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REVIEW • Cogitare enferm. 26 • 2021 • https://doi.org/10.5380/ce.v26i0.71073 copy

STRATEGIES TO MINIMIZE ERGONOMIC RISKS IN THE CLEANING STAFF: AN INTEGRATIVE REVIEW

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to identify strategies to minimize ergonomic risks in the cleaning staff.

Method:

an integrative review, carried out on LILACS, Scopus, and MEDLINE/PUBMED databases, between August and September of 2019. The descriptors “ergonomics”, “cleaning service”, and their synonyms were combined using Boolean operators.

Results:

from the 21 articles analyzed, intervention studies prevailed and were classified with a level of evidence 2 (52%); carried out in the year 2012 (33.3%), in Sweden (38%), with hospital cleaning staff (47.6%). The use of ergonomic education strategies, changes in work tools, aerobic exercise, a method for risk assessment, surveillance protocol, task diary, updating with organizational and psychosocial factors at work were evidenced.

Conclusion:

the evidenced strategies proved to be effective and may contribute, for the health area, in the promotion and recovery of the physical condition of the cleaning staff.

DESCRIPTORS:
Worker's health; Ergonomics; Housekeeping; Health promotion; Review

DATABASE	SEARCH STRATEGY
LILACS	((“ergonomia” OR “análise ergonômica” OR “avaliação ergonômica” OR” engenharia humana” OR “ergonomia cognitiva” OR “ergonomia física” OR “institucional ergonomia visual” OR “psicologia da engenharia”)) AND ((“serviço de limpeza”))
MEDLINE (via PUBMED)	((((“ergonomics” [MeSH Terms] OR “ergonomic analysis” [MeSH Terms] OR “ergonomic assessment” [MeSH Terms] OR “human engineering” [MeSH Terms] OR “cognitive ergonomics” [MeSH Terms] OR “physical ergonomics” [MeSH Terms] OR (“institutional ergonomics” [MeSH Terms] OR “visual ergonomics” [MeSH Terms] OR “engineering psychology” [MeSH Terms]) AND (“housekeeping hospital” [MeSH Terms] OR “housekeeping” [MeSH Terms]))
SCOPUS (Elsevier)	(TITLE-ABS-KEY (((“ergonomics” OR “ergonomic analysis” OR “ergonomic assessment” OR “human engineering” OR “cognitive ergonomics” OR “physical ergonomics” OR “institutional ergonomics” OR “visual ergonomics” OR “engineering psychology”))) AND (((“housekeeping hospital” OR “housekeeping”)))

