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Background: multisite musculoskeletal pain is common and disabling. This study aimed to prospectively investigate the distribution of musculoskeletal pain anatomically, and explore risk factors for increases/reductions in the number of painful sites.Methods: using data from participants working in 45 occupational groups in 18 countries, we explored changes in reporting pain at 10 anatomical sites on two occasions 14 months apart. We used descriptive statistics to explore consistency over time in the number of painful sites, and their anatomical distribution. Baseline risk factors for increases/reductions by ≥3 painful sites were explored by random intercept logistic regression that adjusted for baseline number of painful sites.Results: among 8927 workers, only 20% reported no pain at either time point, and 16% reported ≥3 painful sites both times. After 14 months, the anatomical distribution of pain often changed but there was only an average increase of 0.17 painful sites. Some 14% workers reported a change in painful sites by ≥3. Risk factors for an increase of ≥3 painful sites included female sex, lower educational attainment, having a physically demanding job and adverse beliefs about the work-relatedness of musculoskeletal pain. Also predictives were as follows: older age, somatizing tendency and poorer mental health (each of which was also associated with lower odds of reductions of ≥3 painful sites).Conclusions: longitudinally, the number of reported painful sites was relatively stable but the anatomical distribution varied considerably. These findings suggest an important role for central pain sensitization mechanisms, rather than localized risk factors, among working adults.Significance: our findings indicate that within individuals, the number of painful sites is fairly constant over time, but the anatomical distribution varies, supporting the theory that among people at work, musculoskeletal pain is driven more by factors that predispose to experiencing or reporting pain rather than by localized stressors specific to only one or two anatomical sites.

Objective: A consensual definition of occupational burnout is currently lacking. We aimed to harmonize the definition of occupational burnout as a health outcome in medical research and reach a consensus on this definition within the Network on the Coordination and Harmonisation of European Occupational Cohorts (OMEGA-NET). Methods: First, we performed a systematic review in MEDLINE, PsycINFO and Embase (January 1990 to August 2018) and a semantic analysis of the available definitions. We used the definitions of burnout and burnout-related concepts from the Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) to formulate a consistent harmonized definition of the concept. Second, we sought to obtain the Delphi consensus on the proposed definition. Results: We identified 88 unique definitions of burnout and assigned each of them to 1 of the 11 original definitions. The semantic analysis yielded a first proposal, further reformulated according to SNOMED-CT and the panelists` comments as follows: "In a worker, occupational burnout or occupational physical AND emotional exhaustion state is an exhaustion due to prolonged exposure to work-related problems". A panel of 50 experts (researchers and healthcare professionals with an interest for occupational burnout) reached consensus on this proposal at the second round of the Delphi, with 82% of experts agreeing on it. Conclusion: This study resulted in a harmonized definition of occupational burnout approved by experts from 29 countries within OMEGA-NET. Future research should address the reproducibility of the Delphi consensus in a larger panel of experts, representing more countries, and examine the practicability of the definition. This study was supported by the University of Lausanne and European Cooperation in Science and Technology, Action CA 16216 "Network on the Coordination and Harmonisation of European Occupational Cohorts” (OMEGA-NET). info:eu-repo/semantics/publishedVersion

Musculoskeletal disorders are the most common occupational diseases in Estonia and in the European Union as a whole. Sewing machine operators’ work is very monotonous, in continuous sitting position, with repetitive one-side movements of the upper limbs and legs. Working in an awkward posture and doing the same movements for a long period of time increases the risk of musculoskeletal system disorders, and in longer perspective, could cause work disability. The aim of the study was to analyse the prevalence of musculoskeletal disorders, intensity and duration of pain in a different body regions and to assess the changes of the functional status of the musculoskeletal system before and after the intervention among workers with partial work ability. The target group was 57 sewing machine operators, who were presented with an anonymous online questionnaire and agreed to participate in the intervention program. The study group was 12 sewing machine operators with partial work ability. RULA (Rapid Upper Limb Assessment) method was used for evaluating ergonomic workstations. The pain assessment was studied by NPRS, Numeric Pain Rating Scale. Online questionnaires were based on BQ (Baecke Physical Activity Questionnaire) and NMQ (The Nordic Musculoskeletal Questionnaire). The results showed that musculoskeletal status among workers with partial work ability improved after the intervention. Associations between individual and job related factors and musculoskeletal pain were observed. The research allows to make actual proposals for workplace layout of sewing machine operators, to provide ergonomic deployment and offer suitable exercise movements for rest breaks.

Introduction The Defence Forces’ members are exposed to high-level noise that increases their risk of hearing loss (HL). Besides military noise, the other risk factors include age and gender, ototoxic chemicals, vibration, and chronic stress. The current study was designed to study the effects of personal, work conditions-related risk factors, and other health-related traits on the presence of hearing problems. Materials and Methods A cross-sectional study among active military service members was carried out. Altogether, 807 respondents completed a questionnaire about their health and personal and work-related risk factors in indoor and outdoor environments. The statistical analysis was performed using statistical package of social sciences (descriptive statistics) and R (correlation and regression analysis) software. Results Almost half of the active service members reported HL during their service period. The most important risk factors predicting HL in the military appeared to be age, gender, and service duration. Also, working in a noisy environment with exposure to technological, vehicle, and impulse noise shows a statistically significant effect on hearing health. Moreover, we could identify the effect of stress on tinnitus and HL during the service period. Most importantly, active service members not using hearing protectors, tend to have more tinnitus than those who use it. Conclusions The members of the Defence Forces experience noise from various sources, most of it resulting from outdoor activities. Personal and work conditions-related risk factors as well as stress increase the risk of hearing problems.

