Forskning som miljösköterska

… vägen dit?

… väl där?

… sen’ då?

NU-dagarna Malmö 8 maj 2014

Kerstin Kronholm Diab

Regionmiljösköterska, Med Dr

Min historia

Utbildning inom hälso- och sjukvård …

• 1976 Leg sjuksköterska

• 1981 Hälso- och sjukvårdsadministration, 60 hp

• 1983 Vidareutbildning i medicin och kirurgi, 30 hp

• 1985 Arbetsmiljölära,15 hp

• 1986 Företagssköterskeutbildning

• 2002 Vårdvetenskap, 31 – 80 hp

• 2003 Kvalitativa forskningsmetoder

• 2004-12 Doktorand, halvtid (8 år)

Forts Min historia

Arbete?

1977 Kirurgi - Helsingborgs lasarett

1978 Gynekologi - Morges, Schweiz

1979 – 82 Olika sjukskötersketjänster inom primärvård,

gerontologi, MVC

1982 – 91 Företagshälsovård, Malmö

1991 Arbets- och miljömedicin, Lund

Vad hände när jag hade bestämt mig?

Ansökan – antagning 2004-12

Huvudhandledare Jørn Nielsen

Biträdande handledare Edith Andersson

Arbete, kurser, arbete …..

Mittseminarium 2011-11

Slutseminarium 2014-01

Disputation 2014-04

Forskarutbildning (240 hp)

Totalt kurskrav, 22.5 hp

Obligatoriska forskarkurser

• Introduktionskurs, 1 hp

• Forskningsetik, 1.5 hp

• Statistiska metoder inom medicins forskning, 1.5 hp

• Vetenskaplig kommunikation, 1.5 hp

• Muntlig kommunikation, 1.5 hp

Valbara forskarutbildningskurser

Portfoliosystem

Avhandlingen, minst 180 hp

Delmål

Vilka kurser valde jag utöver obligatoriska?

• EndNote - referenshantering

• SPSS - statistikprogram

• Hur man skriver och illustrerar en vetenskaplig artikel

• Introduktion till epidemiologisk metodik

• Kvalitativa metoder med fokus på forskningsintervjun

• Advanced course in Grounded Theory – Situational Analysis

• Livskvalitet som utfallsmått i vårdforskning, KI

• Yrkes- och miljömedicin - tillgodoräknande

Female hairdressers Respiratory symptoms, mechanisms and health-related

quality of life and their views on the work environment

Kerstin Kronholm Diab

Arbets- och miljömedicin, Lund

Hairdressing – dream profession?

In 2010 about

• 2 400 work sites with an average of three employees

• 15 000 one-man enterprises

• 5 700 employees

• mean age just above 30 years

• 85 – 90% female hairdressers

• 2600 hairdressers graduated

• about 40% still active 8 years after graduation

• affiliation to Occupational Health is very low, 12-13 %

In 2005 – 2009

• Hairdressers reported 292 work-related illnesses

• Female hairdressers reported more cases of hypersensitivity and skin

problems than all branches of activity

Hairdressing

Hairdressers are exposed to numerous hair chemicals in

hair dyes, bleaching products, permanent wave solutions,

hair sprays and various styling products potentially

harmful to the airways.

Bleaching products contain persulphates (ammonium,

potassium and/or sodium persulphates) in concentrations

up to 60%, and are mixed with an oxidizing agent, mostly

hydrogen peroxide. During mixture powder or granules

whirl in the air and are easily distributed to the eyes and

the airways.

Young hairdressers

In a cohort of just below 300 recently graduated

hairdressers in Southern of Sweden examined

2006 – 2010 …

… about 50 % atopics

… 25 – 32 % nasal symptoms

… 8 – 14 % ocular symptoms

… 2 – 9 % dry cough

… 2 – 8 % wheeze/dyspnea

Ur Aktuellt fredag 4 april

http://www.svt.se/nyheter/sverige/var-tredje-frisor-drabbad-

av-arbetsrelaterade-nasbesvar

Frisör med både näsbesvär och astma arbetar trots sina

besvär

Overall aim of the thesis

To gain knowledge of …

the occurrence of asthma,

the mechanism of work-related nasal symptoms,

the variations in respiratory symptoms and effects on

the health-related quality of life during a work period,

how young hairdressers reason about their work

environment

Studies

Study I (1997-98) Cohort, retrospective study

Study (2002) Nasal challenge study

Study III II (2004-05) Cohort, short term study

Study IV (2009-11) Qualitative interview study

Papers I - IV

I Albin M, Rylander L, Mikoczy Z, Lillienberg L, Dahlman Hoglund A, Brisman J, Toren

K, Meding B, Kronholm Diab K, Nielsen J. Incidence of asthma in female

Swedish hairdressers. Occup Environ Med 2002, 59;2:119-123.

II Kronholm Diab K, Truedsson L, Axmon A, Nielsen J. Persulphate challenge in female hairdressers with nasal hyperreactivity suggests immune cell, but not IgE reaction. Int Arch Occup and Environ Health 2009, 82;771-777.

III Kronholm Diab K, Jönsson BAG, Axmon A, Nielsen J. Work related airway symptoms, nasal reactivity and health related quality of life in female hairdressers - a follow-up study during exposure. Int Arch Occup Environ Health 2014, 87:61–71.

IV Kronholm Diab K, Nielsen J, Andersson E. Swedish female hairdressers’

view on their work environment – a qualitative study. Journal of Occupational Health 2014,56;2:2014; 56:100–110.

Study I

Aim

To examine the risk of asthma

To examine if hay fever during childhood, smoking and specific

hair treatments have an impact on the risk of asthma

Retrospective corhort study of 3 957 female hairdressers and

4 905 referents from the general population

Postal questionnaires

Self-reported asthma and time of onset

Hair treatments – bleaching and hair spray

Employment time

Study I

Results

Hairdressing work moderately increased the incidence

of asthma. Hay fever during childhood and smoking

did not modify the risk from hairdressing work.

The time to onset of asthma was 6 years among the

participating hairdressers

The incidence of asthma was slightly higher, but not

significant, in the most frequent users of bleaching

products and hair spray than in the others.

Study II

Aim - To examine the meaning and the mechanism of

persulphate in hairdressers with bleaching powder-associated

rhinitis

Nasal challenge with potassium persulphate

3 groups – female hairdressers with bleaching powder-

associated nasal symptoms, asymptomatic hairdressers and

atopic women

Outcomes

Nasal symptoms

Acoustic rhinometry

Inflammatory markers in nasal lavage fluid

Specific serum antibodies to potassium persulphate

Lymphocytes in blood

Study II

Results

Symptomatic hairdressers had an increase in nasal

symptoms and in albumin in the nasal lavage

Atopics reacted to a lesser intent

Symptomatic hairdressers had an increase in Th1

cells

No evidence of a Type 1 reaction to potassium

persulphate

Study III

Aim

To examine how respiratory symptoms, inflammatory

markers and nasal reactivity against persulphate

develop in hairdressers with bleaching powder-

associated rhinitis during one month of exposure after

an exposure-free period

To examine how HRQoL is influenced during this work

period and to compare the HRQoL with that of pollen

allergic women during the season

Study III

Diary of symptoms and work tasks during 4 weeks 3 groups – female hairdressers with bleaching powder-associated nasal

symptoms, asymptomatic hairdressers and pollen allergic women (during

the first month of the season)

Outcomes

• Nasal symptoms

• Work tasks

• Inflammatory markers in nasal lavage fluid

• SF-36 and RQLQ

• Nasal reactivity (symptomatic hairdressers)

Study III

Results

Symptomatic hairdressers increased steadily in nasal symptoms

parallel to a decrease in HRQoL during the exposure period

Symptomatic hairdressers used more hairspray

Albumin in nasal lavage of the symptomatic hairdressers increased

after 1 w, and further enhanced after 4 w

ECP in the nasal lavage of the symptomatic hairdressers was

significantly higher after 4 w of exposure compared to after 1 w

Nasal reactivity to potassium persulphate did not increase during the

exposure

Study IV

Aim

To examine how hairdressers after three to four years

of work reason about their physical, social and

psychological work environment with special focus on

work related risks, possibilities to influence,

implementation of knowledge, financial impact and

impact of work related symptoms

Study IV

Qualitative interview study with 14 hairdressers

Covering aspects of the physical, social and psychological

work environment

Open ended interviews using a thematic guideline

Opening question: How is your work environment?

Recorded interviews, verbatim transcription

Manifest and latent content analysis

Study IV

Main findings

An awareness of the impact of the work environment

and the possibilities of influencing it, but also an

inability to achieve preventive improvements emerged

Various symptoms did not change this

The organization, teachers and the acceptance of the

work environment were important issues

Making the work environment an active part of their

business was not common

Main theme

AWARENESS of the impact of the work environment and of possibilities to

influence it

Themes Subthemes

Seeing one’s work environment Influencing the work environment

Applying knowledge

Planning work

Seeing one’s customers Adjusting to the customer’s needs

Caring for the customer

Seeing one’s profession Developing and continuing in the

professional role

Being creative and getting variation at

work

Seeing one’s symptoms Accepting one’s symptoms

Managing one’s symptoms

Managing one’s waste

Är det värt allt arbete?

Absolut, om du …

• har ett område/frågor som väcker ditt intresse

• kan förankra det

• är nyfiken

• vill vidareutvecklas

• är analytisk

• har energi och tid

… är det jätteroligt och enormt stimulerande

och utvecklande att doktorera ….

Hur gör man?

Förslagsvis kontakta

• Professor Irene Jensen på Kompetenscentret för företagshälsovård, http://www.fhvforskning.se/, professornharordet.blogspot.se

- forskning inom företagshälsovård

• Annan institution

- kan vara arbets- och miljömedicinsk enhet, universitet/ högskola med arbetsforskning, eller någon annan institution inom din intressesfär

• Leta efter doktorandtjänst

• Mer information om forskarutbildning i Lund på http://www.med.lu.se/utbildning/utbildning_paa_forskarnivaa

More hairdresser studies-

Exposure

2012 – 2013 Chamber study of bleaching

• 12 hairdressers with nasal bleaching powder-associated symptoms performed bleachings and the concentration of particles and irritating compounds were examined

• Symptoms and imflammatory markers were measured before,

during and after the exposure

• The results are still preliminary, but it seems that mixing is

crucial for the exposure, and also the dried bleach

Sara börjar blanda

blekmedel i exponerings-

kammaren

More hairdresser studies-

Exposure

More hairdresser studies-

Prospective for three years

Follow-up study of recently graduated hairdressers

(results are being processed)

• To understand the selection out of the profession

• To see the incidence of respiratory symptoms

Follow-up study of hairdresser students for three years

• To understand the selection out of the hairdressing

schools

• To see the incidence of respiratory symptoms

Skin symptoms

Incidence of skin symptoms

Hairdressers

• Hairdressing 23,8 per 1000 py

<25 years of age 37,1 per 1000 py

Change of profession due to skin symptoms

• Hairdressers 6,2 %

• Referents 1,9 %

LIND M et al., 2007. Incidence of hand eczema in female Swedish hairdressers.

Occup Environ Med, 64, 191-5.

Praktiska slutsatser för frisörer

• Det finns ett kemikalieproblem

• Medvetandet om detta bör höjas

• Höjd skyddsnivå (ventilation, handskar)

• Ventilationskrav bör förtydligas

• För tidigt för rekommendationer om enskilda produkttyper

• Dialog med frisörer, leverantörer och

tillsynsmyndigheter

Ekologiska färger hos Friekosör, Stockholm

Rekommendationer för frisörer

• Skydda huden mot hårfärgämnen

- Byta handskar mellan varje kund

- Använda handskarna endast en gång!

- Klippa håret före färgningen

• God ventilation – allmän, dragskåp, punktutsug

• Frisörprodukter – byta ut farliga produkter

• Korrekta arbetsmetoder – och växla mellan arbetsuppgifterna

• God hygien

Diskutera frisörernas arbetsmiljö?

Mitt telnr 046-17 31 79

Min email kerstin.diab@skane.se, kerstin.diab@med.lu.se

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Länkar – artiklar om frisörers arbetsmiljö • Arbetsmiljöforskning - http://www.arbetsmiljoforskning.se/search/node/fris%C3%B6rer

Arbetsliv - http://www.prevent.se/sv/Arbetsliv/Sok-i-artikelarkivet/

• Naturskyddsföreningen -http://www.naturskyddsforeningen.se/nyheter/giftiga-harprodukter-pa-frisorsalongen

http://www.naturskyddsforeningen.se/sveriges-natur/2010-4/harvardsprodukter-som-skadar

• Arbetsmiljöverket – http://www.av.se/dokument/publikationer/rapporter/RAP2012_06.pdf

file:///I:/Bra%20arbetsmilj%C3%B6%20f%C3%B6r%20fris%C3%B6rer.pdf

• Forskning.se -http://www.forskning.se/nyheterfakta/nyheter/nyheterfranforskningse/kemikalierutgorhalsoriskforfrisorer.5.61fbca9812ec690a32180001030.html

• Miljösamverkan Skåne - http://projektwebbar.lansstyrelsen.se/miljosamverkanskane/Sv/projekt/pagaende-projekt/Pages/frisorer.aspx

• Hållbar Utveckling Skåne (HUT) - http://www.hutskane.nu/projekt/avslutade-projekt-3/hallbar-frisor/

• Frisörtidningen – fyra artiklar under 2012 (nr 4,6,8,10)

• Bulletin 2012:2, s 4, 6, 1012:3 s 2 - http://www.skane.se/sv/Webbplatser/Labmedicin_Skane/Verksamhetsomraden/Arbets--och-miljomedicin/Publikationer/Bulletin---Nyhetsbrev/