Return to work and psychosocial trajectories after breast cancer: a longitudinal and sequential approach.

PURPOSE: We aimed to describe the psychosocial adjustments according to return to work (RTW) trajectories in breast cancer survivors (BCS) using a sequential and temporal approach. METHODS: We used BCS data included from February 2015 to April 2016 in the Longitudinal Study on Behavioural, Economic and Sociological Changes after Cancer (ELCCA) cohort. RTW trajectories were identified using the sequence analysis method followed by a clustering. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale and the EORTC quality of life questionnaire was used at inclusion and all follow-up visits to assess Health-Related Quality of Life (HRQoL). RESULTS: Fifty-two BCS were included in the study among whom four clusters of RTW trajectories were identified and labeled: slow RTW (N = 10), quick RTW (N = 27), partial RTW (N = 8), and part-time work (N = 7). Quick and slow RTW clusters showed slightly lower baseline mean levels of anxiety and higher levels of HRQoL. In the 4 years following diagnosis, BCS in the quick RTW cluster tended to report higher HRQoL in terms of functioning and less symptoms of pain and fatigue while those in the partial RTW cluster showed a lower HRQoL on almost all dimensions. All clusters showed an increase in pain and fatigue symptoms until 6 months followed by a tendency to recover baseline levels. CONCLUSIONS: The results of this study suggest that BCS who return to full-time work (slow and quick RTW patterns) recover better than patients who return to part-time work (partial and part-time RTW patterns).

Impact of breast cancer care pathways and related symptoms on the return-to-work process: results from a population-based French cohort study (CONSTANCES).

BACKGROUND: Breast cancer (BC) treatments and related symptoms may affect return to work (RTW). The objective of this study was to investigate the impact of BC care pathways (timing and sequence of treatments) and related symptoms on RTW. METHODS: The study population included working-age women with BC who were enrolled in the French CONSTANCES cohort from 2012 to 2018. BC treatments, antidepressant/anxiolytic and antalgic drug deliveries (used as proxies of depression and pain, respectively) and statutory sick pay (used to estimate RTW and time to RTW) were assessed monthly using data from the French national healthcare system database. BC care pathways were identified with the sequence analysis method. Cox models with time-dependent covariates were used to investigate the impact of BC care pathways and related symptoms on RTW and time to RTW, after adjusting for age and socioeconomic characteristics. RESULTS: 73.2% (231/303) of women returned to work within 2 years after BC diagnosis. Five BC care pathway patterns were identified: (i) BC surgery only, (ii) BC surgery and radiotherapy, (iii) BC surgery and chemotherapy, (iv) BC surgery and chemotherapy and radiotherapy, and (v) BC surgery and long-term alternative chemotherapy/radiotherapy. The hazards ratios of non-RTW were significantly higher for women who received BC surgery and long-term alternative chemotherapy/radiotherapy and for > 55-year-old women. Time to RTW was significantly longer in women who received chemotherapy (patterns iii to v) and in women with antidepressant/anxiolytic and antalgic drug deliveries. CONCLUSION: This study highlights the value of considering the dynamic, cumulative and temporal features of BC care pathways and related symptoms to facilitate the RTW of women with BC.

Comparison of Machine Learning Methods in the Study of Cancer Survivors' Return to Work: An Example of Breast Cancer Survivors with Work-Related Factors in the CONSTANCES Cohort.

