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Department of Occupational Medicine Copenhagen University Hospital Glostrup, Denmark

The sick building syndrome revisited

PhD thesis Charlotte Brauer, MD

University of Copenhagen 2005


PhD thesis

The sick building syndrome revisited
By Charlotte Brauer, MD Department of Occupational Medicine Copenhagen University Hospital Glostrup, Denmark

Supervisors: Sigurd Mikkelsen, MD, DMSc Department of Occupational Medicine Copenhagen University Hospital DK-2600 Glostrup, Denmark Henrik Kolstad, MD, PhD Department of Occupational Medicine Aarhus University Hospital DK-8000 Aarhus C, Denmark Palle Ørbæk, MD, DMSc National Institute of Occupational Health DK-2100 Copenhagen Ø, Denmark Opponents: Finn Gyntelberg, Professor, MD, DMSc Clinis of Occupational and Environmental medicine Bispebjerg Hospital DK-2400 Copenhagen NV, Denmark Jens Peter Bonde, Professor, MD, DMSc Department of Occupational Medicine Aarhus University Hospital DK-8000 Aarhus C, Denmark Åke Thörn, MD, DMSc The Norrbotten County Council S-971 89 Luleå, Sweden



I want to thank Sigurd Mikkelsen who made me interested in the subject and made it possible for me to carry out this study. I want to thank my three supervisors. Copenhagen University Hospital in Glostrup during my employment as a staff specialist (2002-2005). Thank you very much for your encouragement and patience.This PhD thesis is based on three manuscripts: • The context of a study influences the reporting of symptoms. Int Arch Occup Environ Health 2006. 76: 621-624. support and discussions. To the secretaries at our department. First. Copenhagen. 5 . PREFACE This thesis was done at the Department of Occupational Medicine. I am also grateful to Henrik Kolstad and Palle Ørbæk for their thorough remarks and inspiring discussions. I would like to say a big thank you for your assistance in co-ordinating the questionnaire survey. No consistent risk factor pattern for symptoms related to the sick building syndrome: a prospective population based study. The Danish Working Environment Council and the Danish Medical Research Council. The sick building syndrome . He has taught me so much and given me an indescribable support throughout the study. Last but not least. his good discussions and his friendship.a chicken and egg situation? Int Arch Occup Environ Health 2006. And to my colleagues and fellow members of the Center for Indoor environment and Stress research. thank you for your interest. Charlotte Brauer. Int Arch Occup Environ Health 2003. I would like to thank all the participants. I also wish to thank Peder Skov for his collaboration in the validation study. July 2005 • • The study has received financial support from the Danish Working Environment Authority. especially Gitte Grubbe Baunsgård.

CONTENTS BACKGROUND __________________________________________________ 7 Introduction _________________________________________________________7 History of health aspects related to the indoor environment __________________8 Definition of the sick building syndrome __________________________________9 Previous research on SBS ______________________________________________9 Comparison of SBS with other conditions with non-specific symptoms _________9 Factors influencing the SBS symptoms __________________________________10 PRESENT STUDY AND AIMS _____________________________________ 11 VALIDATION STUDY ____________________________________________ 12 Study population ____________________________________________________12 The Glostrup Questionnaire ___________________________________________12 Statistical analyses ___________________________________________________12 Results _____________________________________________________________14 Discussion __________________________________________________________14 THE PROSPECTIVE STUDY ______________________________________ 16 Study population ____________________________________________________16 Questionnaire _______________________________________________________16 Statistical analyses ___________________________________________________18 Results _____________________________________________________________21 Discussion __________________________________________________________22 OVERALL CONCLUSIONS AND IMPLICATIONS____________________ 26 ENGLISH SUMMARY____________________________________________ 27 DANSK RESUMÉ________________________________________________ 29 REFERENCES __________________________________________________ 31 APPENDICES___________________________________________________ 39 Tables and manuscripts 6 .

frequency and workrelatedness of the symptoms. Many of the employees told that they had not attributed the symptoms to the indoor environment until they were informed of the mould. I found only a moderate agreement concerning the responses as to whether the symptoms were experienced especially at work. even years. I became involved in this process in 1996 when the questionnaire was to be pilot tested and validated. ear ache. I experienced that statements about this work-relatedness often seemed vague. It can be downloaded in Danish on the website: www. Instead of referring to the presence of symptoms when staying in the specific building. The experience from these interviews made me interested in studying whether awareness affects the reporting of symptoms and whether 7 . This resulted in different expert assessments of whether a specific building was “sick” or not and consequently in different decisions on the action to be taken to “cure” the building. approximately 175 employees at four different workplaces were interviewed by two of my colleagues and me.000 persons. In the open-ended questions almost 25% of the interviewed persons mentioned well-defined diseases caused by microorganisms or symptoms without a biologically plausible explanation in the indoor environment. sinusitis. The questionnaires varied considerably with respect to the symptoms queried about. The uptake area is the Copenhagen County with a population of approximately 600. During the years quite a few of the patients referred to us by general practitioners had symptoms attributed the indoor environment. Thus the in-depth interviews indicated that employees may ascribe their symptoms to the indoor environment in the workplace. The questionnaire is now called "the Glostrup Questionnaire". On this background we established a working group in 1995 in order to develop a standardised Danish questionnaire on symptoms and perceived indoor environment. pneumonia. Furthermore. dental problems. Some of the employees described their symptoms in almost identical words or sentences. many of the symptoms that the employees perceived as similar turned out to be rather different when specified further. Often the occupational health services or the Labour Inspection Authority had been involved and frequently surveys about symptom prevalence already have been conducted. The interviews began with an open-ended question about symptoms that the employee considered related to the indoor environment and were followed by systematic questions about the character. but also clinically defined diseases that had other well-known causes. It seemed to include not only non-specific symptoms. In two of the workplaces another argument for perceiving a symptom as work-related was that mould growth had been discovered in the workplace. when they were explored in detail. During the validation study. the time frames of perceived symptoms and how to evaluate their workor building-relatedness. if their colleagues report apparently similar symptoms or if they have become aware of a potential indoor environment problem. was established in 1989. for example herpes zoster.BACKGROUND Introduction The Department of Occupational Medicine. and cystitis. irregular menstrual However.cis. a taste of metal. they had no well-established reference values with which to compare the survey results of complaints in a specific building. a common argument for perceiving the symptoms as work-related was that many of their colleagues had similar symptoms. These surveys were conducted with a number of different questionnaires.suite. Copenhagen University Hospital. I conducted the validation study and a subsequent study that included collection of normative data [22]. but now they were certain that their symptoms were caused by the mould. Glostrup. candida infection. In many of these workplaces complaints about the indoor environment had persisted for a long time. Hence the interplay between perceived health and indoor environment may be very complex. We were also regularly contacted by workplaces because of suspected indoor climate problems and symptoms among the employees. The group consisted of specialists in occupational medicine and public health medicine as well as representatives from the occupational health services and the Danish Working Environment Authority. When I compared interview information with the employees’ responses in questionnaires.

A working group was assembled by the World Health Organization (WHO) in 1979 to evaluate health aspects related to indoor air quality [126]. a nutritious diet and fresh air were important to improve public health. In the 1970s much attention was drawn to asbestos and radon in buildings due to the cancer risk of the occupants. and not too crowded. 62]. In the 1850s he proposed that the indoor air was unclean due to volatile organic substances from the occupants' breath and skin and suggested a limit value of carbon dioxide in the indoor air as a measure of an adequately ventilated room [86]. However. water-damage with growth of a toxin-producing mould in the homes of the infants was suspected to have caused these outbreaks of disease. The WHO group found it reasonable to assume that a true environmental health problem had emerged and introduced the term sick building syndrome. In Denmark. The group reported that an increasing number of case stories especially from the Scandinavian countries and the United States reported similar non-specific symptoms that they attributed to indoor climate problems. In 1994. because emissions from the construction materials now tended to remain in buildings longer and at higher concentrations. He recommended that a dwelling was kept dry. nausea and dizziness. mould in the indoor environment has received extensive media coverage and is often mentioned in sensational headlines. buildings have been evacuated and torn down due to 8 . clean. headache. pain in the nerves. Initially. draught and dry air could cause nausea. the first professor of Hygiene in Sweden. Since the Cleveland cluster of disease. headaches. History of health aspects related to the indoor environment The health impact of the indoor environment has attracted much interest of hygienists. 96]. coughing and possibly nausea due to environmental tobacco smoke. wheezing. well ventilated. mental fatigue. itching and unspecific hypersensitivity. The latter category comprised buildings. wrote the book "The indoor air of our homes" in which he discussed health effects of indoor air in rooms that were insufficiently ventilated [51]. The energy crisis in 1973-1974 resulted in energy-conserving measures being taken with insulation of buildings and reduction in ventilation. the group described health effects in terms of irritation of the eye and respiratory tract due to release of formaldehyde from building material as well as eye irritation. In his experience unclean air. 48. common cold. Apart from the cancer risk related to asbestos and radon. Since then the risk of allergic sensitisation of house dust mite and mould spores in dwellings has been extensively studied [44. catarrh or irritation in the lower respiratory system and a sensation of dryness in the throat. rheumatism. claimed that cleanliness. erythema. This in turn led to concern about an increasing risk of exposure to indoor air pollutants. a subsequent thorough review of the case studies found inadequate evidence supporting a causal relationship between these cases of illness and the mould [3]. public health scientists and engineers for centuries. a dramatic change in suspected adverse health effects of the indoor environment was seen when a cluster of the serious disease "acute pulmonary haemorrhage" was reported among infants in Cleveland. nose and throat irritation. The German hygienist Max von Pettenkofer. In the 19th century the importance of living in good sanitary conditions to prevent the spread of infectious diseases was well known. where normally no obvious cause was evident and where the symptoms would persist for years and sometimes would be resistant to extensive remedial action. hoarseness. where the symptoms would decrease in time and mostly disappear. high frequency of airway infections and cough. sensation of dry mucous membranes and skin. The group distinguished between temporarily sick buildings and permanently sick buildings. The former category comprised newly constructed or newly remodelled buildings. who was closely involved in investigating cholera epidemics. The role of fungi and mould growth in asthma and hay fever has been considered since the 1930s and the house dust mite was suspected as being a producer of house dust allergens in 1964 [68. although the direct cause of the infections was unknown. Ohio. In 1881 Elias Heyman. In 1982 a WHO working group once more discussed the impact of indoor air pollutants on health [127]. The symptoms described were: eye.perceived exposures in the indoor environment is associated with symptoms with a biologically plausible explanation in the indoor environment as well as with symptoms without such an explanation. In the 20th century concern about allergic diseases related to indoor allergens has appeared.

