HSE Health & Safety

Executive

Effective design of workplace risk communications

Prepared by the University of Nottingham and the Health & Safety Laboratory

for the Health and Safety Executive 2003

RESEARCH REPORT 093

HSE Health & Safety

Executive

Effective design of workplace risk communications

Dr Eamonn Ferguson, Dr Peter A Bibby and Joanna Leaviss

School of Psychology University of Nottingham

Nottingham NG7 2RD

UK

Dr Andrew Weyman Health & Safety Laboratory

Broad Lane Sheffield

S3 7HQ

This report focuses on the design of risk communication leaflets. Qualitative and quantitative data from six studies (survey, cross-sectional and quasi-experimental) are reported. These studies focused on risk communication design with respect to the use of ear defenders and manual handling, drawing on samples from the mining industry, foundries and NHS staff. Three essential design features of leaflets were explored: (1) usability (e.g. readability), (2) usefulness (e.g. relevance) and (3) framing. Framing refers to presenting the same risk information in either a negative way (what you will lose if you do not follow safe working practice) or positive way (what you will gain from following safe working practice). The results showed that some current Health and Safety Executive (HSE) leaflets were at a reading age level that was higher than desired for the national workforce, and were not easily comprehended. Furthermore, the extent to which a leaflet was perceived as useful and useable was associated with greater intentions to follow safe working practice. Positively framed messages also were generally found to increase intentions to follow safe working practice, but this was to an extent influenced by past behaviour and experience. It was shown that it is possible to redesign leaflets to make them objectively and subjectively more useable and useful. Based on the results a five step procedure for designing leaflets to make them useable, useful (both objectively and subjectively) and framed is provided.

This report and the work it describes were funded by the HSE. Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.

HSE BOOKS

© Crown copyright 2003

First published 2003

ISBN 0 7176 2175 8

All rights reserved. No part of this publication may bereproduced, stored in a retrieval system, or transmitted inany form or by any means (electronic, mechanical,photocopying, recording or otherwise) without the priorwritten permission of the copyright owner.

Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to hmsolicensing@cabinet-office.x.gsi.gov.uk

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Acknowledgements

Members of the project team would like to thank all those who participated in these studies. We are grateful to all the organisations that allowed access to their employees. Many thanks also to all those trainers, team leaders and managers within the organisations who gave up their time to facilitate the data collection.

We would also like to thank those in the participating organisations for comments on the initial version of the report.

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1 Executive summary............................................................................................................1 1.1 Background. ...............................................................................................................11.2 Methods......................................................................................................................1 1.3 Findings......................................................................................................................1 1.4 Implications................................................................................................................2

2 Background to the Project..................................................................................................3 2.1 Traditional Theoretical Models of Workplace Self-Protective Behaviour ................5

2.1.1 Threat-Related Beliefs .......................................................................................5 2.1.2 Self- Efficacy & response efficacy ....................................................................5 2.1.3 Emotional Factors ..............................................................................................5 2.1.4 Perceived Barriers ..............................................................................................6 2.1.5 Normative Expectations.....................................................................................6 2.1.6 Intentions............................................................................................................6

2.2 The Use of Leaflets in Risk Communication.............................................................6 2.2.1 Usability and Usefulness....................................................................................7 2.2.2 Fear Appeals. .....................................................................................................8 2.2.3 Prospect Theory and message framing ..............................................................8 2.2.4 Framing Effects in Health Promotion ..............................................................10 2.2.5 Prevention Versus Detection Behaviours ........................................................10 2.2.6 Framing Effects and involvement ....................................................................11 2.2.7 The influence of past behaviour.......................................................................11

2.3 Summary and Aims..................................................................................................12 2.3.1 Noise ................................................................................................................12 2.3.2 Manual Handling .............................................................................................12

2.4 Overall Summary of Aims. ......................................................................................13 2.5 Project Studies .........................................................................................................13

2.5.1 Study 1: Objective usability analysis of current HSE leaflets on noise and manual handling...............................................................................................................13 2.5.2 Study 2: Subjective usability and usefulness analysis of current HSE leaflets13 2.5.3 Study 3: Developing Relevant Framed Messages – A Qualitative Study of Employees Involved with Manual Handling or Noise at Work.......................................14 2.5.4 Study 4: The relationship between usability, usefulness, frames and intentions with respect to manual handling ......................................................................................14 2.5.5 Study 5: Framing intervention study for noise and manual handling ..............14 2.5.6 Study 6: The effect of narrative structure on intentions to follow safe practice for manual handling .........................................................................................................14

3 Study One: Readability and Content Analysis of Current HSE Leaflets on Noise and Manual Handling .....................................................................................................................15

3.1 Readability ...............................................................................................................15 3.2 Comprehension ........................................................................................................16 3.3 Message content.......................................................................................................16 3.4 Aims of Study ..........................................................................................................17 3.5 Leaflet selection .......................................................................................................17 3.6 Readability analyses.................................................................................................17

3.6.1 Method .............................................................................................................17 3.6.2 Results..............................................................................................................17

3.7 Comprehension analyses (the Cloze test) ................................................................18 3.7.1 Participants.......................................................................................................18 3.7.2 Method .............................................................................................................18

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3.7.3 Results..............................................................................................................18 3.8 Content analyses ......................................................................................................19

3.8.1 Method .............................................................................................................19 3.8.2 Results..............................................................................................................21 3.8.3 Framing analyses .............................................................................................21

3.9 Discussion ................................................................................................................22 3.9.1 Readability and comprehension .......................................................................22 3.9.2 Content.............................................................................................................22 3.9.3 Framing ............................................................................................................22

4 Study Two: Subjective Usability and Usefulness Analysis of Current HSE Leaflets on Noise and Manual Handling. ...................................................................................................25

4.1 Aim of the study.......................................................................................................25 4.2 Method .....................................................................................................................25

4.2.1 Participants.......................................................................................................25 4.2.2 Materials ..........................................................................................................26 4.2.3 Measures ..........................................................................................................26 4.2.4 Procedure .........................................................................................................27

4.3 Results......................................................................................................................27 4.3.1 Manual handling data analyses ........................................................................27 4.3.2 Noise data analyses ..........................................................................................31

4.4 Behavioural analysis of PPE use..............................................................................33 4.4.1 Method .............................................................................................................33 4.4.2 Results..............................................................................................................33

4.5 Discussion ................................................................................................................34 4.5.1 The prediction of intentions .............................................................................35 4.5.2 Usability and Usefulness..................................................................................35 4.5.3 Behavioural Outcomes.....................................................................................35

5 Study 3: Developing Relevant Framed Messages through anticipated quality of life losses – A Qualitative Study of back pain (Manual Handling) and Deafness (Noise). ...........37

5.1 Method .....................................................................................................................37 5.2 Results......................................................................................................................37

5.2.1 Readability .......................................................................................................38 5.2.2 Narrative Structure...........................................................................................38

5.3 Discussion ................................................................................................................39 6 Study Four: The Effects of Positively or Negatively Framing Risk Communications on Users Intentions to Follow Safe Practice, their Perceptions of Usability and Usefulness, and their Risk-Related Cognitions and Emotions...........................................................................41

6.1 Aim of study ............................................................................................................41 6.2 Method .....................................................................................................................41

6.2.1 Leaflets.............................................................................................................41 6.2.2 Participants.......................................................................................................41 6.2.3 Measures ..........................................................................................................41 6.2.4 Procedure .........................................................................................................42

6.3 Results......................................................................................................................42 6.3.1 Perceived usability and usefulness and the leaflets .........................................42 6.3.2 Differences among the 3 leaflets......................................................................42 6.3.3 Predictors of Intentions ....................................................................................43

6.4 Discussion ................................................................................................................44 6.4.1 Framing effects on intentions...........................................................................45 6.4.2 Framing effects on perceived risk....................................................................45

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6.4.3 Importance of leaflet design factors – frames, usability and usefulness..........45 7 Study Five: Framing Intervention Study for Use of Ear Defenders and Manual Handling- An Exploration of Individual Differences as Moderators of Framing Effects. .....................47

7.1 Aims of study...........................................................................................................47 7.2 Method .....................................................................................................................47

7.2.1 Participants.......................................................................................................47 7.2.2 Materials ..........................................................................................................48 7.2.3 Measures ..........................................................................................................48 7.2.4 Procedure .........................................................................................................50

7.3 Results......................................................................................................................50 7.3.1 Noise data analyse............................................................................................51 7.3.2 Manual Handling data analyses .......................................................................53 7.3.3 Summary of Framing Effects...........................................................................55

7.4 Discussion ................................................................................................................55 7.4.1 Frames and intentions ......................................................................................56 7.4.2 The influence of positive and negative frames ................................................56

8 Study Six: The Effects of Narrative Structure and Frame on Intentions to Follow Safe Practice for Manual Handling..................................................................................................57

8.1 Aims of Study ..........................................................................................................58 8.2 Method .....................................................................................................................58

8.2.1 Design ..............................................................................................................58 8.2.2 Leaflets.............................................................................................................58 8.2.3 Participants.......................................................................................................58 8.2.4 Measures ..........................................................................................................58 8.2.5 Procedure .........................................................................................................58

8.3 Results......................................................................................................................59 8.3.1 Usability and Usefulness: ................................................................................59 8.3.2 Cognitive and emotional factors ......................................................................59

8.4 Discussion ................................................................................................................61 8.4.1 Usability and Usefulness..................................................................................61 8.4.2 Narrative Structure...........................................................................................61 8.4.3 Some hypotheses concerning narrative structure.............................................61

9 References........................................................................................................................63 10 How do design your own framed, usable and useful leaflets: a user's guide to the 5-stepplan ..........................................................................................................................................67 11 Summaries........................................................................................................................75 12 Appendices.......................................................................................................................87

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1 Executive summary

1.1 Background.

The main focus of this research programme has been to explore the influence of risk communication design features with respect to workers intentions to follow safe working practices. The following design features were explored: (1) Usability (how easy is the material to read, remember and comprehend), (2) Usefulness (is the material relevant to the target audience) and (3) message framing effects (what is the influence of presenting the same risk information as positives or negatives). A negative frame highlights the negative consequences of not adopting safe working practices and a positive frame emphasise the benefits of adopting safe working practices. Positive frames should be beneficial for prevention behaviours (e.g., wearing ear defenders) and negative frames beneficial for detection behaviours (e.g., monitoring systems). These latter design features have never been explored in the context of occupational risk communication before. However, the general health promotion literature suggests that messages that are appropriately framed for the target behaviour, and are also usable and useful will have an impact on behavioural intentions.

1.2 Methods.

The work focused on two prevention behaviours: (1) the use of ear defenders and (2) manual handling. A mixture of qualitative and quantitative methods was used. Qualitative analyses involved content analyses of a sample of current HSE risk communication leaflets. The quantitative analyses examined objective measures of readability and comprehensibility of HSE and specially designed leaflets. This was supplemented by quasi-experimental surveys and interventions studies. For the work on ear defenders samples were drawn from the mining industry and foundries. For the manual handling studies samples were drawn from a wide spectrum of health care professionals.

1.3 Findings.

There are 5 main findings.

· On average current HSE leaflets have an objective reading age that is higher then desired and at a level of comprehensibility suited to undergraduates. The sample analysed in this project contained primarily negatively framed information.

· Redesigning messages improved their objective and subjective usability (ease to read and understand).

· Workers intentions to adopt safe working practice were influenced by the usability and usefulness of the risk communication leaflets. This effect of usability and usefulness was in addition to effects attributed to demographic factors and perceptions of risk and worry. Therefore, communication design is a very important consideration when trying to influence safe working practice.

· Risk communications (specifically designed for the study) framed as ‘positives’ (the long-term benefits of adopting safe working practices) were generally more influential

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on intentions to act than negative frames or the current sample of HSE leaflet(s). However, there was evidence that prior-exposure to negative health outcomes (in this case either back pain or deafness) or past-behaviour (i.e., the extent to which PPE has been used in the past) influenced the effectiveness of positive and negative frames. This indicates that when targeting specific groups for an intervention, information on their prior-exposure and past-behaviour should be taken into account.

· While frame and usability /usefulness of leaflet design were consistently related to cognitions associated with safe working practice, effects of narrative structure were less robust. An equal balance between consequences and solutions however, should be maintained.

1.4 Implications.

When designing risk communication messages they should primarily be designed to maximise their usability and usefulness. Furthermore, if the behaviour is a prevention behaviour (e.g., wearing ear defenders) then framing the message to emphasise the benefits of adopting safe working practise (a positive framed message) should be considered.

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2 Background to the Project

The past 30 years have seen a dramatic reduction in the incidence of workplace accidents and ill health (DETR 2000). However, health and safety failures are still estimated to cost £18 billion annually (HSE 1999). The Health and Safety Commission and Executive (HSC and HSE) are committed to reducing the incidence of occupational accidents and ill health. Ergonomic solutions to occupational health and safety (making the working environment safe and healthy) remain an important focus for workplace interventions. Alongside this approach, however, is an increasing emphasis on enabling employees to take responsibility for their own safety through the uptake of safe working practice. Occupational risk communications are produced to allow employees to be well informed on relevant health issues and in so doing have the relevant knowledge to adopt safe working practice. However, this information is not always acted on appropriately (see Ferguson, 2001).

Traditional psychological models of behavioural change, that is, getting people to change their current practices have focused primarily on individual’s intentions to follow health and safety recommendations (see figure 1 and Connor and Norman 1996 for an extensive review). Traditionally a number of other factors (e.g., perceptions of risk) are seen to influence intentions (these are described briefly in the next section). The current project examines these traditional factors and adds to them by considering actual design features of the risk communication materials. Three specific risk communication design feature were examined: (1) usability (2) usefulness and (3) message framing. Usability refers to the ease with which the communication can be read, understood and remembered.

Usefulness refers to the communications relevance and how helpful it is perceived to be. To this point few programmes of systematic research have examined the potential importance of usability and usefulness to predict occupational health and safety intentions and behaviours. Health messages can be framed either as ‘negatives’ (e.g., negative consequences of not performing a safe working practice) or ‘positives’ (e.g., positive consequences of performing a safe working practice). Using the appropriate frame for a risk communication can influence intentions to follow safe practice and actual behaviour. To this point the systematic use of framing has not been studied in occupational health and safety settings, but it has been examined in the general health literature.

The effectiveness of a risk communication can be demonstrated through its influence on intentions to follow safe practice (see figure 1). It can also be demonstrated through its influence on risk-related attitudes and emotions. The main aim of this project, therefore, was to study:

· the additional influence of usability, usefulness and framing on occupational health and safety intentions and behaviour, once the influence of more traditional predictors had been examined.

There were also subsidiary aims to:

· examine some of the HSE’s current risk communication leaflets for usability, usefulness and framing.

· develop a methodology for developing usable, useful and framed risk communications.

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Traditional Factors (Individual Differences)

Risk Perception

Response Efficacy

N p

Usefulness

Non-Traditional Factors (Leaflet Design)

Worry and Seriousness

Self Efficacy

Barriers

ormative Ex ectations

Usability

Framing

INTENTIONS BEHAVIOUR

individuals to follow safe practice.

Traditional models of intentions to follow health recommendations focus on individual

differences. The current project examines the additional role of leaflet design on influencing

Figure 1 Diagram to show project summary

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The rest of this introductory chapter provides a brief explanation of

· traditional models of behavioural change,

· the use of leaflets as a means of communicating risk,

· the concepts of usability and usefulness

· framing effects.

2.1 Traditional Theoretical Models of Workplace Self-Protective Behaviour

Interventions designed to encourage workers to take self-protective behaviour typically focus on the identification of factors that are thought to be predictive of the desired behaviour. This reflects traditional models of health-related behaviours. These include the Health Belief Model (Becker 1974), the Theory of Reasoned Action (Ajzen and Fishbein 1980), and Protection Motivation Theory (Rogers 1983). Connor and Norman (1996), provide a detailed review of these models with respect to the general health literature on the uptake of exercise, health screening, use of prohibited substances, following a healthy diet.

These models emphasise the importance of individuals’ threat-related beliefs (e.g., perceived risk: see DeJoy 1996) as motivators of intentions to act. They have provided conceptual frameworks that form the basis of tailored health interventions. Such campaigns target specific threat-related cognitions and emotions (internal stimuli) shown to influence intentions (see figure 1). Whilst such models are applied frequently to general health behaviours, they are rarely applied to workplace self-protective behaviour. Six factors from these models were used in the current study and are detailed below (see figure 1).

2.1.1 Threat-Related Beliefs

These are beliefs held by the individual concerning the perceived severity of the consequences of exposure to a specific hazard, and the individuals’ perceptions of risk, (i.e., how likely they are to suffer adverse consequences of exposure to the hazard). Threat-related beliefs have been shown, in varying degrees, to influence individual’s intentions to take precautionary action for a wide range of health behaviours.

2.1.2 Self- Efficacy & response efficacy

Self-efficacy refers to an individual’s perception that they are capable of performing the action required to avoid harmful consequences. Perceived self-efficacy has been shown to be predictive of intentions to perform a variety of health behaviours (see Connor & Norman, 1996). Response efficacy refers to an individual’s perception that the advised precautionary action is an effective method of preventing the harmful consequences. Again, perceived response efficacy has been shown to predict behavioural intentions in several settings (see Connor & Norman, 1996).

2.1.3 Emotional Factors

Worry about the consequences of exposure to a health hazard is frequently measured in traditional models of health behaviour. Many health interventions seek to raise levels of

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fear/anxiety for the consequences of not taking precautionary action. The effectiveness of such interventions has been widely debated in the literature, as will be discussed later. Some studies show worry to be predictive of intentions and others show the opposite effect.

2.1.4 Perceived Barriers

This refers to an individual’s perceptions of control over their ability to perform the required precautionary behaviour. This may be especially relevant for workplace self-protective behaviour. Aspects of job design may interfere with the use of certain protective equipment in certain circumstances, or perceived time constraints may deter the uptake of certain safe practice. Studies have shown job-related barriers to influence non-compliance of use of personal protective equipment (Cleveland, 1984, Terrell, 1984). This is different from self­efficacy, which refers to the perceived ability to perform a behaviour. Thus a person may feel able to perform a particular behaviour, but their circumstances (e.g., time pressure, faulty equipment, social environment) prevent them from so doing.

2.1.5 Normative Expectations

This refers to the effect the social environment has upon uptake of safe practice. The effect of ‘social norms’, (i.e., whether colleagues support or encourage the recommended precautionary behaviour) has been shown to influence many health behaviours. A review by McAfee and Winn (1989) suggests that feedback from colleagues and supervisors in the workplace is one of the key determinants of uptake of safe practice.

2.1.6 Intentions

Whilst there are inevitable inconsistencies between intentions to act and actual behaviour (see Orbell and Sheeran 1998), a relationship between intentions and action is often found (see Ferguson, 1996, 2001). Previous studies have explored factors that influence intentions to follow safe practice for the behaviours focused on in the present project (i.e., use of ear defenders and following of manual handling guidelines) and as such intentions is an important link to this small existing literature.

All the above is based on the assumption that workers are aware of the risk and know what self-protective behaviours to use. However, it is surprising to note that the role of intervention materials themselves in predicting intentions to follow safe practice has received less attention in the field of workplace safety. Therefore, the discussion now turns to a brief examination of the literature on the use of leaflets for risk communication.

2.2 The Use of Leaflets in Risk Communication

A common method of communicating risk information is through the use of leaflets that highlight specific hazards and how to avoid them. These leaflets typically alert the individual to the negative consequences associated with a particular harmful behaviour, followed by recommendations for avoiding the potential harm. The use of leaflets in health promotion is widespread and may be a useful tool for three main reasons. First, they are relatively cheap to produce and easy to distribute, thus making them a potentially cost-effective intervention. Second, they are versatile, portable, and contain more information than posters. Third, they may be used alone or in conjunction with additional interventions (see Harvey et al. 2000). The main aims of a health promotion leaflet are to increase knowledge of a risk, improve

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attitudes towards the risk reducing behaviour, and ultimately to motivate behavioural change. The use of health promotion leaflets has been shown to be effective in these ways for a variety of health behaviours, even when used as a stand-alone intervention. For example, Watkins et al. (1987) studied the effectiveness of a leaflet for hypertensive patients sent out in the post. Patients who received the booklet, containing information on the condition and how to control it, were unaware they were taking part in a study. They, and a control group of hypertensive patients who did not receive the booklet, were followed up after one year. The authors found a significant increase in knowledge after one year in patients who had received the leaflet compared with the group who had not.

Whilst encouraging the widespread distribution and use of health leaflets is of interest to practitioners, leaflet design issues also need to be considered. Aspects of leaflet design may have a significant impact on their effectiveness. Three such factors are usability, usefulness and message framing.

2.2.1 Usability and Usefulness

Usability and usefulness are often explored together and so are discussed separately to framing. In order for leaflets to work as an effective intervention, however, the information must first be understood and considered relevant by the recipient. A serious barrier to effective risk communication is illiteracy. One fifth of the UK population is estimated to be functionally illiterate (Moser Report, 2000). Any intervention that aims to increase uptake of safe practice in the workplace should therefore be designed at a level that is easy to read and understand. Little work has been carried out on the readability and comprehensibility of workplace risk communication material. However, studies of other written health educational materials have highlighted potential problems.

Whilst it is accepted that knowledge of a health risk may not in itself be sufficient to influence a positive change in behaviour, it is considered to be a pre-requisite for movement to a stage where an individual contemplates a change in their behaviour (Baranowski, 1992­3). Materials provided to present information about a risk may not be accessible to an individual because they are written at a level that is too difficult to comprehend.

A study by Dollahite et al. (1996) reviewed the readability of 209 leaflets designed to provide information on a variety of health topics (e.g. smoking, diabetes, healthy eating, alcohol consumption, blood pressure). They concluded that the majority of the leaflets were not readable by many of the population with lower levels of literacy. 68 percent of the leaflets had a reading level above that able to be understood by someone with an average reading age. Alongside this finding, a study by Powers (1988) discovered that 50% of patients admitted to an accident and emergency ward had a reading ability less than 13 years of age. Streiff (1986) found health education materials were written at a level too difficult for over half of patients in an ambulatory care setting. Meade and Byrd (1989) concluded that a disparity existed between the level at which health promotion materials were written and the reading skills of target populations.

A few studies have attempted to find evidence that the readability of health information leaflets does influence their effectiveness. Calabro et al. (1996) studied this relationship using leaflets about avoiding alcohol in pregnancy. Previous findings had shown that many prenatal information leaflets were written at reading levels too high for the target audience (e.g., Zion and Aiman, 1989). Calabro et al. (1996) found that women reading a leaflet on alcohol and pregnancy written at a level for reading age 8 years showed greater changes in knowledge,

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attitude and behavioural intention (i.e., not to drink alcohol during pregnancy) than those who had read a leaflet written at a reading age of 15 years.

It is possible that individuals with higher reading levels may dislike leaflets written for lower reading levels, or find them offensive. However, studies have shown this not to be the case. Davis et al. (1996) demonstrated that parents of all reading levels preferred a simplified version of a vaccine information pamphlet than an earlier version with a higher difficulty. A further study showed comprehension was significantly greater for the lower reading level compared with the higher reading level leaflet (Davis et al. 1998). The authors also found that individuals with higher literacy levels were not insulted by the simplicity of the lower level leaflet, and no participants found either leaflet too simple. In general, people want easy-to-read materials rather than materials containing many technical terms (Breen, 1993).

2.2.2 Fear Appeals.

Whilst printed health communications have been shown to have some success in motivating behavioural change, many practitioners have begun to cast doubt on the effectiveness of mass health promotion campaigns. A sizeable proportion of health promotion materials use fear as a motivator. Studies have provided evidence of a bias towards negative information. Fiske (1992) found that negative information provokes a stronger reaction than positive information. One possible reason for this effect is that for most people, it is more important to avoid losses than to maximise gains (Highhouse and Pease 1996). Health promotion materials may attempt, therefore, to highlight negative consequences in order to optimise the message’s impact. Many of these materials are based upon psychological theories such as the Protection Motivation Theory. These theories suggest that persuasion can be induced by raising an individual’s perceptions of threat by presenting information relating to the consequences of harmful behaviour, and then reducing those feelings of threat and susceptibility by presenting coping information which provides effective solutions to that threat. It is assumed that the greater the reduction in the feelings of threat, the more effective the message will be in influencing behavioural change.

However the use of this type of message is beginning to be questioned. Many individuals faced with a high fear-arousing message continue to perform the harmful behaviour. Fear is an uncomfortable psychological state. Message recipients who already engage in the harmful behaviour will seek to reduce that state, but this may not be in an adaptive way, which would be to follow prescribed recommendations for avoiding the health risk. These messages may be ineffective for several reasons. Firstly, the message may be counter-argued, or its credibility doubted. Secondly, the recipient may disregard the message as they may perceive it as irrelevant. Finally, instead of processing the message at all, the recipient may divert his/her attention to non-message related activities (Keller, 1999). Whether a message should highlight negative information, emphasising the costs associated with not following a health recommendation, or highlight positive information emphasising the benefits associated with adhering to a health recommendation has been the subject of much debate over recent years. In addition to studying the effect of usability and usefulness in leaflet design, this project also considers the debate about use of fear as a motivator for behavioural change, with a specific emphasis on message framing effects drawn from work in Prospect Theory.

2.2.3 Prospect Theory and message framing

The study of ‘framing effects’ evolved from work on human decision-making processes. There is evidence that human cognitive processes are subject to a number of systematic

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biases that serve to distort how they process information about risk (Payne and Bettman 1992; Pidgeon et al., 1992). For a message to be effective, these cognitive biases must be addressed. Of specific importance here is the development of Prospect Theory by Kahneman and Tversky (1979, 1984: see also Tversky and Kahneman, 1981). Prospect Theory shows how decision-makers are influenced to choose different courses of action when faced with factually equivalent alternatives, depending on the ‘framing’ of information. Information can be framed in terms of ‘gains’ (sometimes referred to as positive frames), which stress advantages or benefits, or ‘losses’ (sometimes referred to as negative frames), which highlight disadvantages or costs. This was demonstrated originally, and has been replicated many times, by the following problem:

“Imagine that the UK is preparing for an outbreak of an unusual disease, which is expected to kill 600 people. Two alternative strategies to combat the disease have been proposed. Assume that the exact scientific consequences of the programmes are as follows”:

Frame 1 (gain/benefit)

PROGRAMME A: 200 people will be saved

PROGRAMME B: There is a 1/3 probability that 600 people will be saved and a 2/3 probability that no people will be saved.

Respondents must choose between programme A or programme B. Programme A represents a ‘sure thing’ or ‘certainty’. Programme B represents a ‘risky choice’. When faced with Frame 1 (the positive frame), respondents tend to choose A, the ‘certain’ option, over B, the ‘risky’ option (typically around 70% versus 30%). In this sense, they are said to be ‘risk averse’.

Frame 2 contains the same information but is framed as losses.

Frame 2 (loss/cost)

PROGRAMME C: 400 people will die

PROGRAMME D: There is a 1/3 probability that nobody will die, and a 2/3 probability that 600 people will die.

Respondents must choose between programmes C or D. Programme C represents the certainty. Programme D represents the risky choice. When faced with Frame 2 (the negative frame), the opposite results to Frame 1 are seen. Respondents tend to choose D, the ‘risky’ option, over C, the ‘certain’ option (typically around 80% versus 20%.). When faced with the information framed as losses, they are said to be ‘risk seeking’. The outcome of C and D are the same as they are for A and B. The only difference is the change from a gain frame (lives saved) to a loss frame (lives lost). This subtle difference dramatically alters how people perceive and respond to the information.

When gains (or positives) are made salient, people will tend to try to avoid negative consequences (in order to maximise gains), whilst when losses (or negatives) are emphasised people will tend to take chances (losses loom large). Framing has not been applied to health protective behaviours in the work place, but has been applied extensively to general health promotion.

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2.2.4 Framing Effects in Health Promotion

The idea of message framing has been refined and extended to address real world issues in health promotion. Health promotion messages tend to present information to the recipient outlining health risks, and offer recommendations on how to avoid those risks. The message recipient is faced with a choice of performing the recommendation, thus avoiding the risk, or ignoring the recommendation and remaining exposed to the risk.

Health related information can be framed in such a way as to emphasise either ‘negatives’ associated with not adhering to the recommended behaviour, or the ‘positives of adhering to the recommended behaviour. Knowing how best to manipulate the frame – presenting the information as either negatives or positives - can therefore have important persuasive consequences. Naturalistic Decision Making highlights the importance of complexities such as time constraints, ill-defined goals and high personal stakes, which characterise decision­making in real-world settings (Lipshitz et al., 2001). Although the study of framing effects has evolved from formal, laboratory-based decision-making settings, many studies have successfully applied framing effects to these ‘real-world’ situations, and have shown framing to influence actual behaviour (e.g. Detweiler et al., 1999).

The accumulated evidence suggests that framing effect for health related behaviours depend on the type of behaviour and two types are general distinguished: prevention and detection.

2.2.5 Prevention Versus Detection Behaviours

Rothman and Salovey (1997) reviewed the framing literature relevant to the health domain, showing that the type of health behaviour being promoted influenced which frame was more successful. Some health promotions seek to encourage behaviours that can detect a health problem, for example persuading women to examine their breasts to detect potentially dangerous lumps, or checking moles to detect early signs of skin cancer. Studies of framing effects for these behaviours have shown negatively framed messages to be more persuasive (Meyerowitz and Chaiken, 1987; Rothman and Salovey 1997). Alternatively, some health promotions seek to encourage behaviours that can prevent a health problem occurring, for example using sun-cream to prevent skin cancer, or using a seatbelt whilst driving to prevent injury in the event of an accident (Rothman and Salovey 1997; Treiber 1986). Studies of framing effects for these kinds of behaviours typically show positive framed messages to be more persuasive. For example, a study on message framing and tobacco use (Schneider et al., 2001) found positive frames to be more persuasive for smoking avoidance than negative frames.

