Upper Extremity in Poultry Proc

AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 51:24–36 (2008)

Upper Extremity Musculoskeletal Symptoms andDisorders Among a Cohort of Women Employed in

Poultry Processing

Hester Lipscomb,� Kristen Kucera, Carol Epling, and John Dement

Background We evaluated musculoskeletal problems amongwomen employed in poultryprocessing in rural northeastern North Carolina. Poultry processing is the largest singleemployer of women in this economically depressed region with a black majoritypopulation.Methods Data were collected from a cohort of 291 women through interviews andphysical exams conducted at 6-month intervals over 3 years. An index of cumulativeexposure, based on departmental rankings and work history, was the primary exposurevariable. Other variables of interest included work organization factors, other medicalconditions, depressive symptoms, children in the home, and hand intensive home activities.Poisson regression with generalized estimating equations was used to evaluate factorsassociated with occurrences of upper extremity symptoms and incidence of disorders atfollow-up.Results Symptoms making it difficult to maintain work speed or quality and depressivesymptoms at baseline were associated with symptoms at follow-up; age, being overweight,and job insecurity at baseline were associated with incident disorders. After consideringthese factors, the exposure response pattern was J-shaped with risk decreasing inthe second quartile of cumulative exposure and then going steadily up; the effect wasstronger for disorders.Conclusions The pattern of risk is consistentwith onset of earlymusculoskeletal problemsamong women new to the industry followed by a later increase with continued exposure.Among this highly exposed population, the effects of depressive symptoms and workorganization factors were diminished when cumulative exposure was considered,illustrating the contextual nature of the complex relationships between physical workexposures and psychosocial factors. Am. J. Ind. Med. 51:24–36, 2008.� 2007 Wiley-Liss, Inc.

KEY WORDS: cohort study; poultry processing; musculoskeletal disorders; women’shealth; work-related

BACKGROUND

As early as the 18th Century, musculoskeletal problems

were clinically described in terms of work-relatedness, and a

number of disorders—bricklayer’s shoulder, stitcher’s wrist,

gamekeeper’s thumb, carpet-layer’s, and housemaid’s knee—

have been named for the occupational groups in which they

were identified [Hales and Bernard, 1996]. Besides this history

� 2007Wiley-Liss, Inc.

Duke University Medical Center, Durham, North CarolinaContract grant sponsor: National Institute of Environmental Health Sciences; Contract

grant sponsor: National Institute of Arthritis Musculoskeletal and Skin Diseases; Contractgrant number: R01ES10939.

*Correspondence to: Hester Lipscomb, Box 3834, DUMC, Durham, NC 27710.E-mail: [email protected]

Accepted10 September 2007DOI10.1002/ajim.20527. Published online inWiley InterScience

(www.interscience.wiley.com)

of clinical observation, there is a body of more recent

epidemiologic literature linking musculoskeletal disorders

(MSDs) with occupational exposures, such as repetitiveness

of work, force requirements, posture, vibration, lifting, and

combinations of these factors [NIOSH, 1997]. Despite

established clinical labels and epidemiologic literature,

attribution of work-relatedness to musculoskeletal problems

has been an area of contention in occupational health.

The lack of full acceptance may result, in part, from

limitations in the existing scientific work. The vast majority

of epidemiologic studies of MSDs in industry have been

cross-sectional. In addition, there is a limited understanding

of the exact roles that psychosocial factors play in develop-

ment, expression, care seeking and disability related to these

disorders [Westgaard and Bjorkland, 1987]. Monotonous

work, time pressures, and perceived high work load have all

been described as being associated with work-related MSDs;

however, the findings are not consistent across studies, and

the reported associations could be attributed to physical work

factors associated with these variables [Bongers et al., 1993].

Worker capacity and skill, as well as work environment and

organization may influence the development and/or expres-

sion of MSDs [Hagberg, 1992]. Complicating interpretation,

psychosocial and physical demands may also be highly

correlated in some situations [Bernard et al., 1993].

Unfortunately, attention to psychosocial dimensions of the

problem may contribute to perceptions that workers who

report musculoskeletal symptoms are ‘‘malcontents’’ or

more likely to complain for reasons independent of physical

pathology [Hadler, 2003].

We responded to a request from women in rural

northeastern of North Carolina to evaluate health effects of

their employment in poultry processing, the largest single

employer of women in this economically depressed rural

area. The study counties are among the poorest in the state

with black majorities [U.S. Census Bureau, 2004]. The

poultry plant, which provides yearly salaries of about US

$17,000, is among the higher paying jobs of women in

the area. In 1989, N.C. Occupational Safety and Health

Administration (OSHA) inspectors cited the plants in the

area for serious upper extremity repetitive motion problems,

[NC Dept of Labor, 1989] and the National Institute for

Occupational Safety and Health (NIOSH) confirmed the risk

in a subsequent Health Hazard Evaluation (HHE) [Kiken

et al., 1990]. Primary community concerns continued to

center on upper extremity musculoskeletal disorders as well

as quality of life issues.

METHODS

Study Design

We conducted a longitudinal study of women employed

in this industry to explore the relationships among health

outcomes, tenure in the plant, exposure differences, and

coping strategies. We hypothesized that the development of

symptoms and disorders would be associated with the

physical work exposures/demands. We were also interested

in evaluating relative contributions of work organization

factors in this fast-paced upper extremity intensive work. In

this poor economic region, we were concerned that economic

depravity might influence women to remain in jobs that might

be harmful to their health due to lack of alternative

employment.

Based on community concerns and the history of the

industry’s poor labor relationships, locally as well as

nationally [NC Dept of Labor, 1989; Kiken et al., 1990;

Griffith, 1993; Human Rights Watch, 2000; Fink, 2003], we

conducted the study in a manner that did not require the

cooperation of the employer. This decision influenced the

research methods and necessitated community involvement.

