Palsson-1998-Absence Attributed to Incapacity

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Occup. Med. Vol. 48, No. 5, pp. 289-295, 1998

Copyr ight© 1998 Lippincott-Raven Publishers for SOM

Printed in Great Britain. All rights reserved

0962-7480/98

Absence attributed to

incapacity and occupational

disease/accidents among female

and male workers in the

fish-processing industry

B. Palsson, U. Stromberg, K. Ohlsson and S. Skerfving

Departm ent of Occupa tional and Environm ental Med icine, University

Hospital, Lund Sweden

Sick-leave between 1984 and 1989 was higher among both female (n = 515) and

male n = 304) fish-processing workers [observed/expected (O/E) 2.24 and 1.69,

respectively] than among non-exposed groups (0.62 and 0.89). Diagnoses in the

musculoskeletal system dominated {i.e., neck/upper limbs; females, exposed vs .

non-exposed workers: 30 vs. 12 ; males: 11 vs. 5.8 ). In subjects who left

employment, the O/E-ratio decreased (females: 3.02 vs. 1.55; males: 2.40 vs. 1.55).

Among those women hired before the start of the observation period, exposed

subjects had higher frequencies of sick-leave than non-exposed, for both total illness

and musculoskeletal diagnoses. In the men, there were corresponding differences,

though not fully statistically significant. Reported occupational diseases [O/E:

fem ales: 4.5; (95 confiden ce interval) Cl = 3.2-6.1; males: 2.3; Cl =

1.3-3.9]

and

accidents (females: 4.3; Cl = 3.0-5.9; males: 1.8; Cl =

1.2-2.7)

were also higher in

female than in male fish-processing workers, and much higher than in non-exposed

workers. In conclusion, work in the fish-processing industry was associated with

increased frequencies of sick-leave, especially because of diagnoses of the

musculoskeletal system, and occupational disorders and accidents, in particular

among female workers.

Key words:

Musculoskeletal disease; neck; occupational disease; occupational accident;

repetitive work; social insurance; sickness cash benefit; upper limbs; work environment.

Occup. Med. Vol. 48, 289-295, 1998

Received 14 April 199/'-.accepted in final form 4 Decem ber 1997.

I N T R O D U C T I O N

Work environment conditions are important risk

factors for musculoskeletal diseases and accidents.

1

3

In partic ular, industrial w ork involving repetitive move-

ments is associated with a considerable risk of

musculoskeletal disorders.

4

6

Thus, among workers in

the fish-processing industry, disorders in the muscu-

loskeletal system are prevalent. In particular, females

are affected.

7

10

Although some data indicate that the

risk is similar in women and men, with identical work

tasks,

11

gender-related health risk has seldom been

directly addressed.

Correspondence and reprint requests to: B. Palsson, Department of

Occupational and Environmental Medicine, University Hospital, S-221

85 Lund, Sweden.

Absence attributed to incapacity (in the following

referred to as 'sick-leave') places a heavy economic

burden on society and industry.

1

'

12

Musculoskeletal

disorders are a major cause of sick-leave.

13

In Sweden,

sick-leave is more prevalent among women than in

men.

2

-

14

'

15

It is not known to what extent this is due

to differences in working conditions.

Some countries keep databases on occupational

diseases and accidents. Such statistics provide an

important tool for society to monitor occupational

hazards so as to set priorities for preventive work and

to follow the development over time. However, studies

have only rarely investigated whether such statistics

accurately reflect risk.

The aims of this study were to compare the

frequency of sick-leave among female workers and

male workers in the same industry, and to compare

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B. P lsson

e(

a/.: Occupational disease

in the

fish-processing industry

291

Table 1

Studied populations of exposed workers in the fish-processing industry and non-exposed groups

Study base n

Non-responders n ( )

Studied n

Age*

Mean

Range

Employment time* (mo.)

Mean

Range

Full-time workers

Immigrants

Study

Females

581

113 (19)

468

34

16-65

61

3-516

71

9

Exposed

of sick-leave

Males

352

85 (24)

267

34

17-65

77

3-586

80

11

Study of occupational

disease/accidents

Females

646

131 (20)

515

34

16-65

58

3-516

66

9

Males

390

86 (22)

304

34

17-65

71

3-586

71

10

Non-exposed

Study of sick-leave and

occupational disease/accidents

Females

181

3(2)

178

40

19-63

125

3-408

58

5

Males

120

3(3)

117

44

19-64

156

7-483

93

3

* At end of employment, or end of observation period (1984-89).