Code	Objective	Country of origin	Design and Level of Evidence*
A1⁽³⁾3. Dahlqvist C, Nordander C, Forsman M, Enquist H. Self-recordings of upper arm elevation during cleaning – comparison between analyses using a simplified reference posture and a standard reference posture. BMC Musculoskeletal Disorders. [Internet]. 2018 [accessed 14 ago 2019]; 19(402). Available from: http://doi.org/10.1186/s12891-018-2328-8. http://doi.org/10.1186/s12891-018-2328-8...	To compare analyzes for self-registration of arm elevation	Sweden	Randomized clinical trial LE=2*
A2⁽⁴⁾4. Landstad BJ, Gelin G, Malmquist C, Vinberg S. A statistical human resources costing and accounting model for analysing the economic effects of an intervention at a workplace. Ergonomics. [Internet]. 2002 [accessed 21 ago 2019]; 45(11). Available from: https://doi.org/10.1080/00140130210136053. https://doi.org/10.1080/0014013021013605...	To investigate the contribution of preventive intervention in the absence of disease in the company	Sweden	Quasi-experimental LE=3*
A3⁽²⁵⁾25. Lidegaard M, Sogaard K, Krustrup P, Holtermann A, Korshoj M. Effects of 12 months aerobic exercise intervention on work ability, need for recovery, productivity and rating of exertion among cleaners: a worksite RCT. Int Arch Occup Environ Health. [Internet]. 2018 [accessed 29 set 2019]; 91(2). Available from: https://doi.org/10.1007/s00420-017-1274-3. https://doi.org/10.1007/s00420-017-1274-...	To compare the effectiveness of aerobic exercise at work	Denmark	Randomized clinical trial LE=2*
A4⁽²⁹⁾29. Luz EMF da, Magnago TSB de S, Greco PBT, Ongaro JD, Lanes TC, Lemos JC. Prevalence and factors associated with musculoskeletal pain in hospital cleaning workers. Texto contexto-enferm. [Internet]. 2017 [accessed 05 dez 2019]; 26(2). Available from: http://dx.doi.org/10.1590/0104-07072017000870016. http://dx.doi.org/10.1590/0104-070720170...	To analyze the effect of gender on work/family balance strategies and working hours	Canada	Mixed methods LE=6**
A5⁽⁵⁾5. Korshoj M, Jorgensen MB, Lidegaard M, Mortensen OS, Krustrup P, Holtermann A, et al. Decrease in musculoskeletal pain after 4 and 12 months of an aerobic exercise intervention: a worksite RCT among cleaners. Scand J Public Health [Internet]. 2017 [accessed 22 ago 2019]; 46(1). Available from: https://doi.org/10.1177/1403494817717833. https://doi.org/10.1177/1403494817717833...	To investigate aerobic exercise to decrease musculoskeletal pain after 4 and 12 months	Denmark	Randomized clinical trial LE=2*
A6⁽²⁶⁾26. Wallius MA, Rissanen SM, Bragge T, Vartiainen P, Karjalainen PA, Räsänen K, et al. Effects of mop handle height on shoulder muscle activity and perceived exertion during floor mopping using a figure eight method. Industrial Health [Internet]. 2016 [accessed 29 set 2019]; 54(1). Available from: https://doi.org/10.2486/indhealth.2015-0108. https://doi.org/10.2486/indhealth.2015-0...	To compare the effects of mop handle height on shoulder muscle activity and repetitive exertion	Finland	Randomized clinical trial LE=2*
