Factors affecting preventive behaviours of the complications of musculoskeletal disorders in industry workers: a qualitative study from Iran

Abstract

Introduction

Musculoskeletal disorders (MSDs) in the workplace are a major health problem which is significantly related to the adverse effects on the workforce’s health in different occupations, including the petrochemical industry employees. Many health behaviors can play a significant role in preventing complications caused by MSDs; however, in developing countries such as Iran, there is a lack of clarity about the factors affecting the prevention of complications from these disorders from the perspective of petrochemical industry employees. This study aimed to investigate effective factors to prevent complications caused by MSDs in petrochemical industry workers in Iran.

Methods

This qualitative study was conducted using the conventional content analysis method. The data were collected using in-depth and unstructured interviews with 23 employees and managers of the petrochemical industry. In this study, the participants were selected from different industry centres using the purposeful sampling method and based on the maximum diversity (work duties, age, level of education). The collected data were then analysed using the initial matrix developed based on the available literature.

Results

The analysis of the data from 23 interviews resulted in the identification of four main categories: educational-consultative support, organisational-management structure transformation, infrastructure security and physical environment redesign, and self-care necessity. These categories are the primary factors that influence the preventive behaviours related to MSDs among employees in the petrochemical industry.

Conclusion

The concepts that have emerged based on the results of this study can potentially help to develop comprehensive and appropriate training and health promotion programmes in creating, maintaining and promoting preventive behaviours of complications caused by MSDs in petrochemical industry workers.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Mixed-methods approach: this study employs a qualitative methodology in a mixed-methods design, including an experimental clinical trial to investigate musculoskeletal disorders (MSDs) in industrial workers thoroughly.

• Diverse perspectives: the study involves participants—employees, experts and managers from the petrochemical industry—offering a comprehensive view of the factors contributing to the emergence of MSDs, which enriches the analysis of their causes and possible solutions.

• Intervention framework: a multidimensional intervention framework has been developed to improve managerial structures, design effective educational programmes and enhance occupational health infrastructure, aiming to provide evidence-based strategies for mitigating the impacts of MSDs.

• Cultural and organisational factors: the effectiveness of the intervention framework is influenced by cultural, social and organizational contexts that affect its implementation.

• Need for further research: all workers of this industry, because of hard working condition, were male, so future studies should provide female experiences accordingly. Furthermore, additional studies are necessary to assess the broader applicability and contextual adaptability of the proposed framework, including the identification of implementation challenges and opportunities across diverse settings.

Introduction

Musculoskeletal disorders (MSDs) are injuries or conditions that affect the bones, tendons, nerves, joints, cartilage, ligaments, blood vessels, discs and the intervertebral spine.¹,³ These disorders can result from prolonged repetitive stress or acute trauma. When such conditions are specifically caused by work, they are referred to as work-related MSDs (WMSDs).⁴ These disorders are common across various industries, particularly in sectors such as healthcare, transportation, textiles, steel and petrochemicals.^{5 6} WMSDs can range from mild discomfort to severe pain and are associated with serious health, economic and social consequences.⁷ These disorders often lead to decreased productivity and quality of work,^{8 9} resulting in both direct and indirect financial costs for employers and healthcare systems globally.¹⁰,¹²

MSDs are multifactorial, with risk factors categorised into four groups: physical, psychological-social, demographic and lifestyle factors. Physical factors include heavy or static work, repetitive movements and exposure to vibrations, while psychological-social factors involve workplace stress, poor management and inadequate ergonomics. Demographic factors such as age, gender and body mass index, along with behavioural and psychological traits, also contribute to the development of these disorders.¹³,¹⁷

According to the International Labor Organization, WMSDs are the second most common occupational disease globally, affecting a large portion of the workforce worldwide.¹⁸,²¹ Studies suggest that between 40% and 90% of workers globally suffer from these disorders,²² with prevalence varying by region.²³,²⁸ In the petrochemical industry, the reported prevalence of WMSDs is approximately 41.5%,⁶ which is considerably higher than that in other industries. Furthermore, workplace injuries, which arise due to poor working conditions and a lack of injury prevention programmes, have led to an increased rate of WMSDs in various sectors, including petrochemicals.^{29 30} Workers in the petrochemical industry are exposed to numerous risk factors for MSDs, as products are produced continuously.^{31 32} Long sitting hours, high mental workload and repetitive tasks are commonly reported among employees.³³

