International Journal of Industrial Ergonomics 76 (2020) 102935

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International Journal of Industrial Ergonomics

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

Associations of ergonomic and psychosocial work hazards with

musculoskeletal disorders of specific body parts: A study of general
employees in Taiwan
Hsi-Chen Liu a, b, Yawen Cheng a, *, Jiune-Jye Ho c
a
Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taiwan
b
Department of Labor and Human Resources, College of Social Sciences, Chinese Culture University, Taiwan
c
Institute of Labor, Occupational Safety and Health, Ministry of Labor, Taiwan

A R T I C L E I N F O A B S T R A C T

Keywords: Background and aims: Musculoskeletal disorders (MSDs) are major occupational health concerns. This study
Musculoskeletal disorders examined the associations of ergonomic and psychosocial work hazards with the risks of MSDs of specific body
Psychosocial hazards parts and their distribution across a wide range of occupational groups.
Ergonomic hazards
Methods: Study participants comprised 8,937 male and 7,052 female employees aged 20–65 years from a
Survey
Taiwan
nationwide survey in 2016. A self-report questionnaire was administered to obtain information regarding de­
mographic characteristics, work conditions, ergonomic and psychosocial work hazards, and MSDs of different
body parts in 12 months. Multivariate logistic regression models were used to estimate prevalence ratios of MSDs
in relation to ergonomic and psychosocial work hazards.
Results: In professionals and skilled workers, MSDs of the neck and shoulders were more prevalent, whereas in
manual workers, MSDs of the hands, wrists, and lower back were more prevalent. Psychosocial work hazards,
including high psychological demand and low workplace justice, were major work-related risk factors for
shoulder and neck disorders, whereas ergonomic hazards were major work-related risk factors for lower back and
wrist or hand disorders.
Conclusion: Different workplace hazards contribute to the risks of different MSDs. To prevent the development of
MSDs, occupational health professionals should evaluate both ergonomic and psychosocial work hazards and
develop health prevention programs tailored to the risk profiles of working populations.

1. Introduction risks of MSDs. Additionally, psychosocial work hazards are found to be

Musculoskeletal disorders (MSDs) are major occupational health
concerns worldwide. A study by the Global Burden of Disease 2017 Risk
Factor Collaborators estimated that occupational ergonomic factors
contributed to 15.9 million disability-adjusted life years annually (GBD,
2017 Risk Factor Collaborators, 2018). However, the contribution of
psychosocial work hazards to the risks of MSDs has not attracted the
same level of attention as that of ergonomic work hazards.
Studies have shown that women and individuals with lower socio­
economic status (SES) had higher risks of MSDs both in general pop­
ulations (Guillemin et al., 2014) and in working people (Mehlum et al.,
2013; Parker et al., 2013; Toivanen, 2011; van der Molen et al., 2018). In
terms of workplace hazards, ergonomic hazards contribute greatly to the
risk factors of MSDs and may have a synergistic effect with ergonomic
work hazards (Bongers et al., 1993; Buckle, 2005; Huang et al., 2002).
Studies have also suggested that the risks of MSDs of different body parts
vary with the type of workplace hazard (So et al., 2017; van den Heuvel
et al., 2005; Wang et al., 2017). Ergonomic and psychosocial work
hazards are differently distributed across various socioeconomic and
occupational groups and may contribute differentially to different
MSDs. Furthermore, because women tend to have higher risks for MSDs
than men, which may be a result of differences between them in terms of
physical structure, muscle strength, and stress-responses, the effect of
workplace hazards on the risks of MSD could differ according to sex
(Bernard, 1997).
However, only few studies have systematically examined the

* Corresponding author. No. 17, Xu-Zhou Road, Taipei, Taiwan.

E-mail address: ycheng@ntu.edu.tw (Y. Cheng).

https://doi.org/10.1016/j.ergon.2020.102935
Received 25 October 2019; Received in revised form 8 February 2020; Accepted 9 February 2020
Available online 15 February 2020
0169-8141/© 2020 Elsevier B.V. All rights reserved.
H.-C. Liu et al. International Journal of Industrial Ergonomics 76 (2020) 102935

Table 1
Demographic characteristics and employment conditions in relation with the presence of MSDs of specific body parts: male employees.
Total Any body parts Shoulders Neck Lower back wrists or hands (n ¼
(N ¼ (n ¼ 5,169; 57.8%) (n ¼ 3,475; 39.1%) (n ¼ 2,687; 30.2%) (n ¼ 2,758; 31.0%) 2,258; 25.4%)
8,937)

