Effectiveness of Parents-Centered Ergonomic Educational Intervention on Their Performance Regarding Safe Musculoskeletal Growth and Development among Their School-age and Adolescent

Background: Musculoskeletal health is a global concern for school-age children and adolescents. Children often face ergonomic risk factors in their daily activities, so it is important to raise parental awareness to prevent musculoskeletal disorders in their children. Aim: To assess the effectiveness of parent-centered ergonomic educational intervention on their performance regarding safe musculoskeletal growth and development among their school-age and adolescent. Subjects and method: A randomized controlled trial was conducted at pediatric outpatient clinics affiliated with Mansoura University Children's Hospital and Tanta University Hospital. A total of 110 parents and their children were randomly selected. Data collection tool was an interview schedule that included five parts as follow: baseline parents and their children's characteristics; an ergonomics knowledge test, an ergonomics-reported practices checklist, the Standardized Nordic Body Map Questionnaire (SNBMQ), and the Rapid Upper Limb Assessment (RULA). Results: The intervention group of parents showed significant improvements in ergonomic knowledge and reported practices compared to the control group (P < 0.001). Additionally, the children in the intervention group showed significant differences in musculoskeletal pain and posture three months after the education. Conclusion and recommendations: The study suggests that parent-centered ergonomic education can improve knowledge and reported practices and it recommends ergonomic educational interventions to promote safe musculoskeletal growth and development in children


Introduction
So, the nurse's primary preventative role is to ensure that the child reaches their full potential for genetically determined musculoskeletal growth, normal posture, perfect balance, and acceptable physical activity.
In Adolescents may be affected psychologically by the dramatic changes in their physical appearance associated with puberty.Many adolescents demonstrate poor posture, a tendency to round shoulders and a shambling, slouchy walk.This is due in part to the imbalance of growth; the skeletal system growing a little more rapidly than the muscles attached to it.In addition, poor posture particularly seems to develop in adolescents who reach adult height before their peers.They slouch to appear no taller than anyone around them.
Furthermore, girls may slouch to diminish the appearance of their breast size if they are developing more rapidly than their friends.This also can occur from carrying backpacks that are too heavy.Yang et al. (2020).

Method:
Research design: This study was conducted through parallel randomized, controlled trial.

Research Hypotheses:
To achieve the study's aim, the following research hypotheses were developed:

H₁:
The post-intervention parents' knowledge regarding ergonomics in the study group would be better than that in the control group.

H₂:
The post-intervention parents' reported practices regarding ergonomics in the study group would be better than in the control group.

H₃:
After the intervention, the children in the study group would be less musculoskeletal pain and discomfort compared to the control group.

H₄:
After the intervention, the children in the study group would have better posture than the control group.

Settings:
The study was conducted at pediatric out-patient clinics affiliated to Mansoura University Children's Hospital and Tanta University Hospital.

Subjects and sampling:
The study subjects were the parents

The implementation phase:
The

The evaluation phase:
The

Conclusion and recommendations:
This study concluded that the findings supported the study hypotheses, as the educational intervention had a significant effect on improving the parents' knowledge and practices toward safe , defined as the increase in body size as assessed by weight and height gain.The growing phase is when human beings experience the greatest biopsycho-social vulnerability.One of the most important indicators of physical development and somatic health of children and adolescents in particular is the state of the musculoskeletal system.Children's musculoskeletal healthy development needs a continuous, cohesive approach considering emerging needs.Genetic, environmental, dietary, psychotropic, pathological, and ergonomic variables are only a few of the aspects that either directly or indirectly affect a child's development (Alves & Alves, 2018).However, the latter still sparks debates regarding its effect on the growth and development of children and adolescents (Gumasing et al., 2023).
there are three general causes of musculoskeletal complaints in school-aged children: a heavy schoolbag (weighing more than 10% of body weight), furniture that is not designed to fit the dimensions of a human body, and the children's poor postures.In addition, Alhowimel et al. (2022) noted that low levels of physical activity, psychological disease, and a high body mass index were significant contributors it may affect academic achievement.On the other side, the medical costs of diagnosis and treatment are a concern.Furthermore, these disorders may lead to more severe consequences in adulthood, as they may affect the individual's career.Some of the a fore mentioned risks have been investigated by previous researchers, with recommendations made to develop future intervention strategies for reducing these risks.Intervention programs that have been considered previously include the use of ergonomic furniture, health promotion packages, exercises, and other ergonomic interventions, such as education and training, which can positively affect children' postures and decrease some musculoskeletal complaints reported that proper parental understanding of ergonomics and its related risk factors that cause injuries and health issues among children can reduce the multifaceted ergonomic risks.As the parents exert a powerful influence on the physical, mental, psychological, neural, and musculoskeletal growth and development of their offspring (Gee & Cohodes, 2021).Parental' education is a significant part of a nurse's role.Education empowers parents to improve their children's healthy habits and maintain ideal posture.Besides it enables them to optimize the ergonomically designed environment to enable child to study and play with greater comfort.Engaging parents in their children's interventions increases the chances of positive outcomes.For the development of parents' roles in their offspring's care, the role of nursing professionals covers many dimensions as follows: promotion of parents' role construction; guidance and support for the implementation of physical health care; Hussain, 2022).The purpose of this investigation was to evaluate the effectiveness of two sessions of a parents-

