Risk Evaluation in Occupational Safety and Health Research: Results From a Benchmarking Exercise of Federal and Academic IRBs.

OBJECTIVE: Research involving working populations can pose unique ethical and risk evaluation challenges. The purpose of this benchmarking project was to assess how federal agencies and academic institutions approach the interpretation and application of key risk evaluation concepts in research involving workers in their places of employment. METHODS: Key informant interviews were conducted to ascertain current practices related to assessing soundness of research design, determining risk reasonableness and research relatedness of risks, and evaluating the risk of noninvasive clinical tests in occupational settings. RESULTS: There were noteworthy commonalities among the approaches described to review and address critical aspects of risk evaluation for occupational safety and health research involving human participants. CONCLUSIONS: The insights gleaned may help guide institutional review boards and Human Research Protection Programs as they consider the ethical issues of human subjects research in occupational settings.

Preparing the occupational safety and health workforce for future disruptions.

BACKGROUND: Despite some emerging lessons learned from the COVID-19 pandemic, evidence suggests the world remains largely underprepared for-and vulnerable to-similar threats in the future. METHODS: In 2022, researchers at the US National Institute for Occupational Safety and Health (NIOSH) led a team of volunteers to explore how future disruptions, such as pandemics, might impact work and the practice of occupational safety and health (OSH). This qualitative inquiry was framed as a strategic foresight project and included a series of activities designed to help better understand, prepare for, and influence the future. RESULTS: Findings from a thorough search for indicators of change were synthesized into nine critical uncertainties and four plausible future scenarios. Analysis of these outputs elucidated three key challenges that may impact OSH research, policy, and practice during future disruptions: (1) data access, (2) direct-to-worker communications, and (3) mis- and dis-information management. CONCLUSIONS: A robust strategic response is offered to address these challenges, and next steps are proposed to enhance OSH preparedness and institutionalize strategic foresight across the OSH community.

Four Futures for Occupational Safety and Health.

Rapid changes to the nature of work have challenged the capacity of existing occupational safety and health (OSH) systems to ensure safe and productive workplaces. An effective response will require an expanded focus that includes new tools for anticipating and preparing for an uncertain future. Researchers at the U.S. National Institute for Occupational Safety and Health (NIOSH) have adopted the practice of strategic foresight to structure inquiry into how the future will impact OSH. Rooted in futures studies and strategic management, foresight creates well-researched and informed future scenarios that help organizations better prepare for potential challenges and take advantage of new opportunities. This paper summarizes the inaugural NIOSH strategic foresight project, which sought to promote institutional capacity in applied foresight while exploring the future of OSH research and practice activities. With multidisciplinary teams of subject matter experts at NIOSH, we undertook extensive exploration and information synthesis to inform the development of four alternative future scenarios for OSH. We describe the methods we developed to craft these futures and discuss their implications for OSH, including strategic responses that can serve as the basis for an action-oriented roadmap toward a preferred future.

Expanding the Focus of Occupational Safety and Health: Lessons from a Series of Linked Scientific Meetings.

There is widespread recognition that the world of work is changing, and agreement is growing that the occupational safety and health (OSH) field must change to contribute to the protection of workers now and in the future. Discourse on the evolution of OSH has been active for many decades, but formalized support of an expanded focus for OSH has greatly increased over the past 20 years. Development of approaches such as the National Institute for Occupational Safety and Health (NIOSH)'s Total Worker Health® concept and the World Health Organization (WHO)'s Healthy Workplace Framework are concrete examples of how OSH can incorporate a new focus with a wider view. In 2019, NIOSH initiated a multi-year effort to explore an expanded focus for OSH. This paper is a report on the outputs of a three-year cooperative agreement between NIOSH and The University of Texas School of Public Health, which led to subject matter expert workshops in 2020 and an international conference of global interest groups in 2021. This article traces the background of these meetings and identifies and assesses the lessons learned. It also reviews ten thematic topics that emerged from the meetings: worker health inequalities; training new OSH professionals; future OSH research and practice; tools to measure well-being of workers; psychosocial hazards and adverse mental health effects; skilling, upskilling and improving job quality; socioeconomic influences; climate change; COVID-19 pandemic influences; and strategic foresight. Cross-cutting these themes is the need for systems and transdisciplinary thinking and operationalization of the concept of well-being to prepare the OSH field for the work of the future.

