J Occup Rehabil (2010) 20:220234
DOI 10.1007/s10926-009-9210-3
A Systematic Review of Workplace Ergonomic Interventions
with Economic Analyses
Emile Tompa Roman Dolinschi
Claire de Oliveira Benjamin C. Amick III
Emma Irvin
Published online: 5 November 2009
Springer Science+Business Media, LLC 2009
Abstract Introduction This article reports on a systematic
review of workplace ergonomic interventions with eco-
nomic evaluations. The review sought to answer the ques-
tion: what is the credible evidence that incremental
investment in ergonomic interventions is worth undertak-
ing? Past efforts to synthesize evidence from this literature
have focused on effectiveness, whereas this study synthe-
sizes evidence on the cost-effectiveness/financial merits of
such interventions. Methods Through a structured journal
database search, 35 intervention studies were identified in
nine industrial sectors. A qualitative synthesis approach,
known as best evidence synthesis, was used rather than a
quantitative approach because of the diversity of study
designs and statistical analyses found across studies. Evi-
dence on the financial merits of interventions was synthe-
sized by industrial sector. Results In the manufacturing and
warehousing sector strong evidence was found in support of
the financial merits of ergonomic interventions from a firm
perspective. In the administrative support and health care
sectors moderate evidence was found, in the transportation
E. Tompa (&)
R. Dolinschi
C. de Oliveira

B. C. Amick III
E. Irvin
Institute for Work & Health, 481 University Avenue, Suite 800,
Toronto, ON M5G 2E9, Canada
e-mail: etompa@iwh.on.ca
E. Tompa
Department of Economics, McMaster University,
Hamilton, ON, Canada
E. Tompa
Dalla Lana School of Public Health, University of Toronto,
Toronto, ON, Canada
B. C. Amick III
School of Public Health, University of Texas
Health Science Center, Houston, TX, USA
123
sector limited evidence, and in remaining sectors insuffi-
cient evidence. Conclusions Most intervention studies
focus on effectiveness. Few consider their financial merits.
Amongst the few that do, several had exemplary economic
analyses, although more than half of the studies had low
quality economic analyses. This may be due to the low
priority given to economic analysis in this literature. Often
only a small part of the overall evaluation of many studies
focused on evaluating their cost-effectiveness.
Keywords Economic evaluation
Ergonomics

