Facilitators and Barriers to Implementing Interventions to Prevent Musculoskeletal Disorders in Blue-Collar Workers: A Scoping Review

Purpose Blue-collar workers generally have less healthy lifestyles, poorer health, and a lower life expectancy than white-collar workers. At least in part this may be attributed to their work and working conditions. Employers increasingly provide interventions to improve health and wellbeing and prevent musculoskeletal disorders. However, they often do not reach blue-collar workers. The aim of this scoping review was to identify the facilitators for and barriers to implementing such interventions among blue-collar workers. Methods A scoping review in which the study population of the selected studies consists of blue-collar workers (≥ 18 years old) in paid employment. Furthermore, included studies should report facilitators and barriers to implementing interventions to prevent musculoskeletal disorders. The literature search was conducted in six databases. The resulting studies were extracted with the help of the updated Consolidated Framework for Implementation Research. Results 15 articles were included; these were reviews, intervention studies, qualitative studies and process evaluations. A main facilitator was a participatory approach, which involves the blue-collar worker in the entire process of defining, developing, and implementing a multidimensional preventive intervention. The main barriers on the worker level were unfavorable worker characteristics and unsupportive behavior/attitudes. The main barriers on the organization level were a culture with a high production standard, a hierarchical culture, inflexible work, and an unsupportive attitude from the employer. Conclusion This review showed the multifaceted nature of implementation. A tailored implementation plan that involves the stakeholders (including workers) is important.


Introduction
About 15-50% of the world's adult population suffers from musculoskeletal disorders (MSDs) [1][2][3][4].The wide range in prevalence can be partly explained by the extensive range of definitions for MSDs in scientific literature [4].The number of people with MSDs is predicted to grow exponentially in the next two decades because of the age distribution of populations and their longevity [5,6].MSDs such as back, neck and shoulder pain have a major impact on daily functioning and participation, including work [7].As a result, MSDs strain the healthcare, employment, and social security systems [5,6].MSDs are affected by physical, psychological, and social factors [6,8].
In the working population, job dissatisfaction, high job demands, and repetitive movements are strongly associated with the occurrence and prognosis of MSDs [3].This is particularly the case for blue-collar workers: those who predominantly perform manual labor [3,8,9].The prevalence of MSDs among them can be attributed to their work, at least in part [10][11][12].On average, they have less healthy lifestyles, poorer health, and a lower life expectancy than white-collar workers [13].There is a growing awareness of the need to prevent the development of MSDs in the workplace, especially for blue-collar workers [14][15][16][17].There is also a social and ethical urgency to improve health equality and prevent MSDs, particularly in the blue-collar workforce, as they impact the individual, occupational, and social levels of workers [18,19].
Increasingly, employers are providing interventions (e.g., task rotations, customized training, and knowledgerelated interventions) with the aim of improving health and wellbeing and preventing MSDs [14,16,19].However, these interventions often do not reach blue-collar workers and, even if they participate, they drop out earlier and do not comply as well as white-collar workers [20,21].Multiple systematic reviews have concluded that interventions for blue-collar workers are not as effective as interventions for white-collar workers [7,13,14], but the reasons have not been investigated systematically.Researchers mention reasons related to occupational, individual and cultural factors (e.g., financial constraints, or interventions that are not attractive enough for blue-collar workers) [20,21].It is unclear which facilitators and barriers influence the implementation of interventions to prevent MSDs in bluecollar workers, and implementation science can help us investigate this systematically [22].
To this end, it is extremely important to better understand the facilitators and barriers to implementing interventions to prevent MSDs among blue-collar workers.Therefore, this scoping review aims to identify these facilitators and barriers.We will summarize and discuss the results from studies that address facilitators and barriers to implementing preventive interventions, with the hope that they can be used to improve the implementation of interventions to prevent MSDs among blue-collar workers.

Design
A scoping review was used to identify and analyze gaps in knowledge bases.A scoping review has a broader scope than a systematic review [23]: the scoping process is iterative (not linear) and it requires researchers to engage with each stage in a reflective way and, where necessary, to repeat steps to ensure that the literature is covered comprehensively [24].The review was reported according to the Prisma checklist for scoping reviews [25].