This issue is particularly pronounced in developing countries like Iran, where insufficient awareness of occupational hazards, poorly designed workstations and a lack of effective control measures have contributed to a rise in MSD prevalence.^{5 28} In Iran, particularly in the petrochemical sector, workers are frequently exposed to various risk factors, including poorly designed workstations,³⁴ inadequate equipment, prolonged sitting and standing, manual material handling, excessive force, repetitive tasks, spinal bending and rotation,²⁵ psychological and social risk factors,³⁵ lack of rest cycles, shift work³⁶ and the absence of an effective injury prevention plan. Psychological factors, such as work pressure, lack of social support at the workplace, demographic factors, individual capacities and lifestyle choices like physical activity and addiction, are some of the causes of MSDs.^{37 38} Studies show that most of these causes are related to behavioural factors.^{20 21 38}

These conditions not only threaten the health of workers but also lead to decreased productivity and increased absenteeism, ultimately imposing a substantial financial burden on organisations.¹¹ Therefore, organisations must identify, reduce and eliminate the causes of WMSDs to prevent the costs associated with these disorders from affecting employees and the organisation.

Although considerable efforts have been made to improve environmental and ergonomic factors through workstation redesign and safety enhancements,^{5 12 39} there remains a significant gap in research regarding the role of behaviours in preventing WMSDs. Few studies have examined the behavioural factors influencing MSD prevention among workers, particularly in industries like petrochemicals, where the combination of physical, psychological and environmental factors is particularly complex. This gap in the literature has led to the design of the present study, which aims to explore the factors influencing preventive behaviours for MSDs among workers in the petrochemical industry of Asalouye, located in southern Iran. By understanding these factors, we hope to provide strategies to reduce the prevalence of these disorders and improve workers’ health and productivity.

Methods

Study design

This qualitative study used the conventional content analysis approach.⁴⁰,⁴² As part of a research project titled ‘Design, Validation, and Evaluation of a Tool for Measuring Preventive Behaviors of Musculoskeletal Disorders in Petrochemical Industry Employees: A Mixed Methods Study’, this study was conducted to analyse the factors that influence the performance or non-performance of preventive behaviours of MSDs from the perspective of employees and executives of the petrochemical industry.

The research is grounded within a constructivist paradigm, as it seeks to understand the subjective experiences and meanings that both employees and managers attribute to their preventive behaviours. The rationale for this choice lies in the complex and multifaceted nature of behavioural influences in workplace settings, which are best understood through qualitative methods.^{43 44}

Study setting

This study was conducted from 19 February to 21 September 2024, in one of the petrochemical companies in Asalouye, Iran.

Study population

The participants were 23 employees and executive agents of the petrochemical industry who were a rich source of information and were willing to participate in the research. The criteria for entering the study are having MSDs caused by work for at least 6 months (after this period, the patient has gone through the crisis period and can express his experiences), having work experience for more than 2 years, age over 18 years old and being willing to share experiences.

The sample size of 23 participants was determined based on the goal of achieving data saturation. In qualitative research, particularly with an inductive approach, a smaller sample size is often sufficient for in-depth exploration of participants’ experiences.⁴⁰,⁴² We used a purposeful sampling method to ensure diversity across variables such as age, gender, socioeconomic status, level of education and employment status. As we reached saturation, no new themes emerged, which further justified the sufficiency of the sample size. This approach is consistent with qualitative research practices where sample sizes typically range from 15 to 30 participants.⁴⁵

Sampling approach

First, participants who were eligible to enter the study and registered for participation were selected by the purposeful sampling method.⁴⁶ For this purpose, the participants’ phone numbers were selected from the registration list. The samples were selected to maximise diversity. Then, the potential participants were contacted and provided with information about the importance and objectives of the research, as well as assurances regarding the confidentiality of the interview. As soon as the participants agreed to participate in the study, the time and place of the interview were coordinated with them.