A distinction has, therefore, been highlighted between how people will respond to framed messages encouraging prevention behaviours and those encouraging detection behaviours. Prospect Theory has shown people to be risk seeking when faced with losses (negatives), and risk averse when faced with gains (positives). Rothman and Salovey (1997) suggest that detection behaviours can be perceived as a risky choice – an individual runs the risk of detecting a health problem (e.g. breast self-examination). This may explain why negative frames are more persuasive for detection behaviours (risk seeking), whilst positive frames are more persuasive for prevention behaviours (risk aversion). To date, these theories have not been applied to an occupational setting. The current project seeks to rectify this by applying framing to two occupational risk behaviours, both of which would be defined as prevention behaviours: using ear defenders and using appropriate lifting techniques. These are

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prevention behaviours, as adopting the appropriate behaviour will reduce the risk of deafness and back-problems.

2.2.6 Framing Effects and involvement

Finally, within the occupational setting the construct of involvement may also be important. Framing effects may depend on how personally relevant the message is to the recipient. In a study on hypothetical infant immunisation, Donovan and Jalleh (2000) found no framing effects for highly involved respondents. However the positive frame was more persuasive for low involved respondents. Similarly, Maheswaran and Meyers-Levy (1990) found that, for taking a blood cholesterol test, low involved respondents (i.e. young adults told that the risk of cholesterol in people their own age was low) were more influenced by the positive frame.

Donovan and Jalleh (2000) argue that when recipients feel highly involved, they are less susceptible to framing effects, as comprehensive processing and consideration of the message will drive them to consider both negatives and positives. However, respondents with low involvement will be susceptible to other cues, for example the positive affect generated towards the recommended behaviour in a positive framed message.

In the occupational setting respondents may have varying degrees of involvement in terms of personal experience of family members or work colleagues having hearing or back-problems due to work related exposures. For these people message framing effects may not be so strong. As well as personal experience, other factors may influence the relationship between design factors of a leaflet and intentions. One such factor is past behaviour (see Ferguson and Bibby, 2002).

2.2.7 The influence of past behaviour

Ferguson and Bibby (2002: see also Oullette and Wood, 1998) have shown that with respect to a single behaviour people can be divided into those who do the behaviour occasionally and those who do it regularly. Different cognitive and emotional factors act as predictors for these two groups. The distinction between occasional and regular use has also been shown to map onto stages of change models (see Ferguson and Chandler, 2003). Stages of change models are based on the premise that for people to adopt and eventually maintain using safe behaviour they pass through a series of stages (Prochaska et al., 1992, 1994). These stages basically involve the person being made aware of the problem, deciding to act, acting, and eventually maintaining the behaviour. This distinction between occasional and regular use maps onto the acting and maintaining stages. A further component of these stage models is their emphasis on processes of change. The basic idea is that different interventions are best suited to people who need to be made aware of a problem, to those that are just about to start to do the behaviour to those who require encouragement to maintain the behaviour.

Based on these models, evidence shows that techniques such as counter conditioning (i.e., highlighting positive aspects of behavioural change) are likely to be effective for regular (maintaining) users (see Prochaska, et al., 1992). Counter conditioning has similarities to positive framing and therefore, those who regularly adopt safe working practise should be more likely to be influenced by positive frames. For people in the initial stages of action or occasional users, theory suggest that more experiential and/or emotionally arousing interventions are likely to be more effective (see Prochaska et al., 1992). Therefore, it might be that negative frames, which it is argued are more emotionally charged (see Rothman and

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Salovey, 1997), should be more effective for those who occasionally adopt safe working practises.

2.3 Summary and Aims.

It would appear that in general, for prevention behaviours positive framed messages have been shown to be more persuasive, and for detection behaviours negatively framed messages have been shown to be more persuasive.

To date, framing effects have not been systematically and experimentally applied to occupational risk behaviours and occupational risk communication. Occupational risk behaviours can be designated either as detections (e.g. using a radiation counter) or preventions (e.g. wearing personal protective equipment). The current project seeks to investigate framing effects for workplace risk communication messages. It is believed that similar effects to those demonstrated in the health literature can be extended to, and observed, in the occupational field. For detection behaviours messages should be more persuasive if they highlight losses (e.g. ‘if you do not monitor your radiation badge you could be exposed to dangerous levels of radiation’). Conversely for prevention behaviours a message framed as a positive should be more effective (e.g. ‘wearing your ear defenders will protect your hearing in later life’). The focus of the project will be on prevention behaviours, namely use of ear defenders and following of manual handling guidelines. Both issues are of relevance across many industries, and, as reported previously, cause high levels of occupational ill­health and financial loss in this country.

2.3.1 Noise

Noise at work and use of ear defenders is an important focus of study in the UK and around the world. A Medical Research Council (MRC) survey in 1997-1998 estimated that over half a million people in Great Britain suffer from work-related noise-induced hearing difficulties. Almost fifteen thousand of these receive disability benefit for occupational deafness. The highest incidence of occupational deafness is found in craft-related occupations and plant machine operatives. One of the particularly at risk settings is foundries and is therefore one of the settings for the current project.

Studies focusing on use of ear defenders in the workplace have traditionally been centred around the health behaviour models mentioned previously. In one study of 226 male employees working in noisy industrial plants, Rabinowitz et al. (1996) identified susceptibility, severity, effectiveness and barriers as significant predictors of use of ear defenders. In a manufacturing setting Malamed et al. (1996) founds predictors of ear protection to be perceived risk, perceived severity, perceived effectiveness and barriers. Similarly, Lusk et al. (1994) found response efficacy, perceived barriers, self-efficacy, gender and age to influence whether employees chose to use ear defenders.

2.3.2 Manual Handling

Encouraging employees to follow manual handling guidelines is also of great importance, not only for the health of those concerned but also for financial reasons. A survey carried out in 1995 showed that sickness absence due to poor manual handling cost employers £335 million per year. The rate of injury in the health professions is high. Half of all accidents reported to the HSE in health care are due to manual handling. 3600 nurses retire each year due to back

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injury caused by manual handling. Many of the studies which have examined ways to reduce these figures, have focused on ergonomic solutions (e.g., Corlett et al., 1992) and training in lifting techniques (e.g., McGuire and Dewer, 1995). Employee values and attitudes have also been implicated as leading to reluctance to follow safe practice (Hack, 1996).

2.4 Overall Summary of Aims.

The project will therefore comprise of a series of studies, all of which relate to use of ear defenders or manual handling. The main aim of the project is to demonstrate that appropriately framing occupational risk messages to highlight either negatives or positives, will increase intentions to perform prevention behaviours. In addition, current HSE leaflets will be assessed both objectively and subjectively in terms of their content, readability and usefulness. The relationship between these factors and leaflet recipients’ risk-related cognitions, emotions and intentions to follow guidelines will be examined. Recommendations will be made regarding the reading level and content of future HSE leaflets.

2.5 Project Studies

This project seeks to add to the traditional models of risk communication that typically focus on the individual differences outlined above. As was shown previously in figure 1, the primary aim was to assess the impact of aspects of leaflet design, specifically usability, usefulness and framing, on intentions. A secondary aim was to identify additional, individual differences that may influence intentions. Six studies are reported which aim to address the objectives.

2.5.1 Study 1: Objective usability analysis of current HSE leaflets on noise and manual handling

An objective content and readability analysis of a sample of current HSE leaflets on use of ear defenders and manual handling at work was undertaken. As reported earlier, many health promotion materials are written at a level that may be too difficult for much of their target audience. Current HSE leaflets were analysed using readability indices to assess their reading level. Comprehension tests were used to assess how easy they are to understand. A content analysis was performed to categorise the nature of the information contained within the leaflets. This was to identify whether these current leaflets are written highlighting positives or negatives.

2.5.2 Study 2: Subjective usability and usefulness analysis of current HSE leaflets

This was a subjective analysis of the perceived usability and usefulness of a sample of the current HSE leaflets. Whilst previous work had considered the readability of occupational risk information materials (Harvey et al. 2000), to date no work had been carried out exploring how this relates to intentions to follow recommendations. Employees from noisy workplaces and those involved in manual handling at work evaluated the leaflets. Respondents rated the perceived usability and usefulness of the leaflets and responded to items measuring their risk-related cognitions, emotions, and intentions to follow the advice given in the leaflets.

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2.5.3 Study 3: Developing Relevant Framed Messages – A Qualitative Study of Employees Involved with Manual Handling or Noise at Work

This was a qualitative study of employees’ perceptions of quality of life changes associated with the consequences of not following safe practice. Responses to these interviews were used to develop the new, experimental leaflets.

2.5.4 Study 4: The relationship between usability, usefulness, frames and intentions with respect to manual handling

To date no work had been carried out on the relationship between message frame and usability and usefulness of risk communications. The study explored this relationship. Domestic staff working in health care settings evaluated a current HSE leaflet and newly developed leaflets written either in a positive or negative frame. Cognitive and emotional measures were also taken. The relationship between all these factors and intentions to follow correct manual handling guidelines was examined.

2.5.5 Study 5: Framing intervention study for noise and manual handling

Newly developed leaflets written in either positive or negative frames were used to evaluate their effectiveness in persuading employees to increase their intentions to follow safe practice. Respondents were employees in both noisy workplaces and health care workers involved in manual handling at work. Pre-intervention measures were compared with post intervention measures. The success of the framing intervention was assessed in terms of employees’ risk-related cognitions, emotions, and intentions to follow recommendations. As was reported previously, a variety of cognitions may be relevant to health related behaviours (e.g. perceptions of control, efficacy, perceived risk). These variables were measured in the intervention study. Frames may have differential effects on different cognitions, and it may be these that relate to changes in intentions.

2.5.6 Study 6: The effect of narrative structure on intentions to follow safe practice for manual handling

This study manipulated the order of the consequences and solutions sections of experimental leaflets and explored the effect on users’ intentions, cognitions and emotions. These factors and ratings of the usability and usefulness of the leaflets were analysed to identify predictors of intentions to follow safe practice.

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3 Study One: Readability and Content Analysis of Current HSE Leaflets on Noise and Manual Handling

Usability of a text is dependent on how easy the material is to read and understand. The following sections will explore issues of readability, comprehension and message content.

3.1 Readability

Readability of health promotion materials can lead to knowledge increase and heighten the persuasion of a message. Current HSE leaflets on noise and manual handling will be analysed for their readability.

Increasing the readability of a text can increase the reader’s level of motivation and interest in the topic. Readability is also directly related to comprehension. The readability of a text can depend on many factors, including print legibility, use of illustrations, and the complexity of words and sentence structure. If a reader has difficulty reading a text fluently, they may become discouraged and fail to complete or comprehend the message effectively.

Word complexity, sentence structure and length are easily measured with standard readability formulae There are approximately 40 different readability formulae (D’Alessandro et al., 2001). Typically, readability formulae produce a ‘reading age’ for the text. This refers to the chronological age of a reader who could just comprehend the analysed text. Consequently, if a text has a reading age of 16 years, it is able to be understood by someone with the reading level of an average 16 year old.

Flesch Reading Ease Score

Style Average Reading Age

Typical Reading

90-100 Very easy 9-10 Comics 80-89 Easy 10-11 Pulp fiction, The Sun 70-79 Fairly easy 11-12 US News 60-69 Standard 12-14 Sherlock Holmes, Reader’s

Digest, The Daily Mirror 50-59 Fairly difficult 14-16 Secondary school texts,

magazines such as Harper’s 30-49 Difficult 17-22 A level texts, undergraduate

texts, The Guardian 0-29 Very difficult 22+ Professional journals,

postgraduate texts

Table 1: Flesch scores for typical texts adapted from Singer & Donlan (1989)

There are several objective methods of assessing the readability of a text. These mostly involve counting the numbers of words and sentences in paragraphs, counting the number of syllables, finding average sentence and word lengths and applying readability formulae. For the purpose of this study, the Flesch Reading Ease Score and Flesch-Kincaid Grade level scores will be used to assess the readability of current HSE leaflets on noise at work or manual handling guidelines. The Flesch Reading Ease formula yields scores ranging from 0­100. Scores are calculated using sentence length and polysyllabic words. The lowest score achievable (i.e., 0) represents the highest difficulty text. A score of 100 represents text with

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the lowest possible difficulty. Using this scale, ‘Plain English’ is considered to be text that falls within the range of 60-70. The Flesch-Kincaid Grade score gives a US grade level for grades from 3-12 (for example a score of 6 means that an average sixth grader could understand the document). The Flesch-Kincaid cannot distinguish between text that is more or less difficult than this range. To make these US grade levels compatible with the UK, reading age is calculated by adding 5 to the grade level. For example, text with a Flesch-Kincaid grade level of 6 is equivalent to a reading age of 11 years. Table 1 shows the calibration for this scale.

3.2 Comprehension

A sample of current HSE leaflets on noise and manual handling were analysed for their comprehensibility. The readability of a text is directly related to how easy it is to comprehend. Comprehension of a text can be assessed using the Cloze procedure (Taylor, 1953). Cloze testing, from the word ‘closure’, is based upon the concept that an individual will only be able to complete a task once its pattern has been determined. ‘A Cloze unit may be defined as: any single occurrence of a successful attempt to reproduce accurately a part deleted from a ‘message’ (any language product), by deciding from the context that remains, what the missing part should be.’ (Taylor, 1953). Cloze testing can assess the predictability and comprehensibility of a passage of text.

The Cloze procedure consists of a passage of text that contains missing, deleted words. The subject must try to determine what the missing word is, using their knowledge of the language and the context of the rest of the text. There are five main types of Cloze test. In the fixed rate deletion test, every nth word (usually the fifth or the seventh) from the text is deleted. In the selective deletion test, the test compiler chooses which words he/she wishes to delete. In multiple-choice cloze tests, the subject is offered a selection of words to choose from to complete the blanks. In the ‘cloze elide’, incorrect words instead of blanks are inserted into the text – the subject must identify the incorrect words and replace them with a more appropriate word. Finally in the ‘C-test’, a part of every second word is deleted from the text – the subject must complete the missing parts. For all of these tests, increased comprehension is indicated by a higher number of blanks being appropriately filled. Exact word or SEMAC scoring may be used. With exact scoring, a word is identified as being correct only if it matches the exact word that was deleted originally. With SEMAC scoring, subjects may be given a ‘correct’ point if the word is not an exact match, but is still grammatically and lexically appropriate. The optimum length of a Cloze test, i.e. numbers of words deleted from the text is reported to be around 20-25.

3.3 Message content

Current HSE leaflets relating to noise and manual handling were analysed to determine whether they were framed positively or negatively. In addition, the content of the leaflets was analysed to discover the proportion of the text that was devoted to particular subject matter. Most health promotion materials contain information outlining the risks, or causes, of a health problem. In addition they provide information on the consequences of exposure to those risks, and offer solutions on how to avoid those consequences. For the current study, the HSE leaflets were content analysed to determine the percentage of text devoted to these three main categories: causes, consequences and solutions.

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3.4 Aims of Study

There are three main aims -

· to obtain individual and average readability scores for current HSE leaflets on noise at work or manual handling at work.

· to use the Cloze procedure on a sample manual handling leaflet and a sample noise leaflet to identify how easy they were to understand.

· to content analyse current HSE leaflets to determine the percentage of their text devoted to the main and sub-categories.

3.5 Leaflet selection

A sample of noise and manual handling leaflets currently available from the HSE were sampled and analysed. The sample consisted of all the leaflets available through the HSE library at the time of the study. The end sample consisted of 13 leaflets on noise at work and 10 leaflets on manual handling/musculoskeletal disorders (MSD) (see appendix 1 for lists of titles). All sample leaflets were scanned into a computer.

3.6 Readability analyses

3.6.1 Method

The scanned leaflets were analysed for reading age using a built-in Microsoft Word readability program. This program generates Flesch Reading Ease and Flesch-Kincaid Grade levels.

3.6.2 Results

A full list of Flesch Reading Ease scores and reading ages for individual HSE leaflets can be found in appendix 2. Table 2 shows average and range of readability scores for the leaflets.

Average Readability Manual Handling/ MSD Noise (n=13) (n=10)

Flesch Reading Ease 58.4 (fairly difficult’) 58.8 (fairly difficult) Flesch-Kincaid Grade 8.5 (13.6 years) 8.7 (13.7 years) Level

Range of Scores Reading Ease Manual Handling/MSD Noise ‘Easiest’ 77.9 (11.9 years) ‘Watch Your 85.6 (9.1 years) ‘Hear

Back’ This!’ ‘Most Difficult’ 47.8 (15 years) ‘Work Related 44.3 (15.8 years)

Upper Limb Disorders’ ‘Protection of Hearing’

Table 2: Readability scores for HSE leaflets (noise and manual handling)

The results of the readability analysis show that the average reading level for the manual handling leaflets was 58.4 (average reading age 13.6 years). This falls within the range

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defined as ‘fairly difficult’. There was a large variation in reading levels between the leaflets, with the most difficult having a reading ease score of 47.8 (reading age 15 years). This falls within the range defined as ‘difficult’.

The average reading ease score for the noise leaflets was 58.8 (reading age 13.7 years). This also falls within the range defined as ‘fairly difficult’. Again, a large variation between the readability scores for the noise leaflets was found. The most difficult leaflet had a reading ease score of 44.3 (reading age 15.8 years). This is defined as ‘difficult’. The easiest leaflet had a reading ease score of 85.6 (reading age 9.1). This can be defined as ‘easy’.

3.7 Comprehension analyses (the Cloze test)

3.7.1 Participants

Subjects were a convenience sample of 21 university undergraduate and postgraduate students (11 subjects for manual handling, mean age 23, 10 subjects for noise, mean age 21).

3.7.2 Method

One leaflet on manual handling and one leaflet on noise at work were selected to be Cloze tested. The leaflets chosen were those that most closely represented the average readability scores for all the HSE leaflets tested. Cloze tests were prepared for each leaflet using the ‘fixed rate deletion method’. Every 5th word of the text was deleted from a passage containing about 250 words. These were the first 250 words from the leaflets. The prepared Cloze tests for noise and manual handling can be seen in Appendix 2. A section of the noise Cloze test can be seen in figure 2. Subjects were asked to complete the missing parts of the text by filling in the blanks with a word that they thought was most appropriate.

“The dangers ________ noise are often underestimated. ________ can grow so used ________ excessive noise levels that ________ accept them as a ________ part of their working ________ - but in fact they ________ beginning to lose their ________. They may not even ________ aware that their hearing ________ deteriorating until it is ________ late, when the inner ________ has been damaged. This ________ an irreversible deafness that ________ be corrected using a ________ aid, unlike other types ________ deafness.”

Figure 2: Section of noise Cloze test as used in the current study

3.7.3 Results

Tests were marked using the exact word scoring method. Table 3 shows the results of the Cloze tests for the manual handling leaflet and the noise leaflet. Mean Cloze score represents the percentage of the blanks that were correctly filled by the subjects. Scores under 45% can be translated as meaning the text caused ‘frustration’ for the subject. 45-60% = ‘material can be used with the help of a teacher’. Over 60% = ‘little or no difficulty’.

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‘Handling the News’ (n=11) ‘Noise’ (n=10) Mean Age of Subject 23 21 Mean Cloze Score 57.8% 48.6% Median 58 50 Range 16 (min 50, max 66) 18 (min 41, max 59)

Table 3: Results of Cloze tests on HSE documents

Results show that for both the manual handling and the noise leaflet, undergraduates achieved a level of comprehension needing, on average, ‘help from a teacher’ to understand the materials. 3 subjects failed to reach a level of comprehension above ‘frustration’.

After the initial Cloze test, the ‘noise’ leaflet was re-written to increase its readability. Reducing word and sentence length and rewriting passive sentences did this. The content of the text was kept the same. The readability of the passage was increased from 55.9 (reading age 14.5) to 70.2 (reading age 12). 10 additional undergraduates (mean age 22) were then asked to complete the Cloze procedure on the passages with increased readability. Results from the test are shown in table 4.

‘Noise’ (original) Flesh Score = 55.9 (age 14.5)

‘Noise’ (increased ease) Flesch Score = 70.2 (age 12)

Mean Age of Subject 21 22 Mean Cloze Score 48.6% 63.4% Median 50 63 Range 18 (min 41, max 59) 22 (min 54, max76)

Table 4: Results of Cloze tests for original ‘Noise’ and increased reading ease ‘Noise’ leaflets

Results show that increasing the readability of the leaflet increased the level of comprehension achieved by undergraduates. The average Cloze score was raised to 63.4% from 48.6%. This score indicates subjects had ‘little or no difficulty’ understanding the text. A t-test showed the increase in comprehension to be significant.

3.8 Content analyses

3.8.1 Method

All 23 leaflets (previously scanned into a computer) were analysed with the aid of QSR NUDIST, a qualitative data analysis software package. NUDIST supports the process of coding data into an index system, allowing searches of text and patterns of coding. Inter­coder reliability between two researchers was high (81% concordance including sub­categories).

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DEFI

ICS I

I

I IONSRISK FACTORS GENERAL FACTS

NING THE PROBLEM

STATIST

PHYSICAL LIFESTYLE

NDIVIDUAL HEALTH EMPLOYER

CONSEQUENCES

FURTHER INFO

EMPLOYER EMPLOYEE

ADVICE

MANUFACTURERS

EQU PMENT

SOLUT ONS REGULAT

CONTROL

ROOT

Figure 3: The main categories and sub categories identified from the content analysis of the leaflets

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3.8.2 Results

Content fell into 3 main categories and further sub-categories. These are illustrated in the index tree shown in figure 3. ‘Root’ refers to all text. The 3 main categories were coded into smaller sub categories. ‘Defining the problem’ sub-divided into ‘risk factors’ and ‘general facts’ about the hazard. ‘Consequences’ sub-divided into ‘statistics’, ‘consequences’ to individual health (physical and lifestyle) and to the employer. ‘Control’ sub-divided into where to find ‘further information’, ‘solutions’ to the problem (advice to employer and employee), and information on the ‘regulations’. The number of sentences falling under each of the categories and sub-categories was analysed for each leaflet, and also averaged for all leaflets. Results of the content analysis for each individual leaflet for all categories and sub­categories can be seen in appendix 3. Average results can be seen below in table 5.

Totals for All Documents for Main Categories Category Defining the Problem Consequences Control Sentences 523 188 1354 % of Total 22.8% 8.2% 59%

Table 5: Distribution of type of content for main categories of information

Individual leaflets varied greatly in the proportion of content dedicated to the three main categories: Defining the Problem (e.g., risk factors, general facts about noise/manual handling); Consequences (e.g., to the employer through absenteeism, lost production etc., to the employees'’ physical health or lifestyle, statistics about prevalence); and Control of the Problem (e.g. through referral to other sources of information, description of the Regulations, description of specialist equipment, or advice aimed at employers or employees).

Most of the leaflets devoted less than 10% of the total content to statements relating to the potential consequences of noise/manual handling. One in six of these contained no statements at all. A quarter of the leaflets dedicated less than 10% of the total content to statements defining the problem (e.g., risk factors/causes). The majority of the content of all documents was dedicated to describing solutions to the problem. In some cases, however, much of this was taken up by descriptions of the regulations or facts about equipment. For example, in ‘Don’t Put Your Back Into It’ 30% of the total content is dedicated to controlling the problem. However, 18% of this is description of the Regulations, and there are no statements offering advice specifically directed at the employee. Over 40% of leaflets analysed dedicated less than 1% of the total content to advice for the employee. Some leaflets did have a high content dedicated to advice specifically for the employee. The highest of these was ‘Protect Your Hearing’, with 86%. However there were no statements in this leaflet describing the causes or consequences of the problem.

3.8.3 Framing analyses

The leaflets were also analysed for the number of positively framed statements (those relating to the health benefits of following the recommendations), versus the number of negatively framed statements (those relating to the health costs associated with not following the recommendations). Less than 10% of total statements contained ‘framed’ information (156 statements). Of these, only 6 statements (0.3% of the total statements) were framed positively (e.g. ‘The everyday sounds and noises we hear help keep us in touch with the world around us). The remaining framed statements were framed negatively (150 statements, or 6.5% of

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total statements). For example, ‘Once ears have been damaged by noise there is no cure’. Examples of all categories and framed statements can be seen in appendix 3.

3.9 Discussion

The results from this study suggest that

· many of the current HSE leaflets are written at a level that may be too difficult for much of their target audience.

· readability scores varied widely between leaflets, with some written at levels suitable for undergraduate textbooks or broadsheet newspapers.

· cloze testing carried out on the materials using undergraduate students showed that many had difficulty understanding the information. Poor comprehension caused by high readability levels of risk communication materials can be a major barrier to effecting behavioural change in target employees, i.e. uptake of safe practice.

· The content of the messages is not equally balanced between causes, consequences and solutions.

These findings are expanded on below.

3.9.1 Readability and comprehension

A direct relationship was demonstrated between the readability level of the leaflet and the level of comprehension achieved by Cloze test subjects. This demonstrates how simple changes to a text can cause dramatic changes in comprehension levels. As has been demonstrated in the readability studies reported earlier, this could cause an increase in knowledge, leading to more positive attitudes and an increase in safe practice.

3.9.2 Content

The content analysis revealed a wide variation in the proportion of leaflets dedicated to the three main categories usually used in health promotion materials, (i.e. causes, consequences and control). Many leaflets contained only a very small amount of information outlining the consequences of not following guidelines. To date there has been little, if any, work looking specifically at the effects of content proportion dedicated to these main categories. It seems likely, however, that a leaflet that gives no information to the reader about the benefits of following recommendations, or indeed the consequences of not following recommendations, may be less effective in promoting safe and healthy behaviour. Studies suggest that adults prefer to read text in a problem to solution pattern (Bettinghaus and Cody, 1987). Leaflets that contain a balance between cause, consequence and control may therefore be more effective than those that contain no information in one of these categories. Further study in this area is needed to determine how manipulating the content of risk communication materials can affect levels of persuasion.

3.9.3 Framing

Finally, this study found that the majority of the framed information contained in the leaflets was framed negatively. Only a tiny number of statements highlighted the benefits of

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following recommendations. Most statements regarding the consequences of failing to follow safe practice were framed negatively. Again, framing can be manipulated relatively simply. For example, where a negative statement might say ‘if you do not wear your ear defenders you risk permanent damage to your hearing’, an equivalent positive statement would say ‘by wearing your ear defenders you can avoid permanent damage to your hearing’. The final two studies in this series seek to determine whether framing occupational risk information in this way is more effective than framing it negatively.

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4 Study Two: Subjective Usability and Usefulness Analysis of Current HSE Leaflets on Noise and Manual Handling.

The previous study objectively assessed the usability of current HSE leaflets. Many of the leaflets have very low reading ease scores. The effect of this on comprehension was demonstrated by Cloze testing on undergraduates. These subjects failed to achieve adequate levels of comprehension for the leaflet written with low reading ease. When rewritten, however, with increased reading ease, subjects demonstrated that they understood the material with little or no difficulty.

There have been many studies examining the readability of health promotion materials and health related risk information. These have shown that the majority have reading levels that are too difficult for many of their target audience. Very few of these studies have examined occupational health and risk information materials. The initial objective analysis of the health and safety leaflet sample performed for the current research programme showed that they are difficult to read and understand. A remaining question was how employees, the intended recipients of such materials, would subjectively evaluate the leaflets.

The current study sought to explore how employees involved with noise and manual handling at work rated a sample of current health and safety leaflets relevant to their occupation. The effect of perceived readability and relevance of this type of literature on persuasion has not been studied to date. Traditionally, studies of intentions to perform recommended health behaviours explore the effect of various cognitive and emotional factors. The current study sought to link some of these factors to factors relating to the leaflets, and how these affected respondents’ intentions to follow the safety advice given in the leaflet. The study measured traditional, theory-derived factors shown to influence intentions. These were perceptions of risk, perceptions of worry and seriousness, prior exposure to the health problem, and biographical factors. It addition respondents were asked to rate the leaflets in terms of their perceived usability and usefulness. All these factors were then examined for their effect on intentions to follow safe practice.

4.1 Aim of the study

The aim of the study was to examine the relationship between a number of factors on leaflet users’ intentions to follow safe practice. These factors were traditional cognitive (e.g., risk perception), emotional (e.g., worry) and biographical (e.g. age) factors as well as assessment of usability and usefulness. The study was carried out using two occupational groups: employees in noisy workplaces and health care employees involved in manual handling.

4.2 Method

4.2.1 Participants

Manual handling sample– 245 health care professionals including qualified nurses, auxiliary nurses, student nurses, physiotherapists and radiographers were sampled (of those who indicated gender, 203 were females, 28 were males). The mean age of the sample was 30 years (range 18-59). The mean number of years in the job was 12 (range 0.5-35 years). Participants for the manual handling evaluation were recruited at the beginning of manual handling training sessions.

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Noise sample – 200 workers employed in noisy environments, including 130 foundry workers and 70 mineworkers were sampled (196 males, 4 females). The mean age of the sample was 40 years (range 20-62). The mean number of years in the job was 10 (range 0.5-44 years). Subjects for the noise evaluation were recruited during health and safety training sessions or approached individually on site and asked whether they would participate.

4.2.2 Materials

4 leaflets were evaluated, 2 for manual handling and 2 for noise.

Manual handling leaflets – 2 leaflets were selected. The HSE do not produce a manual­handling leaflet specifically designed for use by health care staff. Therefore, it was necessary to choose a general manual handling leaflet, ‘Getting to Grips with Manual Handling’, to be evaluated. This leaflet was selected because it had an average reading ease level (Flesch score = 61, reading age 12.1). The Royal College of Nursing (RCN) produce a manual-handling leaflet specifically designed for use by health care staff. Therefore, half of the participants were asked to evaluate the RCN, ‘Guide to Patient Handling’, in order to explore the influence of relevance on intentions. This leaflet had a Flesch reading ease score of 46, reading age 15, which is ‘difficult’.