The project background and details of the community-based

study design have been previously described [Lipscomb

et al., 2005]; key elements are presented briefly here.

Between May 2002 and March 2004 community-based

staff recruited women employed in poultry processing in

northeastern North Carolina to participate in the longitudinal

study. Women were enrolled largely through social networks

without regard for their current symptoms or prior medical

history. Initial recruitment was limited to individuals who

were relatively new hires (9 months or less) to the industry

intentionally over-sampling women who were new to the

industry.

This cohort participated in interviews and physical

exams conducted in a community-based office at 6 month

intervals over a maximum of 3 years. Questionnaires were

administered by the community-based staff; this allowed

collection of data from individuals who might lack necessary

reading skills to complete the detailed tool on their own.

Trained study nurses performed standardized physical exams

based on the protocol developed for the Washington State

Department of Labor and Industries Safety and Health

Assessment and Research Program (SHARP) upper extrem-

ity musculoskeletal study [Viikari-Juntura, 2000]. Informa-

tion on work exposure in each department and changes in

work processes was collected through 39 key informant

interviews with current and past poultry workers represent-

ing each department in the plant.

Participants received $40 for each interview/exam

encounter or qualitative interview. All procedures were

approved by the Duke University Medical Center Institu-

tional Review Board.

Upper extremity outcomes

Participants were asked about current musculoskeletal

symptoms and symptoms they had since their last follow-up

(in the last 12 months at baseline) using items adapted from

Musculoskeletal Disorders in Poultry Processing 25

the questionnaire developed by the NIOSH Research

Program for the prevention of work-related musculoskeletal

disorders [NIOSH, 2000]. Participants with hand symptoms

were asked to complete a hand diagram, documenting areas

of pain or paresthesias. The diagrams were rated by one

occupational medicine physician (CE) for probable or classic

carpal tunnel syndrome (CTS) as described by Katz et al.,

[1990] as well as for pain in the radial, flexor, or extensor

wrist, and numbness or pain in the ulnar nerve distribution.

We separately evaluated the presence of symptoms and

musculoskeletal disorders at follow-up. Women with all

three of the following criteria were considered symptomatic:

(1) upper extremity or neck symptoms (pain, aching, stiff-

ness, burning, numbness, or tingling) that lasted a week or

longer or that occurred more than three times since their last

follow-up, (2) onset of symptoms after beginning work at the

plant, and (3) no prior acute trauma to the painful region such

as a fracture or sports injury. To be defined as having a

musculoskeletal disorder a woman had to have the above

symptom threshold and positive physical exam findings in

the same body region as her reported pain consistent with a

musculoskeletal disorder (tendonitis, tenosynovitis, nerve

compression syndromes). The disorder definitions were

based on reported criteria for defining musculoskeletal

disorders in epidemiologic studies [Palmer et al., 2000;

Sluiter et al., 2001]. The exact criteria for the case definitions

are provided in the attached Appendix. In both cases, we

combined all upper extremity conditions (disorders or

symptoms) involving the hand/wrist, forearm/elbow, and

shoulder due to limited statistical power to evaluate them

separately.

Exposure assignment

Our primary exposure of interest was an index of cumu-

lative exposure. This index was created by assigning a rank of

high, medium, or low exposure to each department in the

poultry plant based on assignment at the time of the NIOSH

HHE. The exposure assignments were based on exposure to

repetitive and forceful movements and/or extreme, awkward

upper extremity postures observed in walk-through assess-

ments [Kiken et al., 1990]. High exposure rank was assigned

to evisceration (gutting of birds), grade and rehang (birds are

assigned a grade based on quality of meat and rehung on

shackles to move through the plant), deboning (deboning of

white meat fillets and packaging), and cut-up (cutting and

packaging of chicken pieces); low exposure was assigned to

inspection (US Department of Agriculture meat inspection

helper), giblets (packaging of livers and gizzards), sanitation

(clean-up), and other jobs including clerical work. We

assigned a medium grade of exposure to women working in

overwrap (packaging) and whole bird bagging. The rank

(3¼High, 2¼Medium, 1¼Low) was then multiplied

by time in the department for each person based on their

reported work history. For example, a woman working one

full-time year (always assigned 2,000 hr per year) in

evisceration (H¼ 3) and two fulltime years (4,000 hr) in

overwrap (M¼ 2) had a cumulative exposure assignment of

(3� 2,000)þ (2� 4,000)¼ 14,000 rank-hours. Values for

individuals who had worked in more than one department

were summed at the baseline evaluation. Additional

cumulative exposure was assigned at each follow-up period

based on self-report of job changes.

Risk factors or possible confoundersfor upper extremity disorders

Individuals were queried about prior medical history

including musculoskeletal problems, injuries or surgery, as

well as history of diabetes, sickle cell, thyroid disease, lupus,

kidney failure, trauma, pregnancies, and smoking history.

Specific questions were included on hormonal therapies as

well as a report of use of any other regular medications.

Because of the possible relationships between depres-

sion and pain complaints, we included the Center for

Epidemiologic Studies Depression Scale (CES-D) as a

measure of depressive symptoms [Radloff, 1977]. This 20-

item self-report tool has been used to assess depressive

symptoms in varied population groups including African-

American populations and women [Miller et al., 2004;

Nguyen et al., 2004]. Values over 16 represent evidence of

depressive symptoms.

Levels of psychological demand and control (latitude),

or job strain, were measured using the Job Content

Questionnaire (JCQ) developed by Karasek [Karasek et al.,

1998]; high strain was defined among individuals with high

psychological demands and low decision latitude with cut

points at the median for the study population. The JCQ

includes scales to assess social support, physical job

demands, isometric load (sustained awkward work postures),

job insecurity and dissatisfaction; these scales were dicho-

tomized at the population median.

