Health and Safety Executive

Triggers for non-specific symptoms in the workplace Individual differences, stress and environmental (odour and sound) factors

Prepared by the University of Nottingham and the Health and Safety Laboratory for the Health and Safety Executive 2006

RR501 Research Report

Health and Safety Executive

Triggers for non-specific symptoms in the workplace Individual differences, stress and environmental (odour and sound) factors

Professor Eamonn Ferguson BSc, PhD, CPsychol, AFBPsS, FRSH Dr Helen J Cassaday MA, PhD Ms Jane Ward BSc, MSc School of Psychology University of Nottingham Nottingham NG7 2RD

Dr Andrew Weyman BSc, PhD Health & Safety Laboratory Harpur Hill Buxton Derbyshire SK17 9JN

Non-Specific Symptoms (NSS) are symptoms that are not related to any given disease and include fatigue, weakness, sleep difficulties, headache, muscle aches. They have a high reported incidence in the work place and are related to workplace absenteeism. Work-related ill-health and absenteeism remain a significant concern for UK organisations and employees alike, translating into 32.9 million working days a year lost through illness, with stress, depression and anxiety accounting for the majority of days lost (13.4 million). Identifying aspects of the work environment, characteristics of individual workers, external factors and physiological factors that contribute to reporting non-specific symptoms are therefore important and make them the focus of this research.

This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.

HSE Books

© Crown copyright 2006

First published 2006

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Acknowledgements

We would like to acknowledge the time and support of all the organisations who took part in this work and to their staff who took the time to complete the surveys, diaries, saliva sampling and the experimental odour chamber study. We would also like to thank Professor Colin MacKay for his support over the course of this project.

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INDEX

INDEX 3

EXECUTIVE SUMMARY 7

GENERAL BACKGROUND ..........................................................................................................................7

VARIABLES ASSESSED ..............................................................................................................................7

GENERAL FOCUS AND ADVANCES .......................................................................................................8

GENERAL METHODOLOGICAL RATIONALE .......................................................................................8

GENERAL FINDINGS.....................................................................................................................................8

1. INTRODUCTION 9

1.1 RATIONALE .......................................................................................................................................9

1.2 QUESTIONS ADDRESSED ...........................................................................................................9

1.3 SYMPTOMS, WORK AND ABSENTEEISM ...........................................................................10

1.4 MODELS OF SYMPTOM REPORTING ....................................................................................10

1.5 ENVIRONMENTAL FACTORS....................................................................................................13

1.6 PSYCHONEUROIMMUNOLOGICAL APPROACHES ..........................................................15

1.7 METHODOLOGICAL RATIONALE FOR THE RESEARCH PROGRAMME ..................17

2. METHOD 19

2.1 THE RESEARCH PROGRAMME DESIGN AND PROCEDURES. ....................................19

2.2 SELECTING THE INITIAL COHORT AND SURVEY METHODS ......................................19

2.3. DAILY DIARIES...............................................................................................................................22

2.4 ATMOSPHERE CHAMBER STUDY ..........................................................................................26

2.5 DATA ANALYSIS ...........................................................................................................................26

2.6 SMELLS AND SOUNDS FREQUENCIES ................................................................................27

2.7 SMELLS AND SOUNDS VALENCE ..........................................................................................28

3. PATTERNS OF SYMPTOMS 34

3.1 OVERVIEW.......................................................................................................................................34

3.2 ENTRAINMENT TO DAYS AND WEEKS – TIME LINKED COVARIATE........................34

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3.3 RESULTS & DISCUSSION ..........................................................................................................34

4. COMPARING MODELS: CROSS-SECTIONAL SURVEY 35

4.1 OVERVIEW.......................................................................................................................................35

4.2 LISREL MODELLING ....................................................................................................................35

4.3 RESULTS..........................................................................................................................................36

5. PREDICTING DAILY SYMPTOM VARIATION 44

5.1 OVERVIEW.......................................................................................................................................44

5.2 TYPES AND FREQUENCIES OF ODOURS AND SOUNDS EXPERIENCED ...............44

5.3 MULTI-LEVEL MODEL ANALYSIS – MEAN SYMPTOMS .................................................44

5.4 LAGGED EFFECTS OF STRESS, SOUND AND ODOUR ..................................................45

5.5 DISCUSSION ...................................................................................................................................46

6. PHYSIOLOGICAL MEDIATORS 48

6.1 OVERVIEW.......................................................................................................................................48

6.2 BACKGROUND MEASURES ......................................................................................................48

6.3 DAILY MEASURES ........................................................................................................................48

6.4 SAMPLES .........................................................................................................................................49

6.5 BACKGROUND COVARIATES ..................................................................................................49

6.6 S-Ig-A AND CORTISOL ASSAYS..............................................................................................49

6.7 RESULTS..........................................................................................................................................50

7. ATMOSPHERE CHAMBER 52

7.1 RATIONALE .....................................................................................................................................52

7.2 HYPOTHESES.................................................................................................................................53

7.3 METHOD ...........................................................................................................................................53

7.4 RESULTS..........................................................................................................................................56

7.5 DISCUSSION....................................................................................................................... 56

8. DAILY JOB DEMANDS AND CONTROL 59

8.1 INTRODUCTION .............................................................................................................................59

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8.2 METHOD ...........................................................................................................................................59

8.3 RESULTS..........................................................................................................................................60

8.4 DISCUSSION ...................................................................................................................................61

9. CONCLUSIONS & RECOMMENDATIONS 62

9.1 KEY FINDINGS AND SUPPORTING EVIDENCE ..................................................................62

9.2 RECOMMENDATIONS – PRACTICAL .....................................................................................63

9.3. RECOMMENDATIONS – RESEARCH......................................................................................63

10. ORGANIZATIONAL FEEDBACK 65

11. REFERENCES 66

11. APPENDICES 75

11.1 APPENDIX 1: SYMPTOM DIARY...............................................................................................75

11.2 APPENDIX 2: SALIVA DIARY ....................................................................................................87

11.3 APPENDIX 3: JOB CHARACTERISTICS DIARY ..................................................................99

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EXECUTIVE SUMMARY

GENERAL BACKGROUND

Non-Specific Symptoms (NSS) are symptoms that are not related to any given disease and include fatigue, weakness, sleep difficulties, headache, muscle aches. They have a high reported incidence in the work place and are related to workplace absenteeism. Work-related ill-health and absenteeism remain a significant concern for UK organisations and employees alike, translating into 32.9 million working days a year lost through illness, with stress, depression and anxiety accounting for the majority of days lost (13.4 million). Identifying aspects of the work environment, characteristics of individual workers, external factors and physiological factors that contribute to reporting non-specific symptoms are therefore important and make them the focus of this research.

VARIABLES ASSESSED

The following key variable are examined in relation to non-specific symptoms –

1. Work/job characteristics a. Job Control – the amount of control someone perceives they have over their

work b. Job Demands – the amount of work someone perceives that they have to do

(e.g., time pressure) c. Job Stress – the extent to which someone describes their job as stressful.

2. Individual Characteristics d. Neuroticism – the extent to which someone is emotionally unstable, and

perceives the world in a generally negative way e. Positive affectivity – the extent to which someone perceives the world in a

generally positive way f. Health anxiety – the extent to which someone worries about their health g. Chemical intolerance – the extent to which someone believes that everyday

chemicals (e.g., paint) make them feel ill 3. Environmental Characteristics

h. Odour – assessments of daily experience of odour, how severe these are and what they are (e.g., paint)

i. Sound – assessments of daily experience of sound, how severe these are and what they are (e.g., drilling)

4. External Factors / parameters j. Time of the day and day or the week – do people report more symptoms at

particular times of the day or week? That is, independent of the factors described in 1-3, is it the case that people just feel less well in the afternoons or on Monday?

5. Physiological k. Cortisol – a hormone that provides a general index of physiological stress l. Salivary Immunoglobulin A – this is general index of the integrity of mucosal

aspects of the immune system m. Pro-inflammatory cytokines levels – an aspect of the immune system associated

with symptoms that are similar to NSS (e.g., pain, fatigue, fever etc.)

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GENERAL FOCUS AND ADVANCES

• No previous study has examined all of the above variables within a single study, within an occupational setting.

1. This makes it possible to examine the importance of a variety of individual characteristics, work-characteristics, external factors and physiology as predictors of NSS

• This study is the first to highlight and explore the role of daily odour. 2. Odour has been experimentally linked to symptom reporting but never

explored in an occupational setting

• This study is the first to explore time of day and day of week effects

GENERAL METHODOLOGICAL RATIONALE

The work reported here uses a mixture of cross-sectional survey (e.g., personality measures, general symptoms), longitudinal design, 8 day diary methodology (symptoms, work-characteristics, odour, sound, cortisol and SIg A assessed AM and PM) and an experimental exposure study (exposed or not exposed to Toluene at 3 parts per million). The design is nested such that those in the initial survey were invited to participate in the diaries and those in the diaries to participate in the experiments. The longitudinal, diary and experimental studies were designed to explore the predictive status of the individual differences, job-characteristics and environmental factors with respect to symptom reports. This is important as stress is theoretically a process.

GENERAL FINDINGS

The following general conclusions can be drawn from the results of this research –

1. Odour is related to occupational symptom reporting

a. The extent to which people rate odours as a trigger for symptoms is related to greater symptom reporting

b. Stronger odours are related to an increase in future symptom reporting. Also there was evidence that lingering odours were associated with increased symptom reporting

c. People reported increased respiratory symptoms when exposed to low concentration (3 ppm) sub-threshold levels of Toluene

d. The most frequently cited odours were – cooking, paint, smoke and coffee

2. There are a number of time of day and day or the week effects

e. Daily symptom assessments were higher in the afternoon

3. Appraisals of the work environment (especially control and stress) continue to be important with respect to work related symptom reporting.

4. Individual differences (Health anxiety and Neuroticism) were significant predictors of symptom reporting, in the work place.

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1. INTRODUCTION

1.1 RATIONALE

This research compares three theoretical perspectives on symptom reporting in the workplace. The perspectives examined are: (1) personality (neuroticism and positive affectivity) (Feldman, Cohen, Doyle, Skoner, & Gwaltney Jr., 1999; Watson & Pennebaker, 1989), (2) job-characteristics (job-control, stress & job demands) (Karasek & Theorell, 1990) and (3) environmental factors (odour and sound) (Ferguson & Cassaday, 2002). No single occupational study has compared all three perspectives. Therefore, the main aims of this work are to (1) integrate these within a single programme of research and (2) explore their relative efficacy with respect to predicting occupational symptom reporting. These aims are addressed with respect to a series of questions.

1.2 QUESTIONS ADDRESSED

The main and subsidiary questions addressed in this report are detailed below. The main questions ask the extent to which psychological factors (personality, job-characteristics/stress and environmental factors) predict symptom reporting and the role of physiological parameters in this process. The subsidiary questions address the idea that symptom reporting may relate to natural cycles of work. Exploring these cycles is important if we want to show that psychological and physiological factors can independently predict symptom reports above and beyond natural cycles.

1.2.1 The Main Questions – psychological & physiological prediction

1. To what extent are levels of general symptoms and daily reported symptoms predicted by (1) personality, (2) job-characteristics and (3) environmental factors?

2. Are daily symptom reports related to endocrine (Cortisol) and immunological (Salivary Immunoglobulin A) factors?

3. Does exposure to a specific odour alter reports of symptom severity and alter immune system parameters (Interleukin-6 and Ig E), and is this related to personality, job-characteristic and environmental triggers?

1.2.2 The Subsidiary Questions – natural symptom cycles

1. Are symptom reports linked to aspects of the daily/weekly working cycle? For example, do people tend to report more symptoms in the afternoon or towards the end of the working week?

Answers to these questions should allow for a more detailed set of conclusions regarding both the predictors of symptom reports, and the development of interventions. The remainder of this introduction details (1) why symptoms at work are a problem, (2) the three main theoretical perspectives and why it is important to integrate these, and finally (3) the methodological rational for the programme of research.

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1.3 SYMPTOMS, WORK AND ABSENTEEISM

Work-related ill-health and absenteeism remain a significant concern for UK organisations and employees alike. The national household survey (Occupational Health Statistics Bulletin, HSE, 2002/2003) of 2001/2002, estimated that 2.3 million people in Great Britain were suffering from an illness they believed was caused or made worse by their current or past employment. This translates into an estimated 32.9 million working days a year lost through illness, with stress, depression and anxiety accounting for the majority of days lost (13.4 million). Moreover, the number of people suffering from work-related stress has more than doubled since 1990 (O’Neill, 2003), with more than 7,000 more cases of work-related mental health problems each year (Occupational Health Statistics Bulletin, HSE, 2002/2003). Therefore, investigating the causes of work-related ill-health is clearly a priority for both UK employers and employees. One particular avenue to explore in this context is the nature and structure of non-specific symptom reporting in the work place.

1.3.1 Non-Specific Symptoms

Non-Specific Symptoms (NSS) can be conceptualised as symptoms which, in and of themselves, are not related to any given disease. Symptoms which come under the NSS umbrella include fatigue, weakness, sleep difficulties, headache, muscle aches and joint pain, dizziness, dry mouth and shortness of breath (Barsky & Borus, 1999) and are often reported in a number of clinical syndromes such as chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, and multiple chemical sensitivity (Wessely, Nimnuan, & Sharpe, 1999).

Focusing on NSS in the work place is important for the following reasons:

• These symptoms have a high incidence in working populations. For example, 22% of the Dutch working population (Kant et al, 2003) and 54% of healthcare workers in a UK study (Hardy, Shapiro & Borrill, 1997) reported fatigue.

• NSS are associated with increased absenteeism (Vaananen, Toppinen-Tanner, Kalimo, Mutanen, Vahtera & Peiro, 2003; Piirainen, Rasanen & Kivimaki, 2003).

Understanding predictors of NSS in general has wider implications:

• There is a high incidence of NSS in the general population (Verbrugge & Ascione, 1987, Creed & Barsky, 2004; Rief, Hessel & Braehler, 2001; Hiller & Fichter, 2004). About 35% of UK medical outpatient admissions are accounted for by symptoms with no apparent pathology (Hamilton, Campos & Creed, 1996; Wessely et al, 1999).

There is a consensus developing in the literature that NSS should be treated as a single symptom cluster (Barsky & Borus, 1999; Ferguson & Cassaday, 1999 & 2002; Wessely et al, 1999). Therefore, in this report we focus on a single factor of NSS, which also provides a wider applicability to occupational health.

1.4 MODELS OF SYMPTOM REPORTING

Symptoms have to be sensed, perceived, interpreted and expressed. Psychological processes are involved in each of these steps (Pennebaker, 1982; Van den Bergh, Winters & Devriese, 2002). There are a number of theoretical models and approaches that have been suggested to explain symptom reporting. This report integrates these and examines them in an occupational setting.

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There are three main approaches that we will consider within the scope of this project: personality, job characteristics, and environmental triggers.

1.4.1 Personality

Two major personality domains are explored in this research: Neuroticism/Negative Affectivity (N/NA) and Positive Affectivity (PA).

1.4.1.1 Neuroticism / negative affectivity.

N/NA is a personality domain conceptualised as concerning an individual’s emotional reactivity, tendency to worry and susceptibility to negative mood (Costa & McCrae, 1987).

N/NA is studied as (1) it offers a parsimonious construct that subsumes other personality domains (e.g., hopelessness and self-esteem, ‘hardiness’ and dispositional optimism) (Marshall, Wortman, Vickers, Kusulas & Hervig, 1994), (2) it has been shown to be the most consistent predictor of symptom reporting (Cohen , Doyle, Skoner, Fireman, Gwaltney & Newsom, 1995; Deary, Clyde & Frier, 1997; Feldman et al, 1999; Korotkov & Hannah, 2004; Watson & Pennebaker, 1989), and (3) it is the focus of specific theoretical models that have been developed with respect to N/NA and symptom reporting (e.g., Watson & Pennebaker, 1989).

The major theoretical perspective with respect to N/NA and symptom reporting is the symptom perception hypothesis (Watson & Pennebaker, 1989). This hypothesis suggests that people who score high on N/NA show attentional and memory biases with respect to the interpretation and recall of symptoms, which are not related to physiological parameters of disease (the psychosomatic hypothesis) (Larsen 1992; Pennebaker, 1982; Watson & Pennebaker, 1989; Williams & Wiebe, 2000).

However, some recent work on Type D personality suggests that N/NA may be related to physical health outcomes. Type D personality (‘distressed personality’: Denollet, 2000; Pedersen & Denollet, 2003) is based on two broad traits of N/NA and social inhibition (SI). There are an increasing number of studies that support the notion that this combination of personality traits is associated with increased risk of mortality from heart disease, (Denollet Stroobant, Romboits, Gillebert & Brutsart, 1996; Denollet, Vaes & Brutsaert, 2000).

1.4.1.2 Positive affectivity.

PA reflects general levels of energy and enthusiasm, with individuals high in this dimension judged to lead full and interesting lives, with a high activity level (Watson & Clark, 1984). PA has been relatively less studied in respect to health and health behaviours (Watson & Pennebaker, 1989). However, recent evidence suggests that PA may be an important factor associated with positive health outcomes and shown to be related to (1) reduced reporting of NSS (Cohen, Doyle, Turner, Alper & Skoner, 2003), (2) slower progression through HIV (Moskowitz, 2003), and (3) enhanced immunological functioning (Davidson, Coe, Dolski & Donzella, 1999; Scheier & Carver, 1987).

The influence of PA on environmental appraisals (e.g., perceived control) is explored in this programme of research, as a potential mechanism by which PA influences symptom reports.

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1.4.2 Work characteristics: nature of work, job-characteristics & stress

To date, much of the research with respect to health and well-being in the workplace has focused upon the impact of job characteristics and stress. Job-characteristics are referred to here as subjective appraisals of the work environment. The basic idea is that certain aspects of the work environment will be deleterious to individuals’ health by leading to feelings of stress (Karasek & Theorell, 1990; Siegrist, 1996). The research reported here focuses primarily on three aspects of work: (1) the nature of work (job status), (2) perceived control and demands, and (3) emotional stress.

1.4.2.1 Nature of the work environment – job status

For the purpose of this research job status and tenure will be used to define more objective indices of the work environment.

Status is important as there is evidence indicating that people in lower status jobs report: (1) worse health outcomes (Gallo, Bogart, Vranceanu & Walt, 2004) and (2) lower job-control (Niezborala, Marguie, Baracat, Esquirol & Soulat, 2003). There is also evidence from the animal and human physiological literature showing that lower status (occupational and rank) is related to increased levels of ‘stress’ hormones and reduced immune system function (Craig, Boylan, Yip, Mijares, Inman, Socransky, Taubman & Haffajee, 2002; Fitchett, Collins, Mason, Barnard & Cassaday, 2005).

