I want the answer without similarity at all, and Conceptual and professional, they’re important, I want to follow the instructions in the picture. I want it to be 5 pages.
Chapter 3
GLOBAL
HEALTH:
SYSTEMS,
POLICY, AND
ECONOMICS
Chapter 3: Overview
• Introduction
• Micro and Macro Models
• Convergence of Problems and Responses
• Nature of Tradeoffs, Ideology, and Ethics
• Policy-Making Around the World
• Conclusion
Introduction
• World Wide Challenge of health policy
making in the 21st century
• Medicine within social organizations
• Government intervention or non
intervention
• Policy-making challenges
• All nations have problems with cost,
quality, access and health outcomes
Micro and Macro Models
• The political process
• Involves governmental and
nongovernmental organizations (NGO)
and individuals
• Micro and macro frameworks
• Analogous to economics
Micro and Macro Models
• Characteristics of the policy marketplace model
• Assumptions
• Policy actors
• Disparities in power
• Currency used
• Impact of governmental regulation
Micro and Macro Models
• The policy systems model:
Characteristics
• Complexity
• Interrelatedness
• Interdependent
• Cyclical processes
Micro and Macro Model
• Longest’ s model of health policy
development
• Recognition of inputs
• Policy formation
• Policy outputs
• Implementation
• Outcomes
Convergence of Problems
and Responses
• Convergence of variations in health
organizations
• Cost containment
Convergence of Problems
and Responses
• Access to care
• Disadvantaged subpopulations
• Informal payments (bribes)
• Political instability
Convergence of Problems
and Responses
• Impact of new technologies
• Cost and complexity
• Balance between old and new
• Economic and ethical conflict
Convergence of Problems
and Responses
• Quality of care considerations
• Technologic complexity
• Enable the aggregation of data
• New information technology
Convergence of Problems
and Responses
• Measuring health outcomes
• Potential benefit of health IT
• Consensus about existing problems
• US system expensive, wasteful,
unsustainable
Convergence of Problems
and Responses
• Sustainability
• Growing financial stress on public
and private sectors
Convergence of Problems
and Responses
• Achieving sustainability
• Quest for common ground
• Digital backbone
• Incentive realignment
Convergence of Problems
and Responses
• Achieving sustainability
• Quality and safety standardization
• Resource deployment
• Innovation
• Adaptability
Convergence of Problems
and Responses
• Assessment of progress in policymaking
• Technology based sustainability
• Quality and safety standardization
Convergence of Problems and
Responses
• Price Waterhouse Cooper (PWC) study
recommended solutions:
• Quest for common ground
• Digital backbone
• Incentive
• Quality and safety standardization
• Strategic resource deployment
• Climate of innovation
• Adaptable delivery roles and structures
Nature of Tradeoffs,
Ideology, and Ethics
• Tradeoffs
• Source
• Importance
• Economic efficiency and political
equity
• Prioritizing efficiency and equity
Nature of Tradeoffs,
Ideology, and Ethics
• Tradeoffs
• Political obstacles
• Expectations of the populace
• Ethical and ideological
disagreements
• Social experimentation without public
consultation
• Undeveloped “rule of law”
Nature of Tradeoffs,
Ideology, and Ethics
• Tradeoffs
• Components of justice
• Libertarian perspective
Policy-Making Around the World
• Assessment of ability to address
challenges
• Assessment of sustainability of US
system
• No reform will lead to de facto rationing
• Reform faces significant political problems
• Something major will occur in the next
one or two decades
Policy-Making Around the World
• Equating national health service with
rationing
• Situation in developing countries
• Political instability
• Social inequality
• Immature economies
Conclusion
• Not at all clear how leadership will meet the
health system challenges in the next 20 years
• Absence of a true US national health systems
and stable international health systems is
creating de facto rationing
• Advocates argue for cost controls on expenditures
and/or more taxes on upper-income citizens
• Significant backlash against the ACA
• Should not lose sight of past achievements
This Section Reserved
for Instructors
Suggested Discussion or
Research Questions
Discussion or Research Questions
• Describe how health policy making is a political
process.
• Describe the characteristics associated with the
Policy Marketplace Model (Micro model) of health
policy decision making.
• What are the characteristics associated with the
Policy Systems (Macro) model of health policy
making?
Discussion or Research Questions
• What are the stages of the Longest model of health
policy making how do they impact on individual
health policies?
• Describe the major problems faced by all nations as
they attempt to formulate health policy and their
implications on health system development.
• What are the implications associated with an
increased emphasis on the use of outcomes
measurements on the delivery of health care
services?
Discussion or Research Questions
• How does having a truly integrated
national health system impact the
implementation of technical and structural
reforms?
• What are the benefits of having a robust
health information infrastructure
integrated within the healthcare delivery
system?
• What is the primary underlying trade-off in
the development and implementation of a
national healthcare delivery system?
Discussion or Research Questions
• What are the primary political obstacles in using
explicit trade-off analysis in health policy making?
• Describe how the individual and social components
of justice influence the debate on ethical health
policy.
Discussion or Research Questions
• Describe how health policy making is a political process.
• Describe the characteristics associated with the Policy Marketplace Model (Micro model) of health
policy decision making.
• What are the characteristics associated with the Policy Systems (Macro) model of health policy
making?
• What are the stages of the Longest model of health policy making how do they impact on individual
health policies?
• Describe the major problems faced by all nations as they attempt to formulate health policy and their
implications on health system development.
• What are the implications associated with an increased emphasis on the use of outcomes
measurements on the delivery of health care services?
• How does having a truly integrated national health system impact the implementation of technical
and structural reforms?
• What are the benefits of having a robust health information infrastructure integrated within the
healthcare delivery system?
• What is the primary underlying trade-off in the development and implementation of a national
healthcare delivery system?
• What are the primary political obstacles in using explicit trade-off analysis in health policy making?
• Describe how the individual and social components of justice influence the debate on ethical health
policy.
General Question Categories
• Structure and Evaluation Healthcare Services and Systems
• Global Burden of Disease
• Cultural Influences
• Medical Travel and Tourism and Off Shoring
• Health Communication, Marketing, Social Marketing
• Data and Measurement
• Policy, Strategy, and the Regulatory Environment
• Global Health Leadership
• International Best Practices
Suggested Topic Areas To Use When Facilitating Discussions, Projects, or
Case Studies
• Engagement of stakeholders
• Effectively working in and managing teams
• Learning how to get in front of the problem or identify opportunities
• Learning to communicate effectively
• Assessment of solutions that fit the country
• Embracing systems thinking
• Recognize and embrace diversity
• Sustaining the mission of health as well as health care
551
Work 71 (2022) 551–564
DOI:10.3233/WOR-210239
IOS Press
Review Article
Application of the rapid upper limb
assessment tool to assess the level of
ergonomic risk among health care
professionals: A systematic review
Venkata Nagaraj Kakaraparthia,d,∗ , Karthik Vishwanathanb , Bhavana Gadhavic ,
Ravi Shankar Reddyd , Jaya Shanker Tedlad , Paul Silvian Samueld , Snehil Dixitd ,
Mastour Saeed Alshahranid and Vamsi Krishna Gannamanenie
a Department of Physiotherapy, CR4D Unit of Parul University, Vadodara, Gujarat, India
b Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Parul University,
Vadodara, Gujarat, India
c Department of Physiotherapy, Parul University, Vadodara, Gujarat, India
d Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University,
Abha, Saudi Arabia
e College of Applied Medical Sciences, Department of Physiotherapy, Hail University, Hail, KSA
Received 11 February 2021
Accepted 23 March 2021
Abstract.
BACKGROUND: Work-related musculoskeletal disorders (WMSDs) and ergonomic risk factors are widespread problems
in the healthcare sector.
OBJECTIVE: The primary objective of this review is to evaluate the application of the Rapid Upper Limb Assessment
(RULA) tool in various healthcare professionals and to assess the level of ergonomic risk among them.
METHODS: The databases MEDLINE, EMBASE, CINAHL, LILACS, SCIELO, DOAJ, PubMed, and PEDro were searched
with terms associated with ergonomics, assessment, health care providers, risk factors, workplace, and RULA. We reviewed
the literature from 2000 to 2020, including studies assessing RULA’s effectiveness for evaluating the WMSD’s and ergonomic
risk in health care practitioners. We excluded the studies which were not open access and freely available.
RESULTS: Overall, 757 records were screened; of these 40 potential studies, 13 different healthcare professionals were
identified as eligible for inclusion. In most studies, the RULA tool was established as an effective tool in application and
evaluating the level of the ergonomic risk among them.
CONCLUSIONS: The RULA tool assessed the high ergonomic risk levels in dental professionals and low ergonomic risk
levels in professionals working in the pharmacy department, clearly suggesting potential changes in work postures were
necessary to prevent or reduce these risk factors.
Keywords: Ergonomics, assessment, musculoskeletal disease, health care providers, risk factors, workplace, RULA
∗ Address for correspondence: Venkata Nagaraj Kakaraparthi,
(Ph.D. Scholar), Department of Physiotherapy, CR4D Unit of
Parul University, Vadodara, Gujarat, India. E-mail: kvnagaraj13@
yahoo.com.
ISSN 1051-9815/$35.00 © 2022 – IOS Press. All rights reserved.
552
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
1. Introduction
Work-related musculoskeletal disorders (WM
SDs) are injuries or dysfunctions that affect the
muscles, nerves, tendons, joints, ligaments, and softtissue structures and include strains, sprains, and
injuries to the surrounding structures [1]. Healthcare
practitioners, particularly individuals who engage in
direct patient interactions, represent the occupationbased population with the highest rate of WMSDs,
due to occupational loads and awkward positions
during their work-related duties [2]. Continuous
movements in ergonomically adverse postures can
lead to the development of MSDs, negatively affecting efficiency [3].