Noise leaflet – 2 leaflets were selected. These were ‘Noise at Work’, with a Flesch reading ease score of 71 (reading age 11.9), and ‘Noise in Foundries’, with a Flesch score of 65 (reading age 12.8). Participants at the foundry were asked to evaluate ‘Hearing Protection in Foundries’. Participants at the mine were asked to evaluate ‘Noise’.

4.2.3 Measures

Questionnaires were developed to obtain ratings of the leaflets and measures of cognitive and emotional factors as well as the usability and usefulness of the leaflets. The items were developed based on theories of health behaviour and measured risk-related cognitions, emotions, and intentions. Biographical data was also obtained.

The assessment of Usability and Usefulness –7 items asked respondents how usable and useful the leaflets were. These items were ‘how easy is the leaflet to read’; ‘how easy is the information to understand’; ‘how easy is the information to remember’; ‘how informative do you find the leaflet’; ‘how relevant do you think the leaflet will be in your work’; ‘how accurate do you think the information provided is’; and ‘how helpful do you think the information will be in your work’. Items were scored by participants on a 5-point Likert-type scale ranging from 1 (not at all) to 5 (extremely).

The assessment of cognitive and emotional factors – questionnaire items measured: respondents’ perceived risk to themselves ‘to what extent do you feel you are personally likely to suffer injury/ill health as a result of manual handling/noise’; perceived risk to others ‘to what extent do you feel your colleagues are likely to suffer injury/ill health as a result of manual handling/noise’; worry ‘are you concerned about developing back pain/hearing problems through your work’; and perceived seriousness ‘do you feel back pain is a serious health problem’. These items were also measured on a 5-point Likert-type scale ranging from 1 (not at all) to 5 (extremely).

Assessment of exposure to health problems - exposure to the health problem was measured with the items: ‘have you ever suffered back pain/hearing problems that you attribute to

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manual handling/noise at work’ and ‘do you know anyone who has suffered back pain/hearing problems through manual handling/noise at work’. These were assessed used a yes/no tick box.

Assessment of Intentions: Participants’ intentions to follow the advice given in the leaflet were measured with the following items: ‘how likely is it that you will follow the advice given in the leaflet next time you are handling loads/in a noisy area at work’, and ‘how likely is it that you will follow the advice given in the leaflet in the future’. These were measured on a 5-point scale, with 1 being ‘not at all’ and 5 being ‘extremely’.

Assessment of Bio-graphics: Participants were also asked their age, gender, and years in job. A copy of the questionnaires used for this study can be found in appendix 4.

4.2.4 Procedure

The procedure used was consistent for both manual handling and noise. All participants were asked to read a copy of one of the appropriate leaflets. Once they had finished reading the leaflet they were then asked to complete the questionnaire. Participation in the study was voluntary. Respondents were asked to sign a consent form agreeing to take part. They were assured that all data collected would remain confidential and anonymous, and that all data would be used only for the purposes of the research.

4.3 Results

Results were collated and analysed using SPSS version 10. Manual handling and noise data were analysed separately. Manual handling results will be reported here first, followed by noise results. Additional statistical detail for all analyses can be found in appendix 5.

4.3.1 Manual handling data analyses

4.3.1.1 Perceived Usability and Usefulness

Figure 4: Components identified for ratings of manual handling leaflets

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A principal components analysis followed by varimax rotation (see Ferguson and Cox, 1993) was carried out on responses to the leaflet evaluation items. Results revealed that subjects identified 2 separate components to the leaflets. 2 separate scales were therefore constructed. These were ‘usability’ and ‘usefulness’. Items making up each component can be seen in figure 4.

‘Usability’ contained items relating to the ease of the leaflets to read, understand and remember. ‘Usefulness’ contained items relating to the relevance, helpfulness and accuracy of the leaflet. As ‘informative’ loaded on to both factors, it was subsequently dropped from further analyses. A high score for usability meant the leaflet was perceived to be easy to read, understand and remember. A high score for usefulness meant the leaflet was perceived to be accurate, relevant and helpful.

4.3.1.2 Factors Influencing Perceived Usability and Usefulness of the Leaflets

Data was analysed to examine the relationships between perceptions of usability and usefulness, and the cognitive, emotional and biographical factors measured. The influence of these factors on intentions to follow recommendations was also examined.

Results comparing usability and usefulness ratings of both leaflets can be seen in figure 5.

Mean ratings for usability and usefulness of leaflets

Mea

n

4.1 4

3.9 3.8 3.7 3.6 3.5 3.4 3.3

RCN

HSE

Usability Usefulness

Measure

Figure 5: Mean leaflet ratings for both manual-handling leaflets

There were no differences in respondents’ ratings of the usability of the two leaflets. As would be expected given the occupational relevance of the RCN leaflet, participants found the RCN leaflet significantly more useful than the general HSE guide. In particular, participants found the RCN leaflet more relevant and helpful.

4.3.1.3 Factors Influencing Perceived Risk

Perceived risk of injury through manual handling was shown to be influenced by participants’ prior exposure to back pain. Figure 6 shows participants perceived risk of injury to themselves and others by exposure group.

The most highly exposed participants rated their own risk of injury through manual handling at work higher than the other groups. Those who know someone with back problems but have never experienced problems themselves view their own risk of harm as smaller than other’s

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risk of harm. In addition, for all groups together, participants rated their own risk of injury as significantly lower than the perceived risk to others.

3.8 3.7 3.6 No Exposure 3.5 3.4 Know Someone 3.3

Know Someone & 3.2 Personal Experience

3.1 3

Risk Self Risk Others

Figure 6: Perceived risk to self and other through manual handling at work by exposure to back pain

4.3.1.4 Factors Influencing Worry and Perceived Seriousness

Prior exposure to back problems also influenced how worried participants were about back pain and how serious a health problem they perceived it to be. Figure 7 shows levels of worry and perceived seriousness by prior exposure group.

4.8 4.6 4.4

No Exposure 4.2

4Know Someone

3.8 3.6 Know Someone & 3.4 Personal Experience 3.2

3Worry Seriousness

Figure 7: Worry about and perceived seriousness of back pain or injury caused by manual handling at work by prior exposure group

Results show that with increasing exposure to back pain, participants are more worried about the problem. All participants view the problem as serious. Figure 8 shows how level of work experience affected worry about back pain.

Whilst both student nurses and working health care professionals view back pain as equally serious, student nurses were significantly more worried about suffering from it than experienced nursing staff.

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3

4

3.2 3.4 3.6 3.8

4.2 4.4 4.6 4.8

Student Working

Worry Seriousness

Figure 8: Students and working health care professionals’ level of worry and perceived seriousness of back pain

4.3.1.5 Predictors of Intentions to Act

The data was analysed to discover predictors of intentions to follow the advice given in the leaflets. Both leaflet ratings and cognitive and emotional factors as well as biographical data were entered into a linear regression. Full statistical details of the linear regression can be found in appendix 5. Table 6 shows the percentage of variance in intentions to follow the advice given in the leaflet explained by all factors.

Variables % Cumulative % General Biographics Age *Sex Experience

4% 4%

Prior Exposure Back Pain – Self Back Pain – Others

1% 5%

Perceived Risk & Emotional Response Risk – Self Risk – Others Worry *Seriousness

9% 14%

Leaflet Ratings *Usability *Usefulness

19% 33%

Table 6: Predictors of intentions to follow manual handling guidelines

An asterisk denotes the variable is a significant predictor of intentions to follow the advice given in the leaflet. The regression shows that 33% of the variance in participants’ intentions to follow the advice can be explained by the variables measured. The only biographical predictor of intentions was sex, with females more likely to follow the advice than males. Neither prior exposure nor perceived risk of injury predicted intentions. Worry did not predict intentions to follow the guidelines. However, perceived seriousness of back pain as a health problem did significantly predict intentions, with higher perceived seriousness predicting greater intentions scores. The largest predictors of intentions to follow the guidelines were the ratings of the leaflets. The perceived usability and perceived usefulness of the leaflets

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themselves both predicted intentions to follow the recommendations. Higher ratings of usability and usefulness predicted greater intentions.

4.3.2 Noise data analyses

4.3.2.1 Perceived Usability and Usefulness

As with the manual handling data, a principal components analysis followed by varimax rotation was carried out on noise participants’ responses to the leaflet evaluation items. Again, results revealed that participants identified 2 separate components to the leaflets. Two similar separate scales were, therefore, constructed. These were, again, ‘usability’ and ‘usefulness’. Items making up each component can be seen in figure 9.

Figure 9: Diagram to show identified components for ratings of noise leaflets

The 2 noise scales differed slightly from those developed from the manual handling data. ‘Usability’ contained items relating to the ease of the leaflets to read, understand and remember. This was the same as the manual handling data. In addition to these items, accuracy was also related to ‘usability’. ‘Usefulness’ contained items relating to the relevance and helpfulness of the leaflet, and how informative it was perceived to be.

4.3.2.2 Factors Influencing Perceived Risk

Perceived risk of damage to hearing through noise at work was shown to be related to participants’ prior exposure to occupational hearing problems. Figure 10 shows participants perceived risk of damage to hearing to themselves and others by exposure. Results showed that prior exposure to hearing damage caused by noise at work had a significant effect on participants’ perceptions of risk. Perceived risk rises significantly with increased exposure to the problem. Those with no exposure reported the lowest perception of risk of damage to hearing. Those with the highest exposure, i.e. having suffered themselves and knowing someone who had suffered, had the highest perceived risk, both for themselves and others. In addition, for all groups together, participants rated their own risk of injury as significantly lower than the perceived risk to others. Perceived risk to self and others was significantly correlated with worry.

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4.3.2.3 Factors Influencing Worry and Perceived Seriousness

Prior exposure to hearing problems also influenced how worried participants were about occupational deafness and how serious a health problem they perceived it to be. Figure 11 shows levels of worry and perceived seriousness by prior exposure group.

3

4

i

3.2

3.4

3.6

3.8

4.2

4.4

4.6

Mean

No Exposure

Know Someone

Know Someone and Personal Exper ence

Personal Others

Figure 10: Perceived risk of hearing damage to self and others through noise at work by exposure to occupational hearing problems

3

4

i

3.2

3.4

3.6

3.8

4.2

4.4

4.6

4.8

Mean

No Exposure

Know Someone

Know Someone and Personal Exper ence

Worried Serious

Figure 11: Worry about and perceived seriousness of hearing problems caused by noise at work by prior exposure group

Results show that with increasing exposure to hearing problems, participants are more worried about the problem. However, all three groups viewed the problem as equally serious.

4.3.2.4 Predictors of Intentions to Act

The data was analysed to discover predictors of intentions to follow the advice given in the leaflets. Both leaflet ratings and cognitive and emotional factors as well as biographical data were entered into a linear regression. Full statistical details of the linear regression can be found in appendix 5. Table 7 shows the percentage of variance in intentions to follow the advice given in the leaflet explained by all factors.

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Variables % Cumulative % General Biographics Age Site Years in Company Years in Job

3% 3%

Prior Exposure Hearing Problems – Self Hearing Problems – Others

0% 3%

Perceived Risk & Emotional Response Risk – Self Risk – Others Worry *Seriousness

6% 9%

Leaflet Ratings *Usability Usefulness

17% 26%

Table 7: Predictors of intention to wear ear defenders when working in noisy environment

An asterisk denotes the variable is a significant predictor of intentions to follow the advice given in the leaflet. The results show that 26% of the variance in intentions to wear ear defenders can be explained by the factors measured. There were no biographical predictors of intentions. As was seen with the manual handling data, neither prior exposure to the problem nor perceived risk significantly predicted intentions. Worry again failed to predict intentions. In another reflection of the manual handling data, perceived seriousness was a significant predictor, with higher perceived seriousness predicting greater intentions. However, the largest single predictor of intentions to follow the advice given in the leaflet was the perceived usability of the leaflet. This highlights the importance of these features of leaflet design in influencing intentions.

4.4 Behavioural analysis of PPE use.

The current study sought additionally to explore the effect of the evaluation study on actual behaviour.

4.4.1 Method

A counter system was devised in order to establish the number of earplugs being taken from dispensers placed at 3 locations at the mine. The counters were fitted in co-operation with site managers, and pre and post leaflet evaluation readings were taken. Employees were unaware that earplug uptake was being measured.

4.4.2 Results

Figure 12 shows the measurements for a period of 13 days prior to the evaluation of the leaflets, and for the period 13 days after the evaluation.

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500 450 400 350 300

ear plugs taken 250200 150 100

50 0

pre post

1 2 3

location of dispenser

Figure 12: Number of earplugs taken 13 days pre and 13 days post leaflet evaluation at 3 sites at the mine

Use of the earplug dispensers was shown to increase significantly at all three dispensers. Use of earplug dispensers increased across locations 1, 2, and 3 by 35%, 70% and 571% respectively.

4.5 Discussion

The current studies revealed 3 main findings related to the design of occupational risk leaflets :

· Participants distinguished between two components of the leaflets: usability and their usefulness. Usability concerns how easy they are to read, understand and remember. Usefulness concerns how relevant and helpful they are perceived to be. For manual handling, judgements of usefulness of a leaflet were related to its occupational relevance.

· Usability and usefulness were the biggest predictors of intentions to follow safe practice, over and above the influence of cognitive and emotional factors.

· An evaluation study of an easy to read leaflet was shown to be effective in influencing an index of behavioural change1.

In addition to these main results, subsidiary findings were revealed. Different groups identified within the overall sample population varied in their cognitions and emotional responses to the risks outlined in the leaflets. Results from this study showed that leaflets could play an important role in influencing employees’ intentions to follow safe practice.

In both the noise and the manual handling samples, exposure to the consequences of not following safe practice increased people’s worries and concerns about those consequences

1 It is possible that this change in behaviour reflects a more generalised effect of intervening in the workplace rather than the specific effect of the leaflets since not all the employees actually read the leaflet. Given the anonymous nature of the behavioural measurement there is no way to guarantee that this is not the case.

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but this was not directly related to their intentions to follow safe practice. Safety leaflets designed to target worry by raising levels of fear may be ineffective. Perceived seriousness of the consequences of not following safe practice did predict intentions. Perceived seriousness was predicted by the perceived usefulness of the leaflet. Increasing the relevance of safety leaflets may therefore increase perceived seriousness and consequently influence persuasion.

4.5.1 The prediction of intentions

The largest predictors of intentions in these studies were those relating to the leaflets themselves. Whilst the objective readability of health materials has previously been shown to influence intentions and behavioural outcomes, the current study demonstrates how subjective evaluations of a leaflet’s usability and usefulness can also be influential. In the current study, the usability and usefulness of the leaflets were shown to be bigger predictors of intentions than the cognitive and emotional factors traditionally measured in studies of intentions to follow health recommendations.

4.5.2 Usability and Usefulness

The objective readability analyses conducted in the previous study demonstrated that current leaflets can be improved in terms of how easy they are to use, that is how easy they are to read and therefore understand. The current study shows that individuals with higher perceptions of the usability of a leaflet are more likely to have higher intentions to follow safe practice. Leaflets designed to increase users’ intentions to follow safe practice therefore need to be designed with usability in mind. In addition, for the manual-handling sample, usefulness was also an important predictor of intentions. Increasing the relevance of risk communications where possible may also directly influence intentions and behavioural outcomes.

4.5.3 Behavioural Outcomes

Finally, the potential effect, on behaviour, of conducting the intervention was examined by recording the number of earplugs taken pre and post the intervention in the mine. The results showed that more earplugs were taken (across the site) after the leaflet evaluations had been conducted. It is not possible to say that this was due to reading the leaflets per se. It may be that the general awareness raised by the intervention itself highlighted the issue for the employees (cf. Maguire, 1986).

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5 Study 3: Developing Relevant Framed Messages through anticipated quality of life losses – A Qualitative Study of back pain (Manual Handling) and Deafness (Noise).

The previous study identified usefulness as a predictor of intentions to follow safe practice. Relevance was especially important. Therefore, to optimise the effectiveness of the newly designed leaflets, health consequences considered relevant by the sample population were identified. These consequences were then used in the framed sections of the experimental leaflets used for studies 4, 5 and 6.

5.1 Method

A convenience sample of health care employees (N=6), and foundry workers (N=5) were asked to generate a list of ways in which the quality of their life would change if they were to suffer back pain/hearing loss. This information was attained using structured interviews. Participants were asked to provide examples of ways they would be affected in their work, in their social lives, at home, and emotionally. Examples of the most common of the potential changes generated would then be incorporated into the ‘framed’ sections of the experimental leaflets.

5.2 Results

For both noise and manual handling, responses were collated and all examples given by interviewees were divided into the appropriate categories: changes in work, social life, at home and emotionally. The results are presented in tables 8 and 9. Table 8 shows examples of quality of life changes generated by manual handling respondents. Table 9 shows examples generated by noise respondents.

Health Care Professionals’ Reported Quality of Life Changes (Back Pain) In Work Social Life At Home Emotional Difficulty handling and mobilising patients; Difficulty walking around the hospital; Less able to assist in patient care; Difficulty scrubbing for cases; Difficulty standing for long periods of time;

Difficulty exercising (jogging, dancing, swimming etc.); Driving; Walking; Long journeys difficult due to pain;

Difficulty playing with the children; Housework; Gardening; Decorating; Difficulty participating fully with family life; Entertaining; Climbing stairs; Financial situation might suffer if work not possible

Depression; Loss of independence; Reduced self-esteem; Reduced contentment at work due to inability to participate fully; Frustration; Don’t like being in pain;

Table 8: Examples of quality of life changes for manual handling

Examples of the most common of the potential changes generated were incorporated into the ‘framed’ parts of the leaflets. Many health promotion materials do not give statistical data on risk that can be reversed for positive and negative frames. It is possible though to frame general health information, as provided by these respondents. Selected statements were

37

highlighted as potential ‘losses’ for the negatively framed leaflet, and highlighted as potential ‘positives’ for the positively framed leaflet. For example, ‘By not wearing your ear defenders you may suffer the frustration and embarrassment of not keeping up with conversations’ (negative frame), versus ‘By wearing your ear defenders you can avoid the frustration and embarrassment of not keeping up with conversations’ (positive frame).

Foundry Workers’ Reported Quality of Life Changes (Deafness) In Work Social Life At Home Emotional Wouldn’t be able to Difficulty listening to Hearing the doorbell; Frustration; hear the tannoy music; Watching TV; Embarrassment – going off; Driving; Listening to your not catching what Difficulty speaking Keeping up with children – people say; on the phone; conversations in the communicating with Annoyance (and Communicating with pub; your family; embarrassment) of other workers; Difficulty DIY; having to wear a Difficulty hearing socialising; Speaking on the hearing aid; fire alarms and Might lose your phone; Stressful; warnings; friends if it becomes Hearing smoke Isolating; Couldn’t hear difficult talking to alarms; Devastating; vehicles e.g. forklifts you; Listening to coming; birdsong; People can’t hear There may be you because you financial costs e.g. don’t realise you are buying special speaking quietly; equipment;

Table 9: Examples of quality of life changes generated by noise respondents

Using the statements collected from these participants, just over a quarter of each leaflet was ‘framed’ either positively or negatively. The remainder of the leaflets were identical. The majority of the framed information described the consequences of failing to follow correct manual handling procedure/wear ear defenders (negatively framed) or the benefits of following correct manual handling procedure/wear ear defenders (positively framed). Frames were designed to have an appropriate reading age.

5.2.1 Readability

In study one, it was demonstrated that text that is easy to read is easier to comprehend. Leaflets were, therefore, designed to have an increased reading ease level. Text was simplified in terms of word complexity and sentence length. Number of passive sentences was reduced whilst keeping the meaning and the content of the information provided. Flesch reading ease scores were calculated for the new leaflets. The experimental manual-handling leaflet had a Flesch Reading Ease Score of 61 (standard/Plain English). This gives a reading age of 12.9 years. The experimental noise leaflet had a Flesch Reading ease Score of 70.5 (easy). This gives a reading age of 11.8 years.

5.2.2 Narrative Structure

Previous research suggests that risk communication messages with a balance of causes, consequences and solutions to a risk may be more effective. The content analysis conducted in study one showed that many of the current leaflets did not contain such a balance. The new

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leaflets were therefore written to include a paragraph describing the causes of the problem (i.e. incorrect manual handling and failure to wear ear defenders), the consequences of not following the recommendations (i.e., back pain and deafness), and a paragraph of recommendations to avoid these consequences.

All experimental leaflets derived from these analyses and used in the subsequent experimental studies can be found in appendix 6.

5.3 Discussion

The previous studies demonstrated the importance of usability and usefulness in leaflet design. The experimental leaflets were therefore designed for optimum reading ease and relevance. This was done relatively simply. Usability was shown to increase by reducing sentence complexity and word length. Usefulness was increased by identifying consequences of exposure to the hazard salient to the intended user groups. This was achieved by interviewing a number of employees at whom the message is aimed. Whilst no previous work has been conducted to establish the optimum narrative structure of a risk leaflet, this may also influence the persuasive impact of a message. Therefore the experimental leaflets were designed with a balance of information on causes, consequences and control.

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6 Study Four: The Effects of Positively or Negatively Framing Risk Communications on Users Intentions to Follow Safe Practice, their Perceptions of Usability and

Usefulness, and their Risk-Related Cognitions and Emotions.

Study four examined the effect of ‘framing’ risk information as either negative or positive way on intentions to follow safe practice. The content analysis in study one highlighted that most health and safety leaflets are currently written in a negative frame. The literature on framing suggests that, for prevention behaviours, positive framed messages may be more effective in persuading the message recipient to adhere to the health recommendations. For the initial phase of this study, experimental leaflets were designed in both positive and negative frames (see study 3).

6.1 Aim of study

The current study examined NHS domestic staff’s responses to 3 leaflets about manual handling at work. The study sought to demonstrate that participants would respond more favourably (i.e., increase their intentions to follow safe practice) to the leaflet written in a positive frame rather than an equivalent leaflet written in a negative frame. A current HSE leaflet on manual handling was also rated in this study. The study also sought to examine the effect of frame on participants’ risk-related cognitions and emotions, and their perceptions of the usability and usefulness of the leaflets.

6.2 Method

6.2.1 Leaflets

Three leaflets were evaluated. One was the HSE manual-handling leaflet evaluated in study 2. The remaining 2 leaflets were the newly written positive and negatively framed leaflets developed for the experiment. 32 participants read the positively framed leaflet, 33 the negatively framed leaflet, and 32 read the HSE leaflet.

6.2.2 Participants

Participants were 97 domestic staff at a local NHS Trust. The sample included: Caterers, porters, secretaries, maintenance staff, electricians, scientists, technicians and administrative staff. All were recruited during their mandatory load handling training sessions. Ages ranged from 17 to 63 years. Length of time working for the NHS ranged from new starters to 33 years.

6.2.3 Measures

Questionnaires developed and used in study 2 were used for this study (see appendix 4). Items assessed leaflet usability and usefulness, perceived risk to self and others, prior exposure, worry, perceived seriousness and intentions to follow the advice given in the leaflet.

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6.2.4 Procedure

The procedure was the same as for study 2. Participants were given one of the sample leaflets to read. Following this they were asked to complete the questionnaire. Again, participants were volunteers and were assured of confidentiality and anonymity.

6.3 Results

Mea

nResults were collated and analysed using SPSS version 10. Detail of the statistical analyses of all results can be found in appendix 5.

6.3.1 Perceived usability and usefulness and the leaflets

A principal components analysis followed by varimax rotation revealed that, as in study 2, participants distinguished 2 separate components to the leaflets. For this sample, ‘usability’ referred to the ease of the leaflet to read, understand and remember. ‘Usefulness’ referred to how relevant and helpful the leaflet was. Therefore, a high score for usability meant the leaflet was perceived to be easy to read, understand and remember. A high score for usefulness meant the leaflet was perceived as relevant and helpful.

6.3.2 Differences among the 3 leaflets

Figure 13 shows participants’ ratings of the usability and usefulness of each of the three leaflets.

Ratings of Usability and Usefulness

4.6

4.4

4.2

4

3.8

3.6

3.4

3.2

3 Usability Usefulness

iPositive Negat ve HSE

Figure 13: Usability and usefulness ratings for all leaflets

Usability differences - There were no significant differences between the usability of the newly written positive and negatively framed leaflets (see figure 13). However, the positively framed leaflet was rated as significantly more usable than the HSE leaflet.

Usefulness differences- The positively framed leaflet was rated as significantly more useful than the HSE leaflet (see figure 13). The positive leaflet was rated as more useful than the negative leaflet, with this difference almost reaching statistical significance.

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Perceptions of Risk

4

3.8

3.6

3.4

3.2

3

2.8

2.6 M

ean

2.4

2.2

2

ive NegatiHSE

Positve

Personal injury Others injury

Figure 14: Perceptions of risk by leaflet

Perceptions of risk differences between leaflets: - Figure 14 shows participants who read the positively framed leaflet rated their own as well as others risk of injury through manual handling as significantly higher than those who read the negative leaflet.

Concern and seriousness differences between leaflets - Participants rated how concerned they were about developing back pain through manual handling and how serious a health problem they perceived back pain to be. There were no significant differences for these ratings between any of the 3 leaflets.

Intentions to follow Guidelines differences - Participants who read the positively framed leaflet rated themselves as being significantly more likely to follow the advice given in the leaflet next time they were handling loads than those who read the negative leaflet and those who read the HSE leaflet (see figure 15). The same pattern was repeated for the likelihood that they would follow the advice in the future.

Intentions to Follow Guidelines

4.3

4.1

3.9

3.7

3.5

itii

4.5

4.7

4.9

Mea

ns Pos ve Negat ve HSE

Follow next time Follow in future

Figure 15: Intentions to follow the advice in the leaflets, next time they were handling loads and in the future

6.3.3 Predictors of Intentions

A linear regression was carried out to identify predictors of intentions to follow guidelines. Table 10 shows the percentage of variance in intentions to follow the advice given in the leaflet next time explained by all factors.

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Variable % Cumulative % Frame *Positive Negative

13% 13%

Biographics Age Sex Years NHS Years Job

8% 21%

History of Back Pain Self Others

1% 22%

Health Beliefs *Risk – self *Risk – others Concern *Seriousness

18% 40%

Leaflet Ratings *Usability Usefulness

7% 47%

Table 10: Percentage of variance, explained by all measured variables, in intentions to follow guidelines next time

An asterisk denotes that the variable was a significant predictor of intentions. 47% of the total variance in intentions to follow the advice in the leaflet can be explained by the above variables. Perceived risk to self and others and perceived seriousness of back pain as a serious health problem were significant cognitive and emotional predictors of intentions to follow the guidelines. Higher scores on each of these items predicted greater intentions to follow the guidelines.

In addition to these variables, the usability of the leaflets was, as in previous studies, a significant predictor of intentions. Higher usability scores predicted greater intentions to follow guidelines. ‘Frame’ was also a significant predictor. Reading the positively framed leaflet rather than the negative or HSE leaflets predicted intentions to follow safe practice whilst reading the negatively framed leaflet rather than the positive or HSE leaflet did not.

6.4 Discussion

This study compared three leaflets relating to manual handling at work. Whilst the HSE leaflet differed from the others in terms of length, content and use of diagrams, the newly developed leaflets were identical apart from the framed passage – one as negative and one as positive. Results showed that participants reading the positive-framed leaflet:

· rated it the highest of the three in terms of usability and usefulness.

· reported the highest levels of perceived risk of injury to themselves and others.

· reported significantly higher intentions to follow the advice next time they were handling loads and in the future than those reading the negative leaflet or the HSE leaflet.

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· predicted participants’ intentions to follow the advice given in the leaflet whilst the negative leaflet did not.

These findings are elaborated on below.

6.4.1 Framing effects on intentions

Previous studies have shown that positive framing risk messages for prevention behaviours can increase persuasion. To date no such studies applied framing effects to occupational health behaviours. The results of the current study show that intentions to perform a self­protective behaviour can be strongly influenced by the way a message is framed. This supports the theory that risk communication messages for prevention behaviours should highlight the benefits of following safe practice rather that the costs of not following safe practice.

6.4.2 Framing effects on perceived risk

In addition to influencing intentions, the differently framed leaflets in this study affected other cognitive and emotional factors. Those reading the positive leaflet recorded higher perceptions of the risk associated with suffering injury through manual handling at work, compared to those who read the negative framed message. Perceptions of risk, for this sample, were shown to positively predict intentions to follow the guidelines. None of the biographical variables predicted intentions, whilst again, the usability of the leaflets was a significant predictor.

6.4.3 Importance of leaflet design factors – frames, usability and usefulness

These results all highlight the important role that the design of risk communication materials can play in persuading employees to follow safe practice in the workplace. Health interventions are typically designed around target variables, usually cognitive or emotional, which have been identified as predicting intentions. Whilst it has been shown that these can be effective, the message will fail at the outset if the usability is so low that the reader is neither interested in processing the message or potentially is unable to do so due to the level of difficulty of the text.

Increasing the usability of safety leaflets can increase persuasion. In addition to increasing usability, framing prevention messages to highlight positives rather than negatives is another relatively simple yet effective method of increasing the potential of a leaflet to persuade the reader to follow safe practice. Negatives can usually be turned around with little difficulty into positives, whilst keeping the relevant content in place.

Finally, the narrative content of the leaflet may have some influence on persuasion. The newly developed leaflets used in this study were written to contain a balance of causes, consequences and solutions. The current HSE leaflet that was tested did not contain this balance. Although the effect of balance of content was not specifically tested for, it is possible that it may have had some role in the more positive responses to the newly developed leaflets over the existing HSE one. This is an area that would require further study.

In conclusion, the results of this study suggest that to maximise the potential of risk communication leaflets, they should be written not only with optimum usability and usefulness, but, for prevention behaviours, they should also be written in a positive frame.

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7 Study Five: Framing Intervention Study for Use of Ear Defenders and Manual Handling - An Exploration of Individual Differences as Moderators of Framing

Effects.

