Posture-Related Musculoskeletal Problems among Hotel Receptionists in Mumbai: A Cross-Sectional Study.

BACKGROUND: Receptionists are the front-liners carrying the image of the hotel. They are involved in 8-h shift work in prolonged standing positions, exposing them to various risks.
OBJECTIVE: The aim of the study was to identify the work-related musculoskeletal problems and health problems experienced by receptionists.
MATERIALS AND METHODS: A cross-sectional study was conducted on 50 receptionists from 11 hotels working in 15 three-star and 35 five-star hotels in Mumbai, using a questionnaire that included background information, Rating Scale for Discomfort Intensity, Nordic Musculoskeletal Questionnaire (NMQ), and OWAS posture assessment tool. The statistical analysis of the quantitative variables was performed using Statistical Package for the Social Sciences (SPSS) software program, version 16.0.
RESULTS: Receptionists generally suffered from sleeplessness (37.50%) and frequent headaches (34%) due to the change in shift timing. Severe discomfort was found in low back, calf, neck, and ankle/feet by the end of the day. The strong association between standing posture and calf pain (Phi value: 0.736; P ≤ 0.05) and standing posture and ankle pain (Phi value: 0.881; P ≤ 0.05) was found.
CONCLUSION: Prolonged standing increased the lower limbs musculo-skeletal disorders among the receptionists, whereas change in shift timing affected their sleep pattern. Copyright:

INTRODUCTION

The hotel business is one of the major services in the hospitality industry.[1] A hotel lobby conjures up exciting images of international dignitaries, celebrities, community leaders, attendees of conventions and large receptions, business persons, and family vacationers. The front office is the most visible and essential focal point of all hotels.[2] The receptionists are responsible right from greeting and assisting guests to helping people make reservations, managing room status, issuing room keys and handling guest requests/complaints, or solving any problems that may arise during the course of a stay. The work at the hotel front desk often involves repetitive work, awkward postures, and standing for prolonged periods of time.[3] The average hotel front desk employee spends the majority of his/her 8-h shift standing in front of a chest-level counter, looking down at a computer, or over at a guest. With shift work, fatigue becomes more prevalent, as the employee is forced to work against his/her natural circadian rhythms.[4] Physiological and psychological health effects of shift work can include disturbed sleep patterns, stomach trouble, and stress.[5] Work in hotels is often demanding and hectic; hotel staff is required to provide service to guests efficiently, courteously, and accurately while maintaining a pleasant demeanor.[6]

Prolonged standing jobs may lead to discomfort and occupational injuries to workers.[78] In a study,[9] approximately 50% of healthy workers complained of lower back discomfort after continuously standing for 2 h. Another study asserted that prolonged standing contributes to foot pain at the end of the day.[10] Workers exposed to standing for more than 50% of working hours showed higher frequency of chronic venous insufficiency than the workers spending less time in standing position.[11]

Jobs and tasks requiring prolonged constrained standing postures frequently cause fatigue, body-part discomfort, and lower extremity impairments.[12] Fatigue and discomfort, though not leading to compensable disability, may lower the resistance of these employees to certain illnesses, or even lead to some occupational symptoms and diseases which may reduce productivity.[13] According to Seo et al.,[14] continuous standing or sitting work style, commonly observed in various workplaces, causes leg swelling, pain, varicose veins, and skin ulcers as a result of insufficient blood and lymph flow. It is reported that pregnant women who are standing for more than 8 h in a working day have high chance of spontaneous abortion.[15]

Therefore, this study aimed to demarcate the work activities, posture, and shift timing of the receptionists and find its association with work-related musculoskeletal disorders and health.

MATERIALS AND METHODS

Participants

The study was carried out in three-star and five-star hotels mainly near the airport in Urban Mumbai. Only 11 hotels gave permission and agreed to participate in the cross-sectional survey. Non-probability sampling method was used for study as only those who gave consent were studied. A total of 50 Subjects, 28 males and 22 females, who voluntarily agreed to be part of the study and the subjects less than 1 year of experience, were excluded in the study. The subjects were mostly involved in attending phone calls, greeting guests, assisting guests for check-in and check-out procedures, reservations, managing room status, issuing room keys, and handling guest requests/complaints. All these activities were performed in 8-h shifts mostly in standing position behind the front desk. The subjects wore black formal footwear having at least 2-inch heels during their entire shift work. They worked continuously for 15 days in one shift and thereafter a change in shift took place.

