The influence of occasional and frequent work from home on musculoskeletal complaints

Abstract

BACKGROUND:

The coronavirus 2019 (COVID-19) pandemic acts as a recent driver for telework on a global scale. While visual display unit (VDU) workplaces are usually subject to regulatory requirements or occupational health and safety controls, mobile workplaces may increase the risk of developing work-related musculoskeletal complaints (MSCs).

OBJECTIVE:

This study aimed to explore the influence of work from home (WFH) on musculoskeletal complaints in the context of German municipal administrations.

METHODS:

This paper is based on an online survey conducted as part of the Health and Digital Change project in cooperation with three municipal administrations in North Rhine-Westphalia, Germany. A multivariate model was constructed to calculate the odds ratio for MSCs including various control variables.

RESULTS:

While bivariate analysis showed a 0.96-fold risk for employees who work from home, the multivariate model with a split between occasional (OR = 0.79) and frequent (OR = 1.59) WFH revealed a more complex effect. Both odds did not reach the significance level. However, the influence of being female (OR = 3.34) and being overweight (OR = 1.51) was confirmed. Regarding age the OR increases by 1.02 per year of life. Other control variables were the municipal affiliation, university entrance qualification, working hours and feeling overstrained. The regression model improved by 0.07 (McFadden R²) compared to the null model.

CONCLUSION:

Although WFH is discussed as a rising risk factor for MSCs, the findings in this study indicate, that occasional WFH acts as a rather protective factor against work-related MSCs.

Keywords

Occupational medicine COVID-19 teleworking musculoskeletal pain

1 Introduction

As the coronavirus 2019 (COVID-19) pandemic spread in early 2020, the German Federal Government addressed all employers to shift as many office-workers as possible into work-at-home. Since January 2021, the proportion of employees in Germany who predominantly work from home (WFH) has increased roughly six-fold (4% pre-pandemic to 24% as of January 2021) [1]. COVID-19 is thus proving to be a strong driver of the digitization of workplaces on the way to Work 4.0 [2]. Alipour et al. [3] calculate that the maximum capacity for telework in Germany is about 55%. As a result, healthy work design at home is becoming increasingly important for the field of public health.

Meanwhile musculoskeletal complaints (MSCs) and musculoskeletal disorders (MSDs) are the most common cause of chronic pain and functional impairment in the general population of Germany [4, 5]. It is estimated that EUR 17.2 billion production loss and EUR 30.4 billion loss of gross value added arise from MSDs. They generate higher costs than any other diagnosis group in Germany [6]. For an EU wide comparison there is currently insufficient data regarding the costs of MSCs, but based on disability-adjusted life years (DALYs), the share is estimated at 15% of total costs [7].

1.1 Musculoskeletal complaints and disorders

Work-related MSDs relate to “impairments of bodily structures such as muscles, joints, tendons, ligaments, nerves, bones and the localized blood circulation system, that are caused or aggravated primarily by work and by the effects of the immediate environment in which work is carried out” [8]. They may result from repeated exposure to loads or tension or occur after accidents like fractures and acute traumas. More recently psychological and social factors have been investigated as a cause for certain MSCs and MSDs, like lower back pain. However, studies are inconclusive and they only focused on a restricted number of factors [9]. Nevertheless, the majority of studies underline a correlation between MSCs and psychological and social factors, like high job demands [9 –11]. This relationship applies for psychological and social conditions in the working context as well as in private life [12 –15]. Recurring work-related influence factors are high job demands (i.e. workload, conflicting demands, and fast work pace) and low social support [16]. Especially demands like mental workload affect the prevalence of MSCs and MSDs [17, 18]. In the present paper we focused on back pain and joint diseases of the upper extremity since they are often related to ergonomic conditions in the workplace [10, 19]. Besides improper design of the visual display unit (VDU), working time emerges as an important influencing factor for MSCs [20, 21].

In relation to the individual, overweight and a lack of exercise and physical activity are already frequently named as important risk factors [22, 23]. Other commonly analyzed individual risk factors include age, gender, and level of education. The findings of the 2017 Global Burden of Disease Study underline this. With increasing age, the probability of suffering from MSCs also increases [24]. In terms of gender, in a survey by the Robert Koch Institute, women reported back pain significantly more frequently with a prevalence of 66.0% than men with 56.4% [25]. The prevalence is consistent with a variety of studies on pain perception in men and women [26]. Several studies indicate a relationship between educational status and MSCs [27, 28]. Explanations for this are vague and are related, for example, to the associated work tasks [27]. In addition, the influence of more nonspecific individual factors has been little studied. Influences such as sports, diet, (psychological) stress in private life, and pre-existing genetic conditions are rarely included in effect models.

