International Journal of Environmental Health Research

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/cije20

Indoor air quality and sick building syndrome in a

university setting: a case study in Greece

Efthymia Tsantaki , Emmanouil Smyrnakis , Theodoros C. Constantinidis &

Alexis Benos

To cite this article: Efthymia Tsantaki , Emmanouil Smyrnakis , Theodoros C. Constantinidis

& Alexis Benos (2020): Indoor air quality and sick building syndrome in a university setting:
a case study in Greece, International Journal of Environmental Health Research, DOI:
10.1080/09603123.2020.1789567

To link to this article: https://doi.org/10.1080/09603123.2020.1789567

Published online: 07 Jul 2020.

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INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH
https://doi.org/10.1080/09603123.2020.1789567

ARTICLE

Indoor air quality and sick building syndrome in a university

setting: a case study in Greece
a
Efthymia Tsantaki , Emmanouil Smyrnakisa, Theodoros C. Constantinidisb
and Alexis Benosa
a
Laboratory of Primary Health Care, General Practice and Health Services Research, Department of Medicine,
Aristotle University of Thessaloniki, Thessaloniki, Greece; bLaboratory of Hygiene and Environmental Protection,
Medical School, Democritus University of Thrace, Alexandroupolis, Greece

ABSTRACT ARTICLE HISTORY

The perceived Indoor Air Quality (IAQ), the prevalence of Sick Building Received 20 March 2020
Syndrome (SBS) symptoms and its contributing risk factors were assessed Accepted 26 June 2020
in a university during the period of the economic crisis in Greece. Data was KEYWORDS
collected from 613 employees via questionnaires. Hierarchical linear sick building syndrome;
regression analysis was performed. The most prevalent perceived IAQ indoor air quality;
complaints were ‘Dust and dirt’ (63.2%), ‘Room temperature too low’ mediterranean climate;
(24.9%) and ‘Varying room temperature’ (24.4%). The most frequently economic crisis; Greece
reported SBS symptom was ‘Fatigue’ (34.1%). The prevalence of General,
Mucosal and Dermal symptoms was 40.8%, 19.8% and 8.1%, respectively.
Several contributing risk factors were identified, such as IAQ Discomfort
Scale, atopy, sleep problems, female, exposure to biological and chemical
agents, PC-use, Psychosocial Work Scale and job satisfaction. Poor per­
ceived IAQ and high prevalence of SBS symptoms were reported from the
university staff in a temperate climate country. SBS seemed to be
multifactorial.

Introduction
In the last few decades, Indoor Air Quality (IΑQ) has been gaining research and public interest as
people spend most of their time indoors (Klepeis et al. 2001). Indeed, the health risks from exposure to
indoor air pollution may be greater than those related to outdoor pollution (Cincinelli and Martellini
2017). Moreover, IAQ has become a significant concern for environmental and occupational health
professionals, as an increasing number of workers are employed in non-industrial work environments
(Carrer and Wolkoff 2018). However, it is a difficult area to study, as many different indoor air
pollutants may exist (Cincinelli and Martellini 2017), the individual sensitivity of the exposed worker
may vary (Andersson 1998), the symptoms are often nonspecific (Mendell 1993; Norback 2009), and
the psychosocial work environment seems to be an important factor (Lahtinen et al. 2004).
It is widely accepted that poor IAQ may lead to undesired health effects ranging from sensory
irritation or general discomfort to serious health problems (Berglund B 1992) and it decreases the
health-related quality of life (Selinheimo et al. 2019). Additionally, improved IAQ has been
associated with less general health costs and more productivity benefits (Al Horr Y et al.2016).
The adverse health effects, in non-industrial environments, could be divided into two main
categories: specific diseases, caused by known and identifiable agents, referred as Building-

CONTACT Efthymia Tsantaki efug2000@yahoo.gr Laboratory of Primary Health Care, General Practice and Health
Services Research, Department of Medicine, Aristotle University of Thessaloniki, Pellis 1, PO BOX 57010, Thessaloniki, Greece
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 E. TSANTAKI ET AL.

Related Illness (e.g. Legionellosis, etc.) and non-specific Building-Related symptoms with unknown
etiology, commonly called Sick Building Syndrome (SBS) (Norback 2009).
The term SBS has been used in order to describe a cluster of nonspecific symptoms such as
headache, fatigue and irritation in the upper respiratory tract, throat, eyes, hand and facial skin,
which are influenced by IAQ (Redlich et al. 1997; Burge PS 2004) and have a significant effect on
productivity (Niemela et al. 2006). This symptom pattern has been described in the general
population and in various non-industrial environments (Norback 2009). SBS symptoms have
been extensively studied in relation to several environmental risk factors, such as thermal aspects
(Jaakkola JJK et al. 1989; Norback 2009), relative humidity (Lukcso et al. 2016), ventilation
(Wargocki et al. 2002), dampness (Bornehag et al. 2001), chemical exposure to CO2 and total
volatile organic compounds (Lu et al. 2015), formaldehyde and particulate matter (Lukcso et al.
2016), biological agents (Laumbach and Kipen 2005), personal risk factors such as gender (Brasche
et al. 2001; Burge 2004), age (Runeson et al. 2006; Norback 2009), self-reported atopy (Reijula and
Sundman-Digert 2004; Runeson et al. 2006; Norback 2009), tested atopy (Bjornsson et al. 1998;
Bakke et al. 2008b), anxiety and depression (Bjornsson et al. 1998; Magnavita 2015) and psycho­
social work environment (Lahtinen et al. 2004; Runeson et al. 2006; Magnavita 2015). Thus, SBS
seems to be multifactorial (Norback et al. 1990; Mendell 1993).
The university sector is a workplace where the IAQ has not been systematically studied, even
though it is a working environment that potentially exposes its employees to various occupational
risks. Previous studies investigating IAQ in the university environment have focused either on
specific departments and microenvironments, such as offices (Ongwandeea M. 2010), libraries
(Fantuzzi et al. 1996) and research laboratories (Di Giulio et al. 2010) or on specific associated
IAQ factors (Emre Can 2015; Lanthier-Veilleux et al. 2016). To our knowledge, there are no
published studies estimating the perceived IAQ and SBS symptoms at the entirety of a university,
as a single organization. This approach could be particularly important from the point of view of
public, environmental and occupational health services, as it would provide useful information on
identifying and prioritizing needs.
Limited data exist about IAQ in working environments from Mediterranean countries. The bulk
of the published studies is mainly from northern Scandinavian countries, USA and more recently
from Asia (Sundell 2017).
Thus, the main research hypotheses were that university staff from a Mediterranean climate
country complaint about perceived IAQ problems and report SBS symptoms. Additionally, SBS
symptoms are associated with personal, health status, work-related, psychosocial work factors and
complaints about perceived IAQ.
The aim of the present study was to estimate the perceived IAQ and the prevalence of SBS
symptoms in the entirety of a Mediterranean university, during a period of limited financial
support. Moreover, the contribution of several factors (personal, health status, work-related,
psychosocial work factors and complaints about perceived IAQ) was investigated.