Researcher characteristics and reflexivity

The principal researcher (ZM) is a PhD student in Education and Health Promotion, possessing practical experience in the field of occupational safety and health. This academic and practical background enables her to engage effectively with participants, informed by an understanding of the relevant safety issues and challenges. Furthermore, her familiarity with qualitative research methodologies allows her to gather rich and meaningful data concerning participants’ experiences.

The researcher’s gender and age may influence her interactions with employees, particularly in a predominantly male industry such as petrochemicals. These characteristics may facilitate the establishment of trust and comfort among participants; however, they may also raise questions about potential power imbalances in these interactions. The researcher entered this study with certain presuppositions that could impact the interpretation of the results, including particular attitudes and beliefs regarding safety behaviours in the workplace.

She endeavoured to account for these presuppositions by ensuring maximum diversity in the selection of participants, thus aiming to mitigate biases in data collection. Additionally, the researcher aimed to create a safe and non-threatening atmosphere during the interviews, encouraging participants to freely share their experiences and opinions. This approach not only contributed to the richness of the data but also provided the researcher with a deeper understanding of the factors influencing preventive behaviours.

Data collection

The main researcher (ZM) contacted the employees (employee information was available in the electronic system of the safety and health department of the petrochemical company) and tried to invite potential interviewees with maximum diversity. While introducing herself, the researcher explained the objectives of the study, and if the employees agreed, the time and place of the interview would be coordinated with them.

The unstructured interview method was used to collect data. The interviews were conducted individually and in the screening room of the centre in a private manner, which was approved by the participants. At first, written informed consent was obtained from the participants. The duration of the interview sessions varied from 30 to 70 min, and the average of each interview was 50 min. All the interviews were recorded with the consent of the participants. Following the completion of the interviews, the recorded materials were transcribed in Persian accurately at the earliest opportunity, the text was presented to the supervisors and the necessary guidance was obtained to improve the next interview process.

The interview began by asking the participant a general question: “Please describe your experiences with pain from musculoskeletal disorders?” Then, the questions align with the goals of specialised research. For example, the participant was asked, “Please explain why you don’t observe preventive behaviors of musculoskeletal disorders while doing work?” After each participant answered these questions, probing questions were asked as appropriate. “Can you explain more about this?”, “Can you explain clearly what you mean?”, “What did you do?”, “What happened after that?”.

The interviews continued until the participants had no more information to provide. If necessary, such as participant fatigue or lack of data saturation, the interview was continued in subsequent sessions with the same participant. We increased the sample size to ensure data saturation.

Data analysis

To analyse the data, the inductive content analysis method provided by Graneheim and Lundman was used.⁴⁷ After the end of each interview and before the next interview, the recorded file was immediately written verbatim in the Persian language, and then, the entire text of each interview was considered as a unit of analysis to extract semantic units from it. Then, inductive categories were obtained from the raw data, and the coding test was performed. The coding process and the extracted codes were reviewed and approved by the experts of the research team. Then, the text of one of the interviews was returned to the staff for review. At this stage, the entire text was coded by the researcher to ensure that the extracted codes corresponded to the participants’ views.

Then, the stability of the coding was re-examined, and the researcher identified and extracted the emerging categories in collaboration with the experts of the research team. Finally, all the coding steps were documented to ensure the reproducibility of the research process (table 1).

Table 1. The process of the data analysis.

Category	Subcategory	Code	Meaning unit
Infrastructure security and physical environment redesign	Improving and equipping the quantitative and qualitative resources and infrastructure of the health environment	Lack of suitable equipment for moving heavy loads (elevator, hand wheel)	Because we don’t have an elevator here, we have to carry heavy loads by hand to the upper floors
		Lack of proper personal protective equipment in the work environment (shoes, gloves, hats, masks, fireproof and acidproof clothes)	We do not have fireproof clothing in the workplace.
		Lack of sufficient labour force	The number of workers in the warehouse is not enough and we have to do a large number of tasks alone.
		Lack of required medicine in the workplace clinic	The clinic always faces a shortage of drugs
	Creating facilities and social support	Lack of a suitable place to rest	We do not have a place to rest during work
		Lack of welfare and club services at work	The company does not have a gym to exercise
		Failure to provide health insurance services to employees	We don’t have insurance and we have to pay all the costs of the disease ourselves.

