Journal of Occupational Health
Online ISSN : 1348-9585
Print ISSN : 1341-9145
ISSN-L : 1341-9145
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Showing 1-31 articles out of 31 articles from the selected issue
Original Articles
  • Satoru Kanamori, Taishi Tsuji, Tomoko Takamiya, Hiroyuki Kikuchi, Shig ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12115
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objectives: Very few longitudinal studies have investigated the question of whether differences in company size may give rise to health inequalities. The aim of this study was to examine the relationship between company size of the longest-held job and mortality in older Japanese adults.

    Methods: This study used longitudinal data from the Japan Gerontological Evaluation Study. Surveys were sent to functionally independent individuals aged 65 or older who were randomly sampled from 13 municipalities in Japan. Respondents were followed for a maximum of 6.6 years. The Cox proportional hazards model was used to calculate mortality hazard ratios (HRs) for men and for women. Analysis was carried out on 35 418 participants (197 514 person-years).

    Results: A total of 3935 deaths occurred during the 6-year follow-up period. Among men, in Model 1 that adjusted for age, educational attainment, type of longest-held job, and municipalities, mortality HRs decreased significantly with increasing size of company (P for trend = .002). Compared to companies with 1-9 employees, the mortality HR (0.78, 95% confidence interval: 0.68-0.90) was significantly lower for companies with 10 000 or more employees. However, there were no significant differences among women (P for trend = .41).

    Conclusions: In men, mortality in old age may decrease with increasing size of company of the longest-held job. To reduce health inequalities in old age due to differences in size of company, studies should be conducted to determine the underlying mechanisms and moderating factors and those findings should be reflected in labor policies and occupational health systems.

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  • Patrycja W. Zając, Bożena Czarkowska-Pączek, Aleksandra Wyczałkowska-T ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12112
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objective: The aim of the study was to determine and compare the prevalence of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) antibodies and DNA among nurses working in different profiles of healthcare activity.

    Material and methods: The study population comprised 120 women (90 exposed healthcare workers and 30 controls). Blood samples were investigated using chemiluminescent microparticle immunoassays (CMIA) tests to detect the presence of EBV VCA IgM, IgG, and CMV IgM, IgG. Plasma CMV and EBV DNA levels were assessed using real-time polymerase chain reaction (PCR).

    Results: CMV IgG antibodies were present in 87.80% nurses (86.70% in controls), EBV IgG were present in all the nurses studied and in the control group. No statistically significant differences were noted between the subgroups of nurses and the control group as regards IgG CMV, VCA IgG EBV. CMV IgM/EBV IgM antibodies were negative in all the nurses. CMV/EBV DNA was reported only in the study group. It was not found in any of control group participants.

    Conclusions: The positive PCR CMV/EBV markers only in the study group can be indicative of the exposure of nurses to these pathogens being greater than in other people not being professionally involved in patient care. In addition, it was observed that the level of CMV IgG antibodies as well as EBV VCA IgG antibodies tended to be linked to the age and the length of work of nurses working in pediatrics.

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  • Ying Li, Yao Song, Weimin Dang, Lijun Guo, Weixian Xu
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12113
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objectives: Chromogranin A (CgA) is regarded as an indicator of sympathetic tone and adrenomedullary system activity. Catestatin is one of CgA-derived fragments through proteolytic processing. Many studies have confirmed the correlation between anxiety/depression and the salivary CgA level. The study was to investigate the associations between anxiety/depression and plasma CgA/catestatin levels in healthy workers without cardiovascular disease.

    Methods: The study included 263 healthy workers (175 men and 88 women). The symptoms of anxiety and depression were measured with the Hospital Anxiety and Depression Scale (HADS). Plasma CgA and catestatin levels were measured by ELISA kits.

    Results: In bivariate correlation analysis, anxiety and depression were positively associated with plasma CgA level, respectively (r = 0.298, P < .001; r = 0.304, P < .001), but not significantly associated with plasma catestatin level.

    The anxiety group had significantly higher plasma CgA level than that in the no-anxiety group (median 158.60 vs 70.90, P < .001). The similar results were found for depression scales. The depression group had significantly higher plasma CgA level (median 145.60 vs 82.40, P < .001).

    In the multiple linear regression model, after adjusting for age, gender, and BMI, anxiety was positively correlated with plasma CgA level (β = 0.359, P < .001), while anxiety was negatively correlated with plasma catestatin level (β = −0.128, P = .044), depression was also positively correlated with plasma CgA level (β = 0.343, P < .001).

    Conclusions: Plasma CgA was associated with anxiety and depression in healthy workers. It can be considered as the blood indicator for the evaluation of anxiety and depression.

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  • Anna Kołcz, Karolina Jenaszek
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12108
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objectives: The problem of spinal pain among nurses and lack of compliance with workplace ergonomy is increasing. The study aimed to assess the pressure pain threshold (PPT) at the cervical and lumbar spine in nursing staff.

    Methods: The sample of this prospective and observational study consisted of 30 female nurses with a mean age of 38.6 ± 11.1 years. The standardized Oswestry (ODI) and the Neck Disability Index (NDI) were used, as well as the Authors’ Designed Questionnaire (ADQ) was used to assess compliance with ergonomic principles. The PPT analysis using a computerized pressure algometer (CPA) was performed to examine the level of PPT.

    Results: A mild disability was found in 56% of nurses (NDI and ODI). A value of <4 kg/cm2 (CPA), indicating musculoskeletal overload was observed in 57% of subjects. Also, 60% of nurses work with a lying patient; 73.4% grabs the patient's armpits while transferring in bed; 16.7% never adjusts the height of the bed, and only 13.4% choose specialist footwear for work. There is a correlation between PPT values for trapezius and erector spinae muscles on the same side of the body in nurses with mild and moderate disability (P < .05).