Methods
Aristotle University of Thessaloniki
The study was conducted in AUTh, located in the city center of Thessaloniki, in northern Greece.
The main campus covers an area of approximately 334,000 m2. It is comprised of 11 schools with 41
departments. Τhe central building was built in the 1960 s. Since then, many building additions and
renovations have taken place. Most of the buildings have air conditioners, but they also have
windows, as insulation is not required due to the mild climate throughout the year. Smoking
indoors is not permitted in any of the offices.
 INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 3

Study design, population and timeframe

A cross-sectional study with the use of printed and electronic questionnaires was performed.
AUTh’s employees were invited to participate in the study. Staff employed for less than 6 months,
aged ≤18 years old or working mainly outdoors were excluded.
University employees who were working at the main administration building were asked to fill in
a printed form of the questionnaire. The main administration building was selected as a typical
building of the campus regarding the construction, heating and ventilation systems. Furthermore, it
had high occupant density and all the employees were constantly working in the same environment.
In total, 216 employees were approached and 138 printed questionnaires were returned (64%). The
rest of AUTh’s employees were invited with a digital message (e-mail) in their institutional address
to fill in the electronic form of the questionnaire via a link (Lime Survey, an Open Online Survey
Tool) LimeSurvey Gmbh. The approach through an e-mail was considered to be a more convenient
method for this study sample. A total of 2912 employees were approached and 787 (27%) employees
answered the digital form. It is of value to note that the main difference between the two study
samples was that in the main administration building no academic staff was employed.
The goal of the study was clearly stated in the informing letter for all the participants. Two more
reminders at 2-week intervals were provided for both printed and e-mail questionnaires. Moreover,
an announcement was placed in many different visible locations of the university in order to remind
employees to participate in the study. The study was conducted from November to March, during
the influenza season and before the main pollen season.
The study protocol was approved by the Committee for Bioethics and Ethics, School of
Medicine, AUTh University.

Questionnaire
The perceived IAQ and SBS symptoms were assessed through the use of a standardized question­
naire, the MM 040 NA for workplaces (Andersson 1998). The questionnaire examines four
domains: Work Environment, Work Conditions, Atopy and Present Symptoms.
The Work Environment parameters are: ‘Draught’, ‘Too high room temperature’, ‘Varying room
temperature’, ‘Too low room temperature’, ‘Stuffy air’, ‘Dry air’, ‘Unpleasant odour’, ‘Static elec­
tricity often causing shocks’, ‘Passive smoking’, ‘Noise’, ‘Light that is dim or causes glare and/or
reflections’, ‘Dust and dirt’. The recall period is the past three months. The possible responses are:
‘Yes, often (every week)’; ‘Yes, sometimes’; and ‘No, never’. Only the answer ‘Yes, often (every
week)’ was considered positive and scored 1. These scores were added in order to calculate the
Discomfort Scale (Magnavita 2015), which ranges from 0 to 12, with higher values indicating higher
burden.
The Work Conditions domain evaluates the psychosocial work environment, using four ques­
tions: ‘Do you regard your work as interesting and stimulating?’, ‘Do you have too much work to
do?’, ‘Do you have any opportunity to influence your working conditions?’, ‘Do your fellow workers
help you with problems you may have in your work?’. There are four possible responses to each
question: ‘Yes, often’; ‘Yes, sometimes’; ‘No, seldom’; ‘No, never’ and they score 1,2,3,4, respectively
(the question ‘Do you have too much work to do’ scored in reverse order). These scores were used
to calculate the ‘Psychosocial Work Scale’ (ranging from 4 to 16) with higher values indicating
higher burden (Lahtinen et al. 2004).
Atopy is assessed with three questions (asthmatic problems, hay fever and eczema). Participants
who ever had asthma or hay-fever were classified as atopic (Andersson K 1990).
Finally, the Present Symptoms domain estimates 12 building-related symptoms classified into
three categories: five General symptoms (‘Fatigue’; ‘Feeling heavy-headed’; ‘Headache’; ‘Nausea/
dizziness’; and ‘Difficulties in concentrating’), four Mucosal symptoms (‘Itching, burning, or
irritation of the eyes’; ‘Irritated, stuffy, or runny nose’; ‘Hoarse, dry throat’; and ‘Cough’) and
4 E. TSANTAKI ET AL.

three Dermal symptoms (‘Dry or flushed facial skin’; ‘Scaling/itching scalp or ears’; and ‘Hands dry,
itching, red skin’) (Andersson 1998). The possible responses are: ‘Yes, often, (every week)’; ‘Yes,
sometimes’; and ‘No, never’. Only the response ‘Yes, often (every week)’ was considered positive
and scored 1. Four symptom scores were calculated: General (0–5), Mucosal (0–4), Dermal (0–3)
and Total Symptom Score (0–12).
As there are no reference data for the Greek population, we compared the prevalence of each
IAQ complaint and SBS symptom with data of a Swedish reference population from nine work­
places (seven offices and two schools) in ‘healthy’ buildings (Andersson and Larsson 1990;
Andersson 1998). This reference population has been used in several studies (Bakke et al. 2008a;
DN 2010; Tahtinen et al. 2019). The proposed guidelines by authors for calculating necessary
differences between compared groups were used (Andersson K. 1989).
Moreover, data about personal factors (gender, age, years of education), health status factors
(smoking habits, sleep problems), job characteristics (job category, years working in the current work­
place, absenteeism) and work-related risk factors (exposure to physical, biological, chemical, ergonomic,
psychosocial factors) were also collected. In particular, sleep problems were assessed with a single
question (‘Yes’ or ‘No’). Single-item measures for sleep problems have been proven useful in previous
studies (Hui and Grandner 2015). Job satisfaction was estimated by a single-item question with a 5-point
Likert scale and lower score indicated higher burden. It is proposed that the psychometric properties of
a single-item question about job satisfaction are good (Dolbier et al. 2005). Moreover, Personal
Computer (PC) use-related problems at work were assessed in five different areas: screen, keyboard,
office, work seat and software. The answers were recorded using a 5-point Likert scale and the ‘PC Scale’
score was calculated (ranging from 0 to 20). Higher score indicated higher burden.

Statistical analysis
Continuous variables are presented as mean values with standard deviation (SD) or as median with
interquartile range (IQR), while frequencies as percentages for categorical variables. Chi-square test (x2)
was applied to investigate the relationship between categorical variables. Independent samples t-test and
the non-parametric test of Mann–Whitney were used to compare the means and medians of contin­
uous variables between groups. Hierarchical multiple linear regression analysis was performed using
Total, General, Mucosal and Dermal Symptom Score as dependent variables. Five predictive models
were formed for each symptom score. The parameters were added as groups step-wisely: 1) Personal
factors, 2) Health status factors 3) Job characteristics and Work-related risk factors, 4) Psychosocial
factors and 5) IAQ complaints (Discomfort Scale). Correlations were examined among independent
variables for multicollinearity. Highly correlated variables (≥0.7) were not included to the linear
regression model. Unstandardized β coefficients and 95% Confidence Intervals (CIs) were calculated.
Univariate correlations between all remaining parameters with Total, General, Mucosal and Dermal
Symptoms Scores were examined. Variables with p < 0.2 in univariate analysis were included in
hierarchical linear regression models. Unstandardized β coefficients and their 95% CIs were determined
in multivariate analyses. Additionally, R-square and R- square change were calculated. The improve­
ment of the prediction of the new variables added in any step was estimated with significant F-change.
Relationships with a p-value (p) ≤0.05 were considered as statistically significant. All reported
p-values were two-sided. Data were analyzed in the Statistical Package for the Social Sciences 25.0
(IBM Corp. Released 2012. IBM SPSS Statistics for Windows).