Systematic review
Introduction
Workplace ergonomic programs are implemented to help
ensure that work systems (equipment, tools, work stations,
work and workplace organization and policies/procedures)
enhance employee health and safety and optimize business
performance (i.e. efficiency, productivity, quality and
profitability). In the last few years, there has been increasing
recognition of the importance of ergonomics in workplace
settings. The scientific evidence on the effectiveness of
ergonomic programs, policies and practices for reducing
injuries is less robust than one might expect despite the
increased use of ergonomic standards and guidelines [1].
Several systematic reviews have investigated the effec-
tiveness of ergonomic interventions. Among them, Rivilis
et al. undertook a systematic review of the effectiveness
of participatory ergonomic interventions [2]. The review
found partial to moderate evidence that participatory ergo-
nomic interventions can reduce musculoskeletal (MSK)
symptoms, workers compensation claims and sickness
absence. Brewer et al. conducted a systematic review of
J Occup Rehabil (2010) 20:220234
workplace interventions directed at preventing/reducing
MSK and visual symptoms and disorders among computer
users [3]. They found mixed evidence that office interven-
tions among computer users have an effect on MSK or visual
health. The study also found moderate evidence for no effect
of workstation adjustment, no effect of rest breaks and
exercise and positive effect of alternative pointing devices.
Amick et al. [1], in an article on evidence-based best ergo-
nomic practices, suggest that best practices are not about
specific ergonomic tools/procedures, but are more about
integrated approaches to control exposure. There is no strong
evidence for any one specific intervention being effective.
However, there is effectiveness evidence for multi-compo-
nent programs and combinations of interventions [1]. The
study draws these conclusions from a synthesis of several
systematic reviews on the topic of ergonomics. The intent is
to provide actionable messages for safety professionals,
since they are unlikely to sift through the mass of scientific
publications, or review the findings from several systematic
reviews where each review synthesizes the evidence on one
aspect of ergonomics to identify best-practice guidelines.
Given the growing awareness of workplace ergonomics
importance amongst safety professionals and researchers, it
is surprising that the literature regarding the financial
merits of ergonomic programs is underdeveloped. Most
published ergonomic intervention studies focus on an
interventions effectiveness, not its cost-effectiveness/
financial merits. This may be due to limited expertise in
economic evaluation methodologies by occupational health
and safety (OHS) researchers, or due to the low priority
given to economic analyses by evaluators. The lack of cost-
effectiveness evaluations is also likely related to practical
workplace limitations that can make it difficult to obtain
good quality financial data. Undoubtedly, complete infor-
mation on the financial implications of ergonomic inter-
ventions is as critical for decision making as is knowledge
about their effectiveness. This systematic review attempts
to provide new information to decision makers by syn-
thesizing the evidence across a number of studies on the
financial merits of ergonomic interventions. Specifically, it
seeks to answer the question: What is the credible evi-
dence that incremental investment in ergonomic interven-
tions is worth undertaking? This is one of the first
systematic reviews of ergonomic interventions to investi-
gate the financial merits of such interventions.
Methods
Overview
In this study we synthesize the evidence on the financial
merits of ergonomic interventions that include an economic
221
evaluation using a qualitative evidence synthesis approach
known as best-evidence synthesis [4, 5]. This is a well
established methodology that has been used extensively to
synthesize evidence of quantitative phenomena in cases
where Meta analysis is not possible due to the diversity of
study designs and statistical analyses in the literature being
reviewed.
The essence of the approach involves considering three
aspects of the evidence base(1) the quality of studies, (2)
the number of studies, and (3) the consistency of findings
across studiesto make statements about the level of evi-
dence about a phenomenon.The systematic review process
consists of six steps: (1) developing a question, (2) con-
ducting a structured and comprehensive literature search, (3)
identifying relevant studies, (4) assessing the quality of
studies, (5) extracting data from studies, and (6) synthesizing
the evidence. The question guiding this review was identified
above. Below we describe steps two through six in detail.
Literature Search and Study Identification
This review is a sub-set of a systematic review that
included all types of OHS interventions [6]. Thus, the lit-
erature search described draws on the methods from that
study. Relevant English-language studies were identified
through four sources: (1) structured database searches; (2)
other systematic reviews completed or underway [2, 7]; (3)
a summary table of studies on office ergonomics (Goggins
RW, 2006, personal communication); and (4) a request for
studies identified by content experts. We also searched the
bibliographies of included studies for incremental studies.
For articles with multiple case studies, each study was
considered separately.
Five journal databases were considered: MEDLINE,
EMBASE, BIOSIS, Ergonomic Abstracts and Business
Source Premier. Several other databases were tested, but
did not produce relevant studies. A keyword search was
developed for use with MEDLINE based on four criteria:
(1) the type of study (e.g. intervention); (2) the setting (e.g.
workplace); (3) the outcome measure (e.g. work injury)
and (4) the type of economic analysis or outcome measure
(e.g. cost-benefit analysis). At least one keyword from each
of the four categories needed to be included in the title,
abstract or classification terminology of a citation. This
framework was subsequently customized for the remaining
databases.
Several additional inclusion/exclusion criteria were
developed and considered while reviewing titles, abstracts
and full articles in an effort to narrow the focus. First, studies
had to be published from 1990 onward. This decision was
based on the findings of an environmental scan [8], where
few workplace studies with economic evaluations published
prior to 1990 were identified. Second, only studies published
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in a peer-reviewed journal were considered. Third, studies
were excluded based on several criteria concerning context
and subject matter: (1) if the intervention was undertaken in
a developing country (based on the notion that the OHS
context in developing countries is very different than that in
developed countries); (2) if the industry/context was army-
related or on a military base; and (3) if the intervention was
focused exclusively on non-health consequences such as
cost reduction and/or productivity/quality improvement
(these were included only if there was a primary or sec-
ondary prevention outcome). For example, an engineering
study that focused on redesigning equipment and work flows
to increase productivity, without considering or measuring
health consequences would not be included. In contrast, a
study that focused on reducing insurance costs, would be
included if it gave consideration to the health outcomes
underlying insurance claims and costs.
Quality Assessment
All studies that met the subject matter and other inclusion
criteria were retained for quality assessment and data
extraction. The quality assessment tool we developed was
based on a recently published environmental scan of OHS
intervention studies with economic analyses that reviewed
methodological issues and identified guidelines for good
practice [8]. The guidelines consist of 10 issues to consider
in an economic evaluation, clustered under three broad
categories: (1) study design and related factors, (2) mea-
surement and analytic factors, and (3) computational and
reporting factors. These guidelines have been expanded
upon and discussed at length in an economic evaluation
methods text for researchers [9]. We refer readers to these
sources for details.
The questions in the quality assessment tool were divi-
ded into four sections: (1) overarching issues that frame the
purpose of the study and the nature of the intervention; (2)
study design and issues related to evaluating the interven-
tions effectiveness; (3) measurement and analytic issues
related to the economic analysis; and (4) issues related to
the discussion and interpretation of results. The tools
primary focus was to assess the quality of evidence related
to the economic analysis, though consideration was given
to the effectiveness analysis.
The quality assessment tool included 14 questions
(Table 1). Each item was ranked on a five-point Likert
scale, where one corresponded to the lowest score and five
to the highest. Use of a Likert scale to assess the quality of
a study on a particular dimension is a common technique in
best-evidence synthesis. In some cases where a question
was not applicable to a particular study the question was
labeled NA and was not counted in the quality assessment
scoring for that study.
Two reviewers with expertise in the economic evalua-
tion of OHS interventions assessed the quality of each
study. The reviewers met on a regular basis to discuss their
assessment of each study. The intent of these meetings was
not to reach consensus, but rather to ensure that the quality
assessment of each study was based on a sound consider-
ation of all relevant aspects of the study.
The average score across the 14 items in the tool con-
stituted the overall study score given by a reviewer. The
average of the overall scores between the two reviewers
constituted the final study score. A study with a final score

Table 1 Quality assessment

Overarching questions that frame the purpose of the study and the nature of the intervention
tool
(1) Was the conceptual basis of, and/or the need for the intervention explained and sound?
(2) Was the intervention clearly described?
(3) Were the study population and context clearly described?
Study design and issues related to evaluation of the interventions effectiveness
(4) Rank the means by which selection and confounding are controlled for through study design?
(5) Were appropriate statistical analyses conducted?
(6) Are exposure, involvement, and intensity of involvement in the intervention appropriate?
(7) Are the outcomes included in the analysis appropriate?
Measurement and analytic issues related to the economic evaluation
(8) Were all relevant comparators explicitly considered?
(9) Was the study perspective explicitly stated and appropriate?
(10) Were all important costs and consequences considered in the analysis, given the perspective?
(11) Are the measures of costs and consequences appropriate?
(12) Was there appropriate adjustment for inflation and time preference?
(13) Was there appropriate use of assumptions and treatment of uncertainty?
Discussion and interpretation of results
(14) Did the presentation and discussion of study results include all issues of concern?

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J Occup Rehabil (2010) 20:220234 223

between 1 and 2.4 was considered to provide low quality
evidence related to the economic analysis. A final score
between 2.5 and 3.4 represented medium quality, and a
score between 3.5 and 5 indicated high quality. Only
studies receiving a score in the medium and high quality
range were retained for evidence synthesis.
Data Extraction
Evidence for a particular stratum of studies was first tested
against the criteria for the strong evidence, and if it was not
met, the criteria for moderate evidence were considered. If
these criteria were not met, the criteria for limited evidence
were considered. If the evidence did not meet any of the
criteria for the three levels, then it fit into one of the two
categories, mixed evidence or insufficient/no evidence. The
evidence ranking algorithm can be found in Table 2.

