Musculoskeletal disorders refer to any tissue damage to the musculoskeletal system that impairs the functioning of organs (1). These disorders could lead to injuries in the components of the musculoskeletal system, such as joints and bones (1). One of the most common musculoskeletal disorders is caused in the workplace, which is considered one of the main problems of health, disability, and absenteeism in industrialized societies, accounting for about a third of treatment costs (2). These disorders cause 70 million Americans to visit medical centers annually (2), which has made them the second most important occupational disorder (3). Forty percent of all documented occurrences of musculoskeletal problems could lead to permanent disability, and these conditions account for 50% of long-term absences from work (4).

In a study by Jamil et al., 93.2% of the participants had a musculoskeletal disorder, and only a few (32.9%) were aware of workplace ergonomics (5). According to the findings of another study on Chinese computer users, their backs (29.2%), shoulders (10.5%), and hands and wrists (6.2%) were the most commonly damaged areas after a year of work (6). A systematic review and meta-analysis of work-related musculoskeletal disorders in different cities in Iran showed a high prevalence of these issues among employees (7). One of the groups that are exposed to musculoskeletal disorders due to their job responsibilities is nurses. Nurses working in hospitals are considered the main part of the health and treatment system in Iran, and their health status is important in terms of providing healthcare services.

In recent years, due to the COVID-19 pandemic, nurses had to cover long-term shifts, and the lengthened working hours and their increased workload led to serious complications such as stress (8), depression (9, 10), job burnout (11, 12), lack of emotional control (13, 14), reduced resilience (15), and the occurrence of musculoskeletal disorders (16, 17). Most recent studies have focused on nurses and reducing the aforementioned complications. The issue of musculoskeletal disorders in this group has long been the concern of a large group of researchers. The use of educational interventions in order to improve these disorders in nurses has been proposed by the researchers, as these interventions would increase the knowledge, motivation, and ability of nurses to access, evaluate, and use health information (18). In addition, training in managing work and preventing the occurrence of musculoskeletal disorders as one of the life skills increases the strength and abilities of nurses in their jobs (19).

Some previous studies conducted in Iran have shown that education based on health education models has been able to reduce musculoskeletal disorders in nurses and be effective in modulating their pain (20, 21). Among the many models and patterns, the PRECEDE-PROCEED model is an effective one for this purpose (22). In this model, which is also effective in the training of employees, the enablers and reinforcers of behaviors are determined (22). According to this model, the effective factors affecting the results could be determined before designing any intervention. Hence, the PRECEDE-PROCEED model is one of the planning models in health education and health promotion, focusing on changing behaviors, and it has been successful in previous evaluations (23).

The need for an educational program based on an educational model is felt to properly guide nurses in order to prevent the occurrence of musculoskeletal disorders in their workplace. Taking a look at the models of health education, the PRECEDE-PROCEED model is an effective one. Therefore, the aim of this study was to determine the effect of using the PRECEDE-PROCEED model on promoting the preventive behaviors of musculoskeletal disorders in the nurses of Izeh City Hospital in Iran in 2021.

The study’s control and intervention groups’ demographic data are displayed in Table 3. According to the results of the paired t-test, age (p = 0.215) and job experience (p = 0.648) of participants did not differ between the experimental and control groups. Moreover, the results of the chi-square test revealed no difference in gender (p = 0.068), marital status (p = 0.426), education (p = 0.578), or history of musculoskeletal problems (p = 0.159) between the two groups (Table 3).

The independent t-test found no difference in knowledge (p = 0.221), attitude (p = 0.136), enabling factors (p = 0.325), reinforcing factors (p = 0.548), self-efficacy (p = 0.421), or behavior (p = 0.257) between the groups prior to the intervention. However, following the intervention, there was a noteworthy distinction between the two groups in terms of the mentioned variables (p = 0.001) (Table 4).