    Conclusions: Pain complaints are associated with lower PPT of trapezius and erector spinae muscles and asymmetry of muscle tension. Also, it was noted that the lack of implementation of ergonomic principles by nursing staff affects their degree of disability.

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  • Siamak Pourabdian, Parastoo Golshiri, Mohsen Janghorbani
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12114
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objective: Long-distance professional drivers, as an occupational group, are hypothesized to have a higher risk of overweight and obesity. The aim of this study was to estimate the prevalence and risk factors of overweight, underweight, and obesity in long-distance professional drivers.

    Methods: A cross-sectional study was conducted on 36 625 male long-distance professional drivers age ≥20 years, from April 2013 to Sept. 2016. Drivers were interviewed and underwent clinical and laboratory examinations including measures of blood pressure (BP), blood tests, anthropometric data, and visual and hearing acuity. The mean (standard deviation [SD]) age of participants was 41.9 (10.2) years with a mean (SD) duration of a professional driving of 15.3 (9.6) years and mean (SD) body mass index (BMI) was 25.7 (4.0) kg/m2.

    Results: The prevalence of overweight and obesity was 39.1% (95% confidence interval (CI) 38.6, 39.6) and 10.8% (95% CI 10.5, 11.1), respectively. A total percentage of 2.7 (95% CI 2.5, 2.9) were underweight. A total percentage of 10.6 had BMI 30-40 kg/m2 and 0.2% had BMI ≥40 kg/m2. Using a stepwise binary logistic regression model for overweight, underweight, and obesity, age had a significant independent relationship with underweight, overweight, and obesity. Duration of work, BP, fasting plasma glucose, triglyceride, and cholesterol had significant independent positive association and smoking had a negative association with overweight/obesity when other covariates were considered.

    Conclusions: These findings indicate that overweight and obesity are prevalent among long-distance professional drivers in Iran and appears to be similar to the general population.

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  • Koji Mori, Seiichiro Tateishi, Tatsuhiko Kubo, Yuichi Kobayashi, Ko Hi ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12111
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objectives: At the Fukushima Daiichi Nuclear Power Plant, run by the Tokyo Electric Power Company, new procedures were introduced as part of the fitness for duty program in July 2016. These were designed to ensure that treatment and further investigations identified as necessary during health examinations were carried out. This study aimed to assess the effectiveness of the initiative by testing whether workers who needed further health examinations obtained them promptly, and whether the number with unmet health needs decreased and the number of workers being treated increased.

    Methods: The primary contractors reported aggregated quarterly results of health examinations of both their own and their subcontractors’ employees, and follow-up visits to medical institutions were also reported over the next two quarters. The study used data for the period from July 2016 to December 2018. Incident rate ratios were estimated using a multilevel Poisson regression model, including the logarithm of the number of workers who took health examination for each primary contractor company as offset. The linear trend was assessed by treating the number of periods as a continuous variable.

    Results: The incident rate ratio for workers who needed treatment having a follow-up examination promptly showed a significant decrease over time. The incident rate ratio for those with unmet needs decreased, and those being treated increased over time.

    Conclusions: The findings showed that the initiative was effective, with the number of early visits for further health examinations increasing and a decrease in the number of people with unmet health needs.

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  • Naoki Sakane, Kazuhiko Kotani, Akiko Suganuma, Kaoru Takahashi, Juichi ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12109
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objectives: Using annual health check-up data, the aim of this study was to identify target populations for lifestyle interventions to effectively prevent diabetes in a real-world setting.

    Methods: The Japan Diabetes Outcome Intervention Trial-1, a prospective, cluster-randomized controlled trial, was launched to test if year-long telephone-delivered lifestyle support by health professionals can prevent the development of type 2 diabetes (T2D) in people with impaired fasting glucose (IFG) identified at health check-ups. A total of 2607 participants aged 20-65 years with IFG were randomized to an intervention arm (n = 1240) or a control arm (n = 1367). We performed subgroup analysis to examine the effects of the intervention on the incidence of T2D in participants with body mass index (BMI) ≥25, metabolic syndrome (MetS), and non-alcoholic or alcoholic elevated liver enzymes at the baseline. Cox regression analysis adjusted for sex was used to calculate the hazard ratios (HRs).

    Results: In addition to IFG, the presence of BMI ≥25, MetS, and elevated liver enzymes increased the incidence of diabetes by two- or three-fold. During a median follow-up period of 4.9 years, only the non-alcoholic elevated liver enzyme group showed a low incidence rate owing to lifestyle interventions (adjusted HR: 0.42, 95% confidence interval: 0.18-0.98).

    Conclusion: The results suggest that people who have IFG and non-alcoholic elevated liver enzymes are a good target population for lifestyle interventions to effectively reduce the incidence of diabetes in a real-world setting.

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Brief Reports
  • Shinobu Yamamoto, Akito Takeuchi, Toru Ishidao, Hiroaki Ohkuma, Masayo ...
    Type: BRIEF REPORT
    2020 Volume 62 Issue 1 e12105
    Published: 2020
    Released: March 25, 2020
    JOURNALS OPEN ACCESS

    Objectives: The purpose of this research was to develop and validate an analytical method for rapid determination of the exposure of workers to ortho-phthalaldehyde (OPA) at the ceiling threshold concentration.

    Methods: A 2,4-dinitrophenylhydrazine (DNPH)-silica cartridge was chosen as a sampler. OPA collected by the DNPH-silica cartridge was subsequently extracted with 5 mL of acetonitrile. A 50-µL aliquot of phosphoric acid/acetonitrile solution (2%, v/v) was added to 950 µL of the extraction solution and allowed to stand for 30 minutes at room temperature. This solution was then analyzed by high-performance liquid chromatography tandem mass spectrometry. The basic characteristics of the proposed method, such as recovery, repeatability, limit of quantification, and storage stability of the samples, were examined.