Data extraction focused on four areas of the study: (1)
contextual factors such as jurisdiction, industry and occu-
pational group targeted; (2) details of the intervention; (3)
characteristics of the epidemiologic design and related
statistical analyses; and (4) characteristics of the economic
evaluation. In total there were more than 40 items extracted
from each study [6]. Although all studies meeting subject
matter inclusion criteria underwent data extraction, only
medium and high quality studies were included in evidence
synthesis.
Evidence Synthesis
The primary stratification for evidence synthesis was by
industrial sector. Evidence was also synthesized across all
studies regardless of sector, and also for the subset of
studies that were about participatory ergonomic interven-
tions. Slavins best evidence synthesis approach was used
for this purpose [4, 5]. As noted, it is a qualitative approach
that assesses the level of evidence on a particular rela-
tionship based on the quality, quantity and consistency of
findings in the relevant studies.
The level of evidence was ranked on a five-category scale
consisting of strong evidence, moderate evidence, limited
evidence, mixed evidence and insufficient evidence.
Stakeholder Involvement
An advisory committee consisting of representatives from
the policy arena (from the workers compensation authority
and from the Ministry of Labour in Ontario, Canada), rep-
resentatives from the provincial health and safety associa-
tions in Ontario, a private sector business representative, and
a senior academic researcher in the ergonomics field was
formed to guide the design and execution of this systematic
review. The group met at three points during the systematic
review process. The committee was consulted at the initial
stages of developing the project, mid-way when study
identification stage had been completed and near the end of
the project when the final report was being developed. The
committee was consulted to get feedback on aspects of the
review such as subject matter framing, review scope, search
strategy, synthesis criteria and presentation of findings.
Results
Literature Searches
The MEDLINE search resulted in 6,381 hits, EMBASE in
6,696 hits, BIOSIS in 2,568 hits, Business Source Premier

Table 2 Criteria for levels of evidence

Level of evidence Minimum criteria

Strong Three high quality studies agree on the same findings

(If there are more than three studies, then at least 75 per cent of medium and high quality studies agree.)
Moderate Two high quality studies agree
or
Two medium quality studies and one high quality study agree
(If there are more than three studies, then at least 67 per cent of the medium and high quality studies agree.)
Limited There is one high quality study
or
Two medium quality studies that agree
or
One high quality study and one medium quality study that agree
(If there are more than two studies, then at least 50 per cent of the medium and high quality studies agree.)
Mixed None of the above criteria are met and findings from medium and high quality studies are contradictory
Insufficient There are no high quality studies, only one medium quality study and/or any number of low quality studies

123
224
in 687 hits, Ergonomic Abstracts in 25 hits and other
sources in 199 hits. Once these citations were merged and
duplicates were removed, the total number of citations was
12,903. After inclusion/exclusion criteria were applied, 67
articles with 72 case studies with economic analyses were
left, 35 of which focused on ergonomic interventions. Note
that the modest number of studies identified was due to the
fact that few effectiveness studies in the OHS literature
undertake an economic evaluation, not because there are
few good quality studies assessing the effectiveness of
ergonomic interventions. A summary of the number of
ergonomic studies identified by industry can be found in
Table 3.
Descriptive Statistics of Included Studies
The studies covered a broad range of industries (n = 9). In
a few cases, an intervention was assigned to an industrial
sector based on the occupation rather than industry. For
example, a study by Rempel et al. [10] was undertaken in
the health care sector, but the occupational group was
customer service workers at a computer based call center.
The study was included in the administrative and support
sector because other studies in this group also focused on
workers at computer terminals.
Although 35 ergonomic intervention studies with eco-
nomic evaluations were identified, only sixteen were
retained in the synthesis based on the criteria of receiving a
medium or high quality score in the quality assessment
phase (i.e. studies receiving a low quality score were
Table 3 Summary of the number of ergonomic studies identified
by industry
Administrative and support
8 interventions: 2 high quality, 1 medium quality, 5 low quality
Educational services
1 intervention: 1 low quality
Health care
10 interventions: 3 medium quality, 7 low quality
Information and culture
1 intervention: 1 medium quality
Manufacturing and warehousing
9 interventions: 3 high quality, 2 medium quality, 4 low quality
Public administration
1 intervention: 1 low quality
Multi-sector
1 intervention: 1 low quality
Retail and trade
1 intervention: 1 medium quality
Transportation
3 interventions: 1 high quality, 2 medium quality
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J Occup Rehabil (2010) 20:220234
excluded from the synthesis). In the discussion section we
provide a detailed description of the key methodological
shortcomings identified in the studies. The 16 remaining
studies were in six industry sectors: administrative and
support services, health care, information and culture,
manufacturing and warehousing, retail and trade and
transportation.
Most studies (10 of 16) were undertaken in the United
States. Two studies were in Canada, two in Australia and
one each in Sweden and the Netherlands. Four studies were
participatory ergonomic interventions and three were
ergonomic education programs on back health and safety.
Most studies were focused on primary prevention with one
study considering both primary and secondary prevention.
Disability management interventions with an ergonomic
education component are reported elsewhere [11] and were
therefore excluded from this evidence synthesis. The spe-
cific interventions ranged in scale and intensity. They
covered a wide range of features, some of which were
labor-intensive (e.g. participatory ergonomics teams) while
others were capital intensive (e.g. mechanical patient lifts
in hospitals, highly adjustable office chairs and workstation
modifications).
Fourteen of the sixteen studies undertook full economic
evaluations (i.e. considered both costs and consequences),
while two undertook a partial evaluation (i.e. considering
only consequences in monetary terms).
The predominant economic outcomes were workers
compensation expenses, including both the wage replace-
ment and health care components of these expenses and the
monetary value of absenteeism. In terms of perspective, all
adopted a firm perspective.
Table 4 provides details on each of the sixteen studies
retained in the systematic review. It includes an overall
description of the intervention and details on both the
effectiveness and economic analyses, as well as details on
the quality assessment of each study.
Evidence Synthesis
As noted, the first cut of the evidence synthesis was by
industrial sector. There were six sectors that had high and/
or medium quality studies: administrative and support,
health care, information and culture, manufacturing and
warehousing, retail and trade and transportation. Three
sectors (educational services, public administration and
multi-sector) had only one low quality study each. Of the
six sectors with high and/or medium quality studies, four
had a sufficient number of studies to make a definitive
statement about the evidence. Two sectorsadministrative
and support, and retail and tradehad only one medium
quality study each, which was insufficient to make any
substantive conclusions about the level of evidence.
 Table 4 Details of high and medium quality studies
Study DeRango et al. [12] Lahiri et al. [13] Rempel et al. [10] Collins et al. [15]

