Applied Ergonomics 51 (2015) 180e188

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Applied Ergonomics
journal homepage: www.elsevier.com/locate/apergo

Association of individual and work-related risk factors with

musculoskeletal symptoms among Iranian sewing machine operators
Iman Dianat a, *, Madeh Kord b, 1, Parvin Yahyazade b, 1, Mohammad Ali Karimi c, 2,
Alex W. Stedmon d, 3
a
Department of Occupational Health, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran
b
Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
c
Islamic Azad University, Bushehr Branch, Bushehr, Iran
d
Human Systems Integration Group, Faculty of Engineering & Computing, Coventry University, UK

a r t i c l e i n f o a b s t r a c t

Article history: This cross-sectional study evaluated working conditions and the occurrence of self-reported musculo-
Received 5 February 2014 skeletal symptoms among 251 Iranian sewing machine operators. A questionnaire and direct observa-
Accepted 27 April 2015 tions of working postures using the rapid upper limb assessment (RULA) method were used. A high
Available online 28 May 2015
prevalence of musculoskeletal symptoms, particularly in the neck/shoulders, back and hands/wrists were
found. The mean RULA grand score of 5.7 highlighted a poor sewing workstation design and indicated
Keywords:
that most operators (with posture assessed at action level 3) needed an investigation and changes in
Sewing operation
their working habits soon. Work-related factors (including number of years worked as an operator,
MSDs
RULA
prolonged working hours per shift, long duration of sitting work without a break, feeling pressure due to
work and working postures) and individual factors (including age, gender, BMI and regular sport/physical
activities) were associated with musculoskeletal symptoms in multiple logistic regression models. The
findings add to the understanding of working conditions of those jobs involving sewing activities and
emphasise the need for ergonomic interventions to reduce musculoskeletal symptoms in the future.
© 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

1. Introduction of risk factors including physical, psychosocial, organizational and

Musculoskeletal disorders (MSDs) are a major health problem in
both industrialized and industrially developing countries (Buckle
and Devereux, 2002; Colombini and Occhipinti, 2006; Oztürk € and
Esin, 2011; Nazari et al., 2012; Widanarko et al., 2014). MSDs have
considerable impact on both individuals and countries worldwide
(Coury et al., 2000) and, more specifically, work-related MSDs have
been recognised as a significant problem within the European
Union in terms of individual ill health and economic factors such as
impact on production and revenues (Buckle and Devereux, 2002).
This also seems to be the case in other parts of the world such as the
United States and Asia (Lewis et al., 2002; Oh et al., 2011). A number
* Corresponding author. Tel.: þ98 41 33357580; fax: þ98 41 33340634.
E-mail addresses: dianati@tbzmed.ac.ir (I. Dianat), madeh.kord@yahoo.com
(M. Kord), pyzade@yahoo.com (P. Yahyazade), karimi_a@live.com (M.A. Karimi),
alex.stedmon@coventry.ac.uk (A.W. Stedmon).
1
Tel.: þ98 33357581; fax: þ98 41 33340634.
2
Tel.: þ98 9177742003; fax: þ98 771 5559858.
3
Tel.: þ44 (0) 2477 657 390.
socio-demographic aspects have been identified as being associ-
ated with the development of MSDs among different occupational
groups, particularly in those involved in sedentary and repetitive
activities (McLean et al., 2001; Buckle and Devereux, 2002;
Fogleman and Lewis, 2002; Johnston et al., 2008; Dianat and
Salimi, 2014). Prevention of MSDs is, therefore, one of the most
important factors that can have a major impact on productivity
enhancement and on promotion of health and safety at work (Kogi
et al., 2003).
With specific reference to sewing machine operators, this is an
occupational group that may experience a high prevalence of MSDs
€
(Wang et al., 2007; Oztürk and Esin, 2011; Sealetsa and Thatcher,
2011) that is often attributable to poor working postures that
have to be maintained during the whole working period as well as
to repetitive hand and arm movements that characterise this kind
of work (Li et al., 1995). Typically, sewing machinists perform
pieceework activities, assembling component parts of a final
garment or product. The fragmentation of work in this way means
that the task are often highly repetitive, potentially dangerous and

