Finnish Institute of Occupational Health

Danish National Research Centre for the Working Environment

Norwegian National Institute of Occupational Health

Is there a gender difference in the effect of work-related physical and psychosocial risk
factors on musculoskeletal symptoms and related sickness absence?
Author(s): Wendela E Hooftman, Allard J van der Beek, Paulien M Bongers and Willem van
Mechelen
Source: Scandinavian Journal of Work, Environment & Health, Vol. 35, No. 2 (March 2009), pp.
85-95
Published by: the Scandinavian Journal of Work, Environment & Health , the Finnish Institute
of Occupational Health , the Danish National Research Centre for the Working Environment ,
and the Norwegian National Institute of Occupational Health
Stable URL: http://www.jstor.org/stable/40967762
Accessed: 20-05-2015 19:20 UTC

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 - gender
Originalarticle andoccupational
health
Scand J WorkEnviron Health 2009;35(2):85-95

Isthere
a gender intheeffect
difference ofwork-related and
physical
risk
psychosocial factors
onmusculoskeletal
symptomsandrelated
sickness
absence?
E Hooftman,
byWendela 2Allard
PhD,1> 2Paulien
JvanderBeek,PhD,1> M Bongers, 3
PhD,2'
Willem PhD
vanMechelen, 1>2

HooftmanWE,vanderBeekAJ,Bongers W.Isthere
PM,vanMechelen a gender intheeffect
difference ofwork-
related andpsychosocial
physical riskfactors
onmusculoskeletal
symptomsandrelated
sickness
absence?Scand
JWork Environ
Health.
2009;35(2):85-95.
Objectives The objectiveofthisstudywas to determinewhethertherearegenderdifferencesin theeffect
ofexposureto work-related
physicalandpsychosocialriskfactors
on lowback,neck,shoulder, orhand-arm
symptoms andrelatedsicknessabsence.
Methods Dataofa prospective cohort
(studyonmusculoskeletal absenteeism
disorders, stressandhealth)with
a follow-upperiodofthreeyearswereused.Questionnaireswereusedto assessexposureto riskfactorsand
musculoskeletalsymptoms.Sicknessabsencewas registered Female-to-male
continuously. genderratios(GR)
werecalculated todetermine
whethertherewereanydifferencesintheeffect.
A GR value>1.33 or<0.75 was
regardedas relevant.
Results Exceptfortheeffectofbendingthewristandtheneckbackwards (GR 1.52-2.55),mengenerally had
a higher
riskofsymptoms (GR range0.50-0.68)withequalexposure.Forsicknessabsence,a GR valueof>1 .33
wasfoundfortwisting theupperbody,working inuncomfortablepostures, thewrist,
twisting bending theneck
backwards,andcoworker andsupervisorsupport For
(GR range1.66-2.63). driving vehicles,hand-arm vibra-
tion,squeezing,
working aboveshoulderlevelorbelowkneelevel,reaching, twistingtheneck,job demands,
andskilldiscretion,
theGR valuewas <0.75. Forjob satisfaction,
a GR valueof0.50 was foundforabsence
duetobacksymptoms, whiletheGR valuewas 1.78forsicknessabsenceduetoneck,shoulder, orhand-arm
symptoms.
Conclusions Although womenareexpectedto be morevulnerable to exposureto work-relatedriskfactors,
theresults
ofthisstudyshowedthat,inmanycases,menaremorevulnerable. Thisstudycouldnotexplainthe
genderdifferenceinmusculoskeletal
symptoms amongworkers.

Keyterms absenteeism;
back;gender;
neck;upperextremity.

Many studies have reportedgender differencesin the
prevalence of musculoskeletalsymptoms(1-3). Most
studiesreporthigherprevalencesamong women (3-7).
However, prevalences of back symptomshave been
reportedto be higherformenin some studies(4, 8). Simi-
larly,genderdifferenceshave also been foundforsickness
absence due to musculoskeletalsymptoms(9-12).
One explanationforthese genderdifferenceslies in
theso-called"vulnerabilityhypothesis"(13, 14); similar
exposure to the same risk factorsmighthave a larger
effecton women thanmen as a resultof differencesin
biological [eg, hormones,physiology(15-18)] or psy-
chological factors[eg, copingstrategies(19)]. An earlier
review(20) attemptedto answerthequestionof whether
thereindeed are genderdifferencesin vulnerabilityto
work-relatedphysical and psychosocial risk factors
betweenmen and women. Strongevidence of a gender
difference was foundfortheeffectof exposureto heavy
lifting,hand-armvibration,and awkwardarmpostures.
However,women were foundto be more vulnerableto

1
Departmentof Public & Occupational Health,EMGO Institute,VU UniversityMedical Center,Amsterdam,Netherlands.
2
Body® Work,Research CentrePhysicalActivity,Workand Health,TNO VU UniversityMedical Center,Amsterdam,Netherlands.
3 TNO
Qualityof Life, Workand Employment,Hoofddorp,Netherlands.