A7⁽⁶⁾6. Lofqvist L, Osvalder AL, Bligård LO, Pinzke S. An analytical ergonomic risk evaluation of body postures during daily cleaning tasks in horse stables. Work. [Internet]. 2015 [accessed 23 set 2019]; 51(4). Available from: https://doi.org/10.3233/WOR-152022. https://doi.org/10.3233/WOR-152022...	To evaluate ergonomic problems in physical work and the association with tool design	Sweden	Randomized clinical trial LE=2*
A8⁽⁷⁾7. Jonker D, Gustafsson E, Rolander B, Arvidsson I, Nordander C. Health surveillance under adverse ergonomics conditions – validity of a screening method adapted for the occupational health service. Ergonomics [Internet]. 2015 [accessed 23 set 2019]; 58(9). Available from: https://doi.org/10.1080/00140139.2015.1019575. https://doi.org/10.1080/00140139.2015.10...	Validate a health surveillance protocol for WRMD⁺	Sweden	Randomized clinical trial LE=2*
A9⁽⁸⁾8. Habib MM, Rahman SU. Musculoskeletal symptoms (MSS) and their associations with ergonomic physical risk factors of the women engaging in regular rural household activities: A picture from a rural village in Bangladesh. Work [Internet]. 2015 [accessed 23 set 2019]; 50(3). Available from: https://doi.org/10.3233/WOR-151990. https://doi.org/10.3233/WOR-151990...	To explore the prevalence of musculoskeletal symptoms, the interruption of normal activities and the association with ergonomic risk factors	Bangladesh	Transversal LE=4***
A10(9)	To compare the effectiveness of ergonomic education on muscle activity, postural and cardiovascular load during cleaning	Denmark	Randomized clinical trial LE=2*
A11⁽¹⁰⁾10. Missar VJ, Metcalfe D, Gilmore G. Transforming a hospital safety and ergonomics Program: a four year journey of change. Work [Internet]. 2012 [accessed 25 set 2019]; 41(suppl1). Available from: https://doi.org/10.3233/WOR-2012-0988-5912. https://doi.org/10.3233/WOR-2012-0988-59...	To examine active coverage, regulatory compliance, frequency, and severity of losses by occupational injuries	United States of America	Prospective study LE=6*
A12⁽¹¹⁾11. Silva-Junior JS, Correa LRC, Morrone LC. Evaluation of lumbar overload in hotel maids. Work [Internet]. 2012 [accessed 29 set 2019]; 41(supl1). Available from: https://doi.org/10.3233/WOR-2012-0488-2496. https://doi.org/10.3233/WOR-2012-0488-24...	To identify the association between work activities and MSP^§	Brazil	Transversal LE=6*
A13⁽¹²⁾12. Madeleine P, Søgaard K, Holtermann A, Samani A. Level of self-reported neck/shoulder pain and biomechanical workload in cleaners. Work [Internet]. 2012 [accessed 28 set 2019]; 41(supl1). Available from: https://doi.org/10.3233/WOR-2012-0195-447. https://doi.org/10.3233/WOR-2012-0195-44...	To investigate the relationship between WRMD⁺, muscle activity and postural load	Denmark	Randomized clinical trial LE=2*
A14⁽²⁴⁾24. Öhrling T, Kumar R, Abrahamsson L. Assessment of the development and implementation of tools in contract cleaning. Appl Ergon [Internet]. 2012 [accessed 24 set 2019]; 43(4). Available from: https://doi.org/10.1016/j.apergo.2011.11.006. https://doi.org/10.1016/j.apergo.2011.11...	To analyze problems with the implementation and use of ergonomic and technical tools in the cleaning process	Sweden	Randomized clinical trial LE=2*