WMSDs place a substantial burden on society, in
part due to the costs associated with work absenteeism associated with these disorders [4]. The
occurrence rates and numbers of missed working days
associated with WMSDs differ across varying populations, resulting in discrepancies in the financial
consequences. For example, in the United Kingdom,
approximately 4.5 % health care practitioners were
associated with WMSDs, whereas in the Netherlands
around approximately 28%, and in Germany, this
number was 21% [4].
Proper assessment tools might prevent the development of musculoskeletal symptoms associated with
ergonomic risks and WMSDs [5]. One important
evaluation tool that has been developed is the Rapid
Upper limb Assessment (RULA). The RULA is
commonly used to assess the ergonomic risks in professions that are frequently associated with WMSDs
in the upper extremities [6] as it demonstrated higher
intra-rater reliability than inter-rater reliability. Corlett and McAtamney developed the RULA (1993) as
an observational tool, used to evaluate an individual’s vulnerability to load aspects due to the posture
of the head, neck, arms, trunk, upper limb, and the
support of the lower limbs, in addition to muscle use
and additional loads during work. The scoring system
considers all of these factors to produce a total RULA
score, ranging from one to seven. This score evaluates
the possibility of injury as a result of musculoskeletal
burden. Higher scores indicate a greater likelihood of
musculoskeletal damage. Scores of one or two indicate that the scored work posture is satisfactory, as
long as it is not maintained or performed repetitively
for extensive periods of time. Scores of three or four
indicate that additional examination is necessary and
that postural changes may be necessary. Scores of
five or six suggest that postural changes should be
implemented rapidly, and a score of seven suggests
that immediate postural changes are required [7].
The primary objective of the present study was
to perform a systematic review that focused on the
application of the RULA tool among healthcare practitioners and to assess the level of ergonomic risk
among them.
2. Methodology
The protocol is registered at INPLASY under no.
202110120.
2.1. Search Strategy for data extraction
An efficient review of methodology was utilized
to focus this present research question by using
methods to minimize the bias in collecting, reviewing, and describing the research evidence, following
the procedures outlined by PRISMA. The search
databases included for this review were MEDLINE,
EMBASE, CINAHL, LILACS, SCIELO, DOAJ,
PubMed, PEDro, Saudi digital library, NHS EED,
PROSPERO, Google Scholar, Scopus, and Web of
Science. We searched these databases from 2000
until 2020, and 757 studies were obtained in the initial search. The following search terms were used:
ergonomics; assessment; health care providers; musculoskeletal disease; workplace, risk factors, and
RULA. The resultant levels of methodological quality of included cross-sectional and observational
studies were evaluated using Quality assessment
tool for observational, Cohort, and Cross-sectional
studies provided by study quality assessment tools
of National Institute of Health (NIH) scale, USA;
included case-control studies were evaluated by
Quality assessment of case-control studies provided
by study quality assessment tools of NIH scale,
USA; included experimental studies were evaluated
by Quality assessment tool for Before-After (prepost) studies with no control group provided by study
quality assessment tools of NIH scale, USA; and
included randomized control trials (RCTs) were evaluated by using Physiotherapy Evidence Database
(PEDro scale). All the studies, which all scored six
or more points on these scales, were included for the
review process, and finally, 40 studies were included
in this systematic review.
2.2. Screening methods
Two independent reviewers screened the relevant
studies based on the inclusion criteria and extracted
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
the risk of bias. The reviewers extracted the full texts
of all relevant cross-sectional, experimental, observational, case-control, and randomized control trials.
2.3. Categories of studies
In this systematic review, we only included the
studies that determined the application of RULA
among various health care professionals.
2.4. Selection criteria
2.4.1. Inclusion and exclusion criteria
Inclusion criteria: Articles published in English
with full text, published from the year 2000 until
2020; Studies that evaluated the application of RULA
and assessed the level of ergonomic risks in different
health care professionals.
Exclusion criteria: Identical publications; Studies
related to commentaries, professional opinions, and
letters to the editor; Study articles with inaccessible
full text, identical, and who did not assess musculoskeletal outcomes were also excluded.
2.5. Quality assessment / risk of bias analysis
The evaluation of the risk of bias of the incorporated studies was approved out with PRISMA
guidelines [8]. The risks of bias are evaluated in
relationship to the particular design, conduct, and
outcomes. Two reviewers resolved all differences
through discussion, and a third reviewer was involved
when no consensus was reached.
2.6. Types of outcomes
The primary outcome measure for the present systematic review was to evaluate the WMSDs among
health care professionals by using RULA. The secondary outcome was to assess the level of ergonomic
risks among them.
2.7. Methodological quality
Two independent reviewers assessed the included
studies, and the differences were rectified together
with a third reviewer until an agreement was reached.
These assessors were not blinded towards the authors,
organizations, or journals during the review procedure. The quality of cross-sectional and observational
studies were selected based on the NIH scale (14points) scoring system as good (9–10 points), fair
553
(6–8 points), and poor (< 6 points). However, the
quality of experimental and case-control studies was
selected based on NIH scale (12-points) scoring system as good to fair (> 6 points) and poor (< 6 points).
Both the reviewers evaluated the studies cautiously,
and the adjustments were resolved together with a
third reviewer until an arrangement was reached.
Lastly, the quality of the randomized control trials
was carefully chosen based on the PEDro scoring
classification as excellent (9–10 points), good (6–8
points), fair (4–5 points), or poor (< 4 points). In case
of disagreement between two reviewers, the decision
of the third reviewer was considered to be final.
3. Results
In total, 757 studies were noticed using the search
strategy which has been mentioned above. Out of
which, 501 studies were excluded for not assessing the musculoskeletal outcomes. After a careful
screening of the remaining 256 studies based on the
inclusion standards, 169 studies lack adequate data;
21 studies did not have full text; 18 studies did not
address the research question; 8 studies provided
irrelevant results were excluded, and the remaining
40 studies were selected for this review. We followed
PRISMA guidelines for reporting this review results
flow diagram (Fig. 1).
In total, 13 healthcare specialty categories were
identified, including surgeons [9–22], dental practitioners [23–34], nurses [35–37], pharmacists [38,
39], ophthalmologists [40], otology physicians [41],
microbiologists [42], laboratory technicians [43],
medical sonographers [44], laryngologists [45],
mammographers [46], biomedical scientists [47], and
clinical workers [48]. The numbers of studies identified for each healthcare specialty are presented in
Table 1.
The NIH scale scores of included cross-sectional
are listed in Table 2a; observational studies are listed
in Table 2b, case-control studies in Table 3, experimental studies in Table 4, and PEDro scores for RCTs
are listed in Table 5.
Among the five cross-sectional studies, four studies were done on dental practitioners [24, 26, 28, 29],
and one study was performed on intensive care unit
nurses [37]. These included cross-sectional studies
have NIH scale scores that range between 6 and 8
points (Table 2a). However, the majority of the studies in this review were observational studies. Among
25 studies, 11 studies were done on different surgeons
554
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
Fig. 1. PRISMA flow diagram explaining the results of the search.
Table 1
No. of studies according to health care specialty wise
Health care specialty
Surgeons
Dental practitioners and students
Nurses
Pharmacists
Ophthalmologists
Otology Physicians
Microbiologists
Laboratory technicians
Medical sonographers
Laryngologists
Mammographers
Biomedical Scientists
Clinical workers
Total Studies
No. of studies
14
12
3
2
1
1
1
1
1
1
1
1
1
40
[9–13, 17–22], 7 studies were done on dental practitioners [23, 25, 27, 30–32], 2 studies on professionals
working in the pharmacy department [38, 39], and
one each study on otology physicians [13], microbiology staff [42], medical laboratory technicians
[43] medical sonographers [44], and mammographers [46]. These included observational studies have
NIH scale scores that range between 6 and 9 points
(Table 2b).
Along with this, two case-control studies [16, 45]
(Table 3) and two RCTs [14, 15] (Table 4) were
included in this review. All these four studies have
been done on surgeons. The case-control studies have
NIH scale scores that range between 6 and 8 points
and included RCTs have PEDro scale scores that
range between 7 and 8 points.
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
555
Table 2a
(Cross-sectional Studies) Quality assessment tool for Observational, Cohort, and Cross-sectional studies provided by study quality
assessment tools used by NIH scale
S. No
Author/ Reference
1
2
3
4
5
6
7
8
9
10
11
12
13
14
NIH score
1
2
3
4
5
McLaren et al. [24]
Movahhed et al. [26]
Sezgin et al. [37]
Tirgar et al. [28]
Rafie et al. [29]
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
N
N
Y
N
N
Y
N
NR
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
Y
N
NA
Y
N
Y
Y
NA
NA
NA
NA
NA
Y
Y
Y
Y
Y
Y
NR
Y
NR
N
N
N
N
N
N
N
N
N
N
Y
7/12
7/12
7/13
6/12
8/12
Table 2b
(Observational studies) Quality assessment tool for Observational, Cohort, and Cross-sectional studies provided by study quality
assessment tools used by NIH scale
S. No
Author/ Reference
1
2
3
4
5
6
7
8
9
10
11
12
13
14
NIH score
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Mills et al. [23]
Van ’t Hullenaar et al. [9]
Yazdanirad et al. [38]
Govil et al. [13]
Van ’t Hullenaar et al. [10]
Li et al. [11]
Dabholkar et al. [12]
Marcon et al. [25]
Carvalho et al. [42]
Rosso et al. [39]
Park et al. [27]
Corrocher et al. [30]
Govil et al. [41]
Maulik et al. [43]
Golchha et al. [31]
Roll et al. [44]
Garcia et al. [32]
Craven et al. [17]
Noh et al. [33]
Hermanson et al. [22]
Youssef et al. [18]
Sanchez-Margallo et al. [19]
Taylor-Phillips et al. [46]
Lee et al. [20]
Person et al. [21]
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NR
N
NR
NR
NR
N
NR
N
N
N
NR
N
NR
NR
NR
N
NR
N
NR
N
N
N
NR
N
N
NR
Y
N
N
N
NA
N
NR
N
N
N
NR
N
NR
NR
NR
N
N
N
N
NR
NR
N
N
N
Y
NR
N
N
N
N
N
N
N
N
N
N
N
N
N
NA
N
N
N
N
N
N
N
N
N
Y
N
N
N
NR
Y
N
N
N
Y
Y
N
N
N
N
Y
Y
Y
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
NA
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
Y
N
NR
N
N
N
N
Y
N
N
N
N
N
N
N
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
NR
N
N
NR
N
NR
N
NR
N
NR
N
N
N
N
N
N
N
N
N
N
N
N
N
N
NA
N
N
N
N
NR
NR
N
N
NR
N
N
N
N
N
N
NR
NR
N
NR
N
NR
N
Y
N
Y
N
N
Y
Y
N
N
NR
N
N
N
N
Y
Y
Y
N
N
N
Y
Y
Y
N
N
9/12
7/12
7/12
6/12
6/12
8/13
7/12
6/12
6/11
7/13
6/12
6/12
6/12
7/12
7/12
8/12
8/13
7/14
6/12
6/13
7/13
8/12
7/12
6/12
6/12
∗ Y = Yes (Score = 1), N = No (Score = 0), NA = Not applicable (Score nullified), NR = Not reported (Score = 0), CD = cannot determine
(score = 0). 1. Research Question. 2. Study population. 3. Participation Rate. 4. Uniform eligibility criteria. 5. Sample size justification. 6.