Results
Characteristics of participants
Thirt-seven subjects were excluded as they did not meet the inclusion criteria and 275 due to
missing data. Finally, 613 employees (483 email-questionnaire, 130 printed form of questionnaire)
 INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 5

were included in the study. The mean (SD) age of participants was 47.64 (10.68), 41.7% were males
and 48.7% were educational personnel. Almost all participants (98.3%) used PC at work. Personal
and health status factors, job characteristics and work-related risk factors of participants are
presented in Table 1.

Complaints about perceived ΙΑQ

The most common environmental complaint was ‘Dust and dirt’ (63.2%). The majority of employ­
ees (78.7%) reported at least one perceived ΙΑQ complaint. This percentage dropped to 64.6%,
when ‘Dust and dirt’ was excluded from the analysis. The median score of Discomfort Scale was
2.29 (2.1) (Table 2).

SBS symptoms
The prevalence of SBS symptoms is presented in Table 3. The most frequently reported symptoms
were the General symptoms (40.8%) and the most common among them was ‘Fatigue’ (34.1%),
followed by ‘Feeling heavy headed’ (16.6%) and ‘Headache’ (15.4%). Dermal symptoms had the
lowest prevalence (8.1%).

Table 1. Personal and health status factors, job characteristics and work-related risk factors of participants.
Characteristics Total Males Females p-value
Ν† (%) 613 (100) 256 (41.8) 357 (58.2)
Personal
Age (years)‡ 47.64 (10.68) 49.23 (11.66) 46.49 (9.78) 0.002§
Education (years)¶ 18 (5) 21(5) 18 (5) 0.007††
Health status
Atopy# n (%) 197 (32.1) 80 (32.9) 117 (35.5) NS‡‡
Smoking status n (%)
Current 180 (31.3) 67 (27.5) 113 (34.1) NS‡‡
Former 149 (25.9) 70 (28.7) 79 (23.9)
Never 246 (42.8) 107 (43.9) 139 (42)
Pack-years¶ 11(18) 15 (23) 9 (14) <0.001††
Sleep problems n (%) 132 (23.3) 61 (25) 71 (22) NS‡‡
Job characteristics and work-related risk factors
Job category n (%)
Educational personnel 285 (48.7) 146 (59.8) 139 (40.8) <0.001‡‡
Administrative staff 238 (40.7) 68 (27.9) 170 (49.9)
Other Staff 62 (10.6) 30 (12.3) 32 (9.4)
Working in current workplace (years)¶ 13 (18) 15 (19.5) 11 (17) 0.001††
Radiation exposure n (%) 146 (26.2) 62 (26.4) 84 (26.1) NS‡‡
Biological exposure n (%) 119 (20.7) 58 (24.3) 61 (18.1) NS‡‡
Chemical exposure n (%) 141 (24.1) 67 (27.3) 74 (21.8) NS‡‡
Working with PC (hours per day)‡ 6.64 (2.62) 6.41 (2.91) 6.8 (2.39) NS
PC Scale¶ 7.11 (5.25) 6.29 (5.09) 7.68 (5.29) 0.002††
Repeated wrist/shoulder movements n (%) 397 (66.8) 151 (60.9) 246 (71.1) 0.010‡‡
Awkward posture at work n (%) 212 (35.8) 85 (34.1) 127 (37) NS‡‡
Job satisfaction¶ 3 (1) 3 (1) 3 (2) 0.014††
Absenteeism n (%) 271 (46.6) 102 (41.5) 169 (50.4) 0.035‡‡
†
Data for some characteristics were missing for some participants
‡
mean (SD)
§Differences between males and females calculated with Student’s t-test
¶
median (IQR)
††
Differences between males and females calculated with Mann–Whitney U test
‡‡
Differences between males and females calculated with Chi-square test
§§
Atopy here defined as current or earlier problems with asthma or hay fever
NS: Not Significant.
6 E. TSANTAKI ET AL.

Table 2. Complaints about perceived Indoor Air Quality.

Indoor Air Quality complaints† Total Males Females OR‡ 95% CI p-value
Ν§ (%) 613 (100) 256 (41.8) 357 (58.2)
1. Draught 78 (13.6) 23 (9.4) 55 (16.8) 1.95 1.16–3.26 0.011¶
2. Room temperature too high 68 (11.7) 30 (11.7) 38 (11.2) 0.90 0.54–1.50 NS¶
3.Varying room temperature 143 (24.4) 45 (18.4) 98 (28.7) 1.78 1.19–2.65 0.005¶
4. Room temperature too low 148 (24.9) 49 (19.7) 99 (28.6) 1.64 1.11–2.42 0.013¶
5. Stuffy ‘bad’ air 114 (19.1) 35 (14.2) 79 (22.5) 1.76 1.14–2.72 0.011¶
6. Dry air 51 (8.9) 11 (4.6) 40 (11.9) 2.82 1.42–5.62 0.002¶
7. Unpleasant odour 136 (22.8) 45 (17.9) 91 (25.5) 1.63 1.09–2.44 0.016¶
8. Static electricity often causing shocks 18 (3.1) 8 (3.2) 10 (2.8) 0.93 0.36–2.39 NS¶
9. Passive smoking 66 (11.1) 29 (11.6) 37 (10.7) 0.92 0.55–1.53 NS¶
10. Noise 100 (16.8) 37 (14.9) 63 (18.3) 1.28 0.82–1.99 NS¶
11. Light that is dim or causes glare and/or reflections 94 (15.3) 37 (15) 57 (16.7) 1.13 0.72–1.78 NS¶
12. Dust and dirt 386 (63.2) 139 (54.5) 247 (69.2) 1.89 1.35–2.64 <0.001¶
At least one environmental complaint 480 (78.7) 182 (71.4) 298 (83.9) 2.05 1.39–3.03 <0.001¶
At least one environmental complaint (No dust and Dirty) 396 (64.6) 149 (58.2) 247 (69.2) 1.61 1.15–2.25 0.006¶
Discomfort Scale†† 2.29 (2.1) 1.91 (1.95) 2.56 (2.16) <0.001‡‡
†
Only the answers ‘Yes, often’ (every week) are used.
‡
Reference category: Females/Males
§
Data for some characteristics were missing for some participants
¶
Pearson Chi-square tests have been calculated using the dichotomous (Yes = Yes, Often ‘every week’, No = rest answers)
††
mean (SD)
‡‡
Student’s t-test
OR: Odds Ratio; CI: Confidence Interval; NS: Not Significant.

Table 3. Prevalence of SBS Symptoms.

Symptoms† Total Males Females OR‡ 95% CI p-value§
Ν¶ (%) 613 (100) 256 (41.8) 357 (58.2)
General symptoms 250 (40.8) 78 (30.5) 172 (48.2) 2.12 1.51–2.97 <0.001
Fatigue 209 (34.1) 64 (25.3) 145 (41) 2.05 1.44–2.92 <0.001
Feeling heavy-headed 100 (16.6) 28 (11.2) 72 (20.5) 2.06 1.28–3.29 0.002
Headache 93 (15.4) 23 (9) 70 (20%) 2.52 1.53–4.17 <0.001
Nausea/Dizziness 25 (4.2) 4 (1.6) 21 (6.1) 3.99 1.35–11.78 0.007
Difficulties concentrating 50 (8.3) 17 (6.7) 33 (9.5) 1.46 0.79–2.68 NS
Mucosal symptoms 121 (19.8) 41 (16) 80 (22.5) 1.53 1.01–2.31 0.051
Itching, burning or irritation of the eyes 56 (9.2) 13 (5.1) 43 (12.2) 2.59 1.36–4.39 0.003
Irritated, stuffy or runny nose 50 (8.3) 23 (9.1) 27 (7.8) 0.85 0.47–1.51 NS
Hoarse, dry throat 50 (8.3) 14 (5.5) 36 (10.3) 1.95 1.03–3.70 0.038
Cough 46 (7.7) 16 (6.3) 30 (8.7) 1.45 0.78–2.72 NS
Dermal symptoms 49 (8.1) 12 (4.8) 37 (10.5) 2.35 1.2–4.6 0.015
Dry or flushed facial skin 17 (2.8) 3 (1.2) 14 (3.9) 3.37 0.96–11.86 0.045
Scaling/itching scalp or ears 18 (3) 7 (2.8) 11 (3.1) 1.13 0.43–2.97 NS
Hands dry, itching, red skin 27 (4.5) 4 (1.6) 23 (6.6) 4.31 1.47–12.63 0.004
Any symptom 303 (49.4) 102 (39.8) 201 (56.3) 1.95 1.40–2.69 <0.001
†
Only the answers ‘Yes, often’ (every week) are used
‡
Reference category: Females/Males
§
Differences between males and females calculated with Chi-square test
¶
Data for some characteristics were missing for some participants
OR: Odds Ratio; CI: Confidence Interval; NS: Not Significant.

Complaints about perceived ΙΑQ and SBS symptoms by gender

Females complained more often than males about perceived IAQ. ‘Dry air’, ‘Draught’ and ‘Dust and
dirt’ were reported approximately twice as commonly by women than by men [OR: 2.82 (95% CI:
1.42–5.62), OR: 1.95 (95% CI 1.16–3.26) and OR: 1.89 (95% CI 1.35–2.64), respectively]. Moreover,
females had worse values in the score of ‘Discomfort Scale’ (Table 2).
Females reported at least one SBS symptom more often than males (56.3% versus 39.8%,
p < 0.001). Most of the examined SBS symptoms were more prevalent in women (Table 3).
 (A) WORK ENVIROMENT (B) SYMPTOMS
(often bothered) % (Yes, often)%
Draught Fatigue
80 Room temperature Hands dry, itching, 40 Feeling heavy-
Dust and dirty
too high red skin headed
60 30
Light that is dim or Varying room Scaling/itching scalp
causes glare and/ 40 temperature 20 Headache
or ears
or reflections 20 10
Room temperature Dry or flushed facial
Noise 0 0 Nausea/Dizziness
too low skin

Passive smoking Stuffy “bad” air Difficulties

Cough
concentrating
Static electricity Itching, burning or
Dry air Hoarse, dry throat
often causing shocks irritation of the eyes
Unpleasant odor Irritated, stuffy or
runny nose

(C) SYMPTOMS women

men (D) SYMPTOMS
(Yes, often)% men/ref (Yes, often)% women/ref
Fatigue Fatigue
Hands dry, itching, 30 Hands dry, itching, 50 Feeling heavy-
Feeling heavy-headed
red skin 25 red skin 40 headed
Scaling/itching scalp 20
Headache Scaling/itching scalp 30
or ears 15 Headache
or ears 20
10
5 10
Dry or flushed facial Dry or flushed facial
0 Nausea/Dizziness 0 Nausea/Dizziness
skin skin

Difficulties Difficulties
Cough Cough
concentrating concentrating
Itching, burning or Itching, burning or
Hoarse, dry throat Hoarse, dry throat
irritation of the eyes irritation of the eyes
Irritated, stuffy or Irritated, stuffy or
runny nose runny nose
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH

Figure 1. A. The prevalence of often bothered IAQ complaints of all participants compared with reference data. B. Symptoms prevalence of all participants compared with reference data.
C. Symptoms prevalence of men compared with reference data. D. Symptoms prevalence of women compared with reference data.
7
8 E. TSANTAKI ET AL.

Comparison with reference data

The participants reported almost all of the perceived IAQ complaints more often compared with the
reference population from ‘healthy’ buildings. The prevalence of ‘Dust and dirty’ showed the
highest difference between the studied and the reference population (63% vs 10%), followed by
‘Room temperature too low’ (25% vs 5%), ‘Varying room temperature’ (24% vs 5%) and
‘Unpleasant odour’ (23% vs 5%). Of note, the only complaints that were lower in the present
study were ‘Dry air’ (9% vs 20%) and ‘Static electricity’ (3% vs 4%). The prevalence of perceived IAQ
complaints compared with the reference data is shown in Figure 1A.
General Symptoms were more prevalent compared to the reference data. ‘Fatigue’ had the most
prominent difference (34% vs 10%), followed by ‘Feeling heavy headed’ (17% vs 5%) and ‘Headache’
(15% vs 5%). Dermal symptoms and the ‘Irritated, stuffy or runny nose’ were reported at lower rates
than in the reference population (Figure 1B). Both sexes in the present study showed higher
prevalence of SBS symptoms compared to reference population. Interestingly, the observed differ­
ences between women (Figure 1C) were much higher compared to the corresponding differences
between men (Figure 1D).

Psychosocial work environment

Women had higher mean (SD) score in Psychosocial Work Scale than men [9.13 (1.65) and 8.74
(1.69); respectively, p = 0.005]. The mean score (SD) for all participants was 8.96 (1.68).

Risk factors associated with symptoms – regression analysis

‘Years of working in current workplace’ was the only factor excluded from linear regression models,
due to high inter-correlation (≥0.7) with ‘age’. Although in univariate analysis, smoking
(p-value>0.2) did not meet the criteria, it was included in the model, as it was considered clinically
significant and has been widely used in previous studies with conflicting results (Skov et al. 1989;
Azuma et al. 2015; Magnavita 2015). The univariate associations between the examined predictor
factors and Total, General, Mucosal and Dermal Symptoms Scores are shown in appendix
(Table A1).
Hierarchical linear regression analysis revealed that each new added group of predictors showed
a significant improvement in R2 of the Total and General Symptom Score, while for the Mucosal
and Dermal Symptom Score, an improvement was shown only with the addition of health status,
job characteristics and work-related risk factors, as well as perceived IAQ complaints. In particular,
the prediction model of the Total SBS Symptoms Score increased its predictive ability from 4.4%
when personal factors were involved, to 13.5% with the introduction of health status factors, to
18.4% by adding job characteristics and work-related risk factors, to 21.1% when the psychosocial
parameters were added and finally, to 25.4% with the Discomfort Scale of IAQ (Table 4). The final
predictor models explained 21%, 15% and 12% of the variance of General, Mucosal and Dermal
Symptom Score, respectively.
Additionally, the final regression model indicated several contributing risk factors for Total
(Table 4), General, Mucosal and Dermal Symptom Score (Table 5). Smoking was not a significant
predictor for any of the score symptoms (p > 0.05).