Sector Administrative and Support Administrative and Support Administrative and Support Health Care
Country United States United States United States United States
Intervention Highly adjustable chair and a one-time Lumbar pads and backrests were made Four workplace interventions compared: A musculoskeletal injury
details office ergonomics training workshop available to employees to reduce back Intervention A: ergonomics training prevention program consisting of
with a series of educational follow-ups discomfort. Back school workshops were also mechanical lifts and
Intervention B: trackball and ergonomic
conducted concurrently with the chair conducted repositioning aids, a zero lift
training
distribution policy, and worker training on
Intervention C: forearm and support board lift usage
J Occup Rehabil (2010) 20:220234

(armboard) and ergonomics training

Intervention D: forearm support board
(armboard), trackball, and ergonomics
training
Type of study Before-after with control Before-after uncontrolled Randomized controlled trial Longitudinal (interrupted time
series) uncontrolled
Measurement 12 months 144 months 12 months NA
time period
Type of Cost-benefit analysis Cost-benefit analysis Cost-benefit analysis Cost-benefit analysis
economic
evaluation
Perspective Employer Employer Employer Employer
Key outcome Value of productivity per year Medical care costs associated with low-back Workers compensation expenses Workers compensation expenses
measures pain cases; value of lost work time due to sick (medical and indemnity
leave (productivity); productivity loss due to payments) related to resident
low-back pain at work; and productivity handling injuries
enhancements due to intervention
Economic The benefit-cost ratio was 24.61 Net savings per year were $70,441 with savings The payback period was 10.6 months, The payback period was slightly
evaluation per worker of $111. The benefit-to-cost ratio based on the assumption that the less than 3 years
results was 84.9 and the payback period was incidence of accepted claims for neck/
0.5 months (2002 dollars) shoulder injuries among customer service
operators at the company is 0.0144 and
the neck/shoulder injury reduction from
the intervention is 49% (taken from the
estimated hazard rate)
Details of Study Overall: 3.55 (High) Overall: 3.55 (High) Overall: 2.8 (Medium) Overall: 3.35 (Medium)
Score (overall (1) 4; (2) 5; (3) 3.5; (4) 4; (5) 4; (6) 4; (7) (1) 3; (2) 3.5; (3) 3; (4) 2.5; (5) 3; (6) 2; (7) 4; (1) 3.5; (2) 4; (3) 4; (4) 4; (5) 4; (6) 3; (7) 4; (1) 5; (2) 5; (3) 4.5; (4) 3.5; (5) 4;
score and 4; (8) 5; (9) 2.5; (10) 4; (11) 3.5; (12) 1; (8) 3; (9) 4; (10) 5; (11) 3; (12) 5; (13) 4; (14) (8) 2; (9) 2; (10) 1; (11) 1; (12) NA; (13) (6) 3; (7) 4; (8) 3; (9) 3; (10) 3;
individual (13) 3; (14) 2.5 4.5 1; (14) 2.5 (11) 3; (12) 1; (13) 1; (14) 4
item scores)
225

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 Table 4 continued
226

Study Chhokar et al. [14] Evanoff et al. [16] Hocking [26] Lanoie and Tavenas [17]

123
Sector Health Care Health Care Information and Culture Manufacturing and Warehousing
Country Canada United States Australia Canada
Intervention Introduction of mechanical ceiling lifts Introduction of a participatory ergonomics An intervention consisting of workplace A participatory ergonomic intervention to
details and training team ergonomic assessments and the reduce back disorders at an alcohol
introduction of new equipment and distributor. Six principal problems were
training. Three teams of engineers were addressed by the joint worksite safety
trained in ergonomics, and then committee
progressively assessed and improved the
equipment and associated work practices
for a range of projects, which were
subsequently released in the field with
instructions, presentations, and publicity.
Type of study Before-after uncontrolled Before-after with control for effectiveness Before-after with control (set of injuries Longitudinal (interrupted time series)
analysis not associated with manual handling) uncontrolled
before-after without control for economic
analysis
Measurement 108 months 110110 months 48 months 57 months
time period
Type of Cost-benefit analysis Cost-consequence analysis Cost-benefit analysis Cost-benefit analysis
economic
evaluation
Perspective Employer Employer Employer Employer
Key outcome Workers compensation expenses Workers compensation expenses Manual and non-manual handling Direct and indirect expenses associated
measures accidents expenses with back-related injuries
Economic Upper- and lower- bounds estimates Total workers compensation expenses for The net present value was $3,995,000. The net present value for the duration of
evaluation translate into a payback period of orderlies was $24,443 pre-intervention Although the Telecom project was the intervention was (-$7,982.64) and
results 2.50 years and 0.83 years, for the ($237 per FTE) and $34,207 post- apparently ineffective in reducing injury, over the time period that included future
lower and upper bounds respectively intervention ($139 per FTE), paradoxically it was economical (note projections was $187,700.79. The net
(1998 Canadian dollars) representing a 41% decrease in expenses that the individual costs and present value becomes positive in the
per worker, or total savings of $22,758. consequences provided in the study do year following the measured intervention
These savings can be compared to the not add up correctly). time period (1989 Canadian dollars)
$5,000 costs incurred over 2 years
Details of Overall: 2.9 (Medium) Overall: 2.55 (Medium) Overall: 3.4 (Medium) Overall: 3.85 (High)
Study Score (1) 4; (2) 4; (3) 4; (4) 3; (5) 3; (6) 2.5; (7) (1) 5; (2) 4.5; (3) 1; (4) 2; (5) 2.5; (6) 2; (7) (1) 3.5; (2) 5; (3) 2; (4) 3.5; (5) 2.5; (6) (1) 5; (2) 5; (3) 4; (4) 3.5; (5) 4; (6) 4; (7)
(overall score 3.5; (8) 2; (9) 1; (10) 2; (11) 3; (12) 1; 3; (8) 2; (9) 2; (10) 2.5; (11) 2; (12) 1; 4.5; (7) 3; (8) 3; (9) 3; (10) 4; (11) 4; (12) 3; (8) 3; (9) 4; (10) 4; (11) 3.5; (12) 5;
and (13) 3; (14) 4 (13) 2; (14) 5 3; (13) 2; (14) 5 (13) 3; (14) 3
individual
item scores)
J Occup Rehabil (2010) 20:220234
 Table 4 continued
Study Lahiri et al. [13] Lahiri et al. [13] Abrahamsson [18] Halpern and Dawson [19]