Exposure assessed prior to outcome. 7. Sufficient timeframe to see an effect. 8. Different levels of exposure examined. 9. Exposure measures
valid, reliable, and consistent. 10. Repeated exposure measurement. 11. Outcome Measures valid, reliable, and consistent. 12. Blinding of
outcome assessors. 13. Follow up rate. 14. Statistical Analysis.
Table 3
Quality assessment of Case-control studies provided by study quality assessment tools of NIH scale
S. No.
Author/ Reference
1
2
3
4
5
6
7
8
9
10
11
12
NIH score
1
2
Statham et al. [45]
Bartnicka et al. [16]
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
NR
N
N
N
NR
NR
N
N
Y
Y
Y
Y
N
Y
6/12
8/12
∗ Y = Yes (Score = 1), N = No (Score = 0), NR = Not reported (Score = 0), CD = cannot determine (score = 0). 1. Research Question. 2. Study
population. 3. Sample size justification. 4. Uniform controls. 5. Uniform eligibility criteria. 6. Case and Control definitions. 7. Random
Allocation. 8. Concurrent Controls. 9. Exposure assessed prior to outcome. 10. Exposure measures and assessment. 11. Blinding of outcome
assessors. 12. Statistical analysis.
Concerning the six experimental studies, two studies were done on nurses [35, 36], and one each study
on ophthalmology residents [40], clinical workers
[48], dental professionals [34], and biomedical scientists [47]. These included experimental studies have
NIH scale scores between 7 and 8 points (Table 5).
556
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
Table 4
Quality assessment of randomized controlled trials using Physiotherapy Evidence Database (PEDro) scale
S. No.
Author/References
1
2
3
4
5
6
7
8
9
10
11
PEDro score (11)
1
2
Singh et al. [14]
Bensignor et al. [15]
Y
Y
Y
Y
N
Y
Y
Y
Y
N
Y
N
N
Y
Y
Y
N
N
Y
Y
N
Y
7/11
8/11
∗ Y = Yes (Score = 1), N = No (Score = 0). 1. Eligibility criteria were specified. 2. Subjects were randomly allocated to groups. 3. Allocation
was concealed. 4. The groups were similar at baseline regarding the most important prognostic indicators. 5. There was blinding of all
subjects. 6. There was blinding of all therapists who administered the therapy. 7. There was blinding of all assessors who measured at least
one key outcome. 8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not
the case, data for at least one key outcome was analyzed by “intention to treat”. 10. The results of between-group statistical comparisons
are reported for at least one key outcome. 11. The study provides both point measures and measures of variability for at least one key
outcome.
Table 5
(Experimental studies) Quality assessment tool for Before-After (pre-post) studies with no control group provided by study quality
assessment tools of NIH scale
S. No.
Author/References
1
2
3
4
5
6
7
8
9
10
11
12
NIH score (11)
1
2
3
4
5
6
Ratzlaff et al. [40]
Garosi et al. [35]
Sezgin et al. [36]
Shafti et al. [48]
Gandavadi et al. [34]
Kilroy et al. [47]
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
Y
Y
N
Y
N
Y
N
N
Y
Y
Y
Y
Y
N
Y
Y
Y
N
N
Y
N
N
N
Y
N
N
N
N
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
8/12
7/12
7/12
7/12
8/12
8/12
∗ Y = Yes (Score = 1), N = No (Score = 0). 1. Was the study question or objective clearly stated? 2. Were eligibility/selection criteria for the
study population pre-specified and clearly described? 3. Were the participants in the study representative of those who would be eligible
for the test/service/intervention in the general or clinical population of interest? 4. Were all eligible participants that met the pre-specified
entry criteria enrolled? 5. Was the sample size sufficiently large to provide confidence in the findings? 6. Was the test/service/intervention
clearly described and delivered consistently across the study population? 7. Were the outcome measures pre-specified, clearly defined, valid,
reliable, and assessed consistently across all study participants? 8. Were the people assessing the outcomes blinded to the participants’
exposures/interventions? 9. Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?
10. Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that
provided p values for the pre-to-post changes? 11. Were outcome measures of interest taken multiple times before the intervention and
multiple times after the intervention (i.e., did they use an interrupted time-series design)? 12. If the intervention was conducted at a group
level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine
effects at the group level?
The associated information for the included studies according to the study type, population, outcome
measures, and RULA score related to various health
care professionals are reviewed in Table 6.
4. Discussion
This systematic review is the first of its kind,
in which we examined the effectiveness of application of RULA to assess the level of ergonomic
risk among various healthcare practitioners. The incidence rates and outcomes broadly differed between
the studies, possibly due to evaluating of different
factors, including physical factors, anthropometric
determinants, psychosocial job requirements, public interactions at exertion, and interpersonal social
factors, which were correlated with WMSDs. We
observed the highest level of ergonomic risk (RULA
score > 6), especially in surgeons and dental professionals, and less ergonomic risk level (RULA score
2–3) in otology professionals. All of these studies were implemented in actual workplaces, which
included both in-patient and outpatient departments.
4.1. Plastic surgery
Li et al. [11] assessed the factors that contributed
to pain and discomfort in the neck among plastic surgeons when wearing head-mounted magnifiers
during operations. The results showed that different
RULA scores (beyond 3) were obtained for a variety
of positions and suggested that RULA can be useful
for performing risk assessments and reducing occupational risks, particularly when selecting magnifiers
and modifying the height of the operating table for
surgeons.
Table 6
Summary of the study design, population, outcome measures used, and RULA score related to health care practitioners
Study design
Population
Year, Country
Outcome measures used
Mary E. Mills
et al.
Observational
Study
2020, USA
Photograph method, and
RULA
3
Ratzlaff T.D.
et al.
Prospective
interventional
pilot study.
Observational
study
Dental students and
dental hygiene
students.
Ten ophthalmology
residents
2019, Canada
RULA
>4
First assistants during 2019, Netherlands
robotic assisted
surgery.
Nurses
2019, UAE
RULA, Dutch
Musculoskeletal
Questionnaire
Borg scale CR10, EMG,
RULA
4–5
Pharmaceutical,
automotive, and
assembly in the
Isfahan province.
Two Neuro-Otology
physicians
ICU Nurses
2018, Turkey
RULA, LUBA, NERPA,
NMQ.
2–4
2018, USA
RULA
2–4.5
2018, Turkey
4–5
Dental students
2018, United
Kingdom
2018, Netherlands
Descriptive of Nurses
and Ergonomic Risk
Reporting Form,
RULA, ICU
Environment
Assessment Form, and
Personal interviews
form
RULA
RULA, Mental and
physical load scores,
NASA-TLX, and LED
score were registered.
3–4
2017, China
MOO, and RULA.
>3
2017, India
RULA
4–5
Van’t Hullenaar
et al.
Garosi, E et al.
Experimental
Study
Yazdanirad et al.
Comparative
Study
Goyil, N et al.
Observational
study
Pre and post-test
design
Sezgin, D et al.
McLaren et al.
Van’t Hullenaar
et al.
Li, Z.L et al.
Dabholkar et al.
Cross-sectional
study
Comparative
study
Surgical interns and
residents using the
da Vinci skills
simulator during
robotic surgery.
Preliminary study Plastic surgeons
Observational
study
Laparoscopic
surgeons
RULA Score Conclusion
3
5–6
Overall, it was established that the use of photographs for risk
assessment through the RULA tool was effective in
decreasing the students risk scores for MSDs (23).
The RULA injury risk scores reduced after completion of the
module (95% CI 2.10¡2.77), representing a slighter risk for
injury to the Ophthalmologist (40).
RULA scores shown high-risk ergonomic risk scores for all
measured movements that were accomplished during surgery
(9).
The postures of the wrist, arm, and shoulder regions were
adjusted from Rapid Upper Limb Assessment action level 3
to 2 (35).
Low-risk levels in NERPA, medium-risk levels in LUBA, and
high-risk levels in RULA are assessed (38).
Overall, the RULA scores were 4.5 with patients in the seated
position, and 2 with patients in the supine lying position (41).
RULA ergonomic risk scores were considerably reduced,
while exercise frequency was improved (36).
No students were categorized as having satisfactory posture
and most required postural variations soon (24).