Context: Hearing loss (HL) is a major health concern among military personnel due to noise from shooting, blasts, military vehicles, and noisy training environments. Nevertheless, one’s exposure can be partially reduced by using personal protective equipment (PPE). The aim of this study is to estimate the prevalence of HL among military personnel, to analyse associations between HL and self-reported occupational and leisure noise exposure, and use of PPEs. Materials and Methods: A cross-sectional study was conducted among 150 military personnel during their routine medical examinations. First, all participants filled in a questionnaire about their exposure to noise and later the respondents went through an audiometric test. The diagnostic criteria for slight, moderate, and severe HL was HL of 25–40, 41–60, and >60 dB at 4 and 6 kHz, respectively. The associations between noise exposure and HL were studied with multinomial logistic regression analysis. Results: The prevalence of slight to severe HL in high frequencies (4 and 6 kHz) among study participants was 62.7%. Nevertheless, the majority of it was slight, as the prevalence of severe HL was 9.3%. The prevalence of any kind of HL was highest in the Navy and the prevalence of severe HL was highest in the Central Command Units. The relative risk ratios (RRRs) for HL were higher among those who had been working for a long time in a noisy environment, working with noise-producing equipment, driving in a PASI or a Bandvagn or had been shooting with blanks at least once per week. It also appeared that military personnel who had HL, reported tinnitus more often. Respondents’ previous health problems, music-listening habits, and amount of exposure to loud noise in non-military environments were not independently associated with HL, but in several cases it increased the RRRs together with military exposure. We also found significantly more frequent HL among those never using PPEs. Conclusion: HL loss was more prevalent among personnel who are more often exposed to military noise, especially among those who never use PPEs. The effect was enhanced by leisure time noise, but it was not independently associated to HL.

IntroductionNoise-induced hearing loss is one of the most common health problems among military service personnel. Exposure to noise in military vehicles constitutes a large proportion of total noise exposure. This pilot study aimed to evaluate in-vehicle noise levels depending on the type of vehicle, riding compartment and road surface.MethodNoise levels were measured in armoured personnel carriers and heavy all-terrain trucks, in the cab and rear passenger compartment, while driving on paved or off-road surfaces. The results were compared with national LLV and allowed noise exposure times were calculated per vehicle and surface.ResultsThe equivalent noise levels in the cab of SISU XA-188 (p=0.001) and peak noise levels in MAN 4620 (p=0.0001) and DAF 4440 (p=0.0047) were higher on paved road, compared with off-road. The equivalent noise levels in the canvas covered rear compartment of MAN 4620 were significantly higher than in the cab on both paved (p=0.004) and off-road (p=0.0003). Peak noise levels in the cab of DAF 4440 exceeded the parameters measured in the canvas covered rear compartment on both paved (p=0.002) and off-road (p=0.0002). In most cases, peak noise levels were below the LLV (p=0.02–0.0001). The maximum noise exposure to passengers in the canvas covered rear compartment of MAN 4620 despite road surface was calculated 0.6 hours per working day.ConclusionA high risk of noise-induced hearing loss among military personnel occurs during long distance transportation with vehicles showing noise levels higher than allowed LLV.

ObjectivesTo explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain.MethodsAs part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs.Results861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4).ConclusionsSickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention.

The aims of this study were to describe job-specific factors and prevalence of musculoskeletal pains (MSPs) by the occupation and body regions in the past 12 months and past month, to analyse multisite and disabling pain and sick leave among office workers (OW), nurses and caregivers (CG); and to find relationships between the observed indicators. The study groups were selected by random sample method. Questionnaire responses on demographic parameters, job-specific factors, and MSPs by body parts in the past 12 months (MSP-12) and past month (MSP-1) were analysed. A questionnaire was sent to 1291 participants. The response rate was 54%. Most of the participants were women, with mean age 41.2 (±11.5) years, working on average 42.8 (±6.7) hours per week and had service length more than five years. Repetitive movements of wrist/hands and working under time pressure were more often reported risk factors by the nurses. Lifting weights 25 kg and more, climbing up and down, kneeling more than one hour a day and piecework finished in the work shift were the most often reported job-related risk factors for the CGs. Use of a keyboard was the same frequent work-related risk factor for the OWs. The most prevalent MSP-12 was low back pain for CGs (66.3%) and nurses (56.1%) and neck pain for OWs (51.5%). The most often reported MSP-1 was shoulder pain for nurses and OWs (84.4% and 65.7%, correspondingly), and elbow pain for CGs (74.9%). In the the entire sampled group, low back pain (53.9%) in the past 12 months and shoulder pain (70.9%) in the past month were the most often reported pain regions. A higher prevalence of multiple and disabling MSP and sickness absence were reported by CGs, compared to other occupation groups (p < 0.05). Correlation analysis showed positive relationships between job-related risk factors, like repetitive movements, physical load, and time demands, and MSPs and sick leave, especially among CGs (p < 0.05). Job-specific factors need more attention to prevent multiple and disabling pain and sick leave among office and hospital workers.