and noise [11. 52. In the United States. 53. 103. general symptoms such as fatigue and headache. Mucous membrane symptoms have been associated with perception of dry air. humidity. notably mould in seat dust. schools. 79. mould litigation is frequently occurring. 58. Several investigations have been performed in so-called "sick" buildings in which a high proportion of workers have experienced symptoms. 128]. 113. In the 1990s attention was drawn to volatile organic compounds. 36. 81]. 112. However. 91]. There is also disagreement about whether the term refers to a population or an individual. 57. Thus. Studies about health effects due to airborne particles in non-industrial buildings are inconclusive [98]. Some researchers define the SBS as a population in a specific "sick" building and require an excess of symptoms in the building [39. despite a considerable improvement in the building and housing standard in the industrial countries during the past centuries. General symptoms have been related to reported odours. but most studies have concentrated on non-industrial workplaces such as offices. and damp and mouldy buildings. 33. There is no agreement on how the temporal relationship between the building and the symptoms is defined and on how often the occupants have to experience the symptoms. temperature. 58. man made mineral fibres. and wall-to-wall carpeting. 123]. Previous research on SBS Extensive research has tried to identify factors in the indoor environment. 34. and dust [79. 19. noise. 83. 39. number of persons occupying the room. Comparison of SBS with other conditions with non-specific symptoms The symptoms associated with SBS are nonspecific symptoms that are quite common in the 9 . but there is little consistency in the findings. 70. 38. 52. formaldehyde. visual display units. 26. which they attributed to the indoor environment already before the study took place [11. 61]. 4. particulates. the evidence that indoor mould growth plays a role as a causative agent for health effects in terms of SBS symptoms is weak [18. The only longitudinal epidemiological study of which I am aware found only a few statistically significant associations between SBS symptoms and an extensive panel of objectively measured exposure variables [26]. 9. 103]. In the 1980s focus was on ventilation. 87. Cross-sectional studies with objective measurements of exposures have often found statistically significant associations. 83]. 19. 78-80. In the following this group of symptoms will be referred to as SBS symptoms. 79. and possibly skin symptoms. 110. 120. Ventilation seems to be associated with perceived air quality and SBS symptoms [9. 74. 83]. 61. static electricity. Some authors also include lower respiratory symptoms. static electricity. there seems to be agreement that the SBS typically includes mucous membrane symptoms. 72. 85. However. 85]. 121. Mechanical ventilation. Cross-sectional studies examining the SBS have found numerous associations between reported symptoms and self-reported exposures in the indoor environment. 69. floor dust and other “established” indoor environmental factors had no significant association with SBS symptoms. 47. and insurance companies have paid millions of dollars in claims to occupants of mould damaged buildings [55]. relative humidity. the indoor environment is still considered a potential health hazard and almost a more serious health hazard than a hundred years ago. Some studies have examined the indoor environment in dwellings. 25. Others make a case definition of SBS on an individual basis. a high prevalence of symptoms has also been found in buildings without pre-existing assumptions that these symptoms were building related [39. Several large scale studies have been performed. 71. 20. especially in the United States and Europe but also in Asia [1. too little air movement. 17. too little air movement. Signs of dampness appear to increase the risk of pulmonary symptoms and SBS symptoms [18. 65. but not in air samples or floor dust. which could be the cause(s) of SBS symptoms. and some define a constellation of core symptoms as diagnostic of SBS [13. 109. 85. 115]. 80. Definition of the sick building syndrome The WHO group did not state a precise definition of the sick building syndrome (SBS) and even today there is no general consensus on a definition. despite extensive research no objectively measured factors in the indoor environment have consistently been associated with SBS symptoms. temperature. day-care centres and hospitals. However. 77. Thus. 73.mould and a few lawsuits have been brought to court because of chronic diseases ascribed to mould in the workplace.

They can accompany other illnesses and can occur without connection to the environment [17. 102. 95]. constipation. 66. low age and atopy have also been associated with an increased prevalence of symptoms [16. headache by noise. Assuming that SBS symptoms are related to the indoor environment in a building. the symptoms are attributed to environmental factors that are tolerated by the majority of people. but also other environmental exposures with low-level concentrations of chemicals or emissions have been associated with the occurrence of non-specific symptoms. According to the toxicogenic theory. A tendency to report physical and emotional stress symptoms has been associated with chronic heart disease [45]. low back pain or other musculoskeletal symptoms [11. Some of the conditions have been described as clinical entities or syndromes such as Gulf war syndrome.g. 93. many of the symptoms are quite similar to the symptoms related to the SBS. 120. 50. dissatisfaction with superiors or colleagues. 84. 37. 75. 107]. 104. These psychosocial factors included work satisfaction in general. Hence research on the SBS should attempt to get a 10 . but the personality trait negative affectivity was not. 95. 64]. 76. 122]. Several studies have shown that environmental worry and awareness of a potential environmental hazard may influence the reporting of non-specific symptoms [30. 124]. 109]. only indications of objective health effects have been found. and some of these indications were in biologically unexplainable directions [49]. Provocation challenge studies of SBS symptoms have shown that exposure to low concentrations of volatile organic compounds. Factors influencing the SBS symptoms Psychosocial work characteristics have been associated with the SBS symptoms in several studies [79. Not only the indoor environment. 49. eye irritation by dust. Female sex. Thus the SBS has many similarities with the other environmental illnesses: The symptoms are related to multiple organs and no specific cause can be identified. 88]. 63. and electrical hypersensitivity [27. 80. the symptoms presumably either are present only when a person stays in that specific building or get worse in that building. Studies on psychosomatic symptoms have shown that persons with a general tendency to exaggerate or overrate their work stress may report more symptoms [41]. waste disposal site syndrome. Today this term usually also includes the other abovementioned conditions [50. However. symptom reporting was associated with psychiatric and somatic conditions rather than an environmental exposure in the majority of the cases [21]. As research has failed to establish a link between the suspected environmental cause and the symptoms. 94.general population and are seldom accompanied by pathological abnormalities. A low sense of coherence was associated with a higher prevalence of SBS symptoms. suggesting that perception and cognition mediate symptoms [29]. 106]. a high level of stress. Several theories have been formulated for the mechanisms behind IEI [60. Provocation challenge studies of IEI have demonstrated that symptoms could only be reliably associated with chemical exposures at levels above the olfactory or irritant threshold. 14. Toxic chemicals were regarded as the most probable cause in only five of these cases. quantity of work. 80. a working group convened by WHO recommended in 1996 to use the term idiopathic environmental intolerance (IEI) instead of multiple chemical sensitivity [2]. Nevertheless. Many of the symptoms in the SBS can theoretically be explained by some chemical or physical exposures in the environment e. multiple chemical sensitivity. while the psychogenic theory suggests that it is a functional somatic syndrome characterised by an overvalued idea attributing symptoms to environmental agents [108]. Among 264 patients presenting with supposed environmental illness. The relationship between symptom reporting and SBS symptoms has not been investigated. 104. 87. 107]. chemical sensitivity to very low levels of almost any environmental agent accounts for the multi-system symptoms. 106. and climate of co-operation. 56. 89. Only a few authors have examined the impact of personality traits on SBS symptoms [11. Likewise a provocation test of persons with alleged electrical hypersensitivity did not show relationships between symptoms and the actual presence of electromagnetic fields [6]. In spite of the fact that the exposures are rather different. office dust or office equipment is associated with reported mucous membrane symptoms and headache [12. for example bad nerves. 128]. Symptoms for which there is no biologically plausible explanation in the indoor environment has also been reported in buildings with reported problems in the indoor environment.

PRESENT STUDY AND AIMS The thesis includes a 1-year prospective study of a random sample of the Danish adult population as well as a validation study. for example the workplace. if worry and awareness influence the reporting of symptoms. The main aims of this PhD thesis were to examine: 1. which are included in this thesis (appendix II to IV). Validation of the questions about SBS symptoms and perceived indoor environment was another purpose of the study (Appendix III and thesis). After this. This suggests that awareness and beliefs may influence self-reports on the buildingrelatedness of SBS symptoms. Initially. 35. is it then possible to get a valid description of this relationship? In only a few published studies. However. Whether symptoms are more likely to be reported as work-related. The results of the prospective study are reported in the three manuscripts. if attention is focused on the indoor environment at work (Appendix II). Whether perceived exposures in the indoor environment is associated with symptoms with a biologically plausible explanation in the indoor environment as well as with symptoms without such an explanation (Appendix IV).description of the temporal relationship between the occurrence of symptoms and staying in the building. One study took account of "awareness” and found that the prevalence of work-related SBS symptoms increased when the employees were informed that a study of the indoor environment was going on [73]. How the perceived indoor environment is associated with the prevalence. Most of these studies have either compared questionnaire information with a physician's diagnosis or assessed the test-retest agreement. 24. Parts of the validation study are mentioned in one of the manuscripts. 4. 73. 11 . 2. 125]. the prospective study is described. the validity of an SBS questionnaire is described [7. incidence and persistence of the non-specific symptoms that are traditionally included in the sick building syndrome (SBS symptoms) (Appendix III). How a general tendency to report symptoms may influence the reporting of SBS symptoms (Appendix III). 3. I will describe the validation study in further details.

hoarseness. nasal congestion. The remaining 5 perceived exposures (dry air. see below. range 0-3). Alternative response options were "no difference days off/working days" and "I don't know". sometimes". and breathlessness. and difficulty in concentrating. a noise index (noise in the room. static electricity. which can be downloaded on the web site http://www. unidimensionality. too low temperature. and a light index (illumination problems and reflective surfaces) [28]. dry skin on the hands or arms. and each question had four response options: "no". If a symptom was more pronounced on working days. irritation of the throat. We constructed four symptom indices by the sum of the dichotomised variables. but were tested for dimensionality to assess whether these could be grouped in an index. wheezing in the chest. a stuffy air index (stuffy air and unpleasant odour). The participants were asked to consider symptoms experienced during the past four weeks. range 0-3). cramped for space and poor cleaning) were not initially grouped. several times a week". the participants had to specify for each symptom. if that particular symptom was more pronounced "on days off" or "on working days". the questions from the Glostrup Questionnaire about symptoms related to the SBS and the indoor environment were 947 employees participated. daily". In addition. and internal consistency. cough. In all. They had a mean age of 44 years (range 18-68) and were predominantly women (73%). Statistical analyses The constructed indices of symptoms and perceived indoor environment were examined with respect to item bias. headache. and difficulty in concentrating.2. and hoarseness. range 0-5).ku. Based on previous research the questions were grouped into a thermal index (draught.VALIDATION STUDY Prior to the prospective study. and general symptom index (fatigue. Data were dichotomised so that a symptom occurring several times a week or daily was a positive answer. irrespective of 12 . environmental tobacco smoke. nose irritation. sex and allergic diseases. Atopy was defined as reporting either allergy to pollen. The tests for unidimensionality and item bias were conducted with the software program DIGRAM. "yes. "yes. wheezing in the chest. These analyses were carried out in the validation sample (N=947) and were cross-validated in the baseline study sample from the prospective study (N=2164). and flushing face. The symptom indices were: mucous membrane index (eye irritation. The symptoms were chosen as relevant for SBS on the basis of the existing literature. temperature variations and draught along the floor). Item bias Item bias analyses test whether each item in an index functions in the same way. Exposures were regarded as relevant if they were present several times a week or daily. Perceived exposures in the indoor environment (17 items) were assessed with the following question: "Have you been exposed to any of the following factors in your work environment during the past four weeks?" with the same four response options as for the questions on symptoms. nasal congestion. range 0-2). it was considered to be workrelated. noise from other rooms and noise from outside). nose irritation. pulmonary index (cough. The Glostrup Questionnaire The “Glostrup Questionnaire” comprised questions about the following 13 symptoms: eye irritation. The test-retest reliability was assessed in two of the eight workplaces from the validation sample. hay fever or childhood eczema. and "yes. All the workplaces were located in Greater Copenhagen. too high temperature. flushing face. furry animals or house dust mite or a history of asthma. The characteristics of the eight workplaces and employees are shown in table 1. irrespective of the symptoms being reported as work-related or not. Figure 1 shows an example of a question about SBS symptoms. In addition the questionnaire included question about age. skin index (dry skin on the hands or arms. breathlessness. fatigue. irritation of the throat. headache. Study population The validation took place in eight workplaces that had contacted our department in the years 1998-2000 because of suspected indoor climate problems and symptoms among the employees.biostat. All other statistical analyses were done with SAS® System version 8.