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

Age *** *** *** *** ***

20-35 2,907 1,401 (48.3) 920 (31.8) 702 (24.2) 713 (24.6) 639 (22.1)
35-50 3,731 2,260 (60.7) 1,571 (42.3) 1,274 (34.3) 1,221 (32.9) 972 (26.2)
50-65 2,299 1,508 (65.7) 984 (43.1) 711 (31.1) 824 (36.1) 647 (28.3)
BMI (kg/m2) *** *** *** *** ***
underweight (<18.5) 208 116 (55.8) 77 (37.2) 64 (30.8) 61 (29.5) 55 (26.6)
normal (18.5–24) 4,420 2,450 (55.5) 1,655 (37.6) 1,249 (28.4) 1,267 (28.8) 1,083 (24.6)
overweight (24–30) 3,689 2,227 (60.5) 1,495 (40.7) 1,174 (32.0) 1,216 (33.1) 937 (25.5)
obesity (�30) 476 315 (66.5) 216 (45.8) 172 (36.4) 185 (39.0) 158 (33.5)
Education level *** *** *** *** ***
lower secondary or below 1,516 1,024 (67.7) 676 (44.9) 466 (31.0) 589 (39.2) 760 (21.3)
upper secondary 3,090 1,852 (60.0) 1,230 (40.0) 918 (29.8) 1,046 (34.0) 493 (32.7)
bachelor or equivalent 3,588 1,903 (53.1) 1,288 (36.0) 1,055 (29.5) 959 (26.8) 877 (28.5)
master or above 743 390 (52.5) 281 (37.9) 248 (33.4) 164 (22.1) 128 (17.2)
Employment grade *** *** *** *** ***
administrators and 354 205 (57.9) 150 (42.5) 130 (36.7) 92 (26.0) 69 (19.5)
managers
professionals 1,070 581 (54.3) 417 (39.0) 362 (33.9) 248 (23.2) 211 (19.8)
non-manual skilled 1,624 840 (51.8) 567 (34.9) 475 (29.3) 441 (27.2) 306 (18.9)
non-manual low skilled 1,464 775 (53.1) 507 (34.9) 394 (27.1) 429 (29.4) 313 (21.5)
manual skilled 2,143 1,372 (64.2) 907 (42.6) 670 (31.4) 752 (35.4) 703 (33.0)
manual low skilled 2,282 1,396 (61.3) 927 (40.8) 656 (28.9) 796 (35.0) 656 (28.9)
Type of industry *** *** *** *** ***
manufacturing 3,306 1,820 (55.2) 1,211 (36.8) 918 (27.9) 944 (28.7) 798 (24.2)
construction 1,547 1,049 (67.9) 724 (47.0) 531 (34.5) 609 (39.7) 509 (33.1)
service 3,921 2,210 (56.5) 1,487 (38.1) 1,201 (30.8) 1,150 (29.4) 899 (23.1)
others 163 90 (55.6) 53 (32.7) 37 (22.8) 55 (34.0) 52 (32.1)
Size of enterprise *** *** *** *** ***
<10 workers 2,643 1,634 (61.9) 1,094 (41.6) 788 (29.9) 890 (33.8) 813 (30.9)
10–49 workers 2,742 1,589 (58.0) 1,070 (39.2) 843 (30.8) 853 (31.2) 693 (25.4)
50–499 workers 1,780 1,009 (56.9) 672 (38.0) 533 (30.1) 513 (29.0) 397 (22.5)
�500 workers 842 438 (52.0) 316 (37.6) 262 (31.2) 234 (27.9) 182 (21.7)
government 930 499 (53.9) 323 (35.0) 261 (28.3) 268 (29.0) 173 (18.7)

*p < 0.05 **p < 0.01 ***p < 0.001.

distribution of MSDs across occupational groups and the independent
effects of ergonomic and psychosocial work hazards on MSDs of the
different body parts across SESs, occupations, and sexes. A better un­
derstanding of the social distribution of the risks of MSDs and their risk
factors is required for effective prevention. This study utilized data from
a nationwide survey to examine the distributions of MSDs across so­
cioeconomic groups and the associations of ergonomic and psychosocial
work factors with the risks of MSDs of specific body parts in male and
female employees.
2. Materials and methods
2.1. Study participants
Study participants were selected from a nationwide survey con­
ducted by the Institute of Labor, Occupational Safety and Health of the
Ministry of Labor, Taiwan in 2016. A two-stage stratified random-
sampling scheme was adopted. In the first stage, all districts and vil­
lages were stratified by the level of urbanization, and a representative
sample was drawn from each stratum. At the second stage, a random
sample of households was drawn from each chosen district or village and
all economically active residents of the selected households were invited
to participate in the survey. Study participants were asked to complete a
self-administered questionnaire that was delivered in person by a
trained interviewer. After approximately 1 week, the interviewer
collected the questionnaires and performed on-site checks to ensure
their completeness. Unanswered items were checked and completed in
person. Completed questionnaires were obtained from 22,068 partici­
pants, yielding a response rate of 78.2%. Employers and self-employed
workers were excluded from this study, and participation was
restricted to employees aged between 20 and 65 years; resulting in 8,937
men and 7,052 women employees being included in the analyses.
Because the study was conducted by a governmental agency and data
were obtained anonymously for this study, no personal information of
the participants was included; thus, the requirement of completing an
ethical review procedure was waived.
2.2. Assessment of ergonomic and psychosocial work hazards
Study participants were asked if they had been exposed to any of the
seven types of ergonomic hazards at their current workplace within 1
week prior to the survey: whole body vibration, lifting or carrying heavy
objects, awkward postures such as bending or kneeling for long periods
of time, standing or walking for long durations, hand vibration, repeti­
tive hand movement, and handling heavy hand tools. For each item, the
response was recorded as “never,” “occasionally,” or “often,” and those
whose responses included “often” were classified as “exposed,” whereas
others were classified as “not exposed.” Lastly, the first four types of
ergonomic hazards were categorized as “whole-body–related ergonomic
hazards,” and the other three types were categorized as “hand-related
ergonomic hazards.”
The experiences of psychosocial work hazards 1 week prior to the
survey were assessed with respect to working hours, work shift, psy­
chological job demands, job control, workplace justice, and job inse­
curity. Weekly working hours were grouped into three categories: <40
h, 40–48 h, and >48 h. Work shift was grouped into three categories:
fixed day or night shifts, regular rotational shift, and irregular shift.
Psychological job demands and job control were assessed using the
Chinese version of the Job Content Questionnaire (Cheng et al., 2003),
which is based on the job strain model proposed by Karasek, (1979). The

