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| Year : 2009
| Volume
: 11 | Issue : 43 | Page
: 93-97 |
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| Self-reported noise exposure as a risk factor for long-term sickness absence |
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Thomas Clausen1, Karl Bang Christensen2, Thomas Lund3, Jesper Kristiansen1
1 National Research Centre for the Working Environment, Denmark
2 Department of Biostatistics, University of Copenhagen, Denmark
3 The Danish National Centre for Social Research, Copenhagen, Denmark
Click here for correspondence address
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Self-reported noise exposure is on the rise in Denmark. Little is known, however, about the social consequences, including sickness absence, of noise exposure. The aim of this paper was to investigate the association between self-reported noise exposure and long-term sickness absence. The association was investigated using the Cox proportional hazards model to analyze outcomes in Danish register data on the basis of Danish survey data (5357 employees aged 18-69 in 2000). The analyses showed that self-reported noise exposure was significantly associated with long-term sickness absence for both men and women when adjusting for demographic factors and health behavior. After further adjustment for physical workload at work the association between noise exposure and sickness absence disappeared for women, but not for men. Men that reported to be exposed to loud noise between one-quarter and three-quarters of their time at work had an increased risk of 43% (CI: 10-85%) for sickness absence of two weeks or longer compared to men that reported never to be exposed to loud noise. Men that reported to be little/rarely exposed to loud noise had an increased risk of 37% (CI: 7-76%). Men that reported to be exposed to loud noise more than three-quarters of their time at work did not have an increased risk of sickness absence. This latter result might be due a healthy worker effect and/or more frequent use of hearing protection in this group. Along with evidence from previous studies these results provide further support for an association between occupational noise exposure and sickness absence. Keywords: Danish Work Environment Cohort Study, DREAM register, epidemiology, occupational exposures, register data, work environment
How to cite this article:
Clausen T, Christensen KB, Lund T, Kristiansen J. Self-reported noise exposure as a risk factor for long-term sickness absence. Noise Health 2009;11:93-7 |
| Introduction | |  |
With the much heralded demise of industrial society and the consequent rise of a postindustrial mode of production, [1] one should expect a significant drop in noise exposure among employees in the contemporary labor market. On this background, however, it paradoxically appears that the number of employees reporting noise exposure is on the rise in Denmark. Over the period between 1990 and 2000 the Danish Work Environment Cohort Study (DWECS) recorded a relative upward change in self-reported noise exposure of more than 20%. [2] Furthermore, this increase in self-reported noise exposure was not only recorded among industrial workers but also among teachers and sales assistants.
The adverse nonauditory health effects of exposure to industrial noise have been the subject of numerous studies, with cardiovascular disorders having received particular attention. [3],[4],[5],[6],[7],[8] Little is known, however, about the social consequences of occupational noise exposure, such as sickness absence. Given the upward trend in self-reported noise exposure it appears to be highly relevant to investigate these effects of noise exposures in order to assess the need for interventions aimed at reducing adverse noise levels in the work environment.
The purpose of the present article was to investigate the relation between self-reported noise exposure and long-term sickness absence in the Danish working population aged between 18 and 69 years of age. Sickness absence can be construed as a proxy for individual health, but can also be considered as a strategy for coping with adverse working conditions. [9] It seems likely, though, that long-term sickness absence to a larger extent than short-term sickness absence reflects a more severe degree of ill physical or mental health of the individual.