Information Source and Search
Multiple systematic searches were performed with the help of a medical librarian until June 22, 2022, in the following databases: Medline(Ebsco), Embase.com,PsycInfo(Ebsco), Cinahl plus with full text(Ebsco), Cochrane Central, and Web of Science(Core Collection).The following terms were used (including synonyms and closely related words) as index terms or free-text words to represent the following concepts: "musculoskeletal complaints" AND "blue-collar workers" AND "prevention" AND publication type.No additional filters were used.The full searches are available in "Appendix 1".All results per database were exported into a single file.The files then were merged and de-duplicated in EndNote using the Bramer method [26].The reference lists of all included reports and articles were searched for additional studies (snowball method).

Study Selection
To be included, studies should investigate facilitators and barriers to implementing interventions for primary and secondary prevention of MSD.Furthermore, the study population of the selected studies must consist of blue-collar workers (≥ 18 years old) in paid employment.Published articles from medical, vocational, and social contexts were included.Only more economically developed countries with a human development index of 0.80-1.0(very high) were included because they have comparable systems comparable to the Netherlands.Included study types were reviews, intervention studies (e.g., randomized controlled trials and cohort studies) and qualitative studies regarding interventions to prevent MSD.To capture the latest evidence, only studies published since 2007 were included.For more detailed information about the eligibility criteria, see "Appendix 2".
Two authors (SM and DS) independently screened all titles and abstracts acquired from the systematic search using RAYYAN [27].The authors checked their degree of agreement four times (after 20, 200, 1000, and all studies) and discussed discrepancies until they reached consensus.When consensus was not reached, a third author (JBS) was involved to make a decision.Full texts of all studies were screened by the same two authors to make a final decision about inclusion.

Data Extraction and Analyses
Results were extracted as follows: author, year of publication, source of origin, study design, sample size, methodology, and variety of intervention.The facilitators and barriers to implementing interventions to prevent musculoskeletal complaints among blue-collar workers were extracted and summarized following the updated Consolidated Framework for Implementation Research (CFIR) [22].The CFIR guide consists of five domains related to the implementation of interventions: intervention, implementation process, individuals, inner setting, and outer setting (see Table 1 for more information).The framework guidance was used to select the most suitable domain [22].The first author screened the articles for reported facilitators and barriers.The second author (DS) had research experience with the CFIR guide and helped to select the most suitable domain [28,29].

Results
The search resulted in 3341 abstracts to screen (Fig. 1) on title and abstract.The authors reached consensus for 96% (3224) of the screened titles and abstracts.117 articles were discussed and, after discussion, six articles were presented to a third author to reach a conclusion.In total, 15 articles were included in this scoping review with full consensus between the two authors after discussion.No additional articles were found by screening the reference lists.
The use of a participatory design might be a facilitator because it raises awareness among workers and management and improves communication [33,38].With a participatory approach, the design and methodology are flexible and can be adapted to risks such as changes in key personnel, internal politics, organizational structures, and global economics [38].
A second facilitator is using the expertise of experienced employees to develop training content and train workers, so they make the intervention their own [12,30,36].A third possible facilitator is having the intervention consist of multidimensional programs with choices for workers, so the program can be tailored to the risk profile of the individual or the workplace [31,32,39].
However, having more than three job rotations in a shift is a barrier to implementation.When using job rotation, it is important that the intervention be feasible and practical (e.g., a maximum of three job rotations during a nine-hour shift) [34].The setting in which the intervention is implemented: e.g., company or industry.There may be multiple inner settings and/or multiple levels within the inner setting Outer setting The setting in which the inner setting exists: e.g., city, country or society.There may be multiple outer settings and/or multiple levels within the outer setting

Implementation-Process-Related Facilitators and Barriers
Facilitators and barriers related to the implementation process were described in two intervention studies [32,37], one qualitative study [39] and one process evaluation [43].
Having sufficient knowledge about the intervention and goals can help workers during an intervention [39].Another facilitator is the use of powerful implementation strategies, in which different implementation strategies were combined in a multifaceted way.For instance, the combination of training (educational strategy) and stimulating collaboration (facilitating strategy) to reduce physical work demands and reduce MSD.) [32].