1.2 Working from home, mobile work and telework

Broadly speaking telework refers to all kinds of employees working detached from their employers premises. German employers and the occupational health and safety law differentiate between mobile work and teleworking from home. The COVID-19 pandemic forced many workers into mobile work, which leaves them to organize their workplace by themselves. Regarding the occupational health and safety law, unlike telework arrangements, the working conditions of mobile work are not controlled by occupational safety specialists or occupational physicians. Therefore, employees are largely responsible for designing their own workplace in such a way that it meets their health-related needs [29]. However, WFH opens up to a variety of individual adjustment possibilities including little breaks and an improved balance for family and professional life [30]. Contrary to the risks described, these factors may also benefit the health of employees.

1.3 Municipal administration in Germany

Considering the eGovernment-Act, employees will spend increasingly more working time on screens. At the same time, sickness rates in public administrations are already high compared to other industries. Neither the number of occupational accidents nor physical and mental stress factors generally surveyed explain these cross-sector differences [31]. Another characteristic is the shortage of staff in municipal administrations, which will continue to increase in the coming years. Lower pay compared to the private sector has an additional impact. In terms of health, this results in an increased workload [32], which is accompanied by excessive demands and higher stress levels.

On the other hand, the health implications of digitization for administrative employees are not yet clear [33]. The importance of health-promoting working conditions is well known and municipal administrations have been implementing various measures for many years that go beyond the scope of the statutory regulations [34]. It seems plausible that successful occupational health management improves working conditions in parallel with digitization.

Concrete analyses of the influence of WFH and workplace design on MSCs gain considerable importance in the context of the WFH trend accelerated by COVID-19.

Initial studies are already looking at the effects of COVID-19 conditional WFH on MSCs. Radulović et al. [35] point to a need for support in structuring working hours and using non-ergonomic equipment as ergonomically as possible.

The present study, as part of a multicenter study to identify health-related stress factors in the process of digitization, addresses this topic using the example of municipal administrations.

2 Methods

In November and December 2020 employees in municipal administration of three digital model regions in North Rhine-Westphalia, Germany, were asked to participate in an online survey on the ongoing digital transformation and health-related aspects. The survey was conducted as part of the project Health and Digital Change (German: Gesundheit und Digitaler Wandel). The model regions were selected in such a way that the entire federal state is adequately represented structurally, for example regarding the relationship between urban and rural regions. Informed consent was obtained from all individual participants included in the study. The questionnaire and methodology for this study was approved by the Human Research Ethics Committee of the University of Witten/Herdecke (Ethics approval number: 158/2020).

The departments participating in the survey and related project were selected by the model regions. They were selected to represent the departments most affected by e-government digitization processes. A sample population of a total of 1,319 employees was invited to participate in the survey. The invitation including the anonymous access link was sent out via e-mail followed up by a 2-week reminder invitation. A total of n = 710 employees participated in the survey (response rate = 53.83). Responses from n = 43 workers were excluded because they work exclusively in the field, i.e., without a workplace in their home environment. A further n = 17 participants do not perform any sedentary activities in their daily work and were therefore excluded. In addition one marginal employed participant and two non-binary employees were excluded for insufficient representation in the analyses. Of the remaining n = 647 employees, 52.86% have answered all relevant questions (completes).

Depending on the exposure variable, whether the participants WFH (since the start of the SARS-CoV-2 pandemic), the relative risk as well as the odds ratio for MSCs was calculated. The survey included typical health problems related to office work. Because medical diagnoses are especially sensitive data, questions were targeted on subjectively perceived complaints. MSCs were present if workers reported pain in the back or the joints of the upper extremity to occur at least “frequently”.

Addressing a possible confounding bias the following control variables were included: Age in years, gender, having at least university entrance qualification, the respective model region, working part-time or full-time, existing overweight (Body Mass Index (BMI)≥25), and regularly feeling overstrained (because of high job demands). For a second comparison and the multivariate model WFH usage was included separately for occasional WFH and working at least frequently from home as two dummy variables. For a second comparison and the multivariate model, a distinction was made between occasional (≤20% WFH) and frequent (>20% and ≤80% WFH) WFH.