http://dx.doi.org/10.1016/j.apergo.2015.04.017
0003-6870/© 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188
complex task involving the coordination of both hands, usually
performed in a seated working posture for a long period of time.
The operation usually requires the operator to lean forward (with a
forward inclined posture of both head and trunk) to focus their
attention and have better visual control of the task. In many ways,
given the fixed nature of the sewing machine, the machinists has to
adapt their posture and viewing angle so that they can conduct this
form of ‘precision work’ (Kroemer, 2009) and this can lead to the
development of MSDs, particularly in the back, neck and upper
limbs (Serratos-Perez and Mendiola-Anda, 1993; Oztürk€ and Esin,
2011; Sealetsa and Thatcher, 2011).
The textile industry in Iran is one of the oldest and largest in-
dustries, which employs more than 10% of all workers in Iran's
manufacturing sector, and accounts for approximately 6% of the
total industrial production of the country (Iranian Statistics Centre,
2002). The textile industry, which is dominated by small and me-
dium enterprises (SMEs), is regarded as a very labour-intensive
industry. While the occupational health and safety programmes
in developing countries have mainly focused on large-scale in-
dustries, SMEs in these countries are a major and very much
neglected sector in occupational health research (McCann, 1996). A
better understanding of the occupational hazards and their control
measures in this sector has the potential for a notable impact on
national productivity and workers' quality of life. Currently, there is
limited research on the occurrence of MSDs and the associated risk
factors among the Iranian sewing machine operators. The findings
from research in this area will help to better understand the
working conditions of those jobs involving sewing operation and to
assist in introducing preventative measures and developing
guidelines in this regard. It also has the potential to inform work
practises in other developing nations with similar industrial sectors
(e.g. the Far East).
1.1. Rationale
Having provided an overview of the textile industry in Iran and
the potential of this work to lead to MSDs research was conducted
to investigate the following factors:
 evaluate the MSD risk levels associated with typical sewing
machinist operating postures,
 evaluate the frequency and severity of musculoskeletal symp-
toms among sewing machine operators,
 evaluate the association between musculoskeletal symptoms
and contributing individual and work-related factors.
2. Materials and methods
2.1. Study design and procedure
A cross-sectional, descriptive-analytical study was conducted
over a five-month period between July and November, 2012. The
study setting was in three provinces of western Iran (e.g. East
Azerbaijan, Kermanshah and Kordestan). Data on the number of
sewing machine operators in the study area was obtained from the
Iranian Ministry of Industries and Mines. There were a total of
approximately 5000 operators involved in sewing machine oper-
ating tasks in the study region who worked at approximately 470
different workshops. Sampling was done by a multi-stage random
selection process. The first stage was to select workshops (n ¼ 60)
using probability proportion to size sampling method. The number
of operators in each of these selected workshops ranged from 6 to
15, with a total of 525. Using the same procedure, 251 participants
(151 males and 100 females) were then selected from these
workshops. Each participant was familiarised with the study
181
procedure and any questions were answered by the investigator. A
written informed consent form was signed by each operator before
participation in the study. The participation was strictly on a
voluntary basis and the operators were under no obligation to
complete the study. The data collection was performed using a
questionnaire and direct observation of the operators during their
work. The operators were not paid for their participation. The study
protocol was reviewed and approved by the ethical review com-
mittee of Tabriz University of Medical Sciences.
2.2. Data collection
Data for demographic, work-related and musculoskeletal
symptoms were recorded using a questionnaire. Demographic de-
tails included: age, gender, height, weight, body mass index (BMI as
weight/height2), educational level (illiterate, primary school, sec-
ondary school and diploma), marital status (single or married) as
well as individual habits such as being involved in regular sport and
physical activities each week and smoking habits of the re-
spondents. The questions regarding the work-related items were
based on the relevant literature (Westgaard and Jansen, 1992; Li
€
et al., 1995; Herbert et al., 2001; Oztürk and Esin, 2011; Dianat
and Salimi, 2014) and included: number of years worked as an
operator, number of hours worked per day and week, job satis-
faction based on the survey question: “How much are you satisfied
with your job? low, moderate and high”, perceived speed of work:
“Does your work require you to work very fast? yes/no”, duration of
continuous work without a break (>10 min): “How many hours do
you usually work without breaks (breaks > 10 min)?”, and
perceived pressure due to work: “Do you feel pressure due to work?
yes/no”. There were also questions regarding the workstation
design including the use of adjustable chairs (yes/no) and opera-
tors' satisfaction with the design of sewing machines and tables
(with response alternatives: low, moderate and high).
The frequency of musculoskeletal symptoms in different body
regions was measured using the standardised Nordic Musculo-
skeletal Disorders Questionnaire (Kuorinka et al., 1987). This
questionnaire was translated and revised into Farsi and has an
established validity and reliability (Dianat et al., 2013, 2014; Dianat
and Karimi, 2014). The respondents were asked to indicate if they
had experienced any ache, pain, discomfort or numbness in the last
12 months for different body regions using a body map. Those
operators who reported musculoskeletal symptoms in any of the
body regions were also asked to indicate the severity of these in
each of the different body areas, using a scale of 0 e no pain to 5 e
very high pain. The questionnaire was administered by one of the
authors interviewing the operators and took approximately 15 min
to complete.
The questionnaire was tested through a pilot study on a sample
of 30 participants and minor word modifications were made on
some items of the questionnaire. The test-retest reliability (stabil-
ity) of the items of the questionnaire was evaluated with Kappa
coefficients. The kappa coefficients ranged from 0.82 to 0.99, indi-
cating a good reliability of the measure.
In addition to these data, Rapid Upper Limb Assessment (RULA)
(McAtamney and Corlett, 1993) was used to evaluate the working
postures of operators at their workstations. RULA, as a reliable and
validated observational method, can be used for assessment of
biomechanical and postural loading on the musculoskeletal system
which is known to contribute to MSDs. This method was designed
for assessing the severity of postural loading and is particularly
applicable to sedentary jobs (Li and Buckle, 1999) similar to the
sewing tasks in the present study. In this method, work postures
are selected in relation to their perceived severity, frequency of
occurrence or other such criteria and a score is calculated for
182 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188

different body regions that are then used to calculate an overall of-fit test. For all statistical tests, p < 0.05 was considered as sta-
‘Grand Score’ which relates to one of four action levels: tistically significant.