A15⁽¹³⁾13. Bell AF, Steele JR. Risk of musculoskeletal injury among cleaners during vacuuming. Ergonomics [Internet]. 2012 [accessed 28 set 2019]; 55(2). Available from: https://doi.org/10.1080/00140139.2011.592605. https://doi.org/10.1080/00140139.2011.59...	To analyze the risk of MSP^§ in the upper limbs during vacuuming	Australia	Transversal LE=6*
A16⁽¹⁴⁾14. Mathiassen SE, Nordander C, Svendsen SW, Wellman HM, Dempsey PG. Task-based estimation of mechanical job exposure in occupational groups. Scand J Work Environ Health [Internet]. 2005 [accessed 29 set 2019]; 31(2). Available from: https://doi.org/10.5271/sjweh.861. https://doi.org/10.5271/sjweh.861...	To compare mechanical work exposure based on occupational tasks	Sweden	Randomized clinical trial LE=2*
A17⁽¹⁵⁾15. Unge J, Hansson GA, Ohlsson K, Nordander C, Axmon A, Winkel J, et al. Validity of self-assessed reports of occurrence and duration of occupational tasks. Ergonomics [Internet]. 2005 [accessed 29 set 2019]; 48(1). Available from: https://doi.org/10.1080/00140130412331293364. https://doi.org/10.1080/0014013041233129...	To analyze the validity of self-assessment reports on event and duration of tasks	Sweden	Mixed methods LE=6*
A18⁽¹⁶⁾16. Joseph B, Naveen R, Suguna A, Surekha A. Prevalence, Pattern and Factors Associated with Work-related Musculoskeletal Disorders (WRMD) among Housekeeping Workers in a Private Tertiary Care Hospital in Bangalore. J Health Manag [Internet]. 2016 [accessed 01 out 2019]; 18(4). Available from: https://doi.org/10.1177/0972063416666151. https://doi.org/10.1177/0972063416666151...	To evaluate the prevalence and factors associated with WRMD⁺ on cleaning workers in a private hospital	India	Transversal LE=4***
A19⁽¹⁷⁾17. Siqueira CE, Roche AG. Occupational health profile of Brazilian immigrant housecleaners in Massachusetts. New Solutions [Internet]. 2014 [accessed 01 set 2019]; 23(3). Available from: https://doi.org/10.2190/NS.23.3.e. https://doi.org/10.2190/NS.23.3.e....	To analyze the occupational health of Brazilian cleaners in Massachusetts	United States of America	Transversal LE=6*
A20⁽¹⁸⁾18. Unge J, Ohlsson K, Nordander C, Hansson GA, Skerving S, Balogh l. Differences in physical workload, psychosocial factors and musculoskeletal disorders between two groups of female hospital cleaners with two diverse organizational models. Int Arch Occup Environ Health [Internet]. 2007 [accessed 21 set 2019]; 81. Available from: http://doi.org/10.1007/s00420-007-0208-x. http://doi.org/10.1007/s00420-007-0208-x...	To analyze differences in physical workload, psychosocial factors, and MSP^§ with the organizational factors of work	Sweden	Randomized clinical trial LE=2*
A21⁽²⁷⁾27. Messing K, Chatigny C, Courville J. “Light” and “heavy” work in the housekeeping service of a hospital. Appl Ergon [Internet]. 1998 [accessed 29 set 2019]; 29(6). Available from: https://doi.org/10.1016/S0003-6870(98)00013-1. https://doi.org/10.1016/S0003-6870(98)00...	To analyze gender organization and exposure to working among hospital cleaning staff	Canada	Mixed methods LE=6*