Patterns of change of multisite pain over 1 year of follow-up and related risk factors.

BACKGROUND: Multisite musculoskeletal pain is common and disabling. This study aimed to prospectively investigate the distribution of musculoskeletal pain anatomically, and explore risk factors for increases/reductions in the number of painful sites. METHODS: Using data from participants working in 45 occupational groups in 18 countries, we explored changes in reporting pain at 10 anatomical sites on two occasions 14 months apart. We used descriptive statistics to explore consistency over time in the number of painful sites, and their anatomical distribution. Baseline risk factors for increases/reductions by ≥3 painful sites were explored by random intercept logistic regression that adjusted for baseline number of painful sites. RESULTS: Among 8927 workers, only 20% reported no pain at either time point, and 16% reported ≥3 painful sites both times. After 14 months, the anatomical distribution of pain often changed but there was only an average increase of 0.17 painful sites. Some 14% workers reported a change in painful sites by ≥3. Risk factors for an increase of ≥3 painful sites included female sex, lower educational attainment, having a physically demanding job and adverse beliefs about the work-relatedness of musculoskeletal pain. Also predictives were as follows: older age, somatizing tendency and poorer mental health (each of which was also associated with lower odds of reductions of ≥3 painful sites). CONCLUSIONS: Longitudinally, the number of reported painful sites was relatively stable but the anatomical distribution varied considerably. These findings suggest an important role for central pain sensitization mechanisms, rather than localized risk factors, among working adults. SIGNIFICANCE: Our findings indicate that within individuals, the number of painful sites is fairly constant over time, but the anatomical distribution varies, supporting the theory that among people at work, musculoskeletal pain is driven more by factors that predispose to experiencing or reporting pain rather than by localized stressors specific to only one or two anatomical sites.

Leveraging Strategic Foresight to Advance Worker Safety, Health, and Well-Being.

Attending to the ever-expanding list of factors impacting work, the workplace, and the workforce will require innovative methods and approaches for occupational safety and health (OSH) research and practice. This paper explores strategic foresight as a tool that can enhance OSH capacity to anticipate, and even shape, the future as it pertains to work. Equal parts science and art, strategic foresight includes the development and analysis of plausible alternative futures as inputs to strategic plans and actions. Here, we review several published foresight approaches and examples of work-related futures scenarios. We also present a working foresight framework tailored for OSH and offer recommendations for next steps to incorporate strategic foresight into research and practice in order to advance worker safety, health, and well-being.

How Will the Future of Work Shape OSH Research and Practice? A Workshop Summary.

Growth of the information economy and globalization of labor markets will be marked by exponential growth in emerging technologies that will cause considerable disruption of the social and economic sectors that drive the global job market. These disruptions will alter the way we work, where we work, and will be further affected by the changing demographic characteristics and level of training of the available workforce. These changes will likely result in scenarios where existing workplace hazards are exacerbated and new hazards with unknown health effects are created. The pace of these changes heralds an urgent need for a proactive approach to understand the potential effects new and emerging workplace hazards will have on worker health, safety, and well-being. As employers increasingly rely on non-standard work arrangements, research is needed to better understand the work organization and employment models that best support decent work and improved worker health, safety, and well-being. This need has been made more acute by the SARS-CoV-2 global pandemic that has resulted in dramatic changes in employment patterns, millions of lost jobs, an erosion of many economic sectors, and widespread disparities which further challenge occupational safety and health (OSH) systems to ensure a healthy and productive workplace. To help identify new research approaches to address OSH challenges in the future, a virtual workshop was organized in June 2020 with leading experts in the fields of OSH, well-being, research methods, mental health, economics, and life-course analysis. A paradigm shift will be needed for OSH research in the future of work that embraces key stakeholders and thinks differently about research that will improve lives of workers and enhance enterprise success. A more transdisciplinary approach to research will be needed that integrates the skills of traditional and non-traditional OSH research disciplines, as well as broader research methods that support the transdisciplinary character of an expanded OSH paradigm. This article provides a summary of the presentations, discussion, and recommendations that will inform the agenda of the Expanded Focus for Occupational Safety and Health (Ex4OSH) International Conference, planned for December 2021.

How Will the Future of Work Shape the OSH Professional of the Future? A Workshop Summary.