Table 2

Total number of days with sickness allowance benefit between 1984-89 among females and males in the fish-processing industry

Cohort

Gender

Employment status

Time

since

hired

(mo)

Exposed (during employment)

Women

Total

Current workers

Leavers

Men

Total

Current workers

Leavers

0-60

>60

Total*

0-60

>60

Total*

0-60

>60

Total*

0-60

>60

Total*

0-60

>60

Total*

0-60

>60

Total*

Exposed (after employment)

Women

Men

Non-exposed (during employment)

Women

Men

0-60

>60

Total*

0-60

>60

Total*

Persons

under

risk

396

164

468

156

87

193

218

58

242

215

106

267

75

59

105

125

39

144

242

144

94

119

178

54

89

117

Observation

time

(person-

years)

607

562

1,169

32 6

368

694

244

131

375

346

398

744

158

283

441

172

88

260

664

353

212

599

811

138

448

586

Obs (days)

22,899

43,344

66,243

11,335

23,955

35,290

10,742

13,679

24,421

9,060

16,946

26,006

2,699

9,710

12,409

5,672

4,424

10,096

24,131

9,535

3,621

9,498

13,119

1,167

10,440

11,607

All diagnoses

Exp (days)

12,646

16,921

29,567

7,148

11,167

18,315

4,411

3,673

8,084

5,916

9,429

15,345

3,112

7,074

10,186

2,465

1,738

4,203

15,599

6,150

4,790

16,508

• 21,298

2,628

10,357

12,985

Sick

Obs/Exp

1.81

2.56

2.24

1.58

2.15

1.93

2.44

3.72

3.02

1.53

1.80

1.69

0.88

1.37

1.22

2.30

2.55

2.40

1.55

1.55

0.76

0.58

0.62

0.44

1.01

0.89

-leave

Musculoskeletal diagnosis

ll

(%)

36

64

54

33

62

52

39

74

58

39

50

46

29

48

44

48

60

53

45

34

28

29

31

36

35

Neck,

upper limb

21

34

30

7.8

12

11

11

12

12

10

5.4

5.8

Low back

pain

7.1

16

13

13

17

16

23

4.6

9.6

3.3

10

9.6

*

Some persons belong to both the 0-60 group and the > 60 group, since during 1984-89 they worked more than five years during

the observation period. Thus, the total number of persons under risk is less than the sum of numbers of persons in each group.

** For different physicians' diagnoses.

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292 Occup. Med. Vol. 48, 1998

ble 3 Occupational diseases (total and musculoskeletal) and accidents (reported to SONS) between 1 984 -89 am ong women and

men exposed in the fish-proces sing industry and in non-exposed groups

Outcome

Cohort

Gender

Employment status

Occupat ional diseases

Exposed

Women

Total

Current workers

Men

Total

Current workers

Non-exposed

Women

Current workers

Men

Current workers

Occupat ional accidents

Exposed

Women

Total

Current workers

Men

Total

Current workers

Non-exposed

Women

Current workers

Men

Current workers

Persons

under risk

51 5

193

30 4

10 5

178

117

51 3

193

30 3

105

178

117

Observation

time

person-

years)

1,873

61 9

1,175

42 3

82 7

57 6

1,829

61 7

1,037

36 9

82 7

513

Ob s

67

40

27

15

13

9

69

37

54

25

8

24

Exp

24.1

8.9

13.8

6.4

11.7

8.4

25.6

8.6

43.4

13.6

10.7

18.2

Total

Obs/Exp

2.8

4.5

2.0

2.3

1.1

1.1

2.7

4. 3

1.2

1.8

0.7

1.3

Cl

a

(2.2-3.5)

(3.2-6.1)

(1.3-2.9)

(1.3-3.9)

(0.6-1.9)

(0.5-2.0)

(2.1-3.4)

(3.0-5.9)

(0.9-1.6)

(1.2-2.7)

(0.3-1.5)

(0.8-2.0)