The previous study examined the effect of ‘framing’ workplace safety leaflets on intentions to follow safe practice. As framing theory predicts for prevention behaviours, positive framed messages were shown to be more persuasive than negatively framed messages. The experimental leaflets were newly written with increased usability. These leaflets were rated as more usable than the current HSE leaflets, and usability predicted intentions. Positive framed messages also influenced perceived usefulness. In addition to these main findings, frame was shown to influence risk-related cognitions, with participants reading positive framed messages reporting higher levels of perceived risk.

The current study sought to explore the effects of framing in more depth. The previous study took measures of cognitions, emotions and intentions directly after the leaflet was read. Very few framing studies take these measures before and after the message is read to assess the extent of change. Frame may be found to have a differential effect on employees’ intentions, cognitions and emotions. Framing may also be found to be influenced by additional factors. Individual differences and situational factors have been shown to interact with framing effects. For example, issue involvement (i.e., the level at which an individual is involved with the risk) has been shown in several studies to influence with framing effects (e.g. Maheswaran and Meyers-Levy, 1990, Donovan & Jalleh, 2000). For occupational health behaviours, issue involvement may be high due to daily exposure to risks. This may affect the influence of frame. Also, as highlighted in the introduction to this report, the effect of past behaviour (i.e., the extent to which each participants reports using PPE in the past) was examined in relation to faming and intentions to act (cf. Ferguson and Bibby, 2002). The current study sought to investigate the effect of frame on a variety of cognitive and emotional factors and intentions to follow safe practice. In addition it sought to explore the effect of individual and situational factors on these variables. The study took measures before and after reading the leaflet (i.e. the intervention), in order to assess change.

7.1 Aims of study

The main aim of the study was to examine the effects of frame on leaflet users’ cognitions, emotions and intentions to follow safe practice. Participants’ cognitive and emotional responses to the leaflets were measured by use of pre and post intervention testing. In addition to these main aims, the subsidiary aims of the study were to identify which of the measured variables other than frame may affect how employees respond to risk information leaflets, and how these relate to intentions to follow safe practice. Behaviours studied were, as in previous studies, use of ear defenders and manual handling.

7.2 Method

7.2.1 Participants

Two samples were recruited, one from the mining and foundry industries to investigate noise and one from the NHS to investigate manual handling. Participants were convenience samples and were randomly allocated to read one of the two framed leaflets.

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Manual handling sample – 263 health care professionals from 2 local NHS Trusts were sampled. These included qualified nurses, auxiliary nurses, student nurses, physiotherapists, midwives and radiographers (215 females, 21 males, 27 not known). All subjects were recruited during manual handling training sessions in their workplaces. The mean age of the sample was 34 years (range 18-59). The mean number of years in service was 11 (range 0-40 years).

Noise sample – 188 workers employed in noisy environments were sampled. 59 were from a mine, 129 were from a foundry. A convenience sample was used. All subjects were male. The mean age of the sample was 38 years (range 18-62). The mean number of years in their current company was 11 (0-36 years).

7.2.2 Materials

Four experimental leaflets were used. These were the leaflets developed in study 3, and used in study 4. 2 related to noise at work (1 positively framed, 1 negatively framed), 2 related to manual handling (1 positively framed 1 negatively framed).

7.2.3 Measures

Questionnaires were developed to obtain measures of risk-related cognitions, emotions and intentions. Items were based on traditional theories of health behaviour. All items were scaled on a 5-point Likert-type scale ranging from 1-5, apart from intentions, which was scaled from 1-10. The following measures were included (the full questionnaire used can be found in appendix 4.

Worry was assessed with 3 items about suffering harm through manual handling/noise at work:

· To what extent are you worried about being injured through manual handling at work/being deafened through noise at work?

· To what extent are you worried about suffering back pain through manual handling at work/hearing problems through noise at work?

· To what extent are you worried about developing back problems in later life through manual handling at work/hearing problems in later life through noise at work?

Seriousness was assessed using a single item measuring employees’ perceptions of the seriousness of back pain/hearing damage:

· To what extent do you believe that back pain is a serious health problem?

Social Norms were assessed using 3 items measuring employees’ normative expectations (i.e., whether colleagues follow safe practice, whether loved ones want them to follow safe practice):

· Do you feel under pressure from your colleagues to follow correct manual handling procedure/wear ear defenders?

· Do you feel that people who are important to you want you to follow correct manual handling procedure/wear ear defenders?

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· Do you believe that most of your colleagues follow correct manual handling procedure/wear ear defenders?

Perceived behavioural control was assessed using 3 items measuring employees’ perceptions of control over performing the recommended behaviour:

· To what extent do you feel you have control of whether you follow correct manual handling procedure/wear ear defenders at work?

· How strongly do you believe that there are events outside your control that could prevent you from following correct manual handling procedure/wear your ear defenders?

· To what extent do you feel that it is up to you whether you follow safe practice for manual handling tasks/wear your ear defenders?

Self-efficacy was assessed with 2 items measuring employees’ perceptions of their own capability to perform the recommended behaviour.

· To what extent do you feel, given enough time and resources, personally able to follow manual handling guidelines/wear your ear defenders?

· How easy would it be for you, given enough time and resources, to follow correct manual handling procedure?

Response-efficacy was assessed using 2 items measuring employees’ perceptions of the effectiveness of the recommended behaviour.

· To what extent do you believe that the manual handling guidelines/wearing ear defenders are an effective way to avoid injury/ill health through manual handling at work/noise at work?

· To what extent do you believe that by following manual handling guidelines/wearing ear defenders you can avoid injury/ill health through manual handling/noise at work?

Perceived risk was assessed with a single item measuring employees’ perceptions of risk to themselves through manual handling/noise at work, and a single item measured perceptions of risk to others.

· To what extent do you feel that you are at risk of suffering injury/ill health/hearing problems through manual handling/noise at work? (risk self)

· To what extent do you think your colleagues are at risk of suffering injury/ill health/hearing problems through manual handling/noise at work? (risk others)

Vividness was assessed with one item, asking respondents to rate how vividly they could imagine the consequences of not following safe practice (i.e. back pain for manual handling, deafness for noise. This was measured on a four point scale, from ‘can not mentally see or feel this image’ to ‘can see or feel this image clearly’.

The main outcome variables were intentions to behave safely and behaviour. These were assessed in the following ways.

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Intentions were assessed using a single item measuring employees’ intentions to follow the recommendations.

· To what extent do you intend following the manual handling guidelines/wear your ear defenders when you are handling loads/in a noisy area?

Past behaviour was assessed using a single item measuring the percentage of time that employees reported they currently follow the recommendations.

· When carrying out tasks involving handling/working in noisy areas, what percentage of time do you follow correct manual handling procedure/wear your ear defenders?

Finally background information was assessed to examine general levels of prior exposure to harm (involvement) and general demographics.

Prior exposure was assessed with a single item (measured with a yes/no tick box) ascertained whether employees had suffered from the consequences of the manual handling/noise themselves, and one item measuring whether they knew anyone who had suffered.

Biographic information on age, years in service, years in job, and gender was measured.

7.2.4 Procedure

The method used was consistent for both manual handling and noise. Participants were asked to complete the questionnaire. This obtained pre intervention measures. Once the questionnaire was completed participants were asked to read a copy of the leaflet – either positively framed or negatively framed. After this was read, they were asked to complete another questionnaire. This was identical to the first. Participation in the study was voluntary. Participants were asked to sign a consent form agreeing to take part. They were assured that all data collected would remain confidential and anonymous, and that all data would be used only for the purposes of the research.

7.3 Results

Results were collated and analysed using SPSS version 10. Manual handling and noise data were analysed separately. Noise data will be reported here first, followed by manual handling results. Additional statistical detail for all analyses can be found in appendix 5.

The main aims of the study were to explore the effects of frame on cognitions, emotions and intentions. Interactions by various groups and the influence of involvement were also explored. The study sought to demonstrate that for prevention behaviours, positively framed messages are more effective in increasing intentions to follow safe practice than negative­framed messages. The results are presented for noise first and manual handling second. Results for variables that were measured but not affected by frame are not reported. This includes perceived behavioural control, response efficacy and vividness.

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7.3.1 Noise data analyse

7.3.1.1 Intentions to wear ear defenders

No overall effects for frame on intentions to wear ear defenders were found. However, groups of employees for whom frame was influential were identified.

Effect of previous behaviour. Employees were categorised according to the self-reported percentage of time they currently wear ear defenders when in noisy areas. There were 3 groups: those that reported they wore ear defenders less than 50% of the time (‘occasional’ users); those that reported they wore ear defenders 51-75% of the time (‘regular’ users); and those who reported they wore ear defenders 76-100% of the time (‘always’ users). The effect of frame on intentions to wear ear defenders for these groups of employees can be seen in figure 16.

4 6 8

10

Occ

asio

nal

ly

Reg

ular

ly

Alw

ays

Pre

4 6 8

10

Occ

asio

nal

ly

Reg

ular

ly

Alw

ays

Pre

Positive Frame

Post

Negative Frame

Post

Figure 16: Intentions to wear ear defenders before and after reading framed leaflets for pre­behaviour groups

Employees who reported regular use showed an increase in their intentions to wear ear defenders after reading the positive frame. Employees who only occasionally wear ear defenders showed an increase in their intentions to wear ear defenders after reading the negative (loss) frame. Frame had no effect on the ‘always’ users, but this group’s reported intentions were at ceiling before the intervention.

i

7

8

9

No

Pre

7

8

9

No

Pre

Posit ve Frame

7.5

8.5

9.5

Yes

Post

Negative Frame

7.5

8.5

9.5

Yes

Post

Figure 17: Intentions to wear ear defenders before and after reading the leaflet by knowing someone with noise induced hearing damage. (‘Yes’ = know someone who has suffered hearing damage, ‘No’ = don’t know anyone who has suffered hearing damage)

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Effect of prior exposure. Employees were also categorised by prior exposure to hearing damage. Framing effects were found for prior exposure group. Figure 17 shows framing effects by whether or not respondents know someone with hearing problems caused by noise at work.

Employees who knew someone with noise induced hearing loss showed an increase in their intentions to wear ear defenders after reading the positively framed message. Those who did not know anyone with noise induced hearing loss showed an increase in their intentions to wear ear defenders after reading the negative-framed message.

7.3.1.2 Influence of frame on Cognitive and Emotional Factors

A variety of cognitive and emotional factors were influenced by frame. For the noise sample, worry and self-efficacy were influenced by frame.

Worry. Worry about being deafened by noise at work was influenced by frame. Figure 18 shows pre and post worry scores for positively and negatively framed leaflets.

4

ive i

Worry

3.2 3.4 3.6 3.8

4.2

Pre Post

PositNegat ve

Figure 18: Worry about being deafened pre and post intervention (worry item 1 – ‘to what extent are you worried about being deafened through noise at work’)

Results show that there was an increase in worry about being deafened for those reading the negatively framed leaflet. There was no increase in worry about being deafened for those reading the positively framed leaflet. Raising levels of worry in employees may be undesirable and, therefore, again the positively framed message seems more appropriate.

Self-efficacy. Framing was shown to affect participants’ perceptions of self-efficacy. Overall framing effects were found for the item ‘how easy would it be to wear ear defenders’. These results are shown in figure 19.

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4

Pre

i

i

Self Efficacy

3.95

4.05

4.1

4.15

4.2 4.25

4.3

4.35

4.4

4.45

Post

Posit ve

Negat ve

Figure 19: Perceived self-efficacy (how easy would it be for you, given enough time and resources, to wear ear defenders) pre and post intervention

Participants reading the positively framed leaflet felt it would be easier for them to wear ear defenders post intervention. There was no increase in self-efficacy for those reading the negatively framed leaflet.

7.3.2 Manual Handling data analyses

7.3.2.1 Intentions to follow manual handling guidelines.

Results for intentions to follow manual handling guidelines produced ceiling effects. Many respondents scored a ‘10’ (i.e., they reported that they already intended to follow the recommendations all of the time). These respondents could not increase their intentions any further. Therefore, for this question only, respondents scoring a 10 at pre-testing were dropped from the analysis.

Effects of prior exposure. Framing effects were found for prior exposure. Respondents were categorised by whether they had suffered back problems through manual handling at work themselves or not. Results showed that the negatively framed message had no effect on either group. However, the positively-framed message was more influential in increasing intentions for employees who had suffered back problems themselves. Figure 20 shows the effect of the positively framed message on respondents with and without personal experience of back pain.

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7

8

9

no

Mea

n

Intentions to follow guidelines

7.5

8.5

yes

pre post

Figure 20: Effects of positive-framed message on intentions to follow guidelines for respondents with and without a history of back problems through manual handling

7.3.2.2 Influence of frame of Cognitive and Emotional Factors:

A variety of cognitive and emotional factors were influenced by frame. For the manual­handling sample, worry and self-efficacy were influenced by frame.

Worry. Framing effects were found for both worry about suffering injury and general back pain worry (see figure 21)

3 i

Pre

i

Pre

Injury Worry

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

Pos tive Negative

Post

Back Pain Worry

3.55

3.6

3.65

3.7

3.75

3.8

3.85

3.9

Pos tive Negative

Post

Figure 21: Effects of frame on injury worry (‘to what extent are you worried about being injured through manual handling at work’) and back pain worry (‘to what extent are you worried about suffering back pain through manual handling at work’)

Results show that reading the negatively framed message significantly increases worries about both injury and back pain. Reading the positive leaflet did not have a significant effect on participants’ level of worry.

Self-efficacy. Framing affected self-efficacy in the manual-handling sample. Framing had differential effects depending on prior exposure to back pain for the item ‘how easy it would be to follow the guidelines?’ Effects were dependent on whether or not employees had experienced back pain through manual-handling themselves. Figure 22 shows the relationship between frame and exposure on self-efficacy.

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4 Pre

4

Pre

Self-efficacy 2 - Positive

3.7

3.8

3.9

4.1

4.2

4.3

Yes No

Post

Self-efficacy 2 - Negative

3.85 3.9

3.95

4.05 4.1

4.15 4.2

4.25 4.3

4.35

Yes No

Post

Figure 22: Perceived self-efficacy for how easy to follow the guidelines for positive and negative frames

Results show that the positive-frame was more influential in increasing self-efficacy for those who have suffered back problems through work themselves. For those who have never suffered themselves, the negative frame was more influential.

7.3.3 Summary of Framing Effects

Table 11 provide a summary of the framing effects reported in this study. These are discussed in detail in the discussion below.

Positive Frame Influence Negative Frame Influence

Overall Effects: Noise Self-efficacy - increases Worry (deafness) –

increases Manual Handling

Worry (back pain) – increases Worry (injury) – increases

Interaction Effects:

Noise Intentions – higher for regular users Intentions – higher for history of deafness (knowing someone)

Intentions – higher for occasional users Intentions – higher for no history of deafness (not knowing anyone)

Manual Handling

Intentions – higher for history of back pain to self Self-efficacy – higher for history of back pain to self

Self-efficacy – higher for no history of back pain to self

Table 11: Summary of framing effects

7.4 Discussion

Leaflets framed as negatives or positives had differential effects on employees’ risk related cognitions, emotions and intentions. The primary aim of the study was to demonstrate that positively framing risk messages for prevention behaviours would be more influential in increasing intentions to follow safe practice than negatively framed messages. There was evidence for this but the picture was more complicated.

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7.4.1 Frames and intentions

Framing effects emerged when participants were categorised both in their reports of current behaviour and their prior exposure to the consequences of the hazard. Both of which had an effect. There were no main effects for framing.

Prior exposure. Prior exposure was shown in the previous studies to affect perceptions of risk and attitudes towards the leaflet. It was possible to identify individual differences in changes in intentions after reading the leaflets that were caused by frame. Whilst one group of participants in the noise sample was more influenced by the negative than the positive frame, most groups were more influenced by the positive frame. The effects of frame in this study were, however, moderated by prior exposure to the consequences of not following safe practice. Framing effects for intentions were dependent on either knowing someone who had suffered health consequences or had suffered them-selves. Participants with this type of prior exposure were more influenced by positively framed messages. Participants who had no prior exposure of this type were more influenced by a negatively framed message. This finding suggest that that those who are aware of the negative consequences may see a positive message as more reassuring, as they already know what is at stake and can be lost. Whereas for those who do not have this experience of actual loss, being made aware of what is at stake is more useful in terms of intentions to change.

Past behaviour. In addition, framing effects were also moderated by participants’ past behaviour (i.e., the extent to which they already follow safe practice). Employees who report that they follow safe practice regularly are more likely to maintain this behaviour after reading the positively framed message. For those who report only occasionally following safe practice, the negative message seemed to be more effective at prompting them to initiate the uptake of safe practice. This pattern of results is consistent with the theory that different interventions are more effective for people at different stages of behavioural change (cf. Ferguson and Bibby, 2002; Prochaska et al., 1992, 1994).

These two effects for past-behaviour and prior-exposure indicate that the effects of frame are complex. However, the results of this study in combination with the other studies documented in this report indicate that positive-frames are generally beneficial. However, if a particular group of workers is to be specially targeted, then the nature of their backgrounds in terms of prior exposure and/or past behaviour should be considered when designing the leaflet for use in the intervention.

7.4.2 The influence of positive and negative frames

Additional effects of frame were identified. Positively framed leaflets were shown to increase perceptions of self-efficacy. Self-efficacy is commonly shown to predict intentions and behaviour. Conversely, negatively framed messages were shown to increase levels of worry. Our previous studies showed that worry has no beneficial effect on intentions to perform the recommended behaviour. In fact, raising levels of worry may sometimes produce adverse effects. Fear-arousing messages can be counter-argued or disregarded by the recipient. This study showed that for most participants, the negatively framed message did not significantly increase intentions.

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8 Study Six: The Effects of Narrative Structure and Frame on Intentions to Follow Safe Practice for Manual Handling

The content analysis of current HSE leaflets conducted for this project identified 3 main areas of content. These were causes of a health problem (or risk factors), consequences of not following safe practice, and solutions (advice and recommendations on how to avoid the negative consequences). Traditional health campaigns tend to follow a consequences­recommendations message format. This type of design is based upon using ‘fear’ as a motivator for behavioural change. Persuasion can be induced by raising an individual’s perceptions of threat (by presenting information relating to consequences of harmful behaviour), and then reducing those feelings of threat and susceptibility by presenting coping information (providing effective solutions to avoiding that threat). The greater the reduction in those feelings, the more effective the message will be in influencing behavioural change.

Few studies have examined the effect of message order on persuasion for health-related campaigns. Results of such studies have been equivocal. Prentice-Dunn et al (2001) studied the effect of message order on coping with breast cancer information. Their findings showed that the high-threat followed by high-coping information format led to more adaptive coping strategies (e.g., change in behavioural intentions, rational problem solving), whilst the reversed format led to more maladaptive coping strategies (e.g., hopelessness, religiosity).

A study by Keller (1999) suggests that the reverse format may be more persuasive and that emphasising negative consequences may cause some individuals to resist the message. For example, emphasising the negative consequences of a harmful behaviour to someone who performs that behaviour can have undesired effects. Such recipients may discount the source of the message, the information in the message, or its relevance. Keller (1999) also differentiates between low and high fear appeals, suggesting that the unconverted may be more persuaded by a low fear appeal than a high one, as this requires less discounting.

Message discounting can be reduced, however. One possible method is to reverse the traditional consequences-solutions message order. Individuals may be more persuaded by a message if the time available for discounting is reduced (i.e., by presenting consequences information last). Keller’s (1999) results using messages advocating condom use support this hypothesis. The unconverted showed increased levels of persuasion and lower discounting when the message order was reversed, whilst this message format did not reduce persuasion for the adherents. In addition, it was confirmed that a low fear appeal was more persuasive for the unconverted than a high fear appeal.

Ordering effects have yet to be studied within the context of ‘framing’. If positively framed messages are assumed to induce ‘low’ as compared to ‘high’ fear arousal, then it is possible that a reversal in the traditional message order may be more effective.

The current study aimed to explore whether the order of consequences and solutions sections had any impact on persuading a sample of leaflet users to follow safe manual handling practice in the workplace.

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8.1 Aims of Study

The study aimed to answer the following questions:

· Does the message order of health and safety leaflets affect intentions to follow safe practice?

· Do message order effects depend on whether the information is framed positively or negatively?

8.2 Method

8.2.1 Design

The study used a 2x2 (frame x order) between groups design. Participants were randomly allocated to read of the four experimental leaflets.

8.2.2 Leaflets

4 newly developed experimental leaflets on manual handling were used for this study. 2 leaflets were framed positively and 2 were framed negatively. The text for these leaflets was developed and used for the intervention study (study 5). Positive and negative leaflets were identical apart from approximately 26% of the text that was ‘framed’ to highlight either the benefits of following safe practice (positive) or the costs of not following safe practice (negative). Narrative structure was also manipulated. 2 leaflets (1 positive and 1 negative) followed a consequences-solutions pattern. 2 leaflets (1 positive and 1 negative) followed a solutions-consequences pattern. All leaflets began with a ‘causes’ section, which was consistent across all leaflets.

8.2.3 Participants

98 individuals involved in manual handling at work participated in the study. 68 were health care workers employed at a local NHS hospital. 30 were student nurses in their second year of study. Of those participants who indicated their sex, 73 were female and 6 were male. The mean age of the participants was 33.12 years (range 18 – 63 years). Participants were recruited at the beginning of obligatory manual handling training sessions or lectures.

8.2.4 Measures

Questionnaires used in studies 2 and 4 were used for this study (see appendix 4). Items were measured on a 5-point Likert-type scale, and measured leaflet ratings – how easy to read, understand and remember the leaflets were (usability) and how informative, relevant and helpful the leaflets were perceived to be (usefulness). The questionnaires also measured worry about back pain, perceived seriousness of back pain as a health problem, perceived risk to self and others, prior exposure to back pain, and intentions to follow safe practice, next time manual handling and in the future.

8.2.5 Procedure

The procedure was consistent with that followed in studies 2 and 4. Participants were asked to read one of the four experimental leaflets and then to complete the questionnaire. All

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participants were informed that the study was voluntary and that they were under no obligation to take part.

8.3 Results

Results from the study were collated and analysed using SPSS version 10.

8.3.1 Usability and Usefulness:

Figure 23 shows perceptions of usability and usefulness of the leaflets. There were no significant difference in perceptions of the usability and usefulness of the leaflets for any experimental condition, however, overall, students perceived the leaflets as more useful than working health care professionals.

4

f

Mea

n

i

Perceptions of usability and usefulness

3.6

3.8

4.2

4.4

usability use ulness

student work ng

Figure 23: Students and working health care professionals’ ratings of the usability and usefulness of the leaflets

8.3.2 Cognitive and emotional factors

Worry about back pain was related to whether participants had suffered with back pain themselves as a result of manual handling. Those who had suffered were more worried about the problem than those who had not. Perceptions of the seriousness of back pain were not affected by prior exposure (see figure 24).

3

4

5

i

Mea

n

no

Worry and perceived serious of back pain by prior exposure.

3.5

4.5

concern ser ous

yes

Figure 24: Perceived worry and seriousness of back pain by prior history of back pain to self through manual handling

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Worry about suffering back pain was also influenced by frame and by narrative order. A significant interaction was found between these factors. In the consequences-solutions order, worry about suffering back pain was higher when participants had read the negatively framed leaflet than those who had read the positively frames leaflet (see figure 25).

3

4

positi i

Mea

n l sol

Worry about back pain

3.2 3.4 3.6 3.8

4.2 4.4 4.6

ve negat ve

cons-so-cons

Figure 25: Worry about back pain by narrative order and frame

There were no significant effects on perceived risk or intentions for prior exposure, frame or narrative order.

7.4.3. Predictors of Intentions:

A linear regression was carried to identify predictors of intentions to follow manual handling guidelines. As neither frame nor narrative order was shown to influence intentions, these were not included in the regression. Table 12 shows the percentage of variance in intentions explained by demographics, cognitive and emotional factors and perceptions of usability and usefulness.

Variable % Variability Cumulative Age Student Sex

5% 5%

Prior exposure: Self Others

2% 7%

Perceived risk: Self Others

Worry Seriousness

5% 12%

Usability *Usefulness 30% 42%

Table 12: Percentage of variance in intentions to follow guidelines

42% of the total variance in intentions to follow the guidelines can be explained by the above variables. An asterisk denotes that the variable was a significant predictor of intentions. For this sample, there were no biographical, cognitive or emotional predictors of intentions. As with the previous studies in this series, prior exposure to back pain also did not predict

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intentions. The largest single predictor of intentions was the perceived usefulness of the leaflet. Perceived usability almost reached significance (p=0.06), and was significantly correlated with intentions. These results complement previous findings in the project that emphasise the importance of these aspects of leaflet design in influencing users’ intentions to follow safe practice.

8.4 Discussion

8.4.1 Usability and Usefulness

Once again, the usability and usefulness of safety leaflets have been shown to be influential in persuading users to follow safe practice, over and above the influence of cognitive and emotional factors. The current series of studies has drawn participants from a wide range of employment settings, with a diversity of educational backgrounds and biographical profiles. The usability and usefulness of risk communication leaflets are consistently shown to influence intentions to follow safe practice. Many HSE leaflets are written at a reading level too difficult for many of their target audience. Increasing the usability and salience of workplace risk communications may influence the uptake of safe practice of many employees.

8.4.2 Narrative Structure

Despite conflicting findings in the literature regarding the influence of narrative order in health communications, neither narrative orders (either highlighting consequences followed by solutions or solutions followed by consequences) was more persuasive in influencing intentions to follow safe practice for this sample. There were no effects for narrative structure on intentions- neither order – consequences-solutions or solutions-consequences was more persuasive for any groups of employees. There was, however, an effect for narrative structure on worry. Worry about a health problem may result in maladaptive coping strategies, for example discounting the message. Traditionally, health leaflets tend to follow a consequences-solutions order. However, as this is shown to increase worry when coupled with a negative (high-threat) message, reversing this order where messages are framed negatively may be beneficial.

8.4.3 Some hypotheses concerning narrative structure

If all the studies in this report, where specially design leaflets have been used, are considered together (studies 4, 5 and 6) the data suggest that it might be the balance causes, consequences and solution that is important rather than their narrative order. That is, in all studies the special developed leaflets were balanced between causes, consequences and solutions. When compared to HSE leaflets, where these components are not balanced the specially designed leaflet was rated more positively, and on some outcomes the positively framed message was rated the most positively.

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How to design your own framed, usable and useful leaflets: A user’s guide to the 5-step plan

A simple five-step procedure can be used to design a framed message that conforms to usability, usefulness and framing design qualities. The basic five steps are shown in figure 26. Figure 26 identifies the steps required for designing workplace risk leaflets, using features identified in this project as important for persuasion. A guide to conducting each of the steps is contained in this section.

Figure 26: The five step procedure for creating framed, usable and useful leaflets

Summary of the Five Step Procedure

Step 1. Interview the relevant employees, to identify examples of salient quality of life changes associated with suffering the consequences of the hazard. Identify the pros of not suffering negative consequences of exposure to the hazard and the cons of exposure to the hazard.

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Step 2. Based on the information collated in step 1 develop framed messages. Try to keep the sentences simple, use the language and descriptions offered by the workers interviewed in step 1 for use in the consequences section of risk leaflets. Avoid passive sentences and embedded clauses.

Steps 3 & 4. These are joined with arrows going back and forth. That is because at this stage of the development a first draft containing appropriately framed consequences section is developed. This is then subjected to objective readability testing and comprehension testing using the Cloze test. Based on the results of the objective analysis the first draft of the message may need to be amended. This would be the case if the reading age were too high (e.g., higher than for the average 11 year old) and the comprehensibility score indicated that the text could only be read with the help of a teacher. Several passes through steps 3 and 4 may need to be conducted until the appropriate levels are achieved.

Step 5. Once a final message/leaflet has been developed that conforms to the pre-specified reading age and comprehensibility levels it needs to be evaluated subjectively. Using a sample of risk relevant employees, conduct subjective evaluations as demonstrated in studies 2, 4 and 6. For studies 2, 4 and 6 we developed a simple 7-item index for usability and usefulness. Participants should read the newly developed leaflet and then rate it on the 7-item scales. The newly written leaflets should be compared with the previous HSE leaflet that should also be rated in the same way.

Further details explaining each of these steps are provided below.

Step One: Ensuring Relevance

The current project identified ‘usefulness’ of leaflets as an important predictor of intentions to follow safe practice. Relevance was especially important. Newly designed leaflets should not only try to target relevant user groups, but should also attempt to highlight health consequences considered relevant by the target population.

Before writing the consequences section of a health and safety leaflet, a sample of employees appropriate to the risk being outlined should preferably be interviewed or at least canvassed via questionnaire. The current study used 5-6 employees for each occupation.

Interviewees should be asked to generate quality of life changes that would be important to them should they suffer the consequences of not following safe practice.

Participants should be encouraged to provide quality of life changes i.e. ‘In what ways would your quality of life change if you…(suffered the consequences of not following safe practice for the relevant hazard)’ in a variety of settings: in their work, their social lives, at home and emotionally. After the initial question, participants should not be asked leading questions other than to give them category headings. Prompts such as ‘can you think of anything else?’ are acceptable. Prompts such as ‘would you miss listening to music?’ are not acceptable.

Responses should be collated and examined for common themes. A vote count procedure can be used, that is counting the number of each similar response and totalling them. The most common can be used in leaflets to increase the salience of these consequences to users.

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Step Two: Developing the Frames

Risk information can be framed positively or negatively. Where statistical detail is available, information can be framed as follows, using the example of blood safety:

Negatively framed: A risk of infection remains. For every 2-million units of blood used, 1-unit will be infected with HIV. For every two hundred thousand units of blood used, 1 unit will be infected with hepatitis C.

Positively framed: The risk of infection is now very small. For every 2 million units of blood used, 1,999,999 units will not be infected with HIV. For every two hundred thousand units of blood used, 199,999 units will not be infected with hepatitis C.