PURPOSE: Machine learning (ML) methods showed a higher accuracy in identifying individuals without cancer who were unable to return to work (RTW) compared to the classical methods (e.g. logistic regression models). We therefore aim to discuss the value of these methods in relation to RTW for cancer survivors. METHODS: Breast cancer (BC) survivors who were working at diagnosis within the CONSTANCES cohort were included in the study. RTW was assessed five years after the BC diagnosis (early retirement was considered as non-RTW). Age and occupation at diagnosis, and physical occupational job exposures assessed using the Job Exposure Matrix, JEM-CONSTANCES, were evaluated as predictors of RTW five years after BC diagnosis. The following four ML methods were used: (i) k-nearest neighbors; (ii) random forest; (iii) neural network; and (iv) elastic net. RESULTS: The training sample included 683 BC survivors (RTW: 85.7%), and the test sample 171 (RTW: 85.4%). The elastic net method had the best results despite low sensitivity (accuracy = 76.6%; sensitivity = 31.7%; specificity = 90.8%), and the random forest model was the most accurate (= 79.5%) but also the least sensitive (= 14.3%). CONCLUSION: This study takes a first step towards opening up new possibilities for identifying the occupational determinants of cancer survivors' RTW. Further work, including a larger sample size, and more predictor variables, is now needed.

Stroke Incidence and Case Fatality According to Rural or Urban Residence: Results From the French Brest Stroke Registry.

Background and Purpose- Recent findings suggest that in the United States, stroke incidence is higher in rural than in urban areas. Similar analyses in other high-income countries are scarce with conflicting results. In 2008, the Brest Stroke Registry was started in western France, an area that includes about 366 000 individuals living in various urban and rural settings. Methods- All new patients with stroke included in the Brest Stroke Registry from 2008 to 2013 were classified as residing in town centers, suburbs, isolated towns, or rural areas. Poisson regression was used to analyze stroke incidence and 30-day case fatality variations in the 4 different residence categories. Models with case fatality as outcome were adjusted for age, stroke type, and stroke severity. Results- In total, 3854 incident stroke cases (n=2039 women, 53%) were identified during the study period. Demographic and socio-economic characteristics and primary healthcare access indicators were significantly different among the 4 residence categories. Patterns of risk factors, stroke type, and severity were comparable among residence categories in both sexes. Age-standardized stroke rates varied from 2.90 per thousand (95% CI, 2.59-3.21) in suburbs to 3.35 (95% CI, 2.98-3.73) in rural areas for men, and from 2.14 (95% CI, 2.00-2.28) in town centers to 2.34 (95% CI, 2.12-2.57) in suburbs for women. Regression models suggested that among men, stroke incidence was significantly lower in suburbs than in town centers (incidence rate ratio =0.87; 95% CI, 0.77-0.99). Case fatality risk was comparable across urban categories but lower in rural patients (relative risk versus town centers: 0.76; 95% CI, 0.60-0.96). Conclusions- Stroke incidence was comparable, and the 30-day case fatality only slightly varied in the 4 residence categories despite widely different socio-demographic features covered by the Brest Stroke Registry.

[Exposure to occupational biomechanical risk factors: The impact of the 2017 reform]. / L'exposition professionnelle aux facteurs de risque biomécaniques : impact de l'ordonnance de 2017.

OBJECTIVE: We aimed to assess the number, the prevalence and the socio-occupational characteristics of the employees who were allowed to benefit from prevention measures due to their exposure to occupational biomechanical factors before and after the modification, by the reform (order n° 2017-1389), of the law dealing with occupational health and safety preventive measures. METHODS: This study was based on the French national survey on occupational exposures (Sumer 2010). Almost 48,000 employees, representative of the French population, were included. Exposure to the four biomechanical factors, initially included in the law and associated with a minimum exposure threshold, were assessed during the employee's interview by the occupational physician. RESULTS: Before the reform, 31.2% of men and 23.6% of women were likely to benefit from measures of prevention due to their exposure to occupational biomechanical factors. Following the reform, 11,6% of men and 13,7% of women employees are still able to benefit from these occupational preventive measures, leading to an overall decrease of 3.3 million of beneficiaries. CONCLUSIONS: Although musculoskeletal disorders (MSD) remain the first cause of recognition as an occupational disease, the exclusion, by the reform, of three biomechanical occupational risk factors of MSDs from the preventives measures in occupational health and safety risk assessment will substantially decrease the number of employees exposed to biomechanical factors that could benefit from these preventive and compensatory occupational measures.