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H.-C. Liu et al. International Journal of Industrial Ergonomics 76 (2020) 102935

Table 2
Demographic characteristics and employment conditions in association with the presence of MSDs of specific body parts: female employees.
Total Any body part Shoulders Neck Lower back wrists or hands (n ¼
(N ¼ (n ¼ 4,435; 63.0%) (n ¼ 3,261; 46.5%) (n ¼ 2,556; 36.4%) (n ¼ 2,276; 32.5%) 2,087; 29.8%)
7,052)

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

Age *** *** *** *** ***

20-35 2,542 806 (31.8) 1,010 (39.9) 806 (31.8) 688 (27.2) 647 (25.6)
35-50 3,000 1,172 (39.3) 1,472 (49.4) 1,172 (39.3) 989 (33.1) 918 (30.8)
50-65 1,510 578 (38.6) 779 (51.9) 578 (38.6) 599 (40.1) 522 (34.9)
BMI (kg/m2) *** *** *** *** ***
underweight (<18.5) 746 222 (29.8) 296 (39.8) 222 (29.8) 193 (26.0) 200 (26.9)
normal (18.5–24) 4,640 1,668 (36.1) 2,128 (46.1) 1,668 (36.1) 1,436 (31.1) 1,343 (29.1)
overweight (24–30) 1,349 556 (41.4) 683 (51.0) 556 (41.4) 535 (40.1) 442 (33.1)
obesity (�30) 195 74 (38.3) 103 (53.1) 74 (38.3) 78 (40.2) 66 (34.2)
Education level * *** ***
lower secondary or below 968 341 (35.6) 475 (49.4) 341 (35.6) 395 (41.2) 364 (37.9)
upper secondary 2,231 767 (34.6) 1,023 (46.2) 767 (34.6) 754 (34.1) 713 (32.2)
bachelor or equivalent 3,458 1,289 (37.4) 1,559 (45.2) 1,289 (37.4) 1,006 (29.3) 913 (26.5)
master or above 395 159 (40.5) 204 (51.8) 159 (40.5) 121 (30.7) 97 (24.7)
Employment grade *** ** *** *** ***
administrators and 92 41 (44.6) 54 (58.7) 41 (44.6) 31 (33.7) 30 (32.6)
managers
professionals 973 383 (39.6) 460 (47.5) 383 (39.6) 304 (31.4) 251 (26.0)
non-manual skilled 1,431 562 (39.4) 671 (47.2) 562 (39.4) 425 (29.9) 352 (24.8)
non-manual low skilled 2,813 944 (33.7) 1,229 (43.8) 944 (33.7) 844 (30.2) 805 (28.8)
manual skilled 312 113 (36.6) 147 (47.7) 113 (36.6) 104 (33.9) 99 (32.3)
manual low skilled 1,431 513 (36.2) 700 (49.3) 513 (36.2) 568 (40.1) 550 (38.7)
Type of industry * **
manufacturing 1,938 672 (34.9) 863 (44.9) 672 (34.9) 595 (31.0) 573 (29.8)
construction 216 89 (41.4) 117 (54.7) 89 (41.4) 77 (36.0) 70 (32.7)
service 4,771 1,739 (36.6) 2,216 (46.6) 1,739 (36.6) 1,547 (32.6) 1,397 (29.5)
others 127 56 (44.4) 65 (51.6) 56 (44.4) 57 (45.2) 47 (37.3)
Size of enterprise *** ***
<10 workers 2,067 700 (34.1) 916 (44.6) 700 (34.1) 659 (32.1) 644 (31.4)
10–49 workers 2,222 764 (34.5) 1,024 (46.2) 764 (34.5) 705 (31.9) 646 (29.2)
50–499 workers 1,449 560 (39.0) 676 (47.1) 560 (39.0) 458 (31.9) 412 (28.8)
�500 workers 526 217 (41.3) 254 (48.4) 217 (41.3) 184 (35.1) 156 (29.8)
government 788 315 (40.1) 391 (49.7) 315 (40.1) 270 (34.4) 229 (29.3)

*p < 0.05 **p < 0.01 ***p < 0.001.