This study was implemented with the aim of investigating the effect of education based on the PRECEDE-PROCEED model on the incidence of musculoskeletal disorders in nurses. Based on the results, the educational program resulted in an increase in knowledge in the experimental group compared to the control group. The PRECEDE-PROCEED model includes efforts that seek to understand variables affecting behavior and related processes in health-related fields. This model reveals health interventions and is considered a valuable tool in the research process. This pattern increases a person’s knowledge of the problem and leads to an increase in knowledge and compliance. This finding is consistent with the results of the studies of Sousa et al. (25), Hosseini et al. (26), and Alam et al. (27).

In our study, education led to an increase in attitude in the experimental group compared to the control group. Probably, the increase in attitude in the experimental group was related to the training given. The PRECEDE-PROCEED model is a cognitive model that evaluates the way people respond to a health-threatening factor and leads to an increase in the individual’s attitude when the status quo becomes available. This finding was consistent with the results of Ziam et al.’s studies, with the aim of determining the possibilities and obstacles related to the prevention of musculoskeletal disorders in the older adult (28). This researcher stated that the existence of attitude as a possibility and its absence are known as obstacles that need to be solved by educational intervention in some cases that are related to the individual himself (28). In addition, the results of Pourhaji et al. (29) were consistent with the results of the present study.

Following the intervention, a substantial increase was experienced in the enabling factors in the experimental group compared to the control group. Training based on the PRECEDE-PROCEED model has led to the evaluation of benefits and costs, and for this reason, the trained nurse can reduce costs, prevent complications, and ultimately lead to increased benefits by following some easy training items and preventive behavior in itself. This finding is consistent with the results of Abdul Halim et al. in reducing skeletal problems in hospital employees (30), the study by Jain et al. aimed at the effect of education on physical activity in reducing musculoskeletal problems (31) and the study by Espin et al. aimed at the effect of education in reducing musculoskeletal problems in eldercare workers (32).

After the intervention, a sharp rise was observed in reinforcing factors in the experimental group compared to the control group. This increase can be attributed to the intervention based on PRECEDE-PROCEED, because one of the structures of this model is the knowledge of strengthening factors, and during the training, nurses gained detailed knowledge of strengthening factors in the preventive direction, which in turn, played a role in raising the reinforcing factors of the participants regarding musculoskeletal disorders. This finding is consistent with the results of Toonders et al. on the reduction of musculoskeletal disorders (33) and the study of Alghtani et al. with the aim of exercise-based interventions to reduce back pain in healthcare workers (34).

According to the findings, the intervention led to an increase in self-efficacy in the experimental group compared to the control group. In the topic of musculoskeletal disorders related to work, some obstacles are related to the work itself and the employer, and others, such as how to sit and stand up correctly, how to move the patient, and how to move the wheelchair, are related to the nurse, which can be led by teaching these things to promote self-efficacy in them. This finding is consistent with the results of van de Wijdeven’s (4) and Larinier et al.’s studies (35). Training based on the PRECEDE-PROCEED model led to self-efficacy evaluation in nurses, and finally, the intervention improved self-efficacy.

Finally, in this study, education based on the PRECEDE-PROCEED model has notably promoted the behavior structure in the experimental group compared to the control group. This finding is consistent with the results of Nashaat et al.’s study aimed at the effect of educational intervention on nurses (36) and Abdelaziz et al.’s study aimed at the effect of educational intervention on reducing pain in the older adult with chronic pain (37).

The educational intervention in the current study, based on the PRECEDE-PROCEED paradigm, resulted in improved nurses’ knowledge, attitudes, enabling and reinforcing structures, and behavior. The necessity of education in a wider dimension and with different tools is becoming more and more apparent in society, given the significance of the role that health education plays in encouraging behaviors related to musculoskeletal disorders in nurses and the significance of observing related behaviors in preventing long-term complications.

The raw data supporting the conclusions of this article will be made available by the authors, upon reasonable request.

The studies involving humans were approved by Shiraz University of Medical Sciences. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

TR: Conceptualization, Methodology, Project administration, Supervision, Visualization, Writing – original draft. ZL: Data curation, Formal analysis, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – original draft. HD: Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft. AKa: Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Validation, Visualization, Writing – review & editing. AKh: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.