DATA COLLECTION TOOLS

Questionnaire

A well-structured self-administered closed-ended questionnaire was developed and each receptionist was requested to answer all the questions with full sincerity. The questionnaire was designed to get information on activities performed, shift work, work-related musculo-skeletal disorder (MSD) problems, frequency of pain/discomfort, severity of pain and other general health problems. A validated Nordic Musculoskeletal questionnaire[16] was adapted to enquire about the MSD symptoms experienced, and for intensity of pain 5-point VAS Rating scale indicating 1 as least painful and 5 as most painful condition was used.

Observation

Each hotel was visited three to four times to observe the receptionist’s involvement in varied activities and postures adopted while performing different activities. The observation method was used to study various postures adopted and no questions were asked during this period.

Posture assessment

Posture was observed and validated OWAS (Ovako Work Analysis System) posture assessment method[17] was used to analyze the risky postures. The information on back, arms, legs, and load/use of force was collected using this method. The most common activity of the front desk employees was attending and receiving phone calls; hence, this method was used for posture analysis.

Statistical analysis

The statistical analysis was done by using Statistical Package for the Social Sciences (SPSS) software program, version 16.0. Frequency and percentages were calculated. The cross-Phi test table and Cramer’s V test was used to find out the association between pain lasting for 7 days and 1 year. Ranking by median was used to find severity and frequency of pain.

RESULTS

General characteristics of the subjects

A total of 50 subjects, 56% males and 44% females, were studied. Table 1 shows the age groups of the subjects studied. The mean age ± standard deviation (SD) of the subjects was 29.5 ± 6.66 years. The educational qualifications showed that the majority (68%) were graduates. The largest proportion (48%) of subjects had work experience of 2–5 years. 38% of subjects reported sleeplessness and 20% reported headache due to change in shift.

Table 1

General characteristics of the subjects studied

General characteristics	Total (n=50)
	n	Percentage
Gender
Male	28	(56.0)
Female	22	(44.0)
Age (years)
21-30	32	(64.0)
31-40	12	(24.0)
41-50	6	(12.0)
Educational qualifications
Diploma	12	(24.0)
Graduate	34	(68.0)
Post graduate	4	(8.0)
Work duration (years)
1-2	11	(22.0)
2-5	24	(48.0)
5-10	14	(28.0)
>10	1	(2.0)
Health-related symptoms due to shift change
Sleeplessness	19	(38.0)
Indigestion problem	4	(8.0)
Headache	10	(20.0)
Frustration	4	(8.0)
Fatigue	4	(8.0)

Work-related musculoskeletal disorders (WRMSDs) experienced by the subjects at the end of the day

Table 2 shows that 68% of the subjects experienced severe to maximal discomfort in their lower back, followed by 32% in their ankle/feet and 24% subjects having discomfort in their neck and calf by the end of the day’s work. For upper extremity, moderate discomfort was reported in upper back (58%) followed by neck (50%) and right shoulder pain (44%), whereas for lower extremity discomfort, majority of the subjects reported moderate pain in the calf (50%–54%); followed by knee pain (36%). The severe discomfort was considered for further analysis.

Table 2

Discomfort experienced by the subjects in upper and lower extremities by the end of the day’s work

Parts of the body	No discomfort	Minimal discomfort	Moderate discomfort	Severe discomfort*	Maximal discomfort
	n (%)	n (%)	n (%)	n (%)	n (%)
Upper extremity
Neck	1 (2)	12 (24)	25 (50)	11 (22)	1 (2)
Right shoulder	13 (26)	10 (20)	22 (44)	5 (10)	0 (0)
Left shoulder	38 (76)	8 (16)	3 (6)	1 (2)	0 (0)
Upper back	6 (12)	8 (16)	29 (58)	5 (10)	2 (4)
Right elbows	35 (70)	8 (16)	7 (14)	0 (0)	0 (0)
Left elbows	42 (84)	7 (14)	1 (2)	0 (0)	0 (0)
Low back	2 (4)	1 (2)	13 (26)	28 (56)	6 (12)
Right wrist	19 (38)	11 (22)	15 (30)	4 (8)	1 (2)
Left wrist	29 (58)	10 (20)	10 (20)	0 (0)	1 (2)
Lower extremity
Right thigh	28 (56)	10 (20)	10 (20)	2 (4)	0 (0)
Left thigh	28 (56)	10 (20)	10 (20)	2 (4)	0 (0)
Right knee	17 (34)	9 (18)	18 (36)	5 (10)	1 (2)
Left knee	17 (34)	9 (18)	18 (36)	5 (10)	1 (2)
Right calf	9 (18)	4 (8)	25 (50)	11 (22)	1 (2)
Left calf	9 (18)	4 (8)	27 (54)	9 (18)	1 (2)
Right ankle	17 (34)	8 (16)	9 (18)	10 (20)	6 (12)

*Severe discomfort was considered for further analysis

Pain in different body parts in last seven days and 12 months (NMQ)

The data of pain experienced in the last 7 days revealed that 90% suffered pain in low back, 74% in calf muscle, 66% in upper back, 58% in ankles/feet, 52% in neck, and 50% in knees, whereas 94% reported low back and neck pain, 88% had upper back pain, 84% in calf, 64% in ankles/feet, and 60% in knees in the last 12 months [Table 3].