job demands scale included five core items (fast-paced work, hard work,
tasks requiring long periods of concentration, hectic workplace, and
understaffed workplace), and the job control scale comprised seven
items, namely five items under the skill discretion subscale (learning
new things, repetitive work, creative work, variety of tasks, and devel­
oping abilities) and two items for the decision authority subscale (no
decision-making power and no influential opinion). All the items were
listed as a statement with responses recorded on a summated scale from
“strongly agree” to “agree,” “disagree,” and “strongly disagree.” Items
stated in the opposite format were inversely scored. The mean scores
were ranked and divided into high and low groups.
The workplace justice scale comprised seven items (trust, reliability
of information, fairness of the work arrangement, fairness of the rewards
arrangement, fairness of the performance evaluation, information pro­
vided during the decision-making process, and respect), which included
four dimensions: distributive justice, procedural justice, interpersonal
justice, and informational justice. The mean score was calculated,
standardized, and divided as high or low with respect to the median.
Information regarding the content and psychometric properties of the
workplace justice scale can be found elsewhere (Cheng et al., 2011).
Job insecurity was evaluated using the single-item question “my job
is secured,” and responses were recorded on a summated scale. Re­
sponses of “disagree” and “strongly disagree” were further classified as
having job insecurity.
2.3. Assessment of MSDs
A set of questions modified from the Nordic Musculoskeletal Ques­
tionnaire was included in the questionnaire (Deakin et al., 1994). Study
participants were asked if they had experienced body pain or
musculoskeletal discomfort of the neck, shoulders, upper back, elbows,
lower back, wrists or hands, hips or thighs, knees, or ankles or feet in the
past 12 months. All responses were coded as “yes” or “no.” This study
focused on four work-related MSDs, namely of the shoulders, neck,
lower back, and wrists or hands, that have been found to be common in
working people (Health and Safety Executive, 2018; Marcum and
Adams, 2017; Safe Work Australia, 2016; Schneider and Irastorza,
2010).
2.3.1. Demographic characteristics and employment conditions
Participants’ demographic data, including age, sex, height, weight,
education level, and occupation, as well as their work conditions were
obtained through the questionnaire. Body mass index (BMI) was
calculated and classified into four categories: underweight (<18.5 kg/
m2), normal (18.5–24 kg/m2), overweight (24–30 kg/m2), and obese
(>30 kg/m2). Occupations were classified into six grades of employ­
ment: administrators and managers, G1; professionals, G2; non-manual
skilled workers, G3; non-manual low-skilled workers, G4; manual skilled
workers, G5; and manual low-skilled workers, G6.
Industry types were classified into four categories: manufacturing,
construction and civil utility infrastructure (electricity, gas, and water
supply), service, and primary industries (agriculture, forestry, fishing
and animal husbandry, and mining and quarrying), and workplace size
was classified into five categories: <10 workers, 10–49 workers, 50–499
workers, >500 workers, and government sectors. The classification of
workplace size was preset in national labor statistics and survey ques­
tionnaires in accordance with regulatory considerations.

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H.-C. Liu et al. International Journal of Industrial Ergonomics 76 (2020) 102935

Table 3
Psychosocial and ergonomic work hazards in association with the presence of MSDs of specific body parts: male employees.
Total Any body part Shoulders Neck Lower back wrists or hands (n ¼
(N ¼ (n ¼ 5,169) (n ¼ 3,475) (n ¼ 2,687) (n ¼ 2,758) 2,258)
8,937)

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

Weekly working hours *** * *** *** *

<40 789 506 (64.5) 318 (40.8) 254 (32.5) 262 (33.5) 216 (27.7)
40-48 6,830 3,858 (56.6) 2,619 (38.5) 1,988 (29.2) 2,047 (30.1) 1,682 (24.7)
>48 1,023 642 (62.8) 440 (43.2) 361 (35.4) 371 (36.4) 290 (28.5)
Work shift *** *** *** *** ***
fixed work 7,315 4,193 (57.4) 2,819 (38.7) 2,155 (29.6) 2,200 (30.2) 1,821 (25.0)
shift work 841 468 (55.8) 303 (36.2) 242 (28.9) 264 (31.5) 197 (23.5)
irregular shift work 554 373 (67.5) 266 (48.1) 214 (38.7) 221 (40.0) 180 (32.7)
Psychological demands *** *** *** *** ***
low 3,758 1,895 (50.6) 1,173 (31.4) 856 (22.9) 908 (24.3) 707 (18.9)
high 5,122 3,244 (63.4) 2,283 (44.7) 1,817 (35.6) 1,829 (35.8) 1,533 (30.0)
Job control *** ** * ** ***
high 4,690 2,623 (56.0) 1,766 (37.8) 1,454 (31.1) 1,382 (29.6) 1,114 (23.8)
low 4,193 2,513 (60.0) 1,693 (40.6) 1,218 (29.2) 1,364 (32.7) 1,129 (27.1)
Workplace justice *** *** *** *** ***
high 4,983 2,528 (50.8) 1,665 (33.5) 1,252 (25.2) 1,292 (26.0) 1,029 (20.7)
low 3,812 2,560 (67.3) 1,759 (46.3) 1,394 (36.7) 1,421 (37.5) 1,192 (31.4)
Job security ** *** ** *** ***
secure 4,650 2,565 (55.2) 1,704 (36.8) 1,335 (28.8) 1,282 (27.7) 1,045 (22.6)
insecure 4,272 2,596 (60.8) 1,767 (41.5) 1,349 (31.7) 1,472 (34.6) 1,210 (28.5)
Whole-body-related *** *** *** *** ***
ergonomic risks
low 5,237 2,636 (50.4) 1,741 (33.4) 1,407 (27.0) 1,275 (24.4) 964 (18.5)
high 3,690 2,526 (68.6) 1,730 (47.2) 1,278 (34.8) 1,480 (40.4) 1,293 (35.3)
Hand-related ergonomic risks *** *** *** *** ***
low 6,015 3,142 (52.3) 2,049 (34.2) 1,572 (26.3) 1,593 (26.6) 1,160 (19.4)
high 2,907 2,016 (69.5) 1,419 (49.0) 1,109 (38.3) 1,159 (40.1) 1,095 (37.8)

*p < 0.05 **p < 0.01 ***p < 0.001.