Note that although framed differently, the information contained within each passage of text is functionally equivalent.

Many health promotion materials do not give statistical data on risk that can be reversed for positive and negative frames. It is possible though to frame general health information. Information can be framed as follows, using an example from the manual-handling leaflet:

Negatively framed: The costs of not protecting yourself from injuries are high. Accidents can cause serious and permanent damage to your upper body.

Positively framed: The benefits of protecting yourself from injury are high. You can guard against serious and permanent damage to your upper body.

Again, note that the information in the two passages of text is equivalent. Only the frame is different.

Framed statements fit most easily into the consequences section of a leaflet. Increasing the perceived relevance of these consequences can increase the effectiveness of the message. Employees can be asked to generate examples of important consequences of a hazard. A method for achieving this is that used in the ‘relevance’ section of this report. The most common of the potential consequences can then be incorporated into the ‘framed’ parts of the leaflets. These should be highlighted as potential ‘losses’ for negatively framed leaflets, and highlighted as potential ‘gains’ for positively framed leaflets. For example, ‘By not wearing your ear defenders you may suffer the frustration and embarrassment of not keeping up with conversations’ (negative frame), versus ‘By wearing your ear defenders you can avoid the frustration and embarrassment of not keeping up with conversations’ (positive frame).

Steps 3 and 4: Conducting Readability and Comprehension Analyses

Increasing the readability of a text can increase the reader’s level of motivation and interest in the topic. Readability is also directly related to comprehension. Designers of safety leaflets should analyse the text for readability.

The readability of a text can depend on many factors, including print legibility, use of illustrations, and the complexity of words and sentence structure. However, a number of features of the readability of a text, including word complexity, sentence structure and

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sentence length have been used to create standardised readability formulae. These readability formulae generally produce a ‘reading age’ for the text.

Most standardised readability techniques involve counting the numbers of words and sentences in paragraphs, counting the number of syllables, finding average sentence and word lengths and applying readability formulae. Readability can be assessed using standardised readability formula either by hand or by using a PC. Both methods are detailed below.

Hand calculations

One of the most popular readability formulae is the Flesch Reading Ease Formula. This can be calculated by hand using the following method (Flesch 1948):

1. Count the number of words in the text. Hyphenated words, abbreviations, figures and symbols should be counted as single words.

2. Count the number of syllables in the text. Abbreviations, figures and symbols should be counted as one word. Count syllables in whole words, as they would be pronounced.

3. Count the number of sentences in the text. A sentence is defined by being marked off with a full stop, a colon, semicolon, dash, question mark or exclamation mark.

4. Calculate the average number of syllables per word. This is obtained by dividing the total number of syllables by the total number of words.

5. Calculate the average number of words per sentence. This is obtained by dividing the total number of words by the total number of sentences.

6. Apply the Flesch formula: Multiply the average sentence length by 1.015. Multiply the average word length by 84.6. Add the two numbers. Subtract this sum from 206.835

The Flesch Reading Ease formula yields scores ranging from 0-100. The lowest score achievable (i.e., 0) represents the highest difficulty text. A score of 100 represents text with the lowest possible difficulty. Using this scale, ‘Plain English’ is considered to be text that falls within the range of 60-70.

PC based calculations

Flesch Reading Ease scores can also be calculated using a built-in program in Microsoft Word:

1. Text must be scanned or typed into Word.

2. On the Tools menu, click Options, and then click the Spelling & Grammar tab Select ‘spelling and grammar’

3. Select the Check grammar with spelling check box

4. Select the Show readability statistics check box, and then click OK.

5. Either (a) Highlight the section of text to be analysed, or (b) place the cursor at the beginning of the document to assess the whole document.

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6. On the Tools menu, select the Spelling & Grammar option

After checking for spelling and grammar Flesch Reading Ease score and a Flesch-Kincaid Grade score is displayed.

The Flesch-Kincaid Grade score gives a US grade level for grades from 3-12 (for example a score of 6 means that an average sixth grader could understand the document). The Flesch-Kincaid cannot distinguish between texts that are more or less difficult than this range. To make these US grade levels compatible with the UK, reading age is calculated by adding 5 to the grade level (see table 13).

Flesch Reading Ease Score

Style Average Reading Age

Typical Reading

90-100 Very easy 9-10 Comics 80-89 Easy 10-11 Pulp fiction, The Sun 70-79 Fairly easy 11-12 US News 60-69 Standard 12-14 Sherlock Holmes, Reader’s Digest,

The Daily Mirror 50-59 Fairly difficult 14-16 Secondary school texts, magazines

such as Harper’s 30-49 Difficult 17-22 A level texts, undergraduate texts,

The Guardian 0-29 Very difficult 22+ Professional journals, postgraduate

texts

Table 13: Flesch scores for typical texts

To simplify a piece of text and thus raise its readability score, sentences should be made less complex (e.g., by removing embedded clauses). Word length should be shortened where possible. Passive sentences should not be used.

Comprehension analyses

Readability of a text is directly related to how easy it is to comprehend. Comprehension of a text can be assessed using the Cloze procedure. Cloze testing can assess the predictability and comprehensibility of a passage of text. Designers of leaflets should Cloze test new materials to assess how easy they are to understand.

The Cloze procedure consists of a passage of text that contains missing, deleted words. The subject must try to determine what the missing word is, using their knowledge of the language and the context of the rest of the text.

There are five main types of Cloze test. In the fixed rate deletion test, every nth word (usually the fifth or the seventh) from the text is deleted. In the selective deletion test, the test compiler chooses which words he/she wishes to delete. In multiple-choice cloze tests, the subject is offered a selection of words to choose from to complete the blanks. In the ‘cloze elide’, incorrect words instead of blanks are inserted into the text – the subject must identify the incorrect words and replace them with a more appropriate word. Finally in the ‘C-test’, a part of every second word is deleted from the text – the subject must complete the missing parts.

For all of these tests, increased comprehension is indicated by a higher number of blanks being appropriately filled. Exact word or SEMAC scoring may be used. With exact scoring, a word is identified as being correct only if it matches the exact word that was deleted

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originally. With SEMAC scoring, subjects may be given a ‘correct’ point if the word is not an exact match, but is still grammatically and lexically appropriate. The optimum length of a Cloze test, i.e. numbers of words deleted from the text is around 20-25.

To assess a piece of text for its comprehensibility, the following steps should be taken:

1. Select the appropriate Cloze test procedure (e.g., multiple choice, fixed rate deletion). Once the procedure has been selected, keep this test as a consistent choice for testing of all documents.

2. Prepare your materials according to the choice of Cloze procedure. For example for fixed rate deletion, keep the first and last sentence intact. Then delete either every fifth or seventh word. For examples of prepared Cloze tests, see appendix 2.

3. Select your marking method (i.e. either exact score or SEMAC). Make sure this is consistent for all tests.

4. Administer the test to an appropriate sample of relevant employees.

5. Count the number of correct blanks filled.

6. Calculate the percentage of correct blanks filled for each subject.

Scores under 45% mean the text causes ‘frustration’ for the reader. Scores between 45-60% mean that the material can be used with help from a teacher. Scores over 60% mean the text can be understood with little or no difficulty.

Step 5: Subjective Evaluation of Leaflets

Once new leaflets have been written and have achieved optimum objective usability, potential users can evaluate them subjectively. Subjective evaluations of new leaflets can be compared with subjective evaluation of old leaflets.

A questionnaire to assess usability and usefulness of leaflets was developed for this project (see figure 27). The questionnaire contains 7 items scored on a 5-point scale ranging from 1 – ‘not at all’, to 5 – ‘extremely’. The questionnaire can be seen below.

The first 3 items relate to usability. The second 4 items relate to usefulness. The means of items 1,2 and 3 therefore give a usability score. The means of items 4,5,6 and 7 give a usefulness score.

A sample of risk-relevant employees should evaluate the old and new leaflets using the above questionnaire. A sample of 30 participants for each leaflet is sufficient. Each participant should read only one of the leaflets.

Once the means for usability and usefulness for each leaflet have been calculated, they can be compared to establish whether the newly written leaflet is perceived as more usable and useful than the old version.

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Please indicate your responses to the following items by circling a number using the scale shown below:

1=Not 5=Extre at All mely

1. How easy is the leaflet to read? 1 2 3 4 5

2. How easy is the leaflet to understand? 1 2 3 4 5

3. How easy is the information in the leaflet to remember? 1 2 3 4 5

4. How informative to you find the leaflet? 1 2 3 4 5

5. How relevant do you think the information is for your work? 1 2 3 4 5

6. How accurate do you think the information provided is? 1 2 3 4 5

7. How helpful do you think the information will be in your 1 2 3 4 5 work?

Figure 27: Questionnaire for the subjective evaluation of leaflets.

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Summaries

1. Summary of Project Aims

2. Summary of Literature Review

3. Summary of Study 1: Readability and Content Analysis of Current HSE Leaflets on Noise and Manual Handling

4. Summary of Study 2: Perceived Usability and Usefulness of HSE Leaflets and their Relationship to Intentions to Follow Safe Practice

5. Summary of Study 3: Developing Relevant Framed Messages - A Qualitative Study

6. Summary of Study 4: Framing Effects for Manual Handling Leaflets - Study of Domestic Staff

7. Summary of Study 5: Framing Intervention

8. Summary of Study 6: Narrative Structure

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Summary of Project Aims

· The project aims to demonstrate that appropriately framing occupational risk leaflets in a positive or negative way will increase intentions to perform prevention behaviours.

· The project also aims to demonstrate that the usability and usefulness of occupational risk leaflets can affect employees’ intentions to follow safe practice.

Summary of Literature Review

· Interventions designed to encourage workers to take self-protective behaviour typically focus initially on identifying target variables from theoretical models of health behaviour.

· Variables shown to influence health behaviour include threat-related beliefs, normative expectations, efficacy and perceived barriers.

· The influence of the design features of risk communication materials on behavioural outcomes are studied less frequently.

· The use of leaflets in health promotion is widespread. Leaflets can serve as cost­effective, versatile interventions..

· A serious barrier to effective risk communication is illiteracy. One fifth of the UK population is functionally illiterate.

· Readability studies of health promotion materials have shown that many are written at a reading level too high for much of their target audience.

· Readability is directly related to comprehension.

· Individuals of all reading abilities have been shown to prefer health information materials that are written at lower reading levels.

· Health promotion materials written at lower reading levels have been shown to cause increased knowledge, more positive attitudes, and be more persuasive than those written at higher reading levels.

· Health information can be presented as either costs (negative/losses) or benefits (positive/gains)

· Traditionally, information outlining health risks tends to highlight costs or losses.

· In the health domain, a distinction can be made between prevention and detection behaviours.

· Positively framed messages are more influential for prevention behaviours. Negative frames are more influential for detection behaviours

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Summary of Study 1: Readability and Content Analysis of Current HSE Leaflets on Noise and Manual Handling

What we knew before study 1

· Readability of health promotion materials can influence knowledge and increase their persuasion. Readability is directly related to comprehension.

· No information available on current HSE leaflets in terms of objective readability, comprehensibility and structure.

What we know after study 1

· 13 noise leaflets and 10 manual handling leaflets were analysed to assess reading age. Reading age scores range from 0-100, with 0 representing the highest possible difficulty text and 100 representing the lowest possible difficulty text.

· Manual handling leaflets had an average reading age 13.6 years. This falls within the ‘fairly difficult’ range. The most difficult leaflet had a reading age of 15 years (‘difficult’) and the least difficult had a reading age of 11.9 years (‘easy’).

· The average reading level for the noise leaflets was 13.7 years. This falls within the range defined as ‘fairly difficult’. The most difficult leaflet had a reading age of 15.8 years and the easiest 9.1 years.

· To comprehend an average manual handling leaflet a teacher is required. The noise leaflet would be ‘frustrating’ for the reader.

· 23 current HSE leaflets on noise and manual handling were analysed for content. Leaflets were analysed to determine the amount of statements framed positively and negatively, and also to determine the proportion of text devoted to information on causes, consequences and solutions to the health risk.

· Leaflets varied greatly in the proportion of text dedicated to information on causes, consequences and solutions. Some leaflets contained no risk information or information about the consequences of a health hazard.

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Discussion points from study 1

· Many current HSE leaflets on noise and manual handling are written at a level that may be higher than desired.

· There was a wide variation in readability levels between individual leaflets.

· Cloze testing showed that undergraduates had difficulty understanding the information in the leaflets.

· Poor readability of risk materials is a barrier to comprehension.

· If a sufficient level of comprehension is not reached, behavioural change is less likely.

· Improving the readability of risk leaflets can be achieved simply. This in turn was shown to improve comprehension.

· Previous readability studies show that for people of all reading abilities, health messages are more effective in influencing behavioural change if they are written at lower reading levels. The readability of the leaflets should be improved.

· The proportion of text dedicated to causes, consequences and solutions to a risk varied widely between individual leaflets.

· Previous studies suggest that a balance between causes, consequences and solutions within a risk message may improve persuasion. Further study is required to identify optimum proportions of these three categories.

· The majority of statements contained in the leaflets studied were framed negatively. Only a tiny proportion was framed positively. Previous studies suggest that for prevention behaviours, positive messages are more persuasive.

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Summary of Study 2: Perceived Usability and Usefulness of HSE Leaflets and their Relationship to Intentions to Follow Safe Practice

What we knew before study 2

· Nothing concerning the role of design features (usability and usefulness) of leaflets in relation to intentions to perform safe working practices.

What we know after study 2

· Participants distinguished 2 separate components of leaflet design. These were ‘usability’ (e.g., readability) and ‘usefulness’ (e.g., relevance to work).

· As expected, for manual handling, an occupation specific RCN leaflet was rated as significantly more useful than a general HSE leaflet.

· Those with a prior exposure to harm (back pain) in the manual handling group rated the leaflets as more useful.

· The largest predictors of intentions to follow safe practice were the usability and usefulness of the leaflets for the manual handling group and usability for the workers where noise was an issue.

· An earplug counter fitted to earplug dispensers at the mine showed an increase in number of plugs taken after the evaluation study, compared to before the study.

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Discussion points from study 2

· Participants distinguished between 2 components to the leaflets. These were their usability and usefulness.

· Different groups identified within the overall user groups vary in their cognitions and emotional responses to the risks outlined in the leaflets. Worry and perceptions of risk are moderated by experience and exposure to the health problem.

· Despite this, the usability and usefulness of the leaflets that subjects read are still the biggest overall predictors of intentions to follow safe practice.

· The readability analyses conducted in the previous study demonstrated that current leaflets can be improved in terms of their usability. Results from the present study show that participants who perceive the leaflets as more useable are more likely to have higher intentions to follow safe practice.

· The importance of usefulness of the leaflet was also identified in this study. This emphasises the importance of tailoring risk communications to target groups.

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Summary of Study 3: Developing Relevant Framed Messages - A Qualitative Study

What we knew before study 3

· The previous studies identified the importance of usability and usefulness in leaflet design. Therefore it was necessary to develop leaflets with optimum usability and usefulness.

· The health consequences of not following safe practice at work can affect many aspects of a sufferer’s life. Before the study nothing was known about which of the potential consequences were particularly important to risk-relevant employees (those involved with noise or manual handling at work).

What we know after study 3

· Reading ease was shown previously to influence how people respond to such leaflets. It is possible to rewrite leaflets to increase the ease of reading. The new leaflets were written with a high reading ease level (average reading ease level 65-70, age 11-12).

· Employees can imagine many potential life changes should they suffer the consequences of not following safe practice. These include changes at work, in their social life, at home and emotional changes. These can be used to develop more relevant consequences sections in risk leaflets.

Discussion points from study 3

· The newly written leaflets contained a balance of information relating to the risk factors associated with incorrect manual handling, the consequences of incorrect manual handling, and guidelines on how to lift correctly.

· The two leaflets were identical apart from 30% of the text. This proportion was framed to highlight ‘gains’ or ‘losses’. The majority of this text was contained in the consequences section. Frames were developed using the methods outlined in the recommendations section of this report.

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Summary of Study 4: Framing Effects for Manual Handling Leaflets - Study of Domestic Staff

What we knew before study 4

· Previous studies have shown that positively framed messages can be more persuasive for uptake of prevention behaviours. This study aimed to show that newly designed positively framed leaflet would increase intentions to follow safe practice more than a newly developed negatively framed leaflet or a current HSE leaflet.

What we know after study 4

· There were no significant differences between the usability of the newly written positive and negative framed leaflets.

· The positively framed leaflet was rated as more usable than the HSE leaflet.

· The positively framed leaflet was rated as significantly more useful than the HSE leaflet.

· Participants who read the positively-framed leaflet rated their-own and others risk of injury as higher than those who read the negative leaflet.

· Most importantly, participants who read the positively framed leaflet rated themselves as being significantly more likely to follow safe practice when manual handling than those who read the negative or HSE leaflets.

· The usability of the leaflets and reading the positive- rather than the negative-framed message significant predicted of intentions to follow the manual handling guidelines.

· Perceptions of risk of injury to self and others through manual handling, and perceived seriousness of back pain as a health problem also significantly predicted intentions to follow safe practice.

· Altogether, the variables measured in this study accounted for 47% of the total variance in intentions to follow safe practice for this sample of domestic staff.

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Discussion points from study 4

· Participants responded differently to the positive and negatively framed leaflets even though they were identical in terms of readability and content. Only 30% of the text was ‘framed’, yet this had a significant effect on participants’ intentions to follow safe practice.

· The frame of the leaflet also influenced participants’ perceptions of usability and usefulness, with the positive leaflet being rated most highly for both these factors.

· Previous studies of framing effects for health behaviours have not explored whether the effect generalises to occupational risk messages. The current study demonstrates that framing can influence employees’ risk-related attitudes and intentions to follow safe practice.

· These results highlight the important role of the design of risk communication materials in influencing persuasion. Simple changes regarding readability, content, and framing can significantly affect employees’ risk-related cognitions. Future leaflets should be written with these factors in mind.

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Summary of Study 5: Framing Intervention

What we knew before study 5

· In the general health promotion literature, for prevention behaviours, positively framed messages are more effective for increasing intentions. Our previous study showed that this finding can be generalised to occupational health behaviours, in this case manual handling.

· The influence of frame on intentions for general health behaviours can be affected by prior involvement with the issue. We know nothing about the effect of prior involvement on framing for occupational health behaviours.

What we know after study 5

· For noise participants, previous behaviour moderated the effect of frame. Those reporting current regular use were more likely to increase their intentions to wear ear defenders by the positive frame. Those who reported current occasional use were more likely to be influenced by the negatively frame.

· Prior exposure to the health problem moderated the effect of frame for both sets of participants. For noise participants, participants who knew someone with noise induced hearing problems were more influenced to increase their intentions to wear ear defenders by the positively framed message. Those who did not know anyone were more influenced to increase their intentions by the negatively framed message.

· Manual handling participants were influenced by frame according to whether they had suffered back pain as a consequence of manual handling. The positively framed message was more influential in increasing intentions to follow safe practice for those who had suffered back problems themselves. The negatively framed message had no influence on intentions for either group.

· For noise participants, worry about being deafened at work was increased by the negatively framed message. For manual handling participants, worry about back pain and injury as a result of manual handling was increased by the negatively framed message.

· For noise participants, perceived self-efficacy was increased by the positively framed message. For manual handling participants with a history of back pain, self-efficacy was increased by the positively framed message. For those without, self-efficacy was increased by the negatively framed message.

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Discussion points from study 5

· Leaflets framed in a negative or positive way had differential effects on users risk­related cognitions, emotions, and intentions.

· Prior exposure to the health consequences and past behaviour (i.e., the extent to which PPE has been used in the past) were shown to influence the effect of frame, for both noise and manual handling samples.

· Negatively framed messages increased worry about health consequences in both samples. Worry can have adverse effects, such as messages being discounted or counter-argued by the recipient. Our previous studies have shown worry has no beneficial effects on intentions to follow safe practice. Therefore, leaflets that increase levels of worry may not be beneficial.

· Positively framed messages increased perceived self-efficacy in both samples. Self­efficacy is commonly shown to predict intentions to perform health behaviours. Therefore, leaflets that increase levels of self-efficacy may be beneficial.

· More beneficial effects for positively framed messages were found in this study than for negatively framed messages. Positively framed leaflets may therefore be a more effective intervention.

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Summary of Study 6: Narrative Structure

What we knew before study 6

· Health promotion messages typically contain a section outlining the consequences of a health hazard, and a section containing information advising the reader how to avoid those consequences.

· The order in which these two sections are presented has been shown to influence persuasion. The literature is equivocal, however. Studies have found persuasive effects by both placing the solutions section after the consequences section, and by placing the consequences section after the solutions section.

What we know after study 6

· For the sample used in this study, manipulating the narrative structure of risk leaflets on manual handling did not influence intentions to follow safe practice.

· The order of presentation was shown to interact with frame in influencing worry about the consequences of not following safe practice. In the consequences-solutions order, worry about suffering back pain was higher when participants had read the negatively framed leaflet than those who had read the positively framed leaflet.

· Prior exposure to back pain increased worry about back pain as a health problem. Student nurses perceived the leaflets to be more useful than working participants. Neither of these groups differed in their intentions to follow safe practice.

· The perceived usefulness of the leaflets predicted intentions to follow safe practice. Altogether, the variables measured in this study accounted for 42% of the total variance in intentions to follow the advice given in the leaflets.

Discussion points from study 6

· Traditionally, health leaflets tend to follow a consequences-solutions order. However, as this is shown to increase worry when coupled with a negative (high-threat) message reversing this order for negatively framed messages may be beneficial.

· Regarding the usability and usefulness of leaflets, results from this study support the findings of the previous studies in this series. Increasing the salience and reading ease of risk communication materials can influence their persuasive effects.

· Participants’ intentions to follow safe practice in this study were not influenced by framing risks as negatives or positives. Neither were their intentions influenced by manipulating the order of the consequences and solutions sections. Significant effects have been shown for both framing and narrative structure in the literature and in previous studies in this series.

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Appendices

Appendix 1 – List of Health and Safety Leaflets Analysed

Appendix 2 – Readability and Comprehension Measures & Examples

Appendix 3 – Content Analysis of HSE Leaflets

Appendix 4 – Questionnaires Used in Project

Appendix 5 – Statistical Details

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Appendix 1 - List of Health and Safety Leaflets Analysed

1. Manual Handling Leaflets

i) Checkouts and Musculoskeletal Disorders

ii) Don’t Put Your Back into It!

iii) Getting to Grips with Manual Handling

iv) Manual Handling Assessment

v) Manual Handling in the Textiles Industry

vi) Upper Limb Disorders

vii) Work Related Upper Limb Disorders

viii) Handling the News

ix) Watch Your Back!

2. Noise Leaflets

i) Ear Protection

ii) Health Surveillance in Noisy Industries

iii) Keep the Noise Down

iv) Noise

v) Noise at Woodworking Machines

vi) Noise at Work Regulations

vii) Noise in Construction

viii) Protection of Hearing

ix) Solutions in Woodworking

x) Hearing Protection in Foundries

xi) Hear This!

xii) Listen Up!

xiii) Noise at Work

xiv) Protect Your Hearing

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Appendix 2 - Readability and Comprehension Measures & Examples

1. Flesch Reading Ease Scores for Individual Leaflets

2. ‘Noise’ Leaflet – Original and Rewritten with Increased Reading Ease

3. Prepared Cloze Tests Used in Study 1

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Individual Readability Statistics for Current HSE Leaflets on Noise and Manual Handling

Manual Handling Leaflets

Title: Checkouts and musculoskeletal disorders Passive Sentences: 13% Flesch Reading Ease: 53.2 Flesch-Kincaid Grade Level (reading age): 8.6 (13.6)

Title: Don’t put your back into it Passive Sentences: 7% Flesch Reading Ease: 72.8 Flesch-Kincaid Grade Level (reading age): 6.6 (11.6)

Title: Getting to grips with manual handling Passive Sentences: 8% Flesch Reading Ease: 61.9 Flesch-Kincaid Grade Level (reading age): 7.1 (12.1)

Title: Manual handling assessment Passive Sentences: 26% Flesch Reading Ease: 56.8 Flesch-Kincaid Grade Level (reading age): 8.6 (13.6)

Title: Manual Handling in the Textiles Industry Passive Sentences: 25% Flesch Reading Ease: 51.4 Flesch-Kincaid Grade Level (reading age): 9.8 (14.8)

Title: Upper limb disorders Passive Sentences: 12% Flesch Reading Ease: 60.8 Flesch-Kincaid Grade Level (reading age): 8 (13)

Title: Work related upper limb disorders Passive Sentences: 16% Flesch Reading Ease: 47.8 Flesch-Kincaid Grade Level (reading age): 10 (15)

Title: Handling the news Passive Sentences: 17% Flesch Reading Ease: 55.5 Flesch-Kincaid Grade Level (reading age): 10.1 (15.1)

Title: Watch your back Passive Sentences: 9% Flesch Reading Ease: 77.9 Flesch-Kincaid Grade Level (reading age): 5.9 (11.9)

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Noise Leaflets

Title: Ear Protection Passive Sentences: 17% Flesch Reading Ease: 53.9 Flesch-Kincaid Grade Level (reading age): 9.8 (14.8)

Title: Health surveillance in noisy industries Passive Sentences: 17% Flesch Reading Ease: 47 Flesch-Kincaid Grade Level (reading age): 11 (16)

Title: Keep the noise down Passive Sentences: 19% Flesch Reading Ease: 52.1 Flesch-Kincaid Grade Level (reading age): 9.6 (14.6)

Title: Noise Passive Sentences: 23% Flesch Reading Ease: 56.1 Flesch-Kincaid Grade Level (reading age): 9.4 (14.6)

Title: Noise at woodworking machines Passive Sentences: 34% Flesch Reading Ease: 53.6 Flesch-Kincaid Grade Level (reading age): 9.6 (14.6)

Title: Noise at work regulations Passive Sentences: 21% Flesch Reading Ease: 58.8 Flesch-Kincaid Grade Level (reading age): 9.1 (14.1)

Title: Noise in construction Passive Sentences: 34% Flesch Reading Ease: 53.6 Flesch-Kincaid Grade Level (reading age): 9.6 (14.6)

Title: Protection of hearing Passive Sentences: 37% Flesch Reading Ease: 44.3 Flesch-Kincaid Grade Level (reading age): 10.8 (15.8)

Title: Solutions in woodworking Passive Sentences: 24% Flesch Reading Ease: 54.7 Flesch-Kincaid Grade Level (reading age): 9.4 (14.4)

Title: Hearing protection in foundries Passive Sentences: 42% Flesch Reading Ease: 65 Flesch-Kincaid Grade Level (reading age): 7.8 (12.8)

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Title: Hear this! Passive Sentences: 15% Flesch Reading Ease: 85.6 Flesch-Kincaid Grade Level (reading age): 4.1 (9.1)

Title: Listen up! Passive Sentences: 18% Flesch Reading Ease: 68.5 Flesch-Kincaid Grade Level (reading age): 7.3 (12.3)

Title: Noise at work Passive Sentences: 16% Flesch Reading Ease: 71.9 Flesch-Kincaid Grade Level (reading age): 6.9 (11.9)

Title: Protect your hearing Passive Sentences: 7% Flesch Reading Ease: 72.8 Flesch-Kincaid Grade Level (reading age): 6.6 (11.6)

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Original Noise Leaflet – Readability Score 55.9.

Noise and sounds are an important part of everyday life. In moderation they are harmless, but too much noise can cause permanent damage to your hearing. Noise may also contribute to accidents by hindering the good communications essential to safety at work.

The dangers of noise are often underestimated. Workers can grow so used to excessive noise levels that they accept them as a natural part of their working life - but in fact they are beginning to lose their hearing. They may not even be aware that their hearing is deteriorating until it is too late, when the inner ear has been damaged. This causes an irreversible deafness that cannot be corrected using a hearing aid, unlike other types of deafness.

The Noise at Work Regulations 1989 set out what has to be done to prevent hearing damage caused by loud noise at work. The danger will only be controlled effectively if noise levels are properly assessed and adequate control measures are taken. Noise levels are measured in decibels (dB(A)).

The general aim of the Regulations is to reduce the risk of hearing damage to the lowest level reasonably practicable, but if exposure is likely to reach one of the three action levels in the Regulations (i.e. a daily personal exposure of 85 or 90 dB(A) or a peak action level of 140 dB) it must be assessed by a competent person so that action can be taken. As far as possible engineering control measures should be used to reduce exposure to noise, rather than ear protectors. HSE's free leaflet Introducing the Noise at Work Regulations: A brief guide to the requirements for controlling noise at work INDG75 (rev) gives full advice on the Regulations.

Employers must also:

· Tell workers if their exposure is likely to reach the action levels, and warn them about the risk to their hearing;

· Provide suitable ear protection where necessary; and

· Provide adequate information and training on, for example, how to use noise control equipment, when and where to use ear protectors, how to look after them, and what to do if defects are found.

Employees must:

· use the protective equipment provided and report any defects.

The self-employed must:

· make sure their noise exposure is assessed and take all the protective action required of employers and employees.

What noise levels might be harmful?

Do you have to shout to be heard at work? If people less than 2 m away find it difficult to hear you then you may have a noise problem. It is recommended that daily exposure should not exceed the equivalent of 90 dB(A) received continually over eight hours. That is roughly equivalent to heavy street traffic.

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The table shows the length of time that workers can be exposed to different sound levels without exceeding that limit.

Sound level Equivalent exposure dB(A) period (hours per day)

90 8

93 4

96 2

99 1

102 ½

105 ¼

Each increase of 3 dB(A) halves the length of exposure time.