Table 3

Pain experienced by the subjects in last seven days and 12 months using Phi value (statistical test)

Body parts	Pain in last 7 days		Pain in last 12 months		Phi value*
	n	Percentage	n	Percentage
Neck	26	(52)	47	(94)	0.263**
Upper back	33	(66)	44	(88)	0.514***
Low back	45	(90)	47	(94)	0.758***
Hips/thighs	10	(20)	20	(40)	0.612***
Knees	25	(50)	30	(60)	0.816***
Calf	37	(74)	42	(84)	0.736***
Ankles/feet	29	(58)	32	(64)	0.881***

**Not significant values (P=0.063 > 0.05). ***Significant values (P≤0.05) *P = significance tested by Cross Phi test at 0.05

Table 3 shows the results of Cross-Phi test and Cramer’s V test to find out the association between pain in the last seven days and pain in the last 12 months in different body parts.

The significant results were found in ankles/feet (Phi value: 0.881; P ≤ 0.05), knees (Phi value: 0.816; P ≤ 0.05), calf (Value: 0.736; P ≤ 0.05), low back (Phi value: 0.758; P ≤ 0.05), hips/thighs/buttocks (Phi value: 0.612; P ≤ 0.05), and upper back (Phi value: 0.514; P ≤ 0.05), respectively.

Severity and frequency of pain in different body parts as experienced by the subjects

The analysis of the severity and frequency of pain in different body parts was done by ranking method using median score [Table 4]. The pain is categorized into severe pain, moderate pain, mild pain and no pain in descending order (4––severe pain to 1––no pain) for severity of pain and daily, weekly and monthly pain in the descending order (3––monthly pain to 0––no pain) for frequency of pain, respectively.

Table 4

Severity and frequency of pain in different body parts as experienced by the subjects according to median ranking

Body parts	Severity of pain			Frequency of pain			Valid frequency n
	Sum (n=50)	Ranked by median	Pain	Sum (n=5)	Ranked by median	Period
Low back	23	4	Severe	20	2	Weekly	50
Neck	18	3	Moderate	20	2	Weekly	50
Upper back	21	3	Moderate	20	2	Weekly	50
Calf	15	3	Moderate	29	2	Weekly	50
Shoulder	18	2	Mild	22	2	Weekly	50
Wrists/hands	14	2	Mild	20	1.5	Between daily and weekly	50
Knees	15	2	Mild	10	1	Daily	50
Ankles/feet	7	2	Mild	9	1	Daily	50
Elbows	40	1	No Pain	40	0	No pain	50
Hips/thighs/ buttocks)	30	1	No Pain	30	0	No pain	50

Severity of Pain – Scale: 1-No pain; 2-Mild Pain; 3-Moderate Pain and 4-Severe pain; Frequency of Pain – Scale: 0-No Pain; 1-Daily Pain; 2-Weekly Pain; 3-Monthly Pain; Special Note to Frequency of Pain with score 1.5 -Pain between Daily and Weekly pain was added to scale

The results [Table 4] reveal that the subjects experienced severe pain in low back, moderate pain in neck, upper back, and calf, mild pain in shoulder, wrists/hands, knees and ankles/feet, and no pain in elbows and hips/thighs/buttocks. The data of frequency of pain revealed that subjects experienced pain weekly in neck, shoulder, upper back and lower back and calf, whereas the subjects experienced daily pain in Wrists and Ankles and did not experience any pain in elbows and hips/thighs/buttocks.

Association between standing and sit-stand posture with calf and ankle pain

Association between standing posture with calf pain and ankle/feet pain was found with the help of Statistical Phi Test, but there was no significant association with other body parts [Table 5]. Strong association between standing posture adopted at work with pain in the calf muscle (Phi value: 0.736; P ≤ 0.05) and pain in the ankle/feet (Phi value: 0.881; P ≤ 0.05) was found significant; indicating standing posture leads to musculoskeletal disorder in lower extremity.