Table 4
Psychosocial and ergonomic work hazards in association with the presence of MSDs of specific body parts: female employees.
Total Any body part Shoulders Neck Lower back wrists or hands (n ¼
(N ¼ (n ¼ 4,435) (n ¼ 3,261) (n ¼ 2,556) (n ¼ 2,276) 2,087)
7,052)

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

Weekly working hours ** *** ** *** ***

<40 748 290 (39.0) 365 (49.2) 290 (39.0) 285 (38.4) 241 (32.5)
40-48 5,401 1,896 (35.3) 2,426 (45.1) 1,896 (35.3) 1,656 (30.9) 1,552 (28.9)
>48 645 260 (40.5) 342 (53.1) 260 (40.5) 243 (37.8) 227 (35.4)
Work shift ** * **
fixed work 5,956 2,154 (36.3) 2,741 (46.2) 2,154 (36.3) 1,902 (32.1) 1,755 (29.6)
shift work 632 209 (33.2) 276 (43.9) 209 (33.2) 210 (33.4) 178 (28.3)
irregular shift work 296 132 (44.8) 159 (54.1) 132 (44.8) 112 (38.2) 99 (34.0)
Psychological demands *** *** *** *** ***
low 3,349 997 (29.9) 1,343 (40.3) 997 (29.9) 873 (26.3) 811 (24.4)
high 3,655 1,541 (42.4) 1,896 (52.2) 1,541 (42.4) 1,386 (38.2) 1,260 (34.7)
Job control ** ** ***
high 3,484 1,319 (38.0) 1,629 (47.0) 1,319 (38.0) 1,098 (31.7) 945 (27.3)
low 3,509 1,217 (34.9) 1,609 (46.1) 1,217 (34.9) 1,158 (33.2) 1,124 (32.2)
Workplace justice *** *** *** *** ***
high 4,005 1,252 (31.4) 1,654 (41.5) 1,252 (31.4) 1,142 (28.7) 981 (24.7)
low 2,917 1,254 (43.1) 1,554 (53.6) 1,254 (43.1) 1,088 (37.6) 1,068 (36.8)
Job security * *** ***
secure 3,756 1,277 (35.7) 1,619 (45.1) 1,277 (35.7) 1,059 (29.6) 959 (26.8)
insecure 3,284 1,273 (37.2) 1,636 (47.9) 1,273 (37.2) 1,211 (35.5) 1,125 (32.9)
Whole-body-related *** *** *** *** ***
ergonomic risks
low 4,858 1,671 (34.6) 2,098 (43.4) 1,671 (34.6) 1,320 (27.3) 1,194 (24.7)
high 2,185 882 (40.6) 1,159 (53.4) 882 (40.6) 953 (44.0) 889 (41.0)
Hand-related ergonomic risks *** *** *** *** ***
low 4,844 1,525 (31.6) 1,955 (40.5) 1,525 (31.6) 1,348 (28.0) 1,137 (23.6)
high 2,196 1,025 (47.0) 1,300 (59.6) 1,025 (47.0) 923 (42.5) 945 (43.3)

*p < 0.05 **p < 0.01 ***p < 0.001.

2.4. Data analyses between the main independent variables, such as ergonomic and psy­
chosocial work hazards, and the main dependent variables, such as the
Descriptive and bivariate analyses were performed. The associations presence of MSDs of the different body parts, were examined using chi-

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H.-C. Liu et al. International Journal of Industrial Ergonomics 76 (2020) 102935

Table 5
Log-linked binominal model of different body parts of MSDs: Male employees.
Any body part Shoulders Neck Lower back Wrists or hands
(n ¼ 8,092) (n ¼ 8,078) (n ¼ 8,082) (n ¼ 8,071) (n ¼ 8,077)

RR 95% CI RR 95% CI RR 95% CI RR 95% CI RR 95% CI

Age
20-35 (reference) (reference) (reference) (reference) (reference)
35-50 1.20 (1.14,1.25) *** 1.28 (1.20,1.37) *** 1.38 (1.28,1.50) *** 1.31 (1.21,1.42) *** 1.16 (1.07,1.27) ***
50-65 1.28 (1.22,1.35) *** 1.33 (1.24,1.43) *** 1.28 (1.17,1.40) *** 1.42 (1.31,1.55) *** 1.26 (1.15,1.39) ***
BMI (kg/m2)
Normal (reference) (reference) (reference) (reference) (reference)
Underweight 1.00 (0.88,1.13) 0.98 (0.81,1.18) 1.05 (0.85,1.30) 0.99 (0.79,1.24) 0.99 (0.78,1.25)
Overweight 1.04 (1.00,1.07) 1.04 (0.99,1.10) 1.09 (1.02,1.16) * 1.11 (1.04,1.18) ** 1.03 (0.96,1.11)
Obesity 1.10 (1.03,1.17) *** 1.16 (1.06,1.28) ** 1.24 (1.10,1.40) *** 1.25 (1.11,1.40) *** 1.23 (1.08,1.41) **
Type of industry
Manufacturing (reference) (reference) (reference) (reference) (reference)
Construction 1.05 (1.00,1.10) 1.09 (1.01,1.17) 1.05 (0.96,1.15) 1.12 (1.03,1.22) ** 1.09 (0.99,1.20)
Service 1.05 (1.01,1.10) * 1.11 (1.04,1.17) ** 1.16 (1.08,1.25) *** 1.09 (1.01,1.18) * 1.05 (0.96,1.14)
Others 0.95 (0.82,1.09) 0.89 (0.70,1.12) 0.89 (0.66,1.19) 1.06 (0.85,1.33) 1.21 (0.96,1.52)
Weekly working hours
40-48 (reference) (reference) (reference) (reference) (reference)
<40 1.04 (0.99,1.10) 1.00 (0.92,1.09) 1.06 (0.95,1.18) 0.97 (0.87,1.07) 0.98 (0.87,1.11)
>48 1.05 (1.00,1.11) 1.05 (0.98,1.13) 1.09 (0.99,1.19) 1.10 (1.01,1.20)* 1.07 (0.96,1.19)

any body part (n ¼ 8,092) shoulders (n ¼ 8,078) neck (n ¼ 8,082) lower back (n ¼ 8,071) wrists or hands (n ¼ 8,077)
RR 95% CI RR 95% CI RR 95% CI RR 95% CI RR 95% CI