1.4.2.2 Emotional stress and perceived control

Two main models of occupational stress have dominated the current literature. These are: (1) the Job Demand-Control (JDC) model (Karasek, 1979) and (2) the Effort / Reward Imbalance (ERI) model (Siegrest, Peter, Junge, Cremer & Seidel, 1990).

Demands

Low High

l

Hi in i

i Hi in

Contro

gh

Low

Low Stra Act ve

Pass ve gh Stra

Figure 1 Job Demands / Control Model (Karasek, 1979)

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The JDC model (see Figure 1) focuses on two dimensions of the work environment: job demands and job control. Job demands refer to the degree of workload experienced by an employee (e.g., time pressure). Job control is conceptualised as an employee’s ability to control his or her work activities.

Stressful jobs are those defined as ‘high strain’ and are related to increases in physical health problems (e.g., heart disease), psychological distress and symptom reporting (Karasek Baker, Marxer, Ahlbom & Theorell, 1981; Van der Doef & Maes 1998; Van der Doef & Maes, 1999).

The ERI model defines a stressful work environment as one where the employee perceives an imbalance between the amount of effort (intrinsic) they have put into their work, and the rewards (financial, status) they receive (Siegrest et al, 1990). There is recent evidence to support this model with respect to physical symptoms and psychosomatic symptoms (see van Vegchel de Jonge, Bosma & Schaufeli, 2005, for review).

Results from studies which have compared the relative contribution of each model, showed that perceived control added to the prediction of physical symptoms (Bosma Peter, Siegrist & Marmot, 1998; de Jonge, Bosma, Peter & Siegrist, 2000; Ostry, Kelly, Demers, Mustard & Hertzman, 2003; Calnan Wadsworth, May, Smith & Wainwright, 2004).

Perceived control. As well as contributing to work stress, perceived control is widely studied in the general literature on symptom reporting. There is evidence that reduced levels of control are related to increases in both physical disease (e.g. de Gucht, Fischler & Heiser, 2003) and psychosomatic symptom reporting (e.g. Fox, Dwyer & Ganster, 1993; Bond & Bunce, 2003). Perceived control also has a long history with respect to stress after-effects, such as anger (e.g. Hahn, 2000) and reduced problem solving (Cox, 1978), as well as forming a conceptual basis for understanding depression and negative affect (e.g. Abramson, Seligman & Teasdale, 1978; Brown & Siegel, 1988).

Therefore, perceived control and a general index of perceived stress were assessed across the studies. An additional diary study explored specifically the daily effects of demand and control on daily symptom reporting.

1.5 ENVIRONMENTAL FACTORS

Odour is explored here as a factor from environmental and behavioural medicine that has been studied as a predictor of symptom reporting. There are a number of mechanisms by which odour may influence symptom reporting: (1) learning, (2) individual differences in sensitisation, (3) toxicity, and (4) top-down cognitive processes.

1.5.1 Odour and learning to report symptoms

The idea that people can learn symptoms is derived in part from evidence of flavour aversion (Garcia & Koelling, 1966; Siegel & Kreutzer, 1997). A familiar example is that people learn to avoid foods that have made them ill. This happens rapidly in humans and other animals, with a single paring of an odour/flavour and the illness inducing stimuli (one trial learning). Once this association is learned it is very hard to unlearn. As with food and drink, the smell of the food or even just thinking about it can re-activate the feeling of illness.

In a similar manner everyday non-toxic odours experienced in the work place can become associated with symptoms experienced in the workplace. These symptoms may be caused by a number of factors: (1) actual illness (e.g., having a cold), (2) feeling anxious, (3) having a vaccination and so on. After a few pairings the odour acts as a trigger for the symptoms. As

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with flavour aversion many pairings of odour and symptoms are not required, and once learned, such an association is hard to forget. This model has recently been extended to clinical presentations with respect to Gulf War Syndrome (Ferguson & Cassaday, 1999, 2002; Ferguson, Cassaday & Bibby, 2004).

There is a substantial body of experimental evidence to support this idea in healthy humans (Van den Bergh, Kempnyck, de Woestijne, Baeyens, & Eelen, 1995; Van den Bergh, Stegen, & de Woestijne, 1997; Van den Bergh, Stegen, & de Woestijne, 1998; Van den Bergh et al, 1999; Devriese et al, 2000; Winters et al, 2003). The learning effects were most pronounced for respiratory symptoms and do not occur for unrelated ‘dummy’ symptoms (Van den Bergh, Winters & Devriese, 2002). Furthermore, conditioning occurs with foul smelling odours. Therefore, while participants are not consciously aware of the associative process, it appears that odour valence is important (cf. Van den Bergh et al, 2001).

Cultural / organizational factors may also operate to influence these processes. Winters et al (2003) found that information about the potential harm of chemical substances facilitated the learning of symptoms in response to odorous chemicals. Extrapolating from this, it may be the case that those working in industries where chemicals are used, may be cognitively sensitised to link odour and symptoms (Alexander & Fedoruk, 1978).

In conclusion there is evidence that odour can act as an associative trigger for symptom reporting and that this associative process may be moderated by organizational expectations.

1.5.2. Multiple chemical sensitivity & chemical intolerance

A second way in which environmental odour can act to trigger symptoms is through a process of direct neurological sensitisation resulting in multiple-chemical sensitivity (MCS) or chemical intolerance (CI). The idea is that people produce an allergic like response to everyday chemicals at levels most people can tolerate and are well below the point at which the chemical has any toxicity. CI is seen as a preclinical precursor to the more severe MCS and defined as the ‘…subjective manifestation of experiencing an altered sense of smell and feeling ill (e.g., nausea, headache, difficulty in breathing) from the odour of low levels of common environmental chemicals such as perfume, solvents, pesticides and gasoline’ (Szarek Bell, & Schwartz, 1997: p 346). Bell and colleagues have produced a large body of data to support the sensitization process for CI (Bell et al, 1996a; Bell, Wyatt, Bootzin & Schwartz, 1996b; Bell et al, 1997; Bell, Schwartz, Hardin, Baldwin & Kline, 1998a; Bell, Baldwin, Russek, Schwartz, & Hardin, 1998b). People who score highly on CI show increased levels of depression and somatization (Szarek et al, 1997), life stress (Bell et al, 1998b) and health concerns (Fiedler, Kipen, DeLuca, Kelly-McNeil, & Natelson, 1996).

An individual differences perspective to CI is taken in the research (see Szarek et al, 1997), as individuals high in CI tend not to have high unemployment rates (Szarek et al, 1997). Therefore, it may have relevance to occupational stress and absenteeism. However, CI has never been explored in an occupational setting, or in relation to personality and job-characteristics.

1.5.3. Toxicity

The third way in which odour may influence ill-health at work is via direct toxicity. Direct exposure to chemical odours, at high concentrations, may have direct effects on physiological systems, which in turn may lead to transient or permanent damage. Examples of this relate to the potential effects of organophosphates (Lotti, 1991). As well as leading to direct physical changes and pathology, such exposures may also lead to either of the two psychological processes described above. This report does not focus on exposure to toxic doses of chemicals

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in the work place, as this topic has been extensively studied and Government guidelines are in place. Rather, this report focuses on the role and experience of everyday non-toxic odours.

1.5.4. Top-down cognitive processes

There is evidence to show that the information that people are provided with about the same odour (e.g., harmful, healthful or neutral), influences not only the pattern of rated intensity of the odour, but also the number of symptoms associated with the odour (Dalton, 1996; 1999; Dalton, Wyocki, Brody & Lawley, 1997; O’Mahony, 1978). The basic pattern of results indicates that if people are told that an odour may be harmful (e.g., the odours used are known to have harmful effects), they rate it as less pleasant and associate it with a greater number of symptoms than if it is described as healthful or left with no description. This obviously has implications for social processes, whereby an odour (one that is not harmful) becomes associated with ill effects, as this mis-attributional bias becomes applied across an organization (see Alexander & Fedoruk, 1978). Indeed, people have even been shown to report symptoms to an odour when no odour is actually present (O’Mahony, 1978; Slosson, 1899).

1.5.4. Summary

The processes described above highlight a number of mechanisms through which odour can effect symptom reporting. The aim of this report is to show in occupational settings that the experience of odour is related to symptom reporting and to compare this to more traditional approaches to symptom predictions: individual differences and job-characteristics/stress. The role of odour is explored in terms of (1) an individual difference in relation to reported sensitivity to odour (chemical intolerance), (2) the relationship between the experience of daily odour and symptoms and finally (3) in terms of unconditioned effects (exposure to odour and symptom reports).

1.6 PSYCHONEUROIMMUNOLOGICAL APPROACHES

N/NA, job-control, stress and odour have all been related to increased symptom reporting, and one possible mechanism underlying these effects is changes to immune system factors. Three potential markers are explored here: (1) cortisol, (2) cytokines, and (3) immunoglobulins.

1.6.1 Cortisol and the Hypothalamic-Pituitary-Adrenocortical (HPAC) Axis

It has long been recognised that the HPAC axis is a key neuroendocrine system that is activated by stress (Argyropoulos et al, 2002). Dysfunctions of the HPAC axis are associated with immunological illnesses such as rheumatoid arthritis, upper respiratory tract diseases and susceptibility to infectious disease (e.g., Chowdrey & Lightman, 1993; Griep, Boersma, & Dekloat, 1993).

The hormone cortisol is one of the final end products of the HPAC axis that participates in the regulation of homeostasis, and controls the organism’s response to stress. During periods of chronic stress, cortisol has the effect of suppressing the immune system, as well as inhibiting the systems responsible for reproduction and growth (Tsigos & Chrousos, 2002). Cortisol is, therefore, often viewed as a physiological marker of the body responding to a stressor or strain, and is a useful means of objectively measuring the body’s stress response to a wide range of stressors. Indeed, in terms of daily work stress there is evidence that stressful events are associated with increased cortisol secretion in white collar workers (van Eck, Berkhof, Nicolson & Sulon, 1996).

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Cortisol shows a diurnal pattern with peak cortisol levels observed shortly after awakening and steadily decreasing thereafter in the absence of significant external stimulation (Stone et al, 2001). The peak morning cortisol levels may be diagnostic of chronic work stress, as it has been shown to be enhanced in individuals with chronic work overload (Schulz, Kirschbaum, Prüßner & Hellhammer, 1998) and high strain jobs (Steptoe, Cropley, & Joekes, 1999 & 2000; Steptoe & Cropley, 2000), but blunted in individuals suffering from ‘burnout’ (Prüßner, Hellhammer & Kirschbaum, 1999).

In summary, cortisol provides a good general objective physiological marker of the HPAC stress response and links to immuno-regulation.

1.6.2. Cytokines

When experiencing physical or physiological stress, the body responds with a series of actions in an attempt to repair the damage, promote wound healing, contain the invading organisms and activate defence mechanisms, such as the immune response. Together, these reactions are termed the acute phase response (APR). The APR is characterised by fever, and a collection of behaviours collectively known as the ‘sickness response’, which include reduced movement, reduced food intake, and increased sleep (Black, 2002; Hart, 1988; Maier & Watkins, 1998). The symptoms of the ‘sickness response’ are almost identical to those often reported as NSS (see Ferguson & Cassaday, 1999). Therefore, the sickness response may in part underlie the reporting of NSS. The sickness response is related to the cytokines Interleukin-1 (Il-1) and indirectly to IL-6.

Cytokines can also, however, act as a physiological marker for psychological stress. Many studies indicate that various psychological stressors can alter pro-inflammatory (e.g., IL-1) cytokine secretion (Black, 2002; Maier & Watkins, 1998). Chronic stressors such as anticipation of academic examinations and caring for sick relatives have been found to result in increases in levels of Il-1 and Il-6, as well as other cytokines (Maes et al, 1998; Lutgendorf Vitaliano, Tripp-Reimer, Harvey & Lubaroff, 1999). The central question is whether or not cytokine activity links perceptions of work stress (or odour) to symptom reporting. Does cytokine activity mediate the stress-symptom reporting or the odour-symptom reporting link?

In summary, cytokine activity as indexed by IL-1 and IL-6 provide some indication of the immune system’s initial reactivity to stress. This is particularly important with respect to NSS as the sickness response produces a pattern of symptoms and behaviour that characterise NSS. As such they provide an important potential biological link to NSS reporting.

1.6.3 Immunoglobulin (IgA & IgE)

1.6.3.1 Salivary Immunoglobulin A (S-IgA).

Salivary Immunoglobulin A (S-IgA) offers an index of general of IgA activity and is believed to be indicative of overall immune status across mucosa (Mestecky, 1993). Therefore, S-IgA offers a useful index of immune system integrity with respect to mucosa. NSS include general upper-respiratory tract infections (URTIs). Immunoglobulin A is responsible for protecting mucosa membranes from infection.

S-IgA has been shown to be reduced when participants perceive their environment to be stressful (Wetherall, Hyland & Harris, 2004; Yang et al, 2002). Therefore, in the context of this research, it would be expected that negative job-characteristics / stress should be related to reduced S-IgA. The main question then becomes does S-IgA link perceptions of stress to symptom reporting, indicating that the symptoms may reflect a biological susceptibility? Or, is

16

the relationship between stress and symptom reporting independent of immune system activity, indicating a purely psychological route?

1.6.3.2 Immunoglobulin E (IgE).

The primary function of this immunoglobulin is with respect to allergic reactions (Kuby, 1997). Specifically, higher levels of IgE are associated with an increased allergic response. Within the context of NSS and odour, IgE is important as the sensitization model suggests that this is based, in part, on an allergic type response.

In terms of perceived stress, whilst there is some evidence to suggest that IgE increases under conditions of chronic stress, to date there is no data on IgE and acute stress (Evans, Hucklebridge & Clow, 2000; Bernton, Hoover, Galloway & Popp, 1995). Therefore, it would be expected that those who report more chronic work stress should have higher levels of IgE, and that this should be even higher for those with higher scores on chemical intolerance.

1.7 METHODOLOGICAL RATIONALE FOR THE RESEARCH PROGRAMME

1.7.1 Basic programme of research

This programme of research aims to identify the relative importance of a number of predictors of NSS. The identification of predictors necessitates some demonstration of causality and ruling out other possible explanations (Ferguson & Bibby, 2003; Ferguson & Kerrin, 2004; Ferguson, 2005). To this end, this research uses a mixture of a cross-sectional survey that forms the basis of a longitudinal component and diary methodologies. Finally an experimental study is conducted. The survey will help to establish correlates of symptoms in terms of personality, chemical intolerance and job control. The longitudinal component and diary aspect should help to show any lagged effects for personality, odour and stress. In the final experimental study exposure to a low concentration odour is manipulated, to see if being exposed does in itself have unconditioned effects on symptom reporting.

More specifically an initial cross-sectional survey was conducted and this became the cohort from which future longitudinal samples were drawn. The initial assessments on this cohort formed the baseline measures for the future longitudinal analyses. These included measures of personality (N, NA and PA), job-characteristics (job-control) and general levels of symptom reporting, as well as background variables (chemical vs non-chemical industry). Given the emphasis on odour, the chemical vs non-chemical industry distinction made it possible to explore any effects attributable to peoples experience in organizations where they might make different attributions about the causal role of odour.

Sub-samples of volunteers from the initial cohort then completed a series of diary studies. In these diaries participants completed assessments of symptoms, stress, and experiences of odour and sounds twice a day (AM and PM) for eight days. A further sub-sample also collected saliva samples 3 times a day (on waking, AM and PM) to be assayed for cortisol and S-IgA. The ‘causal’ roles of job stress and odour were examined through lagged effects. For example, does the experience of odour in the morning lead to increased levels of symptoms in the afternoon? To rule out the possibility that there is just increased environmental awareness, experiences of sound are also assessed and these should not show the types of relationship observed for odour. Finally, to rule out sensitisation processes, a measure of chemical intolerance was taken at baseline, and scores on this were used to statistically control for effects of sensitisation. The daily assessments of stress allowed for a comparison with a traditional job-characteristic model. The baseline measures of personality and job-control meant their direct effects on future symptom reporting could be observed.

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Finally, an experimental blinded chemical exposure study was performed on a small sample of those from the original cohort who also completed the diaries. In this study it was possible to observe if exposure to a non-irritating chemical at very low concentration (3 parts-per-million) influences immune system parameters and symptom reporting. This would show that odour – at low concentration – has an unconditioned effect on symptom reports (it is unconditioned as there is no learning phase in this study).

1.7.2 Organizations studied.

The main environmental factor explored in this research is odour. As such in all cases a comparison will be made (where statistically appropriate sample sizes are present) between those working in occupations where chemicals are used, and those working in occupations where chemicals are not used. This is not because it is thought that those working with chemicals are exposed, rather it is to explore if working in a particular context psychologically sensitizes people to make particular attributions (explanations) about their symptoms. In this way the generalisability of the result is improved.

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2. METHOD

2.1 THE RESEARCH PROGRAMME DESIGN AND PROCEDURES.

A nested cohort design with mixed methods was used. That is, an initial cohort of participants was recruited and baseline measures taken. From this cohort, sub-samples were selected on a volunteer basis to participate in future fixed-interval diary and experimental studies (see Figure 2).

2.2 SELECTING THE INITIAL COHORT AND SURVEY METHODS

Five organisations took part in this study. Organisations were initially contacted by letter, which was followed up, where requested, by a presentation by the research team. Contact with all of the organisations was made through their Personnel or Health and Safety departments.

Three organisations were City Councils whilst the other two organisations were a manufacturing plant and a chemical plant. Participants were employees of these ‘host’ organisations.

In each organisation, the research team worked with staff to identify the sample as well as addressing any specific issues management wished to consider.

Data was collected using a questionnaire format. In all cases the questionnaires were distributed to the identified sample of employees by our key contact within each organisation. Participants returned their questionnaires directly to the University of Nottingham using pre-paid envelopes.

2.2.1 Cohort participants

A total of 711 participants completed the questionnaire from across the five organisations equating to an average response rate of 16%. The mean age of the sample was 41 years (SD = 10.2), with 43% of the sample male and 5 participants not specifying their gender. Mean job tenure was 71.2 months (SD = 77). Mean organisational tenure was 128.6 months (SD = 109.6).

2.2.2 Survey measures

The questionnaire comprised a series questions concerning basic demographics, plus standard measures relating to health, individual differences and job characteristics, reflecting predictors, mediators, covariates and outcomes.