Due to possible additional stressors and the statistically insufficient number of cases in the diverse gender category, these two cases were excluded. One minor employed person was excluded for the same reasons. The influence of the control variables was tested within the framework of a logistic regression. The severity of multicollinearity was assessed by the variance inflation factor (VIF). The model quality was tested using McFadden R². Because nonresponse was found to range from 0 to 36%, missing values were filled for the multivariate model by multiple imputation [36].

The following characteristics were chosen as reference categories: male, model region 1, having a university entrance qualification, always on-site, working part-time, not overweight, not feeling overwhelmed. All statistical analyses were carried out with the R-Studio version 1.4.1103. The syntax code as well as the data set are available from the authors on reasonable request.

3 Results

Table 1 presents the descriptive data including the groups of employees who work at least occasionally from home and employees working exclusively on site.

The ongoing COVID-19 pandemic led to a 3.58-fold increase in WFH usage. 69.34% of the employees are partially working at home.

Table 1
Sample description

Total Occasional Exclusively

WFH on site

N 647 432 191

Age in years (mean, SD) 44.61 (±12.78) 44.51 (±12.00) 43.66 (±14.11)

Gender: male 40% 41% 39%

University entrance qualification 84% 88% 75%

Model region 1 32% 37% 23%

Model region 2 29% 27% 34%

Model region 3 39% 37% 43%

Full-time job 74% 73% 78%

Overweight (BMI≥25) 58% 59% 56%

Satisfied with the ergonomic workplace design 51% 55% 51%

Feeling overstrained 16% 16% 16%

Frequent suffering from MSCs 69% 68% 74%

	Total	Occasional	Exclusively
N	647	432	191
Age in years (mean, SD)	44.61 (±12.78)	44.51 (±12.00)	43.66 (±14.11)
Gender: male	40%	41%	39%
University entrance qualification	84%	88%	75%
Model region 1	32%	37%	23%
Model region 2	29%	27%	34%
Model region 3	39%	37%	43%
Full-time job	74%	73%	78%
Overweight (BMI≥25)	58%	59%	56%
Satisfied with the ergonomic workplace design	51%	55%	51%
Feeling overstrained	16%	16%	16%
Frequent suffering from MSCs	69%	68%	74%

The arithmetic mean of the BMI is 25.73±4.65. For females, it is 24.70±4.74, and for males, it is 27.02±4.35. 58.19% of the respondents are overweight (BMI≥25). This is true for 43.69% of females and 75.72% of males. In total 66.48% report suffering from back pain at least frequently and 37.66% report the same regarding joint pain in the upper extremity. Derived from this, 69.42% of participants frequently suffer from MSCs (78.84% for females and 55.90% for men). Contrary to expectations, fewer employers using WFH than employees working on site suffer from MSCs (68% vs. 74%) and the RR shows a slightly protective effect (OR = 0.94). Furthermore, the self-reported satisfaction with the ergonomic workplace design is evenly distributed among employees on-site and for those in the HO (51% vs. 55%). This result is particularly pleasing for the cooperating municipalities, as their employees also implement ergonomic aspects subjectively well at home.

In the bivariate analysis, a 0.96-fold risk of frequent suffering from MSCs results for employees WFH compared to employees who work exclusively on-site. The chance of suffering from MSCs is OR = 0.88 for employees who occasionally WFH, although the influence is not significant. According to the McFadden Pseudo R², the model is no better than the null model (R² = 0.00).

A second analysis distinguishing between occasional and frequent/always WFH usage reveals a significant difference in ORs. Compared to on-site the chance of suffering from MSCs is OR = 0.79 for occasional WFH (p = 0.215) and 1.58 (p = 0.155) for frequently/always WFH. Neither variable is significant. McFadden Pseudo R² indicates that the model is better than the null model by 0.1. The logistic regression with covariates and a split between occasionally WFH and frequently/always WFH indicates an effect reversal from occasionally WFH to frequently WFH. Compared to exclusively on-site, the multivariate chance of at least frequent suffering from MSCs is 0.79 for employees occasionally WFH and 1.59 for employees frequently/always WFH. However, both ratios are not evident at a significant level (α= 0.05) and therefore should be interpreted as a trend rather than a setestimate.

The difference to the first naïve comparison can most likely be attributed to different effects of occasionally and frequently/permanently WFH. Furthermore, women in this study are less likely to WFH (56% vs. 62%), while, as expected, they suffer significantly more often from MSCs.

Within the framework of this multivariate model, all VIFs are < 2. Therefore we assume that the included variables represent different influencing factors. The log likelihood (Mc Fadden R²) of the regression model improves by 0.07 compared to the null model. An overview of the listed OR coefficients is displayed in Table 2.