Code	Ergonomic risk	Strategy	Ergonomic work analysis	Evaluation and results
A1⁽³⁾3. Dahlqvist C, Nordander C, Forsman M, Enquist H. Self-recordings of upper arm elevation during cleaning – comparison between analyses using a simplified reference posture and a standard reference posture. BMC Musculoskeletal Disorders. [Internet]. 2018 [accessed 14 ago 2019]; 19(402). Available from: http://doi.org/10.1186/s12891-018-2328-8. http://doi.org/10.1186/s12891-018-2328-8...	Lifting arm movement/ WRMD+	Risk assessment method (action levels)	Surveillance protocol in adverse ergonomic conditions, triaxial accelerometer and self-recording of arm elevation and speed	The strategy was positive: self-recording, in combination with activity levels, provide employers with a method for risk assessment as a solid basis for the prevention of WRMD+. In the control group, there was a difference between the two 9° arm elevation references (p<0.05)
A2⁽⁴⁾4. Landstad BJ, Gelin G, Malmquist C, Vinberg S. A statistical human resources costing and accounting model for analysing the economic effects of an intervention at a workplace. Ergonomics. [Internet]. 2002 [accessed 21 ago 2019]; 45(11). Available from: https://doi.org/10.1080/00140130210136053. https://doi.org/10.1080/0014013021013605...	Physical effort and WRMD⁺	Ergonomic education, organizational measures, skills development, environmental measures of physical and psychosocial work	Protocol on costs and human resource accounting	The strategy was positive with an estimated net contribution of 605.6 Euros
A3⁽²⁵⁾25. Lidegaard M, Sogaard K, Krustrup P, Holtermann A, Korshoj M. Effects of 12 months aerobic exercise intervention on work ability, need for recovery, productivity and rating of exertion among cleaners: a worksite RCT. Int Arch Occup Environ Health. [Internet]. 2018 [accessed 29 set 2019]; 91(2). Available from: https://doi.org/10.1007/s00420-017-1274-3. https://doi.org/10.1007/s00420-017-1274-...	Physical effort	Aerobic exercise	Surface electromyography	The strategy was positive for greater work capacity of 0.59±0.27 (95% IC; 0.05-1.13, p=0.03) and significantly decreased the need for recovery by -11.0.
A4⁽²⁹⁾29. Luz EMF da, Magnago TSB de S, Greco PBT, Ongaro JD, Lanes TC, Lemos JC. Prevalence and factors associated with musculoskeletal pain in hospital cleaning workers. Texto contexto-enferm. [Internet]. 2017 [accessed 05 dez 2019]; 26(2). Available from: http://dx.doi.org/10.1590/0104-07072017000870016. http://dx.doi.org/10.1590/0104-070720170...	Psychosocial factors: gender inequity and restricted work shift	Work/family balance strategy	Observation, interview, and task diary	It is recommended to create spaces for discussion about the balance between work and family, the circulation of information to reduce inequalities associated with gender/social status and family responsibilities.
A5⁽⁵⁾5. Korshoj M, Jorgensen MB, Lidegaard M, Mortensen OS, Krustrup P, Holtermann A, et al. Decrease in musculoskeletal pain after 4 and 12 months of an aerobic exercise intervention: a worksite RCT among cleaners. Scand J Public Health [Internet]. 2017 [accessed 22 ago 2019]; 46(1). Available from: https://doi.org/10.1177/1403494817717833. https://doi.org/10.1177/1403494817717833...	Muscular physical effort and MSP^§	Aerobic exercise and health support speeches	Questionnaire	The strategy of aerobic exercise, compared to speeches, was positive in reducing (>30%) the intensity of pain in the neck, shoulders, arms/wrists in the 12 months of follow-up (p=0.07). However, pain in the lower extremities (knees) increased
A6⁽²⁶⁾26. Wallius MA, Rissanen SM, Bragge T, Vartiainen P, Karjalainen PA, Räsänen K, et al. Effects of mop handle height on shoulder muscle activity and perceived exertion during floor mopping using a figure eight method. Industrial Health [Internet]. 2016 [accessed 29 set 2019]; 54(1). Available from: https://doi.org/10.2486/indhealth.2015-0108. https://doi.org/10.2486/indhealth.2015-0...	Shoulder muscle strain	Changes in work tools	Surface electromyography	The strategy was positive: the height of the adjusted mop handle had a statistically significant effect (p<0.001) on the muscle activity of the shoulder or chin, compared to the eye level
