【作者】 董红运；

【导师】 于素芳；

【作者基本信息】 山东大学 ， 公共卫生（专业学位）， 2013， 硕士

【摘要】 背景肌肉骨骼疾患(Musculoskeletal disorders, MSDs)是指影响肌肉、骨骼、神经、肌腱、韧带、关节、软骨和椎间盘的损伤和／或功能障碍。症状轻者会有不舒适或轻微疼痛等感觉,而症状严重者常常无法工作,需借助药物或特殊工具训练,且治疗效果不佳。MSDs在全世界的工作人群中很普遍并且是一个严重问题。鉴于此,美国国家职业安全与健康研究所(National Institute for Occupational Safety and Health, NIOSH)在2002年把MSDs列为重点研究的10个职业卫生问题之一,世界卫生组织把2000年至2010年确定为“骨与关节病十年”。农业作为劳动力密集型产业,尤其受到MSDs的影响。果农和菜农等某些劳动力密集型行业中MSDs患病率尤其突出。中国,作为农业大国,农民的MSDs却没有引起足够的重视。因此研究农民的MSDs及其影响因素具有重要意义。大棚蔬菜已经在山东寿光地区广泛种植,由于其良好的经济效益正向全国范围内迅速普及。然而大棚蔬菜种植是一项十分艰辛的工作,加上蔬菜大棚的特殊工作环境(高温、高湿、高二氧化碳浓度等)及特殊的工作方式(手工作业、体力劳动、特殊体位)等使大棚菜农具有较高的职业健康危险因素暴露,大棚菜农更易患上诸如骨关节炎、下背痛、颈肩痛等MSDs。MSDs的可疑危险因素除职业因素外,还包括个体因素、心理社会因素等。MSDs的危险因素在实际的人群调查中难以准确测量,难以计算各个危险因素的相对水平。并且在现况研究中可疑危险因素与疾病之问的因果关系难以确定。结构方程模型(Structural Equation Model, SEM)是一种建立、估计和验证因果关系的方法,可以筛选可疑危险因素并估计危险因素相对大小,被誉为二十世纪统计学的三大进展之一。近二十年来SEM在慢病等医学领域得到了广泛应用,但是使用SEM分析MSDs危险因素的研究却尚未见报道。本文使用SEM筛选大棚菜农MSDs的危险因素并对危险因素相对大小进行评估,对MSDs的预防、干预研究具有重要的指导和借鉴意义。目的调查大棚菜农和对照菜农MSDs患病情况,探索大棚菜农MSDs的危险因素,估计危险因素相对大小水平,提出针对大棚菜农MSDs的预防措施和建议。方法采用分层整群抽样方法,使用北欧国家肌肉骨骼疾患调查问卷与荷兰肌肉骨骼疾患调查问卷对某蔬菜大棚种植基地的大棚菜农和邻近村庄的非大棚菜农(对照组)进行面对面回顾性问卷调查,计算患病率,比较患病情况,并使用结构方程模型分析大棚菜农MSDs的危险因素。结果患病率共调查639名大棚菜农和318名对照菜农。大棚菜农MSDs患病率为61.2%,对照菜农MSDs患病率为43.4%,并且大棚菜农MSDs患病率高于对照菜农(P<0.05)。大棚菜农前四位MSDs依次是下背疾患、肩部疾患、膝部疾患和颈部疾患。大棚菜农下背疾患、肩部疾患、膝部疾患和颈部疾患的患病率分别为49.6%、29.0%、24.6%和12.8%,对照菜农分别为28.0%、11.6%、10.7%和4.4%,并且大棚菜农下背疾患、肩部疾患、膝部疾患和颈部疾患患病率均高于对照菜农(P＜0.05)。误工卧床情况大棚菜农因MSDs误工364人,误工率为57.0%,对照菜农因MSDs误工135人,误工率为42.5%,并且大棚菜农MSDs误工率高于对照菜农(P＜0.05)。大棚菜农下背疾患、肩部疾患、膝部疾患和颈部疾患的误工率分别为45.5%、25.0%、23.9%和12.5%,对照菜农分别为27.7%、11.3%、10.7%和3.8%,并且大棚菜农下背疾患、肩部疾患、膝部疾患和颈部疾患的误工率均高于对照菜农(P＜0.05)。大棚菜农因MSDs卧床62人,对照菜农因MSDs卧床2人,大棚菜农高于对照菜农MSDs的卧床率(P＜0.05)。危险因素结构方程模型分析下背疾患在下背疾患的SEM中,潜因变量大棚菜农下背疾患的决定系数为0.847,力量施加因素、静态负荷、动态负荷、人体工效学环境因素、重复性负荷和社会心理学因素与下背疾患的结构系数分别为0.385、0.342、0.122、0.064、0.040和0.098(P＜0.05)。力量施加因素、静态负荷、人体工效学环境因素、动态负荷、社会心理学因素、重复性负荷和年龄因素对潜因变量下背疾患的总体影响分别是0.385、0.342、0.285、0.122、0.098、0.040和0.034。大棚环境中潜变量人体工效学环境因素对潜变量大棚菜农静态负荷的直接影响为0.646。肩部疾患在肩部疾患的SEM中,潜因变量大棚菜农肩部疾患的决定系数为0.654,大棚因素、重复性负荷因素、力量施加因素、年龄因素、肩部姿势、性别和不舒适体位因素与肩部疾患的结构系数分别为0.448、0.283、0.106、0.079、0.069、0.065和0.033(P＜0.05)。大棚因素、重复性负荷、力量施加因素、年龄、肩部姿势、性别、不舒适体位因素对潜因变量肩部疾患的总体影响分别为0.660、0.283、0.106、0.079、0.069、0.065和0.033。大棚因素对大棚菜农力量施加因素的直接影响为0.553,对大棚菜农重复性负荷因素的直接影响为0.544。膝部疾患在膝部疾患的SEM中,潜因变量大棚菜农膝部疾患的决定系数为0.674,大棚菜农不舒适体位因素、个体因素(身高、体重)、社会心理学因素和平时健康状况与大棚菜农膝部疾患的结构系数分别为0.632、0.259、0.089和0.039(P＜0.05)。不舒适体位因素、个体因素(身高、体重)、社会心理学因素和平时健康状况对大棚菜农膝部疾患的总体影响分别为0.632、0.259、0.089和0.039。颈部疾患在颈部疾患的SEM中,潜因变量大棚菜农颈部疾患的决定系数为0.736,重复性负荷、颈部姿势、个体因素(年龄)、不舒适体位因素和社会心理学因素与大棚菜农颈部疾患的结构系数分别为0.559、0.344、0.037、0.030和0.001(P＜0.05)。重复性负荷、颈部姿势、个体因素(年龄)、不舒适体位因素和社会心理学因素对大棚菜农颈部疾患的总体影响分别为0.559、0.344、0.037、0.030和0.001。结论1.大棚菜农MSDs患病率较高,主要表现为下背疾患、肩部疾患、膝部疾患和颈部疾患,并且大棚菜农因MSDs明显影响了工作。2.大棚菜农下背疾患的主要危险因素为力量施加、静态负荷、人体工效学环境和动态负荷；肩部疾患的主要危险因素为大棚因素、重复性负荷和力量施加因素；膝部疾患的主要危险因素为不舒适体位和肥胖；颈部疾患的主要危险因素为重复性负荷和颈部姿势。3.建议：完善大棚配置；优化工作组织安排；改进操作方式。更多还原

【Abstract】 BackgroundMusculoskeletal disorders (MSDs) are injuries or dysfunctions affecting muscles, bones, nerves, tendons, ligaments, joints, cartilages, and spinal discs. MSDs cases with mild symptoms often feel uncomfortable or slightly painful, while severe cases are often unable to work and need to be treated with medication or special tools training, usually with unexpected poor prognosis. MSDs are prevalent and are a serious problem among working population around the world. MSDs were listed as one of the ten occupational problems needing intensive research in2002by National Institute for Occupational Safety and Health, NIOSH, and the ten years of2000to2010was identified as "Bone and Joint