The intervention group showed less irrelevant movement and a
slighter deviation from the neutral position of the hands. The
intervention group also scored considerably better on the
RULA tool than the other group (10).
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
Citation
The results exhibited that it is likely to expect the RULA scores
for the series of postures and quantify risk assessment,
mainly in the collection and fitting of loupes and the
description of working height for surgeons (11).
Physical, ergonomic risk is medium as projected by the RULA
scoring method, through this minimally invasive surgical
procedure, demanding the application of modification in the
ergonomic practices (12).
557
(Continued)
558
Table 6
(Continued)
Study design
Population
Year, Country
Outcome measures used
Marcon et al.
Observational
study
Observational
design
Cross over
randomized
study
Operative dentists
2017, Italy
RULA, and NERPA
3–6
Otology surgeons
2017, USA
RULA
3–5
Vaginal surgery
doctors
2016, USA
CMDQ, SURG-TLX,
and RULA.
5–6
2016, France
RULA
>6
2016, France
EMG, RULA, Borg Scale
4–5
Govil N et al.
Singh, R et al.
Bensignor et al.
Shafti A et al.
Randomized
Laparoscopic
crossover
surgeons
stratified study
Experiment study Clinical workers
RULA Score Conclusion
Movahhed T et al. Cross sectional
study
Carvalho F et al. Observational
study
Dental students
2016, Iran
RULA
5–6
Microbiology staff
2016, Portugal
RULA
>6
Rosso C.B. et al.
Observational
study
Pharmacists
2016, Brazil
RULA, Deparis, and
ABC analysis
>6
Park H.S. et al.
Observational
study
Cross sectional
study
Dentists
2015, Korea
RULA, and QEC
>6
Intensive care unit
Nurses
2015, Turkey
RULA
>6
Analytic
cross-sectional
study
Case Study
Dental practitioners
2015, Iran
>6
Surgical ward health
practitioners
2015, Poland
RULA, Demographic
questionnaire, NMQ,
BDA, and CCFT.
OWAS, REBA, RULA,
and NIOSH.
Rafie F et al.
Cross-sectional
Study
Dentists
2015, Iran
Corrocher et al.
Observational
study
Undergraduate dental 2014, Brazil
students
Sezgin D et al.
Tirgar A et al.
Bartnicka J.et al.
3–6
NMQ, and RULA.
>6
RULA
>5
Risk of MSD’s were evaluated in an objective and precise way
(25).
The risk of musculoskeletal disorders surges as the RULA
score increases (13).
RULA postural scores revealed moderate to high
musculoskeletal risk in the neck and shoulders across
surgeons, and the chairs did not have an outcome on the
postural scores (14).
The mean of the three tasks’ RULA score was suggestively
lower with Jaimy chair, and the postural ergonomics were
developed (15).
RULA score and EMG measurements specified the best
presentation in identifying the task difficulty and discomfort
(48).
There was no significant association between RULA score
with working posture (26).
Results of the Rapid Upper Limb Assessment results revealed
that the risk for the development of MSD is present in all
tasks (42).
The findings permitted suggestions for improvement, related
primarily to the procedure of drug dispensation,
organization, and preparation of the work environment (39).
The RULA examination of the dentists’ work posture specified,
“immediate improvement required” in the posture (27).
The Rapid Upper Limb Assessment score for the patient
turning movement was higher than for the twisting down
motion (37).
Based on the RULA scores, 93.3% of the subjects had a
despicable position during uplifting practices (28).
The principle of this method to knowledge-based ergonomic
assessment is the likelihood to re-use the same evidence
depending on the purpose and the process of ergonomic
analysis (16).
The current findings exhibited that the unsuitable posture of
dentists during work has a substantial effect on WRMD’s
(29).
The compromise of developing musculoskeletal disorders was
high in dentistry students; this hazard was not associated
with gender, type of dental procedure, and region being
treated (30).
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
Citation
Citation
Maulik S et al.
RULA Score
Population
Laboratory
technicians
Dental practitioners
Year, Country
2014, India
Outcome measures used
NMQ, VAS, and RULA.
2014, India
RULA, and NMQ
1–2
Pilot
observational
study
Observational
study
Medical
sonographers
2014, USA
RULA
3–5
Dental students
2013, Brazil
OWAS, and RULA
>6
Craven R et al.
Observational
study
Gynaecology
oncology surgeons
2013, USA
RULA, and SI method
>6
Noh H et al.
Observational
study
Observational
and Analytical
study
Observational
study
Dental hygienists
2013, Korea
RULA, and REBA
>6
Physicians
performing surgery
2012, USA
Body Map Assessment,
RULA
>6
Laparoscopy
surgeons
2011, USA
RULA, NASA-TLX, and
VRS
1–4
Prospective
case-control
study.
Data collection
study
Laryngologists
2010, USA
RULA
>6
Laparoscopic
surgeons
2009, United
Kingdom
RULA
>6
Observational
Study
Experimental
design
Mammographers
2008, USA
RULA
5–6
Dental students
2007, United
Kingdom
RULA, and Photograph
method
>6
JSI, and RULA
4–7
RULA
>6
NMQ, BDC, and RULA.
3
Golchha V et al.
Roll S.C et al.
Garcia P.P et al.
Hermanson J.E.
et al.
Youssef Y et al.
Statham M.M.
et al.
SanchezMargallo, F.M.
et al.
Taylor-Phillips S.
et al.
Gandavadi A
et al.
Lee E.C. et al.
Comparative
Study
Person, J.G. et al. Observational
Study
Kilroy, N. et al.
Clinical Trail
Minimal invasive
2005, USA
technique surgeons
Laparoscopy
2001, Canada
surgeons
Biomedical Scientists 2000, Ireland
>6
Conclusion
The final RULA score of 6 ± 1.02 highlights poor workstation
design, which resulted in an unnatural posture (43).
RULA can be utilized as a screening tool for postural risks
following a short training session irrespective of the
evaluator’s knowledge in postural risk assessments (31).
Overall, RULA scores ranged from 3.11 to 5.00, with upper
extremity averaging the highest risk associated with
increased musculoskeletal discomfort (44).
The risk of musculoskeletal disorders in dental students
projected by the OWAS method was medium, whereas the
same risk by the RULA method was exceptionally high (32).
Ergonomic assessment of surgeon activity leads to a mean
RULA score of 6.46 (maximum possible RULA score, 7),
representing a need for additional investigation (17).
RULA score found that the shoulders and wrists were almost
overloaded (33).
The findings have revealed that the most significant concerns
were the discomforts in the neck, shoulders, arms/wrists, and
back (22).
RULA scores were always less for the standing technique and
higher for the side-standing procedure, irrespective of
whether one- or two-handed (18).
RULA and biomechanical analyses have recognized lower-risk
surgeon positioning to be applied during micro-laryngeal
surgery (45).
RULA analyses that these positions mean a high risk to suffer
from muscle alterations (19).
RULA postural analysis showed no overall increase in MSD
risk level (46).
RULA has identified that dental students using a Bambach
saddle seat could sustain an acceptable working posture
during dental treatment, and this seating may decrease the
development of WRMD’s (34).
The JSI and RULA scores for all four tasks were considerably
lower for the telerobotic technique than the manual one (20).
Ergonomic stress scores were reasonably high throughout the
procedure, predominantly for the wrist (21).
The majority had a RULA grand score of three. Examination
of findings specifies that RULA scores generally resemble
reporting symptoms of NMQ and BDC (47).
559
Note: The abbreviations of terms used in the table were provided below. Borg Scale CR10: Borg Scale Category ratio 10. CCFT: Craniocervical Flexion test. LUBA: loading on the upper body
assessment. NIOSH: National Institute for Occupational Safety and Health. NERPA: new ergonomic posture assessment. OWAS: Ovako Working Posture Assessment System. NMQ: Nordic
Standardized Musculoskeletal Questionnaire. VAS: Visual Analogue Scale. NASA-TLX: NASA Task Load Index. SI: Strain index. SURG-TLX: Surgery Task Load Index. VRS: Virtual reality
Simulator. MOO: Multi-objective optimization. JSI: Job Strain index. CMDQ: Cornell Musculoskeletal Discomfort Questionnaires. REBA: Rapid Entire Body Assessment. QEC: Quick Exposure
Check. BDA: Body Discomfort Assessment questionnaire.
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
Study design
Questionnaire
technique
Survey method
560
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
4.2. Neurotology
Govil et al. [13] evaluated the ergonomically optimal position of a patient (sitting versus supine) during
otologic procedures by using RULA. The RULA
scores recorded for neurotologists were significantly
lower when the patient was in the supine position
compared with the seated position. This study suggested that patient position may contribute to the
work-related stress placed on an otolaryngologist’s
upper extremities during otology procedures.
4.3. Robotic-assisted surgery
Van’t Hullenaar et al. [9] assessed the ergonomic
risks associated with the performance of robotassisted surgery using three techniques: RULA,
Nordic musculoskeletal questionnaire (NMQ), and
photographic technique. RULA scores revealed high
ergonomic risks for all evaluated activities in which
the tissue drawing techniques were identified as
the activities with the maximum physical workload
[9]. In another study [10] by the same authors,
an intervention group who received proper training during robot-assisted surgery demonstrated better
ergonomic postures than the control group, based on
superior RULA scores. In an additional study performed by Lee et al. [20], thirteen contestants with
no familiarity as chief surgeons in endoscopic surgery
executed a set of replicated surgical tasks by means of
telerobotic system and a manual endoscopic surgery
system. Telerobot use during endoscopic surgery was
associated with an improvement in ergonomics, as
assessed by lower RULA scores. The surgeons in
this study also reported that this technique was less
stressful than the manual technique.
showed moderate to high ergonomic risks for the
neck and shoulder regions across surgeons. They also
concluded that the chair discomfort scores for the
conventional curved chair and the saddle chair were
considerably higher than the remaining two chair
types during surgery.