Introduction Agriculture is one of the most hazardous industries in Europe, measured by work-related injuries, diseases, disabilities and deaths. Statistics and studies show great differences in national injury and occupational disease rates, as well as approaches and support for prevention of these adverse outcomes. This EU-COST action explores reasons why agriculture lags behind other sectors, and why some countries have been more successful than others in reducing agricultural injuries and diseases. Methods Evaluation of health and safety programmes and approaches on the national level identification of knowledge, attitudes, behaviors and priorities among farmers regarding safety, health and risk management identification of effective measures for training and integrating vulnerable populations (including refugees) into the agricultural workforce development of indicators for monitoring progress and evaluating the impact of interventions on occupational injuries and diseases in agriculture. Results Benchmarked and evidence-based recommendations will be developed to inform and guide national initiatives and efforts. Results will be disseminated to stakeholders and the agricultural community. Discussion This action is in progress; previous Cooperation in Science and Technology (COST) Actions, like Monitoring Occupational Diseases and tracing New and Emerging Risks in a Network (MODERNET) show that such multidisciplinary, international focused exchange programmes are effective to trigger awareness raising and preventive actions.

Aim: Rapid changes in the Estonian health care system have placed extra pressure on the nursing profession, but the potential impacts of psychosocial changes have not been investigated. We aimed to explore the work-related psychosocial risk factors and their relationships with mental health problems (MHPs) amongst nurses at the university hospital in Estonia. Methods: A cross-sectional survey was undertaken amongst registered nurses at Tartu University Hospital (TUH). Psychosocial work factors and MHPs (stress, somatic symptoms, depressive symptoms and burnout) were measured using version two of the Copenhagen Psychosocial Questionnaire (COPSOQ II). Descriptive statistics and Pearson’s r correlation with sequential Bonferroni correction were used to analyse the data. Results: The analysis was based on 404 nurses (45% of the full-time working population of nurses). The highest mean scores recorded for the positive work-related psychosocial factors studied were meaning of work, role clarity, social relationships and mutual trust between employees. The highest scores for the negative factors studied were the demands for hiding emotions, work pace, cognitive and emotional demands. Stress and burnout showed the highest mean scores amongst the MHPs. Quantitative and emotional demands were positively related to all of the studied MHPs, while work pace and role conflicts had a positive correlation with stress and burnout. All of the studied negative psychosocial factors were significantly correlated with burnout. Conclusions: Work-related psychosocial risk factors such as quantitative demands (work load), emotional demands, work pace and role conflicts, had significant positive relationships with MHPs in nurses in Estonia, and may contribute to high levels of stress as well as burnout amongst nurses.

Medical students can learn new knowledge and train technical skills by using simulations. Because the most of simulators are expensive the use of them is limited. The aim of this study is to design new low cost simulator for young veterinarians and surgeons. The simulator corpus has been designed based on the Solid Edge software and printed out with the 3D printer. For monitoring of the results we designed and programmed four exercises using the Arduino software. The monitoring of results is important for students to control the results. Needle suture, camera navigation, hand-hand coordination and tissue cutting are the main exercises for training of student skills. The purpose of simulation training also to increase the pace of skilled movements during simulation sessions, although the duration of every exercise is different. It is important to pay attention to ergonomics too in the designing process. The new simulator has mobile stand for different exercises to train technical skills in different ergonomic postures.

IntroductionWork accidents (WA) in agriculture are a problem all over the world. There are over 1,3 billion agricultural workers, that counts more than 50% of all the worlds’ workforce. Even if the most of work tasks become more automated, farmers, family members and farm workers are facing risks at work that are higher than in most other occupations. Many accidents involve the handling of machinery or animals. The costs of WAs are increasing, exhausting national economy as a whole. The aim of this study is to analyse the main causes and consequences of WAs in Estonian agriculture.MethodThe database of accidents in agriculture (2008–2017) has obtained from the Estonian Labour Inspectorate. WAs statistics is based on official reports of employers. Causes and consequences including injury severity, type and body region are described in the present study.ResultsThe main cause of WAs in agriculture is disregarding of safety requirements (28,9%), whereas more than half of cases remain unclear. Loss of control over animals or machinery (33,4%), falling and slipping (21,5%) and an attack or an assault by cattle (15,8%) are the main activity-based reasons of WAs. During the last decade the most were minor injuries (72,8%). By the type of injury most often wounds and superficial injuries (40,4%), bone fractures (25,6%) and concussion or internal injuries (16,2%) have been registered. Upper and lower limbs (35,7% and 33,6%) were the most often injured body regions.ConclusionsAgriculture is a sector with high accident risks, where injury rate shows steady tendency to increase. It is important to pay more attention on improvement of safety culture and prevention of work accidents in agriculture.

Several laparoscopic simulations have constructed for students to practice skills and precise techniques. Simulations are effective technical tools for teaching professional skills. The aim of the work was to construct a laparoscopic simulation prototype, measure the improvement of manual skills among veterinary medicine students and discomfort in different body parts and assess the need for laparoscopic simulation in education. Simulation had two tasks: coordination and focus- and precision exercise. The number of errors and duration of task time have measured and the results showed that the number of errors and time taken to complete the tasks decreased. In the coordination exercise the total scores improved significantly in the third (p