Ob s

66

40

24

14

9

7

11

6

4

3

6

4

Musculoskeletal

Ex p

19.2

7.1

8.5

3.6

9.6

4.8

7.9

2. 8

7. 2

2. 6

3.2

3.5

Obs/Exp

3.4

5.6

2. 8

3.9

0.9

1.4

1.4

2.1

0.6

1.2

1.9

1.1

Cl

a

(2.7-4.4)

(4.0-7.7)

(1.8-4.2)

(2.1-6.5)

(0.4-1.8)

(0.6-3.0)

(0.7-2.5)

(0.8-4.7)

(0.2-1.4)

(0.2-3.4)

(0.7-4.1)

(0.3-2.9)

Cl = 95 confidence interval.

diseases

and

accidents,

the

ratio

O/E was

also calcu-

lated; more over, a confidence interval

for

the ratio

O/E

was calculated

by

considering

O as a

Poisson variable.

E t h i c a l c o n s i d e r a t i o n s

In connection with

a

personal interview

in

either

1.990

or 1991, we asked

the

men

and

women

in the

exposed

and non-exposed groups

for

permission

to

access

the

information collected

by the

social insurance offices.

Those who

had

left were contacted

by

phone

or

post.

All subjects

in the

study gave written consent.

The

rate

of

non-response was 19%

and

24%

in

the exposed

women

and

me n, respectively. Thi s was mainly du e

to

subjects

who had

left their employment.

The

study

design was approved by the Ethics Committee of Lund

University.

RESULTS

Sick-leave

During employment.

The

exposed w omen

had a

much

higher observed total number

of

days with sickness

cash benefit during employment than expected

(O/E

= 2.24; Table

2).

The exposed men also had considerably

increased figures (ratio

=

1.69). In both women and men,

the ratio between observed and expected increased with

time of employment . In the non-ex posed groups,

the sick-leave

was

lower than expec ted.

The total group

of

exposed women took

54 of

their sick-leave because

of

musculoskeletal diagnoses;

among

the men, the

corresponding figure

was 46

(Table

2).

Th is fraction increased with length

of

employment,

for

women

as

well

for

men. Among

the

exposed females, about half

of the

sick-leave time

attributable

to all

kinds

of

musculoskeletal diagnoses

was

due to

neck/upper limb diagnoses (30%), while

in

the

exposed males, this fraction

was

lower (1 1% ;

Table

2).

Moreover ,

for

both sexes,

the

fraction

increased with time after hiring.

The

fractions

of

musculoskeletal diagnoses were lower

in the non-

exposed groups

(29 and 35 ,

respectively),

and

decreased

in

females with length

of

employment.

Further,

the

sick-days associated with diagnoses

of

neck/upper limb disorders were also higher than

for

the non-exposed,

in

both women

and men, and

increased with time

of

employment, which

was not

the case among the non-exposed (Table 2) . Moreover,

in both sexes

of

exposed workers,

the

sick-leave time

du e

to

low-back pain increased slightly,

and

rose with

time after hiring; among

the

non-exposed women,

it

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B. Palsson ef a/.: Occupationa l disease in the fish-processing industry 293

decreased, while it increased in men.

The currently exposed workers were compared to

the currently non-exposed ones with respect to their

observed numbers of sickdays. Among those who

started their current employment before 1984 there

was a statistically significant difference between the

exposed and non-exposed women

p

< 0.001 for total

numbers of sickdays, as well as for sick-leave days

under musculoskeletal diagnoses), and an almost

significant difference between the male groups

p

=

0.06 for total sickdays,

p

= 0.08 for sickdays unde r

musculoskeletal diagnoses). Among those who started

their employment in 1984 or later, there was a signifi-

cant difference for sickdays under musculoskeletal

diagnoses between exposed and non-exposed women

p = 0.0 4); the othe r differences were not statistically

significant. There was no evidence of confounding by

age or duration of current employment in these

comparisons.

After

employment.

Of the women in the exposed group,

242 left their work during the observation period to

work elsewhere, or in some cases faced unem ploym ent

('leavers')- During exposed work, they had a higher

total sick-leave rate than after leaving the fish-proc-

essing industry (3.02

vs .

1.55; Table 2). A total of 144

males left their jobs in fish-processing. They also had

a higher rate of sick-leave during their employment

in the fish-processing industry than afterwards (2.40

vs.

1.55).