4.6. Other studies in surgery
Bartnicka et al. [16] analyzed various ergonomic
methods to assess the working conditions of the nursing team and surgeons in surgical departments and
revealed that they required significant bodily and postural efforts due to the difficult positions at work. The
RULA method and other evaluation methods were
found to be effective for assessing the postural stress
endured by these practitioners. Finally, Hermanson
et al. [22] also concluded that the estimated frequency
of WMSDs among at-risk physicians appeared to be
high.
4.7. Dental department
This section is further divided into dental practitioners and dental students
4.8. Dental practitioners
A few researchers focused on laparoscopic surgeons and revealed that these healthcare practitioners
were at ergonomic risk according to the RULA
method [12, 15, 18, 19, 21].
Marcon et al. [25] evaluated three unique set-ups in
which dental practitioners performed operations with
bare eyes, with medical lenses, or using a surgical
microscope and compared the postural consequences
of these three different patterns. The RULA risk evaluation score [5, 6] was higher in the neck and spinal
regions when using the medical lenses and bare eyes
compared with the use of a surgical microscope. This
RULA score was similar to those determined by Park
et al. [27] and Trigar et al. [28]. Park et al. indicated
that the posture required to handle maxillary second
molars was more intolerable than that required to treat
the anterior teeth, and Trigar et al. added that female
dental specialists were at higher ergonomic risk than
male practitioners.
4.5. Vaginal surgery
4.9. Dental students
One randomized cross-over study performed by
Singh et al. [14] assessed the effects of four different chairs used by gynecologists during vaginal
surgery; a conventional curved chair, a round chair
with a backrest, a saddle chair with a backrest, and a
Capisco chair. They revealed that the RULA scores
Some authors assessed the ergonomic risks in
dental students while working in dental clinics.
Mills et al. [23] suggested that the RULA method
made the participants more aware of their posture
and enhanced the self-consciousness of ergonomics,
which decreased the hazards of developing WMSDs
4.4. Laparoscopy
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
among dental hygiene students. Other studies [24, 26]
reported that most dental undergraduates did not have
acceptable working postures and were at a high risk
of developing WMSDs. Movahhed et al. also showed
no substantial relationship between RULA scores and
gender, educational year, or dental clinic division.
4.10. Nursing
Garosi et al. [35] designed an infusion connector instrument and compared it against the use of a
manual connection while performing nursing tasks.
The RULA risk score was reduced from 3 to 2 when
the designed tool was utilized. Sezgin et al. [36]
assessed the ergonomic risk factors in nurses in an
intensive care unit. The mean RULA scores significantly decreased when the exercise frequency among
nurses increased, resulting in reduced musculoskeletal pain and ergonomic risk among nurses. Another
study, performed by Sezgin et al., [37] investigated
the incidence of musculoskeletal symptoms among
intensive care nurses. Most musculoskeletal symptoms were reported in the legs and back, especially
when the nurses rotating or twisting down the patient.
4.11. Pharmacy
Yazdanirad et al. [38] compared three different
ergonomic risk assessment methods; RULA, loading on the upper body assessment (LUBA), and new
ergonomic posture assessment (NERPA) for the evaluation of the upper extremity MSD’s in workers in
the pharmacy department. The results demonstrated
that the RULA was the best technique for evaluating MSD’s between the three tested methods. Rosso
et al. [39] performed an ergonomic assessment of
employees in an emergency pharmacy department,
using Deparis, RULA, and ABC analysis methods.
All three methods were found to improve comfort
and working conditions for the pharmacy workers.
4.12. Ophthalmology
Ratzlaff et al. [40] categorized variations in body
position in ten ophthalmology residents during the
performance of a uniform slit-lamp examination. All
practitioners received an educational training program on ergonomics, and the ergonomic risk was
assessed pre-and post-training using RULA, which
was analyzed using biomechanical software. The outcome of their study showed that training offered the
promising ability to decrease injury risk.
561
4.13. Microbiology
Carvalho et al. [42] evaluated microbiologists
under real working conditions and assessed associated WMSD’s. RULA was used to evaluate the level
of risk, and the RULA scores showed that a risk for
the progression of MSD’s was identified for all tasks.
They suggested the implementation of precautionary
measures to decrease the level of risk.
4.14. Laboratory
Maulik et al. [43] concluded that technological
developments in medical laboratories might have
increased the number of ergonomic risks for laboratory professionals due to their nature of work.
The RULA scores emphasized that poor workstation strategies resulted in abnormal work postures.
The use of administrative and addition of engineering pedals may be able to considerably reduce these
ergonomic hazards and further decrease the final
RULA score.
4.15. Medical Sonography
The working postures of medical sonographers
were assessed because 90% of these professionals
often suffer from musculoskeletal pain and discomfort. Roll et al. [44] conducted a pilot study to identify
the relationship between sonographer pain and work
environments during 24 sonographic examinations
using RULA. Overall, the RULA scores revealed poor
upper extremity postures, which were associated with
musculoskeletal pain and discomfort.
4.16. Micro laryngoscopy
In a case-control study, Statham et al. [45] examined three different micro laryngeal operational
positions in laryngologists; a sustained work position
in a chair with arm support, a sustained position with
the arms relaxing on a mayo stand, and a position
with the arms unsupported. RULA and biomechanical evaluations indicated a lower risk associated with
laryngoscopy surgeon positioning in a chair with arm
support, which must be used during micro laryngeal
surgery.
4.17. Mammography
In the United Kingdom, the Breast Screening
program, has increasingly been shifting from film
562
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
to digital mammography, which has been associated with a concomitant modification in workstation
ergonomics. Three workstation types were examined:
one with film and digital mammograms, one with
only film mammograms, and one with only digital
mammograms. RULA scores showed no increase in
the WMSD hazard levels associated with the shift
from a film only to a digital mammogram workstation
[46].
4.18. Other studies
An ergonomic evaluation of female microbiologists was performed by Kilroy et al. [47] using RULA,
NMQ, and the body discomfort chart (BDM). This
study was piloted in three stages: before, during,
and after the intervention. The final RULA scores
revealed a decrease in the incidence of musculoskeletal problems and body distress after the intervention.
As a final study, Shafti et al. [48] determined the
importance of using RULA to evaluate ergonomics
in clinical work environments.
Even though RULA was found to be an efficient
tool in assessing the level of ergonomic risk among
health care professionals, some of the researchers
found some unsatisfactory results. Van’t Hullenaar
et al. stated that the tissue drawing technique was
the most demanding activity performed by nurses
throughout the robot-assisted surgery, but RULA
delivered a highly unfavorable score during this technique [9]. Van ’t Hullenaar et al. concluded that
the low RULA scores reported in the control group,
which indicated ideal posture, were not guaranteed
when utilizing the console of the da Vinci surgical
system during training [10]. Dabholkar et al. determined that the postural hazard was medium, based
on the RULA scoring method during the withdrawal
period of this minimally invasive surgical technique,
requiring modifications to ergonomic practices [12].
Govil et al. were not able to identify differences in
RULA scores between male and female surgeons,
likely due to the small sample size of the research
[13]. Bartnicka et al. used OWAS, RULA, REBA,
and NOISH approaches to perform an ergonomic risk
assessment in surgical divisions and specified that
in Polish conditions, the OWAS method was more
useful than the other tested ergonomic methods [16].
Youseff et al. reported that surgeons who perform
laparoscopic procedures experienced greater wrist
flexion and bending, despite receiving low RULA
scores, suggesting conflicting results that could be
due to the compensatory upper limb and trunk movements. [18]
Golchha et al. concluded that the posture evaluated
by RULA was not correlated with WMSD documented using the Standard Nordic Musculoskeletal
Questionnaire among the dental practitioners in their
study [31]. Garcia et al. showed that the RULA
assessment method requires more time and preparation for the evaluators to apply because the risk scores
are primarily evaluated based on measurements of the
abnormalities in the body evaluated segments [32].
The present study has some limitations. First,
due to the lack of language expert’s availability, we
limited our search to papers published in English
language. Second, due to digitalization, the grey literature and manual search were limited in this review,
so the likelihood happens that some studies were
ignored.
Further research should include different interventional strategies, especially in high-risk health care
professionals, to evaluate the ergonomic risk based
on RULA scores.
5. Conclusion
The current systematic review examined the significance of RULA for assessing the level of ergonomic
risk among healthcare practitioners. In some studies, RULA was used in addition to other assessment
tools, however RULA was found to provide more reliable results than these other approaches. Overall, this
review suggested that RULA is an effective method
for evaluating the postural risks associated with different health sectors as it provides a user-friendly
evaluation tool that needs minimal time, effort, and
equipment.
Funding
The authors are thankful to the Deanship of Scientific Research, King Khalid University, Abha, Saudi
Arabia for financially supporting this work (RGP
2/40/42).
Conflict of interest
The authors declare that they have no conflict of
interest.
Ethical standard
This article does not contain any studies with
human or animal subjects performed by the any of
the authors.
V.N. Kakaraparthi et al. / Application of the rapid upper limb assessment tool
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Environ Monit Assess
(2022) 194:166
https://doi.org/10.1007/s10661-022-09815-x
An assessment of the health risks associated with shared
sanitation: a case study of the community ablution blocks
in Durban, South Africa
Preshod S. Ramlal · Johnson Lin ·
Christopher A. Buckley · Thor Axel Stenström ·
Isaac D. Amoah
Received: 29 May 2021 / Accepted: 22 January 2022
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022
Abstract Shared sanitation facilities have been
hailed as an innovative approach to solve the challenge
with sanitation access. However, these facilities may
act as hotspots for disease transmission due to unhygienic conditions. In this study we used quantitative
(based on Escherichia coli contamination) techniques
to assess the health risks associated with the use of
community ablution blocks (CABs). The most contaminated surfaces were the cistern handle (5.7 Log10
We regret to state that Prof. C. Buckley passed away while
this manuscript was under review.