2.2.2.1 Predictors

Demographics. Participants were asked to indicate their sex, age, organisational tenure and tenure within their current job. Participants were also asked to indicate their contractual hours, and if their job contained any form of supervisory responsibility, and also indicate the type of work they did, from full to temporary.

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Figure 2 Diagram of study design

Undertaken on 4th-5th

October 2004.

Survey

–

3-

U

-

-

SURVEY

DIARY 1

DIARY 2

SALIVA DIARY SYMPTOM DIARY ONLY

ATMOSPHERE CHAMBER STUDY

Undertaken between September 2002 April 2003

Undertaken in January 2003, and again in January 2004.

Diary 1 undertaken between 9 months after Survey

ndertaken in September 2003, and again in July 2004.

Diary 2 undertaken between 11 15 months after Survey

Atmosphere Chamber undertaken between 16 24 months after

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SURVEY N = 711, Mean Age = 41, 43% Male, Mean Organisational Tenure = 128.6 months, Mean Job Tenure = 71.2 months

DIARY 1 N = 190, Mean Age = 42, 39% Male, Mean Organisational Tenure = 131.3 months, Mean Job Tenure = 58.3 months

DIARY 2 (TOTAL) N = 53, Mean Age = 41, 46% Male,Mean Organisational Tenure = 143.4 months,Mean Job Tenure = 58.3 months

SALIVA DIARY N = 44, Mean Age = 41, 41% Male,Mean Organisational Tenure = 152.1 months,Mean Job Tenure = 65.5 months

SYMPTOM DIARY N = 9, Mean Age = 43, 67% Male,Mean Organisational Tenure = 101.7 months,Mean Job Tenure = 23.7 months

ATMOSPHERE CHAMBER N = 12, Mean Age = 43, 17% Male, Mean Organisational Tenure = 76.3 months, Mean Job Tenure = 50.8 months

Neuroticism. This was measured using the Neuroticism items from the short-scale version of the Eysenck Personality Questionnaire (EPQ; Eysenck, Eysenck & Barrett, 1985), which is a shortened 12-item version of the original EPQ (Eysenck & Eysenck, 1975). In this scale, participants were required to indicate whether a statement related to them, using a dichotomous Yes or No response. Example items include ‘do you suffer from nerves?’ and ‘are you feelings easily hurt?’. This measure showed good internal consistency: α = .83. This scale is scored as a continuous measure with high scores equating to higher levels of neuroticism.

NA/PA. This was measured using the PANAS developed by Watson, Clark and Tellegen (1988). For this research, we were assessing trait negative and positive affectivity, and therefore asked individuals to indicate to what extent they generally felt the feelings and emotions described on the 20-adjective checklist. The PANAS uses a 5-point Likert-type scale (where 1 = ‘very slightly or not at all’; to 5 = ‘extremely’). Example items include words such as ‘scared’, ‘guilty’ and ‘hostile’ for negative affectivity, and ‘strong’, ‘alert’ and ‘determined’ for positive affectivity. Our sample did not differ significantly from the authors’ original norm data for an adult population within the ‘General’ time frame instruction, and both scales showed good internal consistency: Negative Affectivity - α = .88; Positive Affectivity - α = .89. These scales are scored as a continuous measure with high scores associated with high levels of negative affect, and positive affect respectively.

Job Control. This was measured using a scale developed to assess worker control and decision authority (Dwyer & Ganster, 1991). Subjects were asked to consider their current job, and respond to each question using a 5-point response format (where 1 = ‘very little’; to 5 = ‘very much’ α = .90). Example items for this scale include ‘how much control do you have personally over how much work you get done?’, and ‘how much are you able to predict what the results of decisions you make on the job will be?’ This scale is scored as a continuous measure, with high scores equating to a higher amount of perceived control in one’s job.

2.2.2.2 Mediators

Health Anxiety. This was assessed using a nine-item version of the Whiteley Index (Pilowsky, 1967; Barsky, Wyshak, & Klerman, 1986). Subjects were asked to respond using a 5-point response format (where 1 = ‘strongly disagree’; to 5 = ‘strongly agree’; α = .74). Example items on this scale include ‘I am afraid of illness’, and ‘if I feel ill and someone tells me I look better, I become annoyed’. This scale is scored as a continuous measure with high scores equating to increased levels of health anxiety.

Chemical Intolerance. This was measured using the Chemical Intolerance Index (CII) (Szarek et al, 1997). The CII asks participants to self-report the frequency of feeling ill from the odour of five substances: pesticide, paint, perfume, car exhaust and new carpeting. Ratings are made using a 5-point Likert-type scale (where 1 = ‘almost never’; to 5 = ‘almost always’: α = .79). Example items include ‘drying paint’ and ‘new carpet’. This scale is scored as a continuous scale with high scores equating to increased chemical intolerance. Cut-off scores have been suggested for this scale. These range from 20 or greater (Bell, Baldwin, Russek, Schwartz & Hardin, 1998), using median splits (Bell, Schwartz, Bootzin, & Wyatt, 1996) of 22 or greater (Ferguson, Cassaday & Bibby, 2004). This later cut-off is based on findings that clinically ill, chemical-intolerant patients score an average of 22 on the CII (see also Bell, Peterson & Schwartz, 1995; Bell et al, 1998b).

2.2.2.3 Covariates

Masking. This was measured using an index developed as part of the Quick Environmental Exposure and Sensitivity Inventory (QEESI) (Ashford & Miller, 1998). This 10-item measure gauges ongoing exposures that may affect an individuals’ awareness of their

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intolerances, as well as the intensity of their responses to environmental exposures. Participants were required to indicate if they had experienced an exposure by answering Yes or No. Example items for this measure include ‘do you smoke once a week or more often?’, and ‘do you routinely use perfume, hairspray or other scented personal care products?’. This scale is scored as a continuous measure with high scores equating to higher numbers of masking behaviours.

2.2.2.4 Outcome variables

Non-Specific Symptoms (NSS). These were measured using a 12-point checklist derived from Isaac et al (1995) and Robins and Kirmayer (1991). Symptoms included breathlessness, dizziness, and pain in joints. Participants were asked to consider to what extent they have experienced the symptoms contained within the list, during the previous six-month period. Participants had to indicate the severity of their experience of any given symptom, using a 6-point Likert-type scale (where 0 = ‘have not experienced the symptom’, to 5 = ‘have experienced the symptom very severely’: α = .80). This scale is scored as a continuous measure with high scores equating to a greater severity of symptoms experienced.

2.3. DAILY DIARIES

2.3.1 Procedures

The diary study phase of the research programme aimed to examine symptoms and their environmental triggers longitudinally. This part of the project comprised two diary studies, both completed twice daily, over an eight-day period. The first diary study (Diary 1) was undertaken in the winter months, with the second study (Diary 2) undertaken in the summer months. The purpose of undertaking diaries across two seasons was to control for seasonal effects in symptom reporting – e.g. allergic reactivity in the summer months, and symptoms associated with colds and influenza in the winter months.

Those participants completing the questionnaire were asked if they would like to volunteer for the second diary phase. Those who were interested in participating were asked to indicate their interest by completing the removable perforated form at the back of the questionnaire booklet. Participants were asked to give their email address and / or telephone number, in order for a member of the research team to contact them further about participating in the second study. Having made a note of the subject ID number, all forms were removed and stored separately from the questionnaires, to ensure the anonymity of the data.

Prior to contacting the participants further, the Research Team agreed the diary procedure with host organisations, and negotiated a mutually suitable diary study period over which time the participants would undertake the diaries. This period comprised either a 2- or 3-week period, from which participants could identify which week would be easiest for them to complete the diary.

For Diary 1 (Winter months), participants were formally contacted between 2 – 7 months after the initial questionnaire study. The length of this period was dependent upon the time commitments for the host organisation, and the proximity of the initial questionnaire distribution to the season allocated for the first diary study. At this stage, volunteers were sent further information about the diary study, and asked to confirm their continuing interest in participating in the study.

For Diary 2 (Summer months), only participants who had undertaken Diary 1 (Winter months) were contacted again, to enquire if they wished to participate in a further summer diary study. Participants were approached between 4-6 months after having undertaken Diary 1. Again this time period was dependent upon the commitments for both the Research Team

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and the host organisation. As with the first diary study, participants were provided with information about Diary 2, and asked to indicate their interest in continuing their participation in the study. Those taking part in this diary were also asked to provide 3 saliva samples each day (on waking, AM and PM).

For both diary studies, having confirmed their interest with the Research Team, participants were sent a ‘Project Pack’ during the week prior to commencing the diary study. For Diary 1, this pack contained the symptom diary, participant information and consent forms, and 8 pre-paid envelopes. For Diary 2, those undertaking the saliva-sampling were additionally sent 24 sterile sampling kits, further information and consent forms, as well as a short medical questionnaire.

All participants throughout both diary studies were required to complete and return consent forms to the Research Team with their first daily diary sheet.

2.3.2 Design of the symptom and odour diary

Common to both Diary 1 and Diary 2 was the symptom and odour diary (Appendix 1). Participants were required to complete this twice per day, over an 8-day period. This diary asked participants to complete two identical half-day sections, once at lunchtime (AM), and once again in the evening or after work (PM). At the end of each day, having completed both morning and afternoon sections of the diary, participants were then required to post the daily diary sheet back to the Research Team directly, using the pre-paid envelopes provided. Participants were asked to indicate what the day and date were at the top of the page. They were also asked whether they were completing the diary late, and whether they were at work that day. This information was collected to help assess compliance. A diary return was judged to be non-compliant if the participant indicated that the diary was being completed late. All non-compliant assessments were removed from the data prior to analysis. If the participant had not indicated whether or not the diary was being completed late, the assessment was regarded as missing –complaint data and removed prior to analysis.

It is important to assess compliance in diary completion, due to its potential affect upon accuracy of recording and the impact upon causal inference. For example, if X is believed to predict Y, it is critical that both factors have been recorded accurately and in the reported temporal order, for inferences about the impact of X upon Y to be made. It is for this reason that all data recorded late, or where there is missing data about the lateness of completion, was removed from the data, in order to ensure only concurrent assessments in the correct temporal order, are included in the analysis.

In addition to indicating compliance, participants were also asked to consider their symptoms and report the severity of their experience of any of twelve symptoms from the same symptom checklist used in the main survey. They were then asked to identify any smells and sounds they experienced over that half-day period, as well as their strength and duration. Lastly, they were asked to indicate the extent to which they had felt stressed or anxious during that half day assessment period. See Section 2.3.6 for full details of the diary measures.

2.3.3 Design of the saliva-sampling diary

Diary 2 also had a further component. In addition to the symptom and odour diary, participants were asked to sample their own saliva, and complete a separate ‘saliva-sampling’ diary (Appendix 2). Participants were however, also given the option to undertake the symptom diary component only, as with the first diary study.

Those participants who agreed to sample their saliva were additionally provided with a pack containing 24 sterile sampling kits (Omnisal) and a saliva sampling diary. Participants were

23

asked to sample their saliva three times each day. The first sample was to be collected within twenty minutes of waking, and before activities such as brushing of teeth, or drinking or eating. The second and third samples were collected as per the times of the symptom diary – once at lunchtime (AM), and once after work, or in the evening (PM). Participants were required to complete the saliva-sampling diary in addition to the symptom diary. The saliva sampling diary asked for information regarding the time of each sample collection, as well as information regarding caffeine and alcohol consumption, and smoking.

Participants involved in the saliva sampling were additionally required to complete a short questionnaire focusing on factors which might have influenced the analysis of the saliva. Basic information was sought regarding height, weight and any medication the participant was currently taking. Questions were also asked about smoking patterns, and alcohol and caffeine related consumption. Female participants were also asked about pregnancy, and contraceptive use.

2.3.4 Participants: Diary 1 - winter diary

A total of 190 participants completed the first winter diary study, from an initial pool of 203 volunteers, equating to a response rate of 94%. Of these, 167 participants returned the full eight diary sheets, with 23 not completing the full eight days of the diary period. Overall there were 3040 potential daily assessments.

The mean age of the sample was 42 years (SD = 9.51). 39% of the sample were male, 60% were female, with 1% of participants not specifying their gender. Mean job tenure was 58.29 months (SD = 66.15), with mean organisational tenure found to be 131.28 months (SD = 110.73). 961 records were deleted due to missing data or missing compliance data, with a further 322 records deleted due to non-compliant data. In total, 1283 records were deleted on the grounds of missing or non-compliant data. Therefore, there were 1757 usable daily assessments.

2.3.5 Participants: Diary 2 - summer diary

A total of 53 participants completed the summer diary study, from an initial pool of 67 volunteers, equating to a response rate of 80%. Of these, 44 participants returned the full eight diary sheets, with 8 only completing part of the diary period. Overall there were 848 potential daily assessments.

The mean age of the sample was 41 years (SD = 7.74). 46% of the sample were male, 52% were female, with 3% of participants not specifying their gender. Mean job tenure was 58.3 months (SD = 66.20), with mean organisational tenure found to be 143.4 months (SD = 104.99). 249 records were deleted due to missing data or missing compliance data, with a further 40 records deleted due to non-compliant data. In total, 289 records were deleted on the grounds of missing or non-compliant data. Therefore, there were 559 usable days of data.

2.3.6 Symptom and odour diary measures

Daily Assessments of Non-Specific Symptoms. These were measured using the same 12-point checklist derived from Isaac et al (1995) used for the survey. Participants had to indicate the severity of their experience of any given symptom, using a 6 point Likert-type scale (where 0 = ‘have not experienced the symptom’, to 5 = ‘have experienced the symptom very severely’). Participants judged their experience of these symptoms over the morning period, and again for the afternoon period at work. Cronbach’s Alpha reliability coefficients were calculated for each half-day symptom period. Reliabilities ranged from α = 0.616 – 0.741 with a mean of α = 0.666 for the winter diary, and α = 0.354 – 0.753 with a mean of α = 0.645 for the summer diary.

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Presence and Severity of Daily Smells & Sounds. These were measured using four questions, which were asked first for smells, and then for sounds: a) ‘Did you notice any particular smell / sound?, b) ‘If YES what was it?’, c) ‘If YES for how long did you notice the smell / sound?’, and d) ‘If YES how strong was the smell?’. Smell and sound duration was measured in hours and minutes, and transferred to minutes upon data entry. The strength of smell and loudness of sound were measured using a 5-point Likert type scale. For strength of smell this scale ranged from 1 (very weak / only just noticeable) through to 5 (very strong / overbearing). For loudness of sound this scale ranged from 1 (very quiet / only just noticeable) through to 5 (very loud / overbearing). Participants were asked to make these judgements twice a day - once for experiences at work in the morning, and once for the afternoon.

Type of Daily Smells & Sounds The descriptions that people offered of the daily sounds and odours they experienced were coded using two methods. The first involved grouping sounds and odours into categories, done at the point of coding. For example, where a participant reported smelling some form of cooking or cooked food, this was grouped into the ‘Hot Food / Cooking’ category. The second coding method was to record the odours and sounds verbatim. This was done under two circumstances: a) if they were judged not to fit into a wider category (for example ‘Nitroglycerine’ and ‘Owl’), or b) if they were considered to be stereotypically ‘pleasant or ‘unpleasant’, and that the effect of the valence of the odour or sound (see below) would be lost if grouped into a wider category (for example ‘fish’ and ‘car alarm’).

Valence of Daily Smells & Sounds. Based on the codes derived above the descriptions that people offered of the daily odours and sounds were categorised as pleasant, neutral or unpleasant. In order to assess the valence of the smells and sounds, a sample of 307 undergraduate students were asked to rate the list of smells and sounds experienced by diary participants. For each smell or sound, participants were asked to categorise them as pleasant, unpleasant or neutral. A series of chi-square analysis were then conducted upon the results of these ratings. Where the chi-square analysis showed a significant difference, the residuals were consulted to indicate whether an odour would be judged pleasant, unpleasant or neutral. The valence of the odour was simply that where there was the largest discrepancy between the observed and expected counts. Where the chi-square result was non-significant, the frequencies were consulted, with the valence simply judged to be that which received the absolute largest count.

Toxicity of Daily Smells Daily odours were categorised on the basis of their ‘toxicity’. Two researchers independently rated the odours as either ‘toxic’ or ‘non-toxic’. Toxicity was defined as having the potential to cause health problems. Following this exercise, 96% agreement was reached regarding the nature of toxicity for the odours listed. Disagreements were resolved by discussion.

Daily Stress / Anxiety This was measured using a 7-point Likert-type scale, where participants were asked to rate the extent to which they had felt stressed or anxious during the half-day period (where 1 = ‘not at all’; to 7 = ‘extremely’). Participants made these judgements twice a day, once for experiences at work in the morning, and once for the afternoon.

2.3.7 Saliva-sampling diary measures

Background Information measured included the day (Monday through to Monday) and date, as well as whether the participant was working on the day in question.

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Saliva Sampling Information was gained by asking participants to report the time of waking, the time of rising and the times that each of the three samples were taken during the day. These times were recorded using a free response format.

Confounding Factors These comprised the amount of cigarettes smoked, the number of alcoholic drinks, and the amount of tea / coffee consumed during the day. In the diary instructions, participants were given information regarding the guidelines for assessing alcohol consumption, based upon Department of Health information.

2.4 ATMOSPHERE CHAMBER STUDY

2.4.1 Study Overview

The final part of the project was the Atmosphere Chamber Study. This part of the research programme aimed to examine the effects of odour upon reports of symptom severity and immune system parameters, using an experimental design in a laboratory setting. Specifically, this study tested the effects of a common paint-like odour upon the immunological factors Ig-E and some cytokines, and to what extent these relationships were moderated by personality factors (e.g. neuroticism). This study will show if there may be unconditioned effects of odour on symptom reports.

2.4.2 Methods

See Sections 7.3-7.4 for a full description of participant demographics and methods.

2.5 DATA ANALYSIS

Detailed below are the procedures for conducting the structural equation modelling and multi-level modelling procedures adopted.

2.5.1 Structural Equation Modelling

In all cases a target model was specified for the whole sample as well as for the chemical and non-chemical industrial samples separately based on zero-order correlations. To assess the impact of masking, these models were assessed again based on partial correlations controlling for masking.

The adequacy of the fit for the SEMs was assessed using the criteria specified by Hu and Bentler (1999). The following fit statistics were used: the incremental fit index (IFI), the comparative fit index (CFI), and the root mean square error of approximation (RMSEA). The CFI and IFI should approach .96 (maximum = 1.0), and the RMSEA should approach .06.

Models for the chemical and non-chemical industries were compared in terms of their significant path coefficients. The relative strength of personality, perceived control and environmental factors (chemical intolerance) were assessed in terms of their total and indirect effects (Ferguson, Daniels & Jones, 2006).

2.5.2 Multi-Level Modelling

These models are specifically focused at predicting variability in average reports of symptom severity of the 16 assessment points as well as lagged effect on symptom reporting.

Symptom reports, assessments of odour, sound, stress and time varying covariates were treated as level 1 variables with the personality (N, health anxiety and PA), job-characteristic (job control), environmental factors (chemical intolerance) and demographics/background

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(e.g., age, sex, industry type, and organizational tenure) treated as level 2 variables. The level 2 variables were measured between 3-9 months before Diary 1 and between 11-15 months before Diary 2. This allows the causal role of the level 2 variables as predictors of the level 1 assessments to be explored.

The full HLM level 1 dataset contained a potential 3888 data points, which were first screened for any missing data. If there was missing data or missing compliance data for any single record (e.g., a missing odour assessment for the AM or PM record for a particular day or missing indication of compliance) it was removed along the remaining level 1 data for that half day period. The number of level 1 records lost at this stage was 1210. Following this, the level 1 data were screened for non-compliance, where all non-compliant data was again removed along with the whole level 1 half day period. Data was defined as non-compliant when the assessment had been reported as being completed late (see Section 2.3.2). All non-compliant records were removed, with number of level 1 records lost at this stage being 362 (in total 1572 records were lost, leaving 2316 level 1 records)

This produced a complete set of compliant level 1 data. The level 2 variables were then screened for any missing level 2 assessments and subjects were removed if this was the case. After removal of subjects lost through level 1 screening, and removal of missing data from level 2, the number of subjects lost at this stage was 49. The level 1 data was again subsequently amended to remove subjects lost from the level 2 data.

Therefore of the original 243 participants 194 remained, with 49 participants having completed both the winter and the summer diaries. These were all included in the data files with a binary code to differentiate those who did and did not complete both. The scores of those who completed both were entered at level 2 twice with separate IDs that matched their level 1 IDs. This gave a final sample of 194 level 2 assessments and 2048 level 1 assessments (thus a further 268 records were lost due to missing level 2 data). (In practice analysing the winter and summer diaries separately did not produce any different results from the main file.)

In all models the pattern of temporal variability (variance-covariance) was modelled as (1) unrestricted, (2) homogeneous and (3) 1st order auto-regressive. In terms of deciding the best fit to the data the following strategy was adopted: (1) the difference between the Deviance statistics for each of these models was compared, (2) the model parameters across the three variance-covariance assumptions was compared and (3) the pattern of variance-covariance observed in the homogeneous and 1st order auto-regressive models was compared to the unrestricted model. Results from the unrestricted model are reported when it has the lowest deviance and this is significantly different from the others, when the coefficients in the unrestricted model are not substantially different to those in the homogeneous and 1st order auto-regressive models and when the a pattern of variance-covariance in the in the homogeneous and 1st order auto-regressive is similar to that observed in the unrestricted model.

In all cases, level-1 variables are group mean centred unless they are dichotomous. Level-2 variables were grand mean centred unless again they were dichotomous or trichotomous.

2.6 SMELLS AND SOUNDS FREQUENCIES

As described in section 2.3.6, when completing each half-day diary, participants were asked to report any odour and sounds they experienced during the period. These results were then coded using the system described previously. Tables 1 and 2 present the types and frequencies of odours and sounds reported in the diaries, listed by season, and by sector.

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2.7 SMELLS AND SOUNDS VALENCE

As described in section 2.3.6, the valence of the odours and sounds was rated by a sample of students and assessed using chi-square analysis. The Tables 3 and 4 display the odours and sounds reported by diary participants, and their associated valence.

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Table 1 Odour Type and Frequency, by Sector and Season

Odour

Public Private

Total W S T W S T

Hot food / 55 7 62 7 1 8 70 cooking Paint 26 - 26 8 1 9 35 Smoke / fire 19 3 22 4 3 7 29 Coffee 16 3 19 10 - 10 29 ‘Chemicals’ 1 - 1 16 1 17 18 Flowers 14 1 15 - - - 15 Perfume 10 2 12 3 - 3 15 Citrus fruit 11 1 12 2 - 2 14 Cleaning 12 - 12 1 1 2 14 products Drains 6 1 7 6 - 6 13 Petrol 7 1 8 5 - 5 13 Urine 12 - 12 - - - 12 Air freshener 6 1 7 3 1 4 11 Faeces 10 - 10 - - - 10 Cigarette 6 1 7 2 - 2 9 smoke Body odour 5 1 6 2 - 2 8 (BO) Traffic fumes 3 2 5 2 - 2 7 Aftershave 6 - 6 - - - 6 Bleach 2 - 2 4 - 4 6 Curry 6 - 6 - - - 6 Grass / damp 1 3 4 - 2 2 6 earth Printer / fax / 5 1 6 - - - 6 photocopier / toner Wax / polish 5 1 6 - - - 6 Musty 5 - 5 - - - 5 New carpet 5 - 5 - - - 5 Solvent / glue - - - 4 1 5 5 Chocolate 3 1 4 - - - 4 Chlorine 2 - 2 - 2 2 4 Herbal Tea 4 - 4 - - - 4 Onions 3 1 4 - - - 4 Toast 4 - 4 - - - 4 Chips 2 1 3 - - - 3 Fish 3 - 3 - - - 3 Garlic 3 - 3 - - - 3 ‘Hospital’ 1 - 1 1 1 2 3 Baby’s nappy 2 - 2 - - - 2 Cat food / dog 1 - 1 1 - 1 2 food

29

Table 1 (Cont) Odour Type and Frequency, by Sector and Season

Odour

Public Private

Total W S T W S T

Dogs Dust / builders dust Fresh air Highlighters / marker pens Nail varnish Olbas Oil Vegetables Anaesthetic Brewery fumes Burning food Carpet cleaner Cats Creosote Eggs Hair bleach (Peroxide) Hair spray Ink Mouldy / ‘off’ food Nitroglycerine ‘Off’ milk Ozone Radiator Rotting animal carcass Sausages Smelly shoes / feet Tar / oil Tarmac Vanilla Vomit Wet roads

2 - 2 2 - 2

1 1 2 2 - 2

1 - 1 2 - 2 - 2 2 1 - 1 1 - 1 1 - 1 - 1 1 - 1 1 - - -1 - 1 1 - 1

- 1 1 - 1 1 - 1 1

- - -1 - 1 - 1 1 1 - 1 - - -

1 - 1 - 1 1

1 - 1 1 - 1 1 - 1 1 - 1 1 - 1

- - -- - -

- - -- - -

1 - 1 - - -- - -- - -- - -- - -- - -- - -- 1 1 - - -- - -

- - -- - -- - -

- 1 1 - - -- - -- - -- 1 1

- - -- - -

- - -- - -- - -- - -- - -

2 2

2 2

2 2 2 1 1 1 1 1 1 1 1

1 1 1

1 1 1 1 1

1 1

1 1 1 1 1

Note: W = winter, S = summer and T = total

30

Table 2 Sound Type and Frequency, by Sector and Season

Sound

Public Private

Total W S T W S T

Construction 81 2 83 2 - 2 85 noise General office 43 8 51 16 7 23 74 noise Computer 38 4 42 15 10 25 67 Loud traffic 50 7 57 3 4 7 64 Drilling 52 2 54 3 4 7 61 Talking 32 10 42 4 1 5 47 Air conditioning 16 5 21 10 1 11 32 Machinery 17 1 18 11 - 11 29 Children playing 23 4 27 1 - 1 28 Fire alarm 24 2 26 - 1 1 27 Printer 27 - 27 - - - 27 Fan heater / 23 - 23 3 - 3 26 extractor fans Phone ringing 18 5 23 1 - 1 24 Television 17 - 17 5 1 6 23 Photocopier / 13 3 16 2 - 2 18 shredder Radio 10 2 12 4 2 6 18 Siren 10 4 14 2 - 2 16 Slamming doors 14 - 14 1 - 1 15 Buzzing 7 - 7 6 1 7 14 Loud music 11 1 12 1 - 1 13 Car Engine 6 3 9 1 2 3 12 Banging 10 2 12 - - - 12 Hoover 10 - 10 1 - 1 11 Central heating / 4 - 4 7 - 7 11 boiler Washing 7 - 7 3 - 3 10 machine Wind 9 1 10 - - - 10 Loud beeping 7 2 9 - - - 9 Shouting 8 1 9 - - - 9 Birds singing 4 1 5 2 - 2 7 Baby / children 2 4 6 - 1 1 7 screaming Door bell 6 - 6 - - - 6 Jet engines / 2 1 3 - 2 2 5 Aeroplanes Dog barking 3 - 3 1 - 1 4 Running Water 3 - 3 1 - 1 4 Lawn mower / - 4 4 - - - 4 strimmer Shop alarm 3 - 3 - - - 3

31

Table 2 (cont) Sound Type and Frequency, by Sector and Season

Sound

Public Private

Total W S T W S T

Alarm clock Sniffing / nose blowing Tram Car alarm Projector Supermarket noise Church bells Refuse collectors Kettle boiling Ringing in ears / tinnitus Whistling Clock Milkman Owl Coughing Hairdryer Waterfall Squeaky wheel Laughter Football crowd Heartbeat Window rattling Fax machine Steam engine

2 1 3 3 - 3

2 - 2 1 1 2 - 2 2 1 1 2

1 1 2 2 - 2 1 1 2 2 - 2

- - -1 - 1 1 - 1 1 - 1 1 - 1 1 - 1 - - -- - -- 1 1 1 - 1 1 - 1 1 - 1 1 - 1 - 1 1

- - -- - -

- - -- - -- - -- - -

- - -- - -- - -- - -

- 2 2 - - -- - -- - -- - -- - -1 - 1 - 1 1 - - -- - -- - -- - -- - -- - -

3 3

2 2 2 2

2 2 2 2

2 1 1 1 1 1 1 1 1 1 1 1 1 1

Note: W = winter, S = summer and T = total

Table 3 Odour Valence

Unpleasant Pleasant Neutral Burning food Petrol Radiator Paint Sausages Vegetables Wood smoke / fire Aftershave Ink Cigarette smoke Toast Cats Baby’s nappy Coffee Carpet cleaner Tarmac Citrus fruit Anaesthetic Drains Flowers New carpet Fish Garlic Printer / fax / photocopier /

Toner ‘Hospital’ Hot food / Cooking Cleaning products Hair bleach (Peroxide) Herbal Tea Ozone Nail varnish Curry Creosote

32

Table 3 (cont) Odour Valence

Unpleasant Pleasant Neutral Body odour (BO) Perfume Nitroglycerine Traffic fumes Olbas Oil Highlighters / marker pens Bleach Air freshener Wet roads Eggs Chocolate Brewery fumes Onions Chlorine Vanilla Musty Fresh air Smelly shoes / feet Wax / polish Mouldy / ‘off’ food Chips Urine Grass / Damp earth ‘Chemicals’ Vomit Faeces ‘Off’ milk Cat food / dog food Dogs Rotting animal carcass Solvent / glue Hair spray Tar / oil Dust / builders dust

Table 4 Sound Valence

Unpleasant Pleasant Neutral Fire alarm Talking Washing machine Loud traffic Birds singing Computer Loud beeping Owl Clock Shouting Wind Phone ringing Construction noise Loud music Milkman Buzzing Television Printer Drilling Waterfall Tram Shop alarm Laughter Fan heater / extractor fan Hoover Children playing Air conditioning Coughing Radio Photocopier / shredder Dog barking Church bells Hairdryer Siren Heartbeat Projector Baby / children screaming Running Water General office noise Car alarm Supermarket noise Squeaky wheel Car engine Alarm clock Football crowd Banging Kettle boiling Slamming doors Central heating / boiler Refuse collectors Door bell Sniffing / nose blowing Fax machine Machinery Lawn mower / strimmer Jet engines / aeroplanes Whistling Window rattling Steam engine Ringing in ears / tinnitus

33

3. PATTERNS OF SYMPTOMS: ARE SYMPTOMS RELATED TO DIFFERENT ASPECTS OF THE WORKING DAY / WEEK?

3.1 OVERVIEW

Anecdotally, people report that they feel better or worse at different times of the day or week. Theoretical models of illness also include the idea that symptoms vary over time (e.g. Leventhal, Hansell, Diefenbach, Leventhal & Glass, 1996). Indeed, there is evidence that patterns of mood are entrained to the day of the week (Larsen & Kasimatis, 1990). Is the same true for symptom reporting?

3.2 ENTRAINMENT TO DAYS AND WEEKS – TIME LINKED COVARIATE

There are a number of possibilities. For example, do people report more severe symptoms: (1) on Mondays compared to all other days [‘Monday blues effect’], (2) on working days compared to non-working days [‘work effect’], (3) in the afternoon compared to the morning [‘time of day effect’], (4) during the week compared to weekend [‘weekend effect’], (5) on days later on in the diary study [‘diary effect’ – ‘nearly the weekend’ effect’1], (6) on week days other than Fridays (‘Friday feeling effect’), and (6) during the winter months compared to the summer months [‘season effect’]. All of these were modelled. Any identified effects were included in all further models as time varying covariates unless otherwise stated.

3.3 RESULTS & DISCUSSION

3.3.1 Entrainment – time varying covariates

Using diary data from the combined summer and winter diaries multi-level model was specified to examine the: (1) Monday blues effect, (2) work day effect, (3) time of day effect, (4) weekend effect, (5) diary effect (6) Friday feeling, and (7) season effect. There was no effect on symptom reporting for whether or not participants had completed only the winter diary or both the winter and summer diaries.

The results showed that more severe symptoms were reported in the afternoons (γ = 0.54, p<.001), on Mondays (γ = 0.32, p<.05), and towards the start of the diary - nearly the weekend effect (γ = -0.06, p<.001). Thus symptom severity is related to aspect of the weekly cycle. In all subsequent models these were held as time varying covariates. When, age and sex are included, as controls of symptom reporting, in a final model with these three predictors the pattern of results is unaltered. These three time varying covariates were included in all subsequent models.

These results show that objective time linked aspects of the working week and the diary studies themselves influence symptom reporting. This is the first time that this has been shown for NSS reporting in occupational settings.

1 Because the diary study runs from Monday to the following Monday, the diary progresses towards the weekend.

34

4. COMPARING MODELS: CROSS-SECTIONAL SURVEY

4.1 OVERVIEW

The main focus of this chapter is to address the first main objective relating to comparing the relative roles of personality, job-characteristics and environmental factors in relation to symptom reporting.

The specific question addressed in the chapter -

To what extent are levels of general symptoms predicted by personality, (2) job-characteristics and (3) environmental factors?

4.2 LISREL MODELLING

4.2.1 Target LISREL path model

The structural model explored from the survey data is presented in Figure 3. Each of the paths A to Z is justified empirically and theoretically as follows:

1. Given the trait nature of N and PA, as well as their high temporal stability, these were both specified as predictors of perceived control, health anxiety, chemical intolerance and symptom reporting (path G to N). Furthermore, there is empirical evidence to support each of these paths.

2. Organizational tenure and job-status were also specified as general predictors, as these are more objective markers of occupational life. Both were specified to predict job-control, chemical intolerance and symptom severity (paths O, P, Q, R , S & T), but not health anxiety. There is evidence linking status to poorer health outcomes (path S) and it is theoretically conceivable that lower job-status is linked to reduced perceptions of control (Seligman, 1975) and perhaps a greater belief that symptoms are associated with chemical exposures. For organizational tenure, those with a longer history of work may experience more symptoms (they are also likely to be older), more control (due to familiarity with the work place) and increased perceptions of chemical intolerance due to a longer potential history of feeling exposed.

3. Perceived job-control is specified to influence chemical intolerance, health anxiety and symptom reporting (paths V, U & X). The link between perceived control and symptoms (path X) is well established in the literature. There is also evidence that perceived control and health anxiety are linked (Ferguson et al., 1998). As perceptions of low control have been shown to be linked to a variety of negative health outcomes it is not unreasonable to predict that this generalises to chemical intolerance (path V).

4. Chemical intolerance and health anxiety are both specified as predicting symptom reporting. These links are also well established in the literature (see introduction to this report).

5. Finally, organizational tenure, status, N and PA are all allowed to correlate (paths A, B, C, D, E & F), as a-priori theoretical causal precedence could not be established here.

35

4.3 RESULTS

4.3.1 Descriptive statistics

4.3.1.1 Descriptive and zero-order correlations

The descriptive statistics and zero-order bi-variate correlations for the whole sample are presented in Table 5. NA and N are highly correlated. To eliminate any problems with multi-collinearity N was selected – based on its theoretical biological basis – for use in all subsequent analyses.

Symptom reporting. The pattern of correlations is consistent with previous findings.

• Symptom severity was found to be associated with all of the main study variables. It was positively associated with CI and masking, health anxiety, N/NA, and negatively associated with PA. Symptoms were found to be positively associated with organisational tenure. Symptom severity also showed predictable associations with the demographic variables, with a positive association with age.

Organisational type. Zero-order bi-variate correlations and MANOVA procedures were used to compare the chemical industries against the non-chemical industries.

• Those in the non-chemical industries scored higher on CI, N, symptom severity and perceived control but lower on masking behaviours.

To see if this difference in chemical intolerance across the industries was attributed to variations in N, symptom severity and perceived control and masking behaviour, these were held as covariates. The resulting MANCOVA still showed a significant difference (F (1, 608) = 13.7, p < .001). With those in the non-chemical industries scoring higher on CI (M = 7.8) than those in the chemical industries (M = 6.6).

4.3.2 Exploratory Factor Analysis: tenure and status

This analysis was conducted to justify creating a composite variable for status and to identify the best marker for tenure. As such, the two tenure measures, two status measures (type of job and supervisory role) and type of industry were entered into an exploratory principle components analysis with a varimax rotation employed. The Scree test was used to judge the number of factors to extract. The KMO (.54) and Bartlett Test of Sphericity (303.6) both indicated that the data were applicable for the analysis. Two factors accounting for 57.2% of the variance were extracted (eigenvalues = 1.7 ands 1.1). The rotated factor pattern matrix is shown in Table 6. As can be seen both measures of tenure were equally highly loaded on factor one. Of these it was decided that organizational tenure should be used as it gave a wider range of experience within a particular organization. Job-type and supervisory experience were summed to create the status variable (high score equate to lower status). Organizational type was not used as it loaded on both factors.