A7⁽⁶⁾6. Lofqvist L, Osvalder AL, Bligård LO, Pinzke S. An analytical ergonomic risk evaluation of body postures during daily cleaning tasks in horse stables. Work. [Internet]. 2015 [accessed 23 set 2019]; 51(4). Available from: https://doi.org/10.3233/WOR-152022. https://doi.org/10.3233/WOR-152022...	Work tools design and WRMD⁺	Changes in work tools	Observation	The strategy was positive: use of tools with better ergonomic design, long axis, or a wheelbarrow (p<0.001)
A8⁽⁷⁾7. Jonker D, Gustafsson E, Rolander B, Arvidsson I, Nordander C. Health surveillance under adverse ergonomics conditions – validity of a screening method adapted for the occupational health service. Ergonomics [Internet]. 2015 [accessed 23 set 2019]; 58(9). Available from: https://doi.org/10.1080/00140139.2015.1019575. https://doi.org/10.1080/00140139.2015.10...	WRMD⁺ neck/ shoulders area.	Health surveillance protocol	Health Surveillance Protocol in Adverse Ergonomics (HECO) and physical examination	The strategy was positive: effectiveness of the HECO protocol for one or more diagnoses in the neck (86%, k ¼ 0.62)/shoulders and elbows/hands (84%, k ¼ 0.49)
A9⁽⁸⁾8. Habib MM, Rahman SU. Musculoskeletal symptoms (MSS) and their associations with ergonomic physical risk factors of the women engaging in regular rural household activities: A picture from a rural village in Bangladesh. Work [Internet]. 2015 [accessed 23 set 2019]; 50(3). Available from: https://doi.org/10.3233/WOR-151990. https://doi.org/10.3233/WOR-151990...	Physical effort and musculoskeletal symptoms in the upper limbs	Prevention: diagnosis and ergonomic care	Nordic Questionnaire	Support for ergonomic attention and interruption of regular activities is recommended
A10⁽⁹⁾9. Samani A, Holtermann A, Søgaard K, Holtermann A, Madeleine P. Following ergonomics guidelines decreases physical and cardiovascular workload during cleaning tasks. Ergonomics [Internet]. 2012 [accessed 25 set 2019]; 55(3). Available from: https://doi.org/10.1080/00140139.2011.640945. https://doi.org/10.1080/00140139.2011.64...	Physical effort, workload (postural and cardiovascular)	Ergonomic education	Observation, surface electromyography, electrocardiogram	The strategy was positive for a lower level of trapezius muscle activity (p=0.03), lower range of motion and angular velocity of the trunk and lower cardiovascular load (p=0.02)
A11⁽¹⁰⁾10. Missar VJ, Metcalfe D, Gilmore G. Transforming a hospital safety and ergonomics Program: a four year journey of change. Work [Internet]. 2012 [accessed 25 set 2019]; 41(suppl1). Available from: https://doi.org/10.3233/WOR-2012-0988-5912. https://doi.org/10.3233/WOR-2012-0988-59...	Occupational injuries, tension, sprain, rise and fall	Ergonomic education	Inspection and interview	Participatory educational programs for the elimination of hazards are recommended; hiring ergonomists and protocols
A12⁽¹¹⁾11. Silva-Junior JS, Correa LRC, Morrone LC. Evaluation of lumbar overload in hotel maids. Work [Internet]. 2012 [accessed 29 set 2019]; 41(supl1). Available from: https://doi.org/10.3233/WOR-2012-0488-2496. https://doi.org/10.3233/WOR-2012-0488-24...	MSP^§, awkward posture, manual cargo transportation and physical effort	Changes in work organization	The general risk assessment questionnaire	It is recommended to reduce the weight of the carts, keeping material replacement areas on each floor
A13⁽¹²⁾12. Madeleine P, Søgaard K, Holtermann A, Samani A. Level of self-reported neck/shoulder pain and biomechanical workload in cleaners. Work [Internet]. 2012 [accessed 28 set 2019]; 41(supl1). Available from: https://doi.org/10.3233/WOR-2012-0195-447. https://doi.org/10.3233/WOR-2012-0195-44...	Postural load, muscle activity and WRMD⁺ on arms and shoulder	Ergonomic education with recordings	Surface electromyography, accelerometer, and the level of perceived pain	The strategy was positive: reduction of the event of WRMD in the lateral flexion angle (p<0.05) Workers with low pain showed greater muscle activity during cleaning (p<0.05)
A14⁽²⁴⁾24. Öhrling T, Kumar R, Abrahamsson L. Assessment of the development and implementation of tools in contract cleaning. Appl Ergon [Internet]. 2012 [accessed 24 set 2019]; 43(4). Available from: https://doi.org/10.1016/j.apergo.2011.11.006. https://doi.org/10.1016/j.apergo.2011.11...	Physical effort	Changes in work tools	Surface electromyography, self-reported measures of comfort level, perceived effort (Borg scale) and interviews	The strategy was positive: decreased muscle activity when using the adjustable mop handle, compared to the non-adjustable mop: for the right deltoid muscle (p=0.003), right trapezius muscle (p=0.000) and left wrist extensors (p=0.004)