Sector Manufacturing and Warehousing Manufacturing and Warehousing Manufacturing and Warehousing Manufacturing and Warehousing
Country United States United States Sweden United States
Intervention Engineering controls and A number of engineering controls Development of new ladle service A participatory ergonomic program was introduced
details workstation modifications were were implemented. Ergonomic department by a consultant company, based on a suggestion from a risk management
instituted following ergonomic dollies were redesigned (to which used different participatory and consulting firm. The intervention included a number
evaluations. New equipment reduce the amount of bending), pedagogical methods in the process of of engineering changes and related training to use new
introduced included adjustable lift and tilt tables were installed designing the new department. The tools/equipment, a stretching program, return-to-work
chairs, conveyors, lift tables, (to allow adjustment of intervention addressed issues related to activities (e.g. increased use of modified duty program),
J Occup Rehabil (2010) 20:220234

anti-fatigue matting, grabbers, workstation heights), and environment, climate factors, the role of and an awareness education effort. Steering committee,
and catwalks to minimize the use mechanical lift assists, and the ladle service in the steelworks, design committee, and medical and claims management
of ladders various platforms and risers were transport routes and production flows. committee worked together with top management
introduced (to reduce loads and The new ladle service department had participation at the implementation stage
awkward back postures) an advanced climate and ventilation
system that kept the heat and smoke
from the ladles out of the working area
Type of study Before-after uncontrolled Before-after uncontrolled Before-after uncontrolled Before-after uncontrolled
Measurement 36 months 48 months 36 months 36 months
time period
Type of Cost-benefit analysis Cost-benefit analysis Cost-benefit analysis Partial economic analysis (before-after comparison of
economic workers compensation expenses)
evaluation
Perspective Employer Employer Employer Employer
Key outcome Medical care costs associated with Medical care costs associated with Value of absenteeism, production quality, Workers compensation expenses
measures low-back pain cases; value of low-back pain cases; value of and production efficiency
lost work time due to sick leave lost work time due to sick leave
(productivity); productivity loss (productivity); productivity loss
due to low-back pain at work; due to low-back pain at work;
and productivity enhancements and productivity enhancements
due to intervention due to intervention
Economic Net savings per year were $76,872, Net savings per year were The Net Present Value was SEK The number of employees at the plant over the study
evaluation with savings per worker of $625. $2,334,409, with savings per 12,053,000. The internal interest rate period rose from 514 to 700. For sewing operations:
results The benefit-to-cost ratio was worker of $1,556. The benefit-to- (internal rate of return) was 36%, the workers compensation expenses related to MSK
15.40 and the payback period cost ratio was 5.5 and the pay-off time (payback period) was disorders fell from $414,000 to $100,000, $54,000, and
was 5.3 months (2002 dollars) payback period was 3.3 months 2.2 years, while the profit (using the $11,000 respectively each year following the
(2002 dollars) annuity method) was SEK 2,732,000 introduction of the intervention (overall decrease of
97%), while the per MSK claim expenses fell from
$31,846 to $5,500 during the same period. For all
operations: total workers compensation expenses
decreased from $723,000 before the intervention to
$420,000 in the third year of the intervention (overall
decrease in total expenses of 42%), while workers
compensation expenses per claim fell from $6,821 to
$3,281 (a 52% decrease).
227

123
 Table 4 continued
228

Study Lahiri et al. [13] Lahiri et al. [13] Abrahamsson [18] Halpern and Dawson [19]

123
Details of Overall: 3.55 (High) Overall: 3.55 (High) Overall: 3.3 (Medium) Overall: 2.55 (Medium)
Study Score (1) 3; (2) 3.5; (3) 3; (4) 2.5; (5) 3; (1) 3; (2) 3.5; (3) 3; (4) 2.5; (5) 3; (1) 5; (2) 5; (3) 3; (4) 3; (5) 2; (6) 5; (7) 3; (1) 4.5; (2) 5; (3) 2.5; (4) 2.5; (5);2 (6) 3; (7) 2; (8) 2; (9) 3;
(overall (6) 2; (7) 4; (8) 3; (9) 4; (10) 5; (6) 2; (7) 4; (8) 3; (9) 4; (10) 5; (8) 2; (9) 2.5; (10) 3.5; (11) 3; (12) 3; (10) 2; (11) 2; (12) 1; (13) 1; (14) 3
score and (11) 3; (12) 5; (13) 4; (14) 4.5 (11) 3; (12) 5; (13) 4; (14) 4.5 (13) 2; (14) 4
individual
item scores)
Study Banco et al. [27] Daltroy et al. [20] Versloot et al. [21] Tuchin and Pollard [22]

Sector Retail and Trade Transportation Transportation Transportation

Country United States United States The Netherlands Australia
Intervention Three ergonomic interventions Back school program consisting of Back school program consisting of three A comprehensive lecture of approximately 120
details were implemented in 3 groups of two training sessions. The training sessions. The first session minutes covered topics such as spinal anatomy;
stores: program included principles of covered topics such as motivation; pain-sensitive structures; causes of back pain
Group A stores: new safety case back safety; correct lifting and responsibility for ones own health; and injury; types of back injuries; spinal
cutters with education; handling; posture exercises and mindbody interactions in relation to biomechanics; correct lifting techniques;
pain management. The therapists illness; stress, coping strategies and methods of care for back problems; effective
Group B stores: old cutters with
(instructors) also examined each relaxation training; and body mechanics exercises; analysis and explanation of
education;
workstation and suggested including sports, working posture, and ergonomics; relationship of back pain to
Group C stores: status quo, i.e. old physical and procedural seat adjustment. The second and third occupation and tasks involved; and effects of
cutters (control group) modifications. The therapists sessions reviewed participants static posture. Prior to giving lecture, a tour of
provided additional experiences since the first session and the workplace was undertaken so that potential
reinforcement training six included a summary of the first session problem areas could be identified and brought
months after the first sessions to the workers attention during the lecture.
and yearly thereafter
Type of study Randomized controlled trial Randomized controlled (not Randomized controlled (not blinded) Randomized controlled (not blinded)
blinded)
Measurement 12 months 65 months 48 months 6 months
time period
Type of Cost-benefit analysis Partial economic analysis (total Cost-benefit analysis Costs and consequences considered separately
economic expenses per back injury claim
evaluation compared using the Wilcoxon
rank-sum statistic)
Perspective Employer Employer Employer Employer
Key outcome Wage value of time-loss from Back injury expenses Absenteeism expenses Absenteeism expenses
measures work due to injury, workers
compensation (indemnity and
medical care) expenses
J Occup Rehabil (2010) 20:220234
 Table 4 continued
Study Banco et al. [27] Daltroy et al. [20] Versloot et al. [21] Tuchin and Pollard [22]

