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EPIDEMIOLOGY UNIT, ASL 5 PIEDMONT REGION
RISK FACTORS FOR UPPER EXTREMITY MUSCOLOSKELETAL
SYMPTOMS IN CALL CENTER EMPLOYEES dErrico A 1,
Caputo P 2, Falcone U 3, Fubini L 3, Gilardi L
3, Mamo C 1, Migliardi A 1, Quarta D 1. 1
Epidemiologic Unit, ASL 5 - Piedmont Region, 2
University of Turin 3 Documentation Center for
Health Promotion of Piedmont Region
Background The call center sector has grown fast
in the last decades in industrialized and in some
less developed countries. In Italy a great
expansion of this sector also occurred, with an
increase from 1,500 workers employed in 1994 to
more than 200 thousands in 2005-2006. In general
terms, call centers are structures through which
organizations of any kind (institutions,
companies, banks, no-profit, etc.) manage
telephone contacts with their clients, in order
to provide information or assistance on the
products/services offered. Call centers have been
defined as modern industries producing services
using the information and communication
technologies (Bagnara e Marti, 2001), owing to
the nature and the organization of work
performed, which expose workers to a variety of
psychosocial, ergonomic and microclimatic
hazards. (Australian CC guidelines) Several
studies have reported increased risks for
different health outcomes among call centers
operators, such as insomnia, anxiety, depression,
visual fatigue and musculoskeletal disorders
(MSDs). In particular, prevalences of
musculoskeletal disorders of the back and upper
limb appear very high in some studies, even
greater than those observed in other occupational
groups also considered at risk (Sprigg, 2003
Norman, 2004 Rocha et al., 2005).

• Aims
• To assess the prevalence of upper extremity
  musculoskeletal disorders (UEMSD) in a
  cross-sectional sample of Italian workers
  employed in the call center industry, and
• to identify ergonomic, organizational and
  psychosocial factors at work associated with
  UEMSD.

Methods Workers from seven call centers
operating in the Turin area were invited to
participate in the survey. During 2005-2006, 775
people working in telecommunications (70),
telemarketing (16) and banking (14) completed a
standardized questionnaire on socio-demographics
and lifestyle, working conditions, symptoms and
diseases. The outcome was defined as the presence
of musculoskeletal symptoms in the upper limb at
any time during the last 28 days, for which a
physician was consulted and/or drugs were taken.
We explored the relationship between UEMSD and
socio-demographic variables, and the following
work-related features sector and job seniority,
weekly hours worked, shift work, workstation
design, lighting, noise, microclimatic
conditions, frequency and duration of breaks,
number of and time between calls, supervisor and
co-worker support, job insecurity, psychological
demand, job control and job strain. The relative
risks of UEMSD were estimated by prevalence rate
ratios obtained from Poisson regression models
with the Huber-White sandwich estimator of
variance (Barros and Hirakata, 2003).
Results Overall, 336 (45) workers reported
upper extremity symptoms for which they consulted
a physician and/or took drugs. Symptoms in the
neck were the most prevalent (39), followed by
shoulder (22), hand-wrist (10) and elbow (4)
169 (50) workers reported symptoms in more than
one region. Among workplace risk factors, the
presence of any upper extremity symptom was
significantly associated with lack of supervisor
recognition, lack of wrist support during
keyboarding, high job strain, continuously
elevated noise and workplace humidity, along with
previous injuries, chronic disease potentially
related to UEMSD and leisure sport activities.
Restricting the analysis to 200 workers with only
neck/shoulder symptoms did not substantially
change these results. As only 22 workers reported
symptoms in the elbow/hand-wrist and not in the
neck/shoulder, we examined all 89 workers with
elbow/hand-wrist symptoms, although 67 (75) had
reported both. Supervisor recognition, aspects of
workstation design and previous injuries were
risk factors common to both upper extremity
regions elbow/hand-wrist symptoms were also
associated with higher seniority in the call
center sector, short interval between calls,
frequent mouse use, job insecurity and low
educational level. These same risk factors were
found for workers who reported symptoms in both
regions.
Table 1 frequency distribution of the study
population by socio-demographic characteristics
Table 2 Relative risks of upper limb
musculoskeletal symptoms by economic sector
(adjusted for age class and sex)
Discussion The results of the present study
confirm the etiologic role of wood and leather
dusts on the genesis of SNC adenocarcinomas,
suggesting also welding fumes and paint mists as
probable causal agents. SNC with other
histologies seem to recognize a different pattern
of risk factors, probably including nickel
compounds and possibly welding fumes and oil
mists. The observed association with welding
fumes, classified by IARC as a certain carcinogen
(class 1), appears consistent with the excess
risks found by Hernberg et al. (1983) among
welders, and by Olsen (1988) in workers employed
in the production of metal containers, where
exposure to welding fumes is supposed to be
widely spread. Paint mists have been reported to
be associated with SNC by Olsen Jensen (1987),
who found a significant 6-folds increased risk in
subjects working in the production of paints and
enamels in Denmark, though based on few cases.
Concerning oils mists, a significant association
with SNC (OR2.8) has been found by a
case-control study conducted in Connecticut
(Roush et al., 1980), while a significant excess
mortality has been observed by the British
Occupational Mortality Surveillance System among
machine tool operators (Winter et al., 1995),
whose main exposure is represented by cutting
fluids.

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