Because of interest in how socioeconomic disadvantage

might influence development of, or impairment from,

musculoskeletal symptoms by limiting the ability of women

to leave jobs that might adversely affect their health,

participants were asked how long they could be out of work

without pay before loss of their income would be a major

problem. They were also asked about children in the home, the

availability of another adult to help with household responsi-

bilities, and weekly frequency of hand and arm intensive

activities such as needlework, keyboard use, or braiding hair.

Analyses

Descriptive statistics were calculated by baseline

demographics and work history variables. Because of the

26 Lipscomb et al.

non-specific nature of many musculoskeletal symptoms and

our interest in their dynamic nature, we evaluated the

occurrence of upper extremity musculoskeletal symptoms,

as opposed to incidence in which the individual would be

censored after first development of symptoms. This approach

allowed us to look at prior symptoms and their severity as

predictors of later symptoms. Individuals with disorders at

baseline were excluded from the symptom analyses because

we did not know when in their exposure history they had

developed their problem. However they did remain at risk for

development of a different disorder. In follow-up, individuals

identified with a given disorder were not at risk for the same

disorder until they had at least one follow-up without that

disorder.

Days at risk were calculated from days between follow-

up assessments. Incidence and occurrence rates and rate

ratios (RR) were modeled using Poisson regression with the

log of person-days included as an offset term [Nizim, 2000].

Generalized estimating equations (GEE) [Liang and Zeger,

1986] were used to control for the statistical dependence

between multiple assessments per worker. Separate models

were created allowing us to compare risk factors associated

with (1) occurrence of symptoms and (2) incidence of

disorders at follow-up.

Covariates were included in the initial models if the

crude RR was greater than 1.2 (or less than 0.85). A step-wise

backwards elimination strategy was used. Variables inde-

pendently associated with the outcome based on likelihood

ratio statistics were retained as were covariates whose

removal resulted in more than a 15% change from the crude

to adjusted risk ratios. No variables were removed from the

models with a P-value of less than 0.10.

RESULTS

Two hundred ninety-one women completed baseline

interviews and physical exams. They were relatively young

(mean age 31.4 years; median 28 years) and predominantly

black (98.3%) (Table I). Few of these working women

reported other non-musculoskeletal chronic medical con-

ditions (kidney disease (0.34%), sickle cell disease or trait

(4.8%), diabetes (3.1%), thyroid disease (2.8%), Raynauds

(0.34%). With the exception of diabetes, none of these

conditions were significant in multivariate analyses and they

are not discussed further. The cohort was markedly obese;

only 16.5% (n¼ 48) were at normal body weight based on

body mass index (BMI). BMI values ranged from 16.4 to

64.4, with a mean of 33.4. At baseline, 47.8% (n¼ 139) had

CES-D scores of 16 or higher indicative of significant

depressive symptoms. Almost all worked fulltime exclu-

sively at the poultry processing plant and about half reported

job rotation most work days (Table II). Most (86%) worked

currently in high exposure departments.

TABLE I. Characteristics of Female PoultryWorkers (n¼ 291),Northeastern North Carolina, 2002^2004

Age 18^61;mean 31.4; median 28Black 286 (98.3)Marital statusSingle 192 (66.0)Married 61 (21.0)Divorced/separated/widowed 38 (13.1)

Numberof people in home 1^13; mean 3.7; median 4Number employed

One 140 (48.1)Two 113 (38.8)Three ormore 38 (13.1)

Number children in homeNone 57 (19.6)One 84 (28.9)Two 85 (29.2)Three ormore 65 (22.3)

Another adult in home to help 175 (60.1)Education<High school 70 (24.1)High school 199 (68.4)>High school 22 (7.6)

Hourly wages $6^$14; mean $8.18; median $8.35Loss of incomemajor problem in1week or less 181 (62.2)2^3weeks 78 (26.8)�1month 32 (11.0)

TABLE II. Work Characteristics of Female PoultryWorkers (n¼ 291),Northeastern North Carolina, 2002^2004

Timeworked in plant at baseline 1^418months;mean 53.8months;median 7months

Work fulltime in poultry plant 273 (93.8%)Job rotationmost days 135 (46.4%)Primary department in plantEvisceration (H) 28 (9.6%)Inspection (L) 2 (0.69%)Grade and rehang (H) 10 (3.4%)Giblets (L) 2 (0.69%)Cut-up (H) 79 (27.2%)Deboning (H) 133 (45.7%)Whole bird bagging (M) 7 (2.4%)Overwrap (M) 13 (4.5%Sanitation (L) 9 (3.1%)Other (L) 8 (2.8%)

Second job away fromplant 18 (6.2%)

H¼ high exposure department; M¼medium exposure department; L¼ low expo-sure department.


One hundred fifty (n¼ 150) women were still actively

employed study participants at the close of follow-up.

Fourteen percent (n¼ 41) were lost to follow-up. The

remaining women no longer worked in the plant but their

reasons for leaving were known and most often included:

quitting for another job (n¼ 55), having been fired or laid off

(n¼ 26), moving from the area (n¼ 8), and family reasons

(n¼ 7). More uncommon reasons included pregnancy,

having returned to school, having been jailed, and one death.

Five women reported that they quit or lost their job because of

upper extremity problems.

Because recruitment of participants occurred over

23 months with initial participants limited to new hires,

participants had variable tenure in the plant and follow-

up time. New hires had from one to six visits (mean and

median 3) and longer-term workers had between one and four

(mean 3; median 4). A total of 696 interviews and exams were

conducted representing 130,737 person-days or 358 person-

years, of follow-up time. Excluding individuals with dis-

orders at baseline, there were 517 visits representing 107,290

person-days or 301 person-years.

It was not unusual for women to have pain in more than

one area of the upper extremity as well as more than one

disorder at a given follow-up visit. Excluding women with

disorders at baseline, a total of 135 occurrences of upper

extremity musculoskeletal symptoms (defined as symptoms

since last visit on more than three occasions or lasting a week

or more) were reported among 78 different women. Twenty-

four (30.8%) had reported work-related symptoms at base-

line. A total of 74 new upper extremity disorders, based on

defined constellations of symptoms and signs from the

physical exam, were identified among 47 women. These

represent a symptom occurrence rate of 44.8 per 100 person-

years (or 25.9 persons with symptoms per 100 person-years)

and disorder incidence rates of 20.7 per 100 person-years of

follow-up (or 13.1 individuals with new disorders per 100

person-years).