    Results: The overall recoveries of OPA from OPA-spiked DNPH-silica cartridges were 93.6%-100.1% with relative standard deviations, representing the repeatability, of 1.5%-10.8%. The limit of quantification was 0.165 ng/sample. The recovery of OPA from DNPH-silica cartridges after 5 days of storage in a refrigerator exceeded 95%.

    Conclusions: The proposed method enabled the determination of the OPA concentration corresponding to the Threshold Limit Value-Ceiling of 0.1 ppb recommended by the American Conference of Governmental Industrial Hygienists, with a minimum sampling time of 18 seconds (corresponding to a sampling volume of 300 mL at 25°C and 1 atm). Thus, this method will be useful for estimating worker exposures to OPA.

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Original Articles
  • Yoshihiro Shimazaki, Toshiya Nonoyama, Yoshikazu Miyano, Yasushi Miyat ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12104
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objective: To investigate the association between dental consultation and oral health status among male Japanese employees.

    Methods: The participants were 3351 male employees who received a workplace oral health examination conducted at the ages of 35, 40, 45, 50, 55, and 59 years before retirement in conjunction with an annual health checkup. Data on dental expenditures were collected from health insurance claims. The number of dental visits and dental care expenses, alone or in combination, were used as indices of the dental consultation status for the analyses. The effects of dental consultation status on oral health status (number of total teeth, number of decayed teeth, and periodontal status) were analyzed using multivariate multinomial logistic regression analyses adjusted for confounders.

    Results: Multivariate analyses revealed that the odds ratio (OR) for 20-27 teeth (losing 1-8 teeth) was significantly higher (OR 1.4, 95% confidence interval (CI) 1.1-1.7) in those who had a high number of dental visits and high dental care expenses than in those who did not have a dental visit. By contrast, the ORs for ≤19 teeth (losing ≥9 teeth), having ≥3 decayed teeth, or having a periodontal pocket ≥6 mm were significantly lower (OR 0.2, 95% CI 0.1-0.6; OR 0.5, 95% CI 0.3-0.6; OR 0.7, 95% CI 0.5-1.0, respectively) in those who had fewer dental visits and lower dental care expenses.

    Conclusions: These results imply that the dental consultation status is associated with oral health status among male employees.

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  • Min Gi Kim, Young Wook Kim, Yeon-Soon Ahn
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12107
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Historically, little was known about the effects of low blood lead level (BLL < 10 μg/dL) on hypertension (HTN). The purpose of this study was to assess the effects of low BLL on blood pressure (BP) and HTN in lead-exposed male workers in the Republic of Korea.

    Methods: From the year 2000 to 2004, 12,060 male workers underwent an Annual Specialised Medical Check-up for lead; 7,341 subjects had a peak BLL < 10 μg/dL and were selected for the study. The quartiles of peak BLL in lead-exposed workers were as follows: first (0.01-3.68 μg/dL), second (3.69-5.19 μg/dL), third (5.20-6.86 μg/dL), and fourth (6.87-10.00 μg/dL). To examine the relationship between BLL and pre-HTN (systolic BP [SBP] ≥120-140 mmHg; diastolic BP [DBP] ≥80-90 mmHg) and between BLL and HTN (SBP ≥ 140 mmHg; DBP ≥ 90 mmHg), the quartiles of BLL were used as independent variables in multiple logistic regression analysis.

    Results: In multiple linear regression analyses, SBP (β 0.04, P < .01) and DBP (β 0.06, P < .01) increased in line with a 1 μg/dL increase in BLL. The odds ratio (OR) of HTN in the fourth versus first BLL quartile (1.54; 95% confidence interval [CI]: 1.26, 1.89) was statistically significant.

    Conclusion: SBP and DBP were statistically significantly associated with peak BLL. A BLL ≥ 6.87 μg/dL was associated with HTN; thus, even in workers with low BLLs (<10 μg/dL), management of BP is likely to be necessary. Modulation of the current safety standards for BLLs in workers will be needed.

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  • Ekalak Sitthipornvorakul, Rattaporn Sihawong, Pooriput Waongenngarm, P ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12106
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objective: This study aimed to evaluate the efficacy of increased daily walking steps on the 6-month incidence of neck pain among office workers.

    Methods: Healthy office workers with high risk of neck pain were recruited into a 6-month prospective cluster-randomized controlled trial. Participants were randomly assigned at the cluster level, into either intervention (n = 50) or control (n = 41) groups. Participants in the intervention group were instructed to increase their daily walking steps to a designated level for a duration of 6 months. Participants in the control group received no intervention. The outcome measures included the 6-month incidence of neck pain as well as its pain intensity and disability level. Analyses were performed using multivariable logistic regression model.

    Results: Of the participants in the intervention and control groups, 22% and 34% reported a 6-month incidence of neck pain, respectively. After adjusting for confounders, a significant preventive effect of walking intervention was found (adjusted odd ratio 0.22, 95% confidence interval 0.06-0.75). No significant difference in pain intensity and disability level was found between those in the intervention and control groups.

    Conclusion: An intervention to increase daily walking steps reduced onset neck pain in high-risk office workers. However, the walking interventions did not decrease pain intensity and disability in those increasing the number of daily walking steps compared to the control group.

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  • Anna Kołcz, Natalia Główka, Mateusz Kowal, Małgorzata Paprocka-Borowic ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12102
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Nurses are extremely exposed to musculoskeletal overloads. Prolonged standing postural balance distributions, functional deficits and pain may affect the symmetry of the load on the feet. The study aimed to assess the distribution of foot load during gait among nurses.