 Action Level 1 ¼ a score of one or two indicates that the posture 3. Results
is acceptable if it is not maintained or repeated for long period.
 Action Level 2 ¼ a score of three or four indicates that further 3.1. Demographic data
investigation is needed and changes may be required.
 Action Level 3 ¼ a score of five or six indicates that investigation Table 1 shows the demographic details of the study participants.
is needed and changes are required soon. The age of participants ranged from 18 to 64 years (mean ¼ 33.2
 Action Level 4 ¼ a score of seven or more indicates that inves- years; SD ¼ 9.9 years). Most of the participants were married
tigation and changes are required immediately. (74.5%) and had a mean BMI of 24.1 kg/m2 (SD ¼ 4.1 kg/m2,
range ¼ 13.1e36.0 kg/m2). Among them, 4.0% were illiterate, 47.0%
The observations and recordings of postures in the present had primary school education, 33.5% had secondary education and
study were performed by two trained observers. Although the 15.5% had diploma. The majority of operators (74.5%) reported that
sewing machine operations required a fairly static posture, the they were not involved in regular sport and physical activities.
investigators made sure to examine the longest adopted posture
during the task cycle for each individual. A separate RULA assess- 3.2. Job characteristics
ment sheet was used for each operator for recording the RULA
scores. The job characteristics of sewing machine operators are pre-
sented in Table 2. The operators had been working in their current
2.3. RULA reliability and validity job between 1 and 42 years (mean ¼ 12.6 years; SD ¼ 9.5 years).
The mean daily and weekly working hours spent on sewing gar-
The original version of RULA checklist was translated and ments (shirts, pants, jackets, etc.) were 9.1 (SD ¼ 1.5) and 54.5
revised into Farsi by Dianat and Salimi (2014). This version was (SD ¼ 11.0) hours, respectively. The majority of participants (60.2%)
used in this study. The inter-rater reliability of the RULA scores reported more than 2 h of continued work without a break
using Kappa coefficients was found to be ‘good’ (with Kappa co- (>10 min) during a daily shift (range ¼ 14 h). All of the partici-
efficients ranging from 0.78 to 0.92 for RULA scores). Moreover, the pants were paid on a piece-rate salary system. A large proportion of
results of Chi-square tests which evaluated the association between the participants indicated that they feel pressure because of work
individual body part scores and the reported pain or discomfort in (89.6%) and had to work very fast (84.5%). Only 10% of the operators
€
the corresponding body region (Massaccesi et al., 2003; Oztürk and had adjustable chairs and less than one-third of them were highly
Esin, 2011), confirmed that the RULA scores provided a good indi- satisfied with the design of sewing machines and tables.
cation of the musculoskeletal loading sustained by the operators.
3.3. RULA assessments of working postures
2.4. Data analysis
Table 3 shows the percentages of operators with each RULA
score, including the RULA scoring for the two different regions of
The analysis of the data, including descriptive statistics was
the body and for the grand score. The upper arms score of the
carried out using SPSS software version 14.0 (SPSS Inc., Chicago, IL,
operators was generally 3, a result that was characterized by the
USA). Demographic data and job characteristics of the study pop-
upper arms being slightly abducted and flexed between 20 and
ulation were presented as mean (SD), range and percentages. Chi
45 . The lower arms score for the majority of operators was also 3,
square and t-test analyses were used to evaluate any gender dif-
ferences. The relationships between the prevalence of musculo-
skeletal symptoms and study variables (demographic and job Table 1
characteristics) was initially assessed using univariate logistic Demographic details of sewing machine operators (n ¼ 251).
regression analyses. Multiple logistic regression analysis was also Variables
performed using backward stepwise procedure to estimate the
Gender (n (%))
association between independent variables and self-reported Male 151 (60.2)
musculoskeletal symptoms for each body region (e.g. different Female 100 (39.8)
regression models were developed for different body parts) in the Age (years)
multivariate context. The independent variables in the logistic Mean (SD) 33.2 (9.9)
Range 18e64
regression models included demographic (age, gender, BMI,
Body mass index (BMI) (kg/m2)
educational level, marital status, smoking and time spent on sport/ Mean (SD) 24.1 (4.1)
physical activities each week) and job characteristics (number of Range 13.1e36.0
years worked as an operator, daily working hours, job satisfaction, Marital status (n (%))
perceived speed of work, duration of continuous work without a Single 64 (25.5)
Married 187 (74.5)
break, perceived pressure due to work, use of adjustable chairs, and Educational level (n (%))
satisfaction with the design of sewing machines and tables) as well Illiterate 10 (4.0)
as three RULA scores including RULA score A (arm/wrist score), Primary school 118 (47.0)
RULA score B (neck/trunk/leg score) and final RULA grand score. Secondary school 84 (33.5)
Diploma 39 (15.5)
Since all of these variables were theoretically of equal importance,
Regular sport/physical activity (n (%))
an equal role was assigned for all of them in the regression models, Yes 64 (25.5)
and therefore no adjusting factor was considered in each model. No 187 (74.5)
The odds ratios (ORs) and 95% confidence intervals (CIs) were Smoking (n (%))
calculated from the multiple logistic regression models. The fit of Yes 51 (20.3)
No 200 (79.7)
the models was confirmed by the HosmereLemeshow goodness-
 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188 183