The distribution of symptoms among individuals with-

out disorders at baseline included: hand/wrist (n¼ 106),

forearm (n¼ 5), shoulder (n¼ 40), and neck (n¼ 12). The

types of disorders identified included: painful flexor nodules

(n¼ 4), ulnar nerve compression at the wrist (n¼ 12), wrist

flexor tendonitis (n¼ 12), wrist extensor tendonitis (n¼ 8),

Dequervain’s tenosynovitis (n¼ 7), lateral epicondylitis

(n¼ 2), shoulder capsulitis (n¼ 8), and rotator cuff tendo-

nitis (n¼ 21). Neither symptoms nor disorders were mutually

exclusive, therefore the total is greater than overall

occurrences. While we identified no new cases of CTS, it is

noteworthy that 40 women reported a prior diagnosis of CTS

at their baseline evaluation. At baseline two women were

identified with CTS and four with ulnar nerve compression at

the wrist.

Crude rates of symptoms and disorders increased with

increasing age (Table III). However, the rates among women

over 40 represent less than 10% of the cases among this

young cohort. The report of UE symptoms that interfered

with work speed or quality at baseline was a stronger

predictor than symptoms at the prior visit. Women who

reported significant depressive symptoms at baseline were at

greater risk of musculoskeletal problems. Women with

diabetes had higher rates of disorders, while those who were

currently pregnant, on hormonal therapies (not shown) or

smokers had lower rates of musculoskeletal problems.

Overall risk estimates tended to be stronger for disorders.

Cut-points for the cumulative exposure indices were

made at the quartiles of cumulative exposure of cases which

ranged from 1,432 to 151,300 rank-hours (mean 31,865;

median 9,446) for symptoms and 2,040 to 151,300 rank-

hours (mean 46,168; median 36,225) for disorders. The

cumulative exposure-response patterns were J-shaped with

risk decreasing in the second quartile of cumulative exposure

and then steadily increasing; the effect was stronger for

disorders (Table IV).

A number of baseline work organization factors were

also associated with symptoms and disorders but the

magnitude of the associations varied with the case definition.

Individuals with job rotation were less likely to have

musculoskeletal problems, while women with second jobs

were more likely to have symptoms.

In the multivariate models, the J-shaped exposure-

response patterns remained after adjustment for other risk

factors (Table V). The mean number of disorders identified

per woman at the quartiles of dose followed this same pattern

(1.7 at the 1st quartile, 1.3 at the 2nd and 3rd, and 2.5 at 4th).

Similarly, the proportion of women with more than one

diagnosis at follow-up varied by levels of cumulative

exposure (41.7% at 1st, 16.7% at 2nd, 25% at 3rd, and 82%

at 4th). Age remained an important risk factor for disorders,

but not for symptoms. Age and the cumulative exposure

index were correlated (correlation coefficient¼ 0.57;

P< 0.0001); consequently, our inclusion of age may over-

adjust for our exposure measure. Dropping age from the

model results in a similar exposure-response pattern with

higher estimates for the top two quartiles of exposure (3rd

quartile RR¼ 1.08 (0.45, 2.59); 4th quartile RR¼ 2.77 (1.14,

6.73). Women who reported difficulty maintaining work

speed or quality at baseline had higher rates of symptoms in

follow-up but not of disorders. Being overweight, having

depressive symptoms and job insecurity were associated with

the occurrence of disorders. No differences in risk were ob-

served for being overweight (BMI 25–< 30) or being obese

(BMI> 30), and they were combined in the presentation.

DISCUSSION

In these longitudinal analyses we were interested in the

potentially dynamic nature of musculoskeletal problems

among workers; consequently, we evaluated occurrences of

28 Lipscomb et al.

TABLE

III.

DistributionofFollow

-UpTime,FrequencyofSym

rptomsatFollow

-up,CrudeO

ccurrenceR

ates,and

RateRatiosbyP

ersonalCovariates*

Follow-uptim

ea

Symptom

sat

follow-up

(n¼135cases)

Cruderateb

(95%

CI)

Cruderateratio

(95%

CI)

Follow-uptime

Disordersa

tfollow-up

(n¼47

cases)

Cruderateb

(95%

CI)

Cruderateratio

(95%

CI)

Age <30

94,829

106

1.12(0.90,1.41)

110,020

280.25

(0.16,0.38)

130^<40

9,747

212.27

(1.55,3.34)

1.84(1.16,2.93)

17,270

150.91

(0.55,1.49)

3.73

(1.83,7.63)

40þ

2,714

83.66

(2.45,5.48)

3.86

(1.98,7.51)

3,447

41.15(0.53,2.51)

5.87

(2.58,13.37)

Children

None

20,306

271.42(0.97,2.10)

125,999

130.51

(0.29,0.88)

1Oneortwo

62,501

801.22(0.93,1.60)

0.89

(0.51,1.55)

76,916

210.26

(0.16,0.45)

0.58

(0.25,1.33)

>Two

24,483

281.22(0.80,1.87)

0.92

(0.46,1.82)

25,822

130.48

(0.28,0.82)

1.06(0.47,2.4)

Timelive

withoutwages

1monthþ

12,816

171.33(1.05,1.70)

115,862

50.33

(0.15,0.72)

1<1m

onth

24,949

280.96

(0.62,1.48)

0.70

(0.30,1.61)

30,613

110.32

(0.17,0.63)

0.79

(0.24,2.57)

<1w

eek

69,525

901.35(0.75,2.43)

1.05(0.48,2.29)