In a study of noise effects in 2368 blue-collar workers, Melamed and co-workers [10] observed significant associations between noise levels and sickness absence in both men and women. Interestingly, they observed a significant effect on sickness absence even at moderate sound levels, that is, below <85 dBA. In a study of the association of noise and sickness absence among 802 white-collar employees exposed to relatively low noise levels (average 63 dBA), Fried and his colleagues [11] found a joint moderating effect of job complexity and gender on the relation between noise and sickness absence. These studies point to an association between occupational noise exposure and increased sickness absence. However, as both of these studies primarily consider short-term sickness absence it is unclear whether they are measuring the relations between noise and ill physical or mental health or whether they are measuring acute coping behavior associated to the stresses and strains of working in a noisy environment. Given the fact that the present study considers long-term sickness absence it is likely to provide a more accurate proxy for more severe ill physical or mental health than appears to be the case for Melamed et al [10] and Fried et al . [11]
A number of studies show that noise exposure appears to have an impact on the well-being of the individual, which again can be construed as a precursor for long-term sickness absence, i.e ., ill physical or mental health. For example, in a study of employees at preschool institutions, Soderberg et al , [12] found an association between noise exposure and fatigue among members of the staffs. A series of laboratory studies seem to confirm the findings of Sφderberg et al , [12] as noise exposure is found to be associated with fatigue, [13] decreasing levels of motivation, [14] and annoyance. [15] Finally, evidence suggests that noise exposure is associated with physiological stress reactions [14],[15] and self-reported stress. [16]
On this background, the present study examines the hypothesis that 'self-reported noise exposure is associated with long-term sickness absence' over an 18-month follow-up period.
| Materials and Methods | | |
Population
This study was part of the project DWECS/DREAM, which is based on a merger between the Danish Work Environment Cohort Study (DWECS) and a national register, DREAM, on social transfer payments. [17],[18] DWECS featured a random sample of 11,437 people living in Denmark, of which 8583 (75%) participated in interviews. Of these, 5357 were aged 18-69 and had worked as employees for at least two months prior to the baseline interview. This interview was conducted in 2000, and assessed exposure to noise and other work environment exposures, age, gender, education, family status, chronic disease, and health behavior. The cohort was followed up in the DREAM register from January 1 st 2001 to June 30 th 2002. DREAM contains weekly information on granted sickness absence compensation for all citizens in Denmark. Sickness absence compensation is given to the employee, who can apply for a refund from the State after two weeks of sickness absence. However, the DREAM register contains no information on the health reasons on which sickness absence compensation is granted.
A total of 5186 persons (96.8%) without missing values on baseline risk factor variables were included in the study: 2529 (48.8%) women and 2657 men (51.2%). They were followed in DREAM for 78 weeks. People who died, emigrated, or retired were censored at the time of death, immigration, or retirement, but were considered to be at risk until that time. Information about death, immigration, and retirement was obtained from the DREAM register. Furthermore, as we analyzed risk factors for the onset of long-term sickness absence, people were censored at first sickness absence spell.
Sickness absence
The outcome variable, sickness absence, was defined as two or more consecutive weeks of sickness absence in the follow-up period from January 1 st 2001 to June 30 th 2002.
Noise
Noise was assessed with the question "Are you exposed to noise so loud, that you have to raise your voice in order to talk with other people?" (response options: "almost all the time," "three-quarters of the time," "one-half of the time," one-quarter of the time," "rarely/very little," or "never"). The population was divided into four groups: "three-quarters to almost all the time," "one-quarter to one-half of the time," "rarely/very little," and "never."
Demographics, occupation, physical workload, and health behavior
Employees provided information on age, gender, education (no high school degree and less than 3 years of vocational education; high school or 3-4 years of vocational education; university degree or >4 years of vocational education), cohabitation (living alone/living with a partner), and children living at home (none, one child, two children, three or more children).
The body mass index (BMI) was calculated from self-reported information on weight and height (BMI = kg/m 2 ) and then categorized according to the standard classification of the National Institutes of Health (BMI < 18.5, underweight; BMI = 18.5-24.9, normal; BMI = 25-29.9, overweight; BMI ≥ 30, obesity). Alcohol consumption was measured with a question regarding the number of units of alcohol per week and then categorized into: (1) no consumption of alcohol, (2) moderate consumption (>14 and 21 units of alcohol per week for women and men, respectively), and (3) heavy consumption (>14/21 units of alcohol per week) in line with the guidelines of the Danish National Board of Health. Smoking status was assessed with a single item. The response options were current smoker, ex-smoker, and nonsmoker. Leisure time physical activity was measured with a single item. The response options were: 0-2 hour per week, 2-4 hour per week, >4 hour per week or strenuous, >4 hour per week and strenuous.
The occupational physical workload was measured with five indices covering lifting, pushing, and pulling, and working with awkward body, arm, or hand positions. [19]
Analyses
In order to examine the relationship between self-reported noise at baseline and the onset of sickness absence during follow up, the data were analyzed using the Cox proportional hazards model. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. Analyses were stratified by gender, and adjusted for age, education, cohabitation, children living at home, BMI, alcohol consumption, and smoking status. This analysis constituted Model 1. Furthermore, as self-reported noise exposure was significantly correlated with self-reported physical workload, and physical workload in a previous study has been demonstrated to be associated with sickness absence, [19] we controlled for this possible confounder by including self-reported physical workload as a covariate. This analysis was Model 2. Data were analyzed using SAS 9.
| Results | | |
The 2529 women and 2657 men in the study were followed between January 1 st 2001 and June 30 th 2002, yielding totals of 3310.96 and 3460.24 years of risk time for women and men, respectively. Of the 5186 persons who entered the study, 900 (17.4%) were absent for more than two weeks in the period between January 1 st 2001 and June 30 th 2002. Of these, 440 (48.9%) were women and 460 (51.1%) were men.
[Table 1] shows HRs and 95% CIs for onset of long-term sickness absence. The HRs are adjusted for age, education, cohabitation, children living at home, BMI, alcohol consumption, and smoking status (Model 1), and additionally adjusted for self-reported physical work environment (Model 2).
Women exposed to noise for more than three-quarters of their working time had a 38% (95% CI: 4-82%) increased risk of long-term sickness absence when adjusting for demographics and health behavior (Model 1). However, this association disappeared when further adjusting with self-reported physical workload (Model 2). In men, those exposed to noise for more than three-quarters of the working time had a 53% (95% CI: 11-110%) increased risk of long-term sickness absence, when compared to the group which reported no noise exposure at its workplace. Increased risk was also seen for men who responded that they were rarely exposed to noise at work (61%, 95% CI: 26-105%) or were exposed to noise between one-quarter and three-quarters of their time at work (107%, 95% CI: 62-163%). As was the case for the results for women, further adjusting for physical workload reduced the risk estimates, but in contrast to women a significant association between noise exposure and sickness absence remained in the group that was rarely exposed (increased risk: 37%, CI: 7-76%) and the group exposed to noise between one-quarter and three-quarters of its time at work (increased risk: 43%, CI: 10-85%).
Finally, the results displayed a remarkable consistency as additional analyses using sickness absence periods of 4-8 weeks, respectively, did not significantly affect the findings (results not shown).
| Discussion | | |
The analysis of the fully adjusted model showed that 'self-reported noise exposure was associated with long-term sickness absence' over an 18-month follow-up period in men but not in women. The results, however, raise a couple of questions that will be addressed in the following.
Firstly, in [Table 1] we were surprised to find that for men only intermediate levels of self-reported noise exposure yielded significant relations with the HRs for long-term sickness absence in the fully adjusted model, whereas no significant relations were found in the case of the most intense level of self-reported noise exposure. One explanation on this somewhat counterintuitive finding may be a healthy worker effect, in the sense that the most vulnerable employees have left jobs characterized by intense noise exposures, thereby reducing the actually observed effects of noise exposure on the risk of long-term sickness absence. A second explanation may be that the use of hearing protection had confounded the association at the highest self-reported noise exposures, but not at lower levels. We have no information about the use of hearing protection, but the use of such devices are more likely at the most intense noise levels.
Another finding worth mentioning pertains to the tangibly different results for male and female employees. One explanation may be the different jobs held by men and women. In general, women are more frequently employed in sectors where noise levels are relatively low, such as social security and healthcare, education and research, and office and administration. Self-reported noise exposure is probably dependent on both objective noise levels and on the work tasks of the respondents. For example, teachers might report of high levels of noise exposure because noise interferes with their teaching although the objective noise levels could be low. This would mean that the reporting of noise exposure means different things in different jobs. For example, in manual jobs (presumably male dominated) with high noise levels self-reported noise exposure primarily reflects the noise levels, while in jobs with low content of manual work (presumably female dominated) self-reported noise exposure reflects the interference with the work tasks. This interpretation is supported by the findings made by Fried et al , [11] who observed that, in white-collar workers, sickness absence was associated with noise levels only in women, and only for those holding complex jobs.