Trustworthiness

In this study, to evaluate the accuracy of the obtained results, the criteria of validity, confirmability, transferability, reliability and authenticity were used^{48 49} (table 2).

Table 2. Evaluating the trustworthiness of the qualitative study of preventive behaviours of musculoskeletal disorders of petrochemical industry workers.

Accuracy of the data acquired through this research	Criterion
Long-term engagement and immersion in data Peer review by experts who were not part of the research team Peer review by contributors (Employees and executives of the petrochemical industry)	Validity
Report on the steps of doing the work, how to extract the codes and findings Receive approval from the experts of the research team	Confirmability
Diverse selection of participants	Transferability
Review by the research team Analyse and supervise external observers Peer review	Reliability
Maximum diversity of participants in data collection and analysis Purposeful sampling	Authenticity

Validity: for this section, the researcher, with supporting evidence, ensures that the findings represent what is being studied.^{49 50}

Confirmability: the researcher assures that the extracted findings are based on the participant’s responses and not the researcher’s interpretation and bias.^{49 50}

Transferability: with contextual information, the researcher determines whether the results can be used in similar situations.^{50 51}

Reliability: the researcher describes the study in detail so the work can be repeated.^{50 51}

Authenticity: authenticity in qualitative research refers to the originality, authenticity and quality of the experiences or phenomena studied.⁵⁰

Findings

A total of 26 men with maximum diversity in terms of age, education level, employment status and work duties participated in this study. Their average age was 41.3 years, and their education level varied from primary education to academic education (table 3).

Table 3. Demographic characteristics of study participants.

Demographic characteristics	Category	Percentage
Characteristics of petrochemical company employees participating in the study (n=23)
Age	30–40 years	38.5
	40–50 years	61.5
Marital status	Single	3.84
	Married	96.16
Education level	Elementary	15.4
	High school	38.5
	Associate degree	11.5
	Bachelor	26.9
	Master’s degree	7.69
Employment status	Official	15.38
	Contractual	84.62
Workplace	Service unit	19.23
	Repairs and maintenance	15.38
	Fireman	7.69
	Warehouse unit	11.53
	Gardener	3.84
	Laboratory	7.69
	The driver	3.84
	Restaurant	7.69
	Control room	7.69
	Protection	7.69
	HSE	7.69
	Administrative	3.84
Work experience	Less than 10 years	15.38
	10–20 years	65.38
	20–30 years	19.24

HSE, Health, Safety and Environment.

In total, 189 primary codes were extracted from the analysis of the obtained data and the identification of semantic units. After the classification and comparison of the primary codes and the formation of subclasses and classes, four main categories, ‘educational-counselling support’, ‘the transformation of the management-organisational structure’, ‘infrastructure security and physical environment redesign’ and ‘the necessity of self-care’, were identified as the influencing factors on preventive behaviours of complications caused by MSDs (figure 1 depicts the subclasses, classes and main categories).

Figure 1. Overview of influencing factors on preventive behaviours for complications associated with musculoskeletal disorders. This figure presents an overview of the subclasses, classes and main categories identified from the analysis of data collected from 23 male participants, characterised by significant diversity in terms of age, educational level, employment status and work duties. The average age of these participants was 41.3 years, with educational backgrounds ranging from primary education to higher academic qualifications.

Implications for practice

Based on the findings of this study, the identified categories indicate a need for targeted interventions to enhance preventive behaviours among employees across various industries. These interventions and education programmes may include the following:

1. Workshops: regularly organised workshops for employees focusing on ergonomic practices and self-care strategies to prevent MSDs.

2. Training programmes for management: development of training programmes aimed at managers to improve their understanding of the importance of supporting preventive behaviours and fostering a culture of health and safety in the workplace.

3. Infrastructure improvement: investment in the redesign of workspaces to ensure ergonomic compliance, which may include adjustable workstations and appropriate equipment to alleviate strain on employees.

4. Health monitoring systems: establishment of health monitoring systems that regularly assess the musculoskeletal health of employees and provide feedback to both employees and management.

These interventions can serve as practical recommendations for industry leaders and policy makers seeking to mitigate the impact of MSDs in the petrochemical sector.

Educational counselling support

Educational counselling support provides effective and practical training and counselling regarding the consequences and complications caused by the occurrence of MSDs. This category includes two subcategories: providing effective and practical education and the formation of a systematic education system.

Providing effective and practical education regarding musculoskeletal disorders

Many participants stated that due to the lack of training on the consequences of skeletal disorders and the consequences of working with non-standard equipment, they committed behaviours that caused MSDs in them.

Because of my job, I have to move heavy loads, I didn’t know that lifting a heavy load can cause neck disc, that’s why I used to put heavy loads on my shoulders and carry them. (participant 8)

Because I didn’t have any information about the signs, and complications of musculoskeletal disorders, I didn’t pay attention to my neck pain during work until it got so bad that I had to have neck surgery. (participant 10)

The loads we carry don’t have handles and are very heavy. I didn’t know that I had to sit and lift them, so I always bent down and lifted them until I got lumbar disc disease. (participant 15)

The formation of a systematic education system

Many participants stated that there is no specialised training for each work task in their work environment, and there is no strict monitoring of the training process and compliance with safety principles during work. This has increased the occurrence of human errors in employees.

Here, there is no specialized training class for any task, and most of the topics are general. (participant 7).

In the work environment, there is no monitoring of the training process and correct behavior during work. (participant 21)

When there is no one to give proper training during our work, to supervise the correct way of doing the work, we are forced to do many things by trial and error. That’s why we often have accidents. (participant 11)

The transformation of the management-organisational structure

The structures and processes of planning and organising the available resources to achieve the goals of the organisation, which determine the interactive patterns, formal coordination mechanisms and the way employees communicate, and monitor the personnel and the field of management, are called managerial-organisational structure. This category includes three subcategories: establishment and improvement of an efficient management system, establishment of an integrated system of recruitment/payment of insurance premiums and wages, and establishment of an integrated system of work and rest/work shifts.

Establishment and improvement of an efficient management system

Many participants stated that the lack of an efficient management system in the workplace has caused inappropriate work relationships with and between employees, unfair division of work duties, loss of work discipline and work pressure on personnel. Also, the fear of job loss has caused employees to perform their duties while feeling the pain caused by skeletal disorders and not protesting against the existing conditions.

I try to do all my work quickly because my manager will get angry if I am left with work. (participant 1)

The division of work is not fair here, some people have too much work and this has increased their stress. (participant 12)

I have to do my work even when I’m in pain so that my boss doesn’t get angry. (participant 14)

If I go to the doctor at my work clinic, I might lose my job because of my musculoskeletal problem. (participant 2)

We cannot protest about the lack of manpower, the difficulty of work, and the lack of facilities because we may lose our jobs. (participant 9)

At work, you can’t talk to anyone about your musculoskeletal pain because they might make fun of you. (participant 6)

Establishment of an integrated recruitment system/payment of insurance premiums and wages

Many participants stated that conditions such as the lack of an official recruitment system, due to the recruitment of workers by contracting companies, a performance-based salary payment system, an insurance premium payment system and proper health insurance coverage, cause delays in payment or deductions from employees’ salaries, non-payment of insurance premiums and forced leave of work due to the termination of the employee’s employment contract. This has created job dissatisfaction among the employees and has negatively affected their body and mind.

Here, managers discriminate between personnel in the division of work duties, and this itself causes a series of mental tensions and even dissatisfaction with their jobs. (participant 23)

I can’t go to the doctor and hospital because of my back pain, because I have to pay the entire cost myself, we don’t get much insurance premium here. (participant 15)

We don’t have any job security here; we can be fired at any moment. (participant 1)

There is no system for changing the status from a contract to an official one for us, and we have to be stressed every moment that our contract may not be renewed and we may be fired. (participant 13)

Establishment of an integrated system of work and rest/shift work

The participants stated that due to the lack of shift work, they could not gain new experiences in different work roles, recognise their strengths and weaknesses in different work tasks and do monotonous work, which weakened their work morale.

They also state that due to not having enough time to rest during work, they have not been able to participate in training classes, do sports activities and do stretching and correction movements, and this has caused them physical and mental injuries.

There is no shift work in this organization, that’s why it is difficult and exhausting for me to perform monotonous work duties. (participant 21)

Because we don’t have work shifts, we can’t get to know other work tasks and I have to be busy with one work task for the entire service period. (participant 17)

I was rarely able to attend the educational classes because we don’t have time off at work to attend the class. (participant 7)

Because we don’t have time to rest, we can’t even exercise and do stretching exercises, which caused my neck pain to increase. (participant 13)

Infrastructure security and physical environment redesign

In this study, the existence of physical, chemical and microbial hazards; the lack of appropriate educational and technical infrastructures to perform work; the limitation of human, material and equipment resources; and the lack of facilities and social support in the work environment endanger the physical and mental health of employees and cause all kinds of diseases in the workforce.

It cannot be acknowledged that all workplace accidents are caused by human errors because many accidents occur due to the lack of safe infrastructure and the lack of spaces and equipment suitable for the workforce. The necessity of preventing all kinds of accidents in the workplace, training and informing the personnel about their work duties, the correct and safe way of using equipment and facilities, and redesigning the workplace based on the needs of the personnel based on the most up-to-date available methods and safety infrastructures.

Therefore, in addition to considering the human component, environmental components should also be considered as factors that cause accidents and try to change and improve them. This category includes two subcategories: improving and equipping quantitative and qualitative resources and health-environmental infrastructure and creating facilities and social support in the work environment.

Improving and equipping quantitative and qualitative resources and health-environmental infrastructure

Improving the work environment includes improving both quantitative and qualitative aspects of human resources, infrastructure and environmental resources.

Many participants stated that they face a lack of resources such as a sufficient workforce, specialist doctors in the workplace clinic, safe and standard equipment for work, enough space to rest and enough space to exercise during work.

The workload is very high because our workforce is very small. (participant 19)

In our workplace, there is no orthopedic doctor. (participant 15)

We don’t have equipment like a trolley with which we can move things. (participant 10)

There is no anti-acid and anti-fire clothing to work on the site. (participant 11)

We don’t have a time and a place for rest. (participant 6)

Creating facilities and social support in the work environment

The presence of environmental facilities and resources in the workplace as support from the organisation can remove the situational and mental barriers created such as paying medical expenses, the costs of using welfare and club facilities, and wasting time, which prevents correct health behaviours and leads a person to perform health-promoting behaviours.

The participants admitted that they do not have facilities such as free tickets to the swimming pool, cinema or sports club in the work environment.

We don’t have a sports club in our workplace where we can exercise. (participant 18)

Here, they don’t even give us a free ticket to the swimming pool or the cinema. (participant 12)

The necessity of self-care

Self-care is a set of learnt, conscious and purposeful actions that each person takes to maintain and improve their health with or without the support of a healthcare provider.

This category has four subcategories: rethinking in improving attitude and motivation, improving self-efficacy and health-promoting lifestyle, empowering to benefit from behaviour-facilitating systems, and improving and strengthening health-promoting behaviours.

Rethinking in improving attitude and motivation

One of the ways to rethink attitude and motivation in this study is to provide training to employees to increase their knowledge, create a positive attitude to shape their motivation, and establish a relationship between their previous experiences and their current situation to perform preventive behaviours of MSDs.

Many participants stated that they did not have sufficient attitude and motivation regarding the preventive behaviours of MSDs, and also, some of them had incorrect beliefs about performing these behaviours.

I don’t know how to stand while doing my work so that there is less pressure on my joints. (participant 8)

No, I don’t know anything special to do to avoid vascular problems. (participant 11)

I always tell myself that my work does not require training. I know everything myself, training for engineering and maintenance personnel, not for cleaning workers. (participant 19)

Here, I’m so tired, I can’t do any corrective or sports movements because it’s midnight by the time I take a shower and eat food, and I don’t have the patience or motivation to go to the gym. (participant 22)

Improving self-efficacy and health-promoting lifestyle

Optimum self-efficacy has a positive effect on motivation and leads a person to perform healthy health behaviours, self-care and a health-enhancing lifestyle.

Some participants stated that they do not have a healthy lifestyle, for example, they do not know healthy eating behaviours, they have addictions, they do not have enough sleep, they do not do sports and they do not know how to control stress and anger.

On days when I smoke, my neck pain is much worse. (participant 11)

Because of my lack of exercise and inactivity, my weight has increased, and my back and neck pains have started again. (participant 21)

I don’t know a special way to control my anger. When I get angry, I just keep silent. (participant 3)

To deliver the work on time, I get stressed, and then my pain becomes much worse. (participant 16)

Empowering to benefit from behaviour-facilitating systems

Due to the advancement of information technology and access to massive amounts of information in various fields, if people do not have the skills to receive information from reliable scientific sources, they may engage in unhealthy behaviours, and their health may be at risk.

Some participants stated that they could not receive scientific and reliable information about MSDs.

I got the information about the exercises that reduce neck pain through social networks. (participant 14)

I learned the movements I was doing from people who had these disorders. (participant 5)

Improving and strengthening health-promoting behaviours

Health-promoting behaviours are among the activities that a person should do continuously to increase or improve his health.

Many of the participants stated that they did not know the behaviours to reduce or prevent the complications of skeletal disorders, and they performed actions during work that caused these disorders to occur in them.

I did not use the medical belt prescribed by the doctor. (participant 9)

When doing my duties, I used to move heavy loads by hand alone. (participant 20)

Discussion

This qualitative study provides valuable insights and experiences about the problems faced by petrochemical industry employees in performing preventive behaviours of MSDs in the work environment.

The participants’ experiences in this study showed that educational support and providing sufficient awareness and training regarding the symptoms, complications and consequences of MSDs are some of the most important factors affecting the preventive behaviours of MSDs in petrochemical industry employees. Yazdani et al reported in their study that education, knowledge and awareness of people about the symptoms, complications and consequences of skeletal disorders play an important role in preventing MSDs in the workplace.⁵² Since the majority of workers who work in the petrochemical industry are low educated and so they possess low sociodemographic characteristics, educational support regarding sufficient awareness and training about MSDs’ symptoms, complications and their consequences could be beneficial for these workers in order to improve their preventive behaviours.

In the present study, due to a lack of proper communication with colleagues and managers, lack of support from managers, lack of trust and fear of job loss, employees could not perform preventive behaviours of complications caused by MSDs. Similarly, the previous studies^{52 53} confirm that without the existence of support systems, commitment from managers and proper communication of employees in work environments, programmes and interventions to prevent MSDs will never work. Furthermore, a previous qualitative study⁵⁴ confirms that lack of organisational support and fear of job loss can be effective in causing MSDs among employees. Moreover, Hoboubi et al¹⁰ confirm that managerial-organisational factors (ie, management methods, staff participation level and staff income) play a role as the main factors in causing MSDs in industrial workers. An existing study showed the reported prevalence of WMSDs in the petrochemical industry is considerably higher than that in other industries,⁶ which is due to poor working conditions and a lack of injury prevention programmes.^{29 30} Workers in the petrochemical industry, because of the products which are produced continuously,^{31 32} are exposed to numerous risk factors for MSDs such as long sitting hours, high mental workload and repetitive tasks.³³ Thus, it seems in this workplace, organisational supportive programmes which lead to WMSDs’ preventive behaviours and job satisfaction are so important and necessary.

The absence of performance-based wage payment systems, insurance premium payment systems and labour recruitment was among the experiences of petrochemical industry employees, which prevented them from performing preventive behaviours against MSDs. A qualitative study by Mokarami et al⁵⁴ showed that employee valuation style and imbalance in salary payment, bonus, insurance premium payment and recruitment process are effective in causing MSDs among this target group. Petrochemical industry employees in this study emphasised that the lack of a work-rest cycle and the lack of shift work in their work environment made them unable to perform preventive behaviours for MSDs. These results are consistent with the findings of other studies conducted by Benson et al,⁵⁵ Heidarimoghadam et al⁵⁶ and Mokarami et al.⁵⁴ Existing evidence revealed that WMSDs are a psychosocial health problem, so risk factors such as work pressure, lack of social support at the workplace, lower sociodemographic factors, lower individual capacities and unhealthy lifestyle choices like lower public physical activity in the workplace of these workers as continuously psychosocial factors^{31 32} could be some of the causes of MSDs among this target group.^{37 38}

The experiences of petrochemical industry employees in this study show that the limitation of health and human resources, safe and standard facilities and equipment in the workplace is effective in not performing preventive behaviours of complications caused by MSDs. Yazdani et al’s study confirms that insufficient resources (eg, financial, equipment and employees) can be an obstacle in carrying out prevention plans for MSDs.⁵² Benson et al’s study shows that resource and equipment limitations in oil and gas industries can lead to health risks including MSDs in employees.⁵⁵ In the petrochemical industry in which this study was conducted, many interviewees verified limited standard facilities and equipment in the workplace and they believed that these limitations contributed to their WMSDs.

One of the most important issues regarding preventive behaviours of MSDs is how to receive, understand and use reliable information from sources regarding MSDs, improve knowledge, change people’s attitudes and beliefs, and create motivation to perform these types of behaviours. The participants in this study did not perform the preventive behaviours of MSDs due to receiving information about the preventive behaviours of MSDs from unreliable sources, as well as due to the lack of sufficient knowledge and motivation to perform these behaviours and having false beliefs. Furthermore, the key informants in this study emphasised the role of health literacy of people in performing preventive behaviours for MSDs. These findings are consistent with previously conducted studies by Fan et al,⁵⁷ Ahmadi et al³⁸ and Yin et al.⁵⁸ Moreover, Mokarami et al’s study confirms that people’s attitudes, abilities and motivation can play an effective role in preventive interventions for MSDs.

The experiences of petrochemical industry employees in this study show that having an unhealthy lifestyle such as lack of physical activity, obesity, addiction, lack of stress management and anger control and also lack of effective self-efficacy prevents them from performing preventive behaviours of MSDs. Norouzi et al’s¹⁴ study reports that having self-efficacy in performing preventive behaviours can be effective in reducing pain caused by disorders. Regardless, the study of Fan and colleagues⁵⁷ confirms that at the individual level, adopting a healthy lifestyle can reduce the incidence of WMSDs.⁵⁴ According to the mentioned evidences, it could be argued that in addition to environmental changes like organisational supportive programmes in the industry which could be so valuable in promoting preventive behaviours for WMSDs, individuals’ educational programmes which improve attitudes, abilities, motivation and self-efficacy of the workers would be so beneficial and could guarantee the preventive behaviours.

The experiences of the participants in this study show that they use preventive strategies (stretching movements, corrective movements and swimming) to reduce pain caused by MSDs. Fan et al’s study emphasises on doing stretching exercises during working time to prevent MSDs.⁵⁷ The effect of stretching and corrective movements in reducing MSDs has been emphasised in another study.¹⁴ In a qualitative study by Boniface et al, it was reported that improving and strengthening and stretching movements were effective in preventing MSDs.⁵⁹ Moreover, Price et al’s study shows that doing sports can play a role in reducing chronic pain caused by MSDs.⁶⁰ Accordingly, the participants of the present study support the benefits of doing strengthening and stretching movements and also correct position of the musculoskeletal system during working.

In spite of strengthening points of this manuscript that highlighted the reasons for not doing WMADs’ preventive behaviours, because all workers of this industry, because of hard working condition, were male, so the data were collected just from male workers, and female workers’ experience were not provided in this study. This is a kind of limitation for this study, so it is recommended in future studies that the maximum variation of participants in all demographic factors including gender will be considered.

Conclusion

Employees regarded the factors affecting the preventive behaviours of MSDs. As it was clear from the experiences of the participants, the preventive behaviours of MSDs can be considered as activities that lead to. It is defined as the prevention of complications caused by MSDs. The creation and improvement of these behaviours among the employees of the petrochemical industry in Iran require the implementation of various measures, which include the existence of educational-consultative support, the existence of safe and standard infrastructures and working environments, the existence of an appropriate management-organisational structure, and the need for self-care. Therefore, managers of the petrochemical industry should strive to increase knowledge, change attitudes and improve employees’ self-efficacy so that employees can improve their health by communicating with an efficient management system and using safe equipment and facilities while performing tasks.

Data availability statement

Data are available upon reasonable request.