Applying the PRECEDE-PROCEED model to promote preventive behaviors of musculoskeletal disorders in computer users

Nowadays, using the computer in doing everything is necessary and there are fewer jobs that do not use the computer to perform tasks. Working with a computer for a long time under static conditions and inappropriate postures can lead to work-related musculoskeletal disorders (WRMSDS). Computer users report a high incidence of WRMSDS, depending on the nature of their work. One of the administrative control strategies to reduce or eliminate the risk factors for WRMSDS in computer users is applying education or training program. Also, providing the devices of office workstations such as chairs and tables adjustable. The results of various studies have been shown that ergonomic training, ergonomic design of workstations and office buildings can be useful in preventing and reducing WRMSDS and its associated symptoms in office settings. Since training is one of the main pillars of health care in our country, it is necessary to pay more attention to designing and planning educational programs based on educational models and theories of behavior and social sciences for various diseases and health issues. In this study, the PRECEDE-PROCEED educational model was used to plan for promoting preventive behaviors of WRMSDS among computer users. This model is introduced as a diagnostic framework for health education planning and health promotion. Model implementation stages include: social diagnosis, epidemiological diagnosis, behavioral and environmental diagnosis, educational diagnosis (identifying predisposing factors, enabling and enhancing health behaviors) and ecological, managerial and policy diagnosis, implementation, process evaluation, evaluation of immediate results and evaluation of long term results. The reason for using this model in this study is that the comprehensive nature of this model makes it applicable to different subjects and populations. This model has an ecological perspective and states that one should not only consider the behavior to change, but also the environment around the individual and the factors that influence behavior change, take into account also. Therefore, in order to obtain useful and effective results, education must be designed based on theories and patterns of behavior change. Therefore, this study was carried out with the aim of applying PRECEDE-PROCEED model in promoting preventive behaviors of WRMSDS among computer users. 

In this randomized controlled trial study, 110 computer users were selected. The risk factors of the workstations have been determined using the Rapid Administrative Stress Assessment (ROSA) method. Computer users who had a high risk of developing WRMSDS and their workstations needed corrective and interventional measures were included in the study. Data were collected using standard Nordic questionnaire, ROSA checklist, and researcher-made questionnaire based on PRECEDE-PROCEED educational model constructs. The validity and reliability of the researcher-made questionnaire were assessed in a pilot study. Individuals were also agreed to enter the study. Data collection tools were completed in three stages. In the first stage, Nordic musculoskeletal standard questionnaire was used to evaluate the prevalence of WRMSDS. To achieve better results, the questionnaire was completed through direct interviews with the participants under study, and the prevalence of WRMSDS was recorded over the past year. In the second stage, the risk factors for WRMSDS and determination of risk levels were determined by ROSA method. This method is proposed to identify the risk factors of computer users and to prioritize the optimal fit between users and workstation devices. In the third stage, the self-made questionnaire consisted of different parts of the PRECEDE-PROCEED model constructs such as individual questions, predisposing factors, enabling factors, and reinforcing factors has been applied. Content validity method was used for scientific validation of self-made questionnaire. The questionnaire was given to 12 professors related to this topic and their corrective comments were applied. Test-retest method was used to calculate the reliability of these questionnaire. The questionnaire was completed by 20 computer users and then completed in two weeks. Cronbachchr('39')s alpha for questionnaire was estimated 0.75. Finally, based on the results of the initial questionnaires, an appropriate educational intervention including training manuals and instructional videos on stretching and corrective movements, training and correct sitting exercises while working with the computer was designed and implemented in the experimental group. The control group received no training. After the implementation of the training program in the evaluation phase of the PRECEDE-PROCEED model, the process of intervention, design and implementation of the program was evaluated. Immediately after the training sessions and two months after the intervention, the impact of the training program on promoting preventive behaviors of WRMSDs of computer users was measured. Data were analyzed before and after the intervention using SPSS.24 software. Mann-Whitney and Wilcoxon tests were used to compare quantitative values ​​between the two groups before and after the intervention and chi-square test was used to compare qualitative values ​​between the two groups.

In this study, 86 (78%) of the participants were men and 24 (22%) were women. The results of chi-square test showed that the distribution ratio of people with different gender was similar between the two groups and there was no significant difference between them (p> 0.05). Findings showed that the mean age of users was 39.7 years and there was no significant difference between the two groups in terms of age. Chi-square test results showed that there was no significant difference between the prevalence of musculoskeletal disorders in the two groups (P> 0.05). The results showed that the highest prevalence of disorders in the experimental group was in the low back, neck and shoulder respectively, and in the control group was in the low back, neck and shoulder, respectively. Before intervention, there was no significant difference between the mean of ROSA final scores, variables of PRECEDE-PROCEED model such as predisposing factors, reinforcing factors and enabling factors in the two groups. There was a significant difference between the mean scores of ROSA final score and its components (p = 0.0001) as well as the mean scores of predisposing factors (knowledge and attitude), reinforcing factors, and enabling factors of PRECEDE-PROCEED model (p = 0.0001). Before the intervention, the Mann-Whitney test results showed no significant difference in the mean scores of the predisposing factors (knowledge and attitude) and PRECEDE-PROCEED model reinforcement factors between the two groups (p> 0.05). There was a significant difference in the mean of the enabling factors in the two study groups before the intervention (p <0.05). The findings of the study showed a significant difference between the mean scores of the predisposing factors (knowledge and attitude), enabling factors and reinforcing factors of the PRECEDE-PROCEED model between the experimental and control groups.

In the present study, in accordance with the educational process of PRECEDE-PROCEED model, the enabling and reinforcing factors have been take into account. The mean of enabling factors had a significant increase in the experimental group after the intervention compared to before the intervention and in the control group there was no significant increase. Prior to training, 36% of the study participants had a background in television, health care, magazines, and newspapers. In the intervention program, 100% of the experimental group received an educational booklet called principles of ergonomics at the computer workstation also instructional videos (including stretching and correcting movements) which caused a significant difference in enabling factors. In this study, encouragement and support of family, coworkers, and verbal encouragement of the educator were considered as reinforcing factors. Results showed that there was a significant difference between the mean of these factors after the intervention in the experimental group compared to the control group. Finally, it was concluded that design and implementation of ergonomic training programs based on PRECEDE-PROCEED model with changes in predisposing factors (knowledge and attitude), reinforcing factors and enabling factors also considering the components of ROSA method is an effective method to promote preventive behaviors of WRMSDs and it can be used as a framework for designing of educational interventions among computer users.