Reprint requests to: Allard van der Beek, EMGO Institute,Van der Boechorststraat7, NL-1081 BT Amsterdam, Netherlands. [E-mail:
a.vanderbeek@ vumc.nl]

Scand J WorkEnvironHealth,vol 35, no 2, themesection 85

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Gender differencesin riskfactorsformusculoskeletalsymptoms
Figure1. Percentage
ofcompaniesemploying<25%, 25-50%,
50-75%,or >75% femaleworkers, forall workersand less
educatedworkers.
exposure only for the relationbetween awkward arm
posturesand neck-shouldersymptoms,while men were
morevulnerableto thetwo otherexposures.No evidence
fora genderdifference was foundfortheeffectof social
support. Due to a lack of high-qualitystudies,therewas
inconclusive evidence for the remainingrisk factors.
Most of the studies assessed in the review focused on
symptomsas the outcome measure,althoughsickness
absence was assessed in two studies,one on back symp-
tomsand the otheron neck-shouldersymptoms.
Therefore,the objective of our studywas to deter-
mine whetherthereare genderdifferencesin the effect
of exposureto work-relatedphysical and psychosocial
risk factorson low back, neck, shoulder,or hand-arm
symptomsand relatedsicknessabsence. The hypothesis
was that,given the genderdifferencesin musculoskel-
etal symptoms,men may show equal or greatereffects
of exposureto work-related riskfactorsin back pain and
womenmay show moreeffectsof exposureto work-re-
latedriskfactorson musculoskeletalsymptomsin other
partsof thebody.
Study andmethods
population
This study employed data from the study on mus-
culoskeletal disorders,absenteeism stress and health
(SMASH). Nearly 1800 employees in 34 companies
participatedin this longitudinalstudy,which focused
on thedetermination of riskfactorsformusculoskeletal
symptoms.At baseline (1994) and during three an-
nual follow-up measurements("waves"), participants
completedquestionnaireson exposuresand symptoms.
Companies continuouslyregistereddata on sickness
86 Scand J WorkEnvironHealth,vol 35, no 2, themesection
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absence. A more-detaileddescriptionof the studycan
be foundelsewhere(21, 22).
Population
At baseline, 87% of the workers(N=1789) filled out
the questionnaire,92% of whom also filledout at least
one follow-upquestionnaire.Workerswho, at baseline,
worked <20 hours a week (N=40), were employed in
theircurrentjob for<1 year (N=37), had a second job
(N=100), had a permanentdisabilitypensionor were on
sicknessbenefit(N=34), were excludedfromthecurrent
analyses. The companies were selected to incorporate
different typesof work and a wide range of exposures,
and included(among others)care workin daycarecen-
ters,assembly-lineworkin a cookie factory, production
workin a pharmaceuticalcompany,computerprogram-
ming in offices,and grindingand welding in a metal
partsfactory.
Figure 1 shows that,in the majorityof the compa-
nies, less than25% of the workersin the sample were
female althoughin about 25% of the companies,more
than75% of theworkerswere female.A similarpattern
was foundamong less-educatedworkers.
For the currentanalyses,workerswithmissingdata
on relevantvariablesin two or moreout of four"waves"
were excluded, leaving the finalnumberof workersin
theanalyses at 1259 (low-back symptoms),1222 (neck
and shoulder symptoms),and 1263 (hand-arm symp-
toms). Since sickness absence was not registeredby
all of the companies.Accordingto table 1, the number
of workersfor absence was lower, namely,762 (low
back-relatedabsence) and 748 (neck-, shoulder-,arm-,
or hand-relatedabsence).
Symptoms
Musculoskeletalpain was assessed using an adaptation
of the Nordic questionnaire(23). Workerswere asked
whetherthey had experienced pain or discomfortin
the past 12 monthsin theirback, neck, shoulders,el-
bows, or hands-wristson a four-pointscale as follows:
"no, never","yes, sometimes","yes, regular",or "yes,
prolonged". The responses for elbow and hand-wrist
symptomswere combined into one measure forhand-
armsymptoms.Cases were definedas theworkerswho
reportedregularor prolongedsymptomsin the past 12
months.
absence
Sickness
The companiessuppliedthedate of thefirstand last day
of,and reason for,each episode of sicknessabsence. An
occupational physiciancoded the reasons for absence
accordingto a modifiedDutch code of theInternational
 Hooftmanet al

Table 1. Descriptionof the studypopulation(N=1578). (SD = ofDiseases.Fromthesedata,information