Discussion
The results of the present study showcase that poor perceived IAQ and high prevalence of SBS
symptoms, General symptoms in particular, were major problems for the university staff in
a Mediterranean country during a period of limited financial funds. Indeed, the prevalence of the
main complaints about perceived IAQ and most of SBS symptoms was higher compared with the
Table 4. Results of Hierarchical Regression Analyses for Total Symptom Score.
Model 1 Model 2 Model 3 Model 4 Final Model
† † † † †
Variables β 95% CI β 95% CI β 95% CI β 95% CI β 95% CI
Personal factors
Sex (Female/Male) 0.712*** 0.34, 1.08 0.695*** 0.34, 1.05 0.623*** 0.27, 0.98 0.561** 0.201, 0.91 0.474** 0.13, 0.82
Age (years) -0.010 -0.03, 0.01 -0.009 -0.03, 0.01 -0.012 -0.03, 0.004 -0.009 -0.03, 0.01 -0.005 -0.02, 0.01
Health Status factors
Atopy (Yes/No) 0.482** 0.12, 0.84 0.367* 0.01, 0.73 0.418* 0.06, 0.78 0.363* 0.02, 0.71
Current Smoking (Yes/No) 0.115 -0.26, 0.49 0.065 -0.31, 0.44 0.033 -0.33, 0.40 0.053 -0.31, 0.41
Sleep problems (Yes/No) 1.114*** 0.69, 1.54 1.004*** 0.58, 1.43 0.899*** 0.47, 1.32 0.802*** 0.39, 1.22
Work-related risk factors
Radiation Exposure (Yes/No) 1.004 0.58, 1.43 0.031 -0.36, 0. 43 -0.007 -0.39, 0.38
Biological Exposure (Yes /No) 0.058 -0.34, 0.46 0.359 -0.06, 0.78 0.360 -0.05, 0.77
PC Scale 0.343*** -0.08, 0.77 0.052** 0.02, 0.09 0.027 -0.01, 0.06
Repeated wrist/shoulder movements (Yes/No) 0.062 0.03, 0.10 0.068 -0.33, 0.46 0.021 -0.36, 0.41
Awkward posture at work (Yes /No) 0.114 -0.29, 0.51 0.071 -0.33, 0.47 -0.041 -0.44, 0.36
Psychosocial factors
Psychosocial work Scale 0.149* 0.03, 0.27 0.107 -0.01, 0.22
Anxiety (Yes /No) 0.097 -0.19, 0.38 0.144 -0.14, 0.43
Job satisfaction -0.141 -0.35, 0.07 -0.191 -0.40, 0.02
IAQ complaints
Discomfort Scale 0.212*** 0.12, 0.31
R2 0.044 0.135 0.184 0.211 0.254
R2 Change 0.044 0.091 0.049 0.027 0.043
p-value of F Change <0.001 <0.001 0.001 0.007 <0.001
†
Adjusted β
β: coefficient of the explanatory variable, CI: Confidence Interval
*p < 0.05; **p < 0.01; ***p < 0.001.
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH
9
 10

Table 5. Results of Hierarchical Regression Analyses for General, Mucosal and Dermal Symptom Scores.
Model 1 Model 2 Model 3 Model 4 Final Model
E. TSANTAKI ET AL.

Variables β† 95% CI β† 95% CI β† 95% CI β† 95% CI β† 95% CI

GENERAL SYMPTOMS Personal factors
SCORE Sex (Female/Male) 0.441*** 0.20, 0.68 0.425 0.19, 0.66 0.373** 0.14, 0.61 0.319** 0.08, 0.55 0.283 0.05, 0.51
Age (years) -0.009 -0.02, 0.002 -0.008 -0.02, -0.011 -0.02, 0.00 -0.009 -0.02, -0.007 -0.02, 0.004
0.003 0.002
Health Status factors
Atopy (Yes/No) 0.156 -0.08, 0.40 0.090 -0.15, 0.33 0.125 -0.11, 0.36 0.094 -0.14, 0.33
Current Smoking (Yes/No) 0.152 -0.10, 0.41 0.120 -0.13, 0.37 0.089 -0.15, 0.33 0.097 -0.14 0.34
Sleep problems (Yes/No) 0.573*** 0.29, 0.86 0.503*** 0.22, 0.78 0.412** 0.13, 0.69 0.370* 0.09, 0.65
Work-related risk factors
Radiation exposure (Yes/No) 0.002 -0.26, 0.27 -0.024 -0.29, 0.24 -0.035 -0.29, 0.22
Biological exposure (Yes /No) 0.307* 0.02, 0.59 0.321* 0.04, 0.60 0.318* 0.05, 0.59
PC Scale 0.042*** 0.02, 0.07 0.034** 0.01, 0.06 0.023* 0.00, 0.05
Repeated wrist/shoulder movements 0.095 -0.17, 0.36 0.056 -0.21, 0.32 0.034 -0.22, 0.29
(Yes/No)
Awkward posture at work (Yes /No) 0.015 -0.25, 0.28 -0.026 -0.29, 0.24 -0.072 -0.34, 0.19
Psychosocial factors
Psychosocial work Scale 0.120** 0.04, 0.20 0.101* 0.02, 0.18
Anxiety (Yes /No) 0.123 -0.07, 0.31 0.141 -0.05, 0.33
Job satisfaction (Yes/ No) -0.124 -0.26, 0.02 -0.144* -0.28, -0.006
IAQ complaints
Discomfort Scale 0.095** 0.03, 0.16