Table 2 The final RULA grand score ranged from a minimum of 4 to a

Job characteristics of sewing machine operators (n ¼ 251). maximum of 7 with an average score of 5.7 (SD ¼ 0.62). For the
Variables majority of operators (90.9%), the final RULA grand scores were
Number of years worked as an operator
determined to be 5 (30.7%) or 6 (60.2%), which indicates an action
Mean (SD) 12.6 (9.5) level of 3. The percentage of machinists with a final RULA grand
Range 1e42 score at action level 4 was 6.4%. Additionally, none of the operators
Daily working hours had a final RULA grand score of 1 or 2 (e.g. an acceptable working
Mean (SD) 9.1 (1.5)
posture). The mean arm/wrist score (score A) was higher in men
Range 5e11
Weekly working hours than in women (4.9 and 4.0, respectively; p < 0.001), although
Mean (SD) 54.5 (11.0) women's mean neck/trunk/leg score (score B) was higher than men
Range 32e66 (4.1 and 2.9, respectively; p < 0.001). Women also received higher
Working very fast (n (%))
RULA grand scores than men (mean 6.1 and 5.4, respectively,
Yes 212 (84.5)
No 39 (15.5)
p < 0.001).
Job satisfaction (n (%))
Low 4 (1.6) 3.4. Prevalence of musculoskeletal symptoms
Moderate 102 (40.6)
High 145 (57.8)
Duration of continuous work without break (>10 min) Tables 4 and 5 show the prevalence of musculoskeletal symp-
<1 h 33 (13.1) toms in different body regions reported by the sewing machine
1e2 h 67 (26.7) operators. A total of 79.6% of the machinists (80.1% males and 79%
>2 h 151 (60.2) females) reported some form of musculoskeletal symptom at some
Range 1e4
Feeling pressure due to work (n (%))
time during the 12 months preceding the data collection. Ninety-
Yes 225 (89.6) one percent of those who reported symptoms indicated more
No 26 (10.4) than one location of pain or discomfort. The most commonly
Use of adjustable chairs affected body regions were low back (58.9%), neck (54.1%), hands/
Yes 27 (10.8)
wrists (40.2%), upper back (37.8%) and shoulders (27.8%). More
No 224 (89.2)
Satisfaction with sewing machine/table design males than females reported symptoms in their upper back, while
Low 77 (30.7) the frequency of hand/wrist symptoms was higher in females than
Moderate 102 (40.6) in males (p < 0.01). The prevalence of shoulder (p < 0.05), knee and
High 72 (28.7) ankle/foot (p < 0.01) symptoms increased with age.
RULA A score (%)
1e4 104 (41.4)
5 147 (58.6) 3.5. Severity of musculoskeletal symptoms
RULA B score (%)
1e4 235 (93.6)
Regarding the severity of complaints, moderate to severe
5 16 (6.4)
RULA grand score (%)
symptoms (3 or 4 on the scale of 0e5) in the low back, neck and
1e4 7 (2.8) upper back areas seemed to be reported more frequently than other
5 244 (97.2) body regions (as shown in Tables 4 and 5). The mean rating of the
severity of complaints in the low back, neck and upper back areas
were 3.8, 3.3 and 3.1, respectively. The severity of ratings for the
and reflected the need for machinists to extend their arms across upper back, low back and hands/wrists (p < 0.01) were found to
the midline of the body with elbow flexion more than 100 . The differ between males and females (Table 4). The severity of symp-
wrist score was generally between 3 and 4, with the wrists in toms for the neck, low back and knees also increased by age group
extension (sagittal plane) of 15 or more. The neck and trunk scores (p < 0.01) (Table 5).
of 2 and 3 for the majority of the machinists also indicated a high
proportion of neck and trunk flexation of more than 20 to the 3.6. Risk factors for self-reported musculoskeletal symptoms
front. However, the most common postures of the legs were
determined to be within normal limit which supported the use of The results of univariate and multiple logistic regression ana-
RULA assessments in the first instance (with its focus on the upper lyses of factors associated with MSDs in different body regions are
body). A typical working posture of an operator at his workstation shown in Table 6 and 7. The results of multiple logistic regression
is illustrated in Fig. 1. analyses indicated that the number of years worked as an operator,

Table 3
Distribution of RULA scoring for study participants (n ¼ 251).

RULA score Mean (SD)

1 2 3 4 5 6 7

n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Upper arms 3 (1.2) 4 (1.6) 244 (97.2) e e e e 2.9 (0.25)

Lower arms e 5 (2.0) 246 (97.6) e e e e 2.9 (0.14)
Hands/wrists e 7 (2.8) 104 (41.4) 140 (55.8) e e e 3.5 (0.55)
Neck e 88 (35.1) 163 (64.9) e e e e 2.6 (0.47)
Trunk e 137 (54.6) 109 (43.4) 5 (2.0) e e e 2.4 (0.53)
Legs 235 (93.6) 16 (6.4) e e e e e 1.0 (0.24)
A score e e e 104 (41.4) 147 (58.6) e e 4.5 (0.49)
B score e 83 (33.1) e 152 (60.6) 16 (6.4) e e 3.4 (1.01)
Grand score e e e 7 (2.8) 77 (30.7) 151 (60.2) 16 (6.4) 5.7 (0.62)
184 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188

Fig. 1. Typical working posture of an operator at his workstation.

Table 4
Musculoskeletal symptoms reported by gender (n ¼ 251).

