AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 49:14–22 (2006)

The Prevalence of and Risk Factors forBack Pain Among Home Care Nursing

Personnel in Hong Kong

Kin Cheung, RN, PhD,1� Marion Gillen, RN, MPH, PhD,2 Julia Faucett, RN, PhD, FAAN,2

and Niklas Krause, MD, PhD, MPH3

Background There is a large gap in research with regard to back pain (BP) among homecare nursing personnel (HCNP); only seven studies have been conducted worldwide.There is a need to identify the magnitude of and risk factors for BP that are unique to HongKong (HK) HCNP.Methods A total population sampling technique was employed in this cross-sectionalquestionnaire-based study. Hierarchical multiple logistic regression analyses were used tocontrol for potentially confounding variables.Results The 12-month prevalence of upper and lower BP was 71.2% (n¼ 265). Threepredictors were identified: physical risk factors in the office (OR¼ 3.57, 95% CI¼ 1.55–8.24), static postures (OR¼ 1.41, 95% CI¼ 1.04–1.90), and psychological job demands(OR¼ 1.11, 95% CI¼ 1.01–1.22).Conclusion HCNP inHKhave a high prevalence of BP. BP inHKHCNP is independentlyattributable to physical work factors in the office, static postures, and psychological jobdemands, and is not primarily associated with patient lifting and transferring which aretraditionally identified as risk factors for BP in hospital nursing personnel. Am. J. Ind.Med. 49:14–22, 2006. � 2005 Wiley-Liss, Inc.

KEY WORDS: musculoskeletal disorders; office work; static postures; job stress

INTRODUCTION

The prevalence of back pain (BP) in nursing personnel

has been well documented in many studies internationally

[Cheung, 1999; Yip, 2001; Edlich et al., 2004; Martinelli

et al., 2004; Violante et al., 2004]. In fact, nursing personnel

have been found to have more BP than those in other

occupations, such as construction laborers, fork-lift truck

drivers, garbage collectors, and teachers [Jensen, 1987; U.S.

Department of Labor, 2005]. Owing to their high incidence

and prevalence, back problems in hospital nursing have

attracted the deserved attention of many researchers.

Unfortunately, BP in home care nursing personnel (HCNP)

has been neglected by researchers. In 1988, a literature

review of low-back injuries among nursing personnel

concluded that back problems in home care had been ignored

by researchers [Jensen et al., 1988]. Sixteen years later,

knowledge about the risk profile for back problems among

HCNP is still unclear. An extensive review of literature

indicates that there is a large gap in research with regard to BP

among HCNP; only seven studies [Skarplik, 1988; Myers

et al., 1993; Smith and White, 1993; Knibbe and Friele, 1996;

Brulin et al., 1998; Cheung, 1999, 2000; Meyer and

Muntaner, 1999] have been conducted worldwide including

� 2005Wiley-Liss, Inc.

1School of Nursing,The Hong Kong Polytechnic University, Kowloon, Hong Kong2Department of Community Health Systems, School of Nursing, University of California,

San Francisco, California3Department of Medicine, Division of Occupational and Environmental Medicine, Univer-

sity of California, San Francisco, CaliforniaKin Cheung and Niklas Krause are Assistant Professors; Marion Gillen is an Associate

Professor; and Julia Faucett is Professor and Chair.Contract grant sponsor: The Hong Kong Polytechnic University; Contract grant sponsor:

University of California, San Francisco.*Correspondence to: Dr. Kin Cheung, School of Nursing, The Hong Kong Polytechnic Uni-

versity, Hung Hom, Kowloon, Hong Kong. E-mail: hskin@inet.polyu.edu.hk

Accepted18 October 2005DOI10.1002/ajim.20243. Published online inWiley InterScience

(www.interscience.wiley.com)

studies from the United States, Britain, Canada, the Nether-

lands, and Sweden. All of these studies indicated that HCNP

were at risk for BP and they faced unique risk factors, such as

working alone, and potentially under poor working condi-

tions on the road, and in patients’ home.