... Test-retest reliability The questionnaire was applied twice with an interval of one week among 110 employees (88%)...... Hence an index consisting of only two or three items may yield lower values....... □ yes...............31 to +0... The partial gamma was calculated for each three-way table............ corresponding to more than expected scoring low on one index and high on the other index. pulmonary....................... we examined item bias in relation to these subgroups. daily.......... and general symptom index...... Large residuals at the edges and small residuals at the diagonal suggested different dimensions...70 are usually regarded satisfactory [111]............ Initially........ but also on the number of items in the scale..... we used the Martin-Löf test to test the hypothesis that the two indices were one dimension [119]. □ on working days................... sex... skin and general symptoms).............. 43]... and a gamma outside the interval -0........... Subsequently........ Respondents who had one or more items in the index unanswered were excluded from the analysis.................. □ If yes....... The gamma coefficient ranges from -1 to +1.... several times a week.. and atopy have been shown to influence the reporting of SBS.................. the alpha is dependent not only on the magnitude of the correlations among the items..... An example of a question about SBS symptoms in the questionnaire During the past 4 weeks have you been bothered by stuffy or runny nose? no........... Because age. pulmonary index......... Are the symptoms most pronounced? on days off ..... as they are not included in the items or index......... □ I don’t know.......05 estimated by the Monte Carlo approximation (1000 simulations) were regarded as significant........ Values of the Cronbach coefficient alpha above 0............................ The Martin-Löf test is a confirmatory test that is suitable for dichotomous items in contrast to factor analysis. However............... The test-retest reliability was assessed as 13 . □ no difference days off / working days ....... If the gamma was significantly outside the interval -0.31 can be interpreted as moderate to large item bias [15].............. The same procedure was followed for the questions on perceived exposures in the indoor environment............ we examined whether the 13 symptoms represented one latent variable such as "the sick building syndrome" or whether it was composed of more underlying dimensions as the four proposed groups of symptoms (mucous membrane... Item bias analyses were done on the four symptom indices: mucous membrane index............... □ yes.... Two sided p-values<0.31 to +0........ □ yes.. Internal consistency Internal consistency in the symptom indices and the indoor environment indices was assessed with Spearmans correlations and the Cronbach coefficient alpha....Figure 1... We used a method based on three-way contingency tables of item score by the exogenous variables of interest stratified by the index score [15.. Unidimensionality Regarding dimensionality. □ subgroup investigated........ we crosstabulated the symptom indices two by two checking the standardised residuals......... skin index... sometimes . I considered the item bias to be of importance. Variables like sex and age are called exogenous variables....31 in any of the populations..................

In the validation sample (N=947) the Cronbach coefficient alpha was 0. but it was not statistically significant (gamma -0.001). In the baseline study sample from the prospective study (N=2164) the Cronbach coefficients were a little lower (table 3).55 (p=0. is a woman or is young. the noise index and the light index represented separate dimensions. too low temperature and draught along the floor) and a temperature index (too high temperature and temperature variations). However. and values less than 0. the same tendency was seen as regards sex. the simple kappa coefficient ranged from 0. Internal consistency All symptom variables were positively correlated. Hence it was divided into a draught index (draught.40 were considered to represent poor agreement [40]. Likewise for the indoor environment indices.75 were regarded to represent excellent agreement beyond chance.49 for the skin index. p<0. the symptom indices ranging between 0. Environmental tobacco smoke could not be combined with any of the other exposures.41 and 0. a score on these indices has different meanings depending on whether a person has atopy. Unidimensionality Test for unidimensionality rejected that any of the four symptom indices could be combined with each other to form a common dimension with highly significant Martin-Löf tests in both samples (p<0.17 for cough and 0. the stuffy air index. but it was not statistically significant.01) and 0.65 (pulmonary index) and 0. values between 0.79 (table 3). p=0.44 and 0. age or atopy as regards the mucous membrane index and the general symptom index. Women (gamma=-0. At a given index score persons with atopy had a decreased tendency to report cough and an increased tendency to report breathlessness with a negative and positive gamma coefficient. Discussion The item bias analyses showed evidence of bias as regards the pulmonary index and the skin index with respect to sex.38 for dry skin).25. The skin index was significantly biased in relation to sex as well as age in the baseline study sample. and 0.41. Results Item bias There was no evidence of important item bias with respect to sex. These indices were tested with respect to internal consistency and reliability. respectively.48 (breathlessness) to 0. Values of the kappa coefficient greater than 0. The simple kappa coefficient was used for the 13 dichotomised symptoms. 0. respectively.75 fair to good agreement. The thermal index turned out to consist of two different dimensions. Consequently. In both samples the coefficients were lowest for the dry air index and space/dust index and highest for the draught index. This may lead to false conclusions. p=0. In the baseline study sample the same tendency was seen with a gamma of -0. age and atopy. The kappa coefficients for the four symptom indices as well as for the eight indoor environment indices indicated good to excellent agreement.002) and older persons (gamma=0. Test-retest reliability For the 13 symptoms analysed separately.66 for the general symptom index.24 for breathlessness.the percentage of full agreement and as the chance corrected agreement by the kappa coefficient and the 95% confidence interval (CI). Table 2 illustrates this bias by showing the three-way table of the item "breathlessness" by atopy stratified by the index score.58 (p=0.93 (general symptom index) and the indoor environment ranging between 0. 0.33. while the weighted kappa coefficient was used for the indices that consisted of more than two levels.64 in the validation population and between 0.001) were more likely to report dry skin on hand or arm than men and younger persons. For the indoor environment indices the Cronbach coefficient alpha ranged between 0.72 in the baseline study sample.40 and 0.03). Item bias analysis was developed in educational 14 . The remaining exposures grouped as follows: a dry air index (dry air and static electricity) and a space/dust index (cramped for space and poor cleaning). if the symptom indices for different groups are to be compared.68. concerning the pulmonary index the items "cough" and "breathlessness" were biased in relation to atopy in the validation sample with a significant gamma of -0.71 for the mucous membrane index.87 (nose irritation) with a mean on 0.61 for the pulmonary index. In the validation sample.58 and 0.

considering that some indices consisted of only two items. However. others require one general symptom and either a mucous membrane symptom or a skin symptom. Some require one general symptom. Nevertheless. The kappa coefficients were at the same level as for other questionnaires measuring indoor environment and SBS symptoms [8. 85. as it is possible to have a good function of the upper limbs. but not being able to walk [10]. the mucous membrane index. The mucous membrane index and the general symptom index comprised two different dimensions and were not biased with respect to sex. age or atopy. otherwise information about the poor function of the lower limbs might be blurred among the items of the function of the upper limbs. only the symptom "dry skin on hands or arm" was sufficiently prevalent to being analysed separately. a questionnaire measuring the functional ability may turn out to be composed of two different dimensions corresponding to lower limb function and upper limb function. Until now the dimensionality of the SBS symptoms has not been investigated. 74. However. A solution to the problem could be to remove the most severely biased item from the index or to analyse the items separately instead of using an index construction. skin symptoms and general symptoms should not be grouped to form an "SBS index". information is diluted and the questionnaire is less sensitive. The indices consisted of only three and two items. according to my study mucous membrane symptoms. 110]. In both samples the mucous membrane index and general symptom index showed the highest degree of internal consistency. so the most obvious solution would be to analyse the items separately. several researchers have made case definition for an SBS case. 43. If an index is formed by items belonging to different dimensions. and others require at least two symptoms among a long list of symptoms [38. one mucous membrane symptom and one skin symptom. but as the gamma was moderate in the other sample and the tendency to bias was in the same direction. 15 . In the present study the bias was not statistically significant in both samples. 72. the general symptom index and the indoor environment indices showed a high degree of reliability and a satisfactory internal consistency. Thus the upper and lower limb function should be measured separately. 99]. In conclusion. The internal consistency showed fair to good homogeneity. I concluded that the bias was of importance. For example. The test-retest reliability analyses indicated good to excellent agreement as regards the symptom indices and indoor environment indices. To my knowledge it has not yet been used in research on SBS. Hence I decided to include only the mucous membrane index and the general symptom index in the following analyses of data from the prospective study. It means that a person may have a high score on one dimension and a low score on another dimension.research and from the 1980s it has been used in medical research as well [10. 125]. respectively. The test for unidimensionality showed that the four symptom indices represented different dimensions in both samples. Thus I believe that the questionnaire used in the study is a satisfactorily reliable and valid tool.

but did not differ from the respondents with respect to age or geographical region.THE PROSPECTIVE STUDY Study population The study population comprised 4000 persons aged 18 to 59 years who were selected randomly from the Danish Civil Registration System with the same number of women and men and an equal number in each year group. 28% were manual workers and 8% were self-employed. 38% had atopy and 32% were current smokers. The time lag of one year was chosen to control for seasonal changes. stress and health related to the workplace and dwelling". Thus at baseline the study group comprised 2164 participants with 1468 participants in group W and 696 participants in group H corresponding to the information letter about the indoor climate at work and at home. a slight change was made in two of the sentences in the letter. The general mental and physical health of the participants was like the average general population when measured with the SF-12 [42]. The majority of the participants were nonmanual workers (64%). At followup. The nonrespondents at baseline were more likely to be men. in addition to being a part of the prospective study. Consequently two thirds were allocated to group W (n=2667) and one third to group H (n=1333). smoking habits. It did not mention the workplace or the home. The participants were invited by mail to take part in "a study about indoor environment. In order to assess whether awareness influences the reporting of symptoms. perceived indoor environment at work. and personal characteristics. Data collection was made by postal questionnaires in April 2001 and April 2002. the workrelatedness of the symptoms and the perceived indoor environment were assessed with the "Glostrup Questionnaire". sex. In the letter to study group H (Home) the word "work" was replaced with "home". Among the non-respondents at follow-up there was an overrepresentation of young persons (<30 years). of whom 1402 were eligible for participation because they were still working and living in the same place as at baseline. selfemployed persons and unskilled manual workers. occupation. respectively. A positive symptom was a symptom experienced several times a week or daily. In the letter to study group W (Work) we stated that knowledge was especially lacking about health effects related to the indoor climate at work. 16 . The 2164 persons in the baseline population were comprised of 1114 women (52%). marital status. Study participants were randomly allocated to the two study groups. unmarried persons. The general purpose of the study was to assess the association between non-specific symptoms and the indoor environment at work and in dwellings. smokers. personality traits. The letter was identical to all participants except for this one word in two sentences. and perception of physical and psychosocial work environment. which is described in details in the section about the validation study. age. The baseline characteristics of the respondents and nonrespondents are shown in table 4. The symptoms related to the SBS. Thus I had to be sure to collect a sufficient number of responses to represent normative data for workplaces. This information was given to all participants in a one-page information letter. Questionnaire The questionnaire included items concerning symptoms related to the SBS. all participants received identical information letters explaining that the purpose of this extra survey was to examine whether the indoor environment was associated with symptoms becoming chronic. but 546 participants were not eligible for inclusion because of being unemployed or receiving education. psychosocial work characteristics. A total of 2065 of the 2164 baseline participants agreed to participate in the follow-up study. Non-respondents were reminded once. the mean age was 41 years (range 18-59). all participants were asked whether they would accept to receive another questionnaire one year later. At baseline. general health. but there was no notable difference in baseline characteristics on perceived indoor environment. At baseline 2710 participants (68%) completed the questionnaire. Figure 2 shows the flowchart of the study. However. the baseline study also served the purpose to obtain normative data for the Glostrup Questionnaire so that work environment professionals could use the results as a reference. mucous membrane symptom index or general symptom index. Group W and group H were comparable with respect to rate of participation. At follow-up 1740 participants (80% of the baseline population) completed the questionnaire.