Body region Prevalence of symptoms Pain severity (scale 0e5)

Men Women All Men Women All

n (%) n (%) n (%) Mean (SD) Mean (SD) Mean (SD)

Neck 85 (56.2) 51 (51.0) 136 (54.1) 3.5 (1.01) 3.1 (0.75) 3.3 (0.93)
Shoulders 46 (30.4) 24 (24.0) 70 (27.8) 2.7 (0.48) 2.4 (0.63) 2.6 (0.80)
Elbows 14 (9.3) 3 (3.0) 17 (6.7) 2.2 (0.48) 2.2 (0.49) 2.2 (0.53)
Hands/wrists 50 (33.1) 51 (51.0) 101 (40.2)b 2.1 (0.37) 2.9 (0.58) 2.6 (0.68)b
Upper back 64 (42.3) 31 (31.0) 95 (37.8)b 3.7 (0.95) 2.2 (0.51) 3.1 (0.94)b
Low back 93 (61.5) 55 (55.0) 148 (58.9) 4.4 (1.13) 3.6 (0.74) 3.8 (0.92)b
Hips/thighs/buttocks 25 (16.5) 13 (13.0) 38 (15.1) 2.4 (0.35) 2.1 (0.36) 2.2 (0.62)
Knees 32 (21.2) 19 (19.0) 51 (20.3) 2.4 (0.78) 2.8 (0.82) 2.6 (0.89)
Ankles/feet 41 (27.2) 22 (22.0) 63 (25.0) 2.8 (1.21) 2.9 (0.88) 2.6 (0.95)

Any regiona 121 (80.1) 79 (79.0) 200 (79.6) e e e

a
Musculoskeletal symptoms in any of the nine body regions.
b
P <0.01.

number of hours worked per day, duration of continuous work
without a break, feeling pressure due to work, and working pos-
tures (assessed by the RULA method), as well as individual factors
including age, gender, BMI and being involved in regular sport and
physical activities were significantly associated with the presence
of musculoskeletal symptoms of different body regions. However,
no significant association was found between the fast working, job
satisfaction, use of adjustable chairs, operators' satisfaction with
the design of sewing machines and tables, marital status, educa-
tional level and smoking habits and the reported symptoms.
4. Discussion
The findings of the present study add to the understanding of the
working conditions of sewing machine operators with respect to the
occurrence of musculoskeletal symptoms and their associated risk

Table 5
Musculoskeletal symptoms reported by age (n ¼ 251).

Prevalence of symptoms Pain severity (scale 0e5)

18e25 yrs 26e40 yrs >40 yrs All 18e25 yrs 26e40 yrs >40 yrs All

n (%) n (%) n (%) n (%) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Neck 29 (49.1) 72 (52.1) 35 (64.8) 136 (54.1) 3.1 (0.99) 3.1 (0.83) 3.7 (0.98) 3.3 (0.93)b
Shoulders 12 (20.3) 35 (25.3) 23 (42.5) 70 (27.8)c 2.5 (0.73) 2.5 (0.81) 2.8 (0.75) 2.6 (0.80)
Elbows 6 (10.1) 5 (3.6) 6 (11.1) 17 (6.7) 2.3 (0.67) 2.2 (0.52) 2.3 (0.48) 2.2 (0.53)
Hands/wrists 16 (27.1) 65 (47.1) 20 (37.0) 101 (40.2)c 2.6 (0.80) 2.6 (0.62) 2.5 (0.73) 2.6 (0.68)
Upper back 15 (25.4) 57 (41.3) 23 (42.5) 95 (37.8) 2.9 (1.03) 2.8 (0.97) 3.1 (0.75) 3.1 (0.94)
Low back 30 (50.8) 87 (63.0) 31 (57.4) 148 (58.9) 3.6 (0.94) 3.7 (0.86) 4.2 (0.96) 3.8 (0.92)b
Hips/thighs/buttocks 6 (10.2) 21 (15.2) 11 (20.4) 38 (15.1) 2.2 (0.93) 2.2 (0.47) 2.4 (0.69) 2.2 (0.62)
Knees 6 (10.2) 22 (15.9) 23 (42.6) 51 (20.3)b 2.3 (0.73) 2.4 (0.72) 3.2 (1.09) 2.6 (0.89)b
Ankles/feet 10 (16.9) 27 (19.6) 26 (48.1) 63 (25.1)b 2.5 (0.88) 2.6 (0.76) 2.9 (0.92) 2.6 (0.95)

Any regiona 47 (79.6) 113 (81.8) 40 (74.0) 200 (79.6) e e e e

a
Musculoskeletal symptoms in any of the nine body regions.
b
P <0.01.
c
P <0.05.
Table 6
Univariate and multiple logistic regression analyses of factors associated with neck, shoulder and hand/wrist symptoms.

Variables Neck symptoms Shoulder symptoms Hand/wrist symptoms

Univariate Multivariate Univariate Multivariate Univariate Multivariate

OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P

Gender
Female 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Male 1.30 0.73e2.31 0.766 e e e 1.33 0.76e2.11 0.258 e e e 0.63 0.38e0.95 0.004 e e e
Age 1.03 1.01e1.06 0.044 e e e 1.04 1.01e1.07 0.001 e e e 1.01 0.98e1.03 0.406 e e e
BMI 0.29 0.96e1.11 0.290 e e e 0.96 0.90e1.03 0.309 e e e 1.01 0.95e1.07 0.727 e e e
Marital status
Single 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Married 1.93 1.04e3.58 0.035 e e e 1.74 0.90e3.34 0.096 e e e 1.58 0.88e2.84 0.124 e e e
Educational level
Diploma 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Illiterate 0.42 0.08e2.11 0.296 e e e 3.35 0.75e14.9 0.113 e e e 3.66 0.87e5.82 0.071 e e e
Primary school 0.46 0.18e1.22 0.121 e e e 0.88 0.42e1.85 0.748 e e e 0.77 0.37e1.60 0.488 e e e
Secondary school 0.48 0.17e1.30 0.150 e e e 0.24 0.09e0.58 0.002 e e e 0.96 0.45e2.06 0.924 e e e
Regular sport/physical activity
e e e e e e e e e e e e e e