36

Figure 3 Conceptual Path Model

J

G I

L

Q

N

P

O

R

S

U

X

W

Z

Y

B

E

C

A

D

F

H

M

K

T

V

Org. Tenure

Low Status

Neuroticism

Positive affect

Job Control

Health Anxiety

Chemical Intolerance

Symptom Severity

37

Table 5 Descriptive statistics and zero-order bi-variate correlations for the main study variables for the whole sample

M SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Demographics 1) Age 2) Sex (1 = male, 2 = Female) 3) Organizational Tenure 4) Job Tenure 5) Type of work (1:P, 4:T) 6) Supervisor (1: Yes, 2: No) 7) Sector (1: Pri, 2: Pub) Predictors

41.1 57% F 128.64

71.1 78% P 43% Y

82% Pub

10.3

109.6 76.9

-.06 1 .46** -.16* 1 .38** -.07* .53** 1 -.07* .16** -.07* .02 1

-.18** .13** -.18** -.08* -.18** 1 .00 .42** -.23** -.12** .12** .06 1

8) Neuroticism 9) Negative Affectivity 10) Positive Affectivity 11) Job Control Mediators 12) Health anxiety 13) Chemical intolerance Co-variate 14) Masking Outcome 15) Symptom severity

4.7 18.7 32.0 63.3

22.0 7.6

4.7

13.0

3.2 6.9 7.1 13.5

5.4 3.3

1.5

0.0

-.06 .17** -.02 -.05 .02 .07* .10* 1 .00 .06 .03 -.04 .01 .03 .05 .68** 1 .07* .03 -.02 -.03 -.01 -.18** .02 -.32** -.21** 1 .01 -.05 -.01 -.08* -.06 -.21** .08* -.19** -.18** .42** 1

.04 -.10* .04 .05 .00 .05 .00 .37** .37** -.22** -.17** 1 .07* .16** .04 .04 .05 .07* .15** .17** .14** .01 -.07* .17** 1

-.11** -.04 .02 .00 .06 .08* -.09** .08* .07* -.07* -.08* .11** .01 1

.12** .05 .09** .06 -.01 .01 .03 .45** .43** -.19** -.20** .38** .23** .13**

Note: For the zero-order correlations the Ns range from 580-706. Organisational Tenure and Job Tenure are measured in months. * p < .05, ** p < .01

38

--------- --------- ---------

Table 6 Exploratory factor analysis of work related demographics

Factor 1: Tenure Factor 2: Status Variable Job tenure .86 .00 Organizational tenure .85 -.16 Type of work .10 .80 Supervisory responsibilities -.14 .67 Sector -.32 .36

Note. Type of work (1 = permanent FT, 2 = permanent PT, 3 = permanent job-share, 4 = Temporary), Supervisory responsibilities (1 = No, 2 = Yes), Sector (1 = Private, 2 Public)

4.3.3 LISREL path analysis results

Model fits The fit statistics for the target model for the whole sample and the chemical and non-chemical industries, both with and without masking partialled are shown in Table 7. As can be seen the target model is an extremely good fit to the data.

Table 7 LISREL fit statistics

Zero-order Partialling masking

Whole IFI CFI RMSAE IFI CFI RMSAE

1.0 1.0 0.0 (.0, .08) 1.0 1.0 0.0 (.0, .08) Non-chemical 1.0 1.0 0.0 (.0, .07) 1.0 1.0 0.0 (.0, .08) Chemical 1.0 1.0 0.0 (.0, .03) 1.0 1.0 0.0 (.0, .16)

Total and Indirect Effects The total and indirect effects of N, PA (personality), job-control and chemical intolerance (environmental factor) on symptom reporting are presented in Table 8.

Table 8 Total and Indirect Effects on Symptom Reporting

Whole sample Chemical Non-chemical

N Total Indirect Total Indirect Total Indirect

.43* .09* .35* .07^ .45* .10* PA -.04 -.04* -.13 .03 -.03 -.05* Control -.12* -.02* .02 -.02 -.13* -.02* CI .12* .14 .12*

Note: N = Neuroticism, PA = Positive Affectivity, Control = Perceived Control, CI = Chemical Intolerance.

The first thing to note from the figures and Table 8 is that the effect of N is much greater than either perceived control or chemical intolerance. The size of the direct effect for N is 3.5 times larger than either perceived control or chemical intolerance. Examining the path coefficients in Figures 4, 5 and 6 again shows that the size of the path coefficient from N to symptoms is larger than the equivalent path for either perceived control or chemical intolerance. A similar picture emerges for the indirect effects (cf. Ferguson, Daniels & Jones, 2006).

39

Figure 4 LISREL path model for the whole sample (N = 530)

-

-

S

-

-

-

- -

-

-

-

-

-

.02 .01

.32*

Org. Tenure

Low Status

Neuroticism

Positive affect

Job Control

Health Anxiety

Chemical Intolerance

Symptom everity

.12*

.34*

.13* .34*

.39*

.07

.13*

.01

.00

.09*

.11*

.12*

.11*

.04

.10*

.09*

.12*

.18*

.12*

.08

.10*

.15*

.04

40

Figure 5 LISREL path model for the chemical industries (N = 118)

-

-

-

-

-

-

-

-

-

Org. Tenure

Neuroticism

Positive affect

Job Control

Health Anxiety

Chemical Intolerance

Symptom Severity

.00

.33*

.02 .29*

.47*

.04

.19

.16

.07

.06

.11

.09

.18*

.14

.02

.13

.04

.02

.04

.24

41

-.14*

Figure 6 LISREL Path model for the non-chemical industries (N = 479)

-

-

-

--

-

-

-

-

-*

-

Org. Tenure

Low Status

Neuroticism

Positive affect

Job Control

Health Anxiety

Chemical Intolerance

Symptom Severity

.12*

.33*

.13* .35*

.38*

.09

.11*

.03

.02

.11*

.08*

.09

.05 .09*

.12*

.12*

.03

.08

.02

.13*

.12*

.14*

.05

.08 .18

.34*

42

Path models. The path models for the whole sample, the chemical industries and the non-chemical industries are shown in Figures 4, 5 and 6 respectively. The pattern of path coefficients was virtually identical when masking was partialled. Therefore, the results are presented for the paths models based on the zero-order correlations.

The first thing to note is that across all 3 path models, N has a direct effect on symptom reporting as well as being mediated through health anxiety. In both cases increased levels of neuroticism and heath anxiety are associated with increased symptom reporting. For the whole sample and the non-chemical industries sample the effect of N was also mediated through perceived control. High scores on neuroticism were associated with low scores on perceived control, with lower scores on perceived control associated with increased symptom reporting.

There is no evidence for any direct effect for PA. However, there is evidence that positive affect influences symptom severity indirectly through levels of perceived control (cf. Table 8). That is, those who experience more positive mood states in general report greater feelings of control, and increased levels of control are related to reduced levels of symptom reporting.

The effect of low status on symptom reporting is also indirect via perceived control. This relationship is such that those who are in lower status employment report feeling less control, and reduced feelings of control are related to increased reports of symptoms.

4.3.4 Summary and discussion of the path analysis results

The main finding from these results is that N is the dominant factor with respect to symptom reporting. The effects for perceived control and chemical intolerance are apparent but much weaker than those for N. The findings for the three main predictors are summarised below.

Personality: N is the driver. Of the two main personality domains - N and PA - N has the strongest effect upon symptoms, both directly and via its influence on job-control, chemical intolerance and health anxiety. Based on these results, N is conceived as driving the symptom reporting process as it influences all the other variables that predict symptom reporting (perceived control, health anxiety and chemical intolerance), as well as having a unique direct effect on symptom reporting. In contrast the effect of PA is an indirect one via job-control. People scoring higher in PA tend to perceive the work environment as more controllable and increased levels of perceived control are related to reduced levels of symptom reporting.

Perceived control: The indirect link. Perceived control has a direct but small effect on symptom reporting. The main role of perceived control appears to be as an indirect link between predictors (job-status and PA) as well as linking N to symptom reporting.

Chemical intolerance: Environmental mediator. Chemical intolerance has not been studied in occupational samples before and the results show that it is an important variable to be considered in this context, as it directly affects symptom reporting as well as partially mediating the effects of organizational tenure.

Health Anxiety: Sub-clinical mediator. Like chemical intolerance health anxiety has not been explored in occupational samples previously. Again the results show that it is independently related to symptom reporting and that it partially mediates the effects of job-control.

43

5. PREDICTING DAILY SYMPTOM VARIATION

5.1 OVERVIEW

The focus of this chapter is to address the main objective of comparing the relative roles of personality, job-characteristics and environmental factors in relation to daily symptom reporting.

The specific question addressed in the chapter -

• To what extent are levels of daily reported symptoms predicted by (1) personality, (2) job-characteristics, and (3) environmental factors?

Specifically this chapter examines the extent to which personality, environmental factors and job-characteristics can predict future daily symptom severity, and the extent to which there are lagged causal effects for daily stress, odour and sound. The data are modelled using HLM-6 (all models contained the 3 time varying covariates identified in chapter 3).

5.2 TYPES AND FREQUENCIES OF ODOURS AND SOUNDS EXPERIENCED

See Sections 2.6-2.7 for a full description of the types, frequencies, and valence of the odours and sounds experienced by study participants.

5.3 MULTI-LEVEL MODEL ANALYSIS – MEAN SYMPTOMS

194 participants provided usable compliant data with 2048 level-1 assessments.

The following modelling steps were undertaken to predict mean levels of symptom severity.

1. Comparing the predictive power of level 1 constructs i. The effects of daily odour and sound severity and duration are

modelled ii. The effects of daily stress and judgments of odour- and sound-

valence are modelled iii. Based on steps i) to ii) the best level 1 predictive model is

constructed

2. Comparing the predictive power of level 2 constructs i. The effects of personality, job-control, environmental factors and

demographics are modelled separately ii. Based on i) the best set of predictors is identified

3. Integrative model based on 1 and 2 and theoretical considerations

5.3.1 Level 1 Model: daily odour, sound and stress as predictors of mean daily symptom severity at zero-lag

Severity and Duration of Odour and Sound as Predictor of Symptoms. The results indicated that people report more intensive symptoms if they reported longer duration odours and more severe sounds (γs = 0.005, 0.13: both p < .05).

Appraisals of Stress and Valance of Odour and Sound as Predictor of Symptoms. The results indicated that higher levels of reported daily stress (γ = 0.67, p < .0001) and the experience of

44

sounds that could be rated as aversive (γ = -0.29, p < .05) were related to increased levels of daily symptom reporting.

Final level-1 model for zero-lag. The final level 1 model, therefore, would include (1) the duration of odour, (2) the severity of sound, (3) appraisals of stress and (4) rating of sound valence.

5.3.2 Level 2 Model: personality, job-control, mediators and demographics as predictors of mean daily symptom severity at zero-lag

Personality (Neuroticism and PA) as Predictors of Daily Symptoms The results indicated that higher levels of N predicted the reporting of more severe daily symptoms (γs = 0.17, p < .01).

Job-Control as a Predictor of Daily Symptoms The results indicated no significant relationship between job-control and symptom reporting (γs = -0.03, p < .13). However, this relationship approached significance when the time varying covariates were removed (γs = -0.13, p < .06).

Mediator variables (Health Anxiety and Chemical Intolerance) as Predictors of Daily Symptoms The results indicated that higher levels of health anxiety predicted higher levels of reported daily symptom severity (γs = 0.19, p < .001).

Demographic variables as a Predictor of Daily Symptoms A model was constructed with age, sex, organizational tenure, participation in the summer diary, masking and industry (chemical vs non-chemical) at time 1 predicting daily symptoms at time 2. There was a significant effect for sex (γ =- 0.94, p < .05) such that male participants reported more severe symptoms.

Final level-2 model for zero-lag The final level 2 model included N, health anxiety and sex.

5.3.3 Final model to predict mean daily symptom severity at zero-lag (Levels 1 and 2 combined)

The final model combined the level 1 and level 2 predictors. This allows us to ask if daily variation in stress appraisals, sound valence, smell duration and sound severity predicts daily symptom severity once N, health anxiety and sex are controlled. The model also contains the three standard time varying covariates (AM:PM, study assessment and Monday blues).

The results show that increased appraisals of stress (0.66, p < .001) and sounds rated as more severe (0.07, p < .068) were related to more severe average daily symptom reports. Furthermore, those with higher levels of health anxiety (0.16, p < .001) also reported more severe daily symptoms. Again, symptoms were reported as more severe in the afternoons (0.35, p < .001), at the start of the diary – nearly the weekend effect (-0.03, p = .053) and by men (-0.67, p = .06)2.

The unrestricted model always had the lowest Deviance and this was significantly lower than the other two, with the auto-regressive function Deviance lower than the homogeneous function.

5.4 LAGGED EFFECTS OF STRESS, SOUND AND ODOUR

The purpose of these analyses is to explore if stress, odour and sound have lagged effects. That is, does stress, odour or sound at one time point predict future levels of symptom

2 These last two effects for the diary (nearly the weekend effect and sex) approached significance.

45

reporting? To explore this we looked at two lagged effects (half day and full day). The half day lagged effect examines the relationships between perceptions of stress, odour and sound in the morning, and the reports of symptoms in the afternoon (within one day), or for perceptions of stress, odour and sound in the afternoon and symptom reports the following morning (across one day). The full day lagged effect examines relationships between perceived stress, odour and sound in the morning, and symptom reports the following morning, or perceptions of stress, odour or sound in the afternoon, and reports of symptoms the following afternoon. Sex was included as a predictor, and of the three time varying covariate the time of day effect was not included.

5.4.1 Half day lagged effects

Morning Severity and Duration of Odour and Sound as Predictors of Afternoon Symptoms There was a significant effect for the severity of odour (0.13, p < .05). Such that the reported experience of more severe odours predicted increased symptom reporting half-a-day later.

Morning Appraisals of Stress and Valence of Odour and Sound as Predictors of Afternoon Symptoms There were no significant effects.

5.4.2 Full day lagged effects

Morning and Afternoon Severity and Duration of Odour and Sound as Predictors of the Subsequent Morning and Afternoon’s Symptoms There were no significant effects.

Morning and Afternoon Appraisals of Stress and Valence of Odour and Sound, as Predictors of the Subsequent Morning and Afternoon’s Symptoms The results showed no significant effects.

5.5 DISCUSSION

There are a number of key findings from these results. a. Individual differences in N and health anxiety measured previously,

predict daily symptom reporting. However, of these, health anxiety is the more important.

b. Severe sounds, longer duration odours and increased appraisals of stress are associated with symptom reporting. There was a lagged effect for the severity of odour, such that more severe odours predict symptoms on a half-day lagged basis.

c. Perceived stress is strongly associated with symptom reporting, but there are no lagged effects.

These imply that odour may have a causal role to play with respect to subsequent symptom reporting. However, this finding as such does not suggest the mechanism that supports it: it may be a sensitization, an associatively learned effect, or reflect some top down processing. The important fact is that in an everyday occupational setting such links are observable, as this broadens the focus of potential occupational health interventions.

5.5.1 Practical implications

The multivariate model shows that appraisals of stress and the experience of severe sounds are related to increased symptom severity reports. As such, this would indicate that interventions to reduce individual stress, and also reduce noise intensity, would be useful in reducing the experience of symptoms. Also the role of individual differences in health anxiety needs to be considered. Again this may be addressed with more individualised interventions aimed at concerns about one’s health. Future research needs to address health anxiety in the

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work place in more detail to identify how these concerns may be manifested in relation to attributions about the causes of ill health at work.

In terms of the univariate analyses there was some evidence that the experience of longer duration odours was also associated with increased symptom reporting. While this effect becomes non-significant in the multivariate model it nonetheless suggests that benefits might be gained from reducing lingering odours. Finally, with more severe odours predicting symptom reports on a half-day cycle, this would again underline the importance of identifying and removing unpleasant odours. The types of odour that might be considered are described in chapter 2.

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6. PHYSIOLOGICAL MEDIATORS

6.1 OVERVIEW

The basic question here relates to whether or not physiological parameters mediate the relationship between stress or environmental experiences, and symptom reporting. Two mediators are examined: (1) Salivary Immunoglubin A and (2) Salivary Cortisol.

In all the subsequent analyses the first question will be whether there is a relationship between the physiological parameters (the mediator) and the outcome variable (reported symptom severity). If this relationship is not significant, then the physiological parameter cannot act as a mediator.

6.2 BACKGROUND MEASURES

For these studies we asked participants:

1. if they were on a diet (YES: NO) 2. if they were on HRT 3. if they were using the combination pill 4. if they were using the mini pill 5. if they were using the hormonal injection 6. their current weight and height.

6.3 DAILY MEASURES

Each day we asked participants to indicate:

1. The time they woke up 2. The time they got up 3. The time they took the morning sample 4. The time they took the AM sample 5. The time they took the PM sample

At the end of the day they indicated how many cigarettes they smoked, how many cups of coffee/tea they had consumed as well as how many units of alcohol.

From these daily measures we calculated:

1. The average waking time for the week (minutes past midnight) 2. The average waking time weekdays 3. The average waking time weekends 4. The average waking time on workdays 5. The average waking time on non-workdays 6. The average lag from waking to the morning sample 7. The average lag from waking to the morning sample on weekdays and weekends 8. The average lag from waking to the morning sample on workdays and non-workdays 9. The average number of cigarettes smoked per week 10. The average number of number of cups of coffee/tea per week 1 . The average number of alcoholic units per week 1 . The average number of alcoholic units on weekdays 1 . The average number of alcoholic units on weekends 1 . The average number of alcoholic units on workdays 1 . The average number of alcoholic units on non-workdays

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6.4 SAMPLES

Data from 44 participants were returned. The mean age of the sample was 41 years (SD = 6.94). 41% of the sample were male, 57% were female, with 2% of participants not specifying their gender. Mean job tenure was 65.5 months (SD = 70.34), with mean organisational tenure found to be 152.14 months (SD = 102.23).

Participants woke up significantly later at weekends (t (41) = 8.2, p < .001) and on non-work days (t (40) = 8.5, p < .001) and drank more units of alcohol at the weekends (t (40) = 4.0, p < .001: 2.4 vs 1.3 units) and on non-work-days (t(40) = 4.6, p < .001: 2.4 vs 1.2 units). There were no significant differences in the amount of caffeine consumed, cigarettes smoked or time lag to taking the morning sample for weekdays versus weekends and working days versus non-working days.

Therefore, waking times and alcohol consumption (weekdays, weekends, workdays and non workdays) as well as the average lag to sample, caffeine consumed and cigarettes smoked were explored as potential confounds for the physiological parameters.