Socioeconomic Disparities in Adverse Birth Outcomes in Urban and Rural Contexts: a French Mother-Child Cohort.

BACKGROUND: Although adverse birth outcomes have been associated with neighbourhood deprivation in urban areas, few studies have addressed this issue in rural zones. This study examines whether associations between neighbourhood deprivation and adverse birth outcomes differ in urban and rural contexts, while taking individual characteristics and spatial accessibility of prenatal care (SAPC) into account. METHODS: Pregnant women from a French mother-child cohort were recruited from 2002 to 2006 in Brittany. Their residential addresses were geocoded into their census blocks (the finest geographical resolution available). Deprivation was assessed at the same neighbourhood level. Models to assess the associations of deprivation, stratified by urban/rural status, with preterm delivery (PTD), with small for gestational age birth weight (SGA) and with small for gestational age head circumference at birth (SHC), estimated odds ratios (ORs), adjusted for maternal socioeconomic characteristics and SAPC. RESULTS: This study considered 2929 liveborn singleton pregnancies from 780 census blocks. Neighbourhood deprivation was associated with increased risks of SGA and SHC (P trend < 0.01 and 0.03 respectively), only among mothers residing in rural areas. Neighbourhood deprivation had statistically significantly heterogeneous effects on SGA and SHC according to the urban/rural status of maternal residence. CONCLUSION: These findings suggest that neighbourhood deprivation affects fetal growth differentially in urban and rural areas and that SAPC does not seem to be responsible for this difference. Comparison of these findings with the literature requires caution in the conceptualisation of urban and rural settings.

Sex-specific differences in fetal growth in newborns exposed prenatally to traffic-related air pollution in the PELAGIE mother-child cohort (Brittany, France).

BACKGROUND: Numerous studies have linked prenatal traffic-related air pollution exposure to fetal growth. Recently, several studies have suggested exploring this association independently among boys and girls because of potential sex-specific biological vulnerability to air pollution. Residence-based factors can also influence fetal growth by enhancing susceptibility to the toxic effects of air pollution and must also be considered in these relations. OBJECTIVE: We examined sex-specific associations between prenatal air pollution exposure and fetal growth and explored whether they differed by the urban-rural status of maternal residence. METHODS: This study relied on the PELAGIE mother-child cohort (2521 women, Brittany, France, 2002-2006). Fetal growth was assessed through birth weight, head circumference and small weight (SGA) and small head circumference (SHC) for gestational age. Nitrogen dioxide (NO2) concentrations at mothers' homes were estimated by using a land use regression model taking into account temporal variation during pregnancy. Associations between estimated NO2 concentrations and fetal growth were assessed with linear regression or logistic regression models, depending on the outcome investigated. RESULTS: An interquartile range (8.8 µg m(-3)) increase in NO2 exposure estimates was associated with a 27.4 g (95% CI 0.8 to 55.6) increase in birth weight and a 0.09 cm (95% CI 0.00-0.17) significant increase in head circumference, among newborn boys only. Their risks of SGA and SHC were reduced (OR 0.70, 95% CI 0.53-0.92, OR 0.76, 95% CI 0.56-1.03, respectively, for an increase of 8.8 µg m(-3)). No statistically significant trends were observed among girls. Urban-rural status modified the effect of air pollution only for SHC and again only for newborn boys. CONCLUSION: Findings from this study confirm the need to consider sex-specific associations between air pollution and fetal growth and to investigate possible mechanisms by which traffic-related air pollution may increase anthropometric parameters at birth.

Association between prenatal exposure to traffic-related air pollution and preterm birth in the PELAGIE mother-child cohort, Brittany, France. Does the urban-rural context matter?

INTRODUCTION: Evidence has accumulated that exposure to ambient air pollution during pregnancy may influence preterm birth (PTB) in urban settings. