (0.4–1.5) (0.5–1.4)
Working very fast No ® 1 1 1 1
Yes 3.9 1.99 1.6 2.4
(0.91–1.8) (.04–1.4) (.06–0.9) (0.5–1.3)
Workload- Always engaged with No ® 1 1 1 1
work Yes 3.3 2.4 29 (2.5–4.3) 1.8
(0.6–1.75) (0.3–1.5) (.01–1.1)
®
Physical porosity- Relaxing in wo- Yes 1 1 1 1
rk No 4.4 1.9 3.1 1.9 (.04–1.3)
(0.85–2.1) (0.1–1.2) (0.5–1.8)
®
Interest in job rotation Yes 1 1 1 1 1 1 1 1 1 1
No 2.1 1.9 2.9 1.9 2.9 (0.7–1.4) 1.1 8 (1.7–2.5) 3.97 (0.8–2) 3.5 3.3 (.7–1.7)
(0.4–1.06) (0.3–.98) (0.7–1.4) (0.1–1.2) (0.2–1.2) (0.9–1.6)
Satisfaction-Sewing machine de- High ® 1 1 1 1 1 1 1 1 1
sign Moderate 0.95 (-.4–0.3) 0.5 (-1–-.3) 0.6 (-.9–−.4) 0.7 (-.6–.04) 0.8 (-.5–0.2) 0.6 (-.9–-.3) 0.5 (-1–-0.3) 0.7 (-.7–.01) 0.8 (-.5–0.2)
Low 1.96 2.3 3.7 2.2 (0.4–1.2) 3.7 1.2 (-.2–0.6) 2.2 1.8 3.2
(0.2–1.1) (0.4–1.3) (0.9–1.8) (0.9–1.8) (0.3–1.3) (.2–1.01) (0.7–1.6)
REBA Score A 2-3 ®
4–7
REBA Score B 1® 1 1 1 1 1 1 1 1 1 1 1 1
2–3 1.8 2.0 (0.3–1.1) 1.7 1.95 1.8 2.1 1.6 (0.1–0.9) 1.8 1.5 1.7 (0.05–1) 2.1 2.3
(0.2–0.95) (0.2–0.9) (.3–1.1) (0.2–.97) (0.3–1.2) (0.1–.98) (.01–0.8) (0.4–1.1) (0.4–1.3)
4–7 4.9 5 (1.1–2.08) 4.9 4.9 3.1 3.6 3.5 (0.8–1.7) 4 (0.9–1.86) 1.7 2.1 3.3 3.7
(1.15–2.0) (1.2–2.0) (1.1–2.1) (0.7–1.6) (0.8–1.8) (.1–0.96) (0.3–1.2) (0.8–1.6) (0.8–1.8)
REBA Grand Score 4-7 ® 1 1 1 1 1 1 1 1 1 1 1 1
8–10 9.78 (1.6–3) 4.9 (0.98–2) 3.4 (.5 1.96)
International Journal of Industrial Ergonomics 70 (2019) 70–83

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 Appendix B (continued)

Variables Left - Upper arm symptoms Right - Upper arm symptoms Left - Forearm symptoms Right - Forearm symptoms Left - Wrist symptoms Right - Wrist symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate
T. Sakthi Nagaraj et al.

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

8.1 7.8 7.1 3.2 8.5 4.9 2.4 6.9 8.8

(1.44–2.7) (1.4–2.7) (1.2–2.7) (1.2–2.4) (1.5–2.9) (0.9–2.3) (0.3–1.5) (1.3–2.6) (.01–2.8)
≥11 10.4 3.9 (-.1–2.8) 15.3 (1.3–4) 4.9 (-.04–3) 7.4 4.2 4.9 (0.5–2.7) 2 (−0.61–2) 2 (−0.4–1.9) 1.8 (0.81–2) 8.4 4.1
(1.1–3.6) (0.9–3.1) (0.1–2.8) (0.9–3.3) (1.5–2.9)
®
Strain Index 1-3 1 1 1 1 1 1 1 1 1 1 1 1
4–6 2.2 2.4 (0.5–1.2) 2.3 2.4 1.5 1.7 2.1 (0.4–1.0) 2 (0.4–1.08) 1.2 1.3 1.7 1.6
(0.48–1.1) (0.5–1.1) (0.5–1.2) (0.1–0.7) (0.2–0.3) (−0.1–.5) (−0.1–.6) (0.2–0.8) (.14–0.8)
≥7 13.4 6.7(1.1–2.7) 15.6 (2–3.5) 8.8 4.9 2.3 5.1 (0.1–2.3) 3 (0.4–1.85) 2.5 2.5 8.4 5.88 (1–2.6)
(0.5–1.1) (1.4–3.0) (.95–2.2) (0.1–1.6) (0.3–1.6) (0.1–1.7) (1.5–2.8)