Rapid and profound changes anticipated in the future of work will have significant implications for the education and training of occupational safety and health (OSH) professionals and the workforce. As the nature of the workplace, work, and the workforce change, the OSH field must expand its focus to include existing and new hazards (some yet unknown), consider how to protect the health and well-being of a diverse workforce, and understand and mitigate the safety implications of new work arrangements. Preparing for these changes is critical to developing proactive systems that can protect workers, prevent injury and illness, and promote worker well-being. An in-person workshop held on February 3-4, 2020 at The University of Texas Health Science Center (UTHealth) School of Public Health in Houston, Texas, USA, examined some of the challenges and opportunities OSH education will face in both academic and industry settings. The onslaught of the COVID-19 global pandemic reached the United States one month after this workshop and greatly accelerated the pace of change. This article summarizes presentations from national experts and thought leaders across the spectrum of OSH and professionals in the fields of strategic foresight, systems thinking, and industry, and provides recommendations for the field.

Potential Scenarios and Hazards in the Work of the Future: A Systematic Review of the Peer-Reviewed and Gray Literatures.

It would be useful for researchers, practitioners, and decision-makers to anticipate the hazards that workers will face in the future. The focus of this study is a systematic review of published information to identify and characterize scenarios and hazards in the future of work. Eleven bibliographic databases were systematically searched for papers and reports published from 1999 to 2019 that described future of work scenarios or identified future work-related hazards. To compile a comprehensive collection of views of the future, supplemental and ad hoc searches were also performed. After screening all search records against a set of predetermined criteria, the review yielded 36 references (17 peer-reviewed, 4 gray, and 15 supplemental) containing scenarios. In these, the future of work was described along multiple conceptual axes (e.g. labor market changes, societal values, and manual versus cognitive work). Technology was identified as the primary driver of the future of work in most scenarios, and there were divergent views in the literature as to whether technology will create more or fewer jobs than it displaces. Workforce demographics, globalization, climate change, economic conditions, and urbanization were also mentioned as influential factors. Other important themes included human enhancement, social isolation, loneliness, worker monitoring, advanced manufacturing, hazardous exposures, sustainability, biotechnology, and synthetic biology. Pandemics have not been widely considered in the future of work literature, but the recent COVID-19 pandemic illustrates that was short-sighted. Pandemics may accelerate future of work trends and merit critical consideration in scenario development. Many scenarios described 'new' or 'exacerbated' psychosocial hazards of work, whereas comparatively fewer discussed physical, chemical, or biological hazards. Various preventive recommendations were identified. In particular, reducing stress associated with precarious work and its requirements of continual skill preparation and training was acknowledged as critical for protecting and promoting the health and well-being of the future workforce. In conclusion, the future of work will be comprised of diverse complex scenarios and a mosaic of old and new hazards. These findings may serve as the basis for considering how to shape the future of work.

Associations of sickness absence for pain in the low back, neck and shoulders with wider propensity to pain.

OBJECTIVES: To explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain. METHODS: As part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs. RESULTS: 861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4). CONCLUSIONS: Sickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention.

Toward an Expanded Focus for Occupational Safety and Health: A Commentary.

Powerful and ongoing changes in how people work, the workforce, and the workplace require a more holistic view of each of these. We argue that an expanded focus for occupational safety and health (OSH) is necessary to prepare for and respond rapidly to future changes in the world of work that will certainly challenge traditional OSH systems. The WHO Model for Action, various European efforts at well-being, and the Total Worker Health concept provide a foundation for addressing changes in the world of work. However, a paradigm expansion to include the recognition of worker and workforce well-being as an important outcome of OSH will be needed. It will also be vital to stimulate transdisciplinary efforts and find innovative ways to attract and train students into OSH professions as the paradigm expands. This will require active marketing of the OSH field as vibrant career choice, as a profession filled with meaningful, engaging responsibilities, and as a well-placed investment for industry and society. An expanded paradigm will result in the need for new disciplines and specialties in OSH, which may be useful in new market efforts to attract new professionals. Ultimately, to achieve worker and workforce well-being we must consider how to implement this expanded focus.

Determinants of international variation in the prevalence of disabling wrist and hand pain.