A third observation that deserves attention is the confounding effect of self-reported physical workload. Significant associations between noise exposure and sickness absence were observed for both men and women, but these associations were markedly weakened when adjusting for physical workload. One possible interpretation of this confounding effect is that the workers that are most exposed to noise are also working in jobs with high physical workload. This of course emphasizes the importance of considering potential confounders when studying nonspecific effects, such as sickness absence.
The findings of the present study point in the same direction as the findings of Melamed et al , [10] who also identified a significant main effect of noise on sickness absence. However, these authors observed an effect for both men and women. There are several possible explanations why our results differ in that respect: Firstly, the study of Melamed et al , [10] focused on blue-collar workers while our study population contained both blue- and white-collar workers. Assuming an association exists between noise levels and sickness absence in blue-collar workers, [5],[6],[10] this effect may have been 'diluted' in our study because of the presence of white-collar workers (who report about noise exposure because it interferes with their work tasks). This 'dilution' would be more significant for women because they, as noted above, are more frequently employed in white-collar jobs than men. A second possible explanation pertains to differences in controlling confounders. We adjusted for various factors associated with lifestyle and health as well as physical workload. The results by Melamed et al . were not adjusted for these potential confounders. Thirdly, the outcome measure in the study by Melamed et al . included both short-term and long-term sickness absence, while our analysis was based on sickness absence for at least two weeks. As noted in the introduction, short-term and long-term sickness absences have different etiologies, and short-term sickness absence could reflect coping behavior to a higher degree than long-term sickness absence.
The results of the analyses have, thus, established an association between self-reported noise exposure and long-term sickness absence. As noted in the methods section, however, the DREAM register contains no diagnoses or information on the health reasons that sickness absence compensation is granted. This study, thus, is not able to identify the underlying diagnoses that are associated with self-reported exposure to noise. Another limitation of this study stems from the self-reported nature of our exposure variables. This problem can be manifest in cases where the intensity of the noise exposure reported by respondents may be influenced by individual awareness of symptoms of ill health - an awareness that furthermore can be viewed as a potential determinant of sickness absence.
A final important issue pertains to the possibilities of residual confounding in our study. In the analyses that we have carried out, we have adjusted for demographics, health behavior, and self-reported physical workload at work. It might, however, be argued that the disclosed associations between self-reported noise exposure and long-term sickness absence are in fact confounded by factors, such as personality traits, for example, anxiety [20] and psychosocial work environment.
In our data, though, we have no information on various personality traits that may confound the association between self-reported noise exposure and long-term sickness absence and, accordingly, we are not able to check for confounding in this regard. However, if personality traits were indeed found to have a confounding effect, this would appear to be a finding of little practical relevance, as interventions within the field of noise exposure would seem a more feasible way to reduce long-term sickness absence as compared to interventions aimed at changing personality traits of employees.
Another group of potential confounders are psychosocial work environment exposures that have also been found to be associated with long-term sickness absence. [18] However, as our measures of psychosocial work environment and our measure of noise exposure are situational appraisals of a self-reported nature, we believe that adjusting one for the other is tantamount to over-adjustment. This is so as our self-reported measures for noise exposure and psychosocial work environment are closely intertwined and, in effect, a situation where perceived noise exposure entails a negative assessment of the psychosocial work environment which again may increase individual sensitivity to noise exposure at the work place is not an unlikely scenario. In sum, we cannot foreclose the possibilities for residual confounding in our analyses, as given the nature of our data we were not able to meaningfully adjust for personality traits and psychosocial work environment exposures.
In conclusion, this study demonstrated an association between self-reported noise exposure and long-term sickness absence for men but not for women, after adjustment for individual demographic and occupational characteristics, and characteristics related to individual health behavior. Given the fact that the analysis is prospective and that the outcome stems from another data source, the study provides some evidence in support of a causal relationship, but confounding stemming from personality traits and psychosocial work environment factors cannot be completely ruled out. Together with findings in previous studies, the results support the hypothesis of an association between noise exposure and sickness absence.
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Correspondence Address:
Jesper Kristiansen
National Research Centre for the Working Environment, Lersø Parkallé 105, DK-2100 Copenhagen Ø
Denmark
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1463-1741.50693
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