    Methods: The sample of this prospective and observational study consisted of 37 female nurses with mean age of 39 years. The Nordic Musculoskeletal Questionnaire (NMQ) was used to evaluate musculoskeletal disturbances and baropodometric gait analysis (BGA) was performed to register distribution of foot load during gait.

    Results: We showed that 68% of nurses declare that they know the principles of workplace ergonomics, but only 14% comply with them. NMQ results indicate that as many as 73% of the respondents feel ailments in the "lower back" area. An asymmetry was observed in the load of IV-V of the metatarsal head between the left and right foot (P = .000) and in the load of the left and right lateral part of the heel (P = .028) in the BGA test. Correlations between ailments occurring in the neck area and loading of the lateral arch of the right foot (P = .032) were found. Moreover, the load in this area correlated positively with the occurrence of "lower back" pain (P = .045).

    Conclusions: Nurses have asymmetric distribution of foot load during gait, which results in a discrepancy between the loads on the three main support points of the foot and which may affect nurses’ work productivity.

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Review Articles
  • Ben Schram, Robin Orr, Rodney Pope, Elisa Canetti, Joseph Knapik
    Type: REVIEW ARTICLE
    2020 Volume 62 Issue 1 e12103
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Osteoarthritis (OA) is a common disorder which affects the joints. As relationships between occupational factors and lower limb OA have been widely studied in systematic reviews, the aim of this umbrella review was to synthesize their key findings in the risk factors for development of lower limb OA.

    Methods: A systematic search was conducted using the databases PUBMED, Cumulative Index of Nursing and Allied Health Literature, and Elton B Stevens Company to identify reviews examining associations between lower limb OA and occupational tasks. These reviews were rated for their methodological quality before key data were extracted and synthesized.

    Results: Sixteen reviews were found, seven pertained to the knee, four to the hip, two to a variety of joints, and three to both the hip and knee. One was deemed to be of high methodological quality, one of critically low methodological quality, and the others of moderate methodological quality. The reviews found moderate to good evidence for heavy occupational lifting to be associated with an increased risk of OA at the knee and the hip. Kneeling, squatting, and climbing, previous injuries to joints, being overweight and obese were also predictive of lower limb OA.

    Conclusion: Occupations which involve heavy physical workloads increase the risk of developing lower limb OA. Heavy lifting, squatting, knee bending, kneeling, and climbing may all increase the risk of developing OA in both the knees and hips. Efforts to reduce exposure to these tasks, reducing joint injuries, optimizing bodyweight may reduce the risks of lower limb OA for occupations which are physically demanding.

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Original Articles
  • Jyunya Takahashi, Hitoshi Nakashima, Nobuyuki Fujii, Tsutomu Okuno
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12091
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Ultraviolet radiation (UVR) emitted during arc welding frequently causes keratoconjunctivitis and skin erythema. The extent of the hazard of UVR varies depending on the welding process and conditions. Therefore, it is important to identify the levels of UVR present under different conditions. The purpose of this study was to investigate the degree of hazard of UVR emitted by the different types of arc welding of cast iron frequently used in industry.

    Methods: In this study, we experimentally measured the UVR emitted during gas tungsten arc welding (GTAW), shielded metal arc welding (SMAW), and gas metal arc welding (GMAW) of cast iron. The degree of hazard of UVR was quantitatively evaluated in accordance with the guidelines of the American Conference of Governmental Industrial Hygienists.

    Results: Effective irradiances measured in this study were in the range 0.045-2.2 mW/cm2 at a distance of 500 mm from the welding arc. The maximum allowable exposure times corresponding to these levels were only 1.4-67 s/day.

    Conclusions: UVR emitted during arc welding of cast iron has the following characteristics: (a) It is more hazardous at higher welding currents. (b) The magnitude of the hazard, which depends on the welding process, increases in the order of GMAW > SMAW > GTAW. (c) It is influenced by the filler material used; that is, the components contained in the filler material affect the hazard of UVR. The effect is Fe > Ni, Cr

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  • Gregor J. Jenny, Georg F. Bauer, Désirée Füllemann, Sylvia Broetje, Re ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12101
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Practitioners and organizational leaders are calling for practical ways to explain and monitor factors that affect workplace health and productivity. This article builds on the well-established Job Demands-Resources (JD-R) model and proposes an empirically tested ratio that aggregates indicators of job resources and demands. In this study, we calculate a ratio of generalizable job resources and demands derived from the JD-R model and then translate the ratio into the language of company stakeholders.

    Methods: We calculated a ratio based on measures applied in a large stress management intervention study (n = 2983) and report the findings from cross-sectional analysis with health and productivity outcomes from same-source and separate-source data.

    Results: Findings showed a strong and unambiguous increase in health and productivity measures with each step of increase in the ratio. Loss in explained variance due to aggregation of two factors into a single ratio is small for measures which are known to be predicted by both factors simultaneously.

    Conclusions: A translation and visualization of the ratio that is accessible to practitioners and organizational leaders is presented and its use in companies discussed.

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Review Articles
  • Zhizhen Xu, Ling Guo, Dongxu Wang, Zhe Bi, Zhaohui Fu
    Type: REVIEW ARTICLE
    2020 Volume 62 Issue 1 e12100
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: With the increasing demand for the detection of occupational hazard factors in workplaces, the national standard determination method for ammonia (sampling with absorbing solution-analysis with Nessler reagent spectrophotometry) in the air of workplace presents many drawbacks during application in China. This review summarized the improvement and the alternate methods of the current sampling and analysis procedures for ammonia, aiming to provide reference to establish an appropriate method for the determination of ammonia in workplace air.