Decade2000-2010" by world health organization, WHO. Agricultural workers are mostly affected by MSDs, especially in labor-intensive practices such as fruit and vegetable planting. China being a vast agricultural country, MSDs among farmers, however, have been paid scarce attention. Therefore, it is of vital significance to study farmers’ MSDs and the risk factors.Greenhouse vegetables have been widely planted in Shouguang, Shandong Province, and are increasingly being cultured in mainland China due to high economic profits. But due to the fact that greenhouse vegetable-planting is an arduous practice, and its peculiar greenhouse microenvironment (high temperature, high humidity, high carbon dioxide, etc.), greenhouse vegetable-planting farmers may be much more likely to be affected by MSDs such as osteoarthritis, low back pain, neck and shoulder pain.Many factors could influence the occurrence and development of MSDs, such as occupational factors, individual factors, psychosocial factors, etc, which are difficult to determine and measure in surveys. What’s more, the causal relationship between possible risk factors and diseases is usually difficult to demonstrate in cross-sectional studies. Structural equation model (SEM), one of the three achievements in statistics in the twentieth century, is a statistical technique for testing and estimating causal relations using a combination of statistical data and qualitative causal assumptions, allowing both confirmatory and exploratory modeling, meaning they are suited to both theory testing and theory development. SEM has been widely used in the field of medicine such as chronic diseases but there have been few studies reported in the application of analysis of MSDs’risk factors. The application of SEM to analyze risk factors of MSDs among greenhouse vegetable-planting farmers and to determine the relative levels, which would benefit the understanding of MSDs’risk factors, is of vital significance to guide future studies.ObjectiveTo study the prevalence of MSDs among both greenhouse vegetable-planting farmers and non-greenhouse vegetable-planting farmers, and to explore the risk factors influencing greenhouse vegetable-planting farmers’MSDs, and to seek measures preventing greenhouse vegetable-planting farmers’MSDs.MethodsA self-administered questionnaire based on the Modified Nordic Questionnaire and the Dutch Musculoskeletal Questionnaire was conducted to both greenhouse vegetable-planting farmers in a greenhouse vegetable-planting area and non-greenhouse vegetable-planting farmers in the near villages by stratified cluster sampling. Then one-year prevalence rate of MSDs was calculated and compared between greenhouse vegetable-planting farmers and non-greenhouse vegetable-planting farmers (control group). Structural equation model was used to analyze the risk factors of greenhouse vegetable-planting farmners’ MSDs and to determine the risk levels.Results1. Study of Prevalence639greenhouse vegetable-planting farmers and318non-greenhouse vegetable-planting farmers completed the self-administered questionnaire. The1-year prevalence rate of MSDs was61.2%among greenhouse vegetable-planting farmers and43.4%among non-greenhouse farmers. The first four MSDs of greenhouse vegetable-planting farmers were low back disorders, shoulder(s) disorders, knee(s) disorders and neck disorders. The1-year prevalence rate of low back disorders, shoulder(s) disorders, knee(s) disorders and neck disorders among greenhouse vegetable-planting farmers was49.6%,29.0%,24.6%and12.8%respectively, statistically higher