Classification
standarddeviation) was gatheredon theoccurrenceof sicknessabsence.
Men Women Missing
Since fewpeople wereabsentdue to neckor shoul-
(N=1096) (N=482) der symptoms, we combinedabsences due to these
symptoms withabsencesdue to hand-armsymptoms.
N % N % N
Cases weredefinedas workers who wereabsentfrom
Age,mean(SD)
ab 36.6 8.4 33.1 9.2 0 workforat leastthreedaysdueto backorneck,shoul-
Education" 15 der,orhand-arm symptoms.
No education
or primaryschool 146 13.4 26 5.5
Lowersecondary Riskfactors
ofvocationalschool 480 44.1 154 32.4
Intermediate Exposuretophysicalriskfactors was assessedusingthe
secondaryor DutchMusculoskeletal
vocationalschool 266 24.4 179 37.7 Questionnaire (24, 25). Ques-
Highersecondary
tionsonhowoftenactivities wereperformed (eg,"How
or vocationalschool 103 9.5 53 11.2 oftendo you have to liftloads of morethan5 kg?")
University 93 8.5 63 13.3 wereaskedon a four-point scale as follows:"never",
Yearsemployed, or
mean(SD)b 10.7 8.3 7.0 5.4 0 "occasionally", "often", "veryoften".Questionson
Hoursworking,
neckandwristpostures (eg,"Do youoftenhavetowork
mean(SD)b 39.2 3.7 35.2 6.4 24 withyourneckbent?")wereaskedon a dichotomous
Symptoms scale ("yes"or"no").
Low back (N=1259) Exposureto work-related psychosocial riskfactors
Baseline 306 34.8 137 36.5 4 was assessedusingtheDutchtranslation of Karasek's
Follow-up1 236 27.9 113 31.0 47
116 32.6 73 job contentquestionnaire.Individualquestions werelater
Follow-up2 246 29.6
Follow-up3 219 26.7 95 27.5 92 combined intothedimensions according to Karasek (ie,
Neck(N=1222) job demands, job control,andsocialsupport) (26). Fur-
Baseline" 143 17.0 146 39.0 8 a singlequestion was askedaboutjob satisfac-
b 118 33.0 53
thermore,
Follow-up1 110 13.6
Follow-up2
b 119 14.9 112 31.3 67 tion.Finally,severalquestionsweresetaboutexposure to
Follow-up3
b 91 11.5 85 24.6 83 psychosocial risk in
factors life
private (27).
Shoulder(N=1222)
Baseline" 134 15.9 138 37.0 6
Follow-up1
b 108 13.5 101 28.3 64 Statistics
Followup 2 b 105 13.3 95 26.9 79
Followup 3 b 102 12.9 84 24.5 90 SincetheSMASHcohort consistedofsamplesofworkers
Arm-hand (N=1263) nestedwithincompanies, a multilevel analysisseemed
Baseline0 120 13.7 69 18.3 11
Followup 1 c 87 10.5 57 15.8 71 However,
appropriate. whenmultilevel wereper-
analyses
Followup 2 b 95 11.6 71 20.0 91 formed ontheSMASH dataset, theestimations obtained
Followup 3 91 11.1 52 15.0 94 fromdidnotdiffer fromthoseobtainedusingstatistical
Sicknessabsence techniquesthatdid notmodelthisnestedstructure. In
Low back (N=762) otherwords,thelevelof companiesdidnotexplainthe
Baseline 50 9.9 12 7.2 89 variancein theSMASH cohort.Althoughit mightbe
Followup 1 52 10.3 14 8.3 86
Followup 2 59 11.5 12 7.5 90 arguedthatmultilevelanalysesarestillthebetteroption
Followup 3 b 57 11.7 3 1.7 96 becausetheyare"safer",we preferred tousegeneralized
Neck-shoulder-arm-hand
(N=748) estimationequationsfortheanalyses.An important ad-
Baseline 22 4.5 9 5.4 89
Followup 1 25 5.0 10 6.0 84 vantageof suchanalysesis thatdatafrompersonswith
Followup 2 17 3.4 8 5.0 89 missingdataon one or twoof thefollow-up measure-
Followup 3 c 18 3.8 14 7.9 91 mentsare notexcludedfromtheanalyses.Hence we
a For
age, educationand workinghours,numbersare forthe complete
decidedthattheadvantageofmultilevel analyses
(analyz-
baselinepopulation(N=1578); forsymptomsand sickness absence the ingthenestedsample)was smallerthanitsdisadvantage
numbersare forthe populationsused inthe respectiveanalyses.
difference
betweenmenand womenat P=0.00. (excludingworkerswithmissing data).Therefore,
logistic
"Significant
c difference
Significant betweenmenand womenat P=0.05. generalizedestimation
equationsanalyseswitha one-year
timelag werecarriedoutto estimate theoddsratiofor
exposureand sicknessabsencedue to low-back,neck,
shoulder,and hand-armsymptoms. Separateanalyses
weremadeforthemenandwomen.All oftheanalyses
wereperformed withStata,version7.0 forWindows
(StataCorporationLP,CollegeStation, TX, USA).

Scand J WorkEnvironHealth,vol 35, no 2, themesection 87

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Gender differencesin riskfactorsformusculoskeletalsymptoms