Work shift
fixed work (reference) (reference) (reference) (reference) (reference)
shift work 0.98 (0.92,1.04) 0.95 (0.86,1.04) 0.99 (0.89,1.11) 1.03 (0.93,1.15) 0.95 (0.84,1.08)
irregular shift work 1.08 (1.02,1.14) ** 1.19 (1.09,1.29) *** 1.21 (1.08,1.35) *** 1.20 (1.08,1.33) *** 1.18 (1.05,1.34) **
Psychological demands
low (reference) (reference) (reference) (reference) (reference)
high 1.15 (1.11,1.20) *** 1.33 (1.26,1.42) *** 1.45 (1.34,1.56) *** 1.37 (1.28,1.47) *** 1.39 (1.28,1.51) ***
Job control
high (reference) (reference) (reference) (reference) (reference)
low 0.99 (0.96,1.02) 0.98 (0.93,1.04) 0.86 (0.81,0.92) *** 0.97 (0.91,1.04) 0.96 (0.89,1.03)
Workplace justice
high (reference) (reference) (reference) (reference) (reference)
low 1.20 (1.16,1.24) *** 1.27 (1.20,1.34) *** 1.40 (1.31,1.49) *** 1.33 (1.25,1.42) *** 1.34 (1.24,1.44) ***
Whole-body-related ergonomic risks
low (reference) (reference) (reference) (reference) (reference)
high 1.17 (1.12,1.22) *** 1.21 (1.14,1.28) *** 1.06 (0.99,1.14) 1.39 (1.30,1.50) *** 1.47 (1.35,1.60) ***
Hand-related ergonomic risks
low (reference) (reference) (reference) (reference) (reference)
high 1.11 (1.07,1.16) *** 1.20 (1.13,1.27) *** 1.33 (1.23,1.43) *** 1.16 (1.08,1.25) *** 1.47 (1.35,1.59) ***

*p < 0.05 **p < 0.01 ***p < 0.001.

square tests. Independent variables that were significantly associated
with the risks of MSDs in chi-square tests were identified and included in
the log-linked logistic regression models to calculate the prevalence
ratios. The initial full models with all significant variables in bivariate
analyses were examined, and these models were further reduced to
exclude variables that were non-significantly associated with the risks of
MSDs of specific body parts. The same set of independent variables was
used in all final models to aid comparison across models of different
MSDs. Analyses were performed using SAS V.9.4 (SAS Institute, Cary,
NC, USA) with the significance level set at p < 0.05. All analyses were
stratified by sex to examine the sex-specific distribution patterns and
associations with the risks of MSDs of the specific body parts.
3. Results
The overall prevalence of MSDs for any of the body parts was 57.9%
and 63.0% in male and female employees, respectively. As shown in
Table 1 and Table 2, the most common MSDs in male employees were of
the shoulders (39.1%), lower back (31.0%), neck (30.2%), and wrists or
hands (25.4%). In female employees, they were of the shoulders
(46.5%), neck (36.4%), lower back (32.5%), and wrists or hands
(29.8%). The prevalence of MSDs increased with age and BMI. In terms
of the risk of MSDs of any body part in male employees, lower SES, as
reflected by education level and employment grade, was associated with
higher risk. By contrast, in female employees, higher SES was associated
with higher risk. However, examination of the risks of MSDs by specific
body part revealed similar distributions of SES in both men and women;
lower SES was associated with higher risks of lower back and wrist or
hand MSDs but lower risks of shoulder and neck MSDs. These findings
suggested that SES–MSD associations actually differed according to the
type of MSD instead of sex.
Evaluation based on the type of industry and size of the workplace
revealed that MSDs of all body parts were more prevalent in the
manufacturing industry and smaller workplaces among male employees,
although the distribution patterns were less consistent among female
employees.
The distribution of psychosocial and ergonomic work hazards in
association with the presence of MSDs of specific body parts in male and
female employees is summarized in Table 3 and Table 4, respectively. It
was found that employees with atypical weekly hours, irregular shifts,
higher psychological demands, lower workplace justice, job insecurity,
and exposure to ergonomic hazards had a higher prevalence of MSDs.
Results of the initial regression models demonstrated that the asso­
ciations of education level, employment grade, enterprise size, and job
security were nonsignificant for all types of MSDs; therefore, these
variables were omitted in the final models.
Findings of the final multivariate regression models, as shown in
Table 5 and Table 6, indicated that in both men and women, higher
psychological job demands, lower workplace justice, and exposure to
work-related ergonomic hazards were significantly associated with

5
H.-C. Liu et al. International Journal of Industrial Ergonomics 76 (2020) 102935

Table 6
Log-linked binominal model of different body parts of MSDs: Female employees.
Any body part Shoulders Neck Lower back Wrists or hands
(n ¼ 6,349) (n ¼ 6,331) (n ¼ 6,332) (n ¼ 6,325) (n ¼ 6,324)