Table 2

OR coefficients

Variable	OR	95% CI	p-value
Intercept	0.36	0.12 –0.96	0.058
Age	1.02	1.00 –1.03	0.011
Gender: female	3.34	2.21 –5.08	<0.001
No university entrance qualification	1.21	0.78 –2.11	0.463
Model region 2	1.45	0.93 –2.40	0.118
Model region 3	0.95	0.65 –1.50	0.780
Occasional WFH	0.79	0.76 –1.96	0.256
Frequently/always WFH	1.59	0.35 –10.91	0.172
Full-time work	0.96	0.57 –1.51	0.858
Overweight (BMI≥25)	1.51	1.06 –2.27	0.034
Feeling overstrained	1.20	0.74 –2.05	0.472

Notes. Significant values are marked bold.

4 Discussion

This study aimed to measure the impact of WFH on MSCs in typical German municipal administrations. The present results are reported despite the partial failure to reach significance level to counteract publication bias.

Our analysis revealed a difference between occasional WFH and frequent WFH for the impact on MSCs. The results indicate influencing factors that were not taken into account. McFadden R² (0.07) underlines this assumption, as 0.2 to 0.4 should be reached to assess a model as good [37]. Reasons for this could be changing ergonomic working postures, changing conditions for job-related psychological factors or differing social conditions.

Referring to the low effect size (McFadden R²), individual factors such as leisure time activities (e.g. sports), underlying medical conditions, and genetic predisposition remain as unexplored risk factors. Studies that include such individual factors are sparse. A few studies indicate the unclear influence of the variables [38].

Overweight could be confirmed as a risk factor for MSCs. Age could also be confirmed with a cumulative effect of 1.02 per year of life. However, 30 percent of respondents did not provide age information. Thus, age is one of the variables most affected by the imputation and should be interpreted with caution.

Full-time work seems to have little to no influence compared to part-time work. One explanation to be investigated for this may be an ergonomically and activity-related similarity in leisure time. It is also possible that the influence is reduced by comparatively more overtime hours among part-time employees, as indicated by additional comments in the original survey. Feeling overstrained indicates a higher chance for MSCs, as expected. Similarly, educational attainment below university entrance qualification increases the odds, too. All three values are not significant, which may be due to the skewed distribution or low prevalence.

In addition to ergonomic working conditions, social and psychological influencing factors (job demands) should not be underestimated [13 –16]. Apart from individual factors from private life, the authors of this paper suspect that a large proportion of the variance is to be found here. A general feeling of being overstrained might not reflect the broad variety of private and work-related psychological and social influence factors. Nevertheless, the direction of the relationship between psychological or social factors and MSCs cannot be clearly determined.

Overall, no difference between the univariate and multivariate models is evident for the impact of WFH on MSCs. The control variables are similarly distributed in the groups, which is probably due to the lack of self-selection or the arrangement of WFH. Since the existing pandemic protection measures in Germany still applies during the writing of this publication, an increase in psychologically and socially induced complaints is already being discussed [39]. Viewed over time, employees who WFH could be even more affected by social distancing and, as a result, be more frequently affected by MSCs. Although post-pandemic many workers will switch back to their on-site workplaces, the use of WFH keeps its relevance. Steadily rapid changes in work design will occur due to faster work processes. If necessary, this will lead to the widespread use of telework and hybrid work design solutions [40]. Considering the findings in this paper, hybrid solutions in particular should be sought in this process. The joint planning of employer and employee most likely represents an occupational health resource that should not be underestimated in the municipal administration.

5 Conclusion

Although WFH is discussed as a rising risk factor for MSCs, the findings in this study suggest a more complex relationship. While occasional WFH is a protective factor against MSCs, frequent/permanent WFH increases the likelihood of MSCs. The indeterminate variance of the multivariate model may be related to social and psychological aspects that are not work-related and should be taken into account in future research.

Ethical approval

The questionnaire and methodology for this study were approved by the Human Research Ethics Committee of the University of Witten/Herdecke (Ethics approval number: 158/2020).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors thank all individuals from the municipal administration offices that took part in this study.

Funding

The project “Health and digital change” was developed in cooperation with three model regions in North Rhine-Westphalia due to the funding of digital model regions. The aforementioned research project is financed by funding from the NRW Ministry of Economic Affairs, Innovation, Digitalization and Energy (MWIDE).

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