than that of non-greenhouse vegetable-planting farmers with the corresponding rate of28.0%,11.6%,10.7%and4.4%respectively (P<0.05).2. Analysis of risk factorsThe coefficient of determination of latent variables on low back disorders was0.847in the structural equation model. The structural coefficient of force exertion, static loads, dynamic loads, ergonomic environmental factors, repetitive loads and psychosocial factors on low back disorders was0.385,0.342,0.122,0.064,0.040and0.098respectively (P<0.05). The total effects of force exertion, static loads, ergonomic environmental factors, dynamic loads, psychosocial factors, repetitive loads and age on low back disorders were0.385,0.342,0.285,0.122,0.098,0.040and0.034respectively. The direct effect of ergonomic environmental factors on static loads was0.646.The coefficient of determination of latent variables on shoulder(s) disorders in the structural equation model was0.654. The structural coefficients of greenhouse factors, repetitive factors, force exertion, age, postures of shoulder(s), gender and uncomfortable postures on shoulder(s) disorders were0.448,0.283,0.106,0.079,0.069,0.065and0.033respectively (P<0.05). The total effects of greenhouse factors, repetitive factors, force exertion, age, postures of shoulder(s), gender and uncomfortable postures on shoulder(s) disorders were0.660,0.283,0.106,0.079,0.069,0.065and0.033respectively. The direct effects of greenhouse factors on force exertion and repetitive loads were0.553and0.544respectively.The coefficient of determination of latent variables on knee(s) disorders in the structural equation model was0.674. The structural coefficients of uncomfortable postures, individual factors (mainly height and bodyweight), psychosocial factors and health status on knee(s) disorders were0.632,0.259,0.089and0.039respectively (P<0.05). The total effects of uncomfortable postures, individual factors (mainly height and bodyweight), psychosocial factors and health status on knee(s) disorders were0.632,0.259,0.089and0.039respectively.The coefficient of determination of latent variables on neck disorders was0.736in the structural equation model. The structural coefficients of repetitive loads, postures of neck, individual factors (age), uncomfortable postures and psychosocial factors on neck disorders were0.559,0.344,0.037,0.030and0.001respectively (P<0.05). The total effects of repetitive loads, postures of neck, individual factors (age), uncomfortable postures and psychosocial factors on neck disorders were0.559,0.344,0.037,0.030and0.001respectively.Conclusions1. The prevalence of MSDs among greenhouse vegetable-planting farmers was quite high, and the first four MSDs were low back disorders, shoulder(s) disorders, knee(s) disorders and neck disorders. What’s more, the everyday work of greenhouse vegetable-planting farmers was affected due to MSDs.2. The main risk factors of low back disorders among greenhouse vegetable-planting farmers were force exertion, static loads, ergonomic environmental factors and dynamic loads. The main risk factors of shoulder(s) disorders among greenhouse vegetable-planting farmers were greenhouse factors, repetitive loads and force exertion. The main risk factors of knee(s) disorders among greenhouse vegetable-planting farmers were uncomfortable postures and obesity. The main risk factors of neck disorders among greenhouse vegetable-planting farmers were repetitive loads and neck postures.3. Suggestions:to improve greenhouse configuration; to optimize work organization; to meliorate operating styles.更多还原