    Methods: Scientific publications in English and Chinese and the standard methods of the Deutsche Forschungsgemeinschaft (DFG) in Germany, the National Institute for Occupational Safety and Health (NIOSH) and Occupational Safety and Health Administration (OSHA) in the United States, and Ministry of Health in China for airborne ammonia collection and analysis in the workplace were reviewed.

    Results: The measures to improve the current sampling and analysis procedures for ammonia in China were firstly summarized. For sampling, the decrease of absorbing solution concentration and the methanesulfonic acid solution as the alternate sampling solution were suggested. For analysis, the anti-interference measures and the optimum reaction condition between ammonia and Nessler reagent were discussed. The alternate methods including sampling conducted using solid sorbent tubes and analysis performed by ion chromatography were then considered for the determination of ammonia.

    Conclusions: The methods-sampling with acid-treated solid sorbent tubes and analysis with ion chromatography-were more suitable for the determination of ammonia in workplace air. However, some details about ammonia sampling and analysis still need further investigation.

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Original Articles
  • Mi Xiang, Huanhuan Hu, Teppei Imai, Akiko Nishihara, Naoko Sasaki, Tak ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12098
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: We aimed to compare the association of body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) with risk of cardiovascular disease (CVD) among middle-aged working Japanese men.

    Methods: A nested case-control study was performed among middle-aged male employees who underwent periodic health checkup. A total of 241 CVD cases were identified and matched individually on age, gender, and worksite with 1205 controls. Data on BMI, WC, WHtR, smoking, hypertension, diabetes, and dyslipidemia collected at 4 years before the event/index date were retrieved. Associations between BMI, WC, WHtR, and CVD risk were assessed by using conditional logistic regression models.

    Results: The strength of the association of BMI, WC, and WHtR with CVD risk was similar. The smoking-adjusted odds ratio (95% confidence interval) for CVD was 1.60 (1.38-1.85), 1.53 (1.33-1.78), and 1.56 (1.35-1.81) for a 1 SD unit increase in BMI, WC, and WHtR respectively. After further adjustment for hypertension, diabetes, and dyslipidemia, these associations were attenuated but remained statistically significant.

    Conclusions: Measures of general (BMI) and abdominal (WC and WHtR) obesity were similarly associated with CVD in middle-aged Japanese men.

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Brief Reports
  • Mélanie Bertin, Thi-Hai-Yen Nguyen, Nathalie Bonvallot, Julie Bodin, Y ...
    Type: BRIEF REPORT
    2020 Volume 62 Issue 1 e12090
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Musculoskeletal disorders, mainly carpal tunnel syndrome, represent a leading cause of compensation claims of workers worldwide. Despite this, and the fact that occupational exposures to biomechanical factors and neurotoxic chemicals have been individually associated with peripheral nerve damage, the prevalence of occupational co-exposure to biomechanical factors and neurotoxic chemicals has rarely been explored. Therefore, our aim was to assess the prevalence of occupational co-exposure to biomechanical factors and neurotoxic chemicals in a national representative sample of the French working population.

    Methods: The study was based on the French representative cross-sectional survey SUMER 2010. A total of 47 983 employees who had worked in their current job for at least one year were included. Occupational exposure to biomechanical factors and neurotoxic chemicals within the previous week of work were assessed using a questionnaire during face-to-face interviews with occupational physicians.

    Results: Approximately 5% of male employees and 1% of female employees were co-exposed to biomechanical factors and neurotoxic chemicals. This prevalence was up to 10% among male blue-collar workers and 13%, 8%, and 6%, respectively, among male employees in the construction, agriculture, and industry sectors. Male employees under 30 years old, in apprenticeships, and working in small companies were more co-exposed to biomechanical factors and neurotoxic chemicals than their counterparts.

    Conclusions: Occupational co-exposure to biomechanical factors and neurotoxic chemicals was observed in a significant proportion of French male employees, suggesting that further studies are required to investigate its potential adverse effects on peripheral neuropathies.

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Original Articles
  • Yuki Furukawa
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12097
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Neck pain ranks 4th highest in terms of disability as measured by years lived with disabilities. This study was conducted to determine whether Tasuki-style posture supporter improves neck pain compared to waiting-list.

    Methods: This trial was an individually-randomized, open-label, waiting-list-controlled study. Adults (20 years or older) with non-specific chronic neck pain who reported 10 points or more on modified Neck Disability Index (mNDI: range, 0-50; higher points indicate worse condition) were enrolled. Participants were randomly assigned 1:1 to the intervention group or waiting-list. Prespecified primary outcome was the change in mNDI at 1 week. The principle of intention-to-treat analyses (as randomized) was applied. This trial was prospectively registered with UMIN (UMIN000034825).

    Results: In total, 50 participants (mean age, 40.9 [standard deviation (SD) = 9.6]; 32 participants [64%] were female, mean mNDI, 14.3 [SD = 2.9]) were enrolled. Of these participants, 26 (52%) were randomly assigned to the intervention group and 24 (48%) to the waiting-list. Attrition rate was low in both groups (1/50). The mean mNDI change score at 1 week was more favorable for Tasuki than waiting-list (between-group difference, −3.5 points (95% confidence interval (CI), −5.3 to −1.8); P = .0002). More participants (58%) had moderate benefit (at least 30% improvement) with Tasuki than waiting-list (13%) (relative risk 4.6 (95% CI 1.5 to 14); risk difference 0.45 (0.22 to 0.68)).

    Conclusion: This trial suggests that wearing Tasuki might moderately improve neck pain. With its low-cost, low-risk, and easy-to-use nature, Tasuki could be an option for those who suffer from neck pain.

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  • Miyuki Hasegawa, Shamima Akter, Huanhuan Hu, Ikuko Kashino, Keisuke Ku ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12095
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objective: The present study aimed to estimate cumulative incidence of overweight and obesity and describe 5-year longitudinal changes in body mass index (BMI) in a large occupational cohort in Japan.