High levels of noise are all around you on the farm:

· Tractors are covered by specific noise legislation. When new, levels of 90 dB(A) inside the cab must not be exceeded even when windows are opened. In some cases, levels in approved 'Q' cabs are now below 85 dB(A). Lowest levels will only be achieved with the doors and windows closed. Use the aperture provided on many tractor cabs for routing cable and electrical controls rather than leaving the rear window open. Many tractors without cabs have noise levels above 90 dB(A) and the driver must wear ear protectors when driving them. Tractors operating near to maximum power or with other mounted or towed machinery may generate higher noise levels.

· Chain saws - always wear ear protectors when operating these saws. Noise levels measured at the operator's ear can be as high as 110 dB(A) and so employers should provide ear protection capable of reducing the noise level at the protected ear to 90 dB(A). Anyone working nearby may also need ear protectors. The chain saw should carry a prominent warning sign to remind users of the hazard. The sign must be in accordance with the Health and Safety (Safety Signs and Signals) Regulations 1996.

EAR PROTECTORS MUST BE WORN.

Barn machinery - buildings can intensify noise from machinery such as milling and mixing plant, grass and grain dryers. Make sure that exposure is properly assessed. If possible, reduce the noise at source. If this cannot be done then:

· prevent noise being transmitted by using acoustic enclosures, screens and barriers;

· set a strict time limit for the operator to be present with equipment running; and

· use ear protectors.

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You may also need to put up a warning sign. New plant should be designed and installed to keep noise to a minimum. For instance, locate control panels and working areas away from areas with high levels of noise, and mount machines on resilient mountings.

Fans can be a considerable source of noise so take this into account when specifying new or replacement units - consider fitting silencers to existing fans. Make sure that by controlling operator noise you do not increase environmental noise.

Also, make sure that the steps you take to control environmental noise do not adversely affect other areas of safety by, for example, limiting ventilation or creating a fire or explosion hazard.

Animals can be very noisy. Large numbers of pigs in a building can create noise levels of 110 dB(A) or above, especially at feeding time. So even short-term exposure can be harmful, particularly if you are exposed to other sources such as milling and mixing during the day. Mechanical or automatic feeding systems reduce the need to enter the building when noise levels reach their peak. If this isn't practicable, wear ear protectors.

EAR PROTECTION

Ear protectors are available in many forms. Whichever type of protector is used, it will only provide the assumed protection if it is in good condition, is the correct size and is worn properly. Three main types of ear protectors are available:

· earmuffs - these are normally hard plastic cups that fit over and surround the ears, and are sealed to the head by cushion seals. The inner surfaces of the cups are covered with a sound- absorbing material, usually soft plastic foam. The user should ensure that they completely surround the ear, and that there are no gaps in the contact between the cushion seal and the head;

· earplugs - these fit into the ear canal. They sometimes have a cord or neckband to prevent loss. Earplugs will only be effective when fitted properly so correct fitting is essential. They may not be suitable for anyone with ear trouble. If you have a history of ear disease or irritation of the ear canal, get medical advice before using earplugs;

· semi-inserts – these are pre-moulded ear caps attached to a headband which presses them against the entrance of the ear canal. This type of protector can be useful for those who need to wear ear protection for short periods of time.

There are other, more sophisticated ear protectors available that provide additional noise control facilities, for example built-in electronic systems. Some ear protectors are available to be used in circumstances where there may be sudden impulse noise like gunfire.

Always wear ear protection properly. Don’t lose your hearing.

95

Rewritten Noise Leaflet – Readability Score 70.2

Noise and sounds are an important part of everyday life. In small doses they are harmless, but too much noise can cause lasting damage to your hearing. Noise may also help cause accidents by making it hard to communicate, which is important for safety at work.

People often do not realise how dangerous noise can be. Workers can grow so used to high noise levels that they accept them as a normal part of their working life. In fact they are starting to lose their hearing. They may not even be aware that their hearing is getting worse until it is too late, when the inner ear has been damaged. This causes a permanent deafness that cannot be made better with a hearing aid, unlike other types of deafness.

The Noise at Work Regulations 1989 set out what has to be done to stop hearing damage caused by loud noise at work. To control this danger, the level of noise must be properly checked, and action taken to reduce it. Noise levels are measured in decibels (dB(A)).

The main aim of the Regulations is to cut down the risk of hearing damage to the lowest realistic level. There are three ‘action levels’ set out in the Regulations. If noise levels are likely to reach one of these levels (being exposed every day to 85 or 90 dB(A) or a ‘peak action level’ of 140 dB) then it must be checked by a trained person so that something can be done. As far as possible, engineering changes should be made to reduce noise, rather than wearing ear protectors. HSE's free leaflet ‘Introducing the Noise at Work Regulations: A brief guide to the requirements for controlling noise at work INDG75(rev)’ gives full help on the Regulations.

Employers must also:

· Tell workers if their exposure is likely to reach the ‘action levels’. Warn them about the risk to their hearing;

· Give proper ear protection where necessary; and

· Give enough information and training on, for example, how to use noise control equipment, when and where to use ear protectors, how to look after them, and what to do if faults are found.

Employees must:

· Use the equipment given to protect them, and report any faults.

The self-employed must:

· Make sure their noise exposure is checked. Do everything needed to reduce noise for employers and employees.

What noise levels might be harmful?

Do you have to shout to be heard at work? If people less than 2 m away find it hard to hear you then you may have a noise problem. Daily exposure should not be more than 90 dB(A) continually over eight hours. That is roughly the same as heavy street traffic.

The table shows the length of time that workers can be exposed to different sound levels without going over that limit.

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Sound level Equivalent exposure dB(A) period (hours per day)

90 8

93 4

96 2

99 1

102 ½

105 ¼

Each increase of 3 dB(A) halves the length of exposure time.

High levels of noise are all around you on the farm:

· Tractors are covered by specific noise laws. When new, the level of noise in the cab must be no more than 90 dB(A) even when windows are opened. In some cases, levels in approved 'Q' cabs are now below 85 dB(A). You will only get the lowest levels with the doors and windows closed. Many tractor cabs have an opening for routing cable and electrical controls. Use this instead of leaving the rear window open. Many tractors without cabs have noise levels above 90 dB(A), and the driver must wear ear protectors when driving them. Tractors that work close to full power or with other mounted or towed machinery may give out higher noise levels.

· Chain saws - always wear ear protectors when using these saws. Noise levels measured at the operator's ear can be as high as 110 dB(A). Employers should give out ear protection that can reduce the noise level at the protected ear to 90 dB(A). Anyone who works nearby may also need ear protectors. The chain saw should carry a clear warning sign to remind users of the danger. The sign must comply with the Health and Safety (Safety Signs and Signals) Regulations 1996.

EAR PROTECTORS MUST BE WORN.

Barn machinery - buildings can make noise from machinery worse such as milling and mixing plant, grass and grain dryers. Make sure that exposure is properly checked. If possible, cut down the noise at source. If this cannot be done then:

· stop noise being made by using sound enclosures, screens and barriers;

· set a strict time limit for the operator to be present with equipment running; and

· use ear protectors.

You may also need to put up a warning sign. New plant should be designed to keep noise as low as possible. For instance, put control panels and working areas away from areas with high levels of noise, and put machines on hardwearing mountings.

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Fans can be a big source of noise. Remember this when getting new or replacement units. Think about fitting silencers to existing fans. Make sure that by cutting down operator noise you do not increase environmental noise.

Make sure that things you do to cut down environmental noise do not badly affect other areas of safety. For example they might limit the flow of air or cause a danger of fire or explosion.

Animals can be very noisy. Large numbers of pigs in a building can make noise levels of 110 dB(A) or above, especially at feeding time. Exposure for short amounts of time can still cause harm. This is made worse if you are exposed to other noise such as milling and mixing during the day. Mechanical or automatic feeding systems cut down the need to enter the building when noise levels reach their peak. If this isn't possible, wear ear protectors.

EAR PROTECTION

Ear protectors come in many forms. Whichever type of protector is used, it will only give the proper protection if it is in good condition, is the correct size and is worn properly. Three main types of ear protectors are available:

· earmuffs - these are normally hard plastic cups, which fit over and surround the ears. They are sealed to the head by cushion seals. The inner surfaces of the cups are covered with a material that absorbs sound, usually soft plastic foam. The user should make sure that they completely surround the ear, and that there are no gaps in the contact between the cushion seal and the head;

· earplugs - these fit into the ear canal. They sometimes have a cord or neckband to prevent loss. Earplugs will only work well when fitted properly, so correct fitting is vital. They may not be suitable for anyone with ear trouble. If you have a history of ear disease or irritation of the ear canal, get medical advice before using earplugs;

· semi-inserts – these are pre-moulded ear caps attached to a headband which presses them against the entrance of the ear canal. This type of protector can be useful for those who need to wear ear protection for short periods of time.

There are other kinds of ear protectors that have even more features to control noise, for example built-in electronic systems. Some ear protectors are made for jobs where there may be sudden impulse noise like gunfire.

Always wear ear protection properly. Don’t lose your hearing.

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Noise Original Cloze Test

Noise.

Noise and sounds are an important part of everyday life. In moderation they are ________, but too much noise ________ cause permanent damage to ________ hearing. Noise may also ________ to accidents by hindering ________ good communications essential to ________ at work.

The dangers ________ noise are often underestimated. ________ can grow so used ________ excessive noise levels that ________ accept them as a ________ part of their working ________ - but in fact they ________ beginning to lose their ________. They may not even ________ aware that their hearing ________ deteriorating until it is ________ late, when the inner ________ has been damaged. This ________ an irreversible deafness that ________ be corrected using a ________ aid, unlike other types ________ deafness.

The Noise at ________ Regulations 1989 set out what ________ to be done to ________ hearing damage caused by ________ noise at work. The ________ will only be controlled ________ if noise levels are ________ assessed and adequate control ________ are taken. Noise levels ________ measured in decibels (dB(A)).

The ________ aim of the Regulations ________ to reduce the risk ________ hearing damage to the ________ level reasonably practicable, but ________ exposure is likely to ________ one of the three ________ levels in the Regulations (i.e. ________ daily personal exposure of 85 ________ 90 dB(A) or a peak action ________ of 140 dB) it must be ________ by a competent person ________ that action can be ________. As far as possible engineering control measures should be used to reduce exposure to noise, rather than ear protectors.

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Increased Reading Ease Cloze Test - Noise

Noise

Noise and sounds are an important part of everyday life. In small doses they __________ harmless, but too much __________can cause lasting damage __________ your hearing. Noise may __________ help cause accidents by __________ it hard to communicate, __________ is important for safety __________ work.

People often do __________ realise how dangerous noise __________be. Workers can grow __________ used to high noise __________ that they accept them __________ a normal part of __________ working life. In fact __________ are starting to lose __________ hearing. They may not __________ be aware that their __________ is getting worse until __________ is too late, when __________ inner ear has been__________. This causes a permanent __________ that cannot be made __________ with a hearing aid, __________other types of deafness.

__________ Noise at Work Regulations 1989 __________ out what has to __________ done to stop hearing __________caused by loud noise __________ work. To control this__________, the level of noise __________ be properly checked, and __________ taken to reduce it. __________ levels are measured in __________ (dB(A)).

The main aim of __________ Regulations is to cut __________ the risk of hearing __________ to the lowest realistic__________. There are three ‘action__________’ set out in the__________. If noise levels are __________to reach one of __________ levels (being exposed every __________ to 85 or 90 dB(A) or a ‘__________action level’ of 140 dB) then __________must be checked by __________trained person so that __________can be done. As far as possible, engineering changes should be made to reduce noise, rather than wearing ear protectors.

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Cloze Test – Manual Handling

Handling the News.

Do you handle newspaper and magazine bundles in your work?

This leaflet contains information ________ people who, for example:

________ bundles by hand; load ________ unload delivery vehicles; pick ________ and handle bundles in ________ premises; and are newsagents, ________ deliverers, or other retail ________.

What's the problem with ________ and magazine bundles?

Manual ________ (lifting, carrying, pushing, pulling etc) ________ newspaper and similar bundles ________ cause strains or serious ________ which may build up ________ time. These may result in ________ disability, but problems may ________ show up until later ________ in your life. Such ________ can stop you from ________ in the future, or ________ that you have to ________ up your leisure activities. ________ good news is that ________ injuries can be prevented. ________ is important to reduce ________ risk of injuries, even ________ you may feel fit ________ strong now.

The Law.

________ Manual Handling Operations Regulations 1992 ________ specific legal duties for ________ and employees. The general ________ of the Health and ________ at Work etc Act 1974 ________ apply. This leaflet does ________ give specific guidance on ________ duties (see the 'Further ________ ' section for more details ________ guidance on the law), ________ concentrates on giving practical ________ about reducing the risk ________ injury resulting from handling ________ and magazine bundles.

How ________ I Reduce The Risks?

________ you have to move ________ by hand, work safely ________ avoiding:

holding or manipulating ________ at a distance from ________ body; twisting, stooping or ________ awkward postures; strenuous pushing ________ pulling; unnecessary repetitive handling; ________ without enough time to ________ or recover;

and carrying loads for long distances.

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Appendix 3 - Content Analysis of HSE Leaflets

1. Analysis of Content:

i) Description of codes.

ii) Examples of coding.

2. Individual documents:

i) Analysis of coding per document

ii) Analysis of coding grouped by category.

3. Analysis of all coding:

i) Total of text units retrieved

ii) Number of documents containing each code, % of documents containing each code.

iii) % of text units retrieved in relevant documents.

iv) % of text units retrieved in all documents.

4. Frameable text units:

i) Number and % for all documents.

ii) Number and % positive/negative.

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Analysis of Content – Description of Codes

Defining the Problem, i.e., background information

Risk Factors, e.g., who is at risk? What behaviours cause the problem? What situations causethe risk?

General Facts, e.g., general information about hearing/health, descriptive facts about noise/handling.

Consequences of the Problem, i.e., what are the adverse effects?

Statistical Information, i.e., about the number of people affected.

Consequences to the Employer/Organisation, e.g., financial/absenteeism/lost production/staff turnover.

Consequences to the Individual

Consequences to the Health of the Individual, e.g., physical symptoms

Consequences to the Lifestyle of the Individual, e.g., hobbies etc.

Controlling the Problem, i.e., Ways to prevent the consequences.

Referral to a further source of information, e.g., further reading, HSE offices.

Regulations, i.e., legal responsibilities.

Solutions, i.e., general statements about reducing the risk, not specific pieces of advice.

Facts about Equipment, i.e., descriptions of particular pieces of equipment designed tocontrol the problem.

Advice for Manufacturers, i.e., advice for manufacturers on how to produce less problematic machinery to eliminate problems at source.

General Advice, i.e., suggestions and advice on how the target audience can reduce risk – ambiguous as to who specifically the advice is aimed at.

Advice for Employers/the Organisation, i.e., specific pieces of advice on how to reduce theproblem aimed at the employer/organisational level.

Advice for Employee, i.e., specific pieces of advice on how to reduce the problem aimed at the individual employee level.

Miscellaneous.

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I I

I

I I

I

I IONSRISK FACTORS GENERAL FACTS

DEFINING THE PROBLEM

STAT ST CS

PHYS CAL LIFESTYLE

NDIV DUAL HEALTH EMPLOYER

CONSEQUENCES

FURTHER INFO

EMPLOYER EMPLOYEE

ADVICE

MANUFACTURERS

EQU PMENT

SOLUT ONS REGULAT

CONTROL

ROOT

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Analysis of Content - Examples of Coding

Defining the problem/risk factors.

“The research shows that various aspects of checkout work can contribute to a risk of musculoskeletal disorders.”

“A poor fit between cashier and checkout can make the work harder and lead to cashiers being dissatisfied.”

“Factors such as long hair, spectacles, earrings hats or leads from personal stereos can reduce the effectiveness of their ear protection.”

“Do the tasks involve: twisting, stooping, or reaching upwards? Holding loads away from the body and trunk? Large vertical movements? Long carrying distances? Strenuous pushing or pulling? Unpredictable movement of loads? Repetitive handling? Insufficient rest time or recovery? A work rate imposed by a process?”

“There is no such thing as a completely ‘safe’ manual handling operation”.

“Don’t forget damage to the building – uneven floors can contribute to handling accidents, for example by making it hard to move roll cages.”

“Bundle weight is an important factor – some bundles may be too heavy for two­handed lifting by some people.”

“Loading or unloading in the back of small delivery vans can pose particular problems because the restricted space can result in awkward postures when lifting.”

“The risk of hearing damage rises significantly at exposures above this level.”

“Individuals differ in the effect noise has on their hearing. Some may be particularly sensitive to hearing damage.”

“Working without ear protectors can seriously reduce the protection given by wearing ear protectors for the rest of the day.”

“Age or general fitness are no protection – young people can be damaged as easily as the old.”

“The danger will depend on how loud the noise is and how long you are exposed to it.”

“People who work in an engineering workshop, a sawmill, a disco or pop concert hall, a bottling plant, or who use noisy machinery on a farm or in forestry, are just some of those who could be exposed to dangerous noise levels.”

“Another employee suffered a back injury as a result of trying to lift a roll of paper which had been marked up at the wrong size and weight.”

“The decision on whether the work involves risk or not depends on a sound assessment.”

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“The working environment – are there: constraints on posture? Poor floors? Variations in levels? Hot/cold/humid conditions? Poor lighting conditions?”

Controlling the problem/regulation

“What the Law Says: The Manual Handling Regulations 1992 require employers to: Avoid the need for employees to carry out manual handling work that could cause injury, so far as reasonably practicable; assess the risk of injury if manual handling can’t be avoided; and reduce the risk of injury to the lowest level reasonably practicable.”

“You have a legal duty under the Noise at Work Regulations 1989 (the noise regulations) to reduce the risk of damage to your employees’ hearing.”

“Provide your employees with ear protection and ensure they use it properly when their daily personal noise exposure exceeds 90dB(A), or when they are exposed to very loud impulsive noise, for example from explosions or when using cartridge tools or drop hammars.”

“Under the management of health and safety at work regulations 1999 employees exposed to certain types of risk, for example high noise levels, should be provided with appropriate health surveillance.”

“Health surveillance is not a substitute for measures to control noise and inform and protect employees, as required by the Noise at Work Regulations.”

“There are laws telling employers what they must do to control noise and when to give you ear protectors.”

“Your employer is legally responsible for supplying you with suitable ear protectors and for maintaining them in good working order.”

“The general aim of the regulations is to reduce the risk of hearing damage to the lowest level reasonably practicable, but if exposure is likely to reach one of three action levels in the Regulations (ie a daily personal exposure of 85 or 90 dB(A) or a peak action level of 140 dB(A) it must be assessed by a competent person so that action can be taken.”

“The manual Handling Regulations do not cover the physical effort required in work which does not involve transporting or supporting a load. For example the action of lashing down the ropes on a wagon after loading is not covered, nor are the operation of controls of weaving or spinning machinery.”

“Tractors are covered by specific noise legislation.”

“In the Health and Safety Executive (HSE) guidance on the Manual Handling Operations Regulations 1992,a clear hierarchy of measures is established.”

“Designers, manufacturers, importers and suppliers etc have duties under section of the Health and Safety at work etc. Act 1974 to reduce the noise from machinery by the greatest extent reasonably practicable.”

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Consequences/individual/lifestyle

“In my free time I used to play sports at weekends and have a game of darts or pool at my local. I used to work in the garden and play the idiot with the kids. Now I can’t sit, can’t stand, can’t sleep and can’t work properly.”

“Such injuries can stop you from working in the future, or mean that you have to give up your leisure activities.”

“It will probably come on gradually, and many people first notice it only when their family complains about the loudness of the television, they cannot keep up with conversations in a group, or they have trouble using the telephone.”

“But there is no real compensation for the social effects of noise induced hearing loss.”

“You’re straining all the while to hear what somebody has said. You never really know what . I would never repeat anything someone has said to me in case I heard it wrongly.”

“Needing to turn up the television too loud, or finding it hard to use the telephone.”

“Well-motivated people have had to give up work because of pain and disablement from ULDs. Others have been so badly affected that simple household tasks become difficult.”

“It could cost you your job and ruin your social life.”

Controlling the problem/referral to other materials

“If you feel unable to decide on suitable steps to reduce risk, you could approach the Environmental Health Department of to your local authority, or you may seek professional help.”

“See the free leaflet Handling the news: Advice for employers on manual handling of bundles, produced by the Printing Industry Advisory Committee (PIAC) for further information.”

“HSE has published advice for employers who are considering employing consultants.”

“A list of those can be found in Schedule 1 of the Provision and Use of Work Equipment Regulations 1992.”

“HSE publishes a range of leaflets and booklets on all aspects of occupational health and safety, including a series of priced noise guides to the Noise at Work Regulations and the free leaflets listed opposite.”

“See the guidance booklet on the Regulations for an example of an assessment checklist.”

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“HSE has also published guidance on the principles of machinery noise measurement.”

“Further detailed information is available in the PABAIC booklet ‘Protection of hearing in the paper and board industry.”

“HSE publishes advice and many textbooks are available on the subject.”

Consequences/individual

“Word distortion – you pick up things wrong. What you think is being said is notbeing said.”

“The damage might take years to become serious, or it can happen more quickly.”

“Hearing loss is not the only problem.”

“What’s my hearing worth in money? I wouldn’t put a figure on it.”

“Noise at work can cause other problems, such as disturbances, interferences withcommunications and stress.”

“Affected people find it difficult to catch the hard consonants like ‘t’ and ‘d’, and the‘s’ sounds, so they might muddle similar words.”

“People I have known over the years think I have conned them because I can hear abit. But they don’t know anything about it all. In the quiet you get all the hiss andbells ringing in the ears, it sometimes keeps me awake at night.”

Consequences/individual/physical symptoms

“You may get aches and pains in your muscles and joints.”

“…until a couple of years ago when my back started giving me trouble. Now my back has got so bad it almost cripples me, even after easy, light jobs.”

“Most of the reported accidents cause back injury, though hands, arms, and feet are also vulnerable.”

“Manual handling of newspaper and similar bundles can cause strains or serious injuries which may build up over time. These may result in permanent disability, but problems may not show up until later in your life.”

“Warning: In some circumstances this practice may put particularly serious pressure on the spine and carry the risk of a disabling injury.”

“While your hearing can adjust for a short while, it does not take long for it to be damaged forever.”

“In moderation they are harmless, but when they become too loud they can damage the delicate mechanism of the inner ear, destroying sensitive nerve cells and causing permanent hearing difficulties.”

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“The damage noise causes to hearing can take many forms, from a loss of sensitivity (sometimes wrongly confused with ageing), through distortion and confusion, to near­total deafness.2

“Tinnitus or ringing in the ears may be caused as well.”

“A full recovery is not always made- the result can be physical impairment or even permanent disability.”

Control/solutions/facts about equipment

“The main types of ear protection are: Earmuffs, which completely cover the ear; ear plugs, which are inserted into the ear canal; semi-inserts (also called canal caps) which cover the entrance to the ear canal.”

“There are many types of handling aids or mechanised handling devices aimed at reducing or eliminating these types of activities, for example boom loaders, roller conveyors, pallets, roll cages, pallet trucks and rotating scissor tables.”

“Disposable ear plugs require no maintenance.”

“Ear muffs (as shown in the diagram) have a number of parts which can be damaged.”

“Figure 7 shows a trolley specially designed for transporting and manoeuvring rolls about the confined spaces often found close to looms. The trolley is small and has two central load-bearing wheels with two smaller wheels at either end which allow it to be easily manoeuvred. A raised handle down one side of the trolley ensures the worker does not have to stoop.”

“Suspended on an overhead rail, the device is free to move within the storage area. Pneumatic grippers grasp the box securely and compensate for the weight of the load, allowing it to be moved with minimal effort.”

“Figure 1 shows a portable extendable conveyor belt used to unload boxes of yarn from the back of a lorry. The angle of the extended arm can be easily adjusted to suit the height at which the boxes are passed to the conveyor belt.”

“Ear protectors vary in the degree of protection given at different frequencies.”

“For larger workpieces, height-adjustable vacuum workbenches are available. On these, the workpiece mounting can be swivelled and locked at any angle to suit the job in hand.”

“Lifting hooks – these enable one person to move smaller panels without the need to bend and enable the panel to be properly gripped. All that is needed is an adjustable steel rod with a hook on one end and a handle on the other.”

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Control/solutions/equipment/advice for manufacturers

“Designers and manufacturers should design noise reduction into machines. In many cases, advice from noise and vibration consultants at design stage and before major machine development will achieve the best reductions in noise emission.”

“Manufacturers can design better vibration damping and restraint for workpieces, improve the design of waste extraction so that excessive noise is not created between woodchips and hoods, as well as fitting silencers to reduce noise at compressed air exhausts and jets.”

“Enclosure mountings should be isolated from sources of vibration to prevent enclosure itself becoming a noise radiator. Enclosures should have a noise attenuating outer skin and a noise absorbant lining.”

Consequences/statistics

“888,000 manual handling injuries (1990 Labour Force Survey) and 5,500,000 working days lost because of manual handling injuries (HSE estimate).”

“More than a third of all over-three-day injuries reported each year to the HSE and local authorities are caused by manual handling – the transporting or supporting of loads by hand or by bodily force.”

“A survey by HSE (part of the Labour Force Survey) provides an estimate of 100,000 cases of work-related ULDs across all industries.”

Consequences/to the employer

“Businesses foot most of the bills, NOT their insurers.”

“Here are some of the hidden costs for those businesses that do nothing: Increased insurance premiums; sick payments; unplanned overtime; fines and compensation payments; lost contracts and production; idle machinery; replacing injured staff and their re-training costs.”

“Many industrial workers have claimed compensation for noise damaged hearing.”

“In addition to the human costs, the financial costs can be enormous.”

“Managers know that insurance payments and premiums are often costly but they are sometimes less aware of the significance of hidden costs. These include production delay, investigation costs, overtime working, loss of experience, clerical and supervisors’ time, hiring and training of replacement staff and even loss of goodwill and of corporate image.”

“Costs to the company can come from: loss of production; poor product quality; sickness payments; accident injury claims and higher insurance premiums; high staff turnover and retraining.”

110

“Lost production when employees take time off sick; and compensation claims from those who have to stop working because of ULDs.”

“There may be a resultant sickness absence and staff turnover, lower output and a drop in product quality. These create further costs.”

“In both the above cases, civil claims for damages have been made against the employers.”

“In 1995 an estimated average 11 working days were lost through musculoskeletal disorders affecting the back, caused by work. HSE estimates that such conditions cost employers up to £335 million.”

“In a substantial number of cases, musculoskeletal disorders will result in sickness absence.”

Control/solutions/advice/for employer

“You need to consider all aspects of risk to adequately control the impact of musculoskeltal disorders.”

“Ensure that your system of work provides adequate breaks to prevent muscular fatigue; discuss the timing of breaks and pauses with your cashiers.”

“Tell your staff it is important for them to report any symptoms as soon as they arise; ensure you have a system for responding to such reports.”

“Ensure equipment is in a good state of repair.”

“Regularly monitor the work in general as well as the effects of any control strategies you implement.”

“Do a walk-through inspection. Look for obvious hazards – some may need a detailed assessment.”

“Controlling noise at source is the most cost-effective means of reducing noise exposure.”

“Ask the people doing the jobs for ideas on how to do them in an easier and safer way.”

“Give HSE’s pocket card ‘Protect Your Hearing!’ to your employees to remind them to wear their ear protection.”

“Wherever possible, provide your employees with a suitable range of effective ear protection so they can choose one that particularly suits them best.”

“Put someone in authority in overall charge of issuing ear protection and checking that it is used properly.”

“Incorporate wearing ear protection in the company safety policy in consultation with workers and their safety and employees representatives.”

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“Where an employee is not wearing ear protection properly you should ask them why, and either sort the problem out or consider giving them a verbal warning and recording it. If employees consistently fail to use protectors properly you should follow your company’s normal disciplinary procedures.”

“Consider automation, particularly for new processes.”

“But you should always consider mechanical aids – they can improve productivity as well as safety. Even something as simple as a sack truck can make a big improvement.”

“Check with the local trading standards office about by-laws on any weight limits that may apply to juveniles.”

Employers should give training about safe lifting, including situations when two­handed lifting is not acceptable.”

“It is good practice for you to keep non-clinical information about your employees noise exposures in a health record that they should be able to see on request.”

Control/solutions/advice/for employee

“Don’t be alarmed, but do tell your supervisor if you feel anything unusual in your back, arm or legs.”

“Make sure you get training so that you can do your work safely; ask for more training if you feel you need it.”

“For a long lift, such as floor to shoulder height, consider resting the load mid-way on a table or bench to change grip.”

“When lifting from a low level, bend the knees, but do not kneel or overflex the knee. Keep the back straight, maintaining its natural curve (tucking in the chin helps). Lean forward a little over the load if necessary to get a good grip. Keep the shoulders level and facing in the same direction as the hips.”

“Adjust you seat so you don’t have long or awkward reaches and ask for a footrest if you need one.”

“Don’t twist the trunk when turning to the side.”

“If you have to move bundles by hand, work safely by avoiding: holding or manipulating loads at a distance from your body; twisting, stooping, or similar awkward postures; strenuous pushing or pulling.”

“Report any defects to your manager.”

“Do wear ear protectors whenever you go into a specially marked ear protection zone.”

“Don’t take off your ear protectors where it is noisy, even for a short time, or even if they feel uncomfortable.”

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“Hand in any damaged ear protectors so they can be replaced.”

“It is in your own interest to take the protection and use it. Look after your protectors and keep them clean.”

“If you think there might be something wrong with your hearing or you have anymedical problems with your ears, see your doctor or works medical department if youhave one.”

“Don’t ignore faulty equipment.”

“Wear ear protectors AT ALL TIMES when in an ‘Ear Protection Zone’.”

“Wear suitable gloves when handling tooling, ie thick enough to prevent projecting cutters/knives from cutting the skin as well as providing an adequate grip.”

“Give yourself proper rest breaks.”

“It doesn’t matter if you are on the ground or up a tree, its vital that the forces on yourback are applied evenly.”