Table 5

Association between standing and sit-stand posture and 12 months pain in calf and ankle/feet

Posture adopted at work	Pain in 12 months						Phi value
Calf
	No pain	Percentage	Pain in both calves	Percentage	Total
Standing	1	3.30	29	96.70	30	100.00	0.736
Stand and sit	7	35.00	13	65.00	20	100.00
Total	8	16.00	42	84.00	50	100.00
Ankle/feet
Standing	4	13.30	26	86.70	30	100.00	0.881
Stand and sit	14	70.00	6	30.00	20	100.00
Total	18	36.00	32	64.00	50	100.00

Analysis of posture (making/answering telephone calls) using OWAS technique

Six types of standing posture and four types of sitting posture were identified and analyzed. Standing with awkward neck and shoulder position, with phone in-between neck and shoulder was the most harmful posture adopted. The other harmful posture adopted was awkward bending/leaning over the counter and both these postures needed immediate action. The sitting postures did not indicate much risk but needed changes in the near future.

DISCUSSION

The results of the study showed that severe discomfort/pain in upper extremity was reported in lower back and in neck regions, whereas moderate discomfort was observed in upper back, neck and right shoulder. For lower extremities, the severity of pain was high in right calf and ankle. It is nice to know the prevalence rate of perceived pain in shoulder, neck and lower back/waist have been reported earlier.[18] Previous findings showed that prolonged standing contributes to foot pain at the end of the day,[10] and fatigue, body or body-part discomfort, and lower extremity impairments.[12] In this study, standing posture was associated with pain in calf and ankle in 60% of the workers.

The statistically significant association of pain in back, calf, ankle/feet, and hips/thighs for past 7 days and 12 months was revealed by phi test at significant value (P ≤ 0.05). In a study on male commercial kitchen workers, the major complaints were shoulder pain (62.3%), finger/wrist pain (43.9%), and neck pain (38.6%), where shoulder pain was found to be statistically significant for almost all groups.[19] Work-related pain was experienced by 75% of respondents during the past 12 months working as hotel cleaners.[20]

This study revealed that the prevalence and severity of pain was highest in low back region with weekly frequency of occurrence, whereas neck, upper back, and calf had pain of moderate severity with weekly occurrence. Knee and ankle/feet pain was daily experienced but was of mild severity. The findings of the study are comparable with the study among hotel workers were the top three highest pain intensity scores were found for the lower back/waist, upper back and finger/wrist, respectively.[18]

Further, the association between standing posture with calf pain (Phi value: 0.736; P ≤ 0.05) and ankle/feet pain (Phi value: 0.881; P ≤ 0.05) was found, indicating that standing posture leads to musculoskeletal disorder in the lower extremity. In a similar study, on hotel employees, they were exposed to the static postures of standing up without moving for a prolonged time at the front desk.[21] Another study stated that hotel workers adapt unnatural postures as they become constrained by the height of the front desk while receiving customers or performing VDT tasks leading to MSD’s.[1]

High risk in neck and shoulder region among receptionists was found as they cradle their phone in-between neck and shoulder that leads to awkward posture. Similarly, hotel workers in the USA were found to be exposed to ergonomic risk factors such as repeatability, unnatural and static postures that are known to cause work-related musculoskeletal disorders.[22]

Further, subjects reported problems of sleeplessness and headache due to change in the shift timings and a few reported indigestion, frustration and fatigue. The higher reliance of hotels on shift work is also likely to cause sleep deprivation.[23] Many researchers have found the relationship between shift work and musculoskeletal symptoms.[2425] Further research is required to establish the relationship between sleep satisfaction and work-related musculoskeletal symptoms.

Limitations of the study

There were a few limitations to this study. The WRMSD problems of males and females were not studied separately. Since the footwear worn by the receptionists (male/female) and body weight were not studied in detail as permission was not given by authorities, its impact on calf and feet/ankle pain could not be studied.

CONCLUSION

This study has identified MSD and other health problems among front desk employees in hotels, which need to be addressed quickly. The suggestions were given to the management and employees primarily to use sit-stand combination at the front desk, place the telephones as close as possible, reduce the depth of the front desk by giving shelf type arrangement on inner side of the desk so that they are closer to the desk and the guests. This design of the front desk will make the employee stand erect, with no leaning forward and no stretching. Second, using soft shoes with insoles and small heels is recommended, with floor under feet carpeted. Third, to solve the problem of sleep and headache 30 days shift change was recommended as this will help employees to get acclimatized. Finally, most importantly, regular physical exercise before start of the shift is a must, which will loosen up the muscles and help in delaying of muscle pain. Regular medical checkups should be done for the welfare and wellbeing of the employees.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.