    Methods: Participants were 55 229 Japanese employees, who were aged 20-59 years and attended at all subsequent annual health check-ups between 2009 and 2014. Mixed model analysis was performed to examine the effects of age and cohort by gender on BMI change, with age as a random variable. Cumulative incidence of overweight (23.0≤ BMI <27.5 kg/m2) and obesity (BMI ≥27.5 kg/m2) was calculated. Logistic regression analysis was used to estimate odds ratios for the incidence of overweight and obesity according to age group.

    Results: The incidence of overweight and obesity was approximately double in men (28.3% and 6.7%, respectively) compared to women (14.3% and 3.9%, respectively). The incidence of obesity decreased with age in men, but did not differ according to age in women (P for trend: .02 and .89, respectively). Among overweight participants, the incidence of obesity was higher in women (18.9%) than men (14.5%) and decreased with advancing age (P for trend: <.001 in men and .003 in women). Mean BMI was higher in men than women in all age groups throughout the period. Younger cohorts tended to have a higher BMI change compared with older cohorts.

    Conclusions: In this Japanese occupational cohort, transition from overweight to obesity is higher in women than men, and the more recent cohorts had a higher change in mean BMI than the older cohorts.

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  • Salah A. Al-Omoush, Khader J. Abdul-Baqi, Margaret Zuriekat, Firas Als ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12093
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: The purpose of the study was to examine hearing thresholds among dental personnel. The secondary aim was to evaluate sound levels among dental equipment that dental personnel are exposed to.

    Methods: Two hundred forty-four dentists, dental technicians, dental assistants, and dental students participated. Sixty-two participated as a control group. Audiological thresholds for the test groups were compared to the control group. All participants were from Jordan University Hospital. Participants completed a questionnaire in addition to their audiometric testing. Otoscopy, tympanometry, and pure tone audiometry were included in their assessment. Three-factor ANOVA and t tests were utilized to assess the statistical differences of hearing thresholds among the groups and between the two ears. Pearson correlation test was used to assess the effect of age, experience, and duration of exposure on the degree of hearing loss in the test groups for both ears.

    Results: The authors reported statistically significant differences among hearing thresholds between the control group and others. Left hearing thresholds were noted to be significantly poorer in the left versus right ear at 1000, 2000, 4000, and 8000 Hz in dental assistants. The authors also reported a significant relationship between the degree of hearing impairment among dental assistants and the daily duration of exposure to dental occupational noise, followed by age.

    Conclusion: Hearing impairment was higher among dental professionals than the control group and especially among dental assistants and technicians. The authors recommended screening guidelines and adapting hearing protection methods for dental professionals and particularly for dental assistants and technicians.

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  • Gaganpreet Kaur, Ram Saran Sethi
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12094
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objective: Poultry farm workers are exposed to barn air and suffer from various respiratory disorders. Due to frequent prevalence of endotoxin in the farm settings workers can get co-exposed to barn air and endotoxin. The study was aimed to explore the pulmonary damage following long-term multiple exposures to poultry barn air with or without endotoxin.

    Methods: We studied the pulmonary expression of Toll-like receptor 4 (TLR4) and Interleukin-1β (IL-1β) by exposing Swiss albino mice to poultry barn air for 6 days (Monday-Saturday) in a week for 5 and 10 weeks. At the end of exposure, animals were challenged with lipopolysaccharide (LPS) or normal saline solution @80 μg/mouse intranasally. Histopathology, bronchoalveolar lavage (BAL) fluid and blood analysis were used to characterize lung damage. mRNA and protein expression of TLR4 and IL-1β were evaluated using quantitative polymerase chain reaction (qPCR) and immunohistochemistry, respectively.

    Results: Histopathology along with TLC and DLC of blood and BAL fluid revealed lung damage following multiple exposures and damage was severe in combination with LPS. Exposures altered mRNA and protein expression of TLR-4 and IL-1β and the expression was more marked following 30 days of exposure. Further LPS co-challenge showed a synergistic effect on the expression of TLR4 and IL-1β.

    Conclusions: The data suggest that long-term exposures with or without LPS caused lung damage and altered the pulmonary expression of TLR4 and IL-1β.

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  • Odgerel Chimed-Ochir, Yuko Mine, Yoshihisa Fujino
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12092
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: The current research aimed to study the relationship between health-related quality of life (poor perceived health/unhealthy days) and workers' pain.

    Methods: This cross-sectional study was conducted among 1360 Japanese workers of a Japanese company in Kyushu. Health-related quality of life was measured by HRQOL-4 tool developed by Centers for Disease Control and Prevention of the USA. Pain was assessed by numeric rating scale with 0-10 points. Regression analysis was conducted to identify the relationship between health-related quality of life and pain.

    Results: Participants who reported pain had significantly greater odds of having poor health compared to those with no pain (AOR = 3.99, 95% CI = 3.82-4.18, < .0001). In general, participants who had a higher frequency and intensity of pain had significantly greater odds of having poor health compared to those with no pain. Compared to those with no pain, participants with pain had an average of 2.85 (95% CI = 2.07-3.63, < .0001), 2.25 (95% CI = 1.52-2.99, < .0001), 4.41 (95% CI = 3.39-5, < .0001), and 1.9 (95% CI = 1.30-2.50, < .0001) more physically unhealthy days, mentally unhealthy days, total unhealthy days, and days with activity limitation, respectively. Headache causes many more unhealthy days and more poor health than any other pain, including back pain, shoulder/neck pain, and joint pain.

    Conclusion: Poor health status and the number of unhealthy days among Japanese workers are strongly associated with the presence of pain and increases with the intensity and frequency of pain.