Individual-Related Facilitators and Barriers
Individual-related facilitators and barriers were described in one scoping review [12], one intervention study [41], and one qualitative study [39].Workers' autonomy in their work and during the intervention, facilitative work behavior and a supportive attitude are facilitators to starting and implementing an intervention [12,41].Barriers include unfavorable worker characteristics (e.g., a lack of knowledge about physical work exposures and skills), impeding work behavior (communication and cooperation with employer and colleagues) and an unsupportive attitude from the employer [39,41].
Overall, organizational culture is an important factor.This includes a supportive organizational climate (e.g., the awareness of employers of adverse physical work demands and a favorable attitude throughout the organization towards prevention of it), job autonomy, favorable job characteristics (e.g., automatic rotation between tasks and/or activities), flexible work processes and the willingness of the employer to change work demands by moving employees from one department to another when starting and implementing an intervention [12,35,41].Additionally, strong, organized, and attentive leadership may facilitate the process and structure of work to allow workers' voices and suggestions to be incorporated into planning for the work [37].Working in a smaller company (< 100  employees) and having greater management engagement in the intervention positively influenced the implementation of an intervention on construction worksites [42].
However, an organizational culture with a high production standard, hierarchical culture, or inflexible work process can be a barrier to implementing preventive programs [39,41].Additionally, workers who work alone and do not allow themselves to take breaks, and the absence of the employer at the workplace are barriers to starting and implementing an intervention [39].If the employer makes incorrect assumptions about job changes and shows little willingness to change when there is no visible work disability, preventive interventions are less likely to be implemented [39,40].

Outer-Setting-Facilitators and Barriers
Barriers were described in one intervention study [37] and one process evaluation [42].We found no facilitators for this domain.
The first barrier is that an economic recession can lead to worker dismissal and/or forcing workers to work part-time.This might affect the amount of the intervention workers receive [42].Another barrier, specific to construction firms, is environmental conditions (e.g., a muddy working environment) and interactions about the intervention with other involved companies that delay the intervention [37].

Statement of Principal Findings
This scoping review found multiple facilitators and barriers that might be important for implementing interventions to prevent musculoskeletal complaints among blue-collar workers.These facilitators and barriers are related to all five domains of the CFIR.This demonstrates the multifaceted nature of implementation.
In summary, a main facilitator is a participatory approach that involves the worker in the entire process of defining, developing, and implementing a multidimensional preventive intervention.Other main facilitators are powerful implementation strategies.
The main barriers on the workers' level involve unfavorable worker characteristics (e.g., lack of knowledge about physical work exposures and skills) and unsupportive behavior/attitudes (e.g., impeding communication and cooperation with employer and colleagues).The main barriers on the organizational level are a culture with a high production standard, a hierarchical culture, inflexible work, and an unsupportive attitude.

Strengths and Weaknesses of the Study
One strength of this study is the use of the recently updated CFIR, a highly cited framework in implementation science that is focused on predicting or explaining facilitators and barriers to implementation effectiveness [22].Moreover, the search string was systematic and the search was thorough (as shown in "Appendix 1").The search string led us to find studies with different designs.
A weakness of this study is that the variety of study designs prevented us from assessing the risk of bias in individual studies.Also, despite the systematic search, this scoping review may have overlooked some studies that could have been found by using different key terms or a broader research question.