Supplementary information The online version
contains supplementary material available at https://doi.
org/10.1007/s10661-022-09815-x.
P. S. Ramlal (*)
eThekwini Municipality Health Department, 9 Archie
Gumede Place, 4001 Durban, South Africa
e-mail: preshramlal@gmail.com
P. S. Ramlal · J. Lin
School of Life Sciences, University of KwaZulu-Natal,
KwaZulu‑Natal, 4001 Durban, South Africa
C. A. Buckley
WASH Research and Development Centre, University
of KwaZulu-Natal, KwaZulu‑Natal, 4001 Durban,
South Africa
T. A. Stenström · I. D. Amoah
Institute for Water and Wastewater Technology, Durban
University of Technology, KwaZulu‑Natal, Durban,
South Africa
cfu/cm2) and internal pull latch (5.8 L
og10 cfu/cm2).
Based on the E. coli contamination, at least two
people out of 100 CAB users might be potentially
infected when they touch “hot” surfaces. These risks
were modelled assuming transfer of potentially pathogenic E. coli from these surfaces to the mouth. The
incorporation of risk-reduction measures, such as
wiping of these surfaces or washing of hands, could
potentially result in significant reduction of infection risks. The most significant risk-reduction intervention was determined to be wiping of the contact
surfaces, especially twice prior to contact. A combination of risk-reduction interventions could further
reduce the risks. This study shows that contamination of contact surfaces within shared CABs could
lead to increased risks of infections, requiring measures aimed at reducing the associated risks. The risk
assessment framework used in this study could therefore be applied in similar settings to estimate associated health risks with the use of such facilities.
Keywords Shared sanitation · Community ablution
blocks · Microbial health risks · Quantitative
microbial risk assessment · Risk reduction
Introduction
Shared sanitation can play a critical role in achieving
sanitation coverage (Garn et al., 2017; Pickering et al.,
2015). For many people living in densely populated
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urban areas, such as informal settlements, the alternative to open defecation is the use of shared sanitation
(Busquet, 2015). However, despite the increase in the
use of shared sanitation, there is divided opinion of
its appropriateness. While some researchers contend
that shared or public toilets (as opposed to individual
household toilets) are the best option for densely populated urban slums due to space constraints (Katukiza
et al., 2012; Schouten & Mathenge, 2010), others
have shown that shared sanitation may be a contributory factor to increased frequency of infections (Fenn
et al., 2012; Heijnen et al., 2014; Patil et al., 2014;
Pickering et al., 2015). This relates to increased risk
of diarrhoea, soil-transmitted helminths (STHs), and
trachoma (Guerrant et al., 2013) due to direct contamination of contact surfaces with pathogens. Airborne
dissemination may also occur, where viruses and bacteria have been found on bathroom surfaces, during
toilet flushing (Barker & Bloomfield, 2000; Gerhardts
et al., 2012). The ambient conditions in the sanitation environment are ideal for microorganism survival
and proliferation, thereby increasing faecal-oral exposure (Kagan et al., 2002; Kay et al., 2006). Survival
of microorganisms on surfaces such as plastics and
metals has been reported extensively (Alsallaiy et al.,
2016; Barker & Bloomfield, 2000; Curtis et al., 2003;
Neely & Maley, 2000).
Furthermore, contamination of contact surfaces
within shared sanitation facilities could be more
frequent, with higher microorganism concentrations, than single-household facilities due to higher
user numbers and frequency. This has led to several
reports of shared sanitation acting as hotspots for
diarrhoeal diseases (Baker et al., 2016; Crocker &
Bartram, 2016; Rah et al., 2015; Ramlal et al., 2019).
Disease transmission in sanitation facilities could
occur either through toilets-to-hands-to-mouth contact or from contaminated hands to surfaces (Barker
& Bloomfield, 2000; Curtis et al., 2003).
Private toilets will not always be cleaner than
shared facilities (Ahmed et al., 2012) but the number of users may play a significant role in the cleanliness of these facilities (Günther et al., 2012). When
the number of households were below 4 per facility, the cleanliness of shared facilities was comparable to private ones (80% clean), while the sharing
of the facilities by more than 10 households resulted
in 40% drop in cleanliness (Günther et al., 2012). In
most settings where shared sanitation is practiced, the
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responsibility of cleaning is shared by the users or
volunteers (Kwiringira, 2017). This has been reported
to result in apathy towards the hygienic maintenance
of these facilities (Kwiringira, 2017; Tumwebaze &
Mosler, 2015). Therefore, the employment of caretakers, living in the communities where shared sanitation facilities are located, like the community ablution blocks (CABs) in the informal settlements of the
eThekwini Municipality, has been recommended as
an alternative.
This study present the assessment of the health
risks associated with the use of shared sanitation facilities, such as the CABs. The quantitative
approach adopted in this study presents the assessment of potential health and safety risks associated
with the use of shared sanitation facilities. This study
aims to make a significant contribution by presenting
techniques that can be used to estimate health risks
associated with shared sanitation and possible mitigation measures that can be implemented to reduce the
risks of infections.
Methodology
Study location
CABs located in two informal settlements in the
eThekwini Municipality (Durban) of South Africa
were selected for this study. Male and female CABs
within these settlements were chosen and the health
risks associated with its usage were determined based
on the concentration of Escherichia coli on key contact surfaces within the CABs. The selected type of
contact surfaces was based on recent studies in the
field (Bohnert et al., 2016; Mpotane et al., 2013).
Swab sampling for E. coli concentration
The contact surfaces selected included cistern handle, toilet seat, floor surface in front of the toilet,
internal pull latch of cubicle door, external door handle of cubicle, tap handle in shower cubicle, internal
common floor surface, and tap in wash hand basin
(Fig. 1). These contact surfaces were chosen based
on recommendations made in studies by Mpotane
et al. (2013) and Bohnert et al. (2016). Samples were
taken with the
LABOCARE™ sterile swab sticks,
with transport media (Amies), following the protocol
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166
Fig. 1 Key contact surface areas swabbed to determine E. coli concentration within internal surfaces of CABs
proposed by Park et al. (2017). One cubicle each in
the male and female CAB toilets was sampled on
three different occasions over a period of one month.
Enumeration of E. coli
Aliquots of 0.1 mL of each sample were spread plated
on agar plates containing specific media for E. coli
(Chromocult media) after a serial of 1 0−4 to 1 0−10 dilutions. The plate lids were slightly left open after spread
plating for 2–3 min to allow for sample absorption. Incubation was made at 37 °C for 24 h. The area swabbed
for each surface is presented in Table S1 (Appendix I)
and used to calculate the concentration of E. coli per
cm2 of surface area. Ten colonies per sampling site
from the Chromocult agar plates were selected based on
morphological characteristics and colour (Lange et al.,
2013). These were confirmed biochemically using the
IMVic test (Lupindu, 2017) and polymerase chain reaction (PCR) (Abid & AL-zuwainy, 2015) where the uidA
gene was used as the marker for the confirmation of E.
coli isolates. The primers used are presented in Table S2
(Appendix I). For quality control, each analysis had an
additional control, swab sticks taken through the sample
analysis process but without actual swabbing. This was
intended to ensuring that there was no contamination
during the sample processing.
Microbial infection risk assessment
The risk of infection was calculated using the quantitative microbial risks assessment (QMRA) approach.
This is an approach that combines mathematical equations with knowledge and information on
microbial ecology, disease epidemiology, and transmission. This tool has been recommended as a useful technique in assessing the risks associated with
bioaerosols, drinking water, reclaimed water, and
irrigation water (Carducci et al., 2016; Ezzat, 2020;
Girardi et al., 2019; Gularte et al., 2019; Petterson
& Ashbolt, 2016). It therefore could be adopted to
provide an assessment approach for the use of shared
toilets, such as the CABs. QMRA consists of four
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interrelated steps: (a) hazard identification; (b) exposure assessment; (c) dose–response assessment, and
(d) risk characterization (Haas et al., 2014).
Hazard identification
The hazard of choice for this study was pathogenic E.
coli. E. coli isolated from environmental samples could
include non-pathogenic environmental strains and the
mean E. coli counts per cm2 would therefore be relatively higher than the pathogenic strains. Therefore,
the risk of infection was calculated assuming that 8%
of average E. coli counts are pathogenic (George et al.,
2013; Howard et al., 2006; Machdar et al., 2013). The
pathogenic E. coli concentrations were then used as
doses that were incorporated into the QMRA at the
dose–response modelling stage to ascertain the risks.
Fig. 2 Scenario for
assessing the exposure and
possible risks associated
with contamination of the
contact surfaces (adapted
from Ryan et al. (2014))
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Exposure assessment
The exposure scenarios used in the health risk assessment were contact with contaminated surfaces within
the CABs. The frequency of exposure to these contaminated surfaces was determined based on the
frequency of use of the CABs as provided by the
respondents during this study. The exposure assessment framework is presented in Fig. 2.
Dose–response assessment
Several dose–response models have been developed for
the estimation of risk posed by exposure to pathogenic
E. coli. In this study, the beta-Poisson dose–response
model was used (Haas et al., 2014). The beta-Poisson
model is defined by the following equation:
Environ Monit Assess
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)(
(
(
))−𝛼
1
d
2𝛼 − 1
p(d) = 1 − 1 +
N50
With p(d) being the risk of infection and “d” the
total concentration of pathogenic E. coli ingested
(Haas et al., 2014). N50 is the median infection dose
representing the number of organisms that will infect
50% of the exposed population and α the dimensionless infectivity constant. The input values for N50 and
α are presented in Table 1. The dose of pathogenic E.
coli ingested was calculated based on the concentration of E. coli measured on the contact surfaces. This
considered that about 8% of total E. coli are pathogenic. Probability distribution functions (PDFs) were
fitted to the concentration of pathogenic E. coli using
@Risk (Palisade Inc., USA) with the best distribution
selected based on the Akaike information criterion
(AIC). The dose of E. coli ingested via the framework
presented in Fig. 2 was then determined by accounting
for the fraction of the bacterial load on the surfaces
that will be transferred to the hands and the fraction
on these bacteria that will eventually be transferred to
the mouth/lips. The transfer efficiency from contact
surfaces to hands and hands to mouth/lips was modelled using the input values presented in Table 1.