nervousness. concentration problems. as they were symptoms that are often included in the SBS (fatigue. and difficulty in thinking clearly. forgetfulness. a temperature index (range 0-2). Flowchart of the study population In accordance with our validation study. sweating. a question designed for the study was asked whether there were patches of damp or mildew in the workplace. fatigue. table 7) [100]. chest pain. The indices were formed by the sum of the symptom variables that were dichotomised corresponding to symptoms experienced several times a week or daily. shortness of breath. Questions on the perceived indoor environment were grouped into the following groups: a draught index (range 0-3). sleeping problems. This grouping was done according to our validation study and covered perceptions reported present several times a week or daily. A variable denoting "symptom reporting 17 . it was considered to be workrelated. emotional and cognitive symptoms experienced during the past four weeks (stomach ache. powerlessness. irrespective of workrelation. mucous membrane index and general symptom index. a noise index (range 0-3). heart palpitations. In addition. unable to relax. a stuffy air index (range 0-2). A general tendency to report symptoms was measured with a symptom checklist including 19 somatic. muscle tension. forgetfulness and difficulty in thinking clearly). a space/dust index (range 0-2). environmental tobacco smoke (range 0-1). concentration problems. in the analyses four of the symptoms were excluded. a light index (range 0-2). the symptoms were grouped in two indices.4000 persons selected randomly. tendency to cry. vertigo. If a symptom was more pronounced on working days. aged between 18-59 years 2710 (68%) respondents 546 persons excluded (unemployed and students) 2164 participants at baseline: 1468 received a letter with emphasis on "work" 696 received a letter with emphasis on the "home" 2065 agreed to participate in the follow-up study 1740 respondents (80% of the baseline participants) 338 persons were excluded: 86 were unemployed or students 230 had changed job 22 had moved to a new home 1402 participants at one-year follow-up Figure 2. a dry air index (range 0-2). However. restlessness. depression. difficulty in making decisions.

The associations were analysed for the separate symptoms. Analyses were done in a three-stage process.05 and beta=0. allergy. atopy and symptom reporting tendency. a tendency to worry about health. job strain. Psychosocial work characteristics were measured with four global questions designed for the present study addressing job demands. adjusting for sex. Secondly. we in addition adjusted for other personal factors and factors in the psychosocial work environment. The personality traits “negative affectivity” and “type A behaviour” were determined by two questions used in a previous study [5]. Information about age. Potential personal or psychosocial confounders comprised marital status. A question about self-efficacy. hay fever or childhood eczema. age. the sample size of 4000 persons was considered sufficient. Perceived indoor environment and prevalence. and effort-reward imbalance. At follow-up. a question covering a tendency to worry about health and a question about support from family or friends were designed for the study. Decisions on where to dichotomise the responses were made a priori on the basis of the wordings in the response options to indicate a high degree of the characteristic. Firstly. The covariates were chosen a priori and entered in the model in one step. A symptom was considered work-related if it was more pronounced on working days. support from family and friends. Incidence of symptoms was defined as a score>0 on the symptom index at follow-up among participants with a score=0 on the respective score index at baseline. social support at home. Focus on the indoor environment at work and work-related symptoms We used multiple logistic regression to examine the effect of the two different information letters on reporting a symptom as work-related allowing for potential confounders. not the symptom indices. social climate at work. In the model we included sex. a symptom reporting tendency. we examined the effect of each of the indoor environment indices. self-efficacy. Atopy was defined as reporting either allergy to pollen. It was scored according to the manual resulting in a physical and a mental summary score. job control. smoking. where a score of 50 is the average and a score above 50 is above average.90]. and effort-reward imbalance [59] [101]. A person who reported smoking tobacco daily was regarded a current smoker. social support at work. It was computed that if an outcome occurred with a prevalence of 5%. job control. it would require a sample size of approximately 1160 persons to detect an odds ratio (OR) of 2 [alpha=0. smoking. sex and municipality of living was obtained from the Danish Civil Register. negative affectivity. Table 5 shows the questions on psychosocial work characteristics and personality traits. At baseline the prevalence of mucous membrane symptoms and general symptoms was assessed as a score>0 on the symptom index. type A behaviour. job control. and perceived indoor environment at work. job demands. furry animals or house dust mite or a history of asthma. job demands. the outcomes of interest were the incidence and the persistence of mucous membrane symptoms and general symptoms. negative affectivity. Statistical analyses Power Power calculations were done before the study. work support. The outcomes were the mucous membrane index (range 0-5) and general symptoms index (range 0-3) described in the section about the questionnaire. These potential confounders were kept in all subsequent models whether significant or not.tendency" was defined as present if at least four of the remaining 15 symptoms were reported to occur very often or often. General health was assessed by the Short Form 12 Health Survey (SF-12) [42]. incidence and persistence of SBS symptoms Logistic regression was used to examine the association between perceived indoor environment at work and mucous membrane symptoms and general symptoms. The follow-up questionnaire consisted of the questions on symptoms and potential risk factors that were identical to the questions at baseline. With an expected participation rate of 70% and assuming that 80% of these participants were in employment at baseline. age. support from colleagues or supervisors. We used backward elimination to choose which of these 18 . Persistence of symptoms was defined as having a score>0 at follow-up as well as at baseline. all other covariates were self-reported.

It was fixed before any analyses were done regarding relationships between exposure and outcome. In order to test whether this was an over-adjustment. An association was regarded as significant if the top level of the index had a 95% CI not including 1. age. and dummy symptoms. Perceived indoor environment. In order to keep the indoor environment as constant as possible. testing whether the effect for individual environment factors could be explained by the other indoor environment factors. atopy. The models were tested for goodness of fit with the Hosmer and Lemeshow method [54]. To test for a dose-response effect we used a test for trend analysing the models with the indoor environment indices as continuous variables in the models. New reports of exposures in the indoor environment was defined as having at least a score of one on the index at follow-up among persons who had a score of zero on the respective index at baseline. Longitudinal data were used to examine the association between indoor environment at baseline and the incidence of SBS symptoms and dummy symptoms at 1-year follow-up as well as the reverse association: whether symptoms at baseline predicted that a person began to report new exposures in the indoor environment at follow-up (figure 3). The other symptoms that were considered not to be SBS symptoms are referred to as dummy symptoms in the following. The dummy symptoms were the same as the symptoms used to describe symptom reporting tendency (table 7). At baseline the prevalence of dummy symptoms was defined as having a score of at least 7. we repeated the analyses without symptom reporting tendency in the models. in order to have a sufficient number of incident cases with dummy symptoms it was necessary to re-define a positive outcome. analyses at follow-up were restricted to the participants who were still employed in the same company and who still lived in the same dwelling as they did at baseline. The variable for symptom reporting tendency was defined as at least four of the 15 symptoms that were reported to occur very often or often. In analyses of follow-up data. 2 and 3. Finally. respectively. Again we used backward elimination at a 0. Baseline data were used to examine the cross-sectional association between the perceived indoor environment and the prevalence of mucous membrane symptoms.covariates to keep in the model and chose 0.0 or if the p-value was below 0. while "sometimes". The incidence was defined as a score of at least 7 at follow-up among persons with a score less than 7 at baseline. Analyses were done in the same three stage process as described above adjusting for sex. "often" and "very often" were assigned a value of 1. general symptoms. This cut-off point corresponded to the 75th percentile and was chosen because it paralleled the dichotomization of the mucous membrane symptoms and general symptoms. other personal factors. psychosocial work characteristics and indoor environment indices. Responses of "never" or "seldom" were assigned a value of 0. However. SBS symptoms and “dummy” symptoms Logistic regression was used to examine the association between perceived indoor environment at work and SBS symptoms as well as other symptoms that cannot plausibly be linked to the indoor environment.05 in the linear tests for trend. None of the dummy symptoms were included in the WHO description of the SBS symptoms. and the outcomes of interest were the prevalence and incidence of these symptom groups as described above. we used information from the baseline questionnaire on the indoor environment and other risk factors as predictors of developing new symptoms or having persistent symptoms after one year. The influence of a symptom reporting tendency In the models described above. The SBS symptoms were grouped into mucous membrane symptoms and general symptoms. symptom reporting tendency was forced in all models as a potential confounder. we additionally adjusted each indoor environment index for the other indoor environment indices.10 significance level to decide which of the other indoor environment indices to keep in the final model together with the potential confounders chosen at stage two. The scores were summed to obtain an overall score for "dummy" symptoms ranging from 0 to 45.10 as the significance level of the Wald chi-square for keeping a variable in the model. which corresponds to reporting 7 or more specific symptoms at least "sometimes". The only difference was that analyses were performed without symptom reporting 19 . but now they were used as an outcome and not as a potential confounder.

"1" indicates cross-sectional analysis at baseline. and "3" indicates the reverse causation in longitudinal analysis. 20 . Models on the predictive relationships between the perceived indoor environment and symptoms.Baseline SBS symptoms: mucous membrane symptoms and general symptoms Follow-up SBS symptoms: mucous membrane symptoms and general symptoms Perceived indoor environment Perceived indoor environment Other symptoms: "dummy" symptoms Other symptoms: "dummy" symptoms Figure 3. "2" indicates longitudinal analysis with normal causal direction between exposure and outcome.

9 and 2.0 or if the p-value was below 0. Likewise.9 and 4.5). No difference was found between manual and nonmanual workers in prevalence or one-year incidence of mucous membrane symptoms or general symptoms. while draught was the only predictor of onset of general symptoms. Work-related mucous membrane symptoms were associated only with high job demands (significant adjusted OR between 1.8 and 5.tendency as a covariate in the models. Results Focus on the indoor environment at work and work-related symptoms (appendix II) A slight difference in the accompanying letter replacing the word "work" with "home" in two sentences influenced the responses considerably. The most common symptoms were nasal congestion (16%) followed by fatigue (15%). the participants were more likely to report that their symptoms were work-related (significant unadjusted odds ratios (OR) between 1. We found no predictors in the indoor environment for the persistence of general symptoms. the participants were more likely to report that their symptoms were more pronounced at home. if focus was on the environment at home (significant unadjusted OR between 5. and noise. we adjusted only for sex.0). and approximately 50% recovered from symptoms during the one-year follow-up period. incidence and persistence of SBS symptoms (appendix III) Mucous membrane symptoms and general symptoms were common. If the information letter focused slightly more on the indoor environment at the workplace than in the home. Persistent mucous membrane symptoms were associated only with perception of stuffy air. dry air. respectively. General symptoms were associated with self-reported stuffy air and dry air in the cross-sectional analysis. To test for trend we also analysed the models with the indoor environment indices as continuous variables in the models. The prevalence estimates of symptoms were similar in group W and group H. and only few changed more than one score on an index (1% to 7%). which was defined as having at least four of the 15 21 . the prospective analyses showed that onset of mucous membrane symptoms was associated with the sensation of draught. Perceived indoor environment and prevalence. and atopy because the small number of cases did not permit further adjustments in the models. headache (12%). but differences were found as regards the reporting of work-relatedness and homerelatedness. All data processing were done with the SAS® System version 8.2 [97]. as 28% of the population at baseline reported to have mucous membrane symptoms regularly and 23% reported to have general symptoms. nose irritation (11%) and eye irritation (10%). Table 6 shows the changes in perceived indoor environment between baseline and follow-up. age. Analyses at follow-up were restricted to the 1402 participants who worked and lived in the same place as they did at baseline. The influence of a symptom reporting tendency (appendix III and thesis) Table 7 shows the symptom check list used to record a symptom reporting tendency. At follow-up the incidence of mucous membrane symptoms and general symptoms was 15% and 9%. The majority of participants remained at the same level of indoor environment complaints (63% to 94%).6). In the analyses of the reverse association. Adjusting the results for several potential confounders mainly led to higher estimates of OR. An association was regarded as significant if the top level of the index had a 95% CI not including 1. persons who reported to have high job demands and low support at work also tended to report work-related general symptoms (significant adjusted OR ranging between 1. Whereas mucous membrane symptoms in the cross-sectional analysis were significantly associated with self-reported high temperature and dry air. As regards the psychosocial work characteristics. In the indoor environment at baseline the most common reported exposure was noise (46%) followed by reports about cramped space or dust (38%) and perception of dry air (30%).6). We found no consistent risk factor pattern in the cross-sectional and the longitudinal analyses for the associations between perceived indoor environment factors at work and symptoms.7 and 20.05 in the linear tests for trend.