82,974

310.38

(0.25,0.56)

1.22(0.46,3.24)

Smokes

No85,354

114

1.30(1.03,1.62)

1102,968

400.38

(0.27,0.54)

1Yes

21,936

211.06(0.69,1.64)

0.78

(0.45,1.34)

26,481

70.27

(0.14,0.55)

0.82

(0.37,1.82)

Weight

Overweight

90,754

121

1.32(1.10,1.62)

119,502

450.41

(0.29,0.59)

1Normal

16,536

140.80

(0.38,1.67)

0.69

(0.30,1.59)

79,551

20.09

(0.03,0.35)

0.14(0.02,0.98)

Diabetes

No102,970

130

1.25(1.02,1.53)

1124,782

440.35

(0.26,0.49)

1Yes

3,758

30.9

9(0.51,1.92)

1.09(0.54,2.21)

4,667

20.43

(0.07,2.6)

1.81(0.30,10.7)

Currentlypregnant

No101,135

131

1.28(1.04,1.56)

1122,621

47Yes

6,155

40.76

(0.33,1.74)

0.78

(0.33,1.86)

6,828

0�

�Depressivesym

ptom

sCES-D

<16

60,846

711.00(0.73,1.37)

170,376

300.24

(0.15,0.39)

116þ

46,444

641.59(1.24,2.04)

1.73(1.09,2.74)

60,361

170.49

(0.33,0.75)

2.08

(1.06,4.09)

Symptom

sinterferedwithwork

No90,122

971.06(0.84,1.34)

195,108

260.27

(0.18,0.40)

1Yes

17,168

382.66

(1.70,4.17)

2.66

(1.70,4.17)

35,629

210.67

(0.41,1.07)

2.47

(1.25,4.89)

Symptom

satpriorvisit

No77,217

691.06(0.84,1.34)

184,801

200.25

(0.16,0.39)

1Yes

30,073

661.66(1.28,2.17)

1.53(0.98,2.41)

45,936

270.56

(0.37,0.85)

2.25

(1.16,4.36)

Homehandactivity

<4hr/week

81,138

102

1.35(0.90,2.01)

198,071

320.33

(0.25,0.47)

14þ

hr/week

26,152

331.23(0.98,1.55)

0.90

(0.51,1.60)

32,666

150.48

(0.26,0.87)

1.53(0.68,3.44)

*Based

onbaselinereports

exceptpregnancyanddiabeteswhichwereallowed

tovaryateachfollow-up.

a Follow-uptim

eforsym

ptom

sexcludedthosewith

anydisordersatbaseline.

b Ratesper1,000

person-daysoffollow-up,cruderatesandrateratioscalculated

wGEE.

29

TABLE

IV.DistributionofFollow

-upTime,FrequencyofSym

ptom

satFollow

-up,CrudeO

ccurrenceR

ates,and

RateRatiosbyW

orkV

ariables*

Follow-uptimea

Symptom

satfollow-up

(n¼135cases)

Cruderateb

(95%

CI)

Cruderateratio

(95%

CI)

Follow-uptim

eDisordersa

tfollow-up

(n¼47

cases)

Cruderateb

(95%

CI)

Cruderateratiob

(95%

CI)

Cumulativeexposureindex

c

Low

31,527

331.08(0.78,1.50)

136,232

120.34

(0.17,0.66)

1Mod-low

28,846

351.01(0.77,1.60)

0.92

(0.57,1.50)

62,976

120.19(0.11,0.32)

0.48

(0.20,1.15)

Mod-high

25,197

331.40(0.97,2.01)

1.28(0.702.33)

22,424

120.54

(0.32,0.92)

1.57(0.64,3.80)

High

21,720

341.55(1.03,2.33)

1.45(0.82,2.57)

9,105

111.23(0.68,2.21)

3.51

(1.38,8.95)

Non-poultry

job

No101,332

127

1.24(1.01,1.53)

1123,023

440.37

(0.27,0.50)

1Yes

5,959

81.25(0.68,2.27)

1.16(0.53,2.53)

7,714

30.35

(0.11,1.2)

0.98

(0.28,3.5)

Jobrotation

Yes

53,810

671.22(0.91,1.62)

161,489

170.4

4(0.30,0.65)

1No

53,480

681.27(0.96,1.68)

0.94

(0.53,2.53)

69,248

300.28

(0.17,0.46)

0.65

(0.34,1.4)

JobContentQuestionnaireScales

Jobstrain

Low

15,611

281.17(0.93,1.47)

1102,328

350.45

(0.22,0.92)

1High

88,682

105

1.65(1.10,2.47)

1.42(0.80,2.5)

18,983

110.33

(0.22,0.48)

1.72(0.83,3.6)

Socialsupport

High

62,430

691.05(0.79,1.39)

167,872

250.35

(0.22,0.55)

1Low

42,010

641.59(1.17,2.03)

1.42(0.90,2.25)

53,439

200.35

(0.22,0.55)

1.0(0.51,2.0)

Isom

etricload

Low

45,956

490.97

(0.69,1.36)

147,051

130.23

(0.10,0.53)

1High

60,794

861.45(1.13,1.85)

1.37(0.86,2.19)

74,260

340.42

(0.29,0.60)

1.78(0.74,4.3)

Jobinsecurity

Low

45,114

521.12(0.81,1.55)

147,963

110.21

(0.09,0.50)

1High

60,361

801.34(1.04,1.72)

1.26(0.79,2.01)

73,348

350.43

(0.31,0.62)

2.04

(0.81,5.17)

Jobdissatisfaction

Low

48,778

561.08(0.78,1.48)

148,848

190.35

(0.21,0.58)

1High

58,512

791.04(0.77,1.41)

1.23(0.78,1.93)

72,463

270.34

(0.21,0.54)

0.98

(0.50,1.92)

Jobhazard

Low

66,135

661.03(0.77,1.37)

170,003

210.31

(0.20,0.52)

1High

40,622

671.61(1.23,2.09)

1.50(0.95,2.36)

51,308

250.38

(0.24,0.61)

1.16(0.59,2.3)

Physicaldemand

Low

15,269

211.24(1.00,1.53)

116,340

30.18(0.04,0.71)

1High

91,640

114

1.30(0.75,2.24)

1.00(0.55,1.83)

104,971

440.37

(0.26,0.53)

2.06

(0.49,8.6)

*Based

onbaselinereports

exceptcumulativeexposurewhich

increasedoverfollow-up.

a Follow-uptim

eforsym

ptom

sexcludedthosewith

anydisordersatbaseline.

b Rates(per100person-daysoffollow-up)andrateratiosareGEEadjusted.

c Cut-pointsatquartilesofexposuredistributionofcases.