BACKGROUND: Previous research has indicated that wide international variation in the prevalence of disabling low back pain among working populations is largely driven by factors predisposing to musculoskeletal pain more generally. This paper explores whether the same applies to disabling wrist/hand pain (WHP). METHODS: Using data from the Cultural and Psychosocial Influences on Disability (CUPID) study, we focused on workers from 45 occupational groups (office workers, nurses and other workers) in 18 countries. Among 11,740 participants who completed a baseline questionnaire about musculoskeletal pain and potential risk factors, 9082 (77%) answered a further questionnaire after a mean interval of 14 months, including 1373 (15%) who reported disabling WHP in the month before follow-up. Poisson regression was used to assess associations of this outcome with baseline risk factors, including the number of anatomical sites other than wrist/hand that had been painful in the 12 months before baseline (taken as an index of general propensity to pain). RESULTS: After allowance for other risk factors, the strongest associations were with general pain propensity (prevalence rate ratio for an index ≥6 vs. 0: 3.6, 95% confidence interval 2.9-4.4), and risk rose progressively as the index increased. The population attributable fraction for a pain propensity index > 0 was 49.4%. The prevalence of disabling WHP by occupational group ranged from 0.3 to 36.2%, and correlated strongly with mean pain propensity index (correlation coefficient 0.86). CONCLUSION: Strategies to prevent disability from WHP among working populations should explore ways of reducing general propensity to pain, as well as improving the ergonomics of occupational tasks.

Burden, Need and Impact: An Evidence-Based Method to Identify Worker Safety and Health Research Priorities.

The importance of research and recommendations to address workforce safety and health derives from the continuing toll from worker fatalities, injuries, and illnesses. Estimates of the societal cost of work-related fatalities, injuries, and illnesses range up to $2.2 trillion in the USA from 2007 to 2015, which may be an underestimate of total societal costs. The ongoing changes in the nature of work, the workforce, and the workplace in the USA challenge old paradigms of worker safety and health research and require new decision criteria that are more solution oriented than observational and that result in interventions that can be readily applied to new occupational hazards and exposures. As public funding for science research programs becomes more constrained, and the demand for increased accountability of government spending grows, the need to demonstrate the impact or return on taxpayers' investment becomes a necessity for research agencies. The National Institute for Occupational Safety and Health has developed an evidence-based method that uses the criteria of 'burden', 'need', and 'impact' to identify research priorities and aid in the evaluation of the taxpayers' investment in research. This approach, named the BNI method, may be useful to other public and private sector research agencies or entities that need a systematic way to set research priorities and allocate increasingly scarce resources for research while ensuring the maximal return on investment.

Epidemiological Differences Between Localized and Nonlocalized Low Back Pain.

STUDY DESIGN: A cross-sectional survey with a longitudinal follow-up. OBJECTIVES: The aim of this study was to test the hypothesis that pain, which is localized to the low back, differs epidemiologically from that which occurs simultaneously or close in time to pain at other anatomical sites SUMMARY OF BACKGROUND DATA.: Low back pain (LBP) often occurs in combination with other regional pain, with which it shares similar psychological and psychosocial risk factors. However, few previous epidemiological studies of LBP have distinguished pain that is confined to the low back from that which occurs as part of a wider distribution of pain. METHODS: We analyzed data from CUPID, a cohort study that used baseline and follow-up questionnaires to collect information about musculoskeletal pain, associated disability, and potential risk factors, in 47 occupational groups (office workers, nurses, and others) from 18 countries. RESULTS: Among 12,197 subjects at baseline, 609 (4.9%) reported localized LBP in the past month, and 3820 (31.3%) nonlocalized LBP. Nonlocalized LBP was more frequently associated with sciatica in the past month (48.1% vs. 30.0% of cases), occurred on more days in the past month and past year, was more often disabling for everyday activities (64.1% vs. 47.3% of cases), and had more frequently led to medical consultation and sickness absence from work. It was also more often persistent when participants were followed up after a mean of 14 months (65.6% vs. 54.1% of cases). In adjusted Poisson regression analyses, nonlocalized LBP was differentially associated with risk factors, particularly female sex, older age, and somatizing tendency. There were also marked differences in the relative prevalence of localized and nonlocalized LBP by occupational group. CONCLUSION: Future epidemiological studies should distinguish where possible between pain that is limited to the low back and LBP that occurs in association with pain at other anatomical locations. LEVEL OF EVIDENCE: 2.

Low back pain among office workers in three Spanish-speaking countries: findings from the CUPID study.