I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188

No 1.00 1.00 1.00 1.00
Yes 0.95 0.50e1.81 0.888 e e e 1.53 0.85e2.78 0.154 e e e 0.29 0.15e0.55 0.001 0.30 0.15e0.60 0.001
Smoking
No 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Yes 2.14 0.94e4.83 0.067 e e e 1.85 0.98e3.49 0.055 e e e 1.55 0.83e2.88 0.162 e e e
Number of years worked as an operator 1.03 1.01e1.07 0.037 1.04 1.01e1.08 0.021 1.07 1.04e1.11 0.001 1.06 1.03e1.10 0.001 1.01 0.98e1.03 0.363 e e e
Daily working hours 1.25 0.97e1.61 0.082 1.63 1.25e2.13 0.001 e e e 0.95 0.76e1.20 0.716 e e e
Working very fast
No 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Yes 1.76 0.85e3.65 0.124 e e e 1.67 0.75e3.72 0.203 e e e 1.16 0.58e2.33 0.662 e e e
Job satisfaction
High 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Low/moderate 0.95 0.53e1.68 0.873 e e e 0.42 0.24e0.75 0.003 e e e 1.31 0.79e2.17 0.289 e e e
Duration of continuous work without break
<1 h 1.00 e e 1.00 e 0.022a 1.00 e e 1.00 e 0.047a 1.00 e e e e e
1e2 h 1.73 0.72e4.11 0.214 2.22 0.84e5.86 0.106 3.02 1.07e6.71 0.040 3.07 1.10e8.58 0.032 2.03 0.82e5.03 0.124 e e e
>2 h 2.85 1.28e6.31 0.010 3.34 1.40e7.95 0.006 3.05 1.12e7.79 0.033 3.12 1.19e8.18 0.020 2.49 1.08e5.72 0.031 e e e
Feeling pressure due to work
No 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Yes 0.65 0.23e1.81 0.415 e e e 1.05 0.44e2.54 0.899 e e e 0.77 0.34e1.73 0.532 e e e
Use of adjustable chairs
No 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Yes 1.76 0.63e2.42 0.312 e e e 1.37 0.71e3.22 0.246 e e e 0.57 0.29e1.09 0.092 e e e
Satisfaction with sewing machine/table design
High 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
Moderate 1.22 0.45e3.29 0.683 e e e 2.23 0.91e5.46 0.077 e e e 0.67 0.27e1.67 0.395 e e e
Low 1.83 0.87e4.14 0.091 e e e 2.52 1.34e4.72 0.004 e e e 1.17 0.64e2.15 0.599 e e e
RULA A score
1e4 1.00 e e 1.00 e e 1.00 e e 1.00 1.00 e e e e e
5 1.81 1.02e3.21 0.040 1.92 1.21e3.84 0.019 5.23 2.07e9.22 0.001 4.13 2.03e8.39 0.001 0.81 0.49e1.35 0.438 e e e
RULA B score
1e4 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
5 0.55 0.19e1.60 0.279 e e e 0.13 0.01e1.01 0.052 e e e 0.98 0.35e2.71 0.969 e e e
RULA grand score
1e4 1.00 e e e e e 1.00 e e e e e 1.00 e e e e e
5 1.88 0.79e5.97 0.323 e e e 2.86 0.34e8.22 0.332 e e e 1.86 0.87e3.96 0.106 e e e

Statistically significant values are shown in bold.

a
P for trend.

185
186 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188

Table 7
Univariate and multiple logistic regression analyses of factors associated with upper back and low back symptoms.