Economic Estimated savings for Group A
evaluation stores were $245 per year per
results store and $29,413 per year for
the chain when compared to the
status quo (Group C stores).
Benefits for Group B stores were
less dramatic and totaled $106
per 100,000 man-hours per store,
with total net savings of $12,773
The effectiveness of the
intervention was not established,
though descriptive statistics of
expenses were presented. The
median total expenses per back
injury were $309 for the
intervention group, and $103 for
the control group. Group
assignment (intervention or
If the change in absenteeism for the
intervention group is assessed in
relation to the change in the control
group, then the net present value is
$103,400. If the change in absenteeism
is assessed only within the intervention
group, then the net present value is
$70,200
Though costs and consequences were only
considered separately, the implied net present
value was $52,080. The authors mentioned that
the saving could be in excess of $50,000 for a
3-month period
J Occup Rehabil (2010) 20:220234

for the chain control) and training status were

not significantly associated with
cost. Workers with a history of
low-back injury had higher
median total expenses, medical
expenses and personnel-
replacement expenses than did
workers without such a history
Details of Study Overall: 2.5 (Medium) Overall: 3.6 (High) Overall: 3.35 (Medium) Overall: 2.75 (Medium)
Score (overall (1) 4; (2) 4; (3) 2; (4) 3; (5) 1; (6) (1) 4; (2) 5; (3) 5; (4) 5; (5) 4; (6) (1) 4.5; (2) 5; (3) 2; (4) 4; (5) 4; (6) 4; (7) (1) 3.5; (2) 4.5; (3) 2; (4) 2.5; (5) 3.5; (6) 1; (7) 3;
score and 2; (7) 3; (8) 4; (9) 2; (10) 3; (11) 4.5; (7) 4; (8) 4; (9) 3; (10) 2; 3; (8) 3.5; (9) 3; (10) 3; (11) 3; (12) 1; (8) 4; (9) 3; (10) 3; (11) 2; (12) NA; (13) 1;
individual item 2; (12) 1; (13) 1; (14) 3 (11) 2; (12) 1; (13) NA/1; (14) (13) 3; (14) 4 (14) 3
scores) 4.5
229