Globally, the demand for home care services has

increased dramatically due to aging populations and shorter

length of hospital stay [U.S. Department of Labor, 1997;

Hospital Authority, 1999; U.S. Department of Labor, 2004].

Working conditions for HCNP are unique because each day

they provide care in patients’ homes, travel on the road, and

work in office settings. In contrast to the standardized, well-

controlled and well-equipped environments of institutions,

HCNP work in unpredictable, uncontrollable, and uncertain

home environments [Cheung, 2000]. In Canada, awkward

home environments and poor road conditions were identified

as possible risk factors for low back injuries among HCNP

[Cheung, 1999]. The working space in patients’ homes and at

nursing offices is more limited in Hong Kong (HK) than in

North America; thus the work environment for HCNP in HK

could potentially produce even greater physical demands on

them.

The majority of patients who need home care services in

HK are low-income persons. They tend to live in public

housing and some live alone without any regular assistance

with daily activities [Hospital Authority, 1996]. Living

spaces in public housing are very small, ranging in size from

16 to 70 square meters, accommodating as many as four or

more habitants. Housing units for senior citizens range from

9 to 28 square meters [Census and Statistics Department,

2003]. The logistics of providing care in HK also differs.

Unlike North American, HCNP who commonly drive from

one patient’s home to another, HCNP in HK generally walk

or take public transportation. In the personal nursing experi-

ence of two authors, HCNP in Edmonton and the San

Francisco Bay Area are more likely to drive than take public

transportation or walk. Most HCNP carry a heavy bag while

walking 1–2 hr of their 8-hr shift. HCNP also frequently walk

up and down stairs since some buildings are not equipped

with elevators.

When nursing personnel experience BP, the injured

workers and the employer suffer, as do the patients who are

often isolated, relying on the services provided by their home

care nurse. When service is disrupted due to injury, ‘‘Patients

will have to start over to build a relationship with a new care

provider and may experience great anxiety in the adjust-

ment’’ [Janizewski and Caley, 1995, p. 54]. Hence, the

quality of patient care in home care could suffer more

seriously from BP among nursing personnel than in insti-

tutional settings. Thus, there is a need to identify the magni-

tude of and risk factors for BP that are unique to HK HCNP.

The ability of HCNP to deliver consistent and sustained

service to their patients depends in part on their ability to

conserve their own health and well-being.

METHODS

Study Population Recruitment

A total population sampling technique was employed in

this cross-sectional questionnaire-based study. All HCNP

(n¼ 491) who worked in Community Nursing Services

(CNS) and Community Psychiatric Nursing Services

(CPNS) under the Hospital Authority of HK from June to

September 2003 were invited to participate in this study. A

cover letter and a questionnaire were distributed to all HCNP

at their workplace. The purpose and procedure of the research

was explained to familiarize HCNP with the study and to gain

their support for the study. Participation in this study was

voluntary and involved no financial remuneration. Most

supervising nurses allowed the investigator to attend a staff

meeting to distribute the questionnaires; some even let the

participants complete and return the questionnaire on site.

All participants, regardless of the manner in which they

received questionnaires, were reassured that the supervising

nurse would not have access to the returned questionnaires.

The investigator had information regarding the total number

of HCNP in each center but did not have access to their

names. Only those respondents who were willing to

participate in future studies (n¼ 13) provided their names

and contact phone numbers to the investigators; otherwise,

no personal or facility identification was recorded on the

questionnaire. No written consent form was required in this

study; completing and returning the questionnaire served as

informed consent to participate, as is typical in research

studies conducted in HK.

Survey Instrument

The HK Back Problems Questionnaire (HKBPQ) was

developed based on information from the literature [Karasek,

1979; Kuorinka et al., 1987; Rossignol and Baetz, 1987;

Johnson and Hall, 1988; Wiktorin et al., 1993; Viikari-

Juntura et al., 1996; Wiktorin et al., 1996; Martin et al., 1997;

Halpern et al., 2001]. The HKBPQ contains five sections.

Section I evaluates self-reported physical workload. Partici-

pants were asked about their normal weekly work schedule

and their work activities on the last day that they worked.

Physical workload in patients’ homes was measured as

percentage of time spent (i.e., almost never, 10%, 25%, 50%,

75%, almost all the time) on lifting/carrying/pushing/pulling

an object or patient, static postures (such as kneeling or

squatting, bending, or twisting trunk), working on slippery or

uneven surfaces, and working from unadjustable heights.

Physical risk factors on the road were assessed as percentage

of time spent on walking, standing, or climbing stairs; riding

a bus or train; lifting/carrying/pushing/pulling an object; and

static postures. Lastly, physical risk factors in the office were

evaluated as percentage of time spent on sitting, walking,

Back Pain Among Home Care Nursing Personnel in Hong Kong 15

kneeling, or squatting, and working in cramped spaces.

Physical exertion and physical isometric loads were

measured as degree of agreement (1¼ strongly disagree

and 4¼ strongly agree) [Karasek, 1985]. Physical exertion

includes lifting heavy loads, rapid and continuous physical

activity, and incorporates required physical effort. Physical

isometric loads were described as being required to work for

long periods with the head, body, or arms in physically

awkward positions. The terms isometric loads and static

loading or static posture are used interchangeably [Corlett

et al., 1986; Niebel and Freivalds, 1999]. Since the term

‘‘static postures’’ is commonly used and understood by most

people, this term rather than the term ‘‘physical isometric

loads’’ will be used in this paper.

Section II focused on 12-month prevalence of pain in

different parts of the body, including the upper back, lower

back, neck, shoulders, knees, and other areas. The 12-month

prevalence is the proportion of people in a population who

have the disease at any time during the year [Knapp and

Clinton Miller, 1992]. It includes cases arising before but

extending into or through the year as well as those having

their inception during the year [Last, 2001]. For those who

reported upper or lower BP, additional questions were asked

in Section III, which assessed functional outcomes related to

their BP. Section IV asked about psychosocial risk factors

related to the subjects’ home care job and their work at home

based on Karasek’s JCQ [Karasek, 1985]. Section V asked

subjects to provide personal and demographic information

on subjects such as age, gender, height, weight, nursing

experience, nursing position, and number of children at

home. In this article, only the 12-month prevalence of and

risk factors for BP (including both upper and lower back) will

be reported.

To ensure face and content validity, seven experts in the

field of occupational health or home care reviewed the

HKBPQ. The panel consisted of three dissertation committee

members in the United States, one professor of occupational

health in Canada, and three local experts in HK (one from the

Labor Department, and two from home care services). They

were asked to rate each item and the entire questionnaire

using a 4-point scale (1¼ not relevant, and 4¼ very relevant

and succinct) [Lynn, 1986]. The strength of validity was

interpreted in terms of a content validity index (CVI).

Portney and Watkins [1993] recommended a CVI greater

than 0.75 for a newly developed instrument. The overall CVI

for HKBPQ is 0.95. The reliability of the HKBPQ subscales,

as used in this study, was acceptable (Cronbach’s Alpha

ranging from. 63 to. 95).

The HKBPQ was translated into Chinese using the

backward translation method. The HKBPQ Chinese version

was pilot tested with 10 HCNP in HK prior to widespread

administration. Minor changes were made to the question-

naire based on the results of the pilot study. Ethical clearance

was obtained from the Nursing Section of the Head Office of

Hospital Authority, the Hong Kong Polytechnic University,

the University of California, San Francisco, and the research

committee of each hospital authorizing the study.

Statistical Analysis

Descriptive statistics were examined for all variables

under study. Pearson correlation coefficients were used to

estimate the bivariate correlation between each risk factor

and BP. Comparisons between HCNP with BP and HCNP

without BP were conducted using Chi-square tests; and

independent samples t-tests. Independent variables that

showed a high degree of correlation with BP were tested

for multicollinearity. If two independent variables were found

to have a correlation equal to or greater than 80, only one

variable was selected for entry into the final hierarchical

multiple logistic regression.

Based on bivariate analyses and evaluation of multi-

collinearity, risk factors that demonstrated a correlation of at

least 0.20 (in absolute value) with BP were considered for

multiple logistic regression analysis. This criterion was

selected because this value represents 4% of variance

explained by a risk factor in bivariate analyses. Finally, the

pseudo R-square value was used to interpret the percentage of

improvement in fit over a null model [Hosmer and

Lemeshow, 2000]. All statistical analyses were performed

using version 11 of the Statistical Package for the Social

Science [SPSS, 1999].

RESULTS

Sample Characteristics

Of the 491 surveys distributed, 411 were returned. Five

participants were excluded from data analysis because they

did not answer at least 80% of the questions. Therefore, the

overall response rate was 82.7%. Characteristics of study

participants are shown in Table I. Participants working in

CNS provide mostly physical care and those working in

CPNS provide primarily psychological counseling and crisis

intervention to patients. Registered nurses (RNs) and enrol-

led nurses (ENs) comprise the majority of workers in HK

home care. Both provide nursing care to patients but RNs are

more likely to be employed in managerial or supervisory jobs

than ENs. Among RNs, about 80% (n¼ 189) had a degree in

nursing. Most participants were in their mid-30s (SD¼ 7.1;

range from 20–56) and their mean number of years spent in

community nursing was 6.8 years (SD¼ 5.9) with a range

from <1 year to 30 years.

Twelve-Month Prevalence of Pain

Participants who had less than 1 year of community

nursing experience were excluded from this analysis (n¼ 31,

16 Cheung et al.

7.6%) since a 12-month prevalence was the variable of

interest in this study. An additional three (0.8%) were exclu-

ded because of missing data, yielding a total of 372 parti-

cipants for analyses.

The total BP prevalence (consisting of either upper or

lower back) was 71.2% (n¼ 265) [See Table II] and was the

second most frequently reported site for pain, following the

shoulder. Among those reporting BP, 86.4% (n¼ 229)

believed that their pain was caused or aggravated by work.

The BP prevalence for CNS (76.4%, n¼ 217) was signi-

ficantly higher than that of CPNS (54.5%, n¼ 48) (w2¼15.67, P< 0.01). However, there was no significant differ-

ence between RNs and ENs (w2¼ 3.15,P> 0.05) with regard

to the 12-month prevalence of BP.

Risk Factors for BP

Participants suffering from BP were more likely to be

younger (t¼ 3.15, df¼ 342, P< 0.01), female (w2¼ 12.13,

P< 0.01), and working in the CNS setting (w2¼ 15.67,

P< 0.01). Table III showed that they experienced higher

exposure to physical risk factors in the patients’ homes (such

as prolonged kneeling, bending, and working in limited

working space), on the road (e.g., lifting or carrying objects),

and in the office (e.g., prolonged position). They also

experienced more physical exertion and static postures.

Overall, participants suffering from BP reported higher

levels of psychological job demand, but results differed for

specific demands. Participants with BP felt more often that

their work was very hectic (t¼�3.25, df¼ 369, P< 0.01),

and they more often had to wait on work from other people

before their job could be completed (t¼�3.39, df¼ 369,

P< 0.01). On the other hand, participants without BP more

often reported that they had enough time to get their job done

(t¼ 2.05, df¼ 369, P< 0.05), and that they were not asked

to do an excessive amount of work (t¼ 2.36, df¼ 369,

P< 0.05).

Table IV shows the results of the hierarchical multiple

logistic regression analysis with incremental adjustment for

potential confounders for BP. It is interesting to note that the

crude effects of age, gender, and type of service were reduced

substantially after adjustment for physical job factors.

Furthermore, in models including all three classes of physical

job factors (office, road, and patient home environment); only

physical job factors in the office remained strong and statis-

tically significant risk factors for BP (OR¼ 3.57, 95% CI¼

TABLE I. Characteristics of Home Care Nursing Personnel in Hong Kong(N¼ 406)

Characteristics n Percentage

GenderMale 52 13.0%Female 349 87.0%

Marital statusSingle 108 27.1%Married 283 70.9%Divorced/widowed 8 2.0%

EducationMaster’s degree 2 0.5%Bachelor of science in nursing 189 47.7%Diploma in nursing 74 18.7%Enrolled nurse 131 33.1%

Job titleManager 34 8.5%Registered nurse 236 58.9%Enrolled nurse 131 32.7%

Type of servicesCNS 308 75.9%CPNS 98 24.1%

TABLE II. The12-Month Prevalence of Pain AmongHome Care NursingPersonnel in Hong Kongby Body Region (N¼ 372)

Body parts in pain N %

NeckYes 236 62.9%No 139 37.1%

ShouldersYes 274 73.1%No 101 26.9%

Upper backYes 191 51.2%No 182 48.8%

Lower backYes 208 55.9%No 164 44.1%

Back (upper & lower back)Yes 265 71.2%No 107 28.8%

ElbowsYes 65 17.3%No 310 82.7%

Wrists or handsYes 113 30.3%No 260 69.7%

Hips or thighsYes 103 27.7%No 269 72.3%

KneesYes 244 65.1%No 131 34.9%

Ankles or feetYes 199 53.4%No 174 46.6%

Back Pain Among Home Care Nursing Personnel in Hong Kong 17

1.55–8.24). After additional adjustment for psychosocial

factors, age showed no effect on BP at all and gender effects

were no longer statistically significant. Physical risk factors

in the office, static postures, and psychological job demands

were significant predictors for BP [See Table IV] and also for

work-related BP (data not shown) even after adjustment for

all covariates.

DISCUSSION

Prevalence of BP in HCNP

The findings of this study confirm a high prevalence of

BP (71.2%, n¼ 265) among HCNP in HK. Clearly, these

results indicate that there is a need for understanding the

TABLE III. Comparison ofHomeCare Nursing Personnel in HongKongwith andWithout Back Pain During thePast12Months

Characteristics Range of scale

Back pain (N¼ 265) No back pain (N¼107) P-value

M (SD) M (SD) t-test

Physical risk factorsIn the patients’ homesa 0^5 1.6 (1.1) 1.0 (1.0) P< 0.01On the roada 0^5 1.8 (0.9) 1.42 (0.8) P< 0.01In the officea 0^5 1.0 (0.5) 0.7 (0.4) P< 0.01Physical exertionb 3^12 8.3 (1.7) 7.4 (1.7) P< 0.01Static posturesc 2^8 5.2 (1.3) 4.4 (1.3) P< 0.01

Psychosocial risk factorsPsychological jobdemandsd 3^21 10.4 (3.1) 9.2 (3.0) P< 0.05

aThe scale’s range is from 0 to 5.bThe scale’s range is from 3 to12.cThe scale’s range is from 2 to 8.dThe scale’s range is from 3 to 21.

TABLE IV. Demographic, Physical, Psychosocial, and Type of Service Factors and12-Month Prevalence of Back Pain AmongHome Care Nursing Personnel inHong Kong:Results FromMultiple Logistic RegressionWith Incremental Adjustment for Potential Confounders (N¼ 372)

VariablesCrude odds ratio (OR)

(95%CI)OR adjusted for ageand gender (95%CI)

OR adjusted for age,gender, and physicala

factors (95%CI)

OR adjusted for age,gender, physicala, andpsychosocialb factors

(95%CI)

OR adjusted for age,gender, physicala,psychosocialb

factors, and type ofservicec (95%CI)

Age (1year) 0.95 (0.92^0.98) 0.95 (0.92^0.99) 0.98 (0.94^1.02) 0.98 (0.94^1.02) 0.98 (0.94^1.02)Female Gender 2.90 (1.57^5.39) 2.81 (1.48^5.35) 2.23 (1.04^4.77) 2.09 (0.96^4.54) 1.75 (0.76^4.06)Service (CPNS)c 0.37 (0.22^0.61) 0.43 (0.24^0.77) 0.80 (0.36^1.77) 0.62 (0.27^1.44) 0.62 (0.27^1.44)Physical risk factors inpatients’ homes

1.84 (1.42^2.38) 1.75 (1.31^2.33) 1.12 (0.72^1.74) 1.14 (0.73^1.78) 1.03 (0.64^1.66)

Physical risk factors onthe roads

1.87 (1.39^2.53) 1.68 (1.22^2.33) 0.94 (0.56^1.56) 0.90 (0.53^1.51) 0.92 (0.55^1.56)

Physical risk factors inthe office

4.03(2.20^7.40) 3.57(1.87^6.82) 3.30(1.46^7.46) 3.43(1.49^7.89) 3.57(1.55^8.24)

Physical exertion 1.40 (1.21^1.61) 1.31 (1.12^1.54) 1.04 (0.84^1.29) 1.00 (0.80^1.27) 0.97 (0.76^1.23)Static postures 1.62(1.35^1.96) 1.58(1.29^1.95) 1.38(1.04^1.84) 1.43(1.06^1.93) 1.41(1.04^1.90)Psychological jobdemands

1.14 (1.06^1.24) 1.11 (1.02^1.21) 1.10 (1.00^1.20) 1.10 (1.00^1.20) 1.11 (1.01^1.22)

Bold represents statistically significant results (P<0.05).aPhysical factors include physical risk factors in patients’ homes, on the roads, in the office, physical exertion, static postures.bPsychosocial factors include psychological job demands.cCommunity psychiatric nursing services (CPNS) compared with community nursing services (CNS).

18 Cheung et al.

causes of BP among HCNP and for the development of

preventive programs. Many published studies on HCNP have

concentrated on back problems among nursing aides (NAs)

[Myers et al., 1993; Brulin et al., 1998; Meyer and Muntaner,

1999; Galinsky et al., 2001]. This is likely because surveil-

lance activities and research have both demonstrated that

NAs are at higher risk of developing back problems as

compared to other care-giving occupations [Jensen, 1987;

Bureau of Labor Statistics (BLS), 1999]. It is believed that

NAs provide more physical care to patients than RNs, and

hence have greater exposure to tasks that are more physically

demanding. In addition, NAs who work in home care settings

suffer from more back injuries than their counterparts in

hospital settings [Myers et al., 1993; U.S. Department of

Labor, 1997].

However, unexpectedly, one study conducted by Knibbe

and Friele [1996] in the Netherlands found that the 12-month

prevalence of back pain for NAs (61.2%) was significantly

lower than that for RNs (71.4%). This finding contradicts the

results of most studies conducted in the United States. Since

no NAs are employed in home care in HK, the target popu-

lation for the present study involved only RNs and ENs. The

results showed that the 12-month prevalence of back prob-

lems for RNs and ENs was 73.7% (n¼ 154) and 64.6%

(n¼ 84) respectively, a non-statistically significant differ-

ence (w2¼ 3.15, P> 0.05). Given that RNs and ENs provide

similar kinds of nursing care to patients, these results are not

surprising. Although the RNs in this sample have more

education than the ENs, the ENs are older and have more

nursing and community nursing experience than the RNs.

The healthy worker effect might be a factor in the lower

prevalence of BP in this sample of ENs.

Furthermore, Knibbe and Friele [1996] found that the

12-month prevalence of BP for RNs was 71.4% (n¼ 135).

Based on job description provided, RNs in their study worked

in settings similar to the CNS setting in HK. However, CNS in

HK experienced a significantly higher 12-month prevalence

of BP (83.1%, n¼ 123) than their counterparts in the

Netherlands (w2¼ 6.31, P¼ 0.01). The reasons for this are

unclear, although this could be related to the work tasks

themselves, or to the work or home environment.

Risk Factors for Back Pain

Office work

HCNP in HK are subject to unique risk factors in

developing BP, which differ from those of their counterparts

in hospitals. Office work, static postures, and psychological

job demands were independently associated with BP,

indicating that the increased risk for BP is not only the result

of static postures or psychosocial job factors, but is also a

result of ergonomically unfavorable workstations in the

agency office—an environment under the direct control of

management. In home care, work in the office is relatively

constant, compared to work performed in the homes of

patients and while on the road. Nurses work in the office for

approximately 3.21 hr (SD¼ 1.74) per day while charting or

making phone calls to patients. Results of this study showed

that the numbers of hours of office work was not associated

with BP (t¼ 0.63, df¼ 363, P¼ 0.53). Rather, activities in

the office, such as sitting (w2¼ 15.59, P< 0.01), lifting, or

carrying objects (w2¼ 15.91, P< 0.01), working in limited

working space (w2¼ 14.16, df¼ 5, P< 0.05), and static

postures (w2¼ 21.80,P< 0.01), were demonstrated to be risk

factors for BP. Among those risk factors identified in the

study, sitting [Westgaard et al., 1985] and static postures

[Knibbe and Friele, 1996] have been previously identified as

risk factors for BP. Furthermore, HCNP are likely to use

computers to perform data entry. One study conducted

in Mexico by Ortiz-Hernandez et al. [2003] found that

computer use led to increases in problems with the hand,

back, and upper extremities. Computer use and office work

performed in a limited working space could pose ergonomic

hazards to HCNP.

Ergonomic standards and guidelines are available for the

design of computer and office workstations to accommodate

the bodily features and limitations of users [Occupational

Safety and Health Council, 2003a]. Under Section 4 of the

Hong Kong Occupational Safety and Health (Display Screen

Equipment [DSE]) Regulation, a risk assessment of a DSE

workstation is required before the station is first used

[Occupational Safety and Health Council, 2003b]. However,

in general, HCNP in HK do not have dedicated computers or

individualized workstations; their offices may also not be

updated as required. For instance, a workstation may not

be equipped with adjustable chairs or footrests. This was

confirmed by informal site visits to several home care offices

where it was clear that many HCNP sit in awkward positions

and at ergonomically unfavorable work stations. In some

settings, the HCNP were observed to sit in very close

proximity to each other, with their shoulders almost touching

each other, providing very little space for stretching or nor-

mal movement. Results of this study suggest that managers

should invest resources to assure that workstations meet

accepted ergonomic standards for each HCNP. Studies have

also found that rotating jobs and taking breaks can be

effective strategies for reducing musculoskeletal disorders

[U.S. Department of Labor, 1999; Yassi, 2000; Ortiz-

Hernandez et al., 2003]. Therefore, HCNP should be

encouraged to take short breaks every hour; perhaps to

perform a 5-min relaxation exercise in the office, such as

stretching, moving one’s toes, raising one’s shoulder, doing

side bends, leg lifting, or curling exercises [Occupational

Safety and Health Council, 2003a].

In the nursing profession, risks related to musculoske-

letal problems from patient handling have been the primary

focus of previous research. Risks posed by office work have

Back Pain Among Home Care Nursing Personnel in Hong Kong 19

largely been ignored and understudied in both hospital and

home care settings. Therefore, it is not surprising that many

HK HCNP believe, because they do not need to lift or trans-

fer patients as often as hospital nurses, that their risk of

developing musculoskeletal problems is much lower than

that of their hospital counterparts. However, the results of

this study showed that the prevalence of low BP alone

among HCNP (55.9%) is considerably higher than that

reported by hospital nurses in HK (40.6%) [Yip, 2001]. These

findings may help to change the widespread perception

among managers and supervisors that the risk of back pain

among HCNP is primarily affected by patient handling

activities.

Static postures

In this study, static postures were measured by asking

participants if their job required their body, head, or arms

to be in physically awkward positions for long periods of

time [Karasek, 1985]. Examples of static postures that may

have occurred to HCNP in this study are: performing a

wound dressing in a limited working space in a patient’s

home; carrying a heavy nursing bag in a crowded bus; and

sitting for long periods of time in the office. As a matter of

fact, all of the variables relating to static postures were

identified in bivariate analyses in the present study as risk

factors for BP. They are: prolonged twisting or rotation,

prolonged bending to the side, prolonged squatting, and

prolonged kneeling in patients’ homes; and prolonged or

sustained positions on the road and in the office. Static work

postures have also been identified as a risk factor for BP

among HCNP in the Netherlands [Knibbe and Friele, 1996].

Studies have found that rotating jobs and taking breaks can

be effective strategies for reducing musculoskeletal dis-

orders [National Institutional for Occupational Safety and

Health (NIOSH), 1997; Yassi, 2000; Ortiz-Hernandez et al.,

2003]. Rotating jobs with different physical demands

reduces the stress put on limbs and regions of the body,

while scheduling breaks allows a person to rest and recover

[National Institutional for Occupational Safety and Health

(NIOSH), 1997].

Often static postures can be improved with simple

interventions in home care. For instance, if the HCNP needs

to perform a wound dressing on the sole of a foot, the HCNP

might position the patient in a lying position. Even though the

height of the bed may not be adjustable, the HCNP can then

stand up during the procedure rather than squatting or

kneeling for sustained periods of time. To reduce the risk of

BP, HCNP should assess the patient’s home environment

before engaging in nursing procedures to allow for maximum

physical flexibility while performing tasks. HCNP can apply

similar strategies to reduce the static postures on the road and

in the office.

Psychological job demands

Our results further suggest that psychosocial job factors

may play an independent role in the etiology of BP. Table IV

shows that the positive association between physical work

factors (in the patients’ homes and physical exertion) and BP

disappeared after adjusting for psychosocial job factors,

highlighting the strong confounding role of psychosocial

factors in this study and supporting observations made in

other occupations [Davis and Heaney, 2000]. Obviously, a

patient’s home is one of the ‘‘worksites’’ for HCNP. HCNP

interact with clients and their family members [Ceslowitz

and Loreti, 1991] in private settings, acting as visitors,

entering the patient’s territory to provide nursing care.

Hence, they need to negotiate their appointment times and

readjust their visiting plans accordingly. While they are

concentrating on performing nursing procedures, such as

wound dressing and urinary catheterization, they might need

to answer the queries of patients or family members. Such

demands may contribute to HCNP perceiving their jobs as

hectic.

The introduction of the Occupational Safety and Health

Ordinance in HK in 1997 has already increased awareness of

safety issues in the workplace. However, deep within the

culture of nursing, it is seen as unethical, unprofessional, and

probably socially unacceptable for nurses to change patient

care practices in order to reduce their own level of discomfort

[Harber et al., 1988]. Nurses should understand that BP does

not have to be an inevitable consequence of their career in the

nursing profession. Only when nurses know how to identify

and change occupational risk factors, can they provide

concomitant quality patient care while preserving their own

well-being and working life.

This study provides an introductory evaluation of the

problem; an on-site assessment of each risk factor is

necessary before intervention programs can be implement-

ed. For instance, many hazards in the office can contribute to

the development of back problems. These include chairs,

work surfaces, working spaces, keyboards, and various

combinations of these factors. Risk assessment should be

performed in the HCNP offices to identify all potential

hazards and to assure that guidelines for prevention or

amelioration of hazards are available [Occupational Safety

and Health Council, 2003a,b]. Because of financial con-

straints, it may be essential to prioritize the reduction of

hazards so that intervention programs can be sequentially

implemented.

Because of the cross-sectional nature of this study, the

antecedent-consequence uncertainty exists; that is, the

correct temporal relationship between causal risk factors

and back problems may remain ambiguous. However, results

from this study serve as a basis for future prospective cohort

or case-control studies. The very high response rate, on the

other hand, is a major strength of our study and reduces

20 Cheung et al.

the possibility of response bias. The combination of the

response rate with a total population sample strategy allows

for generalization of these results to the population of HCNP

working in HK.

Our study is one of very few that documents the hazards

faced by HCNP and the prevalence of BP in this group of

workers. Given the high prevalence, continued occupational

health research on nurses in home care is essential. In-depth

studies that further investigate the working conditions of

HCNP in HK, as well as other regions, would provide

important information to support the improvement of

working conditions and the prevention of BP among this

high-risk group. Advanced epidemiological studies should

include on-site observations of working conditions including

office ergonomics in addition to surveys of workers and their

managers or supervisors.

ACKNOWLEDGMENTS

Funding for this study was provided by The Hong Kong

Polytechnic University and University of California, San

Francisco.

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