6.5 BACKGROUND COVARIATES

Due to the smaller sample sizes (a final sample of 31 level 2 and 311 level 1 assessments) the unrestricted model was not computed (homogeneous level 1 and 1st order auto-regressive level 1 models were computed) and time varying covariates were not employed.

For this sample 6.5% of participants were on diets. Sixteen percent were on prescription medication and 16% were taking over the counter medication (these were 10 different participants), 1 was on HRT and 1 was using the combination pill. This sample has a mean age of 41 (SD = 7.6) and 52% were male.

6.6 S-Ig-A AND CORTISOL ASSAYS

Salivary IgA was measured on COBAS MIRA clinical analyser using an immunoturbidimetric technique. Essentially the method incubates at 37C, 10 microlitres of sample together with 150 microlitres of a (1/150) dilution of DAKO anti-IgA antisera (Q0332) in 0.1M phosphate buffer pH7.4 containing 4% PEG 6000. The turbidimetry is monitored at 340nm over a twelve minute period. Samples are calculated from a log-logit curve fit of a 7 point standard curve covering the concentration range 0-246 mg/l. Quality control material was run with every batch of samples. The between batch precision was 7.1% at 82 mg/l IgA.

Salivary cortisol was measured using an indirect, competitive ELISA assay on a Rosys PLATO robotic immunoassay station. All dilutions used assay buffer of PBS/0.1% BSA/0.05% Tween. 96 well microtitre plate (Nunc Maxisorb) were coated overnight in the refrigerator with 0.2 ug/ml of cortisol-OVA, washed and blocked for 20 minutes with 5% casein and then rewashed. These plates were then ready for use. The cortisol-OVA conjugate was prepared in-house using a standard carbodiimide conjugation using 3-CMO cortisol. Working standard were diluted from a stock solution of cortisol (6.89mM) in methanol using assay buffer to give 7 standards covering the range 0-69nM. 20 microliters of sample or standard in duplicate were incubated with 100 microliters of 1/4K dilution of anticortisol antibody (20Cr50; Fitzgerald industries) for one hour. After washing the plate, 100 microliters of a 1/5K dilution of anti-rabbit Ig (DAKO) was added to all wells and incubated for a further hour. The plate was then washed and colour developed with 100 microliters per well of TMB, after incubation for 30 minutes the reaction was stopped by the addition of 100 microliters of 0.5M sulphuric acid and read at 450 nM. Standards were fitted to a 4 parameter

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curve fit and sample concentration calculated from this curve. Quality control material was run at the beginning, middle and end of each plate. Between batch precision was 9.1% at 5.8 Nm.

6.7 RESULTS

6.7.1 Salivary Immunoglubin A

Scores were calculated as the ratio of S-IgA to Albumin. This is to control for salivary flow rate.

6.7.1.1 Demographics and status

Average daily S-IgA levels were not significantly related to participants’ age, sex, height, weight, dieting behaviour or occupational status.

6.7.1.2 Daily average health behaviours

Average daily S-IgA levels showed a marginally significant effect in relation to the average number of cigarettes smoked (0.24, p<.08) such that those who smoked more also produced more S-IgA.

6.7.1.3 Time lag to 1st sample

There was no relationship between S-IgA levels and the time to the 1st saliva sample.

6.7.1.4 Predicting symptom reports (zero, half-day and 1-day lags)

There was no significant association between S-IgA and symptom reporting at the zero half-day and full-day lags.

6.7.2 Salivary Cortisol (Log transforms and difference scores)

Cortisol scores were log transformed prior to the analyses. To control for variability in waking cortisol and the subsequent drop in AM and PM levels, two difference scores were calculated by (1) subtracting the waking level from the AM level (AM – Waking) and (2) subtracting the waking level from the PM level (PM – Waking). Thus a negative score reflects a decrease from Waking to AM or PM. These difference scores were calculated from the raw scores (as subtracting logs is equivalent to division).

6.7.2.1 Demographics and status

Average daily cortisol levels were not significantly related to participants’ age, sex, height, weight, dieting behaviour or occupational status. Daily cortisol levels, however, were significantly negatively related to time of the day (coefficient = -0.28, p = .011). That is, consistent with the diurnal pattern observed in cortisol, with PM levels significantly lower than the AM levels.

6.7.2.2 Daily average health behaviours

Average daily cortisol levels were not significantly related to the average number of cigarettes smoked, or alcohol or caffeine consumption (weekday/weekend and workday/non-work).

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6.7.2.3 Time lag to 1st sample and Cortisol Difference

There was no relationship between cortisol levels and the time to the 1st saliva sample. The mean cortisol difference score was -13.5 (p < .001). Again this is consistent with the general finding that cortisol decreases from a waking peak.

The cortisol difference score was significantly positively associated with daily cortisol levels (coefficient 0.01, p < .0001). That is, the amount of cortisol produced over a day is greater for those who show a smaller difference between waking and AM and PM cortisol levels.

6.7.2.4 Predicting symptom reports (zero, half-day and 1-day lags)

There was no significant association between cortisol levels and symptom reporting at the zero lag, half-day and full-day lags.

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7. ATMOSPHERE CHAMBER

7.1 RATIONALE

The purpose of the study reported in this chapter is to address the following question:

Does exposure to a specific low threshold odour alter reports of symptom severity and alter immune system parameters (Interleukin-1, Interleukin -6 and Ig E), and is this related to personality, job-characteristic and environmental factors?

Previous work has shown that when people know that they are being exposed to an odour, the description they are provided with for that odour influences both how they perceived the odour, and how it was related to symptom reports (Dalton, 1999). This study sought to investigate if actual exposure to a low threshold odour was sufficient to cause a change in symptom reporting. There is some evidence to suggest that exposure to a low threshold odour – one that does not enter awareness – is related to the neurophysiological changes (Schwartz, Wright, Polak, Kline, & Dikman, 1992; Schwartz, Bell, Dikman, Fernandez, Kline, Peterson & Wright, 1994: see Kline, Schwartz, Dikman & Bell, 2000 for some caveats). There is also evidence that odours can influence behaviour even when the odour does not enter awareness (Degel & Koster, 1999). Thus it seems reasonable to test the idea that low threshold odours – that participants are not aware of – may also influence symptom reporting. That is, as low concentration sub-threshold odours influence neuro-physiology and behaviour they may also influence symptom reports.

In the study reported here there was no learning phase and as such any effect of the odour has to be considered as an unconditioned effect. The main aim is to see of a low-concentration odour can influence symptom reports.

Top-down processes may also influence symptom reporting in this context. To test this, participants were asked to indicate if they thought they had been exposed to an odour. If top-down processes are operating then this should moderate any effect of actual exposure as well as have a direct effect itself. Top-down processes are also indexed in terms of background beliefs about the effect of chemicals were assessed using the CII – do these moderate the effects of actual exposure?

In previous studies participants have been exposed to an odour at detectable concentrations, and the information about the odour has been varied (cf. Dalton, 1999). This study unlike others used a blinded control trial to test if exposure to a chemical (Toluene) at a extremely low concentration (3ppm) influences symptom reports independently of whether or not people believe they were exposed.

This study also sought to test if exposure to an odour (Toluene) would influence specific immunological factors, specifically IL-6 and IgE as well as reports of symptoms. To recap from the Introduction, IL-6 is associated with the sickness responses and non-specific symptoms, and Ig E with allergic responding. Thus, these two markers allow us to see if any response to Toluene is mediated via a pro-inflammatory or allergic immune response.

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7.2 HYPOTHESES

7.2.1 Symptom cluster effects

NSS cover a range of symptoms from sexual problems to pain, fatigue and breathlessness. It is argued that exposure to a specific odour may have differential effects on symptoms, especially as the time frame of exposure is short (15 minutes). It was argued earlier that NSS reflect a general class of symptoms in terms of a single cluster. However, for the specific purposes of this experimental study it was felt that specific symptom clusters would be more appropriate (cf., Dalton, 1999). As such, it is likely to be the case that cardio-vascular/respiratory symptoms are more likely to be affected and pain and other symptoms less likely. As such both general NSS and symptom specific clusters were examined.

7.2.2 Awareness of odour effects

Does a participant’s awareness of an odour moderate its effect upon symptom reports? The odour used was Toluene, which was selected because paint and other solvent style products were mentioned in the diaries as one of the highest frequency odours (cf. Table 1). Toluene is the base chemical in this substance. The participants that were exposed to Toluene were exposed at 3ppm. This is an extremely low concentration (almost undetectable) – the recommended safe limit is 50ppm over an 8-hour period. Therefore, after leaving the atmosphere chamber, participants were asked if they had noticed an odour present.

7.2.3 Immunological effects

Are any changes in symptom reports also related to changes in serum IL-6 and Ig-E?

7.2.4 Personality and Job-Characteristics effects

Are any of the relationships identified above influenced by personality, IQ or job-characteristics?

7.3 METHOD

7.3.1 Procedure

Fifty participants from previous study stages were invited to participate. Participants were invited on the basis that they had previously completed one of the following: the summer saliva-sampling diary, the summer symptom diary, or the summer job characteristics diary. All participants previously completed measures of both personality and job-control, between 24 and 17 months prior to the atmosphere chamber.

Participants were contacted by letter, which provided information about the study, and the two dates over which the study was scheduled to run. No exclusion criteria were given at this stage. Participants were asked to register their interest with the research team, at which point they were allocated to a particular date, and sent an information pack, containing further information about the study, and a medical questionnaire to complete and return to the Chief Medical Officer at the Health and Safety Laboratory.

The medical questionnaire allowed participants to be screened on the basis of asthma, pregnancy, allergies, breathing and circulation problems, hearing and vision problems, medications and any other medical problems which may have affected their participation in the study. The final decision regarding suitability for participation rested entirely with the Chief Medical Officer.

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Of the fifty people invited, a total of 15 agreed to participate in the study. No participants were excluded prior to the study commencing, on the basis of their answers to the questionnaire.

Of the 15 who agreed to participate, a further 2 did not attend the event, with 1 other participant excluded on medical grounds on the day. The final participant total for the study was therefore 12.

7.3.2 Design

The following protocol was followed

1. Participants arrive and are greeted by the researchers; 2. Participants are briefed about the study and the timetable for the day, and then

shown the atmosphere chamber; 3. Participants are then consented for a second time; 4. Participants are then asked to wait in the waiting room; 5. Prior to entering the chamber, participants are assessed by the medical staff as fit

to take part in the study – this is a standard procedure conducted by HSL staff, for all participants involved in research at the HSL laboratory;

6. A small (5ml) sample of blood is taken by the medical staff –a HSL phlebotomist;

7. Participants complete a series of mood and symptom assessments, as well as a number of questions concerning their expectations and feelings about the chamber;

8. Participants consent is sought for a third time, just prior to entering the atmosphere chamber;

9. Participants enter the atmosphere chamber for a total of up to 15 minutes each; 10. Participants leave the atmosphere chamber and a second (5ml) blood sample is

taken, again by the phlebotomist. Mood and symptoms are recorded again, and the participants are asked to rate any odour they detected whilst in the chamber. Participants are also asked to rate their experience of the chamber;

11. Participants complete a series of cognitive ability tests (two of the research team administered the tests);

12. Participants are then assessed by the Medical staff as fit to leave the building; 13. Participants are taken back to the waiting room for a short debriefing and

refreshments; 14. Participants are escorted off the site. Participants are supervised throughout the

course of the day by members of the research team.

The participants, researchers, phlebotomist and medical staff were blind to the conditions. The operator of the atmosphere chamber was not, nor was the lead investigator.

7.3.3 Measures

7.3.3.1 Non-specific symptoms clusters

Participants completed the same measure of NSS used in the survey, but this time indicated the symptoms they were currently experiencing. This was completed both prior to, and after their time in the atmosphere chamber. Three clusters of symptoms were examined: (1) cardio-vascular symptoms - ‘dizziness’, ‘palpitations’ and ‘breathlessness’, (2) irritable bowel symptoms - ‘irregular bowel movements’ and ‘upset stomach’, and (3) pain symptoms - ‘pain in limbs’ and ‘pain in joints’. These clusters were assessed for their reliability by examining the mean inter-item correlations, given the low number of items in each cluster. The mean inter-item correlations for the clusters were: ‘cardio-vascular’ cluster – r = .252 (pre-chamber)

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and r = .638 (post-chamber); ‘irritable bowel’ cluster – r = .137 (pre-chamber) and r = .192 (post-chamber); ‘pain’ cluster – r = -.038 (pre-chamber) and r = .088 (post-chamber). The remaining symptoms were explored separately (‘fatigue’, ‘sexual problems’, ‘sweating’ and ‘tingling in the hands and feet’). Each symptom was responded to on a 6 point Likert-type scale from 0 = ‘not experiencing the symptom’, to 5 = ‘experiencing the symptom very severely’.

7.3.3.2 Cognitive abilities

Verbal and numerical skills were assessed using the AH4.

7.3.3.3 Odour awareness

On leaving the atmosphere chamber participants indicated whether or not they had noticed an odour (YES or NO).

7.3.3.4 Mood assessments

Mood was assessed using the UWIST Mood Adjective Checklist (Matthews, Jones, & Chamberlain, 1990). This comprises three main bipolar scales – Hedonic Tone (high scores equal happiness), Energetic Arousal (high scores equal high alertness), and Tense Arousal (high scores equal high stress) – plus an additional mono-polar Anger/Frustration scale (high scores equal high irritation). Participants rated 29 mood adjectives according to how indicative each word was of their own mood state at the time they were completing the measure. Ratings were made on a scale from 1 = ‘definitely descriptive of current mood state’, to 4 ‘definitely not descriptive of current mood state’ for each word. Example items include ‘happy’ and ‘sorry’ for Hedonic Tone; ‘energetic’ and ‘sluggish’ for Energetic Arousal; ‘nervous’ and ‘restful’ for Tense Arousal; and ‘impatient’ and ‘grouchy’ for the Anger/Frustration scale. The UMACL has good predictive and discriminative validity (Matthews et al., 1990). Reliability estimates for these scales were: α = .68 and α = .84 for pre / post Hedonic Tone; α = .43 and α = .84 for pre / post Energetic Arousal; α = .78 and α = .66 for pre / post Tense Arousal; and α = .84 and α = .71 for the pre / post Anger/Frustration measures.

7.3.3.5 Cytokine & serum Ig E assays

A Multiplex immunoassay of immune cytokines and chemokines using a Luminex BioPlex bead reader was employed to analyse the samples. Using these multiplex beads it is possible to measure the presence of 22 different cytokines and chemokines simultaneously in small volume (0.2 ml) samples of serum.

Peripheral blood taken from volunteers was centrifuged at RCF 1711 x g for 10 minutes at room temperature. The serum was removed and 2 aliquots were made of each sample, these were stored at -400C.

A Fluorokine MAP Human Base kit A (R&D Systems Europe, Ltd, Abingdon) was used with beads conjugated to antibodies corresponding to the following cytokines: IL-1β, IL-6, IFN γ and TNF α (R&D Systems Europe, Ltd, Abingdon). All the samples / beads were added together in a 96 well MultiscreenTM-BV filter plate (Millipore, Watford).

Serum samples were thawed and centrifuged for 10 minutes at 3000g, 50µl aliquots of the serum were then diluted 1 in 4 in the R&D Calibrator Diluent, RD6-40. 25µl of this dilution was added to 25µl of the multiplex bead solution and gently mixed and incubated at 200C for

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180 minutes. The beads were washed by vacuum filtration and addition of excess Wash Buffer according to the manufacturers instructions.

The beads were then resuspended in 25µl of Detection Antibody mixture (for the relevant cytokines) and incubated with mixing for 60 minutes at 200C. The beads were washed as previously described and resuspended in 25µl of Streptavidin Phycoerythrin and incubated for 30 minutes in the dark at 200C. The beads were then washed according to the manufacturer’s instructions and resuspended in 100µl of Wash Buffer.

Calibration curves of standards for each of the cytokines were included in the assay. In addition to the standards, a quality control sample was included; the Human Multiplex Control A, Medium (R&D Systems Europe, Ltd, Abingdon). This was reconstituted in 2ml of Calibrator Diluent RD6-40 and stored in aliquots at –400C. This quality control was tested at a dilution of 1 in 2 (diluted in RD6-40).

The plate was analysed using a BioRad BioPlex (Luminex 100) system using a sample size of 50µl per well, 50 beads per region and 5000 to 10000 Doublet Discriminator gate settings. Software from BioRad; BioPlex Manager 4.0, automatically calculated the concentration of each cytokine (pg/ml) from the standard curves. The software determines the upper and lower detection limits of the assay as well as those values that fall outside of the reliable range of detection. These results were exported to a Microsoft Excel spreadsheet.

Total serum IgE levels were determined using a sandwich format enzyme linked immunoassay (Alpha Diagnostic, International, San Antonio, USA) and concentrations determined from a reference standard IgE (WHO 2nd IRP 75/502).

7.3.4 Atmosphere chamber

Healthy volunteers were exposed to Toluene vapour at concentrations of up to 2-3ppm for 15 minutes, conducted within a Controlled Atmosphere Chamber.

Participants were randomly divided into ‘treatment’ and ‘control’ groups and both were told that they may or may not be exposed to an odour within the atmosphere chamber. A 5ml sample of blood was taken, and mood and symptom assessments were made both pre- and post-exposure to Toluene.

7.4 RESULTS

7.4.1 Sample

The demographic variables for the sampling procedure are shown in Table 9. As can be seen from the demographics, the final sample is representative of the initial sample and as such no sampling bias was introduced.

Table 9 Demographic variables for atmosphere chamber sample

N Age Sex (% female) Invited sample 50 41.7 (9.1) 65% Non responders 35 42.2 (9.0) 62% Responders 15 40.7 (9.6) 74% Attendees 12 42.7 (9.3) 83%

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Representativeness of the Sample: The 50 participants who were invited to take part in the study (Mean age = 41.7, SD = 9.1; % female = 65%) were not significantly different in terms of age (t (700) = 0.4, p = .65) or proportion of females (χ2 (1) = 1.6, p = .23) from the remaining 661 participants in the main cohort who were not invited to participate.

The 15 participants agreed to complete the laboratory study (Mean age = 40.7, SD = 9.6; % female = 73%) did not significantly differ in age (t (36) = 0.5, p = .61) or proportion of females (χ2 (1) = 0.61, p = .43) from the 35 who chose not take part. The final 12 participants were not significantly different in terms of age (t (46) = 0.4, p = .68) or proportion of females (χ2 (1) = 2.3, p = .13) from the 38 who did not take part.