p < 0.05 – Highlighted in bold font (95% confidence level).

® - First category is considered as reference category for multinomial logistic regression analysis.
OR- Odd Ratio at 95% confident interval (CI).

Appendix C
Univariate and Multivariate logistic regression analyses of factors related with lower back, thigh and knee symptoms

Variables Lower back symptoms Left - Thigh symptoms Right - Thigh symptoms Left - Knee symptoms Right - Knee symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

80
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Age 1.1 (0.08–0.17) 1.1(0.07–0.18) 1.2 (0.1–0.18) 1.2(0.09–0.19)

BMI 1.2 (.08–0.2) 1.1 (0.04–0.2) 1.2 (0.1–0.3) 1.3 (0.2–0.3) 1.5 (0.4–0.5) 1.6 (0.36–0.51) 1.6 (0.39–0.54) 1.8(0.49–0.67) 1.5 (0.29–0.42) 1.5(0.35–0.49)
®
Education Primary school 1
Secondary school 0.9 (−0.4–0.25)
Diploma 0.6 (-0.98–-0.1)
Marital Status Unmarried ® 1 1 1 1
Married 2.1 (0.38–1.1) 2.9 (0.6–1.53) 2.2 (0.43–1.2) 2 (0.25–1.1)
Daily walking distance Below 1 km ® 1 1 1 1 1 1 1 1
1–2 km 1.7 (0.1–.98) 1.4 (−0.1–.8) 2.8 (0.6–1.5) 2.5 (0.41–1.43) 2.8 (0.55–1.5) 2.5 (0.3–1.45) 3.9 (1.2–2.1) 5.8 (1.2–2.3)
2–3 km 14 (2.2–3.2) 21 (2.5–3.6) 3.4 (0.8–1.7) 3.7 (0.83–1.77) 4 (0.93–1.8) 8.1 (1.5–2.7) 4.7 (1.1–2.0) 6.5 (1.4–2.4)
SMO Experience Below 1 Year ® 1 1 1 1 1
1–2 Year 0.6 (-.8–-0.2) 1.3 (−0.1–0.59) 2 (0.31–1.1) 0.8 (-.62–0.05) 0.9 (−0.5–0.23)
2–3 Year 0.8 (−0.6–.2) 2.8 (0.57–1.5) 5.2 (1.05–2.2) 1.9 (0.21–1.1) 1.9 (0.14–1.1)
Job Satisfaction High ® 1 1 1 1 1 1 1
Moderate 0.5 (-1–-0.3) 0.6 (-.9–-0.1) 0.6 (.9–-.14) 0.6 (-.92–-0.09) 0.6 (-0.9–-0.14) 0.5 (-1.2–-0.3) 0.7 (-0.78–-0.05)
Low 0.7 (-.7–−0.3) 1.1 (−0.5–0.6) 0.7 (0.8–.03) 0.7 (−0.96–0.18) 0.9 (−0.6–0.28) 0.5 (-1.3–-0.01) 0.7 (−0.7–0.09)
Low ®
Job Stress Moderate
High
Working very fast No ®
Yes
Workload- Always engaged with work No ® 1
Yes 1.9 (0.07–1.2)
Physical porosity- Relaxing in work Yes ®
No
Interest in job rotation Yes ® 1 1
International Journal of Industrial Ergonomics 70 (2019) 70–83

(continued on next page)

 Appendix C (continued)

Variables Lower back symptoms Left - Thigh symptoms Right - Thigh symptoms Left - Knee symptoms Right - Knee symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate
T. Sakthi Nagaraj et al.