In the multivariate analyses, various symptoms Table2. Overview

ofconfounders
considered
foreachsymptom
at the baseline were considered to be confounders, region
includingage, education,nationality,years of employ- Low Neck Hand
back and or
ment, workhours, workdays, physical exposure (at shoulderarm
work and in private life), and psychosocial exposure
a
Socio-demographic
(at work and in privatelife). However, we limitedthe
numberof potentialconfounderson thebasis of theory Ageb V V V
Education0 V V V
or the literature,since not all the risk factorswere rel- Dutchnationality0 V V V
evant to every outcome measure. An overview of the Bodymassindex V V V
confoundersforeach body regionthatwere considered Number offamily
members0 V V V
Smokerbc V V V
in theanalyses can be foundin table 2. First,univariate Alcoholic
beveragesa weekb V V V
analyses were performedto test the relation between Healthy
eating" V V V
the individual potentialconfoundersand the outcome Strenuous inprivate
activity lifeb-c-d-e V V V
Work duration
variables. Variables related to the outcome with a
Yearsemployed0 V V V
P-value of >0.25 were not considered as confound-
Working daysa week" V V V
ers foreithermen or women. Furthermore, to prevent Hoursworking" V V V
collinearity,variables associated with individual risk Work-related
physicalriskfactors
factorswith a correlationof >0.5 were not included Lift
loads>5kgbcde V
Lift
loads>25kgbcde V
as confounders.Second, the remaining confounders
oftheupperpartofthebodyb-c-d-e
Flexion/rotation V
were individuallyenteredinto the univariatemodels. Uncomfortableworking posturesb-c-d-e V
Variables that changed the univariate odds ratio by a vehicle"
Driving V
Repeatedmovements withhandsorarms" ■ V V
>10% formen or women were included in the multi- withhands"
Forceexertion ■ V
variatemodel. Hand-arm "
vibration • V V
In orderto determinethe differencein the effectof Working withhandsaboveshoulder level"•c-d-e ■ V
Working withthehandsbelowkneelevel"•c-d-e • V
exposure between the men and women, we calculated Reaching" • V
gender ratios (GR) values as described by Altman & Squeezefirmly with
thehands" • • V
Bland (28). In this procedure,a ratio of odds ratio is Often bendtheneckorkeeptheneckbent
forwards "cde • V
calculated (the odds ratio for the women divided by Often bendtheneckorkeeptheneckbent
that for the men), which shows the interactionwith backwards "cde • V
Often twisttheneckorkeepthenecktwistedbcde • >/
gender.GR values >1.33 (women havinga higherrisk) Often bendthewrist orkeepthewrist c-d-e
bent"■ • • V
and <0.75 (men havinga higherrisk) were regardedas Often twistthewristorkeepthewrist bcde
twisted • • V
relevantgenderdifferences. Work-related riskfactors
psychosocial
bcde
Skilldiscretion V V V
Psychological demandsbcde V V V
Coworker supportbcde V V V
Supervisor supportbcde V V V
Results Jobsatisfactionbcde V V V
inprivate
riskfactors
Physical life
loads>5 kg"cde
Lift V
Symptoms loads>25 kg"cde
Lift V
oftheupperpartofthebodybcde
Flexion/rotation V
Uncomfortableworking "cde
postures V
Tables 3-5 show the multivariateodds ratio for the
a vehicle"
Driving V
men and women separately; in figure2, the relevant Repeatedmovements withhandsorarms" • V V
GR values, along with theirconfidenceintervals,are withhands"
Forceexertion • V
Hand-arm "
vibration • V V
shown forsymptoms.For most of the risk factors(16
Workingwithhandsaboveshoulderlevel"•c-d-e • V
outof 22), we foundno relevantGR value (ie, theywere Workingwiththehandsbelowkneelevelbcde • V
•
0.75-1.33). The relationbetweenliftingloads of >25 kg Reaching0 V
and low-backsymptomswas largerforthementhanfor Squeezefirmly withthehandsb • • V
Psychosocial factors
risk inprivate life
the women (GR 0.67). Workingbelow knee level was bce
Work influencepersonallife V V V
a strongerrisk forthe men forshoulder(GR 0.63), as Personallifeinfluences
work b-c-e V V V
well as hand-armsymptoms(GR 0.68). For bothneck Disassociatefromwork bce V V V
and hand-armsymptoms, we founda relevantGR value Ableto relaxathomeb-c-e V V V
Busyhomeenvironment bce V V V
of 0.50 forthe effect bendingtheneck forwards.For
of Clubmembership bce V V V
twistingthe neck, a GR value of 0.69 was found for friends
Visiting frequently c-e
b> V V V
homeresponsibilities bce V V V
therelationwithshouldersymptoms.Bendingtheneck Delegate
bcde
Lifeevents V V V
backwards,on theotherhand,was a largerriskfactorfor
the women forbothneck and forhand-armsymptoms at:b= baseline,
a Measured up2-c= follow
up1, e= follow
d=follow up3.

88 Scand J WorkEnvironHealth,vol 35, no 2, themesection

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 Hooftmanet al

Table3. Results
ofthemultivariate forlowbackandnecksymptoms.
analyses inboldface
Figures aresignificant
atP=0.05, in
figures
italics
havea relevant ratio
gender orGR>1
(GR<0.75 .33).(OR= oddsratio,
95%CI= 95%confidence
interval)
Symptoms3 Lowback Neck

Men Women Men Women

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Work-relatedphysicalriskfactors0
loads>5 kgodet
Lift 1.15 1.05-1.27 1.06 0.93-1.22 ■ ...
loads>25 kgodef
Lift 1.26 1.11-1.42 0.84 0.67-1.06' • •
oftheupperpartofthebodyodef
Flexion/rotation 1.22 1.11-1.34 1.21 1.05-1.38 • •
Uncomfortable working posturescdef 1.41 1.24-1.60 1.48 1.22-1.8012 ■ •
Driving c
a vehicle 1.16 1.01-1.33 1.23 0.84-1.792 • ■
Repeated movements withhandsorarms0 ... ... 1.11 0.99-1.25 1.26 1.09-1.45
Hand-arm vibration0 - • 1.07 0.89-1.28 0.87 0.62-1.2312
Often bendthewrist orkeepthewrist bentcdef ... ... ... ...
Often twist
thewrist orkeepthewristtwistedcdef ... ... ... ...
Squeezefirmly withthehands0 ... ... ... ...
Working withhandsaboveshoulder levelodef - ■ 1.13 0.96-1.32 0.97 0.83-1.13
Working withthehandsbelowkneelevelodef ■ • 1.16 0.94-1.43 0.92 0.71-1.20126
Reaching0 • ■ 1.20 0.97-1.47 1.18 0.92-1.52
Forceexertionwithhands0 ... ... 1.06 0.92-1.22 0.99 0.87-1.13
Often bendtheneckorkeeptheneckbentforwards odef ... ... 2.07 2.86-1.49 1.04 1.52-0.7V2
Often bendtheneckorkeeptheneckbentbackwards °-d-e-f • •• • ■• 0.92 0.59-1.44 0.72 0.38-1.391-2-3-4
Often twist
theneckorkeepthenecktwisted odef • • 1.42 0.95-2.13 1.79 1.21-2.661245
Work-relatedpsychosocialriskfactors
Psychologicaldemands odef 1.28 1.05-1.56 1.34 0.97-1.8512 1.45 1.10-1.91 1.18 1.13-1.5812
odef
Skilldiscretion 1.29 1.09-1.52 1.06 0.82-1.36 1.16 0.87-1.54 1.34 0.99-1.8212
Coworker support odef 1.28 1.05-1.57 1.29 0.92-1.792 1.37 1.13-1.67 1.12 0.95-1.3212
Supervisor support0def 1.26 1.06-1.51 1.41 1.07-1.872 1.70 1.30-2.23 1.43 1.02-2.02
odef
Jobsatisfaction 1.17 1.02-1.33 1.12 0.90-1.39 1.20 0.98-1.48 1.13 0.85-1.5112

for:1work-home
a Adjusted 2home-work
interference, 3twisting
interference, theneck,4 bending 5 baselinenecksymptoms,
theneckforwards, 6base-
lineshoulder
symptoms.
bMeasured at:° = baseline,
d= follow-up 2,f= follow-up
1, e= follow-up 3.