previous studies on the SBS are cross-sectional. model without symptom reporting tendency).3 and 7. temperature conditions. dry air and noise were associated with incident mucous membrane symptoms. temperature conditions. When the analyses were repeated without symptom reporting tendency as a covariate in the models. Perceived indoor environment. we found that persons with symptoms at baseline were more likely to report exposures in the indoor environment than persons without symptoms were. the patterns of association for the dummy symptoms resembled those of the mucous membrane symptoms and general symptoms. The only findings from previous studies that could be reproduced in the present study were that mucous membrane symptoms were associated with the perception of dry air and noise.symptoms that cannot plausibly be linked to the indoor environment. and that general symptoms were associated with perceived stuffy air. Symptom reporting tendency was associated with the prevalence of mucous membrane symptoms as well as general symptoms with odds ratios of approximately 2. symptom reporting tendency was similarly associated with the incidence and persistence of mucous membrane symptoms. In the longitudinal analysis only few of the perceived indoor environment factors predicted the development of any of the symptom groups. There is. the estimates of the effects of the indoor environment factors changed only slightly (table 9 and table 10). SBS symptoms and dummy symptoms (appendix IV and thesis) In the cross-sectional analysis. Persons with mucous membrane symptoms at baseline began to report exposures to temperature conditions. General symptoms were associated with stuffy air and light (table 10. In these cross-sectional studies several self-reported exposures. Some of the perceived indoor environment factors predicted not only mucous membrane or general symptoms. table 10 and appendix IV).2. Comparison with other findings Except for a few intervention studies and one longitudinal epidemiological study. but not a confounder in this study. Dummy symptoms were associated with stuffy air index. incidence and persistence of mucous membrane or general symptoms. noise. stuffy air. However. noise. and light conditions while persons with dummy symptoms reported draught. however. but no objective measurements have consistently been associated with mucous membrane symptoms and general symptoms. Mucous membrane symptoms were associated with dry air. Elevated odds ratios were also found regarding the incidence and persistence of general symptoms. temperature and stuffy air (table 9. In the reverse longitudinal analysis. Discussion In my study there was no risk factor in the perceived indoor environment that was consistently and plausibly associated with the prevalence. and draught was associated with incident general symptoms (table 9. no obvious biological pathway between noise and mucous membrane symptoms. The participants were asked a question about the number of people working 22 . SBS symptoms and dummy symptoms also predicted that the participants began to report exposures in the indoor environment at followup. and stuffy air. the perceived indoor environment was associated with symptoms that are traditionally included in the SBS as well as with dummy symptoms. noise index and patches of dampness (appendix IV). Draught. Both the SBS symptoms and the dummy symptoms predicted several new reported exposures in the indoor environment (appendix IV). selfreported lack of office cleanliness and selfreported number of people working in the office were associated with SBS symptoms [26]. but also symptoms without a biologically plausible explanation in the indoor environment (dummy symptoms). model without symptom reporting tendency). dust. dry air index. and light conditions. Persons with general symptoms began to report exposures to draught. but the associations were of borderline significance (table 8). Perceived exposure to dust or dirt was not a risk factor in my study. In a recent longitudinal epidemiological study mould in seat dust. A general tendency to report symptoms was an independent risk factor of mucous membrane symptoms and general symptoms. In addition. Even a small increase in focus on the workplace influenced the responses as to whether a symptom was reported as workrelated or not. Although many were not statistically significant. respectively (table 8). stuffy air. Incident dummy symptoms were associated with dry air.

but I excluded participants who had changed job in order to keep exposure conditions as constant as possible. but also with backache and recurrent stomach ache [87]. In that study. suggested that health and work characteristics may act reciprocally. Hence cross-sectional studies could be suitable to assess acute reactions to the indoor environment. misclassification of the exposure may have occurred. I have no information about changes in the indoor environment during the one-year followup period. Hence I did not include this variable in the models. which may affect the observed associations [26]. on the assumption that the exposure was relatively stable during the oneyear follow-up period. I chose a longitudinal design because of the possibility to assess whether the reported exposures preceded the symptom. Thus altogether. found that pain in the back. However. 118]. These biologically unlikely results seem to be in good agreement with the results of my study. found that self-reported dampness or mould problems in homes were associated not only with many different SBS symptoms. it was of course neither practically nor financially possible to make objective measurements in 23 . Wallace et al. A limitation in the study is that I have only self-reports on the exposure. However. However. This is in good accordance with my results. repeated measurements may influence the reporting of symptoms. For example. found an increased frequency of backache and constipation among adults living in houses with visible damp or mould [88]. a decrease in symptom prevalence will be observed during the follow-up period. Platt et al. Strenghts and limitations of the study The strengths of the present study are the large population and the prospective design. They found that the prevalence of work-related SBS symptoms was three times higher among workers aware of the study relative to those blinded. cross-sectional studies may support a causal relationship. 32. if the studied symptoms or disease develop shortly after the exposure. However. A few other studies on SBS symptoms have focused on the association between exposures in the indoor environment and other symptoms. in occupational stress research the reverse causation hypothesis has been used examining the impact of mental health on future reporting of work characteristics [31. One other study on SBS has also taken account of "awareness" by informing only some of the participants that a study about the indoor environment was going on [73]. A limitation is the interval of one year between baseline and follow-up. studies that have examined the same type of problems seem to support my results. More follow-up rounds with a closer interval than a year would have made it possible to assess more precisely how the symptoms emerged and disappeared in relation to exposure. Longitudinal studies are more informative in etiological analyses. however. It is difficult to assess. This the office or workroom. if it was possible to measure the outcome objectively and thus reduce reporting bias. environmental measurements and questionnaire survey were done every six weeks during a year and included 98 participants. was not statistically significant in univariate analyses. and the study by van Hoof et al. hands or shoulder/neck was associated with glare. Pirhonen et al. which would reduce the associations towards the null hypothesis of no association. SBS symptoms are believed to be acute reactions to factors in the indoor environment rather than chronic symptoms. This choice was made to control for seasonal variations. which cannot plausibly be related to the indoor environment. Thus. My power calculations before the study indicated that approximately 1160 participants were needed in a study with one follow-up round. noise and odour of cosmetics [120]. In addition. Another study examined an outbreak of SBS in a school with mould growth and also found that the perception of symptoms increased after the problem was publicised [46]. fluctuations in the exposure are likely to occur. similar to the findings in my study. There exists no other study on the SBS that has examined the reverse association assessing how the presence of symptoms influences future reporting of exposure. if a design with more repeated measurements would have been more costeffective. The prospective design made it possible to evaluate a temporal relationship measuring the exposure before the outcome. 41. This approach has been used in the only other longitudinal epidemiological study [26]. if the participants are more enthusiastic in the beginning of a study. however. but the validity of this question was doubtful. De Lange et al found that health affected perceived work characteristics both positively and negatively.

However. this will reduce but not eliminate reporting bias. showing that persons with symptoms were likely to begin to report 24 . A possible explanation for the reverse association. The participants who were lost to follow-up did not differ from the cohort in baseline characteristics on perceived indoor environment and symptoms. Assuming that the participants are unable to remember what they answered a year before. The possibility of selection bias must be considered. a risk of reporting bias exists resulting in bias towards more significant positive associations with symptoms. This choice was made because the baseline study had shown that information about work-relatedness may be seriously biased. Nevertheless. one would expect these variables to be stronger associated with SBS symptoms than with other symptoms for which there is no plausible explanation. the symptoms may disappear and reappear during the follow-up period. and that the exposure still persists at follow-up. However. as SBS symptoms are supposed to be acute recurrent symptoms. Pirhonen et al. 114. Furthermore. The prevalence of perceived exposures in the present study population corresponded to the prevalences I have found in 41 non-problem buildings [22]. 92. Although self-reports seem to reflect objectively measurable factors in the indoor environment to some degree [1. a large variation in perceived indoor environment factors was found in the present study. found an increased prevalence of backache and stomach ache in damp buildings [87]. this might lead to underestimation of possible effects. a consistent risk factor pattern would have supported a causal relationship. I had expected that the same factor in the indoor environment would induce symptoms as well as maintain symptoms. the strength of the associations between the indoor environment and SBS symptoms were significantly reduced. This indicates that some associations between SBS symptoms and perceived indoor environment factors could be due to over-reporting. when they analysed data on a sample consisting solely of persons not complaining of backache or stomach ache. if there is no selection bias. 117]. assuming that persons who are sensitive to develop SBS symptoms still exists in the population. The association between mucous membrane symptoms and noise. Nevertheless. because the work-related symptoms are diluted with symptoms that are not temporarily related to the workplace. 23. a number of associations between the reported indoor exposures and SBS symptoms were also biologically implausible. The prevalence could be explained by problems in distinguishing the sensation of dry air with irritation of the eye.more than two thousand workplaces and homes. In the present study. In my study symptom reporting tendency was strongly related with both mucous membrane symptoms and general symptoms in the cross-sectional analysis. in the analyses of follow-up data the exposure and outcome is measured on different points in time. However. was not easily understood. incidence and persistence of SBS symptoms. which may reduce the estimates of incidence and persistence. for example. the most consistent finding was that dry air was associated with the prevalence and incidence of mucous membrane symptoms. it may be assumed that also the participants from the general population are exposed to a wide variation in physical or chemical factors in the indoor environment. As the cohort is a random sample of the general population it is possible that the contrasts in exposure are insufficient to detect true associations. If there is a true biological relation between indoor environmental factors and SBS symptoms. The distribution of reported exposures in these 41 non-problem buildings showed a large or complete overlap with the similar distribution in the 8 problem buildings in my validation study [unpublished data]. Thus. 82. Possible explanations for the findings In the longitudinal analyses I chose to use the symptoms as an outcome without considering whether the participants reported them as more pronounced at work or not. the lack of specificity of associations found in my study may speak against a true causal relation. yielding a consistent risk factor pattern in the prevalence. but may also be due to over-reporting. This may reflect persons with disorders in several organs. because only few presumably work in buildings with severe indoor climate problems. In fact. 90. but not the incidence. that persons do not become immune to SBS symptoms once they have got it. Thus. Thus I consider the drop out to be less important. A response rate of 68% at baseline and 80% at follow-up can be considered satisfactory for a population study.