RR 95% CI RR 95% CI RR 95% CI RR 95% CI RR 95% CI

Age
20-35 (reference) (reference) (reference) (reference) (reference)
35-50 1.18 (1.12,1.23) *** 1.21 (1.14,1.29) *** 1.23 (1.14,1.32) *** 1.20 (1.10,1.30) *** 1.23 (1.13,1.34) ***
50-65 1.24 (1.18,1.31) *** 1.27 (1.18,1.36) *** 1.21 (1.10,1.32) *** 1.41 (1.29,1.55) *** 1.38 (1.25,1.53) ***
BMI (kg/m2)
normal (reference) (reference) (reference) (reference) (reference)
underweight 0.98 (0.91,1.05) 0.93 (0.85,1.02) 0.84 (0.75,0.95) ** 0.90 (0.79,1.03) 1.00 (0.88,1.13)
overweight 1.04 (1.00,1.08) * 1.04 (0.98,1.10) 1.07 (0.99,1.15) 1.15 (1.06,1.24) *** 1.00 (0.91,1.09)
obesity 1.06 (0.97,1.15) 1.02 (0.90,1.15) 0.99 (0.83,1.19) 1.13 (0.95,1.35) 1.10 (0.91,1.32)
Type of industry
manufacturing (reference) (reference) (reference) (reference) (reference)
construction 1.12 (1.05,1.20) ** 1.20 (1.07,1.35) ** 1.26 (1.08,1.47) ** 1.22 (1.02,1.46) * 1.22 (1.01,1.46) *
service 1.08 (1.04,1.13) *** 1.11 (1.05,1.18) *** 1.16 (1.08,1.25) *** 1.17 (1.08,1.27) *** 1.13 (1.04,1.23) **
others 1.05 (0.94,1.17) 1.05 (0.88,1.26) 1.22 (1.00,1.50) 1.20 (0.99,1.46) 1.02 (0.81,1.28)
Weekly working hours
40-48 (reference) (reference) (reference) (reference) (reference)
<40 1.01 (0.96,1.06) 1.01 (0.94,1.09) 1.03 (0.93,1.13) 1.06 (0.96,1.16) 0.99 (0.89,1.11)
>48 1.02 (0.96,1.07) 1.08 (1.00,1.16) * 1.08 (0.97,1.19) 1.01 (0.91,1.12) 1.03 (0.92,1.14)

any body part (n ¼ 6,349) shoulders (n ¼ 6,331) neck (n ¼ 6,332) lower back (n ¼ 6,325) wrists or hands (n ¼ 6,324)
RR 95% CI RR 95% CI RR 95% CI RR 95% CI RR 95% CI

Work shift
fixed work (reference) (reference) (reference) (reference) (reference)
shift work 0.99 (0.93,1.06) 0.96 (0.88,1.06) 0.93 (0.83,1.04) 0.99 (0.88,1.12) 0.91 (0.79,1.03)
irregular shift work 1.00 (0.94,1.07) 1.07 (0.98,1.17) 1.20 (1.05,1.37) ** 1.02 (0.88,1.17) 1.01 (0.86,1.19)
Psychological demands
low (reference) (reference) (reference) (reference) (reference)
high 1.11 (1.06,1.15) *** 1.19 (1.13,1.26) *** 1.33 (1.24,1.42) *** 1.32 (1.23,1.43) *** 1.27 (1.18,1.38) ***
Job control
high (reference) (reference) (reference) (reference) (reference)
low 0.97 (0.94,1.01) 0.92 (0.87,0.97) ** 0.87 (0.82,0.93) *** 0.95 (0.89,1.02) 1.02 (0.95,1.10)
Workplace justice
high (reference) (reference) (reference) (reference) (reference)
Low 1.17 (1.13,1.22) *** 1.23 (1.17,1.30) *** 1.31 (1.23,1.40) *** 1.20 (1.12,1.29) *** 1.33 (1.23,1.43) ***
Whole-body-related
Low (reference) (reference) (reference) (reference) (reference)
high 1.07 (1.03,1.12) *** 1.03 (0.97,1.09) 0.96 (0.89,1.03) 1.34 (1.24,1.44) *** 1.31 (1.21,1.42) ***
Hand-related
Low (reference) (reference) (reference) (reference) (reference)
high 1.19 (1.14,1.24) *** 1.35 (1.28,1.43) *** 1.44 (1.34,1.53) *** 1.34 (1.25,1.45) *** 1.62 (1.50,1.75) ***

*p < 0.05 **p < 0.01 ***p < 0.001.