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Corlett.In order to prevent the "healthy subject effect," in which a subject may appear to have excellent posture while the evaluation is done, this observation-based posture assessment approach tries to analyze posture without notifying the child (Syazwan et al., 2011; Terra, Tonetto et al., 2023).RULA emphasizes the upper body while also including the lower body.It generates a numerical score for the observed posture by using a number of images of various body positions that are gradually combined together.Additionally, suggestions are set to each score between 1:7, categorized into four distinct classes, as shown in Figure 2 Academic experts assessed the effectiveness of the ergonomics program and the study tool regarding their content, language, layout, and structure to compute the content validity index (0.9) of the first draft of the ergonomics program and the study tool.A pilot study was implemented to test the face validity of the first draft of the ergonomics program's assisted materials and tool on 10% of the total sample size of parents (21), who weren't included in the sample.Accordingly, the necessary modifications by the experts and piloted parents were made as adding questions about school bag.were tested by Cronbach's α and emerged as very good (0.80, and 0.94 respectively).Additionally, the Rapid Upper Limb Assessment (RULA) for children reliability emerged as (Cronbach's alpha = 0.81 for arm, 0.79 for wrist, 0.78 for neck, 0.81 for trunk, and 0.83 for leg) Nature of the study did not cause any harm or pain for the entire sample.

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ergonomics program's timetable, including the program's date, time, content, teaching methods, and duration of each session, was distributed among the participating parents individually before the start of the program.The ergonomics program was implemented through three sessions.to illustrate the following content: an introduction to ergonomics and the pediatric musculoskeletal system development and its related disorders; the appropriate ergonomically furniture design; the adaptation of the studying environment to avoid MSDs; the appropriate exercises and relaxation techniques to avoid MSDs; risk assessment skills; ideal neutral postures; correct computing habits; the correct school bag criteria; the appropriate lifting, moving, walking and positioning; The main musculoskeletal disorders.Theoretical Session two: Duration of the session 90 minutes Content of the session  An introduction to ergonomics. Computer using principles  The correct school bag criteria  Ideal neutral postures  The adaptation of the studying environment to avoid MSDS Risk assessment skills  The appropriate body mechanisms during different situations.The exercises to avoid work related musculoskeletal disorders  Correct computing habits  Lifting and moving techniques  Positioning and walking techniques Teaching methods Demonstrations , and re-demonstration The materials and methods of delivering the ergonomics program varied widely and included active learning sessions, discussions, problem-solving exercises, lectures, and informational handouts.