30

symptoms and incidence of disorders. In doing so, we

identified differences in the specific factors associated with

these outcomes and the magnitude of risk. In both cases, after

adjusting for other independent risk factors there was a

decline in the rate of events in the second quartile of

cumulative exposure followed by a steady increase with

increasing exposure to poultry processing work. The stronger

exposure-response relationship observed for incidence of

disorders may reflect that we were modeling non-specific

occurrences of symptoms and more precisely defined

incidence of disorders. We believe that the J-shaped response

curves are consistent with the early development of

musculoskeletal problems in this fast-paced upper extremity

intensive work; consequently, some women may leave the

workforce, others may adapt, and some later develop

additional problems with continued exposures. The lower

levels of disease in the second quartile of cumulative

exposure could represent a latency period for later diseases

different from those developed in the early follow-up period.

It is interesting however that we see the same pattern for

symptoms. Considering that we were not studying an

inception cohort, limited to new hires to the industry, and

that our greatest lost to follow-up occurred early in follow-up,

this pattern could also reflect, in part, a healthy worker effect

[Checkoway et al., 2004].

More specifically, these findings add to a body of work

that raises serious concern about the health and safety of

black women employed in this particular poultry processing

plant in rural North Carolina. We have previously described

prevalence of symptoms and disorders very similar to that

found in a HHE conducted by the NIOSH [Kiken et al., 1990]

over 15 years ago [Lipscomb et al., 2007a]. We have also

documented higher prevalence of upper extremity symptoms

[Lipscomb et al., 2007b] and higher prevalence of depression

among the poultry workers than among other women in low-

wage jobs in their same community [Lipscomb et al., 2007c].

In the early planning of this project, women from the

community raised concerns that their work-related problems

were often dismissed by management and medical providers

as being related to child-care responsibilities, mental health

concerns, and other health problems such as obesity. Child-

care responsibilities were not significant predictors of the

onset of disorders or the occurrence of symptoms in our

multivariate analyses. Longitudinally, the incidence of

disorders was associated with being overweight. However,

the BMI risk estimates are imprecise and do not explain the

TABLE V. Adjusted Rate Ratios (PoissonModelsWith GEE) forMusculoskeletal Symptoms andMusculoskeletal Disorders

Occurrence of symptomsadjusted rate ratio (95%CI)

Incidence of disordersadjusted rate ratiob (95%CI)

Cumulative exposure indexa

Low 1 1Mod-low 0.83 (0.55,1.27) 0.34 (0.15, 0.76)Mod-high 1.24 (0.70, 2.19) 0.72 (0.28,1.86)High 1.39 (0.79, 2.42) 1.75 (0.71, 4.28)

Age<30 � 130^<40 2.79 (1.36, 5.73)<40 6.30 (2.54,45.62

BMIOverweight � 1Normal 0.12 (0.02, 0.83)

Job insecurityLow � 1High 1.86 (0.80,4.31)

Depressive symptomsCES-D<16 1 �CESDGE16 1.67 (1.02, 2.61)

Symptoms interferedwith workNo 1Yes 2.50 (1.64, 3.83) �

aCut-points at quartiles of distribution of events.bAlso adjusted for diabetes (lower among diabetics) and children in home. Children was not a significant risk factor but removalchanged exposure estimate>15%.


population variability among these women. There was

marked lack of variability in the weight distribution of this

population of women; only 15% were of normal body weight

based on BMI measures. Depression was a risk factor for

symptoms but not onset of disorders. When considering these

other risk factors, cumulative work exposure predicted the

presence of symptoms and disorders at follow-up. Although

the high levels of obesity and depression among these women

are of great concern, they do not explain their musculo-

skeletal problems independent of physical pathology or

increasing work exposure.

Interestingly, even when considering symptoms at

baseline, women with high job insecurity at baseline were

more likely to have a disorder at a follow-up visit. We do not

know the precise mechanism behind this association, but

hypothesize this may reflect that individuals who are insecure

about their job continue working with symptoms—perhaps

without seeking treatment or accommodation and thus may

be more likely to develop disorders. This association is

consistent with qualitative data from women in the

community and our knowledge of participants refusing

medical referrals because of fear for their jobs [Lipscomb

et al., 2007a]. This was the only work organization factor

associated with either symptoms or disorders in multivariate

longitudinal analyses even though a number were crudely

associated.

Limitations and Strengths

We have described several limitations to this work in

previous reports [Lipscomb et al., 2005, 2007a,b,c]. First, we

had no direct exposure measures, but utilized the relative

department rankings that NIOSH investigators assigned in

walk-through assessments of the plant at the time of the HHE

in 1989. We recognize that changes have been made in the

plant processes and work conditions since the NIOSH

evaluation. However, the ranks are consistent with recent

qualitative data from key informant interviews, and we

believe that the relative ranking by department is still

appropriate. This approach likely underestimates the expo-

sures for very long-term workers who were in the plant before

changes were instituted. Because of our lack of direct

exposure measures, we cannot discern what specific aspects,

or combinations, of the physical work contribute to these

problems. Because our analyses were limited by small

numbers, we evaluated all upper extremity symptoms and

disorders together making it more difficult to identify

relationships that are not common to all symptoms and/or

disorders we are studying—and likely muting the effect of

our cumulative exposure measure. We did not evaluate the

effect of temperature on the musculoskeletal problems of

these women. Most were exposed to cold conditions; after the

birds are eviscerated they are chilled, and remain so, as they

are moved through the processing plant.