higher risks of MSDs in almost all body parts.
Furthermore, these findings indicated that major predictors for
shoulder and neck MSDs were high psychological job demands and low
workplace justice in male employees, whereas they were exposure to
hand-related ergonomic hazards followed by low workplace justice and
high psychological demands in female employees. Moreover, major
predictors for lower-back disorders were whole-body-related ergonomic
hazards and high psychological demands in male employees, whereas
they were high psychological demands and exposure to whole-body­
–related and hand-related ergonomic hazards in female employees.
Lastly, for wrist or hand MSDs, a major risk factor was exposure to er­
gonomic hazards in both male and female employees.
4. Discussion and conclusions
Findings of this study showed that different MSDs were distributed
differentially across different socioeconomic categories. When not
specifying the type of MSD, male workers in small-sized enterprises had
higher risks and construction workers had remarkably higher risks of
MSDs. Separate examinations revealed that among professionals and
skilled workers, neck and shoulder MSDs were more prevalent, whereas
among manual workers, hand, wrist, and lower-back problems were
more prevalent.
Unequal distributions of various health outcomes have been well
documented, with individuals of lower SES having higher health risks
(Galobardes et al., 2006; Glymour et al., 2014). However, to our
knowledge, few studies have examined the distributions of MSDs across
socioeconomic categories in the general working population, and even
fewer have examined the socioeconomic distributions of specific MSDs.
A small-scale study conducted by Hehlum and colleagues (Mehlum
et al., 2013) revealed that workers with a lower SES were more likely to
report musculoskeletal pain when such symptoms were examined indi­
vidually by body part, but the associations became inconsistent when all
types of MSDs were combined in analyses. Similarly, in the present
study, associations between SES and the presence of MSDs differed ac­
cording to the body part, which were different from the associations of
all MSDs combined. These findings suggest that different MSDs may
have unique causal pathways and risk factors that can be shaped and
influenced by specific work and social conditions. Therefore, when the
type of MSD is left unspecified, the observed distribution of the overall
risks of MSDs with respect to SES or sex could lead to a biased
conclusion.
Construction workers are well-known to often have lower SES, work
under precarious and hazardous conditions, and are hired by small-sized
enterprises or subcontractors (Cheng et al., 2005). These factors may
collectively contribute to greater occupational hazards and health risks,
including for MSDs. Our findings are consistent with those of other
studies from Taiwan and other countries (Chen et al., 2005; Fouquet
et al., 2018; Guo et al., 2004; Lee et al., 2005; Ma et al., 2018).
According to this study, shoulder and neck MSDs were greatly

6
H.-C. Liu et al.
associated with exposure to psychosocial work hazards, including high
psychological demands and low workplace justice, whereas lower-back
and wrist or hand MSDs were greatly associated with exposure to whole-
body-related and hand-related ergonomic hazards, respectively. The
observed associations between psychosocial work hazards and the risks
of MSDs can be explained by stress-induced physiological responses,
such as sympathoadrenal medullary activation, adrenaline release, and
increased muscle tone (Bongers et al., 1993). Similar findings have been
reported previously. For instance, van den Heuvel and colleagues esti­
mated the independent effects of psychosocial and ergonomic work
factors and found that the associations between high psychological job
demands and the risks of neck and shoulder symptoms persisted after
adjustment for ergonomic factors (relative risk was reduced slightly
from 2.2 to 2.1), but the associations between high psychological job
demands and the risks of elbow, wrist, or hand symptoms disappeared
after adjusting for ergonomic factors (van den Heuvel et al., 2005).
According to these findings, exposure to psychosocial work hazards was
the main predictor of the neck and shoulder MSDs, whereas exposure to
ergonomic work hazards better explained the risks of elbow, wrist, and
hand MSDs.
Several studies have examined the effects of ergonomic and psy­
chosocial work hazards on the risks of MSDs; however, the measure­
ments of work conditions were inconsistent, making the results less
suitable for comparison across models and studies (So et al., 2017; Wang
et al., 2017). Compared with previous studies, the present study has the
following strengths: the study population consisted of a large sample
size of nationally representative employees, MSDs were classified into
specific types, standardized scales were used to assess a wide range of
both ergonomic and psychosocial work hazards, and the same set of
predictors were included in the regression models, which facilitated
comparisons across different MSDs.
However, this study had several limitations. First, the nature of a
cross-sectional study design precludes conclusive causal interpretation.
This study assessed workplace experiences 1 week before the survey,
whereas the prevalence rates of MSDs were evaluated over the past 12
months. Thus, participants’ disease occurrences may have affected their
employment and work arrangements. The healthy worker effect is likely
and might have resulted in an attenuation of true associations between
exposures and outcomes. Future research with a follow-up study design
is necessary to evaluate the true effect of workplace hazards on the
development of MSDs.
Second, information on both exposure and MSDs was obtained by the
self-reported questionnaire; thus, common method bias may exist and
the assessment of workplace hazards and MSDs might have been influ­
enced by individual objective perception, thus leading to an exaggerated
association between workplace hazards and disease risks. However,
other research has indicated that self-reported results are highly corre­
lated with those of methods for the assessment of exposure to ergonomic
hazards and MSDs (Punnett and Wegman, 2004).
Despite the aforementioned limitations, the findings of this study
have shown that ergonomic and psychosocial work hazards have
different associations with different MSDs. Therefore, we recommend
that to prevent the development of MSDs, occupational health pro­
fessionals should evaluate both ergonomic and psychosocial work haz­
ards and develop health prevention programs tailored to the risk profiles
of working populations.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare no conflicts of interest. This research did not
receive any specific grant from funding agencies in the public,
7
International Journal of Industrial Ergonomics 76 (2020) 102935
commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Hsi-Chen Liu: Conceptualization, Formal analysis, Methodology,
Writing - original draft. Yawen Cheng: Conceptualization, Data cura­
tion, Formal analysis, Funding acquisition, Investigation, Methodology,
Supervision, Writing - review & editing. Jiune-Jye Ho: Supervision,
Writing - review & editing.
Acknowledgments
We thank the Institute of Labor, Occupational Safety and Health and
Ministry of Labor, Taiwan, which provided access to the database
investigated.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ergon.2020.102935.
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