R2 0.045 0.093 0.146 0.192 0.212

R2 Change 0.045 0.049 0.053 0.046 0.020
p-value of F Change <0.001 <0.001 0.001 <0.001 0.003
(Continued)
Table 5. (Continued).
Model 1 Model 2 Model 3 Model 4 Final Model
Variables β† 95% CI β† 95% CI β† 95% CI β† 95% CI β† 95% CI
MUCOSAL SYMPTOM Personal factors
SCORE Sex (Female/Male) 0.160* 0.02, 0.30 0.155* 0.02, 0.29 0.129 -0.01, 0.27 0.118 -0.02, 0.25 0.093 -0.04, 0.23
Age (years) -0.002 -0.01, 0.004 -0.002 -0.01, -0.002 -0.01, 0.004 -0.002 -0.01 -0.001 -0.01, 0.01
0.004 0.005
Health Status factors
Atopy (Yes /No) 0.251 0.12, 0.39 0.222** 0.08, 0.36 0.228*** 0.09, 0.37 0.218** 0.08, 0.35
Smoking (Yes/No) -0.013 -0.56, 0.13 -0.025 -0.17, 0.12 -0.029 -0.17, 0.11 -0.020 -0.16, 0.12
Sleep disorders (Yes/No) 0.410 0.25, 0.57 0.376*** 0.22, 0.54 0.361*** 0.20, 0.52 0.340*** 0.18, 0.50
Work-related risk factors
PC Scale 0.017* 0.004, 0.03 0.015* 0.002, 0.007 -0.01, 0.02
0.03
Repeated wrist/shoulder movements -0.017 -0.17, 0.13 -0.024 -0.17, 0.13 -0.042 -0.19 0.12
(Yes/No)
Awkward posture at work (Yes /No) 0.105 -0.05, 0.26 0.092 -0.06, 0.24 0.065 -0.09, 0.22
Psychosocial factors
Psychosocial work Scale 0.025 -0.02, 0.07 0.017 -0.03, 0.06
Job satisfaction (Yes/ No) -0.028 -0.11, 0.05 -0.041 -0.12, 0.04
IAQ complaints
Discomfort Scale 0.059*** 0.02, 0.10
2
R 0.013 0.106 0.126 0.131 0.151
R2 Change 0.013 0.093 0.020 0.005 0.020
p-value of F Change 0.054 <0.001 0.020 0.272 0.001
(Continued)
INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH
11
 12

Table 5. (Continued).
Model 1 Model 2 Model 3 Model 4 Final Model
E. TSANTAKI ET AL.

Variables β† 95% CI β† 95% CI β† 95% CI β† 95% CI β† 95% CI

DERMAL SYMPTOM Personal factors
SCORE Sex (Female/Male) 0.086** 0.01, 0.16 0.085* 0.02, 0.01 0.082* 0.01, 0.16 0.065 -0.01, 0.14
Age (years) 0 -0.003, 0.00 0.98, 0 -0.004,0.003 0 -0.003, 0.003
0.003 -0.003
Health Status factors
Atopy (Yes/No) 0.100** 0.03, 0.17 0.081* 0.01, 0.16 0.074* 0.001, 0.15
Current Smoking (Yes/No) -0.052 -0.13, 0.03 -0.060 -0.14, 0.02 -0.054 -0.13, 0.02
Sleeping disorders (Yes/No) 0.064 -0.02, 0.15 0.047 -0.04, 0.13 0.035 -0.05, 0.12
Work-related risk factors
Radiation exposure (Yes/No) 0.075 0.16, 0.13 0.071 -0.01, 0.15
Chemical exposure (Yes/No) 0.097* 0.19, 0.13 0.094* 0.001, 0.19
Biological exposure (Yes /No) 0.004 0.10, 0.07 0.003 -0.09, 0.10
PC Scale 0.003 -0.004, 0.01 -0.002 -0.01, 0.005
Repeated wrist/shoulder movements 0.055 -0.03 0.14 0.043 -0.04, 0.12
(Yes/No)
Awkward posture at work (Yes /No) 0.004 -0.08, 0.09 -0.014 -0.1, 0.07
IAQ complaints
Discomfort Scale 0.039*** 0.02, 0.06

R2 0.013 0.046 0.080 0.116

R2 Change 0.013 0.033 0.035 0.036
p-value of F Change 0.071 0.003 0.022 <0.001
†
Adjusted β
β: coefficient of the explanatory variable, CI: Confidence Interval
*p < 0.05; **p < 0.01; ***p < 0.001.
 INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 13

reference data of ‘healthy’ buildings from a Northern European country (Andersson and Larsson
1990; Andersson 1998). The associated factors to the SBS symptoms (personal, health status and
psychosocial work factors, job characteristics and work-related risk factors, as well as perceived IAQ
complaints) contributed to a varying degree to each cluster of symptoms (General, Mucosal and
Dermal Symptom Scores). Perceived IAQ complaints, atopy and sleep problems were the most
significant predictors of SBS symptoms.

Complaints about perceived IAQ

The majority of employees (79%) reported at least one environmental complaint, the most
prevalent being ‘Dust and dirt’ (63%). Previous studies from non-industrial work environments,
mainly offices (Reijula and Sundman-Digert 2004; Syazwan et al. 2013; Magnavita 2015) and
university microenvironments (Bakke et al. 2008a; Brauer and Mikkelsen 2010; DN 2010), showed
much lower prevalence of ‘Dust and dirt’ (ranging from 7.4% to 25% and from 4.6% to 22%,
respectively). The high rates in the present study could be partially attributed to the lack of cleaning
services during the study period. Moreover, the percentage of employees who reported at least one
complaint about perceived IAQ, after excluding ‘Dust and dirt’, remained significantly high (65%),
indicating that poor perceived IAQ was a real problem for the university staff, requiring further
consideration from occupational and safety services.
Other major complaints about perceived IAQ were ‘Room temperature too low’ (25%), ‘Varying
room temperature’ (24%), ‘Unpleasant odour’ (23%) and ‘Stuffy-bad-air’ (19%). Similar findings
were reported in a recent study from an Italian region, Latium (Magnavita 2015), with the
Mediterranean climate, situated at the same latitude as Thessaloniki. However, several differences
were observed as well, such as ‘Room temperature too low’ which was reported at a lower
percentage in the Italian study (10%). This finding could be partly explained by the heating
problems in the Greek university during the study period. Furthermore, passive smoking was
reported twice as much as in our study and this discrepancy may be due to different policies
permitting indoor smoking. However, more studies from Mediterranean countries are needed to
examine whether there are similar trends in perceived IAQ complaints.
On the contrary, studies from Northern Europe showed that ‘Dry air’ and ‘Stuffy air’ were the
most frequent complaints (Skov and Valbjorn 1987; Reijula and Sundman-Digert 2004).
Concerning the university sector, despite the limited data, complaints about perceived IAQ seem
to follow the same pattern (Bakke et al. 2008a). A totally different pattern was reported in a study
from Malaysia, a country with tropical climate, where ‘Passive smoking’ (14%), ‘Noise’ (12%),
‘Draft’ (11%) and ‘Varying room temperature’ (10%) were the most common complaints (Syazwan
et al. 2013).
In addition, studies conducted in university buildings showcase noise as a main environmental
complaint (Brauer and Mikkelsen 2010; DN 2010). However, in the present study, noise was not
a major complaint. This finding could indicate that noise may not be a significant problem for the
whole university but for specific university buildings such as faculty offices.
The apparent differences in the reported perceived IAQ complaints between the various studies
could be partially explained by the different climate, heating and ventilation of the buildings as well
as cultural trends (such as allowing indoor smoking) and study design differences.

Complaints about perceived IAQ and gender

Women reported discomfort about perceived IAQ, almost for all the studied complaints more
often. This finding is in line with previous studies (Andersson 1998; Reijula and Sundman-Digert
2004; Kim et al. 2013).
14 E. TSANTAKI ET AL.