In estimating cumulative exposure we assigned each

woman reporting fulltime work 2,000 hr of exposure per year,

although women working partial years were proportionately

assigned hours based on the number of months they reported

working, These women have little vacation time (typically

5 days) and do not receive paid sick leave, but they are

eligible for Family Medical Leave Act (FMLA) benefits.

However, we did not ask for a recall of days away from work

each year, for illness, pregnancy, etc. and there may have

been some over-estimation of exposure for some women

because of this. [This over-estimation of exposure is non-

differential with respect to the outcome and is unlikely to bias

our estimates.]

The design we chose, which recruited and followed

employed women in one industry, does not have an

unexposed group. This highly exposed cohort constitutes

neither a full enumeration of potential workers nor a random

sample of the population at risk. The over-recruitment of new

hires to the industry was intentional in the design of the

longitudinal work, and while we do have representation from

a number of departments in the plant, the majority of our

cohort came from areas considered to have high exposure.

While not ruling out selection bias or a healthy worker effect,

these problems are of less concern in a design using internal

comparisons of longitudinal data with reasonable follow-up

over time, such as this one. However, the ratio results should

be viewed with the knowledge of the relatively high exposure

of all workers and the potential over adjustment of

cumulative dose because of its correlation with age.

In addition to the longitudinal design, the work has other

strengths. Although we lacked precise exposure measure-

ments, we were able to estimate a cumulative index of

exposure using work histories that account for time worked in

different departments, qualitative information, and prior

information on relative departmental exposures. We were

able to evaluate contributions of work organization and

psychosocial factors in multivariate analyses with this

cumulative exposure index. Among this highly exposed

population, the effects of depressive symptoms at baseline

and work organization factors were diminished when

cumulative exposure was considered, illustrating the highly

contextual nature of the complex relationships between the

physical work exposures and social factors [Hagberg, 1992].

Because we had physical examination data we were

able to evaluate, not just symptom reports, but also likely

disorders based on clusters of symptoms and findings

recommended for use in epidemiologic studies [Palmer

et al., 2000; Sluiter et al., 2001]. As others have reported

[Miranda et al., 2005], risk differed by outcome definition

demonstrating the utility of differentiating symptoms and

disorders.

Participants were recruited by women in their commun-

ity largely using social networks without consideration

of disease or symptoms. We do not believe that a more

32 Lipscomb et al.

traditional approach involving random selection of workers

through industry cooperation would have been successful

under the circumstances. The community-based approach

allowed the collection of a tremendous amount of informa-

tion from a hard to reach population under circumstances that

made the conduct of the work inherently challenging and all

the more important.

CONCLUSIONS

While these data add to evidence from multiple

investigators that work in poultry processing contributes to

upper extremity musculoskeletal problems, unfortunately,

we are not documenting new problems. Concerns about this

industry have been for decades, and continue to be, the

subject of researchers, journalists, and workers [Armstrong

et al., 1982; Hall, 1989; Anthan, 1991; Yassi et al., 1996;

Campbell, 1999; Nowell, 2000; Quandt et al., 2006]. We

acknowledge that changes have taken place in the plant we

studied since the time of the OSHA citations in 1989. For

example, a number of women reported job rotations.

However, they were often assigned to other high exposure

work areas, which may explain our failure to identify rotation

as a protective factor in our multivariate analyses. Some

processes are now automated that were not at that time of the

OSHA violations. Biomechanical evaluations demonstrate

that mechanical deboning efforts moderately reduce peak

forces, but muscular activity remains high with higher levels

of acceleration and repetition rates [Juul-Kristensen et al.,

2002]. In light of this and the relative paucity of low exposure

work in the industry, it would be prudent to slow the speed of

the lines while working to reduce postural load and force.

This is consistent with the desires of the workforce, and

would help to address some of the negativework organization

issues reported by these women.

In the absence of an enforced ergonomic standard for

this industry in the US, maximal line speeds continue to be set

without regard for worker safety by the Department of

Agriculture, the agency responsible for ensuring food safety.

Since it began setting line speeds in 1968, work pace has

increased from less than 20 birds per minute to the current

maximum of 91 birds per minute [USDA, 2006]. There are

significant challenges to reducing the work exposures of

these women in the present US political climate, focused on

voluntary compliance with occupational safety and health

guidelines.

The citing of poultry processing plants with their

associated work risks, largely in depressed, disadvantaged

areas of the rural southern US, with the employment of large

numbers of workers of color—often African-Americans or

Latinos—illustrates how work can contribute to disparities in

health that might otherwise be attributed to characteristics of

the population. This happens while helping producers keep

their costs low [Griffith, 1993; Nowell, 2000; Fink, 2003].

‘‘The pain and suffering due to work-relatedMSDs. . . are frequently, or perhaps even typically,not captured or recorded by the marketplace.These costs are not reflected in wages or passedon to consumers because poultry oligopoliesbenefit from a seemingly inexhaustible ruralreservoir of atomized unskilled workers with fewalternatives, and are well positioned to extractlabor without having to indemnify their employ-ees for impairments of the value of their laborpower’’ [Linder, 1995, p. 115].

In low-wage, high turnover industries it is difficult to

adequately assess health and safety of the workforce. An

inception cohort is hard, if not impossible, to recruit and

follow, as are random samples of workers. Consideration of

these issues led to our decision to conduct this work outside

of industry. Just as the health effects of precarious work

situations have been the subject of much discussion world-

wide [Quinlan et al., 2001] these women also perceive

precarious employment, which makes research into their

problems more difficult with traditional academically driven

epidemiologic methods. Given the social context, these

findings also illustrate how the health of workers is

influenced not just by their personal characteristics and

direct work exposures, but also by government policy, racial

history, longstanding patterns of exploitation, and economic

opportunity, or lack thereof [Lipscomb et al., 2006].