OBJECTIVES: To assess the differences in the prevalence and incidence of low back pain (LBP) and associated disability among office workers in Costa Rica, Nicaragua and Spain. METHODS: Data were collected at baseline (n=947, 93% response) in November 2007 and at follow-up after 12 months (n=853, 90% response). Six outcome measures were examined: baseline prevalence of (1) LBP in the past 12 months, (2) LBP in the past month and (3) disabling LBP in the past month; and at follow-up: (4) incidence of new LBP in the past month, (5) new disabling LBP and (6) persistent LBP. Differences in prevalence by country were characterised by ORs with 95% CIs, before and after adjustment for covariates. RESULTS: Prevalence of LBP in the past month among office employees in Costa Rica (46.0%) and Nicaragua (44.2%) was higher than in Spain (33.6%). Incidence of new LBP was 37.0% in Nicaragua (OR=2.49; 95% CI 1.57 to 3.95), 14.9% in Costa Rica (OR=0.74; 95% CI 0.41 to 1.34) and 19.0% in Spain (reference). Incidence of new disabling LBP was higher in Nicaragua (17.2%; OR=2.49; 95% CI 1.43 to 4.34) and Costa Rica (13.6%; OR=1.89; 95% CI 1.03 to 3.48) than Spain (7.7%), while persistence of LBP was higher only in Nicaragua. CONCLUSIONS: Prevalence of LBP and disabling LBP was higher in Costa Rican and Nicaraguan office workers than in Spain, but the incidence was higher mainly in Nicaragua. Measured sociodemographic, job-related and health-related variables only partly explained the differences between countries, and further research is needed to explore reasons for the remaining differences.

Descriptive Epidemiology of Somatising Tendency: Findings from the CUPID Study.

Somatising tendency, defined as a predisposition to worry about common somatic symptoms, is importantly associated with various aspects of health and health-related behaviour, including musculoskeletal pain and associated disability. To explore its epidemiological characteristics, and how it can be specified most efficiently, we analysed data from an international longitudinal study. A baseline questionnaire, which included questions from the Brief Symptom Inventory about seven common symptoms, was completed by 12,072 participants aged 20-59 from 46 occupational groups in 18 countries (response rate 70%). The seven symptoms were all mutually associated (odds ratios for pairwise associations 3.4 to 9.3), and each contributed to a measure of somatising tendency that exhibited an exposure-response relationship both with multi-site pain (prevalence rate ratios up to six), and also with sickness absence for non-musculoskeletal reasons. In most participants, the level of somatising tendency was little changed when reassessed after a mean interval of 14 months (75% having a change of 0 or 1 in their symptom count), although the specific symptoms reported at follow-up often differed from those at baseline. Somatising tendency was more common in women than men, especially at older ages, and varied markedly across the 46 occupational groups studied, with higher rates in South and Central America. It was weakly associated with smoking, but not with level of education. Our study supports the use of questions from the Brief Symptom Inventory as a method for measuring somatising tendency, and suggests that in adults of working age, it is a fairly stable trait.

Upper extremity musculoskeletal pain among office workers in three Spanish-speaking countries: findings from the CUPID study.

OBJECTIVES: To estimate the prevalence and incidence of upper extremity musculoskeletal pain (UEMP) and related disability among office workers in Costa Rica, Nicaragua and Spain. METHODS: Data from the multinational Cultural and Psychosocial Influences on Disability (CUPID) study on 947 (93%) participants at baseline with 90% follow-up after 12 months were employed. Logistic regression was used to estimate the associations (ORs and corresponding 95% CIs) between country and six outcomes: baseline prevalence of (1) UEMP in past 12 months, (2) UEMP in past month and (3) disabling UEMP in past month; (4) incidence of new UEMP at follow-up; (5) incidence of new disabling UEMP at follow-up and (6) persistence of UEMP at follow-up, after adjustment for sociodemographic, job-related and health-related covariates. RESULTS: Baseline prevalence of UEMP in the past month was higher in Costa Rica (53.6%) (OR=1.89; 95% CI 1.36 to 2.62) and Nicaragua (51.9%) (OR=1.74; 95% CI 1.28 to 2.35) than in Spain (38.4%). Compared to Spain (33.2%), the incidence of new UEMP was 50.4% in Costa Rica (OR=2.04; 95% CI 1.34 to 3.12) and 60.2% in Nicaragua (OR=3.04; 95% CI 2.06 to 4.50). The incidence of disabling UEMP was higher in Nicaragua (OR=2.57; 95% CI 1.50 to 4.41) and Costa Rica (OR=2.16; 95% CI 1.22 to 3.84) when compared to Spain. CONCLUSIONS: Prevalence of UEMP was approximately twofold higher and its incidence twofold to threefold higher in Costa Rica and Nicaragua as compared with Spain. Between-country differences were only partially explained by the covariates analysed. Research is needed to explore other aspects of work and cultural attributes that might explain the residual differences in UEMP.