exposures in the indoor environment. however. 25 . the SBS are symptoms occurring in a sick building. the indoor environment and health. The result is an increased awareness on external factors. Studies examining problem buildings may. 116]. for example. Based on my experience from interviewing employees in problem buildings. This easily leads to arguing in a circle: a "sick" building may be defined as a building where many occupants have similar symptoms and. which has been the design of some other studies [11. because attention has already been drawn to the problems. difficult to explain why persons with symptoms such as stomach ache or heart palpitation should begin to complain more about draught or temperature conditions. Thus it does not seem likely that individual susceptibility solely explains the reverse associations. In addition. In particular the risk of bias exists when the exposure and outcome are measured simultaneously. if such a mechanism is the explanation of “reversed causation”. An alternative explanation is that people who have many health complaints look for potential causes for example stress at work or problems in the indoor environment. including personal and contextual factors in the models as mediators or effect modifiers in order to explain the causal pathway from environmental exposure to outcome. and a survey will only further increase the focus on the problems. which may produce a spurious association between e. It is. I presumed that selfreports could be biased in cases initiated by concern about health effects among the occupants of a building. Repeating the analyses with eye irritation and nose/throat irritation separately did not alter the associations [data not shown]. so no group behaviour ought to be present. even if a non-problem building is included as a control.g. conversely. and especially if information on exposures as well as outcomes relies exclusively on the participants' subjective evaluation. In the term "sick building syndrome" the cause of the syndrome is incorporated in the definition of the syndrome. I chose to study SBS symptoms in a random sample of the general population instead of studying occupants of a “sick building”. but it is not conceivable that persons with irritation in the nose or throat should complain about the light. a study conducted in a problem building may not be suitable for detecting causal effects of indoor environment factors. It seems reasonable that persons with irritated eyes could be more bothered by glare and reflections. In my study the participants completed the questionnaire at home out of context with the workplace. Thus. is that symptomatic persons may be more susceptible in that specific organ to irritants or other problems in the indoor environment [67]. Other researchers have proposed that the sick building syndrome could be due to or modified by stressrelated factors at work or a group behaviour as a "contagious" condition [105. and that SBS symptoms can be investigated only in a sick building? My results suggest that bias with respect to work-relatedness of symptoms is likely to occur when surveys are conducted in buildings with suspected indoor environment problems. 53]. Subsequently my study has shown that even little awareness may introduce bias in self-reported health. cases initiated because of concern about health effects among the occupants of a building may also be useful for qualitative studies. However several of the findings in my study are not easily understood. be useful to generate important hypotheses and provide information from extreme exposure situations that are rarely encountered in systematic studies. Does this mean that an excess of symptoms in a building is required to call it SBS.

The results suggest that many people experience mucous membrane symptoms and general symptoms regularly. it suggests that the SBS symptoms do not constitute a well-defined syndrome. many symptoms may be misclassified as "building related symptoms" and the term should be avoided. However. 26 . According to my study symptoms such as stomach ache.OVERALL CONCLUSIONS AND IMPLICATIONS In my study three important criteria of causal associations between the indoor environment and symptoms could not be met: temporality. This suggests that these symptoms just as well as mucous membrane symptoms and general symptoms could have been included in the SBS. As the reporting of workrelatedness is severely biased. heart palpitations and muscle tension were also associated with perceived factors in the indoor environment. and consistency. if the occupants of a building were of the conception that these symptoms were related to the indoor climate. The validation study showed that the symptoms included in the SBS represent different dimensions and thus should not be grouped to form an SBS index or an SBS-diagnosis. The reverse associations found in my study indicate bias towards a tendency to over-report. This does not exclude that there may be associations between specific indoor environment factors and health. biological plausibility.

The main aims of the present study were to examine the temporal relationship between reported exposures and SBS symptoms and to examine whether awareness of the indoor environment and a tendency to overrate may affect the association between the perceived indoor environment and SBS symptoms. headache and difficulty in concentrating). Testing for unidimensionality showed that mucous membrane symptoms. In two sentences of the letter the word "work" was replaced with "home". throat irritation and hoarseness) and general symptoms (an index consisting of fatigue. However. a skin index and a pulmonary index. general symptoms or dummy symptoms were more likely to begin to report exposures in the indoor environment than persons without symptoms. However. thus indicating reporting bias. If the symptoms are attributed to the indoor environment. However. 27 . Some statistically significant associations were found between reported exposures in the indoor environment and the prevalence of mucous membrane symptoms and general symptom. I found that persons who had been focused on the workplace were more likely to report their symptoms as more pronounced at work. of whom 1402 were also eligible for inclusion at the one-year follow-up. nasal congestion. item bias was found related to sex. incidence and persistence of these symptoms. fatigue and headache. It was cross-validated in the baseline sample from the prospective study. The study was designed as a follow-up study with two questionnaire surveys conducted with an interval of one year in a random sample of the general population aged 18-59 years. At baseline a slight difference in the introduction letter was made so that some participants received a letter with a bit more attention on the indoor environment at work. It showed a high degree of reliability of the questionnaire. and no consistent pattern was found between the associations found as regards the prevalence. In addition. The study population consisted of 2164 participants at baseline. Finally. The findings suggest a bias towards a tendency to over-report. skin symptoms. a tendency to report many symptoms in general was related with mucous membrane symptoms and general symptoms at baseline. incidence and persistence of mucous membrane symptoms (an index consisting of eye irritation. it has been suggested that awareness of a potential environmental hazard and a personal tendency to overrate exposures or symptoms can influence how people report SBS symptoms and thus affect the association between the perceived indoor environment and SBS symptoms. The findings suggested that reports on work-relatedness may be severely biased. persons who received the other letter with focus on the home were more likely to report their symptoms as more pronounced at home. nose irritation. During the last 20 years several cross-sectional studies have examined relationships between indoor environment factors and symptoms such as irritation of the mucous membranes. Another aim was to validate the questionnaire used for the study. Hence these indices were not used in the subsequent analyses of the follow-up study. this constellation of symptoms has been described as the sick building syndrome (SBS). In addition.ENGLISH SUMMARY This PhD thesis was done during my employment at the Department of Occupational Medicine at the Copenhagen University Hospital in Glostrup. I found that persons having mucous membrane symptoms. Several of the indoor environment factors were associated also with the dummy symptoms. and other participants received at letter that focused slightly more on the indoor environment at home. The outcomes of interest were the prevalence. Furthermore I investigated the reverse order relationship: that symptoms may predict future reports of exposures in the indoor environment. irritation of the skin. the cause(s) of the SBS symptoms are unknown and little is known about the temporal relationship between exposures in the indoor environment and the development of symptoms. I also examined the association between reported exposures in the indoor environment and a group of other symptoms that were biologically implausible to associate with the indoor environment (dummy symptoms). not all associations were biologically plausible. age and atopy as regards the construction of two symptom indices. The validation study took place prior to the follow-up study in 8 workplaces with suspected indoor environment problems (N=947).

it suggests that there is a risk of reporting bias when assessing non-specific symptoms and that the SBS symptoms do not constitute a welldefined syndrome. 28 . where it is difficult to determine what existed first: the outcome or the exposure. the reported indoor environment exposures were associated with symptoms that cannot plausibly be explained by the indoor environment. the results indicates a rather confusing web of pathways between the symptoms and perceived exposures. In addition.pulmonary symptoms and general symptoms belong to different dimensions and thus should not be combined in a common index. In conclusion. The findings do not exclude that there may be associations between specific indoor environment factors and health. However.

der vedrører om et symptom er værst på arbejdspladsen. træthed og hovedpine.DANSK RESUMÉ Ph. at man havde mange andre symptomer. at forhold som opmærksomhed omkring årsager til indeklimaproblemer og en tendens til at overrapportere kan påvirke angivelsen af. hudsymptomer og nedre luftvejssymptomer viste sig at være forbundet med item-bias i forhold til køn. irritation i svælget og hæshed) samt almensymptomer (et index bestående af hovedpine. Desuden er der noget. der også besvarede det andet spørgeskema og som kunne indgå i opfølgningsundersøgelsen.d. som havde fået brevet med mere vægt på arbejdspladsen. Desuden var de personer. der tyder på. Der blev fundet en høj grad af reproducerbarhed. næseirritation. som blev præsenteret for formålet med undersøgelsen på en lidt forskellig måde. afhandlingen er udarbejdet under min ansættelse på Arbejdsmedicinsk Klinik. der var associeret med forekomsten af indeklimasymptomer eller udvikling eller vedligeholdelse af symptomer. idet personer som havde symptomer ved undersøgelsens begyndelse. luftvejs-indexet og almensymptom-indexet tilhørte forskellige 29 . I alt 2164 personer deltog ved første spørgeskemaundersøgelse. mere tilbøjelige til at angive at symptomerne var værst i hjemmet. der havde fået det andet brev. To indexer omfattende hhv. hud-indexet. at personer. Amtssygehuset i Glostrup. Formålet med nærværende undersøgelse har været at undersøge den tidsmæssige sammenhæng mellem en persons oplevelse af indeklimaet og de uspecifikke symptomer. Disse resultater tyder på. Der fandtes endvidere også flere statistisk signifikante sammenhænge mellem disse uplausible symptomer og rapporterede påvirkninger i indeklimaet. at symptomerne skyldes indeklimaet. og man kender kun lidt den tidsmæssige sammenhæng mellem udsættelse for kemiske eller fysiske forhold i indeklimaet og udviklingen af symptomer. alder og atopi. I den første spørgeskemaundersøgelse blev der fundet flere statistisk signifikante sammenhænge mellem selv-rapporterede faktorer i indeklimaet og slimhindesymptomer samt almensymptomer. idet de stadig var ansat på samme arbejdsplads og boede samme sted. begyndte at opleve problemer i indeklimaet i løbet af den 1-årige opfølgningsperiode. der blev skiftet ud med "i hjemmet" i to sætninger i brevet. når de var på arbejde. var mere tilbøjelige til at angive. stoppet/løbende næse. kalder man ofte denne sammensætning af symptomer for "indeklimasyndrom". Der syntes at være en vekselvirkning mellem klager over indeklimaet og symptomer. I ledsagebrevet til den ene gruppe blev der lagt lidt mere vægt på indeklimaet på arbejdspladsen end i hjemmet. Af disse var der 1402 personer. Et andet formål var at validere det spørgeskema. Derfor blev disse to indexer ikke anvendt i analyserne af opfølgningsundersøgelsen. De helbredsmål. træthed og koncentrationsbesvær). at slimhindeindexet. Årsagen eller årsagerne til indeklimasyndrom er imidlertid ukendt. om man har disse symptomer. var slimhindesymptomer (et index bestående af øjenirritation. Spørgeskemaerne er udfyldt to gange med et års mellemrum. Undersøgelsen er en opfølgningsundersøgelse baseret på spørgeskemaer fra en tilfældig stikprøve af danske statsborgere i alderen 18-59 år. I de seneste 20 år har adskillige tværsnitsstudier undersøgt mulige sammenhænge mellem forhold i indeklimaet og symptomer som irritation af slimhinder og hud. I den anden gruppe var det omvendt. Det drejede sig om at ordene "på arbejde". Det viste sig. der havde interesse for undersøgelsen. Ved den første spørgeskemaundersøgelse blev populationen delt op i to grupper. men som på dette tidspunkt ikke klagede over indeklimaet. Den vigtigste risikofaktor for at udvikle nye indeklimasymptomer var. som er blevet beskrevet ved indeklimasyndromet. som er blevet anvendt i undersøgelsen. samt at undersøge hvorvidt opmærksomhed omkring indeklimaet og en overrapporteringstendens er associeret med symptomerne. Undersøgelsen af validiteten blev udført på 8 arbejdspladser. at der kan være store fejlkilder forbundet med de svar man får på spørgsmål. at deres symptomer var værst. hvor man mistænkte at der var indeklimaproblemer (N=947) samt i studiepopulationen fra den første spørgeskemaundersøgelse. som ikke er biologisk plausible at relatere til indeklimaet. Hvis man mener. Analyser af dimensionalitet viste. Der var imidlertid ikke noget konsistent mønster mellem disse fund og de longitudinelle analyser med hensyn til hvilke faktorer i indeklimaet. Dette kunne tyde på rapporterings bias.