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Individual Documents - Analysis of Coding for Per Document

1. Manual Handling Leaflets

i) Checkouts and Musculoskeletal Disorders

ii) Don’t Put Your Back into It!

iii) Getting to Grips with Manual Handling

iv) Manual Handling Assessment

v) Manual Handling in the Textiles Industry

vi) Upper Limb Disorders

vii) Work Related Upper Limb Disorders

viii) Handling the News

ix) Watch Your Back!

2. Noise Leaflets

i) Ear Protection

ii) Health Surveillance in Noisy Industries

iii) Keep the Noise Down

iv) Noise

v) Noise at Woodworking Machines

vi) Noise at Work Regulations

vii) Noise in Construction

viii) Protection of Hearing

ix) Solutions in Woodworking

x) Hearing Protection in Foundries

xi) Hear This!

xii) Listen Up!

xiii) Noise at Work

xiv) Protect Your Hearing

114

Manual Handling Leaflets

Checkouts and Musculoskeletal Disorders Total Text Units: 155 Code Number of Text

Units % of Document

1 Defining the problem 2 1.2 1 1 Defining the problem/risk factors 56 36 1 2 Defining the problem/general facts 2 Consequences of problem 1 0.6 2 1 Consequences/number of people affected 2 3 Consequences/to employer 1 0.6 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 8 5.2 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1.9 3 1 Referral to other source of information 1 0.6 3 3 Regulations 1 0.6 3 2 Solutions 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 1.9 3 2 1 1

Solutions/advice/for employer 58 37.4

3 2 1 2

Solutions/advice/for employee 12 7.7

4 Miscellaneous

Don’t Put Your Back into It! Total Text Units: 50 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 12 24 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 4 2 3 Consequences/to employer 13 26 2 2 Consequences/to individual 2 4 2 2 1 Consequences/individual/physical 3 6 2 2 2 Consequences/individual/lifestyle 3 6 3 Controlling the problem 3 1 Referral to other source of information 1 2 3 3 Regulations 9 18 3 2 Solutions 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 4 8 3 2 1 1

Solutions/advice/for employer 1 2

3 2 1 2

Solutions/advice/for employee

4 Miscellaneous

115

Getting to Grips with Manual Handling Total Text Units: 188 Code Number of Text

Units % of Document

1 Defining the problem 1 0.5 1 1 Defining the problem/risk factors 52 26.1 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 1 0.5 2 3 Consequences/to employer 2 1 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 1 0.5 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 1 0.5 3 1 Referral to other source of information 3 3 Regulations 33 16.5 3 2 Solutions 5 2.5 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 18 9 3 2 1 1

Solutions/advice/for employer 55 27.6

3 2 1 2

Solutions/advice/for employee 30 15

4 Miscellaneous

Manual Handling Assessment Total Text Units: 147

Code Number of Text Units

% of Document

1 Defining the problem 1 1 Defining the problem/risk factors 62 35.4 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 9 5.1 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 4 2.3 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 1 0.6 3 1 Referral to other source of information 2 1.1 3 3 Regulations 3 1.7 3 2 Solutions 6 3.4 3.43 2 2

Solutions/facts about equipment

3 2 2 1 Solutions/equipment/advice to manufacturer 3 2 1 Solutions/advice 1 0.6 3 2 1 1 Solutions/advice/for employer 84 48 3 2 1 2 Solutions/advice/for employee 4 Miscellaneous 3 1.7

116

Manual Handling in the Textiles Industry Total Text Units: 171 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 58 33.9 1 2 Defining the problem/general facts 2 Consequences of problem 1 2 1 Consequences/number of people affected 2 3 Consequences/to employer 1 0.6 2 2 Consequences/to individual 2 1.2 2 2 1 Consequences/individual/physical 1 0.6 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 1 0.6 3 3 Regulations 12 7 3 2 Solutions 3 2 2 Solutions/facts about equipment 29 17 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 14 8.2 3 2 1 1

Solutions/advice/for employer 43 25.2

3 2 1 2

Solutions/advice/for employee

4 Miscellaneous

Upper Limb Disorders Total Text Units: 80 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 13 16.3 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 3 3.8 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 7 8.8 2 2 2 Consequences/individual/lifestyle 1 1.3 3 Controlling the problem 1 1.3 3 1 Referral to other source of information 2 2.5 3 3 Regulations 1 1.3 3 2 Solutions 4 5 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 2 2.5 3 2 1 1

Solutions/advice/for employer 38 47.5

3 2 1 2

Solutions/advice/for employee

4 Miscellaneous

117

Work Related Upper Limb Disorders Total Text Units: 172 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 59 25.4 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 1 0.4 2 3 Consequences/to employer 2 0.9 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 29 12.5 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 26 11.2 3 2 Solutions 11 4.7 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer 3 1.3

3 2 1 Solutions/advice 88 38 3 2 1 1

Solutions/advice/for employer 2 0.9

3 2 1 2

Solutions/advice/for employee 1 0.4

4 Miscellaneous

Handling the News Total Text Units: 88 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 20 22.7 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 5 5.7 2 2 2 Consequences/individual/lifestyle 1 1.1 3 Controlling the problem 3 1 Referral to other source of information 2 2.3 3 3 Regulations 3 3.4 3 2 Solutions 3 3.4 3 2 2 Solutions/facts about equipment 5 5.7 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 37 42 3 2 1 1

Solutions/advice/for employer 5 5.7

3 2 1 2

Solutions/advice/for employee 7 8

4 Miscellaneous

118

Watch Your Back! Total Text Units: 81 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 11 13.6 1 2 Defining the problem/general facts 1 1.2 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 2 2 2 Consequences/individual/lifestyle 13 16 3 Controlling the problem 1 1.2 3 1 Referral to other source of information 3 3 Regulations 3 2 Solutions 1 1.2 3 2 2 Solutions/facts about equipment 6 7.4 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 6 7.4 3 2 1 1

Solutions/advice/for employer

3 2 1 2

Solutions/advice/for employee 38 46.9

4 Miscellaneous

119

Noise Leaflets

Ear Protection Total Text Units: 51 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 3 5.5 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 15 27.7 3 2 Solutions 3 2 2 Solutions/facts about equipment 6 11.1 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 1 1.9 3 2 1 1

Solutions/advice/for employer 29 53.7

3 2 1 2

Solutions/advice/for employee

4 Miscellaneous

Health Surveillance in Noisy Industries Total Text Units: 100 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 6 6 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 1 1 3 1 Referral to other source of information 2 2 3 3 Regulations 4 4 3 2 Solutions 11 11 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 2 2 3 2 1 1

Solutions/advice/for employer 74 74

3 2 1 2

Solutions/advice/for employee

4 Miscellaneous

120

Keep the Noise Down Total Text Units: 84 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 1 1.2 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 1 1.2 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 1 1.2 3 3 Regulations 24 28.6 3 2 Solutions 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 1 1.2 3 2 1 1

Solutions/advice/for employer 54 64.3

3 2 1 2

Solutions/advice/for employee

4 Miscellaneous 2 2.4

Noise Total Text Units: 86 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 11 12.8 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 1 1.2 2 2 1 Consequences/individual/physical 4 4.7 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 2 2.3 3 3 Regulations 7 1.2 3 2 Solutions 1 1.2 3 2 2 Solutions/facts about equipment 13 15.1 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 23 26.8 3 2 1 1

Solutions/advice/for employer 16 18.6

3 2 1 2

Solutions/advice/for employee 3 3.5

4 Miscellaneous

121

Noise at Woodworking Machines Total Text Units: 132 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 38 28.8 1 2 Defining the problem/general facts 12 9 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 3 2.2 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 5 3.8 3 3 Regulations 21 16 3 2 Solutions 3 2 2 Solutions/facts about equipment 1 0.8 3 2 2 1

Solutions/equipment/advice to manufacturer 22 16.7

3 2 1 Solutions/advice 6 4.6 3 2 1 1

Solutions/advice/for employer 18 13.6

3 2 1 2

Solutions/advice/for employee 1 0.8

4 Miscellaneous 2 1.5

Noise at Work Regulations Total Text Units: 120 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 11 9.2 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 1 0.8 2 2 1 Consequences/individual/physical 3 2.5 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 5 4.2 3 3 Regulations 62 52 3 2 Solutions 2 1.7 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 2 1 1

Solutions/advice/for employer 29 24.2

3 2 1 2

Solutions/advice/for employee 1 0.8

4 Miscellaneous 2 1.7

122

Noise in Construction Total Text Units: 40 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 1 2 Defining the problem/general facts 5 10.9 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 17 37 3 2 Solutions 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 2 1 1

Solutions/advice/for employer 20 43.5

3 2 1 2

Solutions/advice/for employee 4 8.7

4 Miscellaneous

Protection of Hearing Total Text Units: 47 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 2 4.3 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 1 2.1 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 2 4.2 3 3 Regulations 1 2.1 3 2 Solutions 7 14.9 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 2 1 1

Solutions/advice/for employer 22 47

3 2 1 2

Solutions/advice/for employee 8 17

4 Miscellaneous 1 2.1

123

Solutions in Woodworking Total Text Units: 142 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 50 34.7 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 1 0.7 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 9 6.3 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 1 4.2 3 3 Regulations 10 6.9 3 2 Solutions 6 4.2 3 2 2 Solutions/facts about equipment 38 26.4 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 11 7.6 3 2 1 1

Solutions/advice/for employer 11 7.6

3 2 1 2

Solutions/advice/for employee 7 4.9

4 Miscellaneous

Hearing Protection in Foundries Total Text Units: 30 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 6 19.4 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 1 3.2 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 2 6.4 3 2 Solutions 3 2 2 Solutions/facts about equipment 7 22.5 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 2 1 1

Solutions/advice/for employer

3 2 1 2

Solutions/advice/for employee 15 48.4

4 Miscellaneous

124

Hear This! Total Text Units: 36 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 4 11.1 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 4 11.1 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 1 2.7 3 2 Solutions 3 2 2 Solutions/facts about equipment 1 2.7 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 2 1 1

Solutions/advice/for employer

3 2 1 2

Solutions/advice/for employee 25 69.4

4 Miscellaneous

Listen Up! Total Text Units: 112 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 15 13.9 1 2 Defining the problem/general facts 10 9.3 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 1 0.9 2 2 Consequences/to individual 16 14.8 2 2 1 Consequences/individual/physical 10 9.3 2 2 2 Consequences/individual/lifestyle 7 6.5 3 Controlling the problem 2 1.9 3 1 Referral to other source of information 2 1.9 3 3 Regulations 4 3.7 3 2 Solutions 2 1.9 3 2 2 Solutions/facts about equipment 1 0.9 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 16 14.8 3 2 1 1

Solutions/advice/for employer

3 2 1 2

Solutions/advice/for employee 15 13.9

4 Miscellaneous 1 0.9

125

Noise at Work Total Text Units: 44 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 2 4.5 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 1 2.3 2 2 1 Consequences/individual/physical 7 16 2 2 2 Consequences/individual/lifestyle 1 2.3 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 9 20.5 3 2 Solutions 1 2.3 3 2 2 Solutions/facts about equipment 1 2.3 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 7 16 3 2 1 1

Solutions/advice/for employer

3 2 1 2

Solutions/advice/for employee 8 18

4 Miscellaneous

Protect Your Hearing Total Text Units: 29 Code Number of Text

Units % of Document

1 Defining the problem 1 1 Defining the problem/risk factors 1 2 Defining the problem/general facts 2 Consequences of problem 2 1 Consequences/number of people affected 2 3 Consequences/to employer 2 2 Consequences/to individual 2 2 1 Consequences/individual/physical 2 2 2 Consequences/individual/lifestyle 3 Controlling the problem 3 1 Referral to other source of information 3 3 Regulations 1 3.4 3 2 Solutions 3 2 2 Solutions/facts about equipment 3 2 2 1

Solutions/equipment/advice to manufacturer

3 2 1 Solutions/advice 3 2 1 1

Solutions/advice/for employer

3 2 1 2

Solutions/advice/for employee 25 86

4 Miscellaneous 2 6.9

126

Individual Documents - Analysis of Coding Grouped by Category

3. Manual Handling Leaflets

i) Checkouts and Musculoskeletal Disorders

ii) Don’t Put Your Back into It!

iii) Getting to Grips with Manual Handling

iv) Manual Handling Assessment

v) Manual Handling in the Textiles Industry

vi) Upper Limb Disorders

vii) Work Related Upper Limb Disorders

viii) Handling the News

ix) Watch Your Back!

4. Noise Leaflets

i) Ear Protection

ii) Health Surveillance in Noisy Industries

iii) Keep the Noise Down

iv) Noise

v) Noise at Woodworking Machines

vi) Noise at Work Regulations

vii) Noise in Construction

viii) Protection of Hearing

ix) Solutions in Woodworking

x) Hearing Protection in Foundries

xi) Hear This!

xii) Listen Up!

xiii) Noise at Work

xiv) Protect Your Hearing

127

Manual Handling Leaflets

Checkouts and Musculoskeletal Disorders Category Code % of Document 1 37.2 2 6.4 3 50.1

Don’t Put Your Back Into It Category Code % of Document 1 24 2 46 3 30

Getting to Grips With Manual Handling Category Code % of Document 1 26.6 2 2 3 71.1

Manual Handling Assessment Category Code % of Document 1 35.4 2 7.4 3 57.1

Manual Handling in the Textiles Industry Category Code % of Document 1 33.9 2 3 3 58

Upper Limb Disorders Category Code % of Document 1 16.3 2 13.9 3 60.1

Work Related Upper Limb Disorders Category Code % of Document 1 25.4 2 13.8 3 56.1

Handling the News Category Code % of Document 1 22.7 2 6.8 3 70.5

Watch Your Back Category Code % of Document 1 14.8 2 17.2 3 62.9

128

Noise Leaflets

Ear Protection Category Code % of Document 1 5.5 2 0 3 84.4

Health Surveillance in Noisy Industries Category Code % of Document 1 6 2 0 3 94

Keep the Noise Down Category Code % of Document 1 1.2 2 1.2 3 97.7

Noise Category Code % of Document 1 12.8 2 5.9 3 68.7

Noise at Woodworking Machines Category Code % of Document 1 37.8 2 2.2 3 56.3

Noise at Work Regulations Category Code % of Document 1 9.2 2 3.3 3 82.9

Noise in Construction Category Code % of Document 1 10.9 2 0 3 89.2

Protection of Hearing Category Code % of Document 1 4.3 2 2.1 3 85.2

Solutions in Woodworking Category Code % of Document 1 34.7 2 7 3 58.3

129

Hearing Protection in Foundries Category Code % of Document 1 19.4 2 3.2 3 77.3

Hear This! Category Code % of Document 1 11.1 2 11.1 3 74.8

Listen Up! Category Code % of Document 1 23.2 2 33.4 3 38

Noise at Work Category Code % of Document 1 4.5 2 20.6 3 59.1

Protect Your Hearing Category Code % of Document 1 0 2 0 3 90

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Analysis of all Coding – Total of Text Units Retrieved

Code Reference

Total Text Units

No. of Documents (out of 23)

% of Relevant Documents

% in All Documents

1 3 2 8.6 0.13 11 492 21 91 21.5 12 28 2 3 2 8.6 0.13 21 4 3 13.4 0.17 23 33 9 39.1 1.4 22 23 6 26 1 221 114 19 82.6 5 222 11 6 26 0.5 3 9 6 26 0.4 31 29 14 60.8 1.3 33 266 22 95.7 11.6 32 60 13 56.5 2.6 322 108 11 47.8 4.7 3221 22 1 4.3 0.96 321 155 17 73.9 6.8 3211 490 17 73.9 21.4 3212 201 16 69.6 8.8 4 14 8 34.8 0.6

Totals for Groups of Coding Code 1 2 3 Text Units 523 188 1354 % of Total 22.8 8.2 59

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Frameable Text Units

Frameable text units:

Retrievals in 19 out of 23 documents = 82%

Total text units = 2292

Total frameable text units = 156 = 6.8%

Of which :

Positive = 6 = 3.9% of frameable text units = 0.3% of total text units.

Examples of Positively Framed Text Units

“What’s my hearing worth in money? I wouldn’t put a figure on it.”

“Whether we are watching television, talking to friends at parties, using the telephoneor just shopping, good hearing helps us to stay in touch.”

“The everyday sounds and noises we hear help keep us in touch with the world around us.”

“In my free time I used to play sport at weekends and have a game of darts or pool at my local. I used to work in the garden and play the idiot with the kids.”

“Sounds and noises are an important part of everyday life.”

Examples of Negatively Framed Text Units

“Here are some of the hidden costs for those businesses that do nothing: Increased insurance premiums; sick payments; unplanned overtime; fines and compensation payments; lost contracts and production; idle machinery; replacing injured staff and their re-training costs.”

“ While your hearing can adjust for a short while, it does not take long for it to become damaged forever.”

“Once ears have been damaged by noise, there is no cure.”

“A full recovery is not always made – the result can be physical impairment or even permanent disability.”

“In addition to the considerable human costs, the financial costs can be enormous.”

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“Possible costs to the individual are: pain; possible permanent disability; time off work; and loss of earnings.”

“People who are exposed to high levels of noise, even for a short time, may experience hearing loss. If they continue to be exposed, serious permanent hearing loss can occur.”

“The damage builds up gradually and you may not notice changes from one day to another, but once the damage has been done there is no cure.”

“Exposure to high noise levels can cause incurable hearing damage.”

“The damage includes loss of hearing ability, possibly made worse by permanent tinnitus (ringing in the ears) and other effects.”

“Noise at work can cause other problems, such as disturbances, interference with communications and stress.”

“ULDs may have serious consequences if you do not act promptly, such as serious ill health.”

“Just because you’re young and fit doesn’t mean you won’t suffer from long lasting pain later on in life. It could cost you your job and ruin your social life.”

“The longer you mistreat your back the more likely you are to suffer a ‘slipped’ or prolapsed disc.”

“Symptoms can lead to lost working time which is not good for employees or management.”

“Now my back is so bad it almost cripples me, even after light easy jobs. Now I can’t sit, can’t stand, can’t sleep and can’t work properly.”

“Such injuries can stop you from working in the future, or mean that you have to give up your leisure activities.”

133

Appendix 4 - Questionnaires Used in Project

1. Noise questionnaire used in study 2.

2. Manual handling questionnaire used in studies 2, 4 and 6.

3. Manual handling questionnaire used in the pre-assessment phase of study 5.

4. Manual handling questionnaire used in the post-assessment phase of study 5.

5. Noise questionnaire used in the pre-assessment phase of study 5.

6. Noise questionnaire used in the post-assessment phase of study 5.

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Noise Questionnaire used in Study 2.

Please fill in the following information

Age: Gender: Job Title: Department:

Years in company: Years in current job:

Please answer the following questions by circling a number using the scale shown below:

1=Not at All 5=Extremely

1. How easy is the leaflet to read? 1 2 3 4 5

2. How easy is the leaflet to understand? 1 2 3 4 5

3. How easy is the information in the leaflet to remember? 1 2 3 4 5

4. How informative to you find the leaflet? 1 2 3 4 5

5. How relevant do you think the information is for your work? 1 2 3 4 5

6. How accurate do you think the information provided is? 1 2 3 4 5

7. How helpful do you think the information will be in your work? 1 2 3 4 5

8. In what ways could the leaflet be improved? (please write on the lines provided below) ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………

9. How likely do you think you are to suffer from hearing problems as a 1 2 3 4 5 result of loud noise at work?

10. How likely do you think your coworkers are to suffer from hearing 1 2 3 4 5 problems as a result of loud noise at work?

11. Are you worried about developing hearing difficulties because of your 1 2 3 4 5 work?

12. Do you feel hearing difficulties are a serious health problem? 1 2 3 4 5

13. How likely is it that you will follow the advice given in the leaflet next 1 2 3 4 5 time you are exposed to loud noise?

14. How likely is it that you will follow the advice given in the leaflet in the 1 2 3 4 5 future?

15. Have you ever suffered from hearing problems that you feel were caused by loud noise at work?

Yes No

16. Do you know someone who has suffered from hearing problems that you feel were caused by loud noise at work?

Yes No

Thankyou for your time

135

Manual Handling Questionnaire used in studies 2, 4, and 6.

Please fill in the following information

Age: Gender: Job Title: Department:

Years in company: Years in current job:

Please answer the following questions by circling a number using the scale shown below:

1=Not at All 5=Extremely

1. How easy is the leaflet to read? 1 2 3 4 5

2. How easy is the leaflet to understand? 1 2 3 4 5

3. How easy is the information in the leaflet to remember? 1 2 3 4 5

4. How informative to you find the leaflet? 1 2 3 4 5

5. How relevant do you think the information is for your work? 1 2 3 4 5

6. How accurate do you think the information provided is? 1 2 3 4 5

7. How helpful do you think the information will be in your work? 1 2 3 4 5

8. In what ways could the leaflet be improved? (please write on the lines provided below) ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………

9. To what extent do you feel you are personally likely to suffer injury/ill 1 2 3 4 5 health as a result of manual handling?

10. To what extent do you feel your colleagues are likely to suffer injury/ill 1 2 3 4 5 health as a result of manual handling?

11. Are you worried about developing back pain through your work? 1 2 3 4 5

12. Do you feel that back pain is a serious health problem? 1 2 3 4 5

13. How likely is it that you will follow the advice given in the leaflet next 1 2 3 4 5 time you are handling loads?

14. How likely is it that you will follow the advice given in the leaflet in the 1 2 3 4 5 future?

15. Have you ever suffered from back pain/other injury that you attribute to manual handling?

Yes No

16. Do you know anyone who has suffered back pain/other injury as a result of manual handling?

Yes No

Thankyou for your time

136

Manual handling questionnaire used in the pre-assessment phase of study 5

Please fill in the following information

Age: Gender: Job Title: Department:

Years in company: Years in current job:

Please answer the following questions by circling a number using the scale shown below:

1=Not at All 5=Extremely 1. To what extent are you worried about being injured through manual

handling at work? 1 2 3 4 5

2. To what extent do you feel, given enough time and resources, personally able to follow manual handling guidelines? 1 2 3 4 5

3. Do you feel under pressure from your colleagues to follow correct manual handling procedure? 1 2 3 4 5

4. To what extent do you believe that back pain is a serious health problem? 1 2 3 4 5 5. To what extent do you feel that you have control of whether you follow

correct manual handling procedure? 1 2 3 4 5

6. How easy would it be for you, given enough time and resources, to follow correct manual handling procedure? 1 2 3 4 5

7. To what extent are you worried about suffering back pain through manual handling at work? 1 2 3 4 5

8. Do you feel that people who are important to you want you to follow 1 2 3 4 5 correct manual handling procedure?

9. Do you believe that most of your colleagues follow correct manual 1 2 3 4 5 handling procedure?

10. To what extent do you feel that you are at risk of suffering injury/ill 1 2 3 4 5 health through manual handling at work?

11. How strongly do you believe that there are events outside of your control 1 2 3 4 5 that could prevent you from following correct manual handling procedure?

12. To what extent do you feel that it is up to you whether you follow safe 1 2 3 4 5 practice for manual handling tasks?

13. To what extent do you think your colleagues are at risk of suffering 1 2 3 4 5 injury/ill health through manual handling at work?

14. To what extent do you believe that the handling guidelines are an 1 2 3 4 5 effective way to avoid injury/ill health through manual handling at work?

15. To what extent are you worried about developing back problems in later 1 2 3 4 5 life through manual handling at work?

16. To what extent do you believe that by following handling guidelines you 1 2 3 4 5 can avoid injury/ill health through manual handling at work?

17. To what extent do you intend following the manual handling guidelines when you are handling loads?

Please indicate your response by circling a number on the scale below:

Do not intend 1 2 3 4 5 6 7 8 9 10 Definitely intend

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18. When carrying out tasks involving handling, what percentage of the time do you follow correct manual handling procedure? _______ % of the time

19. What proportion of nurses have to retire each year because of injuries 1 in 50 1 in 100 1 in 200 1 in 500 caused by manual handling?

20. What proportion of sick days taken by nurses is due to back pain? 1 in 16 1 in 6 1 in 4 1 in 2

21. Do you believe that you are more at risk of suffering back problems More at risk from More at risk from through a single handling accident or through a build up of incorrect single accident build up over time handling behaviour over time?

22. Imagine that you are suffering back pain. How clearly can you see and feel this in your imagination? Please circle only one of the numbers below:

1. Can not mentally see or feel this image

2. Can mentally see or feel this image vaguely

3. Can mentally see or feel this image fairly well

4. Can mentally see or feel this image clearly

23. Have you ever suffered back pain/other injury that you feel was caused by YES NO manual handling?

24. Do you know anyone who has suffered back pain/other injury that they YES NO feel was caused by manual handling?

Thankyou for your time

138

Manual handling questionnaire used in the post-assessment phase of study 5

Please fill in the following information

Age: Gender: Job Title: Department:

Years in company: Years in current job:

Please answer the following questions by circling a number using the scale shown below:

1=Not at All 5=Extremely 1. To what extent are you worried about being injured through manual

handling at work? 1 2 3 4 5

2. To what extent do you feel, given enough time and resources, personally able to follow manual handling guidelines? 1 2 3 4 5

3. Do you feel under pressure from your colleagues to follow correct manual handling procedure? 1 2 3 4 5

4. To what extent do you believe that back pain is a serious health problem? 1 2 3 4 5 5. To what extent do you feel that you have control of whether you follow

correct manual handling procedure? 1 2 3 4 5

6. How easy would it be for you, given enough time and resources, to follow correct manual handling procedure? 1 2 3 4 5

7. To what extent are you worried about suffering back pain through manual handling at work? 1 2 3 4 5

8. Do you feel that people who are important to you want you to follow 1 2 3 4 5 correct manual handling procedure?

9. Do you believe that most of your colleagues follow correct manual 1 2 3 4 5 handling procedure?

10. To what extent do you feel that you are at risk of suffering injury/ill 1 2 3 4 5 health through manual handling at work?

11. How strongly do you believe that there are events outside of your control 1 2 3 4 5 that could prevent you from following correct manual handling procedure?

12. To what extent do you feel that it is up to you whether you follow safe 1 2 3 4 5 practice for manual handling tasks?

13. To what extent do you think your colleagues are at risk of suffering 1 2 3 4 5 injury/ill health through manual handling at work?

14. To what extent do you believe that the handling guidelines are an 1 2 3 4 5 effective way to avoid injury/ill health through manual handling at work?

15. To what extent are you worried about developing back problems in later 1 2 3 4 5 life through manual handling at work?

16. To what extent do you believe that by following handling guidelines you 1 2 3 4 5 can avoid injury/ill health through manual handling at work?

17. To what extent do you intend following the manual handling guidelines when you are handling loads?

Please indicate your response by circling a number on the scale below:

Do not intend 1 2 3 4 5 6 7 8 9 10 Definitely intend

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18. Imagine that you are suffering back pain. How clearly can you see and feel this in your imagination? Please circle only one of the numbers below:

5. Can not mentally see or feel this image

6. Can mentally see or feel this image vaguely

7. Can mentally see or feel this image fairly well

8. Can mentally see or feel this image clearly

Thankyou for your time

140

Noise questionnaire used in the pre-assessment phase of study 5

Please fill in the following information

Age: Gender: Job Title: Department:

Years in company: Years in current job:

Please answer the following questions by circling a number using the scale shown below:

1=Not at All 5=Extremely

1. To what extent are you worried about being deafened through noise at 1 2 3 4 5 work?

2. To what extent do you feel, given enough time and resources, personally 1 2 3 4 5 able to use ear defenders correctly at work?

3. Do you feel under pressure from your colleagues to wear ear defenders? 1 2 3 4 5

4. To what extent do you believe that hearing problems are a serious health 1 2 3 4 5 problem?

5. To what extent do you feel that you have control of whether you protect 1 2 3 4 5 your hearing at work?

6. How easy would it be for you, given enough time and resources, to wear 1 2 3 4 5 ear defenders at work?

7. To what extent are you worried about suffering hearing problems because 1 2 3 4 5 of noise at work?

8. Do you feel that people who are important to you want you to wear you 1 2 3 4 5 ear defenders when it’s noisy at work?

9. Do you believe that most of your colleagues wear ear defenders when it’s 1 2 3 4 5 noisy at work?

10. To what extent do you feel that you are at risk of suffering hearing 1 2 3 4 5 problems because of noise at work?

11. How strongly do you believe that there are events outside of your control 1 2 3 4 5 that could prevent you from wearing your ear defenders when necessary?

12. To what extent do you feel that it is up to you whether you wear your ear 1 2 3 4 5 defenders?

13. To what extent do you think your colleagues are at risk of suffering 1 2 3 4 5 hearing problems through noise at work?

14. To what extent do you believe that wearing ear defenders is an effective 1 2 3 4 5 way to avoid hearing problems through noise at work?

15. To what extent are you worried about developing hearing problems in 1 2 3 4 5 later life through noise at work?

16. To what extent do you believe that by wearing ear defenders you can 1 2 3 4 5 avoid deafness caused by noise at work?

17. To what extent do you intend wearing ear defenders when you are in a Please indicate your response by circling a noisy area at work? number on the scale below:

Do not intend 1 2 3 4 5 6 7 8 9 10 Definitely intend

18. When working in noisy areas, what percentage of the time do you wear _______ % of the time ear defenders?

141

19. Deafness, tinnitus and other ear conditions are responsible for what 1% 5% 10% 20% proportion of all work-related illnesses in the UK?

20. What percentage of these cases are reported to be caused by noise? 20% 40% 80% 100%

21. Do you believe that you are more at risk of suffering hearing problems More at risk from More at risk from through one-off exposure to a very loud noise or through a build up of single very loud noise build up over time exposure to less loud noise over time?