Variables Upper back symptoms Low back symptoms

Univariate Multivariate Univariate Multivariate

OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P

Gender
Female 1.00 e e 1.00 e e 1.00 e e e e e
Male 11.4 5.75e20.5 0.001 10.9 5.1e18.2 0.001 1.27 0.39e2.53 0.467 e e e
Age 1.02 0.99e1.04 0.096 e e e 1.02 0.98e1.06 0.181 e e e
BMI 0.88 0.82e0.94 0.001 e e e 1.05 0.97e1.14 0.186 e e e
Marital status
Single 1.00 e e e e e 1.00 e e e e e
Married 1.21 0.68e2.16 0.500 e e e 1.16 0.55e2.42 0.691 e e e
Educational level
Diploma 1.00 e e e e e 1.00 e e e e e
Illiterate 1.57 0.28e8.59 0.602 e e e 1.36 0.35e3.59 0.524 e e e
Primary school 0.46 0.21e1.02 0.057 e e e 1.21 0.46e3.17 0.690 e e e
Secondary school 0.08 0.03e0.20 0.001 e e e 0.80 0.30e2.11 0.656 e e e
Regular sport/physical activity
No 1.00 e e e e e 1.00 e e e e e
Yes 1.61 0.92e2.85 0.100 e e e 0.50 0.25e1.01 0.056 e e e
Smoking
No 1.00 e e e e e 1.00 e e e e e
Yes 6.06 2.93e12.5 0.001 e e e 1.38 0.57e3.31 0.471 e e e
Number of years worked as an operator 1.08 1.04e1.11 0.001 e e e 1.01 0.97e1.05 0.444 e e e
Daily working hours 2.93 2.19e3.93 0.001 1.71 1.21e2.43 0.002 1.06 1.03e1.12 0.019 1.04 1.01e1.09 0.028
Working very fast
No 1.00 e e e e e 1.00 e e e e e
Yes 2.45 1.16e5.17 0.019 e e e 1.57 0.68e3.60 0.287 e e e
Job satisfaction
High 1.00 e e e e e 1.00 e e e e e
Low/moderate 0.27 0.16e0.47 0.001 e e e 0.90 0.46e1.76 0.776 e e e
Duration of continuous work without break
<1 h 1.00 e e e e e 1.00 e e e e e
1e2 h 1.41 0.97e1.96 0.427 e e e 1.01 0.34e3.00 0.974 e e e
>2 h 1.04 0.93e1.16 0.102 e e e 1.12 0.41e2.99 0.821 e e e
Feeling pressure due to work
No 1.00 e e 1.00 e e 1.00 e e e e e
Yes 2.35 1.78e3.23 0.003 1.89 1.55e2.99 0.006 1.52 0.57e4.05 0.398 e e e
Use of adjustable chairs
No 1.00 e e e e e 1.00 e e e e e
Yes 0.49 0.28e1.22 0.077 e e e 1.22 0.66e3.34 0.208 e e e
Satisfaction with sewing machine/table design
High 1.00 e e e e e 1.00 e e e e e
Moderate 3.59 1.44e8.95 0.006 e e e 1.46 0.41e5.24 0.556 e e e
Low 5.23 2.67e9.12 0.001 e e e 1.14 0.51e2.58 0.739 e e e
RULA A score
1e4 1.00 e e e e e 1.00 e e e e e
5 4.83 1.84e8.42 0.001 e e e 1.28 0.66e2.48 0.458 e e e
RULA B score
1e4 1.00 e e e e e 1.00 e e e e e
5 1.25 1.07e1.41 0.036 e e e 0.88 0.24e3.26 0.859 e e e
RULA grand score
1e4 1.00 e e 1.00 e e 1.00 e e 1.00 e e
5 1.26 1.09e1.20 0.035 1.29 1.12e1.27 0.032 1.67 1.18e2.41 0.002 1.56 1.14e2.50 0.004

Statistically significant values are shown in bold.