SBS symptoms
The assessment of the SBS symptoms revealed that General symptoms (41%) namely ‘Fatigue’
(34%), ‘Feeling heavy–headed’ (17%) and ‘Headache’ (16%) were the most prevalent symptoms
followed by Mucosal (20%), while Dermal (8%) had the lowest prevalence. This pattern of
symptoms had similarities and differences compared with previous studies. Similar rank order of
the SBS symptoms was reported in another Mediterranean country (Magnavita 2015), even though
the prevalence of General symptoms was lower. Similar results were also found in studies conducted
in different climates (Skov and Valbjorn 1987; Syazwan et al. 2013; Dhungana and Chalise 2020).
In university buildings, the same profile of SBS symptoms as our study was observed in a study of
15 university offices in Thailand (DN 2010). Additionally, similar findings were recorded in the two
‘problem’ university buildings in Norway, though at a lower prevalence rate (Bakke et al. 2008a).
However, the prevalence of ‘Fatigue’ was higher in the present study.
On the contrary, several other studies reported a different profile of symptoms. A Finnish study
found that the most prevalent symptoms were ‘Nasal symptoms’, ‘Fatigue’ and ‘Dryness of the
hands’. Interestingly, the prevalence of all General symptoms was approximately twice as high in
our study, while the prevalence of all Mucosal and Dermal symptoms was, approximately, twice as
high in the Finnish study (Reijula and Sundman-Digert 2004). Different profiles of symptoms were
reported from other studies (Marmot et al. 2006; Brightman et al. 2008; Azuma et al. 2015). It is
obvious that there is great diversity among studies regarding the most prevalent SBS symptoms.
Interestingly, even though perceived IAQ complaints seem to follow region-specific patterns, the
SBS symptoms do not. This could be partly explained by the multifactorial etiology of SBS
symptoms where additional factors besides the perceived IAQ complaints and climate may play
an important role in different environments. More studies in Mediterranean countries are needed
in order to investigate whether there are similar trends regarding SBS symptoms.

Comparing perceived ΙΑQ complaints and SBS symptoms with reference data
Employees at AUTh had higher prevalence of almost all environmental complaints (except ‘Dry air’
and ‘Static electricity’) and of General and Mucosal symptoms (except ‘Irritated, stuffy or runny
nose’) compared with the reference data from ‘healthy buildings’ (SG et al. 1989; Andersson and
Larsson 1990; Andersson 1998). This finding indicates that perceived IAQ complaints and SBS
symptoms at AUTh need further investigation and improvement in order to provide a healthy and
comfortable environment for occupants.

Risk factors associated with SBS symptoms – regression analysis

The present study, in accordance with earlier studies, adds to the multifactorial etiology of SBS
symptoms (Norback et al. 1990; Mendell 1993). Associations were found among several factors and
SBS symptoms. Health status factors, job characteristics and work-related risk factors, as well as
perceived IAQ complaints, contributed to the Total, General, Mucosal and Dermal Symptom Score,
while the group of Personal and the group of Psychosocial factors affected only Total and General
Symptom Score.
Total SBS symptoms were associated by gender, atopy, sleep disorders and the Discomfort Scale
of IAQ, as was shown by the final regression model. Our results were in agreement with previous
studies which indicated that females report more symptoms than males in the same indoor
environment (Andersson 1998; Brasche et al. 2001; Burge 2004; Reijula and Sundman-Digert
2004; Azuma et al. 2015). Atopy showed a positive association with SBS symptoms, which is
a common finding (Reijula and Sundman-Digert 2004; Runeson et al. 2006; Magnavita 2015). In
particular, it was a significant predictor for the overall SBS symptoms as well as for Mucosal and
Dermal, but not for General symptoms, in line with some previous data (Andersson 1998;
 INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 15

Magnavita 2015). Concerning sleep problems, there is strong evidence that they are related to many
chronic diseases (Grandner 2014) and that IAQ of the sleeping microenvironment may have
important implications on human health and well-being (Boora 2017). Moreover, sleep problems
have a negative impact on work attendance and performance (Hui and Grandner 2015) and
substantially increases the likelihood of occupational accidents, absenteeism and presenteeism
(Swanson et al. 2011). To our knowledge, it has not been studied adequately, whether sleep
problems make people more susceptible to SBS symptoms. In our study, sleep problems were
found to be a significant predictor of Total, General and Mucosal symptoms. However, the reverse
association cannot be ruled out, as SBS symptoms could lead to poor sleep quality. Future studies
with validated tools examining the whole spectrum of sleep disturbances are needed to investigate
this possible association. Finally, environmental discomfort (Discomfort Scale) was a strong pre­
dictor of all SBS symptoms, even after controlling for other variables. Previous studies reported that
different IAQ complaints were associated in varying degrees with General, Mucosal and Dermal
symptoms (Azuma et al. 2015; Magnavita 2015).
On the other hand, no correlation was found between smoking and SBS symptoms, not even
with Mucosal symptoms. In the literature, data is conflicting (Skov et al. 1989; Lenvik 1993; Azuma
et al. 2015; Magnavita 2015).
In total, quite a small percentage (25%) of Total SBS symptoms’ variability is explained by the
aforementioned factors, which highlights the need to assess other factors attributing to the occur­
rence of the SBS symptoms. This finding is in consistency with previous reports (Magnavita 2015)
and could probably pinpoint the importance of idiosyncratic factors and the diversity of factors
playing significant role in different environments for SBS symptoms.

General, Mucosal and Dermal SBS Symptoms Score and additional related factors
General symptoms were associated with additional risk factors, such as Psychosocial Work scale.
Several studies reported that psychosocial work factors were significantly associated with SBS
symptoms (Lahtinen et al. 2004; Marmot et al. 2006; Magnavita 2015). Job satisfaction was
associated with General symptoms in accordance with a previous study (Azuma et al. 2015)
while several other studies included job satisfaction as a predictor of SBS symptoms (Brasche
et al. 2001; Chao et al. 2003). It should be noted that a direct comparison between studies is
difficult because a different definition of employees’ satisfaction is used. Additionally, General
symptoms were associated with PC use-related problems. The findings in the literature are
conflicted (Skov et al. 1989; Jaakkola MS and Jaakkola 1999; Burge 2004; Kubo et al. 2006;
Azuma et al. 2015). The comparison between studies has an obvious difficulty due to the
different technology of the screens and computers used in studies conducted during different
time periods. Finally, exposure to biological agents, as it is referred by participants, was
associated with General SBS symptoms. Epidemiological studies showed an association between
bioaerosols and SBS symptoms (Laumbach and Kipen 2005). Additionally, a recent experimental
study revealed a link between microbial substances and building-related symptoms (Salin et al.
2017).
Concerning Dermal SBS symptoms, an additional predictor, apart from the atopy, was the self-
reported chemical exposure. It was previously mentioned that chemical exposure was related to
General, upper respiratory and eye irritation symptoms (Azuma et al. 2015).