Comparison with Scientific Literature
In line with our findings, an evaluation study [44] showed that the results of (implementing) an intervention reflect the intertwined aspects of the intervention, the research, and the local context.Therefore, a continuous dialog between stakeholders is important and draws attention to the social dynamics and shifting circumstances when implementing an intervention [44].These shifting circumstances (e.g., recession, environmental conditions) can influence the outcome measures, which could be seen as bias [45,46] or as an authentic process.
In this review, a participatory approach was identified as a facilitator for implementing interventions.Research that enables active involvement by participants is applied in public health and health promotion and is a valuable option for active participation by blue-collar workers and other important stakeholders [44,47].The collaborative development, and especially implementation of the intervention, can also bridge the educational knowledge gap between researchers/developers and workers [45].However, there have been few structured high-quality studies about a participatory approach [46,48].
This review also identified workers' attitudes, behavior, and knowledge and skills as important individual factors that influence implementation.In line with our findings, other qualitative studies also identified a negative attitude as an important barrier to implementation [47,49].Since workers' attitudes can act as both a barrier and a facilitator, it is important to ensure that workers have a positive attitude.Involving blue-collar workers in the development and implementation of the intervention can positively contribute to their attitude and the effectiveness of the intervention [50].
Research also showed that job autonomy is essential for worker engagement and beneficial behavior.This might also lead workers to behave in ways that support preventive interventions [51].Thus, to improve implementation, companies should also focus on and prioritize their workers' autonomy.
In line with other studies, this scoping review shows the importance of cultural success factors (e.g., knowing and meeting employees' needs, leadership involvement and continuity of communication) [28,52].Other studies identified another barrier: a masculine culture (e.g., discouraging talking about personal topics, such as lifestyle and health) among blue-color workers can have a negative effect on their health behavior, and thus requires a culture change on the organizational level [21].

Meaning of the Study: Possible Mechanisms and Implications for Clinicians and Policymakers
This review showed that the implementation of an intervention must be tailored to the inner setting of the company and their workers, and a participatory approach can help to create this.This also indicates that the required measurement of outcomes must be tailored to both employers and employees [53].For example, health outcomes are not always clear for employers and employees.It is important that the assumptions, emphasis and values that health outcomes contain are understandable for both employers and employees [53].A company that wants to start implementing an intervention needs to analyze the existing facilitators and barriers a priori, create a customized action plan to strengthen some facilitators, and understand the development of the barriers and how to overcome them.This is also important for improving the health of blue-collar workers and reducing health-related inequalities [54].

Unanswered Questions and Future Research
There is a need for more high-quality studies focused on identifying the facilitators and barriers that influence bluecollar workers' decisions about participating in healthrelated interventions and determining how to tailor (the implementation of) interventions to increase their effectiveness.Specifically, how can facilitators be embedded and how can barriers be overcome?There also is a need for study designs that monitor facilitators and barriers, process evaluations, and realistic synthesis (with a focus on understanding the mechanisms by which an intervention works or not) to gain a better understanding of facilitators and barriers to implementation [55].

Conclusion and Recommendations
In conclusion, this review showed that multiple facilitators and barriers are related to the implementation of interventions to prevent musculoskeletal disorders among blue-collar workers.The CFIR can help to make the multifaceted nature of implementation visible.When a company wants to start implementing an intervention, it is important to first analyze the existing facilitators and barriers a priori, create a customized action plan to strengthen some facilitators, and understand the development of the barriers and how to overcome them.

Table 1
Domains of the consolidated framework for implementation research

Table 2
Included studies

Table 3
Summarizing main facilitators and barriers of each domain related to the Consolidated Framework of Implementation Research

Appendix 2: Screening Eligibility Criteria
OR SU (cohort* or "follow up" or followup or longitudinal* or prospective* or retrospective* or observational* or multicent* or 'multicent*' or consecutive*)) AND (TI (group or groups or subgroup* or versus or vs or compar*) OR AB (group or groups or subgroup* or versus or vs or compar*) OR SU (group or groups or subgroup* or versus or vs or compar*) or AB ("odds ratio*" or "relative odds" or "risk ratio*" or "relative risk*" or aor or arr or rrr) or (AB ("OR" or "RR") N6 CI)) or TI (versus or vs or compar*) or MH "Comparative Studies" or TI (compar* N1 study) OR AB (compar* N1 study) or SU (compar* N1 study) OR MH "Historically Controlled Study")) NOT (MH "Animals + " NOT MH "Humans + ") NOT (ZT "comment" or ZT "editorial" * or multicent* or 'multi-cent*' or consecutive*) OR AB (cohort* or "follow up" or followup or longitudinal* or prospective* or retrospective* or observational* or multicent* or 'multi-cent*' or consecutive*)