Summary In a large cross-sectional survey, pain affecting 6–10 anatomical sites showed substantially different associations with risk factors from pain limited to 1–3 sites., To explore definitions for multisite pain, and compare associations with risk factors for different patterns of musculoskeletal pain, we analysed cross-sectional data from the Cultural and Psychosocial Influences on Disability (CUPID) study. The study sample comprised 12,410 adults aged 20–59 years from 47 occupational groups in 18 countries. A standardised questionnaire was used to collect information about pain in the past month at each of 10 anatomical sites, and about potential risk factors. Associations with pain outcomes were assessed by Poisson regression, and characterised by prevalence rate ratios (PRRs). Extensive pain, affecting 6–10 anatomical sites, was reported much more frequently than would be expected if the occurrence of pain at each site were independent (674 participants vs 41.9 expected). In comparison with pain involving only 1–3 sites, it showed much stronger associations (relative to no pain) with risk factors such as female sex (PRR 1.6 vs 1.1), older age (PRR 2.6 vs 1.1), somatising tendency (PRR 4.6 vs 1.3), and exposure to multiple physically stressing occupational activities (PRR 5.0 vs 1.4). After adjustment for number of sites with pain, these risk factors showed no additional association with a distribution of pain that was widespread according to the frequently used American College of Rheumatology criteria. Our analysis supports the classification of pain at multiple anatomical sites simply by the number of sites affected, and suggests that extensive pain differs importantly in its associations with risk factors from pain that is limited to only a small number of anatomical sites.

Summary Large international variation in the prevalence of disabling forearm and low back pain was only partially explained by established personal and socioeconomic risk factors., To compare the prevalence of disabling low back pain (DLBP) and disabling wrist/hand pain (DWHP) among groups of workers carrying out similar physical activities in different cultural environments, and to explore explanations for observed differences, we conducted a cross-sectional survey in 18 countries. Standardised questionnaires were used to ascertain pain that interfered with everyday activities and exposure to possible risk factors in 12,426 participants from 47 occupational groups (mostly nurses and office workers). Associations with risk factors were assessed by Poisson regression. The 1-month prevalence of DLBP in nurses varied from 9.6% to 42.6%, and that of DWHP in office workers from 2.2% to 31.6%. Rates of disabling pain at the 2 anatomical sites covaried (r = 0.76), but DLBP tended to be relatively more common in nurses and DWHP in office workers. Established risk factors such as occupational physical activities, psychosocial aspects of work, and tendency to somatise were confirmed, and associations were found also with adverse health beliefs and group awareness of people outside work with musculoskeletal pain. However, after allowance for these risk factors, an up-to 8-fold difference in prevalence remained. Systems of compensation for work-related illness and financial support for health-related incapacity for work appeared to have little influence on the occurrence of symptoms. Our findings indicate large international variation in the prevalence of disabling forearm and back pain among occupational groups carrying out similar tasks, which is only partially explained by the personal and socioeconomic risk factors that were analysed.

Study Design. A cross-sectional survey with a longitudinal follow-up.Objectives. The aim of this study was to test the hypothesis that pain, which is localized to the low back, differs epidemiologically from that which occurs simultaneously or close in time to pain at other anatomical sitesSummary of Background Data. Low back pain (LBP) often occurs in combination with other regional pain, with which it shares similar psychological and psychosocial risk factors. However, few previous epidemiological studies of LBP have distinguished pain that is confined to the low back from that which occurs as part of a wider distribution of pain.Methods. We analyzed data from CUPID, a cohort study that used baseline and follow-up questionnaires to collect information about musculoskeletal pain, associated disability, and potential risk factors, in 47 occupational groups (office workers, nurses, and others) from 18 countries.Results. Among 12,197 subjects at baseline, 609 (4.9%) reported localized LBP in the past month, and 3820 (31.3%) nonlocalized LBP. Nonlocalized LBP was more frequently associated with sciatica in the past month (48.1% vs. 30.0% of cases), occurred on more days in the past month and past year, was more often disabling for everyday activities (64.1% vs. 47.3% of cases), and had more frequently led to medical consultation and sickness absence from work. It was also more often persistent when participants were followed up after a mean of 14 months (65.6% vs. 54.1% of cases). In adjusted Poisson regression analyses, nonlocalized LBP was differentially associated with risk factors, particularly female sex, older age, and somatizing tendency. There were also marked differences in the relative prevalence of localized and nonlocalized LBP by occupational group.Conclusion. Future epidemiological studies should distinguish where possible between pain that is limited to the low back and LBP that occurs in association with pain at other anatomical locations.Level of Evidence: 2

The aim of study was to analyse relationships between individual and job related risk factors and prevalence of musculoskeletal pain among sewing machine operators. The target group was completed of 130 workers from the sewing industry in North-East Estonia. The anonymous e-questionnaire was carried out to analyse the main individual and job related factors and localisation of musculoskeletal pain in different body regions in the past 12 months. Study group was completed by 57 respondents. The response rate was 48.3%. All the participants were female in average age 44.4 ± 8.6 years and most of them had job experience more than 5 years. About half of them had overweight, with average body-mass index (BMI) 26.8 ± 6.5 kg/m 2 . Sewing machine operators’ work is monotonous, in sitting position, with repetitive bending movements of elbow, wrist and fingers. The dominative risk factors for the sewing operators were: high autonomy over work activities and working under stress because of short deadlines and to finish the assignments by a fixed time. More than half of participants had pain in lower back, neck and wrist. Usually pain in three and more body regions was reported. The pain with duration 1–6 days for lower back and neck was mentioned by 47.1% and 31.6%, accordingly. BMI correlated positively with lower back and elbow pain. High autonomy was in positive correlation with pain in lower back (p = 0.02) and elbow (p = 0.01). Repetitive bending and extending of elbow was in positive correlation with pain in both neck and wrist (p = 0.05). In conclusion, associations between individual and job related factors and musculoskeletal pain were observed among sewing machine operators. So, regular breaks and less stress because of deadlines and high work pace could be the main organisational activities provided in the sewing industry.