Figure2. Resultsof the relevant

gender
differences
(genderratio[GR] <0.75 or
GR>1.33formusculoskeletal symptoms.

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Gender differencesin riskfactorsformusculoskeletalsymptoms

Table 4. Resultsofthemultivariateanalysesforshoulderand arm-handsymptoms.Figuresinboldfaceare significant at P=0.05, figures

in italicshavea relevantgenderratio(GFteO.75or GFM.33). (OR = odds ratio,95% CI = 95% confidenceinterval)

Symptoms3 Shoulder Arm-hand

Men Women Men Women

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Work-relatedphysical b
riskfactors
Lift
loads>5 kg cdef ... ... ... ...
loads>25 kgcdef
Lift • • • ...
oftheupperpartofthebodycdef
Flexion/rotation ... ... ... ...
Uncomfortableworking cdef
postures ... ... ... ...
a vehicle0
Driving ... ... ... ...
Repeatedmovements withhandsorarmsc 1.12 0.98-1.27 1.211.05-1.39 1.12 1.00-1.25 1.25 1.05-1.48
Hand-arm vibrationc 1.05 0.88-1.25 0.85 0.62-1.16 1.20 1.02-1.41 1.05 0.71-1.55
Oftenbendthewrist orkeepthewrist bentcdef ... ... 1.40 0.97-2.02 2.15 1.39-3.32^29
Oftentwistthewrist orkeepthewrist twistedcdef ... ... 1.15 0.81-1.63 1.32 0.85-2.05129
Squeezefirmlywith thehands0 ... ... 1.26 1.10-1.45 1.18 0.99-1.41
Working withhandsaboveshoulder levelcdef 1.30 1.12-1.52 1.24 1.05-1.47 0.96 0.75-1.22 0.79 0.57-1.0912-9
Working with thehandsbelowkneelevelcdef 1.17 0.97-1.41 0.74 0.58-0.96 2 1.05 0.88-1.24 0.71 0.50-1.02^
Reachingc 1.28 1.05-1.56 1.53 1.20-1.96 1.20 0.98-1.46 1.03 0.77-1.36
Forceexertionwithhandsc 1.19 1.03-1.38 1.00 0.86-1.16 1.20 1.04-1.38 0.89 0.75-1.06
Oftenbendtheneckorkeeptheneckbentforwards cdef 1.27 1.68-0.96 1.04 1.34-0.8037 1.21 0.85-1.73 0.61 0.35-1.04^"
Oftenbendtheneckorkeeptheneckbentbackwards cdef 0.60 0.37-0.99 1.54 0.78-3.04^2ZA56B1.03 0.64-1.67 1.58 0.74-3.38^^
Oftentwisttheneckorkeepthenecktwisted cdef 1.44 1.05-1.97 0.99 0.70-1.39^2A 1.15 0.79-1.65 1.14 0.76-1.7112 10
Work-relatedpsychosocial riskfactors
demands
Psychological cdef 1.58 1.19-2.11 1.22 0.90-1.6712 1.14 0.90-1.45 1.23 0.91-1.65
cdef
Skilldiscretion 1.19 0.90-1.58 1.52 1.10-2.1112 1.06 0.82-1.36 0.96 0.71-1.28
Coworker support cdef 1.41 1.07-1.85 1.26 0.89-1.7812 1.30 0.95-1.76 1.07 0.73-1.572
Supervisor support cdef 1.40 1.07-1.82 1.29 0.98-1.701-2 1.27 1.02-1.57 0.97 0.74-1.25
Jobsatisfactionc de f 0.94 0.76-1.18 0.99 0.74-1.331 1.19 0.98-1.43 1.12 0.86-1.44

a Adjustedfor:1work-home 2home-work
interference, interference, theneck,4 bending
3twisting 5working
theneckforwards, aboveshoulder
level,
6forceexertionwithhands,7jobsatisfaction,
8 baseline
shoulder symptoms, withthehands,10bending
9squeezefirmly thewrist,
11baseline
arm-hand symptoms.
bMeasured at:c= baseline,
d= follow-up1, e= follow-up2,f= follow-up
3.

Figure3. Resultsoftherelevant
gender
(genderratio[GR]<0.75 or
differences
GR>1.33 forabsencedueto musculo-
skeletalsymptoms.