123
230
In the administrative and support services sector, two
intervention evaluations of high quality [12, 13], and one of
medium quality [10] were identified. From these studies we
concluded that there is moderate evidence that ergonomic
interventions in the administrative and support services
sector are worth undertaking on the basis of their financial
merits.
For the health care sector, there was also moderate
evidence that ergonomic interventions are worth under-
taking for economic reasons. There were three medium
quality studies in this sector [1416]. Two of the studies in
this group evaluated the introduction of mechanical patient
lifts, while the third evaluated the introduction of a par-
ticipatory ergonomics program.
Studies in the manufacturing and warehousing sector
provided strong evidence that ergonomic interventions are
worth undertaking for their financial merits. There were three
high quality studies (two in Lahiri et al. [13], and [17]) and
two medium quality ones [18, 19], and all concluded that the
ergonomic interventions were cost-effective in this sector.
The last stratum with substantive evidence was the
transportation sector. This stratum provided limited evi-
dence that such interventions result in economic returns. In
this group there were three interventions. One was of high
quality [20] and found that the intervention was not
effective. Two medium quality studies [21, 22] found the
interventions to be cost-effective. Interestingly, these
interventions were all ergonomic education programs and
each was undertaken in a different country, namely the
Unites States, the Netherlands and Australia.
In all other sectors in which studies were identified there
was insufficient evidence on the cost-effectiveness of OHS
ergonomic interventions.
Across all sectors, there was a total of six high quality
studies and 10 medium quality ones. Of the sixteen studies,
all but one found the interventions to be worth undertaking
based on their financial merits. Consequently, when con-
sidering evidence across all sectors, we conclude that there
is strong evidence that ergonomic interventions result in
economic returns for the firm.
As noted, only four studies were participatory ergo-
nomic interventions. One of these was of high quality [17]
and three of medium quality [16, 18, 19]. This results in
moderate evidence that participatory ergonomic interven-
tions are worth undertaking based on their financial returns
for the company.
Summary of Studies in Sectors with Substantive
Evidence
The interventions in the administrative and support sector
targeted work station equipment and training for office
workers. Equipment included highly adjustable chairs,
123
J Occup Rehabil (2010) 20:220234
lumbar pads and backrest and track ball and armboards
with computer use. Training included appropriate use of
equipment and back school workshops. Two studies had
more than one intervention arm including a control (both
also used regression modeling techniques to control for
confounders), while a third study was a before-after study
without a separate control. The three studies included in
this sector all undertook a cost-benefit analysis, and con-
sidered insurance and productivity consequences.
In the health care sector, interventions included the
introduction of mechanical patient lifts in two cases and the
implementation of a participatory ergonomics team in the
other. The target populations were individuals working in a
hospital setting, such as nurses, nurses aides and orderlies.
Study designs were before-after without controls, two of
which used regression modeling techniques to control for
confounders. Regarding the economic evaluation method
employed, two studies undertook a cost-benefit analysis
while the other conducted a cost-consequence analysis (i.e.
costs and consequences are analyzed separately rather than
jointly). Only insurance consequences were considered in
the economic analyses.
In the manufacturing and warehousing sector, the inter-
ventions focused on a broad range of MSK injury prevention
measures for individuals working with machinery. In three
cases the interventions were participatory, while in the other
two instances they consisted of engineering controls and
workstation modifications. All were before-after uncon-
trolled studies, with one using regression modeling tech-
niques to control for confounders. Four studies undertook a
cost-benefit analysis, and one was a partial analysis that only
considered insurance consequences.
The three studies identified in the transportation sector
were ergonomic education programs focused on back
injury prevention. All were randomized controlled trials
though not blinded. Regression modeling and analysis of
variance was undertaken to assess the difference between
and within groups. With regards to the economic evalua-
tion component, each study undertook a different type of
analysis. One study was a partial analysis, the second a
cost-consequence analysis and a third a cost-benefit anal-
ysis. Insurance and productivity consequences were con-
sidered. The intervention was not found to be effective in
one study, whereas it was in the other two.
Discussion
Evidence of Financial Merits of Ergonomic
Interventions
The research question addressed in this systematic review
was: what is the credible evidence that incremental
J Occup Rehabil (2010) 20:220234
investment in ergonomic interventions is worth undertak-
ing? Previous reviews have synthesized the evidence on
the effectiveness of office ergonomic interventions [3] and
of participatory ergonomic interventions [2]. However, this
systematic review is unique in that no other review has
examined the financial merits associated with ergonomic
interventions.
From the nine sectors identified, a definitive statement
about the level of evidence could be made in four industrial
sectors: administrative and support services sector, health
care sector, manufacturing and warehousing sector and
transportation. In the other five of the nine sectors, there
was insufficient evidence due to the small number of
studies and/or their low quality. As well, a synthesis of
studies across all sectors suggests strong evidence that
ergonomic interventions result in financial returns for the
firm. There were only four high and/or medium participa-
tory ergonomic interventions, so there was only moderate
evidence in support of the financial merits of these types of
interventions across all sectors.
In the majority of the studies, intervention implemen-
tation was motivated by a high number of workplace
injuries. Related to this was a concern about workers
compensation insurance and absenteeism costs, as these
may bear on business performance. These costs outcomes
were the two main economic outcomes examined in most
studies. All studies included in the synthesis took the
employers perspective, focusing on monetary costs and
consequences borne by the employer. The focus on only
one perspective and a limited set of outcomes was one of
the major shortcomings in this literature.
Methodological Recommendations
Two key methodological findings from the review are that:
(1) few ergonomic intervention studies undertake an eco-
nomic evaluation, and (2) the intervention studies that do
undertake economic analyses present a diversity of meth-
odological approaches and quality with a large number of
low quality studies. Other reviews of the OHS literature
have come to similar conclusions [2325]. Indeed, a
common complaint in the assessments of the research lit-
erature on the economic evaluation of workplace inter-
ventions is that well-designed and conducted evaluations
of programme costs and benefits were nearly impossible to
find [25]. Nonetheless, the review did identify a sufficient
number of high and medium quality studies to make sub-
stantive statements about the evidence in some industrial
sectors.
As noted, the quality assessment of studies was based on
a tool developed from previously completed research that
outlines key issues to consider in OHS economic evalua-
tions, and a methods text on good practice [8, 9]. Details on
231
study scores for each of the 14 quality assessment items
can be found in Table 4. Also included are other method-
ological details and the key outcomes considered in each
study. Although there were several high quality economic
analyses identified in the systematic review [12, 13, 17,
20], and a number of medium quality ones [10, 1416, 18,
19, 21, 22, 26, 27], more than half of the intervention
studies identified were of low quality. This is likely due to
the focus in this literature on effectiveness rather than cost-
effectiveness. Also, undertaking economic evaluations of
OHS interventions can be difficult, and there is little
guidance available on how it should be done. Most meth-
ods texts are designed for use in a clinical setting, but a
number of factors in the workplace setting are different
than the clinical setting. Following is a list of key differ-
ences: (1) the policy arena of OHS and labor legislation is
complex, with multiple stakeholders and sometimes con-
flicting incentives and priorities; (2) there are substantial
differences in the perceptions of health risks associated
with work experiences amongst workplace parties, poli-
cymakers and other OHS stakeholders; (3) there is a con-
sequential lack of consensus amongst stakeholders about
what, in principle, ought to count as a benefit or cost of
intervening or not intervening (this is an issue related to the
appropriate perspective to be taken in a study); (4) the
burden of costs and consequences may be borne by dif-
ferent stakeholders in the system; (5) there are multiple
providers of indemnity and medical care coverage, such
that no one measure accurately captures the full cost of
work-related injury and illness, nor conversely, the benefits
of their prevention; (6) industry-specific human resources
practices (e.g. hiring temporary workers and self-employed
contractors, outsourcing non-core activities) can make it
difficult to identify all work-related injuries and illnesses;
and (7) in general there is an absence of good guidelines
regarding costs and consequences combined with a dearth
of data available from organizations making it both chal-
lenging and expensive to obtain good measures. The above
list of reasons might explain why few studies of OHS
interventions contain an economic evaluation, and why the