Occupational risks in everyday military service are often underestimated as compared to the risks faced during military missions. However, long-term exposure to “common” hazards can lead to chronic illness or, more importantly, affect person’s fitness for military service. A survey of work environment and health risks of Estonian Defence Forces (EDF) was initiated to assess health status and occupational exposures among military personnel in Estonia. A questionnaire was developed to assess self-perceived health and work environment in active service. A web-based questionnaire was sent to all servants of EDF in March 2015. Altogether 788 persons completed the questionnaire. The majority of respondents were male (87.0%) and had a service time over 9 years (67.8%). Self-rated health was assessed as good or very good by 63.8%. The most frequent exposures reported were electromagnetic fields, camouflage pastes, smokes and static work in forced positions. Although the majority (79.8%) was satisfied with their work environment in general, there were higher-risk structural units reporting dissatisfaction or health-related problems (Scouts Battalion, Artillery Battalion, Navy). Health problem during last 12 months limiting their usual activities was reported by 40% of respondents. Injuries causing temporary sick-leaves occurred in 10% of subjects, and they were mainly associated with shooting- or vehicle-related occupations. The most frequent health complaints, associated with work environment, were eye irritation, joint, low-back and neck-shoulder pain and unexplained fatigue. Hearing loss in the last 3 years was reported by 37.7%. Stress and anxiety symptoms occurred in 14.8% and it was associated with service in Special Operations Unit, Intelligence Centre and Artillery Battalion. Overall, the self-reported health status, satisfaction with service and work environment was rated highly among military personnel. In spite of positive results, there are units inside EDF with considerably higher occupational exposures, dissatisfaction of work conditions and consequent health problems.

Particulate matter (PM) is the major air pollution problem with health impacts in Estonia. The prevailing sources of particles are traffic and local heating. In this study, we quantified the health effects of PM in neighbourhoods of five main cities with a health impact assessment (HIA) approach that uses information on exposure, baseline mortality/morbidity and exposure–response relationships from previous epidemiological studies. The exposure was defined as modelled PM2.5 annual levels and daily averages of PM10 (monitoring data in Tallinn and Kohtla-Jarve and modelled levels in Tartu, Narva and Parnu). The modelled results were validated with data from monitoring stations and additional measuring programmes. The annual average concentration of PM2.5 in the neighbourhoods studied varied from 7.6 to 23.6 μg m−3. The analysis indicated that the exposure above natural background corresponds to 462 [95% confidence interval (CI) 120–815] premature deaths, resulting in 6,034 (95% CI 1,583–10,309) years of life lost per year. The average decrease in life-expectancy at birth per resident of Tallinn was estimated to be 0.63 (95% CI 0.16–1.08) years. In the polluted city centres, this average decrease may reach >1 year and in Parnu, it may reach 0.95 year. However, in the least polluted neighbourhood, the decrease of life expectancy was only 0.17 years. In addition, 231 (95% CI 145–306) respiratory and 338 (95% CI 205–454) cardiovascular hospitalisations per year could be expected. The majority of the external costs are related to the long-term effects on mortality and amount to €270 (95% CI 190–350) million annually. In comparison, the costs of hospitalisations contribute just €1.1 (95% CI 0.6–1.6) million. The main differences in health impacts were mostly driven by differences in the pollution sources, the magnitude of such sources and distribution patterns in the atmosphere. The smallest health effects, with the exception of the green residential areas, were observed in the industrial cities Kohtla-Jarve and Narva (due to the small share contributed by local residential heating and relatively little car traffic). However, it is questionable whether the mass of fine particles is the best indicator of air pollution risk in such areas.

Peat will be used more widely for heating in Tartu (Estonia), therefore the potential health effects needed to be assessed. In transition from today's gas heating to burning of peat, the amount of exhaust gases emitted will increase and more than 100 000 people will be exposed to greater health risks. Based on the peat quality data, the emissions were calculated and their dispersion in Tartu was modelled using the air pollution dispersion and deposition model AEROPOL. The AirQ software, developed by the WHO, was used for calculating the health impacts. The number of years of life lost (YLL) due to the emissions from peat burning was estimated to be up to 55.5 in a year within the population of Tartu (101 000 citizens). However, in perspective, this would be about 28 times less than YLL calculated due to emissions from traffic, local heating etc.

The health-promoting hospitals (HPH) movement in Estonia was initiated in 1999. This study aimed to compare the implementation of health-promoting and quality-related activities in HPH and those which have not joined the HPH network (non-HPH). In the beginning of 2005, a postal survey was conducted among the top managers of 54 Estonian hospitals. The questionnaire was based on the WHO standards for HPH and on the set of the national quality assurance (QA) requirements for health services. The study demonstrated some significant differences in the uptake of health promotion and QA activities between HPH and non-HPH. For example, regular patient satisfaction studies were conducted in 83% of HPH and 46% of non-HPH (P < 0.03) and 65% of HPH and 46% of non-HPH cooperated with various patient organizations (P < 0.03). Systems for reporting and analysis of complications were implemented in 71% of HPH and 33% of non-HPH (P < 0.03); also, the implementation of various guidelines was more developed in HPH. All HPH have carried out a risk analysis on the workplace and staff job satisfaction studies were conducted in 89% of HPH and 41% non-HPH (P < 0.05). This study indicates that the concepts of HPH and QA are closely related. Making progress in health promotion is accompanied with QA and vice versa. Implementation of health-promoting activities in hospitals will promote the well-being and health of patients and hospital staff, and creates a supportive environment to provide safe and high-quality health services.