Risk characterization
In the risk characterization, all the outcomes of the hazard
identification, exposure assessment, and dose–response
assessment were combined to characterize the infection
risks for exposed individuals. The risk of infection associated with multiple exposures [P1(A)] was determined
using the following formula:
166
P1(A) = 1 − (1 − P(d))n
where P(d) is the risk of infection from a single exposure to a dose d of the pathogen, calculated using the
beta-Poisson dose–response model presented above;
and n being the number of times/days of exposure to
the single dose d (Sakaji & Funamizu, 1998). Two
different multiple exposure scenarios were considered, daily and yearly exposures. To determine the
risks of infection from multiple exposures within a
day, a user frequency survey was conducted as part
of a larger household questionnaire. Inhabitants of
the two settlements were asked how many times they
used these CABs within a day. This gives information
on the number of times the users could potentially be
exposed to the pathogen. This survey led to modelling
the exposures per day with a uniform distribution of a
minimum of 1 and maximum of 2 times per day. The
yearly exposure risks were modelled assuming that
the CABs are used every day of the year; therefore, an
n value of 365 was used to calculate the yearly risks.
The outcome of the daily risks was used as input for
the P(d) in this case to determine the yearly risks.
Potential impact of risk‑reduction measures on
infection risks
The potential reduction in risks of infection after implementation of risks reduction measures was also determined. Five risk-reduction interventions were considered in this study; these can be further grouped into
three categories: wiping of contact surfaces, washing
of hands (for at least 20 s), and a combination of these
interventions. The various interventions considered
were the following:
Table 1 Input values for the dose calculation and dose–response modelling
Parameter
Input value
Reference
Bacterial transfer from contact surface to hands
Bacterial transfer from hands to mouth/lips
N50
α
Pathogen reduction after one wipe of surfaces
Pathogen reduction after two wipes of surfaces
Pathogen reduction achieved with washing of hands without soap
Pathogen reduction achieved with washing of hands with soap
Uniform distribution (0.13;0.38)
Median value (0.41)
2.11 × 106
1.55 × 10−1
Median value (1 log10)
Uniform distribution (1;3 log10)
Uniform distribution (0.6;1.4 log10)
Uniform distribution (0.9;2.5 log10)
Ryan et al., 2014
Girardi et al., 2019
Tuladhar et al., 2012
Jensen et al., 2015
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Page 6 of 13
6
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Quantitative assessment of risks from contact with
surfaces within the CABs
8
Fl
Results
E. coli concentration (Log10 cfu/cm2)
Comparison of the concentration of E. coli on the various surfaces and the associated risk was performed with
the Kruskal–Wallis test followed by Dunn’s post-test at
a 95% confidence interval (Dinno, 2015). Determination of the statistical significance of the risk-reduction
measures was performed with the Mann–Whitney U
test. All these comparative statistical analyses were performed using GraphPad Prism (version 7).
10
rn
Statistical analysis
te
The input values used for modelling the risks reduction are presented in Table 1. All risk models were subjected to Monte Carlo simulations of 10,000 iterations
for the probability of infections. These models were
constructed using the @Risk 7.5 (Palisade Corporation, USA) software add-on to Excel (Microsoft Cooperation, USA).
(2022) 194:166
location, the highest concentration of E. coli was
detected on contact surfaces within the female toilets
(Fig. 3). The highest concentration of E. coli was on
the cistern handle (6.01
log10 cfu/cm2), floor surface in front of toilet (6.23 log10 cfu/cm2), and tap
handle (6.25 log10 cfu/cm2), all within female toilets (Fig. S1, Appendix I). The difference between
the male and female toilets in relation to the concentration of E. coli was statistically significant
(p-value ≤ 0.05), on the following surfaces irrespective of sampling location; cistern handle, floor surface
in front of toilet, and tap handle in wash basin. However, in some instances the statistically significant
differences between the female and male toilets were
only observed in one settlement (sampling location)
(Fig. 3).
Comparing the different surfaces irrespective of
gender, using the toilet and location, the highest mean
concentration of E. coli was detected on the cistern
handle (5.7 log10 cfu/cm2), internal pull latch (5.8
log10 cfu/cm2), external door handle (5.7 log10 cfu/
cm2), and tap handle in shower cubicle (5.7 log10 cfu/
cm2) (Fig. 3). The Mann–Whitney tests showed a statistically significant difference (p-value ≤ 0.05) in E.
coli concentrations between the cistern handle and
is
1. Wiping of contact surfaces once: According to
Tuladhar et al. (2012) a simple wipe of surfaces
with soap may lead to 1 log10 reduction in bacterial concentration.
2. Wiping of contact surfaces twice: A second wipe
could potentially further reduce the bacterial concentration by 1–3 log10.
3. Hand washing with soap: Jensen et al. (2015)
reported that washing of hands with soap could
achieve a 1.7 (± 0.8) log10 reduction of pathogens.
4. Hand washing without soap: Washing without the
use of soap could potentially result in 1.0 (± 0.4)
log10 reduction.
5. Combination of risk-reduction interventions: The
combined effect of wiping of the contact surfaces
once and washing of hands without soap was
also modelled. These two risks reduction measures were chosen based on the interventions that
require the least effort and resources.
Environ Monit Assess
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166
E. coli concentration on contact surfaces in the CABs
Sampling points
E. coli concentration on the contact surfaces varied,
although not significantly. Irrespective of the study
Fig. 3 Concentration of E. coli on key contact surfaces in
community ablution blocks (CABs) within the two settlements
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toilet seat, the toilet seat and internal pull latch, and
between the toilet seat and tap handle in shower.
Potential risks of infection with pathogenic E. coli on
the contact surfaces before and after incorporation of
risk‑reduction measures
The potential risks of infection with pathogenic E.
coli based on the concentration on these contact surfaces varied in a similar fashion to the variation in
the E. coli concentration measured and presented in
Fig. 3. Table 2 presents the calculated median risks
of infection. Briefly, considering only daily risks, at
least two people out of 100 users of the CABs may
be infected when they touch surfaces such as the cistern handle, internal pull latch, external door handle, and the tap handles in both the shower and wash
basin (10−2) (Table 2). However, the highest risk of
infection was determined to be contact with the internal pull latch (2.5 × 10−2). Based on the earlier user
survey conducted in the study areas, it was observed
that the populations within these informal settlements
use the CABs up to twice a day. We modelled the frequency of exposure in a day and assessed the risks
thereof (daily risks). The daily risks of infection were
higher than the one-time exposure risks reported; for
instance, the risks of infection after contact with the
internal pull latch increased to almost four out of 100
people exposed being infected, compared to the almost
three out of 100 for one-time exposure. This increase
in risk of infection was also observed for contact with
the rest of the other contact surfaces (Table 2). Multiple exposures over the course of the year may also
lead to a statistically significant increase in the risks of
infection with pathogenic E. coli. As shown in Table 2,
yearly exposure may result in almost every person who
touches these surfaces been infected. This is due to the
166
measured risks of either 1 or 9.9 × 10−1 per person per
year; with the exception of the floor surface in front
of the toilet cubicle, which had a risk of infection of
8.6 × 10−1 (± 6.1 × 10−3) per person per year.
Potential risk reduction based on hypothetical
risk‑reduction measures
Implementation of risk-reduction measures, such as cleaning of the surfaces and washing of hands with and without
soap, could potentialy reduce the risks as calculated. For
instance, wiping of the internal pull latch surfaces could
potentially lead to risk estimates of 2.2 × 10−2 (± 3.1 × 10−4),
compared to 2.5 × 10−2 (± 3.0 × 10−4) for the uncleaned
surfaces. Wiping of the surfaces twice reduced the
risks further but not significantly. Furthermore, washing of hands without soap reduced the risks to 2.4 × 10−2
(± 3.0 × 10−4) after contact with the internal pull latch.
Washing of hands without soap also reduces the risks as
well (Fig. 4). Comparatively, wiping the surface twice
achieves the highest reduction of risks among the four
singular risk interventions modelled. Wiping the surface
once achieves similar risk reduction compared to wiping the surfaces twice. Combining one wipe of the contact surfaces with hand washing without soap reduces the
risks further; however, these risk estimates are not significantly lower than the risks when the surfaces are cleaned
(Fig. 4). Detailed information on the calculated risks are
presented in Appendix I (Table S3).