7.4.2 Conditions

Seven participants (1 male and 6 females) were not exposed to odour with 5 participants exposed to odour (1 male and 4 females).

7.4.3 Awareness of odour

A chi-square for odour (present or absent) by awareness (YES or NO) was non-significant (p = .20). Therefore, participants were not aware of the odour.

7.4.4 Exposure Effects on Symptom Cluster

A 2 (exposure: present or absent) by 2 (time: pre- vs. post-atmosphere chamber) repeated measures ANOVA for the respiratory symptoms revealed a significant 2-way interaction (F (1, 10) = 7.1, p = .02, eta2 = .41). There were no other significant main effects. The means and standard errors (se) for this interaction are presented in Table 10.

Table 10 Interaction of exposure with assessment period upon respiratory symptoms

Exposure Odour Absent (se) Odour Present (se)

Pre-chamber Time 0.7 (0.4) 0.6 (0.5) Post-chamber 0.6 (0.5) 1.4 (0.6)

The pattern of the interaction indicates that there are no significant differences in the severity of respiratory symptoms prior to exposure or for those not exposed to Toluene. However, for those exposed to Toluene there is a significant increase in reported respiratory symptom severity after exposure (t (4) = -4.0, p < .05). Therefore, those exposed to a low concentration (2 ppm) and undetectable odour report more respiratory symptoms.

The 2-way interaction remained when N, PA, health anxiety, and job-control were individually held as covariates. However, when chemical intolerance was held as a covariate then the interaction between exposure and time became marginally significant (p = .06). As such, increased levels of chemical intolerance may enhance sensitivity to odour.

7.4.5 Awareness effects on symptom clusters

Whether or not the participants were aware of the odour showed no significant main or interactive effects (with pre- and post-exposure) on severity of reported symptoms. Therefore, the effects of odour on symptom reporting are due to the presence of the odour and not its delectability.

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7.4.6 Immune system effects

There were no significant changes in levels of serum IgE

A 2 (exposure: present or absent) by 2 (time: pre- vs. post-atmosphere chamber) repeated measures ANOVA for the IL-6 levels revealed a significant main effect for time (F (1, 10) = 9.5, p = .012, eta2 = .49). There were no other significant main or interactive effects. The results showed that mean Il-6 levels increased significantly from the pre-chamber values (1.8 pg/ml) to the post-chamber values (2.3 pg/ml). Changes in IL-6 where not related to changes on any of mood dimensions. Thus the experience of being in the atmosphere chamber lead to a significant increase in Il-6 levels, but this is not attributable to changes in mood.

7.4.7 Effects on Mood

A 2 (Exposure: present or absent) by 2 (Time: pre- vs. post-atmosphere chamber) repeated measures MANOVA on the 4 mood dimensions revealed a significant main effect for time (F (4, 5) = 8.7, p = .018, eta2 = .87). These effects were observed for tense and energetic arousal, such that participants were less aroused after exposure than before. There were no other main or interactive effects.

7.5 DISCUSSION

The results of this study show that participants report an increase in respiratory symptoms after exposure to a very low concentration of Toluene (3pmm) to which they are not able to report any awareness of their being exposed. Furthermore, symptom reporting is not related to whether or not participants believed they have been exposed.

With respect to the mechanism involved, these results show that changes in symptom reports are not associated with awareness of an odour, nor are they related to a belief that they might be exposed. If the latter were the case, then there would have been an effect of time (pre- to post-exposure), with participants reporting more symptoms after the atmosphere chamber, regardless of whether or not they were exposed. However, this was not the case as the change in symptom reporting was highest for those exposed. Thus the actual exposure – regardless of awareness – has an effect. This suggests that there are implicit effects of odour on symptom reporting. The precise mechanism that underlies this cannot be ascertained from this study. There is evidence that odour can be involved in implicit learning (Degel, Piper & Koster, 2001) and that there are implicit memory effects for odour (Degel & Koster, 1999). Both of these are possible mechanisms that require further investigation. To show implicit learning effects then a similar experiment containing a learning phase needs to be conducted. At the very least these results show an unconditioned effect of a low concentration sub-threshold odour.

The odour used in this study – Toluene – was chosen as it formed the basis of one of the most commonly reported odours (e.g., paint) from the diary studies. As such, the participants may have, due to prior exposure/experience developed an implicit association/memory for toluene (solvents) or become sensitised to it, and exposure was enough to cause increased symptom reporting. The practical implication of this is that odours in the work place of low concentration – even not entering awareness – may influence symptom reports. This is important as the management of odour in the work place is based on toxicological effects of high concentrations. The realm of sub-threshold effects has not been explored and needs further study.

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8. DAILY JOB DEMANDS AND CONTROL: VALIDATION OF THE HSE MANAGEMENT STANDARDS DIMENSIONS

8.1 INTRODUCTION

The proceeding chapters have detailed the main focus of this report – namely examining the role of general daily work stress and odour as potential predictors of non-specific symptoms. Whilst there were observed effects for odour, there were also consistent effects for general stress. This final chapter provides an additional set of analysis to examine in more detail the role of daily stress by focusing on daily job demands and control as predictors of symptom reporting in contrast to an assessment of general stress. Furthermore, levels of cortisol production and salivary Ig A were also examined as potential mediators.

8.1.1 Control and demand – HSE Management Standards Tool

As stated in the main introduction to this report, demand and control form two central perceived job-characteristics that constitute stress at work. Recently, the HSE has developed a series of standard measures that can be used assess these – as well as 4 other dimensions (role, relationships, change and support; Cousins, Mackay, Clarke, Kelly, Kelly & McCaig, 2004) – in the work place. As part of the validation process for this measure this study examined if these two dimensions, when assessed twice daily – as in the other diary studies – were able to predict symptom reporting in addition to an assessment of general stress, and if they showed any relation to daily variation in physiological parameters.

8.2 METHOD

8.2.1 Sample

8.2.1.1 Full job characteristics diary sample

A total of 43 participants completed the full job characteristics diary study (Appendix 3), from an initial pool of 48 volunteers, equating to a response rate of 90%. Of these, 36 participants returned the full eight diary sheets, with 7 only completing part of the diary period. Overall there were 688 potential daily assessments.

The mean age of the sample was 42 years (SD = 9.05). 70% of the sample was female, and 30% were male. Mean organisational tenure was 133.16 months (SD = 105.6). 309 assessments were deleted due to missing data or missing compliance data, with a further 22 assessments deleted due to non-compliant data. In total, 331 assessments were deleted on the grounds of missing or non-compliant data. Thus there were 357 usable diary days.

8.2.1.2 Job characteristics and saliva diary sample

A sub-sample of the full job characteristics diary sample also undertook saliva sampling across the 8-day diary period. A total of 17 participants completed the job characteristics and saliva sampling diary study, from an initial pool of 18 volunteers, equating to a response rate of 94%. Of these, 15 participants returned the full eight diary sheets, with 2 only completing part of the diary period. Overall there were 272 potential daily assessments.

The mean age of the sample was 40 years (SD = 8.7). 77% of the sample was female, and 23% were male. Mean organisational tenure was found to be 126 months (SD = 102.9). 130 assessments were deleted due to missing data or missing compliance data. 18 further

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assessments were deleted due to non-compliant. In total, 148 assessments were deleted on the grounds of missing or non-compliant data. Thus there were 124 usable diary days.

8.2.2 Procedure

The diary study was conducted in the same manner as the others previously described, except that daily measures of perceived job-control and job-demand were assessed instead of odour, along with the same index of general stress. The same set of personality measures were used as before.

8.2.3 Measures of job control and job demands

Job demands and control were measured based on scales devised by the HSE as part of their ‘Management Standards’ approach to tackling work-related stress (Cousins, Mackay, Clarke, Kelly, Kelly & McCaig, 2004). These were adapted so as to focus on daily experiences rather than demand and control in general. There were 6 items for the job demands and 6 items for the job control scales, both of which were measured using a 5-point Likert-type scale, (where 1=not at all, and 5=very much/to a large extent). Items for the job demands scale include “have you had to work very fast?” and “have you been pressured to work long hours?”. Sample items for the job control scale include “has your working time been flexible?” and “have you had a choice in deciding how you have done your work?” Cronbach’s Alpha reliability coefficients were calculated for each half-day period for both job demands and job control. Reliabilities for job demands ranged from α = 0.696 – 0.863 with a mean of α = 0.794 (Ns = 17-25) for the first job characteristics diary, and α = 0.708 – 0.909 with a mean of α = 0.815 (Ns = 10-17) for the second job characteristics and saliva diary. Reliabilities for job control ranged from α = 0.871 – 0.941 with a mean of α = 0.914 (Ns = 17-25) for the first job characteristics diary, and α = 0.761 – 0.999 with a mean of α = 0.861 (Ns = 10-17) for the second job characteristics and saliva diary.

The analyses were restricted to working days only.

8.3 RESULTS

This data was analysed using the same multi-level modelling procedures and sequences as the main diary study (see Section 2.5.2). For brevity only the final models will be presented here. The first set of analysis will report on the prediction of symptoms (at zero, half day and full day lag) whilst the second will examine the mediating role of cortisol and Sig A.

8.3.1. Construct validity

Daily job-control and job-demands were significantly related (coefficient = -0.40, p <.001). Thus reduced levels of daily job-control are related to increased levels of daily job-demand. This provides some internal validity for the measures. Increased levels of daily job-control were associated with a reduction in levels of daily perceived stress (-0.80 p < .0001). Increased levels of daily job-demands were associated with increased levels of daily stress (1.4, p < .0001).

Additional construct validity of the job-control and job-demand measures was explored in terms of a series of separate multi-level models to look at the relationships between the survey measures of job-control and personality (assessed approximately 2 years previously) and daily variation in levels of job-control and job demands (the results are shown in Table 11). The results in Table 11 provide some additional construct validity for the daily job-control measure, by indicating that employees’ general perceptions of job-control predict future daily variation in job-control. This means that those who perceive their jobs to generally be controllable also rate their jobs as controllable on a daily basis. In addition, health anxiety

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again emerges as an important individual difference predicting daily control, demands and stress.

Table 11 Univariate associations

Daily Job Control Daily Job Demands Daily Stress General Job Control 0.21** -0.19` -0.05* Neuroticism -0.38~ 0.21 0.13** PA 0.10 -0.10 -0.04 Health Anxiety -0.32** 0.26* 0.10** Chemical Intolerance -0.23 -0.41 0.003

Note. ~ p = .08, ` p = .06, * p < .05, ** p < .01

8.3.2 Prediction of daily symptoms

Zero-lags: The zero-lag final model showed that daily symptoms were predicted by levels of health anxiety (coefficient = 0.26, p < .05) and associated with increased daily levels of reported stress (coefficient = 0.68, p < .001).

Half-day lags. Daily levels of job-control showed a half-day lagged effect on symptoms (coefficient = -0.11, p < .05). That is, levels of perceived control in the morning predicted afternoon symptoms, and afternoon levels of control predicted symptoms the following morning. Health anxiety was also still as predictor of symptom levels (coefficient = 0.26, p < .01).

One-day lags. There were no lagged effects.

8.3.3 The Role of Cortisol & Sig A

Cortisol: Replicating the previous study, daily cortisol levels showed a negative relationship with time of the day (coefficient = -0.19, p = .014) and the cortisol difference score was positively associated with daily cortisol levels (coefficient = 0.02, p < .0001). Thus consistent with the diurnal variation in cortisol, cortisol levels were lower in the afternoon compared to the morning, and daily cortisol levels were higher for those who showed a smaller waking to daytime difference. There were no other significant effects.

Sig A: There were no significant effects.

8.4 DISCUSSION

The results from the above validation study indicate that the HSE’s measures of perceived job-control and job-demands have internal validity as a daily assessment and are related in meaningful ways to trait-like predictors. Of the demand and control measures, control appears to be the main associate of daily symptom reports – over a half day lag. However, there were no associations with daily cortisol or S-IgA production. These results should be seen as some initial validation for using these measures for the daily assessment of on-going job-characteristics.

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9. CONCLUSIONS & RECOMMENDATIONS

9.1 KEY FINDINGS AND SUPPORTING EVIDENCE

Five key findings can be drawn from the above report.

1. Odour in the work place should be considered an important variable with respect to symptom reporting.

a. The results from the cross-sectional work showed that the extent to which people rate odours as a trigger for symptoms was related to greater symptom reporting when appraisals of the work environment and other individual differences were controlled.

b. The daily assessments of odour and sound indicated a lagged – i.e. causal – effect for the severity of odour upon reported daily symptoms. That is, stronger odours are related to an increase in future symptom reporting. Also there was evidence that lingering odours were associated with increased symptom reporting.

c. The exposure study showed that people reported increased respiratory symptoms when exposed to a low level of Toluene although they were not aware that they were being exposed.

2. Aspects of the working day are important determinants of symptom reporting.

d. Daily symptom assessments vary across the working day (being higher in the afternoons) and across the working week (being higher at the start of the week).

3. Individual differences, especially health anxiety, are an important predictor of symptoms.

e. The results of the cross-sectional work, as well as the diaries, revealed strong effects for individual differences – indicating that they may have a primary causal role – especially N and health anxiety. These findings are consistent with a recent meta-analytic structural equation modelling study (Ferguson, Daniels & Jones, 2006).

4. The relationship between physiological variables and symptom reporting.

f. There was no evidence that either cortisol or S-IgA were related to symptom reporting.

5. Appraisals of the work environment continue to be shown as important with respect to work related symptom reporting.

g. The cross-sectional analysis revealed that reduced levels of perceived job-control were associated with increased symptom reporting, but this effect was much smaller than that attributable to neuroticism (approximately half the size)

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h. Appraisals of general stress on a daily basis were shown to be associated with increased reporting of symptoms.

i. Higher levels of daily perceived job-control (as assessed by the HSE’s new management standards tool) were related to increased future reports of symptoms.

9.2 RECOMMENDATIONS – PRACTICAL

There are a number of recommendations that can be drawn from this work that have a bearing on the design of future intervention studies.

1. Interventions need to focus on both individuals as well as organizational factors.

a. Given that the data supports a strong influence for individual differences (especially N and health anxiety) it is recommended that interventions to reduce work stress do not only focus on changing organisational factors, but also upon more individually focused interventions.

2. Sources of environmental odour should be sought that employees rate as associated with illness and removed.

b. Given the above evidence it is suggested that organisations identify lingering or intense odours in the work place, that individuals rate as making them feel unwell, and remove them. However, this should be done with extreme care. There is evidence from the literature that misattribution of symptoms to odours can results in mass psychogenic effects (Alexander & Fedoruk, 1986) and that people can imbue neutral or non-toxic odours with causing ill-health effects (Dalton, 1999). The point here is not to change neutral odours to ones that people believe are associated with illness. Future research work needs to look at how odour can be managed in the workplace. This report only serves to show that it is a factor in symptom reporting.

c. One way to start to achieve the above would be to use the odour diaries described here to identify sources of odour in the work place – without asking people to link these explicitly to illness as this may cause additional problems mentioned in (b) above. The results from this could be used to identify any potential problems. The use of diaries in this way – to inform interventions, or as an intervention itself – requires further research to identify the optimal parameters for these to work efficiently. The present research shows that odour is important, and future work is needed to show how this can be translated into practice.

9.3. RECOMMENDATIONS – RESEARCH

1. Symptom reporting varies as a function of time of day, and day of the week.

a. People feel worse on a Monday. Therefore, should interventions be focused on Monday? Again, this is an empirical question.

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2. There was some evidence that individuals report less symptoms at the end of the diary study.

b. This could be because the diary actually acted as an intervention – by having people reflect on the daily symptoms, stress and environment (reactance effects: changed the way they think about work and stress), or that they became bored and reported less accurately. Research needs to try and address where diaries are actually acting as interventions, and if so, how. An additional interpretation is the as the diary studies were run over a single week (Monday to Monday) the reduction in symptom reporting may reflect a reduction in symptoms as the weekend approaches.

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10. ORGANIZATIONAL FEEDBACK

All participating organizations were provided with the opportunity to provide feedback on the 1st draft of this report. The follow represent comment and ideas that were forwarded to us.

The feed back was supportive and found the findings to have organization relevance in relation to

1. sickness absence, 2. health promotion and 3. Stress management

Specifically, the following were highlighted

1. Pay more attention to odours in the work place 2. Potentially focus interventions on Mondays 3. Focus interventions at individual and organizational levels 4. Consider diaries as an intervention 5. Identify controllable aspects of the work environment

Questions arising from feedback

1. Could diaries studies be conducted on line? a. Yes, indeed Ferguson (2005) discusses this.

2. Could diaries be designed to a standard template for use as an intervention? a. This could be achieved but the results and focus of the current

research does not permit this at the moment. Additional work is needed to ascertain first if diaries are effective interventions and also to ascertain optimal design protocols for using diaries in this way.

Quotes –

‘Your findings are a timely reminder that individuals need to be considered alongside whole service approaches’

‘It is anecdotal … but one thing that can cause upset in our … building is people cooking/heating things in the microwave …’

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Schwartz, G. E., Bell, I. R., Dikman, Z. V., Fernandez, M., Kline, J. P., Peterson, J. M., & Wright, K. P. (1994). EEG responses to low level chemicals in normals and cacosomics. Journal of Toxicology and Industrial Health, 10, 633-643.:

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Siegel, S. & Kreutzer, R. (1997). Pavlovian Conditioning and Multiple Chemical Sensitivity. Environmental Health Perspectives, 105, 521-526.

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11. APPENDICES

11.1 APPENDIX 1: SYMPTOM DIARY

This appendix illustrates the symptom diary used as part of Diary 1 and Diary 2 stages of the project.

*Organisation*

Health & Safety Executive / University of Nottingham

Health & Well-being in the Workplace Research Project

Symptom Diary

75

*Organisation*Health & Safety Executive / University of Nottingham

Health & Well-being in the Workplace.

Symptom Diary

This diary consists of two sections. The first section deals with symptoms. You will be asked to record on a daily basis, the extent to which you experience these symptoms on each day, using a symptom checklist.

The second section is concerned with your ‘work environment’. In particular you will be asked questions about the smells and sounds you notice. You will also be asked a question about your levels of anxiety, and to indicate if you are at work or not at work.

You need to complete the diary twice a day - at around noon, for example at lunchtime, and again in the evening, for example directly after work or at dinnertime – for an 8-day period starting on a Monday and finishing on the following Monday. You will be asked to complete the diary for the whole of the 8-day period, including any days you are not working and at the weekends.