quality of economic evaluations is usually poor.
Based on observation of the application of economic
evaluation methods in this literature, several recommen-
dations are offered to help improve future applications of
these methods. The recommendations are drawn from
across all the studies considered in this review, including
the low quality ones. For a more complete discussion of
methodological issues and recommendations we refer
readers to the following sources [6, 8, 9].
A number of studies identified undertook a partial
economic analysis. The phrase partial economic analy-
sis is used to describe studies that considered only con-
sequences in monetary terms, but did not consider
123
232
intervention costs. With the exception of two studies [19,
20], such studies were not of sufficient quality to remain in
the evidence synthesis. Amongst the studies that consid-
ered both costs and consequences, many considered only a
limited subset. Furthermore, we sometimes found a dis-
connect between the effectiveness and economic evalua-
tions. Specifically, one set of analyses fed into the
effectiveness evaluation, and a separate set of analyses
were undertaken for the economic component. In some
cases, the two types of analyses not only relied on different
health outcome data, measurement and analytic time frame,
but also used different study designs, with economic
evaluation often employing a weaker design (e.g. before-
after without a concurrent control group and no statistical
adjustment for confounders). For many studies the eco-
nomic analysis was not the principal focus of the investi-
gation, and for some it was a very small component.
Another concern is that studies employed different
approaches to the computation and analysis of costs and
consequences, making it difficult to compare results across
studies. For example, some studies with cost and conse-
quences in monetary terms used net present value, others
the payback period, yet others a cost-benefit ratio. We
would suggest a standard approach to computations, a type
of reference case as suggested by Gold et al. [28] and
Tompa et al. [9].
Most studies that undertook economic analyses focused
on work absence costs (primarily wage costs or workers
compensation wage replacement costs) and medical care
costs. One concern with using workers compensation
claims costs as the sole or primary outcome measure is that
it does not capture the full set of costs and consequences,
even from a firms perspective. A range of indirect costs
may be incurred by a firm that results in costs substantially
larger than the direct absence costs. A common approach in
many studies taking the firm perspective was to use the
insurers claim expenses in the cost-benefit analysis.
However, in some jurisdictions workers compensation
insurance provided by an insurer are experience rated, and
the losses borne by the insurer are not fully offset by
premium increases to the injury employer. A fraction of the
costs may be pooled across all firms in a particular rate or
risk group. If a firm is self insured, then the full cost of a
claim is borne by the employer. Only one study we iden-
tified made an adjustment for this fact [17]. Furthermore,
workers compensation claims do not reflect the full extent
of work-related injuries and illnesses. Many workplace
injuries and illnesses go unreported, and others are not
compensable [29]. Researchers need to consider other
measures of health and their associated costs, either
through primary data collection or exploitation of other
administrative data sources (e.g. first aid reports, modified
duty, and private indemnity claims).
123
J Occup Rehabil (2010) 20:220234
Many of the high- and medium-quality studies under-
took cost-benefit analysis, and used some variant of a
human capital approach (a measure of productivity) to
value absence time. Several studies went further in their
assessment of productivity implications and considered
at-work productivity changes due to the intervention.
Although financial outcomes and productivity issues may
be of primary interest to most firms, the value of health to
other stakeholders, particularly injured workers and their
families includes much more. Missing in this measure is
the intrinsic value of good health to workers and the value
of health associated with the ability to better perform in
other social roles.
The perspective taken matters for the workplace mea-
sures of health used in an evaluation. In fact, the per-
spective bears on all the costs and consequences considered
in an economic evaluation. All studies included in the
synthesis took the firm perspective, considering only those
costs and consequences experienced by the firm. There is a
strong case to be made for considering other perspectives,
particularly those of the worker and system or society, as
well as for a disaggregation of the costs and consequences
by stakeholder in order to better understand their compo-
sition and distribution.
A number of standard computational practices were also
overlooked in some analyses. For example, when the costs
and/or consequences of an intervention are realized over
more than a year, one should adjust for inflation and time
preference. Data on inflation rates are readily available
from most national statistical agencies. To adjust for time
preference, discounting is required for both costs and
consequences, even if consequences are not measured in
dollars. Many jurisdictions stipulate the discount rate at
which public sector investments are to be discounted. For
the private sector, firms may have their own specific rate
used for project investments. The real discount rates (net of
inflation) commonly used in the literature are 3 and 5%
[30]. Thus, we suggest considering both rates in an anal-
ysis, and possibly undertaking a sensitivity analysis using a
range of rates. In fact, sensitivity analysis should be
undertaken with all key assumptions to test the robustness
of results to these assumptions.
Strengths and Weaknesses of the Review
One of the key strengths of this study is its broad scope.
Evidence on the financial merits of ergonomic interven-
tions of different types and across all sectors was consid-
ered. The literature search was quite thorough. A number
of journal databases were considered and included, and a
detailed and lengthy search strategy was used to ensure all
relevant studies were captured. Another strength is the
inclusion of a stakeholder advisory group from the early
J Occup Rehabil (2010) 20:220234
stages of the review process. The advisory group provided
feedback on the question guiding the review and the
framing of the topic, literature search scope, synthesis
stratification, presentation of individual study data and
evidence synthesis findings. The stakeholder advisory
group represented the primary target audiences for the
evidence synthesis, and therefore ensured that the final
product met all stakeholders information needs.
One potential review limitation is that the gray literature
was not included. The stakeholder advisory group had
initially suggested including the gray literature. They felt
strongly that the lack of evidence on the financial merits of
OHS interventions, and the importance of this information
to them, warranted a broad sweep of the literature.
Although the gray literature may have been a potential
source for relevant evaluations, the published literature
itself was quite vast and not well catalogued for retrieving
studies with economic evaluations. The identification of
almost 13,000 titles and abstracts made for a daunting first
stage of study identification, and adding a gray literature
search would have made the task unmanageable with the
resources available. Another concern was the quality of the
gray literature. Though the quality of each study considered
for inclusion in the synthesis was evaluated, the peer
review process of academic journal publication provided a
rigorous first level of assessment, which would not be
present with the gray literature, and therefore might require
a different, more extensive quality assessment process. A
downside of including only peer reviewed studies is that
there may be a positive publication bias, i.e. studies with
statistically insignificant findings in terms of effectiveness
and cost-effectiveness may be less likely to be published.
Indeed, most studies identified reported positive findings.
Another limitation is that the search was restricted to
studies written in English. This may have precluded
potentially relevant publications in other languages. As
noted many of the included studies were undertaken in the
US (ten in total), although the synthesis did include two
studies undertaken in Europe, two in Australia and two in
Canada. Future research on this topic might include pub-
lications in languages other than English and assess the
evidence implications of including studies in multiple
languages compared to English language literature only.
Conclusion
This review found strong evidence supporting the eco-
nomic merits of ergonomic interventions in the manufac-
turing and warehousing sector, moderate evidence
supporting the economic merits of such interventions in the
administrative and support services sector, and health care
sectors and limited evidence in the transportation sector.
233
The review highlights the need for a more systematic
consideration of the financial merits of ergonomic inter-
ventions and a further development of standardized ana-
lytic methods in order to ensure a larger and more reliable
evidence base on the financial merits of such interventions.
It is recommended that all researchers who are considering
evaluating a workplace intervention seriously consider
including an economic evaluation.
The findings are of value to workplace parties, OHS
practitioners and policymakers who are interested in
knowing what interventions are worth undertaking from a
financial viewpoint. The findings are also of value to OHS
researchers, who might seek to fill some of the gaps in the
literature and strive to improve the quality of future eco-
nomic evaluations. Undoubtedly, the knowledge of the
financial merits of an ergonomic intervention is critical to
employers, insurers and policymakers, so it is to the det-
riment of the value of an intervention evaluation study to
leave economic analysis out of the evaluation plan.
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