Background Cervical and lumbar range of motion limitations are usually associated with musculoskeletal pain in the neck and lower back, and are a major health problem among nurses. Physical exercise has been evaluated as an effective intervention method for improving cervical and lumbar range of motion, and for preventing and reducing musculoskeletal pain. The purpose of this study was to investigate the effects of a home-exercise therapy programme on cervical and lumbar range of motion among intensive care unit nurses who had experienced mild to moderate musculoskeletal pain in the neck and or lower back during the previous six months. Methods A quasi-experimental study was conducted among intensive care unit nurses at Tartu University Hospital (Estonia) between May and July 2011. Thirteen nurses who had suffered musculoskeletal pain episodes in the neck and or lower back during the previous six months underwent an 8-week home-exercise therapy programme. Eleven nurses without musculoskeletal pain formed a control group. Questions from the Nordic Musculoskeletal Questionnaire and the 11-point Visual Analogue Scale were used to select potential participants for the experimental group via an assessment of the prevalence and intensity of musculoskeletal pain. Cervical range of motion and lumbar range of motion in flexion, extension, lateral flexion and (cervical range of motion only) rotation were measured with a digital goniometer. A paired t-test was used to compare the measured parameters before and after the home-exercise therapy programme. A Student’s t-test was used to analyse any differences between the experimental and control groups. Results After the home-exercise therapy, there was a significant increase (p

The aim of the study was to explore the role of managerial style, work environment factors and burnout in determining job satisfaction during the implementation of quality improvement activities in a dental clinic.Quantitative research was carried out using a prestructured anonymous questionnaire to survey 302 respondents in Kaarli Dental Clinic, Estonia. Dental clinic staff assessed job satisfaction, managerial style, work stress and burnout levels through the implementation period of ISO 9000 quality management system in 2003 and annually during 2006-2009. Binary logistic regression was used to explain the impact of satisfaction with management and work organisation, knowledge about managerial activities, work environment and psychosocial stress and burnout on job satisfaction.The response rate limits were between 60% and 89.6%. Job satisfaction increased significantly from 2003 to 2006 and the percentage of very satisfied staff increased from 17 to 38 (p0.01) over this period. In 2007, the proportion of very satisfied people dropped to 21% before increasing again in 2008-2009 (from 24% to 35%). Binary logistic regression analysis resulted in a model that included five groups of factors: managerial support, information about results achieved and progress to goals, work organisation and working environment, as well as factors related to career, security and planning. The average scores of emotional exhaustion showed significant decrease, correlating negatively with job satisfaction (p0.05).The implementation of quality improvement activities in the Kaarli Dental Clinic has improved the work environment by decreasing burnout symptoms and increased job satisfaction in staff.

The effects of developmental lead exposure on the emotional reactivity, contextual fear conditioning and neurogenesis in the dentate gyrus of 60-80 days-old rats were studied. Wistar rat pups were exposed to 0.2% lead acetate via their dams' drinking water from postnatal day (PND) 1 to PND 21 and directly via drinking water from weaning until PND 30. At PND 60 and 80 the level of anxiety and contextual fear conditioning were studied, respectively. At PND 80 all animals received injections of BrdU to determine the effects of Pb on the generation of new cells in the dentate gyrus of hippocampus and on their survival and differentiation patterns. The results of the present study demonstrate that developmental lead exposure induces persistent increase in the level of anxiety and inhibition of contextual fear conditioning. Developmental lead exposure reduced generation of new cells in the dentate gyrus and altered the pattern of differentiation of BrdU-positive cells into mature neurons. A lower proportion of BrdU-positive cells co-expressed with the marker for mature neurons, calbindin. In contrast, the proportions of young not fully differentiated neurons and proportions of astroglial cells, generated from newly born cells, were increased in lead-exposed animals. Our results demonstrate that developmental lead exposure induces persistent inhibition of neurogenesis and alters the pattern of differentiation of newly born cells in the dentate gyrus of rat hippocampus, which could, at least partly, contribute to behavioral and cognitive impairments observed in adulthood.

Background Routine statistics indicate a high frequency of work-related musculoskeletal disorders in Estonia. We aimed to describe the prevalence of musculoskeletal pain (MSP) amongst Estonian nurses, and to explore associations with personal characteristics and occupational risk factors. Methods As a part of an international investigation (the Cultural and Psychosocial Influences on Disability (CUPID) study), a cross-sectional survey was carried out amongst registered nurses at Tartu University Hospital, focusing on pain at six anatomical sites (low back, neck, shoulder, elbow, wrist/hand and knee) lasting for more than a day during the past year and past month. Associations with regional and multi-site (≥2 anatomical sites) pain were analysed by logistic regression. Results Analysis was based on 221 female nurses (response rate 57%). The overall prevalence of MSP was 84% in the past year and 69% in the past month. The prevalence of multi-site pain was 60% in the past year and 40% in the past month. Low back, neck and knee were the sites most commonly painful. Pain in the past year tended to be more frequent at older ages, and with higher emotional exhaustion, and at most sites, with poor self-rated health, and reported distress from somatic symptoms. Multi-site pain was also significantly associated with older age and tendency to somatise. Conclusions The prevalence of MSP among Estonian nurses is high. Psychological risk factors such as somatising tendency have an important impact. However, none of the risk factors examined seems likely to explain the high frequency of work-related musculoskeletal disorders in Estonia.