Limitations
This study has some limitations. Firstly, a cross-sectional study design was used that limits any
causal inference. Secondly, the response rate was relatively low via e-mail questionnaires (27%).
While the participation rates for epidemiologic studies have been declining during the past 30 years
(Galea and Tracy 2007), there is a growing body of evidence to suggest that the response rate may
not be the single proxy measure to indicate study quality (Morton et al. 2012) and the correlation
16 E. TSANTAKI ET AL.

between response rate and study validity is not direct (Mealing et al. 2010). In the present study,
mixed–mode data collection was chosen, in order to reduce ‘non-response error’. The comparison
of the two methodological approaches, e-mail and in-person, did not reveal significant differences
in any principal outcome (Appendix-Table A2). Moreover, the fact that data about perceived IAQ
and SBS were collected by a self-administered questionnaire could be a potential limit. However,
Burge et al. showed a good agreement between data collected by self-administered and medical
interview (Burge PS, Robertson A.S., Hedge A. 1991). Moreover, the higher prevalence of both
perceived IAQ complaints and SBS symptoms may partly be affected by the fact that in our sample
females were more than males. Other relevant studies also reported more females than males
(Brauer and Mikkelsen 2010; Syazwan et al. 2013; Magnavita 2015) and some of them even in the
higher ratio (Skov and Valbjorn 1987; Reijula and Sundman-Digert 2004). Finally, a study was
conducted in one university may not assess the role of indoor air conditions on perceived IAQ or
SBS and may not reflect the general situation in Greece. More studies from Greek universities are
needed.

Conclusions
In conclusion, poor perceived IAQ was an important issue in a university setting in a temperate
climate country. Cleaning and temperature problems were of great concern. SBS symptoms,
General symptoms, in particular, were commonly reported by university staff. Finally, regression
analysis revealed that the IAQ Discomfort Scale was a significant predictor for all SBS symptoms.
Several other predictors were associated with Total (female sex, atopy and sleep problems), General
(sleep problems, exposure to biological agents, PC use-related problems, Psychosocial Work Scale
and Job satisfaction), Mucosal (atopy and sleep problems) and Dermal (atopy and exposure to
chemical agents) symptoms highlighting the multifactorial nature of SBS symptoms. More studies
are needed to investigate whether there is a similar pattern of complaints or SBS symptoms in other
Mediterranean regions.
This study attempted to assess the perceived IAQ and SBS symptoms within the entirety of
a university setting from the perspective of public, environmental and occupational health and
safety services in order to investigate further, prioritize problems and needs and finally tailor future
action.

Disclosure statement
The authors declare that they have no conflict of interest.

ORCID
Efthymia Tsantaki http://orcid.org/0000-0002-0970-3664

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Appendix A

Table A1. Linear regression univariate analysis results for the association with SBS symptom scores.
Total Symptom Score General Symptom Score Mucosal Symptom Score Dermal Symptom Score
E. TSANTAKI ET AL.

a a a a
Variables β 95% CI p-value β 95% CI p-value β 95% CI p-value β 95% CI p-value
Personal factors
Sex (Female/Male) 0.669 0.38, 0.96 <0.001 0.443 0.26, 0.63 <0.001 0.127 0.002, 0.25 0.047 0.084 0.02, 0.14 0.007
Age (years) −0.019 −0.03,-0.01 0.007 −0.017 −0.03, 0.01 <0.001 −0.002 −0.01, 0.004 0.560 0 −0.003, 0.002 0.737
Years of education −0.004 −0.05, 0.05 0.876 −0.010 −0.04, 0.02 0.634 0.010 −0.01, 0.03 0.454 −0.003 −0.01, 0.01 0.563
Health Status factors
Atopy (Yes/No) 0.608 0.32, 0.90 <0.001 0.207 0.02, 0.40 0.034 0.314 0.19, 0.44 <0.001 0.083 0.02, 0.14 0.007
Current Smoking (Yes/No) 0.132 −0.19, 0.45 0.419 0.189 −0.02, 0.40 0.074 −0.017 −0.15, 0.12 0.810 −0.032 −0.10, 0.04 0.355
Sleep problems (Yes/No) 1.124 0.79, 1.46 <0.001 0.577 0.36, 0.80 <0.001 0.452 0.31, 0.60 <0.001 0.094 0.02, 0.17 0.014
Work-related risk factors
Years working in current workplace −0.019 −0.03,-0.01 0.005 −0.016 −0.03, 0.01 <0.001 −0.003 −0.01, 0.002 0.257 0.001 −0.002, 0.003 0.598
Radiation exposure (Yes/No) 0.351 −0.01, 0.71 0.055 0.222 −0.01, 0.45 0.059 0.038 −0.11, 0.19 0.621 0.079 0.01, 0.15 0.029
Biological exposure (Yes/No) 0.281 −0.08, 0.65 0.131 0.236 −0.003,0.47 0.053 0.009 −0.15 0.17 0.905 0.067 −0.01, 0.14 0.085
Chemical exposure (Yes/No) −0.032 −0.38, 0.32 0.860 −0.094 −0.32, 0.13 0.412 −0.039 −0.19, 0.11 0.606 0.104 0.03, 0.18 0.004
PC Scale 0.096 0.07, 0.13 <0.001 0.061 0.04, 0.08 <0.001 0.028 0.02, 0.04 <0.001 0.006 0.00, 012 0.041
Awkward posture at work (Yes/No) 0.605 0.30, 0.91 <0.001 0.324 0.12, 0.53 0.002 0.218 0.09, 0.35 0.001 0.047 −0.01, 0.11 0.131
Repeated wrist/shoulder movements (Yes/No) 0.437 0.12, 0.75 0.007 0.262 0.06, 0.47 0.012 0.098 −0.04, 0.23 0.152 0.064 0.000, 0.13 0.051
Psychosocial factors
Psychosocial work Scale 0.201 0.12, 0.29 <0.001 0.139 0.08, 0.19 <0.001 0.065 0.03, 0.10 0.001 0 −.002, 0.02 0.971
Anxiety (Yes/No) 0.392 0.12, 0.66 0.004 0.289 0.12, 0.46 0.001 0.074 −0.04, 0.19 0.217 0.022 −0.03, 0.08 0.430
Job satisfaction −0.308 −0.46,-0.15 <0.001 −0.225 −0.33,-0.12 <0.001 −0.077 −0.14, −0.01 0.022 −0.012 −0.04, 0.02 0.467
IAQ complaints
Discomfort Scale 0.288 0.22, 0.35 <0.001 0.162 0.12, 0.21 <0.001 0.084 0.06, 0.11 <0.001 0.040 0.03, 0.05 <0.001
a
Unadjusted β
β: coefficient of the explanatory variable, CI: Confidence Interval.
 INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 21

Table A2. Comparison between electronic and printed form questionnaire.

Electronic-form Printed-form
Total n = 483 n = 130 p-valuea
Total SBS Symptom Score 1.24 (1.8) 1.24 (1.77) 1.27 (1.94) NS
General Symptom Score 0.78 (1.18) 0.75 (1.12) 0.88 (1.35) NS
Mucosal Symptom Score 0.33 (0.77) 0.34 (0.77) 0.30 (0.78) NS
Dermal Symptom Score 0.1 (0.36) 0.11 (0.4) 0.1(0.27) NS
Psychosocial Work Scale 8.96 (1.7) 8.9 (1.68) 9.17 (1.65) NS
Discomfort Scale 2.29 (2.1) 2.34 (2.08) 2.14 (2.15) NS
a
Mann–Whitney U test
NS: Not Significant.