22. Imagine that you are deaf. How clearly can you see and feel this in your imagination? Please circle only one of the numbers below:

9. Can not mentally see or feel this image

10. Can mentally see or feel this image vaguely

11. Can mentally see or feel this image fairly well

12. Can mentally see or feel this image clearly

23. Have you ever suffered hearing problems that you feel were caused by YES NO noise at work?

24. Do you know anyone who has suffered hearing problems that they feel YES NO was caused by noise at work?

Thankyou for your time

142

Noise questionnaire used in the post-assessment phase of study 5

Please fill in the following information

Age: Gender: Job Title: Department:

Years in company: Years in current job:

Please answer the following questions by circling a number using the scale shown below:

1=Not at All 5=Extremely

1. To what extent are you worried about being deafened through noise at 1 2 3 4 5 work?

2. To what extent do you feel, given enough time and resources, personally 1 2 3 4 5 able to use ear defenders correctly at work?

3. Do you feel under pressure from your colleagues to wear ear defenders? 1 2 3 4 5

4. To what extent do you believe that hearing problems are a serious health 1 2 3 4 5 problem?

5. To what extent do you feel that you have control of whether you protect 1 2 3 4 5 your hearing at work?

6. How easy would it be for you, given enough time and resources, to wear 1 2 3 4 5 ear defenders at work?

7. To what extent are you worried about suffering hearing problems because 1 2 3 4 5 of noise at work?

8. Do you feel that people who are important to you want you to wear you 1 2 3 4 5 ear defenders when it’s noisy at work?

9. Do you believe that most of your colleagues wear ear defenders when it’s 1 2 3 4 5 noisy at work?

10. To what extent do you feel that you are at risk of suffering hearing 1 2 3 4 5 problems because of noise at work?

11. How strongly do you believe that there are events outside of your control 1 2 3 4 5 that could prevent you from wearing your ear defenders when necessary?

12. To what extent do you feel that it is up to you whether you wear your ear 1 2 3 4 5 defenders?

13. To what extent do you think your colleagues are at risk of suffering 1 2 3 4 5 hearing problems through noise at work?

14. To what extent do you believe that wearing ear defenders is an effective 1 2 3 4 5 way to avoid hearing problems through noise at work?

15. To what extent are you worried about developing hearing problems in 1 2 3 4 5 later life through noise at work?

16. To what extent do you believe that by wearing ear defenders you can 1 2 3 4 5 avoid deafness caused by noise at work?

17. To what extent do you intend wearing ear defenders when you are in a Please indicate your response by circling a noisy area at work? number on the scale below:

Do not intend 1 2 3 4 5 6 7 8 9 10 Definitely intend

143

18. Imagine that you are deaf. How clearly can you see and feel this in your imagination? Please circle only one of the numbers below:

13. Can not mentally see or feel this image

14. Can mentally see or feel this image vaguely

15. Can mentally see or feel this image fairly well

16. Can mentally see or feel this image clearly

Thankyou for your time

144

Appendix 5 – Statistical Detail

1. Study 2

2. Study 4

3. Study 5

4. Study 6

145

Statistical Detail – Study 2

Manual Handling.

Ratings of Leaflets:

The factor analysis for the manual handling leaflets revealed the items loaded onto two separate factors (Bartletts test of sphericity = 685.974, p<0.001, eigenvalues = 3.536 and 1.206, loadings for usability = 0.73-0.87 and loadings for usefulness = 0.62-0.89.

Differences between usability and usefulness of the 2 different leaflets were analysed using a one-way between-groups MANOVA. The MANOVA found no significant difference between the usability of the 2 leaflets. However, it did reveal a significant difference between the usefulness of the 2 leaflets (F = 11.915, p=0.001). Subjects reported finding the RCN leaflet significantly more useful than the HSE leaflet.

Cognitive and Emotional Factors:

Differences in perceived worry and seriousness were explored using a one-way between groups MANOVA. Exposure to back pain affected participants’ worry about the problem (F = 5.531, p<0.01). Students were more worried than working health care professionals (F = 5.455, p<0.05).

Differences in perceived risk were also explored. The most highly exposed group rated their own risk as higher than the other groups (F = 4.374, p<0.05).

Predictors of Intentions to Follow Safe Practice:

Four significant predictors of intentions to lift correctly were found. These were sex (beta = 0.18, R² = 0.04, p<0.001), perceived seriousness of back pain as a health problem (beta = .25, R² = 0.15, p= 0.001), and the usability and usefulness of the leaflets (beta = 0.25, 0.28, R² = 0.33, p<0.001).

Noise.

Ratings of Leaflets:

The factor analysis for the noise leaflets revealed the items loaded onto two separate factors (Bartletts test of sphericity =459.74, p<0.001, eigenvalues = 3.285 and1.234, loadings for usability = 0.62-0.84 and loadings for usefulness =0.60-0.89).

Cognitive and Emotional Factors:

Differences in perceived worry and seriousness were explored using a one-way between groups MANOVA. Exposure to hearing problems affected participants’ worry about the problem (F = 12.285, p=0.001).

Differences in perceived risk were also analysed. Perception of risk to self were affected by exposure to hearing problems (F = 14.778, p<0.001), perceptions of risk to others were affected by exposure to hearing problems (F = 13.190, p<0.001), perceptions of risk to self were affected by exposure to hearing problems (F=14.778, p<0.001).

Predictors of Intentions to Wear Ear Defenders:

146

Two significant predictors of intentions to wear ear defenders were found. These were perceived seriousness of hearing damage as a health problem (beta = 0.24, R² = 0.09, p<0.01) and the usability of the leaflets (beta = 0.36, R² = 0.26, p<0.01).

147

Statistical Detail - Study 4

Leaflet Ratings:

The factor analysis for the noise leaflets revealed the items loaded onto two separate factors (Bartletts test of sphericity =327.13, p<0.001, eigenvalues = 3.456 and 1.594, loadings for usability = 0.79-0.91 and loadings for usefulness = 0.94-0.95).

Differences between usability and usefulness of the 2 different leaflets were analysed using a one-way between-groups MANOVA. The positive leaflet was rated as more usable than the HSE leaflet (F = 5.706, p<0.01). The positive leaflet was rated as more useful than the HSE leaflet (F = 4.129, p<0.019).

Cognitive and Emotional Responses:

Participants who read the positive leaflet rated their own risk of injury as higher than those who read the negative leaflet (F = 3.152, p<0.05). Those who read the positive leaflet rated others risk of injury as higher than those who read the negative leaflet (F = 9.081, p<0.001).

Intentions to Follow Guidelines:

Participants who read the positive leaflet rated themselves as being more likely to follow the advice in the leaflet next time they were handling loads than those who read the negative or HSE leaflet (F = 5.726, p<0.01). The same pattern was found for intentions to follow the advice in the future (F = 9.101, p<0.001).

Predictors of Intentions:

Five significant predictors of intentions to follow the advice given in the leaflet were found. These were reading the positive frame (beta = .420, R² = 0.13, p<0.01), perceived risk to self, others and seriousness (betas 0.431, -0.375, 0.440, R² = 0.4, p,0.05) and the usability of the leaflet (beta = 0.304, R² = 0.47, p<0.05).

148

Statistical Detail - Study 5

Noise:

Repeated Measures MANOVAs were conducted to identify framing effects.

Intentions:

A significant 3 way interaction was found for pre-behaviour group, frame and time (F = 3.804, p<0.05). A significant 3 way interaction was found for knowing someone with hearing damage, frame and time (F = 4.566, p<0.05).

Cognitive and Emotional Factors:

Worry about being deafened increased for those reading the negative frame (F = 7.681, p<0.01).

Self-efficacy significantly increased for those reading the positive frame (F = 8.337, p<0.01).

Manual Handling:

Intentions:

A significant 3 way interaction was found for history of back pain to self, frame and time (F = 6.171, p<0.05). Those with a history of back pain were more likely to increase their intentions after reading the positively framed message. There was no effect for either group for the negative frame.

Cognitive and Emotional Factors:

Worry about injury was significantly increased after reading the loss framed message (F = 7.627, p<0.01). Worry about back pain was significantly increased by reading the loss framed message (F = 5.726, p<0.05).

Self-efficacy - There was a 3 way interaction between history of back pain to self, frame and time (F = 5.855, p<0.05).

149

Study 6 - Statistical Detail

Usability and usefulness:

Differences between usability and usefulness of the 2 different leaflets were analysed using a one-way between-subjects MANOVAs. Students found the leaflets significantly more useful than working participants (F=7.120, p<0.01).

Worry:

Participants who had suffered injury through manual handling at work were more worried about the problem (F=13.412, p<0.001).

There was a significant 2-way interaction between frame and order on worry (F=6.221, p<0.05).

Intentions:

The usability of the leaflets was significantly correlated with intentions to follow safe practice (r = .286, p<0.01). The usefulness of the leaflets was significantly correlated with intentions to follow safe practice (r = .437, p<.001).

Predictors of Intentions:

The usefulness of the leaflets significantly predicted intentions to follow safe practice (beta = .541, R² = 0.30, p<0.01).

150

Appendix 6 - Experimental Leaflets Developed for and Used in Study.

1. Positively Framed General Manual Handling (Domestics)

2. Negatively Framed General Manual Handling (Domestics)

3. Negatively Framed Health Care Manual Handling

4. Positively Framed Health Care Manual Handling

5. Positively Framed Noise

6. Negatively Framed Noise

7. Positively Framed Consequences-Solutions Manual Handling

8. Negatively Framed Consequences-Solutions Manual Handling

9. Positively Framed Solutions-Consequences Manual Handling

10. Negatively Framed Solutions-Consequences Manual Handling

151

152

Experimental Leaflet: Positively Framed General Manual Handling (Domestics)

What is the Problem? Are You at Risk? · Position the feet – feet apart, leading leg as far forward as is comfortable. If

Nearly a third of all workplace accidents reported to You can benefit from being aware of the risks. Risk possible your feet should be pointing in the Health and Safety Executive (HSE) involve factors include: the direction you wish to go. manual handling. About 50% of manual handling accidents cause back injury. Many of these injuries build up over a period of time rather then being caused by a single handling incident.

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine.

· Adopt a good posture. When lifting from a low level, bend the knees. Keep the back straight. Lean forward a little over

The benefits of protecting yourself from injuries are high. You can guard against serious and permanent damage to your upper body and avoid the pain and discomfort this can cause. By looking after your back you can remain mobile, which means you keep your independence. You can avoid the stress, frustration and loss of self-esteem that being dependent on others

· Lifting an uneven load with the weight mainly on one side.

· Lifting with a starting (or finishing) position near the floor.

· Lifting loads at arms length.

·

·

the load to get a good grip.

Keep the load close to the trunk for as long as possible.

Don’t jerk – lift smoothly raising the chin as the lift begins, keeping control of the load.

can cause.

A healthy back helps you to take an active part in family life. If you follow safe manual handling

· Working in cramped areas · Move the feet – don’t twist the trunk when turning to the side.

practice you can continue to participate fully at work and enjoy physical hobbies.

What Can You Do to Reduce the Risk?

By following safe manual handling practice you can decrease your risk of injury:

· Early assessment of back pain may help treatment. Employees who have back pain or other symptoms caused by manual handling should go to their

· Follow existing policies on handling and occupational health service for an co-operate with any new policies. assessment.

· Use handling aids if possible.

· Plan the lift. Do you need help with the load? For a long lift such as floor to shoulder height, think about resting the load mid-way on a table or bench to change grip.

153

Experimental Leaflet: Negatively Framed General Manual Handling (Domestics)

What is the Problem?

Nearly a third of all workplace accidents reported to the Health and Safety Executive (HSE) involve manual handling. About 50% of manual handling accidents cause back injury. Many of these injuries build up over a period of time rather then being caused by a single handling incident.

The costs of not protecting yourself from injuries are high. Accidents can cause serious and permanent damage to your upper body. Injuring your back can result in pain and discomfort and can seriously reduce your mobility. You may lose your independence, which can lower your self-esteem, and lead to stress and frustration.

Being injured can prevent you from taking an active part in family life. If you do not follow safe manual handling practice you may even have to stop work and give up physical hobbies.

Are You at Risk?

You may be particularly at risk. Risk factors include:

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine.

· Lifting an uneven load with the weight mainly on one side.

· Lifting with a starting (or finishing) position near the floor.

· Lifting loads at arms length.

· Working in cramped areas

What Can You Do to Reduce the Risk?

If you do not follow safe manual handling practice you increase your risk of injury:

· Follow existing policies on handling and co-operate with any new policies.

· Use handling aids if possible.

· Plan the lift. Do you need help with the load? For a long lift such as floor to shoulder height, think about resting the load mid-way on a table or bench to change grip.

· Position the feet – feet apart, leading leg as far forward as is comfortable. If possible your feet should be pointing in the direction you wish to go.

· Adopt a good posture. When lifting from a low level, bend the knees. Keep the back straight. Lean forward a little over the load to get a good grip.

· Keep the load close to the trunk for as long as possible.

· Don’t jerk – lift smoothly raising the chin as the lift begins, keeping control of the load.

· Move the feet – don’t twist the trunk when turning to the side.

· Early assessment of back pain may help treatment. Employees who have back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

What Can You Do to Reduce the Risk?

If you do not follow safe manual handling practice you increase your risk of injury:

· Follow existing policies on handling and co-operate with any new policies.

· Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant to use aids because they do not know enough about them, distrust the design or maintenance, or believe that patients dislike them.

· Early assessment of back pain may help treatment. Employees who experience back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

154

Experimental Leaflet: Negatively Framed Health Care Manual Handling

What is the Problem? Are You at Risk?

Nearly a third of all workplace accidents reported to Health care workers may be particularly at risk ofthe Health and Safety Executive (HSE) involve injury. Risk factors include: manual handling. In the health services it is over a half. About 50% of manual handling accidents cause · Handling patients - unlike inanimate loads, back injury. Many of these injuries build up over a people can help (or hinder) manualperiod of time rather then being caused by a single handling. They may feel pain or anxiety,handling incident. they have personal dignity and are unique

and irreplaceable. The costs of not protecting yourself from injuries are

high. Accidents can cause serious and permanent · Patients may be connected to fragile damage to your upper body. Injuring your back can medical equipment and can become violent result in pain and discomfort and can seriously or agitated. This can affect the way they reduce your mobility. You may lose your are handled. They may also have to be independence, which can lower your self-esteem, and placed into or recovered from unusual lead to stress and frustration. positions, such as on an X-ray table or

theatre table. Being injured can prevent you from taking an active part in family life. If you do not follow safe manual · Lifting an uneven load with the weight handling practice you may even have to stop work mainly on one side and give up physical hobbies.

· Lifting with a starting (or finishing) position near the floor

· Lifting loads at arms length

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine. Some nursing staff may spend up to 30% of their time in a stooped position.

What Can You Do to Reduce the Risk?

If you do not follow safe manual handling practice you increase your risk of injury:

· Follow existing policies on handling and co-operate with any new policies.

· Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant to use aids because they do not know enough about them, distrust the design or maintenance, or believe that patients dislike them.

· You can help patients to help themselves if they are able to do so safely. Patients may need information and training in the use of equipment. This will reassure them, gain their confidence and help them co­operate with staff. Practical demonstrations are useful.

· Early assessment of back pain may help treatment. Employees who experience back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

155

Experimental Leaflet: Positively Health Care Manual Handling

What is the Problem? Are You at Risk?

Nearly a third of all workplace accidents reported to Health care workers in particular can benefit fromthe Health and Safety Executive (HSE) involve being aware of the risks. Risk factors include: manual handling. In the health services it is over a half. About 50% of manual handling accidents cause · Handling patients - unlike inanimate loads,back injury. Many of these injuries build up over a people can help (or hinder) manualperiod of time rather then being caused by a single handling. They may feel pain or anxiety,handling incident. they have personal dignity and are unique

and irreplaceable. The benefits of protecting yourself from injuries are

high. You can guard against serious and permanent · Patients may be connected to fragile damage to your upper body and avoid the pain and medical equipment and can become violent discomfort this can cause. By looking after your back or agitated. This can affect the way they are you can remain mobile, which means you keep your handled. They may also have to be placed independence. You can avoid the stress, frustration into or recovered from unusual positions, and loss of self-esteem that being dependent on others such as on an X-ray table or theatre table. can cause.

· Lifting an uneven load with the weight A healthy back helps you to take an active part in mainly on one side. family life. If you follow safe manual handling practice you can continue to participate fully at work

· Lifting with a starting (or finishing) and enjoy physical hobbies. position near the floor.

· Lifting loads at arms length.

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine. Some nursing staff may spend up to 30% of their time in a stooped position.

What Can You Do to Reduce the Risk?

By following safe manual handling practice you can decrease your risk of injury:

· Follow existing policies on handling and co-operate with any new policies.

· Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant to use aids because they do not know enough about them, distrust the design or maintenance, or believe that patients dislike them.

· You can help patients to help themselves if they are able to do so safely. Patients may need information and training in the use of equipment. This will reassure them, gain their confidence and help them co-operate with staff. Practical demonstrations are useful.

· Early assessment of back pain may help treatment. Employees who have back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

156

Experimental Leaflet: Positively Framed Noise

What is the Problem? Are You At Risk? If you work in a noisy place you can benefit from

Sounds and noises are an important part of everyday being aware of when there may be a risk. life. In small amounts they are harmless, but if they · The danger will depend on how loud the are too loud they can cause problems. Hearing noise is and how long you are exposed to damage caused by noise can range from sounds it, daily and over a number of years. Noise appearing muffled to total deafness. Permanent levels are measured in decibel units ‘tinnitus’ or ringing in the ears can be caused as well. (dB(A)). The higher the levels, the less

time it takes to cause damage. Having good hearing helps us to keep in touch with · If you have to shout to be heard by another the world around us. By protecting your hearing from worker standing 2m away, or notice noise you can avoid the risk of suffering permanent ringing in your ears after work, there may damage. Looking after your hearing has many be a problem. benefits. Good hearing is important for your social · Some individuals may be particularly at life. Being able to hear properly means you can keep risk of hearing damage. Age and general up with conversations with your friends, and can help fitness are no protection – young people to keep your family life happy. You can continue to can be damaged just as easily as old. enjoy your favourite music or TV programmes and talk on the phone without any problems. What Can You Do About Noise at Work?

Protect yourself against noise at work and you can There are real benefits to looking after your hearing. avoid serious and permanent damage to your Protect your hearing and you can avoid the stress and hearing. You can avoid deafness caused by noise, frustration caused by deafness. which can not be corrected with a hearing aid.

· Your employer must have the noise in your work area assessed. If you feel you may be at risk you should find out if this has been done.

· Your employer must provide ear protectors where there is serious risk of hearing damage and you must wear them. At some lower noise levels the risk is less but your employer has to offer you ear protectors. It is in your own interest to take the protection and use it.

· There are three main types of ear protectors: ear muffs, which completely cover the ear; ear plugs, which are inserted into the ear canal; and semi­inserts (also called ‘canal-caps’) which cover the entrance to the ear canal.

· Some employees may have a preference for a particular type, or may not be able to use some types of ear protection because of ear infections. Some types may interfere with other protective equipment they are wearing.

· Look after your protectors and keep them clean. Damaged, dirty protectors won’t protect properly and can cause infection.

· Don’t neglect faulty equipment. If you find something wrong with your protectors or equipment to control noise, or if it causes problems, tell your manager, foreman or supervisor, or your safety representative.

· Because noise-induced hearing loss occurs gradually, you may not notice it at first. Don’t neglect your ears. If you think there might be something wrong with your hearing or you have any medical problems with your ears, see your doctor or works medical department if you have one. Remember to tell them that you work in a noisy place.

157

Experimental Leaflet: Negatively Framed Noise

What is the Problem? The higher the levels, the less time it takes to cause damage.

Sounds and noises are an important part of everyday life. In small amounts they are harmless, but if they · If you have to shout to be heard by another are too loud they can cause problems. Hearing worker standing 2m away, or notice damage caused by noise can range from sounds ringing in your ears after work, there may appearing muffled to total deafness. Permanent be a problem. ‘tinnitus’ or ringing in the ears can be caused as well.

· Some individuals may be particularly at Damage to hearing can make us lose touch with the risk of hearing damage. Age and general world around us. If you do not protect your hearing fitness are no protection – young people from noise you are at risk of suffering permanent can be damaged just as easily as old. damage. Deafness can have serious effects on your life. Losing your hearing can affect your social life. What Can I Do About Noise at Work? Damaged hearing means you may not be able to keep up with conversations with your friends, and can If you do not protect yourself against noise at work cause your family life to suffer. You may not be able you risk serious and permanent damage to yourto enjoy your favourite music or TV programmes and hearing. You risk deafness caused by noise which can have problems speaking on the phone. not be corrected using a hearing aid.

· Your employer must have the noise in your There is no real compensation for the effects of noise work area assessed. If you feel you may be induced hearing loss. If you do not look after your at risk you should find out if this has been hearing you risk suffering the stress and frustration done. caused by deafness.

· Your employer must provide ear protectors where there is serious risk of

Are You At Risk? hearing damage and you must wear them. At some lower noise levels the risk is less

If you work in a noisy place you are at risk of but your employer has to offer you earsuffering hearing damage. protectors. It is in your own interest to take

· The danger will depend on how loud the the protection and use it. noise is and how long you are exposed to it, daily and over a number of years. Noise levels are measured in decibel units

· There are three main types of ear protectors: ear muffs, which completely cover the ear; ear plugs, which are inserted into the ear canal; and semi­inserts (also called ‘canal-caps’) which cover the entrance to the ear canal.

· Some employees may have a preference for a particular type, or may not be able to use some types of ear protection because of ear infections. Some types interfere with other protective equipment they are wearing.

· Look after your protectors and keep them clean. Damaged, dirty protectors won’t protect properly and can cause infection.

· Don’t neglect faulty equipment. If you find something wrong with your protectors or equipment to control noise, or if it causes problems, tell your manager, foreman or supervisor, or your safety representative.

· Because noise-induced hearing loss occurs gradually, you may not notice it at first. Don’t neglect your ears. If you think there might be something wrong with your hearing or you have any medical problems with your ears, see your doctor or works medical department if you have one. Remember to tell them that you work in a noisy place.

158

Experimental Leaflet: Positively Framed Consequences – Solutions for Manual Handling

Are You at Risk?

Health care workers in particular can benefit from being aware of the risks involved with manual handling. Risk factors include:

· Handling patients - unlike inanimate loads, people can help (or hinder) manual handling. They may feel pain or anxiety, they have personal dignity and are unique and irreplaceable.

· Patients may be connected to fragile medical equipment and can become violent or agitated. This can affect the way they are handled. They may also have to be placed into or recovered from unusual positions, such as on an X-ray table or theatre table.

· Lifting an uneven load with the weight mainly on one side.

· Lifting with a starting (or finishing) position near the floor.

· Lifting loads at arms length.

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine. Some nursing staff may spend up to 30% of their time in a stooped position.

What is the Problem?

Nearly a third of all workplace accidents reported to the Health and Safety Executive (HSE) involve manual handling. In the health services it is over a half. About 50% of manual handling accidents cause back injury. Many of these injuries build up over a period of time rather then being caused by a single handling incident.

The benefits of protecting yourself from injuries are high. You can guard against serious and permanent damage to your upper body and avoid the pain and discomfort this can cause. By looking after your back you can remain mobile, which means you keep your independence. You can avoid the stress, frustration and loss of self-esteem that being dependent on others can cause.

A healthy back helps you to take an active part in family life. If you follow safe manual handling practice you can continue to participate fully at work and enjoy physical hobbies.

What Can You Do to Reduce the Risk?

By following safe manual handling practice you can decrease your risk of injury:

· Follow existing policies on handling and co­operate with any new policies.

· Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant to use aids because they do not know enough about them, distrust the design or maintenance, or believe that patients dislike them.

· You can help patients to help themselves if they are able to do so safely. Patients may need information and training in the use of equipment. This will reassure them, gain their confidence and help them co-operate with staff. Practical demonstrations are useful.

· Early assessment of back pain may help treatment. Employees who have back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

159

Experimental Leaflet: Negatively Framed Consequences – Solutions for Manual Handling

Are You at Risk?

You may be at risk of injury through manual handling at work. Risk factors include:

· Handling patients - unlike inanimate loads, half. About 50% of manual handling accidents cause ·

people can help (or hinder) manual handling. back injury. Many of these injuries build up over a They may feel pain or anxiety, they have period of time rather then being caused by a single personal dignity and are unique and handling incident. ·

irreplaceable. The costs of not protecting yourself from injuries are

· Patients may be connected to fragile medical high. Accidents can cause serious and permanent equipment and can become violent or agitated. damage to your upper body. Injuring your back can This can affect the way they are handled. They result in pain and discomfort and can seriously may also have to be placed into or recovered reduce your mobility. You may lose your from unusual positions, such as on an X-ray independence, which can lower your self-esteem, and table or theatre table. lead to stress and frustration.

· Lifting an uneven load with the weight mainly on one side

· Lifting with a starting (or finishing) position near the floor

· Lifting loads at arms length

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine. Some nursing staff may spend up to 30% of their time in a stooped position.

What is the Problem?

Nearly a third of all workplace accidents reported to the Health and Safety Executive (HSE) involve manual handling. In the health services it is over a

·

Being injured can prevent you from taking an active part in family life. If you do not follow safe manual handling practice you may even have to stop work and give up physical hobbies.

·

What Can You Do to Reduce the Risk?

If you do not follow safe manual handling practice you increase your risk of injury:

Follow existing policies on handling and co­operate with any new policies.

Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant to use aids because they do not know enough about them, distrust the design or maintenance, or believe that patients dislike them.

You can help patients to help themselves if they are able to do so safely. Patients may need information and training in the use of equipment. This will reassure them, gain their confidence and help them co-operate with staff. Practical demonstrations are useful.

Early assessment of back pain may help treatment. Employees who experience back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

160

Experimental Leaflet: Positively Framed Solutions – Consequences for Manual Handling

Are You at Risk? What Can You Do to Reduce the Risk?

Health care workers in particular can benefit from By following safe manual handling practice you canbeing aware of the risks involved with manual decrease your risk of injury: handling. Risk factors include:

· Follow existing policies on handling and co-· Handling patients - unlike inanimate loads, operate with any new policies.

people can help (or hinder) manual handling. They may feel pain or anxiety, they have personal dignity and are unique and irreplaceable.

· Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant

· Patients may be connected to fragile medical to use aids because they do not know enough equipment and can become violent or agitated. about them, distrust the design or maintenance, This can affect the way they are handled. They or believe that patients dislike them. may also have to be placed into or recovered from unusual positions, such as on an X-ray table or theatre table.

· You can help patients to help themselves if they are able to do so safely. Patients may need information and training in the use of

· Lifting an uneven load with the weight mainly equipment. This will reassure them, gain their on one side. confidence and help them co-operate with

staff. Practical demonstrations are useful. · Lifting with a starting (or finishing) position

near the floor. · Early assessment of back pain may help treatment. Employees who have back pain or

· Lifting loads at arms length. other symptoms caused by manual handling should go to their occupational health service

· Poor posture, such as stooping or stretching. for an assessment. This increases the amount of stress on the spine. Some nursing staff may spend up to 30% of their time in a stooped position.

What is the Problem?

Nearly a third of all workplace accidents reported to the Health and Safety Executive (HSE) involve manual handling. In the health services it is over a half. About 50% of manual handling accidents cause back injury. Many of these injuries build up over a period of time rather then being caused by a single handling incident.

The benefits of protecting yourself from injuries are high. You can guard against serious and permanent damage to your upper body and avoid the pain and discomfort this can cause. By looking after your back you can remain mobile, which means you keep your independence. You can avoid the stress, frustration and loss of self-esteem that being dependent on others can cause.

A healthy back helps you to take an active part in family life. If you follow safe manual handling practice you can continue to participate fully at work and enjoy physical hobbies.

161

Experimental Leaflet: Negatively Framed Solutions – Consequences for Manual Handling

Are You at Risk? What Can You Do to Reduce the Risk?

You may be at risk of injury through manual handling If you do not follow safe manual handling practice at work. Risk factors include: you increase your risk of injury:

· Handling patients - unlike inanimate loads, ·

people can help (or hinder) manual handling. They may feel pain or anxiety, they have personal dignity and are unique and ·

irreplaceable.

· Patients may be connected to fragile medical equipment and can become violent or agitated. This can affect the way they are handled. They may also have to be placed into or recovered from unusual positions, such as on an X-ray table or theatre table.

·

· Lifting an uneven load with the weight mainly on one side

· Lifting with a starting (or finishing) position near the floor

· Lifting loads at arms length ·

· Poor posture, such as stooping or stretching. This increases the amount of stress on the spine. Some nursing staff may spend up to 30% of their time in a stooped position.

Follow existing policies on handling and co­operate with any new policies.

Use equipment as shown in training. Suitable lifting aids are more easily available than they used to be, but they are still often under-used or not used at all. Staff are sometimes reluctant to use aids because they do not know enough about them, distrust the design or maintenance, or believe that patients dislike them.

You can help patients to help themselves if they are able to do so safely. Patients may need information and training in the use of equipment. This will reassure them, gain their confidence and help them co-operate with staff. Practical demonstrations are useful.

Early assessment of back pain may help treatment. Employees who experience back pain or other symptoms caused by manual handling should go to their occupational health service for an assessment.

What is the Problem?

Nearly a third of all workplace accidents reported to the Health and Safety Executive (HSE) involve manual handling. In the health services it is over a half. About 50% of manual handling accidents cause back injury. Many of these injuries build up over a period of time rather then being caused by a single handling incident.

The costs of not protecting yourself from injuries are high. Accidents can cause serious and permanent damage to your upper body. Injuring your back can result in pain and discomfort and can seriously reduce your mobility. You may lose your independence, which can lower your self-esteem, and lead to stress and frustration.

Being injured can prevent you from taking an active part in family life. If you do not follow safe manual handling practice you may even have to stop work and give up physical hobbies.

Printed and published by the Health and Safety Executive C1.25 04/03

ISBN 0-7176-2176-6

CRR 093

780717621767£25.00 9

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