Among the subjects who remained in the

exposed work throughout the observation period

('current workers'), the rates were lower than among

the 'leavers' (women = 1.93; men = 1.22).

Disab i l i ty pens ion ing

There was no elevated incidence of disabi l i ty

pensioning among fish-processing workers as com-

pared with the general po pulation (females: O/E =

1.04, CI = 0.68-1.56; males: O/E = 0.94, CI = 0.50-

1.61).

Occupa t iona l d i seases

During the period between 1984 and 1989, women in

the exposed group had a higher incidence of reports

of occupational diseases than expected (ratio 2.8; Table

3).

Among the exposed men, there was also an

increased incidence (ratio 2.0). Almost all occupational

diseases were ascribed to mu sculoskeletal strain (66/67

in women; 24/27 in men). Accordingly, the ratios for

such complaints were even higher (3.4 in women; 2.8

in males). In neither female nor male non-exposed

persons did the occupational diseases deviate from the

expected.

O c c u p a t i o n a l a c c i d e n t s

Women in the exposed group had a higher incidence

of reports of work-related accidents than expected

(ratio 2.7 ; Table 3). However, among the exposed me n,

the incidence was close to the expected (ratio 1.2).

Many of the occupational accidents were cuts (30/69

in women; 18/54 in men), while relatively few affected

the musculoskeletal system. In the non-exposed group,

the work-related accidents did not deviate from the

expected. Out of the total of 32 accidents, only three

(all in males) were cuts.

DISCUSSION

The present results show that among workers in the

fish-processing industry, occupied mainly with repeti-

tive industrial work, both women and men have far

more sick-leave days than expected; the increase was

higher in exposed women than in men. Further, for

both genders, the sick-leave frequency increased with

time after hiring, and decreased in those who left

employment. In women, the increase of sick-leave

because of musculoskeletal disease appears within just

a few years after employment. In particular, the pro-

port ion of absence because of musculoskeleta l

diagnoses, and especially diagnoses of neck/u pper limb

problems, was high. Moreover, among the fish-pro-

duction workers, there were significant increases of

the incidences of both reported work-related diseases

and accidents (cuts in particular), especially in women.

In another study in the same period, female workers

doing assembly work involving repetitive movements

were studied. As with the present women, there was

a pattern of higher sick-leave in the exposed group

compared with a non-exposed one, as well as a domi-

nance of musculoskeleta l diagnoses , especial ly

diagnoses for neck/upper limbs.

13

Also, similar workers

leaving the exposed work had increased sick-leave

before leaving, and a decrease in their new employ-

ment. Further, the incidence of reported occupational

diseases (occupational accidents not studied) was

much higher than expected in both exposed groups.

16

In the present fish-processing factories, there was

no elevated incidence in regard to disability pension ing.

This is in contrast to an earlier study of female

assembly workers.

13

The reason for this discrepancy

is not clear. One possibility is that there might be a

difference between the populations regarding the

tendency to approach the social welfare system.

Another possibility could be selective incompleteness

of the cohort, or a differential non-response rate.

The findings in regard to sick-leave and occupational

diseases are in accordance with the results of cross-

sectional studies of women in the same fish-processing

factories, which assessed musculoskeletal complaints

via

ques tionnaire, as well as musculoskeletal diagnoses

based on a physical examination i.e., prevalence odds

ratio of a diagnosis in the neck/shoulder and elbows/

han ds, 3.2 and 3.1 , respectively.

7

In males, the corre-

sponding figures were 1.9 and 1.8, respectively

(Nordander

et al,

to be published). Thus, both the

sick-leave and occupational-disease information seems

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294 Occup. Me d. Vol. 48, 1998

to give a fairly accurate picture of the risk.

Sick-leave policy is determined by, among other

things, the social insurance system. There have been

major changes in Sweden since the end of the obser-

vation period. For example, the short-time sick-leave

compensation has been reduced. This has been asso-

ciated with a lowering of the sick-leave rates.

17

Also,

the reporting of occupational diseases and accidents

has decreased, because the compensation system has

been changed. It is not known whether these trends

have also affected high-risk factories of the type

presented in this study.