ACKNOWLEDGMENTS

The questionnaire used to collect musculoskeletal

symptom data was adapted from the questionnaire developed

by the NIOSH Research Program for the prevention of work-

related musculoskeletal disorders. The physical exam

protocol is based in large part on the protocol developed by

Professor Eira Viikari-Juntura for the Washington State Dept

of Labor and Industries SHARP upper extremity muscu-

loskeletal study.

We acknowledge Kristie Wicker for her many efforts

coordinating the project and for her assistance in preparing

the manuscript. We acknowledge the contributions of Steve

Wing and Dana Loomis to the early development of the

project and Robin Argue for project management. We thank

Belinda Lee and Andie Whitehead for their roles performing

the physical exams on study participants; particularly we

acknowledge their flexibility in scheduling that facilitated

participation. Lastly, we acknowledge the essential contri-

butions of the community-based staff including Emma

Pender, Rita Perry, Christal Rankins, and Chaniqua Rodgers

who recruited participants, collected the interview data, and

managed the community project office. Lola Williams is

acknowledged posthumously. She was the inspiration behind


this project, seeking academic partners to address issues of

health disparities in her community. Of note, the study

population is referred to as black, as opposed to African-

American, throughout the manuscript based on the prefer-

ence of the community-based staff. The authors have no

competing financial interests.

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APPENDIX

Criteria used for Definitions of UpperExtremity/Neck Disorders

Disorders are based on symptoms in a given body

region. Possible work-related cases must have had onset

after having begun working at the plant, but worker did

not have to attribute onset to the workplace. The individual

must not have reported previous trauma to that body

region.

Symptom and Sign-based Disorders

Hand/wrist disorders

All include:

. Hand/wrist symptoms > 3 times or lasting at least

a week in the last 12 months at baseline or last

6 months at follow-up

Dequervain’s tenosynovitis

Scandinavian definition1

. Pain, radial side of wrist from hand diagram,

AND

. Positive Finkelstein’s (>0), OR

. Pain on resisted thumb extension, OR

. Pain on resisted thumb abduction

Wrist flexor tendonitis [included individuals meeting

either case definition]

Scandinavian definition

. Pain over flexor tendons (ventral aspect of wrist)

from hand diagram, AND

. Pain provocation on resisted wrist flexion, OR

. Crepitus under symptom area, OR

. Visible swelling of affected region

Southhampton definition2

. Pain with wrist flexion, OR

. Pain with resisted wrist flexion, OR

. Pain with resisted flexion 2–5

Wrist extensor tendonitis [included individuals meeting



. Pain over extensor tendons (dorsal aspect of wrist)

from hand diagram, AND

. Pain provocation on resisted wrist extension, OR

. Crepitus under symptom area, OR

. Visible swelling of affected region

South Hampton definition

. Pain with wrist extension, OR

. Pain with resisted wrist extension, OR

. Pain with resisted extension 2–5

Carpal tunnel syndrome

Scandianavian definition

. Paresthesia/pain in median nerve distribution

(classic or probable CTS per Katz) from hand

diagram

. Positive flexion/compression test, OR

. Positive carpal compression test, OR

. Positive tinel’s sign, OR

. Atrophy of abductor pollicis brevis

Ulnar nerve compression at the wrist

. Probable case based on symptoms, AND

. Weakness or atrophy, ulnar innervated hand

intrinsic muscles, OR

. Positive Tinel’s at Guyon canal

Possible osteoarthropathy hand/wrist

. Swollen/deformed joints (note: we do not differ-

entiate swollen and deformed in our exam

reports), AND

1 This definition is based on Sluiter JK, Rest KM, Frings-Dresen MH.2001. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. Scand WorkEnviron Health27(1):1–102.

2 Palmer K, Walker-Bone K, Linaker C, Reading I, Kellingray S,Coggon DD, Cooper C. 2000. The Southampton examinationschedule for the diagnosis of musculoskeletal disorders of the upperlimb. Ann Rheum Dis 59(1):5–11.


. Limited ROM, OR

. Pain with ROM, OR

. Triggering

Painful hand flexor nodules

. Based on physical exam finding of painful nodules

Triggering of any finger with or without pain

Elbow/forearm disorders

All include:

. Elbow/forearm symptoms >3 times or lasting at

least a week in the last 12 months at baseline or last


Cubital tunnel syndrome

. Probable case by symptom definition, AND

. Positive combined pressure/flexion of ulnar nerve

proximal to cubital tunnel; positive must include

pain and/or paresthesia in ulnar forearm, ring or

little finger

Epicondylitis, lateral

. Local pain on resisted wrist extension

Epicondylitis, medial

. Local pain on resisted wrist flexion

Shoulder disorders

All include:

. Shoulder symptoms >3 times or lasting at least a

week in the last 12 months at baseline or last


Rotator cuff syndrome [included individuals meeting



. Pain on resisted abduction, OR

. Pain on resisted internal rotation, OR

. Pain with resisted elbow flexion, OR

. Painful arc test on upper arm elevation,

Southhampton also includes, OR

. Pain on external rotation, OR

. Pain on internal rotation

Shoulder capsulitis

. Unilateral limitation of ROM and pain

Neck disorders

All include:

. Neck symptoms >3 times or lasting at least a

week in the last 12 months at baseline or last


Radiating neck syndrome

. Pain in UE with active or passive cervical

rotation

Tension neck syndrome

. Abnormal neck ROM, AND

. Pain on palpation of the trapezius, OR

. Pain in neck/trap with passive rotation, OR

. Other pain w ROM

36 Lipscomb et al.

Upper Extremity in Poultry Proc

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