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

No 2 (0.35–1.1) 3.6 (0.69–1.9)

Satisfaction-Sewing machine design High ® 1 1 1 1 1 1 1 1
Moderate 1.1 (0.3–0.5) 1.3 (-.1–.57) 1.5 (.06–.79) 0.9 (−0.5–0.2) 1.1 (−0.2–0.46) 1.4 (0.21–1.0) 1.1 (−0.25–.43) 1.5 (0.01–0.76)
Low 3.9 (0.9–1.8) 2 (0.3–1.1) 1.6 (-.02–0.9) 1.8 (0.17–1) 2.2 (0.35–1.2) 1.6 (-.04–0.97) 2 (.26–1.1) 1.5 (−0.7–0.81)
REBA Score A 2-3 ® 1 1 1 1 1.5 (0.06–0.68) 1 1
4–7 1.4 (.05–.7) 2.1 (0.5–1.1) 1.8 (.23–0.9) 1.4 (.04–.64) 1 1.7 (0.25–0.85) 1.6 (0.10–0.80)
REBA Score B 1® 1 1 1 1
2–3 1.7 (0.2–.9) 1.6 (.06–0.9) 1.4 (−0.7–0.69) 1.1 (-.37–0.48)
4–7 3.3 (0.8–1.6) 2.8 (0.6–1.5) 1.8 (0.17–1.0) 1.7 (0.05–0.99)
REBA Grand Score 4-7 ® 1 1 1 1 1 1 1 1
8–10 5.9 (1.1–2.5) 4.8 (0.8–2.4) 3.9 (0.74–2) 2.3 (0.1–1.6) 1.9 (.01–1.2) 2.3 (0.18–1.5) 2.3 (0.04–1.6) 2 (0.08–1.3)
≥11 3.8 (0.1–2.5) 0.6 (-2–1.1) 15 (1.2–4.3) 3.9 (−0.4–3.1) 1.6 (-.7–1.58) 2.3 (−0.43–2.0) 1.2 (−1.4–1.7) 1.8 (-.56–1.7)
Strain Index 1-3 ® 1 1 1 1 1
4–6 1.9 (0.3–0.9) 1.9 (0.3–.97) 1.5 (.08–0.7) 1.4 (0.0–0.7) 1.2 (-.13–0.5)
≥7 23 (2.2–4.1) 18 (1.9–4.0) 10 (1.7–3.2) 9.2 (1.3–3.1) 3.2 (.49–1.8)

p < 0.05 – Highlighted in bold font (95% confidence level).

® - First category is considered as reference category for multinomial logistic regression analysis.
OR- Odd Ratio at 95% confident interval (CI).

81
Appendix D
Univariate and Multivariate logistic regression analyses of factors related with hip/buttock, lower leg and foot symptoms

Variables Hip/Buttocks symptoms Left - Lower leg symptoms Right - Lower leg symptoms Left - Foot symptoms Right - Foot symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Age 1.1 (0.03–.11) 1.1 1.1 (0.01–0.10) 1.1 (0.05–0.14) 1.1 1.1 (0.08–0.17) 1.2 (0.11–0.23)
(0.03–0.10) (0.06–0.19)
BMI 1.2 (.08–.22) 1.1 1.4 (0.30–0.43) 1.7 1.5 1.7 (0.45–0.61) 1.37 (0.24–0.38) 1.7 1.3 (0.22–0.36) 1.5 (0.32–0.50)
(0.01–0.17) (0.46–0.64) (0.41–0.55) (0.41–0.62)
®
Education Primary school 1 1
Secondary 1 (−0.3–0.36) 1 (0.41–0.30)
school
Diploma 0.6 (-0.9–- 0.6 (-0.98–0.05)
0.02)
®
Marital Status Unmarried 1 1 1 1 1 1
Married 3.7 (0.93–1.7) 22 (2.6–3.7) 2.1 (0.37–1.1) 3.2 (0.71–1.60) 1.6 (0.06–0.83) 2.2 (0.25–1.3)
Daily walking distance Below 1 km ® 1 1 1 1
1–2 km 2.3 (0.4–1.29) 2 (0.19–1.17) 1.9 (0.18–1.13) 1.6 (−0.1–1.04)
2–3 km 5.1 (1.2–2.1) 11 (1.88–2.90) 47 (2.68–5.0) 49 (2.98–5.2)
SMO Experience Below 1 Year ® 1 1 1
1–2 Year 0.8 0.7 (-0.73–0.03) 0.6 (-0.9–-0.07)
(−0.7–0.23)
2–3 Year 3.1 (0.4–1.86) 1.4 2.1 (0.1–1.42)
(−0.12–0.82)
®
Job Satisfaction High 1 1 1 1 1 1
International Journal of Industrial Ergonomics 70 (2019) 70–83