Discussion
Contamination of contact surfaces with E. coli
The detection of E. coli on almost all key contact surfaces in our study shows the potential for these surfaces
Table 2 Calculated median risk of infection (± 90% CI) with pathogenic E. coli due to one-time, daily, and yearly exposure to the
contact surfaces within the CABs
Cistern handle
Toilet seat
Floor surface in
front of toilet
Internal pull
latch
External door
handle
Tap handle in
shower cubicle
Internal common Tap handle in
floor surface
wash basin
One time 1.9 × 10−2
(± 7.1 × 10−4)
1.1 × 10−2
(± 1.4 × 10−4)
3.6 × 10−3
(± 1.5 × 10−3)
2.5 × 10−2
(± 3.0 × 10−4)
1.6 × 10−2
(± 1.9 × 10−3)
2.1 × 10−2
(± 2.1 × 10−3)
9.4 × 10−3
(± 1.8 × 10−3)
1.8 × 10−2
(± 2.0 × 10−3)
Daily
risks
2.7 × 10−2
(± 1.0 × 10−3)
1.6 × 10−2
(± 2.2 × 10−4)
5.4 × 10−3
(± 1.9 × 10−3)
3.6 × 10−2
(± 4.7 × 10−4)
2.4 × 10−2
(± 2.6 × 10−3)
3.1 × 10−2
(± 2.7 × 10−3)
1.4 × 10−2
(± 2.4 × 10−3)
2.7 × 10−2
(± 2.6 × 10−3)
Yearly
risks
1
(± 5.2 × 10−3)
9.9 × 10−1
(± 7.3 × 10−3)
8.6 × 10−1
(± 6.1 × 10−3)
1
(± 4.8 × 10−4)
9.9 × 10−1
(± 3.1 × 10−3)
1
(± 3.8 × 10−3)
9.9 × 10−1
(± 5.4 × 10−3)
9.9 × 10−1
(± 1.8 × 10−3)
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0.03
Median risks of infecon
0.025
0.02
0.015
0.01
0.005
0
Cistern handle
Baselines risks
Toilet seat
Wiping of surfaces once
Floor surface in front
of toilet
Internal pull latch
Wiping of surfaces twice
External door handle Tap handle in shower
cubicle
Hand washing without soap
Internal common
floor surface
Hand washing with soap
Tap handle in wash
basin
Combined risk reducon
Fig. 4 Calculated median risks of infection incorporating different risk-reduction interventions
to act as possible avenues or routes of pathogen transmission. The observation that the cistern handle, floor,
latch of toilet, door handle, and tap handle were the most
contaminated surfaces corroborates with other studies
(Abiose, 2019; De Alwis et al., 2012; Fankem et al., 2006;
Flores et al., 2011; McGinnis et al., 2019; Sabra, 2013;
Verani et al., 2014). For instance, the study by Fankem et al.
(2006) observed that the most contaminated surfaces in
public toilet facilities found in airports, bus terminals, and
universities were toilet seats, sinks, floors, and napkin dispensers. However, that study represented different physical environments, where the prevalence of contamination
can be expected to be much lower (3–21%) compared to
the findings in this study where all surfaces were contaminated. Furthermore, the toilet facilities in their study were
in areas that perhaps had lesser user numbers or frequency
of use compared to the CABs located in the informal settlements. In our study area, the CABs serve as the only
source of sanitation for the inhabitants in these settlements.
Sabra (2013) reported higher occurrence of contamination
of contact surfaces within female public toilets, like the
findings in our study (100%). They also demonstrated that
over 91% of toilet handles were contaminated.
Several reasons could account for the contamination. These include direct deposition of faeces on
these surfaces, unclean hands and soil. For instance,
surfaces such as the cistern handle, the tap handle,
and latch of the toilet door could have been contaminated through unclean hands. A study by De
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Alwis et al. (2012) observed that ntamination of door
handles in male toilets were highly contaminated
compared to female toilets. This was followed by a
survey of the users, who reported that over 50% of
the males using these toilets did not wash their hands.
Therefore, unclean hands could have accounted for the
high contamination rate of regularly touched surfaces.
The contamination of the toilet seats and floors next
to the toilets could be due to the direct deposition or
aerosolization of faecal matter. Flushing of toilets has
been reported to play a role in toilet seat contamination due to the generation of droplets or aerosols that
may contain some faecal matter (Flores et al., 2011).
Studies have shown that droplets or aerosols generated after multiple flushing could still contain bacteria, although in reduced concentrations. For instance,
Johnson et al. (2017) reported a 3 log10 reduction in
bacterial indicators in the bowl water after one flush,
1–2 log10 after two flushes, and thereafter, less than
1 log10 reduction. These reports therefore support our
hypothesis that the contamination of the toilet seats is
primarily due to the presence of E. coli in faecal matter that is deposited either directly on these toilet seats
or due to droplets or aerosols generated during flushing. One of the other most contaminated surfaces was
the floor, which could be attributed to soil from footwear (Flores et al., 2011). The presence of these bacteria in the soil could be from faecal contamination or
normal microflora. During the study we observed that
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children were playing on the floor within these toilet
cubicles, thus highlighting a significant health risk. In
addition to soil being the main source of floor contamination, it could also account for contamination
of the cistern handles, in addition to unclean hands
(Flores et al., 2011). This conclusion was based on
the observation that some people used their feet for
flushing of the toilets and the presence of a similar bacterial community on the toilet floors and the
cistern handles. It has also been reported that some
persons within the study area wipe faeces with their
hands and smear these faeces on walls, either due
to habit or religious reasons. This was corroborated
by our findings, where faecal contamination on the
CAB walls was commonly observed as shown in
results above. This practice could have contributed to
the contamination of the other contact surfaces. The
detection of E. coli on the various contact surfaces
highlights the potential risks of infection. These surfaces could, therefore, be harbouring large concentration of other potentially pathogenic microbes, as
inferred from the concentration of E. coli on these
surfaces.
Risks of infection associated with use of community
ablution blocks (CABs)
The calculated risk due to contact with these surfaces is
high. For instance, almost 3 people out of 100 exposed
to the internal pull latch of the toilet door could be
infected. This risk is for one-time use, with increasing risks when one considers the multiple uses during
a day and the reliance on these facilities throughout
the year. Although the risks were lower for the other
surfaces, these were not statistically significant except
when compared to the internal common floor. The
risk of infection based on the bacterial concentration
on the toilet floor in the common area was 9.7 × 10−3
(± 1.8 × 10−3) per person. This is much lower than the
risks associated with the other seven surfaces, mainly
due to the likelihood of such exposure occurring. As
presented in Fig. 2, hand contact was assumed as the
main route of exposure; therefore, the possibility that
users of the CABs will touch the toilet floor is lesser
compared to touching the other surfaces. Therefore, the
potential risk calculated is less than the other contact
surfaces. None the less when one considers the fact that
on the average uses of the CABs will result in touching more than one surface then the risks presented in
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166
Table 1 could be higher. For instance, on average all
users of the CABs will be exposed to the external door
handle of the toilet cubicle, the toilet seat, and cistern
handle. If they wash their hands, the tap handle is
included. Therefore, the combined risks from exposure to these multiple surfaces will be higher. The risk
estimates calculated in this study are higher than the
estimates reported by Ryan et al. (2014) for touch with
surfaces contaminated with E. coli 0147:H7. In that
study a single touch risks of 1.5 × 10−4 was reported.
The risk estimates in this study are considerably higher
than the tolerable risk figure of 1 in 1 million (10−6)
recommended by Ryan et al. (2014) for touch with
contaminated surfaces. This calls for the implementation of risk-reduction measures.
The risks of infection when simple mitigation measures such as thorough cleaning of the surfaces and washing of hands with and without soap are implemented were
calculated to be lower. A simple wipe of surfaces with
soap could lead to about 1 log10 bacterial reduction on
surfaces (Tuladhar et al., 2012). A second wipe achieved
a further 1–3 log10 reduction. Therefore, regular wiping
on these surfaces by either the users or caretakers could
potentially reduce the contaminations further. This will
subsequently lead to lower risks of infections. A further
reduction in the risks is achievable if the users of these
facilities washed their hands either with or without soap.
Incorporating these possible risk-reduction strategies
resulted in a reduced risk as presented in Fig. 4. The most
important or significant risk-reduction measure among
those considered in this study is wiping the contact surfaces especially twice. For instance, the risk of infection
due to contact with the internal pull latch of the toilet door
after wiping once was reduced to about two out of a 100
people infected (2.2 × 10−2 (± 3.1 × 10−4)) per person per
one-time exposure (Fig. 4; Table S3). Although hand
washing was observed to possibly lead to risk reduction,
the estimates achieved in this study indicate that this is not
the most significant intervention. The reduction in pathogen concentration when hands are washed with soap was
assumed to be only 1.7 (± 0.8) log10 (Jensen et al., 2015).
This therefore could be the main reason for the little effect
of hand washing on its own. It must also be noted that
none of the risk-reduction options modelled in this study
could reduce the risks to the tolerable/acceptable risks
estimate of ( 10−6) recommended by Ryan et al. (2014).
The detection of E. coli, an indicator for faecal pollution, and the associated risks estimated shows the
potential for other pathogens on these surfaces. E.
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coli is widely used and accepted as a faecal indicator
organism (McLellan & Eren, 2014; Wen et al., 2020).
However, the utility of E. coli as an indicator for determination of risk of infection with other pathogens has
been questioned due to reported differences in survival
and infectivity. For instance, most STHs require some
period of latency before becoming infectious. Ascaris
spp. ova/eggs, as an example, require a latency period
of 2–4 weeks at temperatures between 15 and 38 °C
before becoming infectious (Bogitsh et al., 2012).
Therefore, although the detection of E. coli on the contact surfaces gives an indication of the potential risks
of infection for other faecal pathogens, it must be noted
that it may either over- or underestimate the risks.
Conclusions
This study shows that contamination of key contact
surfaces within shared sanitation facilities is a common occurrence. Contamination could be due to several factors pertaining to hygiene practices and general
habits of the users of these facilities including direct
deposition, aerosol generation from toilet flushing,
unclean hands, and soil from footwear. Contamination
of key contact surfaces poses potentially higher risks
of infection, with almost everyone at risk of infection
over the course of a year due to reliance on these facilities. The incorporation of risk-reduction strategies,
such as wiping of surfaces and washing of hands, has
the potential to reduce infection risks; however, the
use of these CABs still poses significant health risks.
Furthermore, this study has shown that QMRA can be
adapted to present a powerful tool for measuring the
potential risks associated with the use of shared sanitation facilities.
Therefore, to reduce the risks associated with the use
of CABs within the study area, the following recommendations are made:
1. Effective cleaning of key contact surfaces: Cleaning
of key contact surfaces could potentially reduce the
concentration of potential pathogens and associated
risks of infection.
2. Re-training of caretakers: To achieve effective …
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