Median
Wilcoxon signed-rank test, rC: effect size of Wilcoxon signed-rank test (matched pairs biserial correlation), U: Mann Whitney, P: Significance.* Significant (p≤ 0.05) Discussion: Parents bear a significant responsibility for the safety of their children's musculoskeletal system development.In the family environment, habits are formed about how to use ergonomic factors.Behavior is shaped through parents , both intentionally and incidentally (Tomczyk, & Potyrała, 2021).Thus, the appropriate parents' performance about the use of ergonomic factors for their children not only allows parents to avoid ergonomic threats but is also a factor in the protection of their children from musculoskeletal problems.(McDougall et al., 2018).To our knowledge, this is the first research to evaluate the effectiveness of parents-centered ergonomic educational intervention on their performance regarding safe musculoskeletal growth and development among their children.The data analysis indicates uniformity on all the studied Scio demographic and clinical characteristics between the interventional and control groups of the parents and their children who participated in the baseline assessment.As, inferential tests showed insignificant differences (P>0.05), this is compatible with a comparative study conducted by Tigli et al., (2020), who reported the similarity between the study and control groups.This similarity is the basic requirement for any casecontrol study, as revealed by a consistent study by (Oner et al., 2019).up with a huge effect size on the intervention group mean scores (ES=0.8),compared to negligible changes in the mean score of the control group results.The results of the current research were supported by the study of Jabeen and Hussain, (2022) who cited that "awareness regarding ergonomics can also prove to be a healthy sign towards students' better posture, comfort, and health."It can be demonstrated through parental education and implementing ergonomic techniques by demonstrating healthy exercises and reducing academic pressure."additionally, a randomized clinical trial that was implemented by Chu et al. (2019) concluded that "parents who received the text-messaging program reported higher levels of improved knowledge at 1 and 3 months of followup compared with the control group."Heavy backpacks, improperly ergonomically designed furniture, and poor computer habits are the most glaring factors that lead to students' postural deviation and persistent pain in the body (Jabeen & Hussain, 2022).Therefore, this research emphasized providing parents-centered education about these factors, which revealed significant improvements in the interventional parent group throughout the three study phases, as demonstrated by RM-ANOVA results (P-value ≤0.001), compared to non-significant differences in the control group.This finding is also supported by Al-Hinai et al. (2018), who cited that "provision of ergonomically designed furniture positively impacts students' posture, comfort, and health."Additionally, Buchman-Pearle et al. (2023), stress on the implementation of interventions such as ergonomically designed furniture, postural education and physical activity breaks leads to improved health outcomes, better posture and improved academic performance.Jabeen and Hussain (2022) cited that "incorporating parents and school authorities in active ergonomic practices is very crucial for students to regain their energy and make them active and agile."Thus, the present research focused on providing the parents with skill-based education about ergonomic risk assessment, correct positioning, walking, lifting, and moving techniques, besides suitable exercises, and relaxation techniques, which revealed significant improvements in the interventional parents group immediately and three months after intervention implementation, as indicated by RM-ANOVA results (P-value≤0.001),compared to non-significant differences in the control group.This finding is supported by Kumar et al. (2020), who suggested that "ergonomics training must be a part of the school curriculum to improve parents, teachers, and students' performance."Additionally, Choudhary et al. (2020) recommended that parents be guided to monitor their children's body posture at home as well to avoid ergonomic risk factors.Hence, the role of parents cannot be ignored in changing the unhealthy computer habits of their children by making them carry appropriate backpacks and enabling them to adopt appropriate body mechanisms during all body postures.The research findings also agreed with Abubakar (2020), who stated that "parents also should become part of the ergonomic system and help their wards in physical exercises and guide them to improve sitting positions at home."Our findings show that the best and most practical approach to generating in depth behavioral changes in schoolchildren is to educate their parents about ergonomics in their children's daily lives.As inappropriate posture and musculoskeletal pain are largely attributable to ergonomic risks, not only in the school environment but also in many other daily activities.Thus, our research included the evaluation of two secondary outcomes: huge effect size regarding all MS pain at (p<0.05), compared to the control group, which showed insignificant results regarding all the reported MS pain at (P>0.05).This outcome agreed with two studies by Bulguroğlu et al. (2023) and Abdolahi et al., (2022), who concluded that "specific training programs including posture and ergonomics may raise ergonomic awareness in terms of reducing musculoskeletal pain."As regards the posture evaluation results after the ergonomics program implementation, the children in the interventional group demonstrated significant improvement with a high effect size in the posture score (P-value≤0.001,rC=0.98),compared to the control group, which showed an insignificant result regarding the posture score (P-value=0.083).This conclusion is compatible with the finding of Khalili et al., (2018) who reported "a significant effect of educational intervention based on the stages-of-change model on practicing the correct posture."This result also agreed with another study by Gaikwad et al., (2023), entitled "Effectiveness of ergonomic training in workrelated musculoskeletal pain and posture among school-going students-an experimental study", which showed a positive effect of the ergonomic training on posture among school-going children.

Part IV: Standardized Nordic Body Map Questionnaire (SNBMQ). This questionnaire was developed by Kuorinka et al. (1987). It
to conclude if the pain is present (positive) or absent (negative).

Table ( 1): Parents' demographic and occupational characteristics P-value for
Chi-square test and/or Independent t test, P Significance * Significant (p≤ 0.05).