OBJECTIVES: To quantify the variation in rates of absence due to musculoskeletal pain across 47 occupational groups (mostly nurses and office workers) from 18 countries, and to explore personal and group-level risk factors that might explain observed differences. METHODS: A standardised questionnaire was used to obtain information about musculoskeletal pain, sickness absence and possible risk factors in a cross-sectional survey of 12 416 workers (92-1017 per occupational group). Additionally, group-level data on socioeconomic variables, such as sick pay and unemployment rates, were assembled by members of the study team in each country. Associations of sickness absence with risk factors were examined by Poisson regression. RESULTS: Overall, there were more than 30-fold differences between occupational groups in the 12-month prevalence of prolonged musculoskeletal sickness absence, and even among office workers carrying out similar occupational tasks, the variation was more than tenfold. Personal risk factors included older age, lower educational level, tendency to somatise, physical loading at work and prolonged absence for non-musculoskeletal illness. However, these explained little of the variation between occupational groups. After adjustment for individual characteristics, prolonged musculoskeletal sickness absence was more frequent in groups with greater time pressure at work, lower job control and more adverse beliefs about the work-relatedness of musculoskeletal disorders. CONCLUSIONS: Musculoskeletal sickness absence might be reduced by eliminating excessive time pressures in work, maximising employees' responsibility and control and providing flexibility of duties for those with disabling symptoms. Care should be taken not to overstate work as a cause of musculoskeletal injury.

BackgroundThe CUPID (Cultural and Psychosocial Influences on Disability) study was established to explore the hypothesis that common musculoskeletal disorders (MSDs) and associated disability are importantly influenced by culturally determined health beliefs and expectations. This paper describes the methods of data collection and various characteristics of the study sample.Methods/principal findingsA standardised questionnaire covering musculoskeletal symptoms, disability and potential risk factors, was used to collect information from 47 samples of nurses, office workers, and other (mostly manual) workers in 18 countries from six continents. In addition, local investigators provided data on economic aspects of employment for each occupational group. Participation exceeded 80% in 33 of the 47 occupational groups, and after pre-specified exclusions, analysis was based on 12,426 subjects (92 to 1018 per occupational group). As expected, there was high usage of computer keyboards by office workers, while nurses had the highest prevalence of heavy manual lifting in all but one country. There was substantial heterogeneity between occupational groups in economic and psychosocial aspects of work; three- to five-fold variation in awareness of someone outside work with musculoskeletal pain; and more than ten-fold variation in the prevalence of adverse health beliefs about back and arm pain, and in awareness of terms such as "repetitive strain injury" (RSI).Conclusions/significanceThe large differences in psychosocial risk factors (including knowledge and beliefs about MSDs) between occupational groups should allow the study hypothesis to be addressed effectively.

Aim The purpose of present study was to examine relations between work environment factors, burnout and state of health of the military personnel and to find factors that can affect the level of burnout and adverse health status. Method The data has been gathered by the anonymous questionnaire in 2008–2009. The target group consisted of 3199 military men. Six structural units were included into the study. Results Study group consisted of 641 persons, whereas 45% of them were servants, 31% executive officers and 20% officers (4% unknown). 55% of respondents were female (mainly servants) and 44% men (mainly officers). The average age of the study group was 39 years (SD 11) and their average work experience 6 years (max 40 yrs). In general military personnel found their health to be good and they were fairly satisfied with their working environment. But the respondents with higher burnout levels assessed more negatively their work environment and health status. They perceived more often work-family conflict, lack of instructions, lower appreciation and less internest toward work. Also, they measured deeper tiredness and depression and more psyco-somatic disorders. Male officers and female servants were more negative in their answers than male noncommissioned officers and male servants. Conclusions That to prevent burnout and health problems among military personnel it is needful to pay more attention on work environment and work organisation.

To inform case definition for neck/shoulder pain in epidemiological research, we compared levels of disability, patterns of association, and prognosis for pain that was limited to the neck or shoulders (LNSP) and more generalised musculoskeletal pain that involved the neck or shoulder(s) (GPNS). Baseline data on musculoskeletal pain, disability, and potential correlates were collected by questionnaire from 12,195 workers in 47 occupational groups (mostly office workers, nurses, and manual workers) in 18 countries (response rate 5 70%). Continuing pain after a mean interval of 14 months was ascertained through a follow-up questionnaire in 9150 workers from 45 occupational groups. Associations with personal and occupational factors were assessed by Poisson regression and summarised by prevalence rate ratios (PRRs). The 1-month prevalence of GPNS at baseline was much greater than that of LNSP (35.1% vs 5.6%), and it tended to be more troublesome and disabling. Unlike LNSP, the prevalence of GPNS increased with age. Moreover, it showed significantly stronger associations with somatising tendency (PRR 1.6 vs 1.3) and poor mental health (PRR 1.3 vs 1.1); greater variation between the occupational groups studied (prevalence ranging from 0% to 67.6%) that correlated poorly with the variation in LNSP; and was more persistent at follow-up (72.1% vs 61.7%). Our findings highlight important epidemiological distinctions between subcategories of neck/shoulder pain. In future epidemiological research that bases case definitions on symptoms, it would be useful to distinguish pain that is localised to the neck or shoulder from more generalised pain that happens to involve the neck/ shoulder region. Para informar sobre la definición de caso para el dolor de cuello/hombro en la investigación epidemiológica, se compararon los niveles de discapacidad, los patrones de asociación y el pronóstico para el dolor que se limitaba al cuello o los hombros (LNSP) y el dolor musculoesquelético más generalizado que afectaba al cuello o los hombros (GPNS). Se recopilaron datos de referencia sobre el dolor musculoesquelético, la discapacidad y los posibles correlatos mediante un cuestionario de 12.195 trabajadores de 47 grupos profesionales (en su mayoría oficinistas, enfermeros y trabajadores manuales) de 18 países (tasa de respuesta del 5%). Se determinó la persistencia del dolor después de un intervalo medio de 14 meses mediante un cuestionario de seguimiento en 9.150 trabajadores de 45 grupos profesionales. Las asociaciones con los factores personales y profesionales se evaluaron mediante una regresión de Poisson y se resumieron en ratios de prevalencia (PRR). La prevalencia a un mes del GPNS en la línea de base fue mucho mayor que la del LNSP (35,1% frente a 5,6%), y tendía a ser más molesta e incapacitante. A diferencia del PSNL, la prevalencia del GPNS aumentó con la edad. Además, mostró asociaciones significativamente más fuertes con la tendencia somatizante (PRR 1,6 frente a 1,3) y la mala salud mental (PRR 1,3 frente a 1,1); una mayor variación entre los grupos ocupacionales estudiados (la prevalencia oscilaba entre el 0% y el 67,6%) que se correlacionaba mal con la variación del LNSP; y era más persistente en el seguimiento (72,1% frente al 61,7%). Nuestros hallazgos ponen de manifiesto importantes distinciones epidemiológicas entre las subcategorías de dolor de cuello/hombro. En futuras investigaciones epidemiológicas que basen las definiciones de los casos en los síntomas, sería útil distinguir el dolor localizado en el cuello o el hombro del dolor más generalizado que afecta a la región del cuello/hombro. Universidad Nacional, Costa Rica Instituto Regional de Estudios en Sustancias Tóxicas