To make it easier to use, the diary has a page of questions per day. On each day you are completing the diary, before answering any of the questions you will need to fill in the required information at the top of each page.

First, you should tick the day and write in the date. Should you forget to complete the diary on the specified day, please indicate this by responding Yes to the question ‘Are you completing this late?’ at the top of the daily diary. You should also indicate the date of the day on which you are actually completing the diary. You will also need to indicate whether or not you are working on the day you are completing the diary for.

Once completed, each page should be returned to the University of Nottingham daily using the pre-paid envelopes provided. Therefore, after completing the afternoon section of the diary, you should tear the page from the booklet, put it into the envelope and post it that day, or the following morning.

SUMMARY

• The diary period runs from Monday through to the following Monday;

• Complete the diary twice a day – at lunchtime and in the afternoon / evening;

• Make sure you fill in the information at the top of each sheet;

• Remember to post your completed daily diary each evening using the pre-paid envelopes provided in your diary pack;

• Try to complete the diary every day at the same times;

• If you have any questions or concerns contact Jane Ward on 0115 951 5325, email jane.ward@nottingham.ac.uk

Please read through the instructions on the following pages

before completing the diary.

76

77

Symptom Diary

PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE STARTING Before completing the diary each day, please remember to fill in the date. If you are completing the diary late, please also indicate the date of completion. Please indicate whether you were working that day or not by circling Yes or No. Section 1 For each day we would like you to indicate how severely you experienced each of the symptoms a) in the morning and b) in the afternoon / evening. To do this, you should aim to complete the diary at around noon, for example at lunchtime, and again in the evening, for example after work or at dinnertime. Please provide a response for each symptom. Make your response using the following scale.

0 = did not experienced the symptom 1 = experienced the symptom very mildly 2 = experienced the symptom mildly 3 = experienced the symptom moderately 4 = experienced the symptom severely 5 = experienced the symptom very severely

For example, if you suffered from a slight knee pain in the morning and bad indigestion all afternoon, you would complete the checklist as follows:

Symptom

AM

PM

Headache 0 0 Dizziness 0 0 Palpitations 0 0 Weak / fatigued 0 0 Upset stomach 0 4 Pain in limbs 1 0 Pain in joints 0 0 Sexual problems 0 0 Breathlessness 0 0 Sweatiness 0 0 Tingling in hands & feet 0 0 Irregular bowel movements 0 0 If you do not experience a symptom, please remember to indicate this with a zero in the appropriate box. Section 2 For each day we would also like you indicate if you noticed any particular smell or sounds. If you did experience either a smell or a sound, please write briefly what it was, and indicate for how long you noticed each smell and sound. For example if it was 1½ hours approximately write 1 hours 30 minutes. If it was just 20 minutes write 0 hours 20 minutes. If you did not experience either a smell or a sound, please write NONE in the space provided. We would also like you to indicate how strong the smell and how loud the noise was, using the following scales: Strength of smell: 1 = very weak (only just noticeable)

2 = weak

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3 = moderate (bearable) 4 = strong 5 = very strong (overbearing)

Loudness of noise: 1 = very quiet (only just noticeable)

2 = quiet 3 = moderately quiet 4 = loud 5 = very loud (overbearing)

For example, if on Monday morning you noticed a strong smell of petrol that lasted for about 10 minutes, followed by a mild coffee smell that went on all afternoon, you would complete the diary like this:

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? Petrol If YES for how long did you notice it? 0 Hours 10 Minutes If YES how strong was the smell? 4

If YES what was it? Coffee If YES for how long did you notice it? 4 Hours 30 Minutes If YES how strong was the smell? 2

With regard to sounds, if you were to hear for example, unpleasantly loud drilling in your office most of Monday morning, followed by a mild humming from the office photocopier for twenty minutes on Monday afternoon, you might complete the checklist as follows:

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? Drilling If YES for how long did you notice it? 3 Hours 0 Minutes If YES how loud was the noise? 5

If YES what was it? Photocopier If YES for how long did you notice it? 0 Hours 20 Minutes If YES how loud was the noise? 2

In addition, there is a question concerning your anxiety level during the course of the day. For this question, you simply need to rate you level of stress or anxiety during the morning and afternoon, using a 1 – 7 scale, where 1 is ‘not at all anxious’ and 7 is ‘extremely anxious’.

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DAY ONE

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

80

DAY TWO

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

81

DAY THREE

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

82

DAY FOUR

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

83

DAY FIVE

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

84

DAY SIX

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

85

DAY SEVEN

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

86

DAY EIGHT

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2004 Are you completing this late? Yes No If Yes, what is the date? / / 2004 Were you working today? Yes No

Symptom

AM

PM

Headache Dizziness Palpitations Weak / fatigued Upset stomach Pain in limbs Pain in joints Sexual problems Breathlessness Sweatiness Tingling in hands & feet Irregular bowel movements

AM

PM

Did you notice any particular smell? (Please circle) Yes No

If YES what was it? ____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how strong was the smell? ____________

AM

PM

Did you notice any particular sound? (Please circle) Yes No

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

If YES what was it? _____________ If YES for how long did you notice it? _______ Hours ________ Minutes If YES how loud was the noise? ____________

How ‘stressed’ or ‘anxious’ have you felt today?

Not at all Extremely 1 2 3 4 5 6 7

Not at all Extremely 1 2 3 4 5 6 7

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

87

11.2 APPENDIX 2: SALIVA DIARY

This appendix illustrates the saliva diary used as part of the Diary 2 stage of theproject.

*Organisation*

Health & Safety Executive / University ofNottingham

Health & Well-being in the Workplace ResearchProject

Saliva Diary

88

*Organisation* Health & Safety Executive / University of Nottingham

Health & Well-being in the Workplace.

Saliva Sampling Diary

This diary is for you to record the details of your daily saliva sampling. It is meant to be completed daily in addition to the symptom diary, and returned each day, along with the daily diary page and your three saliva samples. You need to take your saliva samples three times per day, and each time, complete the diary to record the details of your sample. Saliva samples should be taken:

1) within ten minutes of waking up, and before drinking or brushing your teeth

2) when you complete the AM section of the diary, for

example at noon, or around lunchtime

3) when you complete the PM section of the diary, for example directly after work or at dinnertime

Saliva samples should be taken throughout the 8-day diary period starting on a Monday and finishing on the following Monday. You will be asked to take saliva samples for the whole of the 8-day period, including any days you are not working and at the weekends. To make it easier to use, the diary has a page per day. On each day you are completing the diary, before answering any of the questions you will need to fill in the required information at the top of each page. First, you should tick the day and write in the date. You will also need to indicate whether or not you are working on the day for which you are taking the sample. Once completed, each page should be returned to the University of Nottingham daily using the pre-paid envelopes provided. Therefore, after completing the symptom diary, collecting your three saliva samples, and completing your daily saliva diary, you should tear the pages from the booklets, put them into the envelope and post it that day, or the following morning.

SUMMARY • The diary period runs from Monday through to the following Monday; • Complete the saliva diary three times a day – when collecting a saliva sample • Make sure you fill in the information at the top of each sheet of the saliva diary; • Remember to post your completed daily saliva diary each evening, along with the

symptom diary, using the pre-paid envelopes provided in your diary pack; • If you have any questions or concerns contact Jane Ward on 0115 951 5325, email

jane.ward@nottingham.ac.uk

Please read through the instructions on the following pages

before completing the diary.

89

Saliva Sampling Diary

PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE STARTING This diary is to provide us with details of your saliva sampling activity throughout the 8-day diary period. Please take time to read these instructions through carefully to ensure that both the sampling and the diary are completed correctly. Full instructions on how to take a saliva sample are contained within the Saliva Sampling Participant Information Form. Please read this through fully before undertaking any sampling. This saliva diary should be completed at the following times:

1) when taking Sample 1 (i.e. within ten minutes of waking up, and before drinking or brushing your teeth)

2) when taking Sample 2 (i.e. when you complete the

AM section of the diary, for example at noon, or around lunchtime)

3) when taking Sample 3 (i.e. when you complete the

PM section of the diary, for example directly after work or at dinnertime)

How to complete the Saliva Diary The diary is split into three sections – A, B and C. Please remember to complete all of the sections each day. Section A Please complete the day and the date for which you are collecting the samples. Please also indicate whether or not you are working on that day. Section B When taking Sample 1, please indicate what time you woke up in the morning, and also what time you got up out of bed. Please then indicate what time the sample was collected. Please try to collect this first sample of the day within 10 minutes of waking and before brushing your teeth or eating / drinking. Samples 2 and 3 should be taken at the same time as you record your AM and PM sections of the Symptom Diary. For these samples you should record what time the sample was collected. Section C When you have completed the details of Sample 3, you will need to think about your alcohol, caffeine and cigarette consumption during the previous 24 hours leading up to the collecting of Sample 3. In Section C, please estimate how many cigarettes you have smoked, and how many cups of tea or coffee and units of alcohol* you have drunk. N.B: 1 unit of alcohol represents:

- pub measure of spirits - half a pint of bitter or normal strength lager - half a glass of wine

90

Once the saliva sampling diary has been completed, please then tear the page from the booklet, and return it, along with your daily symptom diary and your 3 saliva samples to the University of Nottingham, using the pre-paid envelopes enclosed in your pack. Each envelope will be marked with your subject number and the day / date. When returning the samples, please use the appropriate envelope, i.e. when returning Tuesday’s samples, please use the envelope marked with your subject number, and marked ‘Tuesday’. *Information taken from Department of Health ‘Drink Sensibly’ Website

91

DAY ONE

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

92

DAY TWO

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

93

DAY THREE

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

94

DAY FOUR

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

95

DAY FIVE

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

96

DAY SIX

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

97

DAY SEVEN

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

98

DAY EIGHT

Section A Day: Mon Tues Wed Thurs Frid Sat Sun Date: / / 2004 Were you working today? Yes No ________________________________________________________________________ Section B Sample 1 What time did you wake up? _______________________ What time did you get up? _______________________ What time did you take the sample? _______________________ Sample 2 What time did you take the sample? _______________________ Sample 3 What time did you take the sample? _______________________ ________________________________________________________________________ Section C Please estimate how many cigarettes you have smoked today: ________ Please estimate how many cups of tea / coffee you have drunk today: ________ Please estimate how many units of alcohol you have drunk today: ________ ________________________________________________________________________

PLEASE REMEMBER TO POST THIS TONIGHT WITH YOUR SALIVA SAMPLES AND YOUR DAILY SYMPTOM DIARY

USING THE PRE-PAID ENVELOPE

99

11.3 APPENDIX 3: JOB CHARACTERISTICS DIARY

This appendix illustrates the job characteristics diary used as part of the final stage ofthe project.

*Organisation*

Health & Safety Executive / University ofNottingham

Health & Well-being in the Workplace ResearchProject

Job Characteristics Diary

100

Health & Safety Executive / University of Nottingham

Health & Well-being in the Workplace.

Job Characteristics Diary

This diary consists of two sections. The first section deals with symptoms. You will be asked to record on a daily basis, the extent to which you experience these symptoms on each day, using a symptom checklist. The second section is concerned with your ‘work environment’. In particular you will be asked questions about your job, and what your work ‘experience’ is like day to day. You will also be asked a question about your levels of anxiety, and to indicate if you are at work or not at work. You need to complete the diary twice a day - at around noon, for example at lunchtime, and again in the evening, for example directly after work or at dinnertime – for an 8-day period starting on a Monday and finishing on the following Monday. You will be asked to complete the diary for the whole of the 8-day period, including any days you are not working and at the weekends. To make it easier to use, the diary has a page of questions per day. On each day you are completing the diary, before answering any of the questions you will need to fill in the required information at the top of each page. First, you should tick the day and write in the date. Should you forget to complete the diary on the specified day, please indicate this by responding Yes to the question ‘Are you completing this late?’ at the top of the daily diary. You should also indicate the date of the day on which you are actually completing the diary. You will also need to indicate whether or not you are working on the day you are completing the diary for. Once completed, each page should be returned to the University of Nottingham daily using the pre-paid envelopes provided. Therefore, after completing the afternoon section of the diary, you should tear the page from the booklet, put it into the envelope and post it that day, or the following morning.

SUMMARY • The diary period runs from Monday through to the following Monday; • Complete the diary twice a day – at lunchtime and in the afternoon / evening; • Make sure you fill in the information at the top of each sheet; • Remember to post your completed daily diary each evening using the pre-paid envelopes

provided in your diary pack; • Try to complete the diary every day at the same times; • If you have any questions or concerns contact Jane Ward on 0115 951 5325, email

jane.ward@nottingham.ac.uk

Please read through the instructions on the following pages before completing the diary.

101

Job Characteristics Diary

PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE STARTING Before completing the diary each day, please remember to fill in the date. If you are completing the diary late, please also indicate the date of completion. Please indicate whether you were working that day or not by circling Yes or No. Section 1 For each day we would like you to indicate how severely you experienced each of the symptoms a) in the morning and b) in the afternoon / evening. To do this, you should aim to complete the diary at around noon, for example at lunchtime, and again in the evening, for example after work or at dinnertime. Please provide your response by circling the appropriate number using the following scale:

0 = did not experienced the symptom 1 = experienced the symptom very mildly 2 = experienced the symptom mildly 3 = experienced the symptom moderately 4 = experienced the symptom severely 5 = experienced the symptom very severely

For example, if you suffered from a slight knee pain in the morning and bad indigestion all afternoon, you would complete the checklist as follows:

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5 NB - Please provide a response for each symptom. If you do not experience a symptom, please remember to indicate this by circling the zero. Section 2 This section refers to your job, and your daily experience at work. We would like you consider how each question relates to your work experience in the morning and afternoon. As with the symptoms, you will be asked to complete these questions twice every day, once at lunchtime, and then again once the working day is over. For each half-day, we would like you to consider these questions, and make your responses by circling the appropriate number from the following scale:

102

Job Characteristic Scale: 1 = Not at all 2 = A little / to some extent 3 = A moderate amount 4 = Quite a bit 5 = Very much / to a large extent

For example, if during the course of the morning you found that you had to work very quickly to complete a task, but then had less to do in the afternoon, you might complete the diary like this:

AM

PM

a) Have you had to work very fast?

1 2 3 4 5

1 2 3 4 5

NB - Please make sure that provide a response for each question. If a question is not appropriate to your job, mark your response with a 1 – ‘Not at all’. In addition, you will be asked to consider your anxiety level during the course of the day. For this question, you simply need to rate you level of stress or anxiety during the morning and afternoon, using a 1 – 7 scale, where 1 is ‘not at all anxious’ and 7 is ‘extremely anxious’.

103

DAY ONE

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Experienced symptom severely

Did not experience symptom

Very much / large extent

Not at all Not at all

Very much / large extent

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

104

DAY TWO

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

105

DAY THREE

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

106

DAY FOUR

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

107

DAY FIVE

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

108

DAY SIX

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

109

DAY SEVEN

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

DAY EIGHT

Date: Mon Tues Wed Thurs Frid Sat Sun / / 2005 Are you completing this late? Yes No If Yes, what is the date? / / 2005 Were you working today? Yes No

Symptom

AM

PM

1) Headache 0 1 2 3 4 5 0 1 2 3 4 5 2) Dizziness 0 1 2 3 4 5 0 1 2 3 4 5 3) Palpitations 0 1 2 3 4 5 0 1 2 3 4 5 4) Weak / fatigued 0 1 2 3 4 5 0 1 2 3 4 5 5) Upset stomach 0 1 2 3 4 5 0 1 2 3 4 5 6) Pain in limbs 0 1 2 3 4 5 0 1 2 3 4 5 7) Pain in joints 0 1 2 3 4 5 0 1 2 3 4 5 8) Sexual problems 0 1 2 3 4 5 0 1 2 3 4 5 9) Breathlessness 0 1 2 3 4 5 0 1 2 3 4 5 10) Sweatiness 0 1 2 3 4 5 0 1 2 3 4 5 11) Tingling in hands & feet 0 1 2 3 4 5 0 1 2 3 4 5 12) Irregular bowel movements 0 1 2 3 4 5 0 1 2 3 4 5

Job Characteristic

AM

PM

a) Have you had to work very fast? 1 2 3 4 5 1 2 3 4 5 b) Have you had to work very intensively?

1 2 3 4 5 1 2 3 4 5

c) Have you had enough time to do everything?

1 2 3 4 5 1 2 3 4 5

d) Have different work groups demanded things from you that have been hard to combine?

1 2 3 4 5 1 2 3 4 5

e) Have you been pressured to work long hours?

1 2 3 4 5 1 2 3 4 5

f) Have you had unachievable deadlines?

1 2 3 4 5 1 2 3 4 5

g) Have you had a choice in deciding how you have done your work?

1 2 3 4 5 1 2 3 4 5

h) Have you had a choice in deciding what you have done at work?

1 2 3 4 5 1 2 3 4 5

i) Have you had a good deal of say in decisions about your work today?

1 2 3 4 5 1 2 3 4 5

j) Have you had a say in your own work speed?

1 2 3 4 5 1 2 3 4 5

k) Has your working time been flexible? 1 2 3 4 5 1 2 3 4 5 l) Have you been able to decide when you take a break?

1 2 3 4 5 1 2 3 4 5

How ‘stressed’ or ‘anxious’ have you felt today?

AM Not at all Extremely 1 2 3 4 5 6 7

PM Not at all Extremely 1 2 3 4 5 6 7

Did not experience symptom

Experienced symptom severely

Did not experience symptom

PLEASE REMEMBER TO POST THIS TONIGHT USING THE PRE-PAID ENVELOPE

Experienced symptom severely

Very much / large extent

Not at all Not at all

Very much / large extent

Published by the Health and Safety Executive 12/06

Triggers for non-specific symptomsin the workplaceIndividual differences, stress andenvironmental (odour and sound) factors

Health and Safety Executive

RR501

www.hse.gov.uk

Non-Specific Symptoms (NSS) are symptoms that are notrelated to any given disease and include fatigue,weakness, sleep difficulties, headache, muscle aches.They have a high reported incidence in the work placeand are related to workplace absenteeism. Work-relatedill-health and absenteeism remain a significant concern forUK organisations and employees alike, translating into32.9 million working days a year lost through illness, withstress, depression and anxiety accounting for the majorityof days lost (13.4 million). Identifying aspects of the workenvironment, characteristics of individual workers,external factors and physiological factors that contributeto reporting non-specific symptoms are thereforeimportant and make them the focus of this research.

This report and the work it describes were funded bythe Health and Safety Executive (HSE). Its contents,including any opinions and/or conclusions expressed, arethose of the authors alone and do not necessarily reflectHSE policy.