A15⁽¹³⁾13. Bell AF, Steele JR. Risk of musculoskeletal injury among cleaners during vacuuming. Ergonomics [Internet]. 2012 [accessed 28 set 2019]; 55(2). Available from: https://doi.org/10.1080/00140139.2011.592605. https://doi.org/10.1080/00140139.2011.59...	Repetitive physical effort and MSP^§ in the upper limbs	Changes in work tools	Filming; risk assessment, rapid assessment of upper limbs (RULA)	It is recommended to use the vacuum cleaner in a backpack type machine (p=0.016), compared to the box type (p=0.011), with a greater risk of developing MSP.
A16⁽¹⁴⁾14. Mathiassen SE, Nordander C, Svendsen SW, Wellman HM, Dempsey PG. Task-based estimation of mechanical job exposure in occupational groups. Scand J Work Environ Health [Internet]. 2005 [accessed 29 set 2019]; 31(2). Available from: https://doi.org/10.5271/sjweh.861. https://doi.org/10.5271/sjweh.861...	Organizational factors, mechanical work, and MSP^§	Exposure to work in tasks and based on occupation (working time and break)	Surface electromyography and observation	The strategy was positive: the interval/pause was significant for both groups in reducing MSP (p=0.002)
A17⁽¹⁵⁾15. Unge J, Hansson GA, Ohlsson K, Nordander C, Axmon A, Winkel J, et al. Validity of self-assessed reports of occurrence and duration of occupational tasks. Ergonomics [Internet]. 2005 [accessed 29 set 2019]; 48(1). Available from: https://doi.org/10.1080/00140130412331293364. https://doi.org/10.1080/0014013041233129...	Physical workload and WRMD⁺	Task diary	Interview and observation	The disparity between the number of reported and observed tasks, underestimating the duration of breaks and less time-consuming activities
A18⁽¹⁶⁾16. Joseph B, Naveen R, Suguna A, Surekha A. Prevalence, Pattern and Factors Associated with Work-related Musculoskeletal Disorders (WRMD) among Housekeeping Workers in a Private Tertiary Care Hospital in Bangalore. J Health Manag [Internet]. 2016 [accessed 01 out 2019]; 18(4). Available from: https://doi.org/10.1177/0972063416666151. https://doi.org/10.1177/0972063416666151...	WRMD⁺	Ergonomic education	Nordic Questionnaire	A significant association between WRMD and the increased hours and years of work (p<0.05). Ergonomic education, job rotation and physiotherapy are recommended
A19⁽¹⁷⁾17. Siqueira CE, Roche AG. Occupational health profile of Brazilian immigrant housecleaners in Massachusetts. New Solutions [Internet]. 2014 [accessed 01 set 2019]; 23(3). Available from: https://doi.org/10.2190/NS.23.3.e. https://doi.org/10.2190/NS.23.3.e....	Uncomfortable working postures, lifting objects and MSP^§	Changes in the organization and work tools	Questionnaire	It is recommended to use ergonomic equipment, comfortable protective equipment (shoes) and work organization (task rotation, a decrease of workload, breaks and improvement in social relationships)
A20⁽¹⁸⁾18. Unge J, Ohlsson K, Nordander C, Hansson GA, Skerving S, Balogh l. Differences in physical workload, psychosocial factors and musculoskeletal disorders between two groups of female hospital cleaners with two diverse organizational models. Int Arch Occup Environ Health [Internet]. 2007 [accessed 21 set 2019]; 81. Available from: http://doi.org/10.1007/s00420-007-0208-x. http://doi.org/10.1007/s00420-007-0208-x...	Physical effort, workload, psychosocial factors, and MSP^§	Organizational factors of work	Nordic Questionnaire; medical and physiotherapist evaluation; pedometer; tilt sensor; heart rate; surface electromyography	The strategy was positive: the group with the organization (intervention) had a lower physical load, heart rate, positions and movements of the head, arms (p<0.001) and wrist (p=0.001) than the control group. The prevalence of MSP§ on neck/shoulders was lower in the intervention group (p=0,04)
A21⁽²⁷⁾27. Messing K, Chatigny C, Courville J. “Light” and “heavy” work in the housekeeping service of a hospital. Appl Ergon [Internet]. 1998 [accessed 29 set 2019]; 29(6). Available from: https://doi.org/10.1016/S0003-6870(98)00013-1. https://doi.org/10.1016/S0003-6870(98)00...	Organizational factors and workload	Exposure to light and heavy work and separated by gender	Observation and interview	It is recommended to assign tasks by sex for excessive work demands, which would be better handled by task redesign

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