Background Occupational use of computers has increased rapidly over recent decades, and has been linked with various musculoskeletal disorders, which are now the most commonly diagnosed occupational diseases in Estonia. The aim of this study was to assess the prevalence of musculoskeletal pain (MSP) by anatomical region during the past 12 months and to investigate its association with personal characteristics and work-related risk factors among Estonian office workers using computers. Methods In a cross-sectional survey, the questionnaires were sent to the 415 computer users. Data were collected by self-administered questionnaire from 202 computer users at two universities in Estonia. The questionnaire asked about MSP at different anatomical sites, and potential individual and work related risk factors. Associations with risk factors were assessed by logistic regression. Results Most respondents (77%) reported MSP in at least one anatomical region during the past 12 months. Most prevalent was pain in the neck (51%), followed by low back pain (42%), wrist/hand pain (35%) and shoulder pain (30%). Older age, right-handedness, not currently smoking, emotional exhaustion, belief that musculoskeletal problems are commonly caused by work, and low job security were the statistically significant risk factors for MSP in different anatomical sites. Conclusions A high prevalence of MSP in the neck, low back, wrist/arm and shoulder was observed among Estonian computer users. Psychosocial risk factors were broadly consistent with those reported from elsewhere. While computer users should be aware of ergonomic techniques that can make their work easier and more comfortable, presenting computer use as a serious health hazard may modify health beliefs in a way that is unhelpful.

Background Health impact assessments (HIA) use information on exposure, baseline mortality/morbidity and exposure-response functions from epidemiological studies in order to quantify the health impacts of existing situations and/or alternative scenarios. The aim of this study was to improve HIA methods for air pollution studies in situations where exposures can be estimated using GIS with high spatial resolution and dispersion modeling approaches. Methods Tallinn was divided into 84 sections according to neighborhoods, with a total population of approx. 390 000 persons. Actual baseline rates for total mortality and hospitalization with cardiovascular and respiratory diagnosis were identified. The exposure to fine particles (PM2.5) from local emissions was defined as the modeled annual levels. The model validation and morbidity assessment were based on 2006 PM10 or PM2.5 levels at 3 monitoring stations. The exposure-response coefficients used were for total mortality 6.2% (95% CI 1.6–11%) per 10 μg/m3 increase of annual mean PM2.5 concentration and for the assessment of respiratory and cardiovascular hospitalizations 1.14% (95% CI 0.62–1.67%) and 0.73% (95% CI 0.47–0.93%) per 10 μg/m3 increase of PM10. The direct costs related to morbidity were calculated according to hospital treatment expenses in 2005 and the cost of premature deaths using the concept of Value of Life Year (VOLY). Results The annual population-weighted-modeled exposure to locally emitted PM2.5 in Tallinn was 11.6 μg/m3. Our analysis showed that it corresponds to 296 (95% CI 76528) premature deaths resulting in 3859 (95% CI 10236636) Years of Life Lost (YLL) per year. The average decrease in life-expectancy at birth per resident of Tallinn was estimated to be 0.64 (95% CI 0.17–1.10) years. While in the polluted city centre this may reach 1.17 years, in the least polluted neighborhoods it remains between 0.1 and 0.3 years. When dividing the YLL by the number of premature deaths, the decrease in life expectancy among the actual cases is around 13 years. As for the morbidity, the short-term effects of air pollution were estimated to result in an additional 71 (95% CI 43–104) respiratory and 204 (95% CI 131–260) cardiovascular hospitalizations per year. The biggest external costs are related to the long-term effects on mortality: this is on average €150 (95% CI 40–260) million annually. In comparison, the costs of short-term air-pollution driven hospitalizations are small €0.3 (95% CI 0.2–0.4) million. Conclusion Sectioning the city for analysis and using GIS systems can help to improve the accuracy of air pollution health impact estimations, especially in study areas with poor air pollution monitoring data but available dispersion models.