Desuden. 30 .dimensioner og derfor ikke bør samles i et fælles index. men viser at der kan være bias forbundet med om man angiver disse symptomer og at symptomerne i indeklimasyndromet ikke udgør et veldefineret syndrom. var de rapporterede indeklimapåvirkninger associeret med symptomer som ikke er biologisk plausible at kæde sammen med indeklimaet. Disse fund udelukker ikke. hvor det er vanskeligt at adskille hvad der kom først: eksponering eller symptomer. at specifikke forhold i indeklimaet kan påvirke helbredet. Sammenfattende viste resultaterne et komplekst netværk af sammenhænge mellem symptomer og oplevede påvirkninger i indeklimaet.

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However.0 d. have 0% and 100%. 1 Hospital ward Social and health care college School No. by definition.f. If there was no item bias the percentage of positive answers to the item "breathlessness" at the index scores 1 and 2 would be the same for non-atopics and atopics. only an approximate number 430 94 63 44 (18-65) 62 >85* 68 46 (24-63) 52 204 64 95 93 100 67 96 59 45 (25-63) 42 (18-66) 39 (22-65) Suspected indoor environment problem Mould growth in the roof construction Dust after renovation of the building Mould growth in the outside walls N 69 40 26 Participation rate (%) 97 91 >85* Women (%) 68 100 100 Age mean (range) 49 (26-63) 42 (24-68) 45 (26-63) Table 2. Breathlessness n* Index score 0 Non-atopic Atopic Index score 1 Non-atopic Atopic Index score 2 Non-atopic Atopic Index score 3 Non-atopic Atopic No (%) Yes (%) 483 250 72 52 7 18 5 11 100 100 94 81 57 44 0 0 0 0 6 19 43 56 100 100 2 χ =6. because respondents with any item unanswered in the index are excluded. . 3 Town hall Dust and mineral fibres from ceilings Water damage Dust after renovation of the building and ventilation problems Water damage and ventilation problems Dust after renovation of the building and ventilation problems * The exact number of employees was not reported. At a score=0 and a score=3. both non-atopics and atopics.58 p=0. Characteristics of the participants in the validation study. here atopics are more likely to have a positive answer to the item "breathlessness" (shown in the hatched fields). 2 Nursing home Technical University School No.=2 p=0. Illustration of item bias with respect to atopy of the item “breathlessness” in the pulmonary symptom index. N=947.032 (two-sided) *N=898.044 gamma=0. respectively.Table 1. Type of workplace School No.

45 0.67 0.98) Internal consistency.65 .94)* (0.0.88 .0.0.61 0.0.57 0.86) (0.0.71 0.58 0.64 0.70 .60 0. N=2164 0. All other kappa values are the weighted kappa.77 0.45 .69 0. Cronbach coefficient alpha Validation sample. N=947 0.93 (95% CI) (0.79) (0.53 0.51 .63 0.81) (0.64 0.65 0.57 80 77 73 85 88 76 87 77 0.58 0.63 .63 0.49 .0.55 .72 0.68 0. N=110 Full agreement (%) Symptom indices Mucous membrane index Pulmonary index Skin index General symptom index Indoor environment indices Draught index Temperature index Stuffy air index Environmental tobacco smoke Dry air index Noise index Light index Space/dust index 76 89 84 94 kappa 0.46 . Test-retest reliability and internal consistency of symptom indices and indoor environment indices Test-retest reliability.66 Baseline study sample.56 .0.58 0.78) (0.44 0. .78 0.61 0.49 0.0.73) (0.74) (0.41 * Simple kappa.58 0.86) 0.41 0.83) (0.89) (0.74 (0.50 0.79 0.84) (0.0.0.Table 3.0.59 0.64 0.0.62 .43 .

68 0.8) (29.4) (9.1) (38. years 18-29 30-39 40-49 50-59 Employment self-employed non-manuals skilled manual worker unskilled manual worker Smoking.Table 4.4) (12.9) (28. living as married Age.5) (26. headache. nose irritation. and hoarseness.10 0.1) (34.8) (8.7) (11.7) (12.3) (25. and concentration difficulty ‡ At least four symptoms among 15 "non-SBS" symptoms § A score of one or more on the index ¶ T-test .8 50.5) (39.13 0.6) P-value 0.6) (20.2) (26.8) (23.1) (80.7) (38.22 0.45 0. nasal congestion.8 50.05 0. throat irritation.5) 207 283 107 113 105 99 46 232 55 71 156 164 122 104 49 107 108 92 113 104 193 54 147 26 156 77 141 61 44 53 87 52 52 102 0.3) (14.77 0.001 0.1) (37.18 0.2) (44.03 0.8) (27.1) (17.9) (27.1) (31.4) (57.5) (13.3) (19.9) (22.16 0.8) (73.2 0.4) (35. daily Atopy Symptoms More than one mucous membrane symptom* More than one general symptom Symptom reporting tendency § ‡ † Respondents.83 0.07 0.9) (12.3) (24.4) (11.3 51.8) (19. Baseline characteristics according to status at one-year follow-up.5) (27.4) (38.7) (23.94 0. N=1740 n 907 1307 290 484 508 458 129 1107 224 231 539 658 485 396 150 464 467 387 421 527 757 293 650 108 668 245 601 311 244 158 307 167 204 338 (%) (52.6) (37.17 0.6) (37.06 0.7) (24. P-values computed with the Chi Square test unless otherwise noted.1) (6.7) (27. co-workers and supervisors Effort-reward imbalance Poor social climate Personality traits Negative affectivity Type A behaviour Self-efficacy Worry about health Poor family support SF12 Physical Health Summary Scale (mean) Mental Health Summary Scale (mean) 50. † General symptoms: fatigue.005 0.7) (27.76 0.3) (7.91 0.0) (25.4) (13.72 0.60 0.7) (9.7) (16.5) (11. N=424 n Women Marital status.8) (24.6) (17.2) (48.02 Perceived indoor environment Draught index Temperature index Stuffy air index Environmental tobacco smoke Dry air index Noise index Light index Space/dust indext Patches of damp/mildew Psychosocial work characteristics High job demands Low job control Poor support.6) (65.6) (13.6) (26.02 0. Non-respondents.1) (10.7) (31.2) (28.001 (%) (48.4) (18.72 0.3) (23.07 0.02 0.2) (26.8) (15.86 0.5) (6.3) (13.87 ¶ * Mucous membrane symptoms: eye irritation.9) (17.02 ¶ 0.4) (14.

seldom. quite a bit. very much nervous. to some degree. quite good. quite a bit. very much Worry about health Social support Do you as a person tend to be worried about Not at all.Table 5. very little demanding Very much. very little. quite a bit. is it possible to obtain the Always. sometimes. to a minor degree. somewhat. very poor Effort-reward imbalance Social climate at work Negative affectivity Type A behaviour Self-efficacy How is the atmosphere and psychological climate at your workplace? Do you as a person tend to be worried. not so much. a little. not very demanding. and somewhat impatient Are you a person who is usually able to solve difficult problems. very little. rather much. very little Job control Job strain* Support at work How much influence do you have in planning and carrying out your work? If you have problems. to a very low degree Very good. somewhat. ambitious. rather much. not so good. rather poor. very little. moderate. somewhat. Characteristic measured Job demands Questions How demanding do you find your work altogether? Answers Extremely demanding. rather little. rather much. very little. rather demanding. * Job strain defined as the combination of high job demands and low job control . somewhat demanding. often. sometimes. never necessary support from family or friends? Bold indicates response alternatives with a hypothesized high risk of non-specific symptoms compared to non-bold response alternatives. rather much. rather good. Not at all. a little. never necessary support from colleagues or superiors? Do you think that your job performance is sufficiently appreciated? To a very high degree. Not at all. quite a bit. very demanding. rather much. is it possible to obtain the Always. a little. Questions about psychosocial work characteristics and personality traits. a little. manage unexpected situations and reach your goals? Not at all. very much jealous. to a high degree. often. very much your health? If you have problems. seldom. to a low degree. or somewhat pessimistic? Do you as a person tend to be competitive. somewhat.

7) Unchanged A change=1 114 121 107 99 111 176 85 155 32 (8.8 8.3) (80.3 0.7 Shortness of breath 4. Results from baseline questionnaire.3 Difficulty in thinking clearly 4.0) (93.8) 945 955 1010 1063 990 828 1086 943 1225 (71.7) (3.0 20.7 9.9 24.4 0.2 4.9 1.1 1.8 11.0) (2.0) (76. sometimes.6) (82.2) (2.6 7.2 0.4 12.1 1.1 1.3) (1. seldom.8) (5.4) (11.5 0. Changes in perceived indoor environment between baseline and follow-up.3 Powerlessness or helplessness 4.1 Nervousness 4.5 3.4 1.2 5.1 27.7 9.9 2.9 16.3 Restlessness 4.6 0.1) Table 7. Symptoms marked in bold are omitted from the total score of "symptom reporting tendency".6 Stomach ache or problem with the stomach 4.1 1.1) (11.8) (4.1 21.1) A change=1 159 160 137 155 187 154 101 176 50 (12.7 4. Number and (%).8 Concentration problems 4.4) (13. because they are often included in the SBS. never.6 0.8 Heart palpitations 4.1 19.1 Difficulty in making decisions 4.1) (2.0 20.1) (7.1) (72.1 1.Table 6.0 20.7) (2.0) (12. * The score ranges from 1 to 5.4 Unable to relax 3.8 8.0) (71.8) (14.0 20.8 1.8 Tendency to cry 4.6) (13.9 7. Prevalence very often/often sometimes (%) (%) 6.5) (8.8 4.1 22.6) (62.0 Vertigo 4.8 Sweating 4.9) (1.3 31.3) (3.8 2.5 Muscle tension 3.9 5.0 21.1 1. where 1=very often and 5=never.4) (11. The response options were: very often.9 14.6 0.6 Sleeping problems 4. N=2164.6 Chest pain 4. Symptom Mean score* SD .8 Forgetfulness 3.1 Fatigue and weakness 3.6) (7.0 1.1) (7.0 10.8 10. often.1) (10. The symptom check list used to record “symptom reporting tendency”.2 0.7 1.3) (3.2 Sadness or depression 4.1 1.7) (3.9 18.7) (74.1 28.1 4.4 Symptoms experienced during the past four weeks.6) (3. Better A change>1 Draught Temperature Stuffy air Environmental tobacco smoke Dry air Noise Light Space/dust Patches of damp/mildew 63 49 41 28 95 27 37 (2.1 11.5) 11 70 25 17 Worse A change>1 48 41 28 (0.3) (6.1) (8.9 12.6) (9.