(continued on next page)

 Appendix D (continued)

Variables Hip/Buttocks symptoms Left - Lower leg symptoms Right - Lower leg symptoms Left - Foot symptoms Right - Foot symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate Univariate Multivariate
T. Sakthi Nagaraj et al.

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Moderate 0.6 (-0.96–- 0.5 (-1.1–-0.2) 0.6 (-0.9–- 0.6 (-1.2–-0.18) 0.65 (-0.8–-0.03) 0.6 (-0.88–- 0.5 (-1.1–-0.15)
0.2) 0.15) 0.10)
Low 0.7 0.6 0.9 (-.48–0.33) 0.6 2.44 (0.39–1.4) 1.7 (0.07–0.98) 0.8
(−0.7–0.09) (−1.1–0.16) (−1.08–0.07) (−0.86–0.48)
®
Job Stress Low 1 1 1 1
Moderate 0.86 0.9 0.9 0.8 (−0.68–0.2)
(−0.52–0.23) (−0.6–0.34) (−0.51–0.21)
High 2.95 (0.57–1.6) 2.3 (0.13–1.5) 2.6 (0.47–1.4) 2.3 (0.22–1.4)
Working very fast No ®
Yes
Workload- Always engaged with No ® 1 1
work Yes 1.89 (0.06–1.2) 5.5 (0.04–3.4)
Physical porosity- Relaxing in work Yes ®
No
Interest in job rotation Yes ® 1 1 1 1 1 1 1 1
No 1.5 (0.09–0.77) 2.6 (0.37–1.5) 2.0 3.4 (0.69–1.77) 26.5 (2.4–4.1) 35 (2.8–4.3) 6 (1.4–2.3) 15 (2.0–3.4)
(0.35–1.03)
Satisfaction-Sewing machine design High ® 1 1 1 1 1 1 1 1
Moderate 1 (−0.5–0.5) 0.9 (−0.45-. 0.8 (-.59–0.08) 1 (−0.41–0.33) 0.92 1.1 (0.39–0.57) 0.7 (−0.71–0.0) 0.6 (-0.9–-0.04)
23) (−0.45–0.29)
Low 3.8 (0.78–1.9) 2.3 (0.4–1.28) 3 (0.67–1.58) 2.6 (0.46–1.41) 1.89 (0.15–1.1) 2.4 (0.24–1.5) 2.3 (0.35–1.31) 3.8 (0.7–1.94)
REBA Score A 2-3 ® 1 1 1 1

82
4–7 1.5 (0.11–0.71) 1.4 (0.01–0.6) 1.5 (0.09–0.73) 1.5 (0.01–0.84)
REBA Score B 1® 1 1 1 1 1
2–3 1.8 1.7 1.6 (0.06–0.83) 1.7 (0.16–0.9) 1.5 (0.02–0.82)
(0.04–1.1) (−0.08–1.1)
4–7 2.9 2.1 (0.07–1.4) 1.3 1.4 (-.05–0.78) 1.4 (−0.1–0.77)
(0.51–1.6) (−0.2–0.68)
REBA Grand Score 4-7 ® 1 1
8–10 7.3 (1.4–2.6) 5.1 (0.88–2.4)
≥11 10 (1.2–3.5) 1.1 (−1.3–1.5)
Strain Index 1-3 ®
4–6
≥7

p < 0.05 – Highlighted in bold font (95% confidence level).

® - First category is considered as reference category for multinomial logistic regression analysis.
OR- Odd Ratio with 95% confident interval (CI).
International Journal of Industrial Ergonomics 70 (2019) 70–83
T. Sakthi Nagaraj et al.
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