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  • Kojiro Yamamoto, Fumiko Matsuda, Tsuyoshi Matsukawa, Nao Yamamoto, Ken ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12089
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objective: Recent attention has been focused on sedentary behavior (SB) affecting health outcomes, but the characteristics of indicators reflecting SB remain to be identified. This cross-sectional study aims to identify the characteristics of indicators of SB, focusing on the examination of correlations, reliability, and validity of sedentary variables assessed by the smartphone app.

    Method: Objectively measured data of SB of eligible 46 Japanese workers obtained from smartphones were used. We assessed the characteristics of current indicators being used with a 10-minute or 30-minute thresholds, in addition to the conventional indicators of total sedentary time, mean sedentary bout duration, and total number of sedentary bouts. They were evaluated from three perspectives: (a) association among the indicators, (b) reliability of the indicators, and (c) criterion validity.

    Results: Total sedentary time under 10 minutes (U10) and U30 had negative associations with Total sedentary time (r = −.47 and −.21 respectively). The correlation between Mean sedentary bout duration and Total number of sedentary bouts was −.84, whereas between Mean sedentary bout duration 10, 30 and Total number of sedentary bouts were −.54 and −.21, respectively. The intraclass correlation coefficients of almost all indicators were around .80. Mean sedentary bout duration, Mean sedentary bout duration 10, Total number of sedentary bouts, Total sedentary time 30, U30 and U10 have significant differences between three BMI groups.

    Conclusion: This study comprehensively revealed the rationale of advantage in the current indicator being used with a 10-minute or 30-minute threshold, rather than the conventional total amount of SB.

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  • Masaru Sakurai, Masao Ishizaki, Katsuyuki Miura, Motoko Nakashima, Yuk ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12088
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: The increasing number of working elderly people has enhanced the importance of workplace health promotion activities. We investigated the association between the health status of workers approximately 60 years of age and the risk of all-cause mortality after compulsory retirement in Japan.

    Methods: The 2026 participants (1299 males and 727 females) had retired from a metal-products factory at ≥60 years of age. Baseline health examinations were conducted at 60 years of age and included questions about medical history and lifestyle factors; the participants also underwent a physical examination. The participants were followed up annually by mail for an average of 7.4 years. The association between health status at age 60 years and the risk of all-cause mortality was assessed by Cox proportional hazards regression analysis.

    Results: During the study, 71 deaths were reported. The age- and sex-adjusted hazard ratio (HR [95% confidence interval]) for all-cause mortality was higher for males (HR, 3.41 [1.73-6.69]) compared with females, participants with a low body mass index (<18.5 kg/m2; HR 3.84 [1.91-7.73]) compared with normal body weight, smokers (HR, 2.63 [1.51-4.58]) compared with nonsmokers, and those with three or more of four metabolic abnormalities (obesity, high blood pressure, dyslipidemia, and glucose intolerance) (HR 2.29 [1.04-5.02]) compared with no metabolic abnormalities. The associations were unaffected by adjustment for these factors.

    Conclusion: Maintenance of an appropriate body weight, smoking cessation, and elimination of metabolic syndrome are required for older workers to prevent early death after retirement.

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  • Jarmo Kuronen, Klas Winell, Sami Riekki, Jelena Hartsenko, Kimmo Räsän ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12087
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Early retirement due to disability is a problem in Finland. That causes pension costs that are heavy for the society. This study was designed to find out whether a quality network can support the reduction in incident disability pensions and promote a shift from full to partial disability pensions.

    Methods: The study population (N = 41 472 in 2016) consisted of municipal employees whose occupational health care (OHC) was provided by the members of the Finnish Occupational Health Quality Network (OQN). The comparison population consisted of all municipality employees whose OHC was provided by non-members of the OQN (N = 340 479 in 2016). The outcomes were measured by comparing the trends in incident disability pensions of full and partial permanent pension and full and partial provisional pension, partial/full pension indexes from 2011 to 2016 according to the principles of Benchmarking Controlled Trials. Linear regression models were used to explore the dynamics of different pension forms. Regression coefficients were calculated to show the average change per year.

    Results: The incidence of permanent disability pensions decreased faster in the study population (P for trend .03) and the study group showed a stronger shift from full to partial permanent pensions (P for trend <.001).

    Conclusion: Quality networking between OHC units including common goal setting, systematic quality improvement, and repeated quality measurements decreased new permanent disability pensions and increased partial permanent pensions. Such changes are important while thriving for increased work participation.

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  • Natsu Sasaki, Kotaro Imamura, Tran T. T, Thuy, Kazuhiro Watanabe, Nguy ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12086
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: The aim of this study was to examine the reliability and validity of the Job Content Questionnaire (JCQ) in Vietnamese among hospital nursing staff.

    Methods: The 22-items version of the JCQ was used. This includes four scales: (a) psychological demands (5 items); (b) job control (9 items); (c) supervisor support (4 items); and (d) coworker support (4 items). All 1258 nurses in a general hospital in Vietnam, excluding 11 who were due to retire, were invited to complete the cross-sectional survey. The internal consistency reliability was estimated using Cronbach's α. Construct validity was examined using exploratory factor analysis (EFA). Convergent validity was evaluated by calculating correlations between the JCQ scores and DASS 21 and overtime work.

    Results: In total, 949 (75%) of the 1258 eligible nurses completed the survey. Cronbach's α values demonstrated acceptable internal consistency in two scales (supervisor support α = .87; coworker support α = .86), while Cronbach's α was below the acceptable threshold of 0.70 for job control (α = .45) and job demand (α = .50). EFA assuming a four-factor structure showed a factor structure that was almost identical to the original JCQ, with two items loading on other scales. The subscales of depression, anxiety, and stress response of DASS 21 and the subscales of JCQ were significantly correlated, as expected.