The present study was made with a cohort method-

ology usually employed in cancer morbidity and in

mortality studies. The method is fully applicable in

the present study setting. One should note that formal

statistical testing of the observed/expected (O/E) ratios

with respect to sickdays is problematic because each

individual generates several sickdays. However, direct

comparisons between the exposed and non-exposed

groups were feasible. For the occupational disease/

accident data, the calculation of confidence interval

for the O/E ratio can be performed by conventional

methods if only the first registration of occupational

disease/accident for each individual is used. The picture

was unaltered if later registrations were included.

The exposed groups were somewhat younger than

the non-exposed. However, the observed numbers of

sickdays in each group were compared with age-

specific regional general population numbers. In the

direct comparisons between exposed and non-exposed

groups, there was no evidence of confounding by age.

The diagnostic information in the SOUS database

on occupational diseases/accidents has limitations.

Thus, in an earlier study, we found that only about

half of the musculoskeletal disorders had been

recorded under this diagnosis.

16

In order to minimize

this bias, we used all report s indicating musculoskeletal

strain as a proxy of musculoskeletal disease.

The sick-leave periods under musculoskeletal diag-

noses were particularly prevalent. The figures were

only slightly lower than those we discovered earlier for

female assembly workers,

13

but higher than for females

in monotonous, repetitive work in general,

3

probably

indicating that the work tasks we studied here were

more extreme. Th e present ratio for observed/expected

occupational diseases for women is similar to that

observed earlier in women in assembly work.

16

The greater sick-leave and suffering from occupa-

tional disorders for employees in fish-processing is

most probably due to the severity of the work envi-

ronment. A series of associated work-environment

factors may influence the tendency to take sick-leave.

Thus, jobs with low decision latitude and high demands

are strongly associated with sick-leave.

18

'

19

The repeti-

tive work of the women in the present study,

7

as well

as in similar work sites,

6

'

7

is associated with bad

psychosocial work-environment conditions.

In addition, there was a large difference in physical

workload between the exposed

7

and the non-exposed

groups. Thus, the deleterious effect of this workload

on the musculoskeletal system is probably the main

explanation for the higher than expected sick-leave

(and occupational disease) frequencies in the exposed

groups. In accordance with this, in another study, home

care service workers with dem anding work had a higher

incidence of musculoskeletal injuries than did nursery

school workers due to physically stressful tasks.

20

T he

association with work-environment factors is strongly

supported by the decrease of risk found after leaving the

factories, which is in accorda nce with earlier findings.

13

In the present study, we assessed exposure in both

women and men. In the general Swedish population,

women have a much higher frequency of sick-leave

than men,

2

'

14

'

15

'

21

while occupational diseases do not

differ, and men have higher accident rates than

women.

22

'

23

In the present exposed groups, women

had much higher rates of sick-leave, occupational

diseases and accidents than men. Interestingly, among

subjects who left for other employment, there was no

gender difference in sick-leave as compared with the

general population. Th e women had very short-cycled,

repetitive work.

13

Further, they had the risks of cuts

and infection in association with the trimming of cod.

Th e m en's work was less repetitive but req uired heavier

lifting and materials handling. Hence, the difference

in frequency of sick-leave is probably due to different

work conditions. Whe ther the re is also a gender differ-

ence in vulnerability is not known. In the non-exposed

group, the women had lower sick-leave frequency as

well as lower occupational accident rates than the men,

while there were no gender differences in occupational

diseases.

The costs of the high sick-leave frequency for the

social welfare system and society are very high.

12

For

this reason, and bec ause of the suffering of individuals,

there is a strong need for primary preventive actions.

In contrast, rehabilitation of the individual worker with

a disorder would probably, for several reasons, have

only a limited chance of success.

CKNOWLEDGEMENTS

Grants were obtained from the Swedish Work Envi-

ronment Fund, the Swedish Council for Planning and

Co-ordination of Research and the Medical Faculty

of Lund University. Valuable assistance was also given

by Ms Monica Hansi, Ms Lothy Granquist, Mr Borje

Bengtsson, MSc, Ms Robyn G. Attewell, MSc and the

staffs of the local and regional social insurance offices,

the National Social Insurance Board and the Swedish

National Archives.

R E F E R E N C E S

1. Lidbom T, Nelander S. Fortidspensionering och arbetsmiljo

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1994; 4.

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B. Palsson ef

al.:

Occupational disease in the fish-processing industry 295

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B ,

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Palsson-1998-Absence Attributed to Incapacity

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