90 Scand J WorkEnvironHealth,vol 35, no 2, themesection

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 Hooftmanet al

Table 5. Resultsofthemultivariateanalysesforabsence due to lowbackand neck-shoulder. Figuresinboldfaceare significant

at P=0.05,
figuresin italicshavea relevantgenderratio(GR<0.75 or GR>1.33). (OR = odds ratio,95% CI = 95% confidenceinterval)

Absence3 Lowback Neck-shoulder

Men Women Men Women

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Work-related
physical b
riskfactors
loads>5 kgodef
Lift 1.26 1.07-1.49 1.24 0.81-1.889
loads>25 kgodef
Lift 1.05 0.85-1.31 0.99 0.49-2.018910
oftheupperpartof
Flexion/rotation
thebodyodef 1.11 0.90-1.37 1.65 1.07-2.55'* ... ...
Uncomfortableworking odef
postures 1.26 1.02-1.56 1.79 1.17-2.75'* ... ...
c
a vehicle
Driving 1.21 0.96-1.52 ' 15
0.90 0.40-1.99*-" ... ...
Repeatedmovements withhandsorarmsc ... ... 1.10 0.85-1.44 0.86 0.53-1.39346916
Hand-arm vibration0 ... ... 1.18 0.87-1.60 0.88 0.39-2.002-3-4-17-18
Oftenbendthewrist orkeep
thewristbentodef ■ ■■ • •■ 0.80 0.37-1.73 0.81 0.30-2.223-4-6-17-18-19
Often thewrist
twist orkeep
thewrist
twistedcdef ... ... 0.88 0.40-1.91 2.02 '3.4.6.17,18.19
0.88-4.67
Squeezefirmlywiththehands0 ... ... 1.74 1.25-2.42 1.24 0.74-2.07™ 20
Workingwithhandsaboveshoulder levelodef ... ... 1.61 1.08-2.39 1.21 0.77-1.9091620
Workingwiththehandsbelowkneelevelode< ... ... 1,35 0.94-1.95 0.89 0.48-1.66*™
Reaching0 ... ... 7.50 1.08-2.31 0.86 0.48-1.54**™
withhands0
Forceexertion ... ... 1.56 1.20-2.02 1.50 1.07-2.11
Oftenbendtheneckorkeep
theneckbentforwards odef ■ ... 0.89 0.46-1.72 1.11 0.32-3.813-461618
Oftenbendtheneckorkeep
theneckbentbackwards odef ■ ... 0.89 0.40-1.98 2.33 0.63-8.66***™'7™
Oftentwist
theneckorkeep
thenecktwistedodef ... ... i66 0.77-3.60 1.09 0.42-2.853*7™'7
Work-related
psychosocialriskfactors
Psychologicaldemands00■•■' 1.01 0.75-1.36 0.98 0.47-2.0611 1.23 0.70-2.19 0.56 0.28-1.15***™™
odef
Skilldiscretion 1.31 0.96-1.78 0.70 0.29-1.688-11-12-13-15
1.04 0.61-1.76 0.46 0.21-1.00***™"™
Coworker supportodef 1.42 1.00-2.03 1.84 0.97-3.4715 0.48 0.26-0.86 0.92 0.46-1.86**'7™'7
Supervisorsupportodef 1.11 0.80-1.53 0.89 0.43-1.8681415 0.86 0.54-1.35 1.42 0.79-2.5720
odef
Jobsatisfaction 1.31 1.03-1.67 0.72 0.28-1.818 1.28 0.88-1.86 2.27 1.27-4.07G*20

a Adjustedfor:1home-work 2bending
interference, theneckforwards,3workingaboveshoulderlevel,4forceexertion
withhands,5jobsatisfaction,
6squeezefirmlywiththehands,7bending 8coworker
thewrist, 9education,
support, 10flexion/rotation
oftheupperpartofthebody,
11lift
loads>5kg,12workingdays,13workinghours,14busyhomeenvironment,15baselinelowbackabsence,16twisting
thewrist,
17workingbelowkneelevel,18reaching,
19repeated
movements withhandsorarms,20baselineneck-shoulder-arm-hand
absence.
bMeasured ° d
at: = baseline,= follow-upe
1, = follow-up f
2, = follow-up
3.

(GR 2.55 and 1.52,respectively). Finally,bendingthe (GR 0.55),(iv) twisting theneck(GR 0.65),(v) highjob
wristwas a largerriskfactorforhand-armsymptoms demands(GR 0.46) and (vi) low-skilldiscretion (GR
forthewomen(GR 1.54). 0.44). The effect ofexposurewas largerforthewomen
for:(i) twistingthewrist(GR 2.31),(ii) bending theneck
backwards (GR 2.63), and (iii) low coworker (GR 1.93)
Sicknessabsence
orsupervisor support(GR 1.66).Forlowjob satisfaction,
Figure3 showstherelevant GR valueforsicknessab- theresults wereinconsistent witha GR valueof0.55 for
sence.We foundno relevantgenderratiofor8 out of sicknessabsencedue to symptoms of thelowerback,
22 riskfactors.
Theeffectofdriving vehicles(GR 0.74) anda GR valueof 1.78 forsicknessabsenceduetoneck,
andlow skilldiscretion
(GR 0.53) on sicknessabsence shoulder, arm,andhandsymptoms.
dueto low-backsymptoms was largerforthementhan
thewomen.On theotherhand,bending andtwisting the
1
upperbody(GR .48) andworking inuncomfortable pos-
tures(GR 1.42) werelargerriskfactors forthewomen. Discussion
For sicknessabsencedue to neck,shoulder, hand,and
armsymptoms, relevant
genderdifferences of <0.75 (GR We expectedthewomento be morevulnerable andthe
range0.44-0.71)werefoundfor: (i) squeezing(GR 0.71), effect of exposure to be in for
larger general female
below
(ii) working kneelevel (GR 0.66), (iii) reaching participants. For musculoskeletal symptoms, we found