factors. The prevalence of self-reported musculoskeletal symptoms
was found to be very high among the study population, where the
most commonly affected body regions were the low back, neck,
hands/wrists, upper back and shoulders, respectively. The mean
rating of severity of complaints in the low back, neck and upper back
areas was generally between moderate and high (3 or 4 on the scale
of 0e5), which is relatively similar to the findings of previous studies
conducted among sewing machine operators (Westgaard and
Jansen, 1992; Sealetsa and Thatcher, 2011). The severity of symp-
toms reported for each body region differed between the genders so
that males experienced more severe symptoms in their upper back
and low back, whereas the mean severity of hand/wrist symptoms
were higher in females than in males.
As shown in this study, musculoskeletal pain and discomfort is a
major problem in sewing machine operators. This is consistent with
previous epidemiological reports of MSDs among this working
€
population (Oztürk and Esin, 2011; Sealetsa and Thatcher, 2011).
The high prevalence of neck/shoulder and back complaints found in
the present study is also in agreement with previous studies among
relatively similar occupations involving sewing operations
(Serratos-Perez and Mendiola-Anda, 1993; Roquelaure et al., 2002;
€
Oztürk and Esin, 2011; Sealetsa and Thatcher, 2011; Nazari et al.,
2012). These findings provide further evidence that MSDs are
highly prevalent among the workers involved in sewing activities.
This is possibly not surprising because the sewing operation, as a
highly repetitive task, involves frequent head and trunk bending
movements for a long period of time, and therefore imposes un-
acceptable postural loading on the body. This is confirmed by the
results of multiple logistic regression models in this study, which
indicated that working posture was a possible risk factor for
 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188
musculoskeletal pain in the neck, shoulders, upper back and low
back regions of sewing machine operators.
The most common posture adopted by the operators during the
sewing task performance was the bending posture of the neck and
trunk (more than 20 flexion) to the front. Such a working condition
can impose excessive physical loads on the musculoskeletal system
of operators, and may eventually lead to the development of
musculoskeletal problems in different body regions if sustained
over long periods of time. The mean RULA grand score of 5.7 in the
present study emphasises that the operators' postures were con-
strained by both the visual and the manual aspects of the sewing
task, and that the design of the sewing workstations had a
considerable influence on the postures adopted. It was found that
the majority (91%) of the study participants (with posture assessed
at action level 3) needed an investigation and changes in their
working habits soon to avoid serious harm and physical damage.
These results are consistent with previous reports of poor working
postures (assessed by RULA method) among sewing machine op-
€
erators (Oztürk and Esin, 2011; Teodoroski et al., 2012).
The findings of this study confirm that the sewing machine
operators had frequent periods of long duration of sewing work
without breaks (e.g. sitting in one place in a static or non-moving
position for more than 2 h). Several previous studies have shown
that the long duration of sitting work without a break may influ-
ence the risk for neck and shoulder complaints among different
occupational groups such as sewing machine operators (Wang
et al., 2007), hand-sewn shoe workers (Dianat and Salimi, 2014)
and office employees (Johnston et al., 2008). In a study conducted
by McLean et al. (2001), it was also shown that regular rest breaks
reduced the neck, shoulder and low back discomfort among com-
puter workers. Our findings also indicated that the duration of
continuous work without a break was associated with the occur-
rence of neck and shoulder complaints. Thus, to reduce MSDs,
sewing machine workers should be advised to take regular rest
breaks in order to alleviate exposure and also to aid recovery from
unhealthy postures.
The prolonged working hours have also been recognised as
another risk factor for development of MSDs among different
occupational groups (Fogleman and Lewis, 2002; Johnston et al.,
2008; Nazari et al., 2012; Dianat and Salimi, 2014). Nazari et al.
(2012) found that the prolonged daily working hours contributed
to a greater number of reports of upper back symptoms among
hand-woven carpet weavers. Dianat and Salimi (2014) also found
that the number of hours worked in a day was significantly posi-
tively associated with knee symptoms in hand-sewn shoe workers.
The significant positive association between duration of sewing
task and reported symptoms in the upper back and lower back
areas in the present study is in agreement with these previous
studies. The findings of the present study also indicated a signifi-
cant association between the number of years worked as an oper-
ator and the presence of symptoms in the neck and shoulders. This
result is also similar to the findings of Ferreira and Saldiva (2002)
who reported a significant association between duration in the
job and MSDs among the operators engaged in computer-
telephone interactive tasks.
Several previous studies have shown that psychosocial factors of
the working environment may have a role in the development or
reporting of MSDs among workers involved in sewing activities
€
(Wang et al., 2007; Oztürk and Esin, 2011; Dianat and Salimi, 2014).
€
Oztürk and Esin (2011) reported that feeling pressure because of
work was associated with musculoskeletal pain in different body
regions of female sewing machine operators in Turkey. Our findings
also indicated that feeling pressure due to work was significantly
associated with the presence of upper back symptoms among
sewing machine operators. This is perhaps not surprising, as the
187
study participants were paid based on the number of items they
completed and this provided an incentive to work at high speed
without adequate rest breaks. The findings of the present study
provide further evidence that both physical and psychosocial job
factors are associated with increased risk of musculoskeletal
problems among workers involved in sewing activities.
Regarding individual risk factors, the results of multiple logistic
regression models indicated that gender was a significant factor for
upper back symptoms with an odds ratio of 10.9 for males in
comparison with females. This may be attributed to differences in
working habits between genders (e.g. the number of hours worked
in a day was higher for men than women). Two other studies have
reported a significant association between age and upper back
symptoms in workers involved in sewing activities (Oztürk € and
Esin, 2011; Dianat and Salimi, 2014). In our study, age was signifi-
cantly positively associated with knee symptoms. A better under-
standing of the task characteristics may provide an insight into the
job design to support the user needs of older workers in future
(Stedmon et al., 2012). It was also shown that those operators
involved in sport activities were less likely to report hand/wrist
symptoms than other workers. Body mass index was also shown to
be significantly positively associated with knee symptoms
(OR ¼ 1.10), which is similar to the observations of Viester et al.
(2013) in a Dutch working population. These findings highlight
the need for consideration of individual factors (such as age, gender
and BMI as well as regular sport/physical activities) in future
analysis of musculoskeletal complaints among this working
population.
The findings of the present study have several implications.
Considering the significant role of SMEs in economic development,
improved working conditions in this sector has the potential for a
significant impact on national economy and workers' quality of life.
The findings also highlight the role of prevention in the workplace
in order to reduce MSDs. These findings emphasise the importance
of both individual and work-related aspects of sewing tasks in as-
sociation with musculoskeletal symptoms. The implications for
ergonomic practice may be to improve the workstation design for
sewing tasks (e.g. to reduce poor working postures) based on
workers' anthropometry. Other specific interventions aiming at
improving work organisation (e.g. through limited working hours
per shift or week and allowing adequate rest breaks) are also rec-
ommended with a view to helping prevent such symptoms in this
working group.
It is important to consider the current findings in the context of
the cross-sectional data collection, and whilst a large dataset was
possible, causal inferences cannot be drawn. It is also necessary to
highlight that the data rely on the reliability and accuracy of self-
report, which may be subject to recall or interviewer bias (where
participants either failed to correctly remember data, or provided
expected answers to the interviewer). The RULA observational
method applied to operators' working postures allowed to perform
rapid and reliable evaluation of the loading on the musculoskeletal
system during the sewing tasks, while direct exposure assessment
methods (e.g. electrogoniometric and video-based motion mea-
surements) may be required if data are to be used for characteri-
sation of joint/limb movements and dynamic physical stress or for
biomechanical modelling purposes (Li and Buckle, 1999; Dianat
et al., 2012).
5. Conclusions
A high prevalence of musculoskeletal pain and discomfort
(particularly in the neck, shoulders, upper back, low back and
hands/wrists) among the sewing machine operators emphasises
the need for ergonomic interventions for improving the working
188 I. Dianat et al. / Applied Ergonomics 51 (2015) 180e188
conditions of this working group. The relatively high RULA scores in
the study highlight a poor sewing workstation design and suggests
that in most cases the operators' postures at their work stations
need to be investigated and some changes are required soon. Work
organization factors including long duration of sitting work
without a break and prolonged working hours per shift, as well as
other work-related variables such as the number of years worked as
an operator and feeling pressure due to work were also found to be
associated with the occurrence of musculoskeletal symptoms in
different body regions. Other recommendations are, therefore, to
reduce the number of hours worked per shift or week, limit the
number of uninterrupted hours of work and allowing adequate rest
breaks, thereby lowering the frequency and severity of complaints.
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