Classification of neck/shoulder pain in epidemiological research: a comparison of personal and occupational characteristics, disability, and prognosis among 12,195 workers from 18 countries.

To inform case definition for neck/shoulder pain in epidemiological research, we compared levels of disability, patterns of association, and prognosis for pain that was limited to the neck or shoulders (LNSP) and more generalised musculoskeletal pain that involved the neck or shoulder(s) (GPNS). Baseline data on musculoskeletal pain, disability, and potential correlates were collected by questionnaire from 12,195 workers in 47 occupational groups (mostly office workers, nurses, and manual workers) in 18 countries (response rate = 70%). Continuing pain after a mean interval of 14 months was ascertained through a follow-up questionnaire in 9150 workers from 45 occupational groups. Associations with personal and occupational factors were assessed by Poisson regression and summarised by prevalence rate ratios (PRRs). The 1-month prevalence of GPNS at baseline was much greater than that of LNSP (35.1% vs 5.6%), and it tended to be more troublesome and disabling. Unlike LNSP, the prevalence of GPNS increased with age. Moreover, it showed significantly stronger associations with somatising tendency (PRR 1.6 vs 1.3) and poor mental health (PRR 1.3 vs 1.1); greater variation between the occupational groups studied (prevalence ranging from 0% to 67.6%) that correlated poorly with the variation in LNSP; and was more persistent at follow-up (72.1% vs 61.7%). Our findings highlight important epidemiological distinctions between subcategories of neck/shoulder pain. In future epidemiological research that bases case definitions on symptoms, it would be useful to distinguish pain that is localised to the neck or shoulder from more generalised pain that happens to involve the neck/shoulder region.

Using a Community-Engaged Approach to Develop a Bilingual Survey about Psychosocial Stressors among Individuals of Mexican Origin.

Hypertension is on the rise among Hispanics and is highest among those of Mexican origin. Recent studies have found a positive association between air pollution and blood pressure and hypertension. Moreover, a link between hypertension and adverse socioeconomic conditions is well established. However, less is known about psychosocial stressors, although their impact on coronary heart disease has been shown. To address this gap in the literature, community perspectives of the health consequences of environmental exposures and psychosocial stressors experienced among the Mexican-origin population in Houston, Texas were obtained through participation in focus groups, the establishment of a Neighborhood Council of Advisors (NCA), and the testing of a pilot questionnaire. Taken together, the findings from the community were used to develop a culturally sensitive, bilingual questionnaire for an investigation of the combined effects of environmental and psychosocial stressors on hypertension among individuals of Mexican origin.

Patterns of multisite pain and associations with risk factors.

To explore definitions for multisite pain, and compare associations with risk factors for different patterns of musculoskeletal pain, we analysed cross-sectional data from the Cultural and Psychosocial Influences on Disability (CUPID) study. The study sample comprised 12,410 adults aged 20-59 years from 47 occupational groups in 18 countries. A standardised questionnaire was used to collect information about pain in the past month at each of 10 anatomical sites, and about potential risk factors. Associations with pain outcomes were assessed by Poisson regression, and characterised by prevalence rate ratios (PRRs). Extensive pain, affecting 6-10 anatomical sites, was reported much more frequently than would be expected if the occurrence of pain at each site were independent (674 participants vs 41.9 expected). In comparison with pain involving only 1-3 sites, it showed much stronger associations (relative to no pain) with risk factors such as female sex (PRR 1.6 vs 1.1), older age (PRR 2.6 vs 1.1), somatising tendency (PRR 4.6 vs 1.3), and exposure to multiple physically stressing occupational activities (PRR 5.0 vs 1.4). After adjustment for number of sites with pain, these risk factors showed no additional association with a distribution of pain that was widespread according to the frequently used American College of Rheumatology criteria. Our analysis supports the classification of pain at multiple anatomical sites simply by the number of sites affected, and suggests that extensive pain differs importantly in its associations with risk factors from pain that is limited to only a small number of anatomical sites.