    Conclusion: The results suggest that the JCQ in Vietnamese can be used with some reliability and validity for examining psychosocial work environment among nurses. Further studies should be done to confirm and expand our findings in a variety of occupational groups and in other Asian low- and middle-income countries.

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  • Hidehiko Adachi, Yuki Sekiya, Kotaro Imamura, Kazuhiro Watanabe, Norit ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12085
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: The aim of this study was to investigate the effect of a training program for managers on their management competencies and work engagement of their subordinate workers and to investigate the mediating effect of management competencies on the subordinate work environment.

    Methods: A training program, developed based on the UK Health and Safety Executive management competencies framework, was offered to managers in a finance company in Japan. Management competency was assessed at baseline and 1 month after the intervention. Work engagement was assessed at baseline and at a 1-year follow-up. Multilevel correlations between changes in components of management competency and changes in subordinate work engagement were analyzed.

    Results: Although 6 of 12 components of management competency increased significantly following the intervention, significant intervention effect on subordinate work engagement was not found. Among 12 components of management competency, the integrity of managers showed significant multilevel correlation with work engagement of their subordinates. Subgroup analyses revealed that this multilevel correlation increased when a manager and a subordinate differed in gender.

    Conclusions: The results of this study indicated that the training program developed in this study effectively improved the management competency of managers and that integrity of managers may facilitate work engagement of subordinate workers, especially when a manager and a subordinate are of different genders. Thus, a training program focused on improving the integrity of managers could enhance the work engagement of employees.

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  • Marc Rocholl, Michaela Ludewig, Swen Malte John, Eva Maria Bitzer, Ann ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12083
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: Since January 2015, squamous cell carcinoma or multiple actinic keratosis of the skin caused by natural ultraviolet irradiation (UVR) is recognized as occupational disease in Germany. Interventions which improve the sun protection behavior of outdoor workers are urgently needed. When developing preventive interventions, the attitudes of target groups need to be taken into consideration. Therefore, outdoor workers’ perceptions and attitudes were investigated.

    Methods: Seven guided, problem-centered qualitative interviews with healthy male outdoor workers were conducted. A qualitative content analysis was used to analyze the data.

    Results: We found an underestimation of the perceived skin cancer risk in the seven outdoor workers and heterogeneous attitudes toward the usage of sun-protective measures. Participants stated that the feasibility of technical sun-protective measures depends on the size of the working area. While using a headgear seemed common, none of the participants stated using additional neck protection. Wearing long-sleeved shirts and long trousers were considered problematic. The interviews revealed important requirements for sun-protective clothes, especially in terms of different materials. Although the usage of sunscreen was common, our interviewees seemed to apply it wrongly.

    Conclusion: Risk perceptions of outdoor workers and their attitudes toward sun protection measures may influence the factual UV protection behavior in the workplace. Structures to facilitate the implementation of technical and organizational sun-protective measures seem to be necessary. Educational interventions and clear instructions which are tailored to the individual needs and attitudes of outdoor workers are required to improve the UV protection behavior and to avoid common mistakes.

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  • Yu-Li Lan, Wan-Tsui Huang, Chi-Lan Kao, Hui-Jung Wang
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12079
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: This study explored the relationship between organizational climate, job stress, workplace burnout, and retention of pharmacists. This study adopted a cross-sectional design and conducted a questionnaire survey of pharmacists working at three teaching hospitals (a district teaching hospital, a regional teaching hospital, and a medical center).

    Methods: The sampling criteria were a license to practice pharmacy and a willingness to sign a written consent form to participate in this study.

    Results: One hundred ten questionnaires were distributed, of which 101 contained valid responses, yielding a valid return rate of 91.82%. A significant correlation was evident between organizational climate, job stress, workplace burnout, and retention. Hierarchical regression analysis revealed that demographic variables, organizational climate, job stress, and workplace burnout had a predictive power of 55.6% for retention (F = 9.712***, P < .001). Organizational climate had a significant positive correlated with retention (β =  0.401*, P < .001).

    Conclusions: The results of this study can help hospitals to create a friendly and healthy workplace, instruct hospital managers how to improve their organizational climates, and reduce pharmacists’ job stress and workplace burnout, thereby enhancing the quality of pharmacy service and medication safety and eventually improving pharmacists’ intention to stay.

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  • Shigeyuki Kajiki, Koji Mori, Yuichi Kobayashi, Kou Hiraoka, Nanae Fuka ...
    Type: ORIGINAL ARTICLE
    2020 Volume 62 Issue 1 e12081
    Published: January 20, 2020
    Released: February 28, 2020
    JOURNALS OPEN ACCESS

    Objectives: To develop and validate a global occupational health and safety management system (OHSMS) model for Japanese companies.

    Methods: In cooperation with a Japanese company, we established a research team and gathered information on occupational health and safety (OHS) practices in nine countries where the target company operated manufacturing sites. We then developed a model hypothesis via research team meeting. The model hypothesis was introduced to local factories in Indonesia and Thailand as trial sites. We evaluated the roles of the company headquarters, the implementation process, and any improvements in OHS practices at the sites. Based on the results, a global OHSMS model was formalized for global introduction.

    Results: The model consisted of both headquarters and site roles. These roles were well-functioning, and OHS at the sites improved. Two issues concerning the functioning of the headquarters were identified: the need to establish a reporting system to the headquarters and the need to support the improvement of specialized human resources. By improving the model hypothesis to address these issues, the model was formalized for global introduction.

    Conclusions: The global OHSMS model was based on the use of methods and specialized human resources relevant to each region and their common objectives, as well as evaluation indicators based on the minimum requirements of the company headquarters. To verify the effectiveness of this model, the experiment should be extended to other countries.

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