6 to 3.2 (0.3 (5.0 to 10.2) 2.2 to 4.6) 7.9 to 3.4 (0.* Max.2 (5.3 (1.7) 1.2) 2. incidence and persistence of mucous membrane symptoms and general symptoms. Associations between "symptom reporting tendency" and the prevalence.2) *Minimum and maximum odds ratios from the models with each of the nine indoor environment indices.9 to 5.2) 2.6 to 3.4 (0.3) 2.7 (0. 2.9 to 5.3) 2.Table 8.7 (1. Odds ratios and 95% confidence interval.4 to 5.8) 7. .8) 2.7 to 2.3 to 4.2 (1.5 (1.0 to 10.8) 2.7) 1.3 (1.3 to 4. Mucous membrane symptoms (N=607) Prevalence Symptom tendency reporting Incidence Persistence General symptoms (N=500) Prevalence Incidence Persistence Min.4 (1.

age.76 0.8 to 1.8 to 3.18 1 0.5) (1.6 to 3.7) (0.35 1.3) (0. N=607 Model with symptom reporting tendency OR* (95% CI) 1 1.2) Persistence.95 1 1.05 1 1.5 to 1.9) (2. N=183 Model with symptom reporting tendency OR* (95% CI) 1 0. Models with and without "symptom reporting tendency".65 1.7) (0.9 to 1.5 to 3.97 2.9) (0.8) (1.5) (1.21 1.0 to 1.16 1.37 1 1.7 to 2.7) (0.95 (0.9) (1.48 (0.9) (0.66 1.7 to 4.95 0.99 1 1.8) (1.51 1.13 1.18 1.2 to 2.71 1.8 to 1.37 1.22 1 1.8) Model without symptom reporting tendency OR* (95% CI) 1 1.9) (0.9) (0.05 1 1.6) (1.9 to 2.3) (0.8 to 3.05 1.7 to 1.9 to 3.5 to 1.5 to 1.0) (0.9) (1.9 to 1.5) (0.98 1 1.9 to 3.8) (0.82 1 1.7 to 1. Adjusted odds ratios (OR) and 95% confidence interval (95%CI).1 to 1.18 1.27 1 1.6 to 2. atopy.19 1.9 to 1.0 to 1.57 1 1.9) (0.Table 9.7 to 1.0) (0.3) (0.7 to 2.0) (0.37 1 0.4) (1.8) (0.30 1 2.8) (0.14 1.7 to 1.51 1 1.7 to 2.4) (0.02 1 1.69 (0.3) (0.1) (0.9 to 1.9 to 2.9) (0.9 to 3.71 1 1.9) (0.83 0.9 to 2.5) (0.5 to 2.7) (1.5 to 5.26 1.6 to 1.4) (0.13 1 1.03 0.2 to 3.6 to 2.68 1 1.4) (0.2 to 5.72 1 1.5 to 2.7 to 1.6) (0.9 to 3.7 to 1.9 to 1.98 1 1.8) (0.6 to 3.43 1.4) (0. other personal factors and psychosocial factors according to the tables in appendix III.8) (1.8) (0.93 1.24 1 1.5) (0.1) Model without symptom reporting tendency OR* (95% CI) 1 1.8 to 1.5 to 1.9) (0.7 to 2.97 1 1.88 1 1.0) (0.7) (0.9) (0.18 1.8 to 1.3) (0.1 to 3.55 1 1.1) Risk factor Draught index Values 0 1 2 3 Temperature index 0 1 2 Stuffy air index 0 1 2 Environmental tobacco smoke Dry air index 0 1 0 1 2 Noise index 0 1 2 3 Light index 0 1 2 Space/dust index 0 1 2 Patches of damp/mildew 0 1 * OR: Odds ratios adjusted for sex.4) (0.17 1 1.0) (0.9 to 3.26 1 1.70 1.6 to 1.21 1.7) (0.9) (0.5) (1.7 to 2.7) (1.6 to 2.02 1.71 (0.3) (0.0) (0.06 1 2.3) (0.34 1 1.6) (0.9 to 1.28 1 1. N=152 Model with symptom reporting tendency OR* (95% CI) 1 1.1) (0.3 to 2.6) (0. Associations between mucous membrane symptoms and perceived indoor environment.0) (1.0 to 1.7) (0.4) (1.22 2.5) (1.28 1.8) (0.1) (1.14 2.1) (0.5) (0.9) (1.6 to 1.2) (0.5) (1.8 to 1.53 1 1.0) (0.76 1 1.9 to 2.9 to 1.13 1 1.85 1 1.4 to 2.9) (0.7 to 1.31 1 1.0) (0.51 1 1.16 1 0.85 1.30 1 0.8 to 1.5) (1.7 to 2.01 1 1.8) (2.6 to 1.5 to 5.3) (0.46 1 1.7 to 1.8 to 1.7 to 2.2) (0.42 1 1.8) Model without symptom reporting tendency OR* (95% CI) 1 1.20 3.9 to 2.19 1.4) (0.3) (0.23 1.7 to 1.1) (1.67 1 1.0 to 1.3 to 2.20 1.60 2.05 1 2.13 1.0 to 2.3) (0.2 to 5.6 to 2.0 to 4.9 to 1.6) (0.49 1.9 to 4.6 to 2.6) (0.22 0.23 3.26 1 0.4 to 1.12 2.76 (0.7) (1.23 1.9 to 2.3 to 1.8) (0.1 to 2.4) (0.8 to 2.9 to 1.87 0.6) (0.0) (0.3) (0. Mucous membrane symptoms Prevalence.0 to 3.7 to 1.7 to 2.16 1 1.99 (0.8) (0.2) (0.3) (0.0 to 2.5 to 2.6) (0.0) Incidence.4 to 2.03 1.2 to 4.1 to 2.2) (0.8 to 3.7 to 1.8 to 1.8 to 2.9) (0.7 to 1.22 1.95 1 1.34 1.6) (0.70 1.8) (0.5) (1.04 1 1.2 to 5.0) (0.27 1.3 to 3.22 1. .7 to 2.4 to 2.2) (0.3 to 4.35 1.2) (1.18 0.49 1.13 1 1.18 1.92 0.62 2.6 to 1.6 to 3.5 to 2.5) (0.30 1 1.7 to 1.

9) (0.3 to 1.55 1.7 to 1.7) (1.21 1.1) (0.21 1.9 to 1.11 1.0) Model without symptom reporting tendency OR* (95% CI) 1 1.7 to 3.0) (1.5) (0.15 0.6 to 3.4) (0.7) (0.00 1.7 to 1.1) (0.41 1 1.1) (1.7) Model without symptom reporting tendency OR* (95% CI) 1 1.96 0.8 to 2.91 2.8 to 2.93 1 1.4 to 2.5 to 2.5) (0.69 0.0 to 2.78 1 1.7 to 2.79 1 1.4 to 1.51 1 1.10 0.02 1 1.3 to 1.7 to 1.7) (0.75 1 0.4) (1.12 1. Models with and without symptom reporting tendency.07 1 1.7) (0.7 to 1.1) (0.68 1 1.5) (0.70 1.73 (0.0) (0.47 1.4) (0.6) (0.5 to 1.7 to 2.8 to 2.7) (0.87 0.4) (0.87 1.7) (0.3 to 1.8 to 1.69 1 1.8 to 3.1) (0.84 0.4 to 1.0 to 5.25 1.44 (0.49 1 0.47 1.6 to 3.86 1 0.80 1.4) (0.2) (0.7) (1.5) (0.1 to 3.07 1 1.6) (1.5) (1.6) (0.3) (0.2) (0.68 0. N=500 Model with symptom reporting tendency OR* (95% CI) 1 1.2) (0.6) (0.03 0.3 to 2.5 to 1.5) (0.2) (0.53 1.7) (0.5 to 3.17 0.9) (0.22 1 1.29 1 1.2 to 2.6) (1.09 (0.15 1.5 to 2.82 1.8 to 1.3) (0.52 1 1.8 to 1.65 1.8 to 3.9 to 3.78 1 1.9 to 4.6 to 2.7 to 3.5 to 1.5 to 1.2) (0.7) (0.3) (0.8 to 2.2 to 2.54 1 0.30 1 1.7) (0.8) (0.7) (0.4 to 1.16 1.6) (0.46 1 0.31 1.9) (0.9 to 2.48 1.8 to 1.6) (0.7) (1.01 0.76 1 1.2 to 4.09 1 1.1 to 3.7 to 2.2) (0.3 to 1.7) (0.6 to 1.4 to 3.5) (0.4 to 2.4) (0.2) (0.65 2.81 (0.5) (0.4 to 3.3 to 2.7) (0.4 to 1.5 to 2.2 to 1.66 0.4) (0.34 1.4) (0.8) (0. age.0) (0.0) (0.2) (0.8 to 1.3) (0.7) (0.27 1.9 to 2.3 to 1.4) (1. N=146 Model with symptom reporting tendency OR* (95% CI) 1 0.8) (0.6 to 3.4) (0.4 to 2.30 1.6) (0.9) (0.48 1 1.7 to 1.1) (0.2) Risk factor Draught index Values 0 1 2 3 Temperature index 0 1 2 Stuffy air index 0 1 2 Environmental tobacco smoke Dry air index 0 1 0 1 2 Noise index 0 1 2 3 Light index 0 1 2 Space/dust index 0 1 2 Patches of damp/mildew 0 1 * OR: Odds ratios adjusted for sex.5 to 1.38 1 1. N=103 Model with symptom reporting tendency OR* (95% CI) 1 1.9 to 2.11 1.3 to 1.1) (0.32 1 1.6) (0.53 1.55 1.75 1 0.25 1 1.2) (0.2 to 1.3) (0.9) Persistence.7 to 2.0 to 5.3) (0.5) (2.7) (1. atopy.7) (0.54 1 0.1) Model without symptom reporting tendency OR: (95% CI) 1 0.18 1.25 1 1.40 1 1.2) (0.7 to 2.9 to 1.22 0.68 1 0.6 to 2. other personal factors and psychosocial factors according to the tables in appendix III .8) (0.66 1 1.3 to 1.7 to 1.4 to 1.24 1.4) (0.4 to 1.2) (0.14 1 0.33 1 1.3 to 2.5 to 3.5 to 1.97 1.21 1 1.5 to 1.08 1 1.1) (0. Associations between general symptoms and perceived indoor environment.9) (0.00 1 1.29 1.5 to 2.02 1 1.9) (1.1) (0.1) (0.47 1 0.3) (0.9) (0.11 1.5 to 1.6) (0.9 to 1.81 1 0.13 1 0.8) (0.7 to 1.7 to 1.9 to 1.9) (0.5) (0.7 to 3.7 to 1.6 to 3. Adjusted odds ratios (OR) and 95% confidence interval (95% CI).0 to 1.0) (0.84 1.90 1 1.73 1 1.8 to 2.4 to 2.8 to 1.52 1.Table 10.72 1 0.7 to 3.7 to 3.94 0.27 1 1.90 3.0) (0.1) (0.88 1.5 to 2.2) Incidence.6 to 1.7 to 3.5 to 2.8 to 2.5) (0.05 1.8 to 1.1) (0.6) (0.93 0.4) (0.10 1.9 to 3.8 to 2.25 (0.0) (0.6 to 1.09 1 1.76 1.13 1 1. General symptoms Prevalence.48 (0.5 to 2.5) (0.60 2.41 1 1.0 to 1.9 to 1.4 to 1.