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Gender differencesin riskfactorsformusculoskeletalsymptoms

a relevantgenderdifference forat leastone symptom shoulder symptoms, and(iii) 1.29forcoworker support

regionfor6 of22 riskfactors; thewomenhada higher andtheabsenceoflow-backpain.Had theseGR values
riskin onlytwocases. In an earliersystematic review beeninterpreted as relevant,itwouldhavecloudedour
(20), strongevidenceforgenderdifferences was only resultssince,exceptforsupervisory support,theypoint
foundforthreeriskfactors, forwhichtwomenhadthe in a directionoppositeto thatof theGR valuewe had
higherrisk.For theremaining riskfactors, we found considered relevantthusfar.
either inconclusive evidenceorno evidencefora differ- ifthereview'scutoff
Similarly, pointswerealtered
ence.Ourresults seemsimilar tothoseofthereview, but to 1.33, the conclusionwould change forthe rela-
wereinthesamedirection onlyforlifting andlow-back tionbetweenkneeling-squatting and lower-extremity
symptoms. In thereview, strong evidencewas foundfor complaintsfrom"inconclusive"to "no evidence"for
womenhavinga higher riskofneck-shoulder symptoms a genderdifference. Fortheremaining riskfactors,
the
due to exposureto awkwardarmpostures,while,in reviewconclusionswouldnotchange,as mostof the
ourstudy,a GR value of 0.63 was foundforshoulder resultswerealreadyinconclusive.
symptoms due to workingwiththehandsbelowknee
level.Furthermore, we foundno genderdifference for
ofthestudy
Limitations
theeffect ofhand-arm vibration, while,inthereview,it
was concludedthattherewas strong evidencethatmen A limitation of thestudywas thatbothexposureand
havea higherriskof neck-shoulder symptoms due to outcomewerebasedon self-reports. Ifeither themenor
exposure to hand-arm vibration. thewomenhad systematically under-or over-reported,
If we combinethe resultsof our studywiththe theresultscouldhavebeenbiased.Weaskedworkers to
resultsofthereview,therestillis strongevidencethat rateboththeirexposureand symptoms on a four-point
theeffectof lifting is largerformenthanforwomen. scale ("never","occasionally", "often", or "veryoften"
However,theevidencefora genderdifference in the forexposureand "no,never","yes,sometimes", "yes,
effectof hand-armvibration on armposturebecomes regular", and"yes,prolonged" forsymptoms). Thisposes
inconclusive. Fortheremaining riskfactors, therewas twopossibleproblems.
eitherno evidencefora difference or inconclusive First,do menandwomeninterpret thesetermsinthe
evidence. sameway?Men and womenhavebeenfoundto differ
For sicknessabsence,we founda relevantgender in symptom description.Forexample,Ekmanet al (30)
difference for14 of the22 riskfactors.For six risk foundthatmenand womenwithchronicheartfailure
factors, womenhad thehigherrisk;forsevenrisk
the choosedifferent descriptorsofbreathlessness whenthey
factorsthemenhad thehigherrisk;and forone risk havetodescribe theirsymptoms. Similarly,Vodopiutz et
factortheresultswere inconsistent forthe different al (3 1) foundthatmenwithchestpaindescribe theirpain
symptom regions. The review included onlytwostudies concretely, whilewomenusea morediffuse descriptionof
on sicknessabsence;therefore, itis difficulttocompare chestpain.However, theseresultsonly show thatwomen
results.It shouldbe notedthat,forsicknessabsence, use different wordsthanmen;theydo notuse more(or
we foundmuchmoregenderdifferences thanforsymp- less)severedescriptors. Furthermore, exposure reporting
toms.Thisdifference seemstobe predominantly caused maybe influenced byanxiety about,as wellas experience
by psychosocial risk factors. We found absolutelyno with,a riskfactor(32). On average,womenseemto be
gender differences in the effect of psychosocialrisk moreconcerned abouthealthmatters thanmen(33) and,
factorson symptoms. However, sicknessabsence,
for therefore, could be to
expected over-report theirexpo-
we founda relevantgenderdifference forat leastone sure.Thisphenomenon was indeedfoundbyHanssonet
symptom region for all of the psychosocial riskfactors. al (34), butwas contradicted byLeijonet al (35). Since
Low supervisor or coworker support seemed to havea theresultsofthesestudiesdo notconsistently showthat
larger effect on women, whilehigh demands orlow-skill either menorwomenover-report theirsymptoms, we find
discretion seemed to have a larger effect on men. The itunlikely thatourresultscanbe explained completely by
for
results job satisfaction were ambiguous. a genderdifference inreporting aboutexposure.
Followingtheworkof Leino-Arjas(29), we used Second,womenin theNetherlands workpart-time
cutoff pointsof0.75and1.33todetermine relevant gen- moreoftenthanmen.Therefore, eventhoughtheterms
derdifferences. The aforementioned review(20) used mayhavethesamemeaning forbothgenders, theweekly
different cutoff points, namely, 0.75and1.25.Therefore, cumulative workexposureforwomenwouldstillinfact
in ourstudy,it was harderto finda work-related risk be lower.In theDutchpopulation, about90% of the
factorthatimplieda largerriskforthewomenthanin menworkat leastfivedaysa weekcompared with63%
thereview.WefoundthreeGR valuesbetween1.25 and of Dutchwomen.Therefore, ifmenand womenreport
1.33: (i) GR 1.26 forbendingtheneckforwards and equalexposure, thecumulative exposure ofmen,infact,
necksymptoms, (ii) GR 1.28 for skill discretion and be An
may higher. equal mechanism could be causedby

