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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
b y g u e s t onM a r c h 1 6 ,2 0 1 6
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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
[Disability pensioning and work environment]. LO gmnskar
1994; 4.
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B. Palsson ef
al.:
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