92 Scand J WorkEnvironHealth,vol 35, no 2, themesection

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 Hooftmanet al

intraclass
confounding, meaning thatwithin
an exposure physicalriskfactorsforwork-related musculoskeletal
category,menand womenmay experiencedifferent disorders?), whofoundno significant genderdifferences
exposures(eg,menlining>25 kgmaybe lifting weights inexposure toawkward postures amongmenandwomen
thanwomenwholift>25 kg)orbecausewomen
heavier doingthesametasks.Itthusseemsas ifmenandwomen
whobendtheirnecksmaydo it forlongerperiodsthan perform specific isolatedtasksina slightly differentway,
men.Therefore, if theeffectof exposureon menand but,inthelargerpicture of"a day'swork",thesediffer-
womenwereequal,we mayfinda largereffect on men. encesmaybecomeobsolete.
However, sincewe foundno genderdifferenceformost A thirdpossibility is thatmenand womendiffer in
oftheriskfactors,
a larger
effectonmenthanonwomen theirexperience of pain.Manylaboratory studieshave
cannotcompletelyexplainourresults. beenperformed to examinegenderdifferences in pain
perception. Womenwerefoundto have a lowerpain
threshold, independent oftheexactstimulus, forexample,
Explaining gender differences
thermal stimuli(hotandcold)(48-50),electrocutaneous
Formostoftheriskfactors, we foundnorelevant gender stimulation (51),andpressure (52).Thisdifference inpain
differences.Ifwedidfinda difference, itmoreoften meant perception hasbeenattributed totheinfluence ofsexhor-
thatthemenhada higher risk.Therefore, ourresultsdo mones(53) andgender roleexpectations (54). Ellermeier
notprovideconvincing evidencethatthevulnerability & Westphal(52) used pupilreactionsto measurepain
hypothesis is thebasisfortheexcessofmusculoskeletal intensity resulting froma high-pressure stimulus. Pupil
symptoms at somebodysitesamongwomen.Theques- reactions arerelatedtopainbutareunlikely tobe biased
tionofwhatexplainsthisexcessremains unanswered. byattitude orculture and,therefore, canbe considered to
Anotherexplanation forthegenderdifferences in be anobjective measure ofpain.Theirresults showedthat
sicknessabsencedue to musculoskeletal symptoms is womendidnotonlyreport morepain,butalso showed
theexposurehypothesis, whichimpliesthatwomen morepupildilation. Thisfinding indicates thatpartofthe
maysimply be more exposed to some risk factorsthan gender difference in pain is due to the factthatwomen
men.Bothat workand at home,thedivisionof labor indeedfeelmorepain.However,thereporting of pain
seemstorunatleastpartly alonggenderlines,resulting also seems to be influenced by social expectations. Rob-
in different jobs and tasks for men and women. Such inson and hiscolleagues have examined the influence of
a difference may lead to different and role on
possiblyhigher gender expectations pain.They found thatwomen
exposureforwomen.However,genderdifferences in areviewedas morewillingto report pain(55) andthat,
musculoskeletal symptoms have also been found be- while women have a lower painthreshold, lowertoler-
tweenmenand womenwithinthesame occupational ancetopain,andlowertemporal summation ofpain,these
class (36) and withthesametasks(37). Furthermore, differences betweenmenand womencouldbe (partly)
ithas beenshownthatthegenderdifference in muscu- explainedby genderroleexpectations (56). It was also
loskeletalsymptoms and relatedsicknessabsencedid shownthatpain-rating behavior couldbe influenced and
notdisappearaftercorrection fora widevariety ofboth that, whena gender-specific expectation ofpaintolerance
physicalandpsychosocial riskfactorsat workas well wasgivenbefore thetest,there werenolongersignificant
as at home(Unpublished data:Hooftman WE, van der gender differences inpaintolerance (56). Combined with
BeekAJ,BongersPM, et al. Genderdifferences in the theresults ofEllermeier & Westphal (52), thesefindings
prevalence ofmusculoskeletal symptoms arenotcaused showthatwomennotonlydetectpainatan earlierstage,
byexposuredifferences). butare also morewillingto reporta stimulus as being
Moreover, evenifmenandwomenperform thesame painful.Forourpresent study, thisfinding mayimply that
tasks,genderdifferences in exposuresto work-related womensimply moreoften report (relatively small)symp-
riskfactors mayoccurdueto genderdifferences in task tomsthatareunrelated toexposure, whilemenreport the
performance. When the task performance of menand moreseveresymptoms causedbyexposure.
womenwasstudied ina laboratory situation,themenand However, ifthiswerethecase,itcouldbe arguedthat
womenwerefoundtoperform thesametaskdifferently, thegenderdifference in musculoskeletal painwouldbe
theresultbeingdifferences in external (18, 38-41), as higher forsymptoms thanformoreobjectiveendpoints,
wellas internal (18, 42-45),exposures. However, when butitdoes notappearto be so. Punnett & Herbert (13)
taskperformance was studiedattheworkplace (eg,with showedthatsomeofthelargest genderdifferences have
videorecordings), no significant differences in external beenfoundinstudieswithrelatively restrictive casedefi-
exposure were found (46, 47). This finding supports the nitions.In ourstudy, we foundmoregenderdifferences
resultsofHooftman et al (Unpublished data:Hooftman forsicknessabsencethanforsymptoms. Therefore, the
WE, van der Beek AJ, van de Wal BG, Burdorf A, Knol extenttowhichgenderdifferences inpainexperience ex-
DL, BongersPM, etal. Equaltask,equalexposure? Are plainthegender differences inmusculoskeletal symptoms
menandwomenwiththesametasksequallyexposedto remains unclear.

Scand J WorkEnvironHealth,vol 35, no 2, themesection 93

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Receivedforpublication:27 February2008
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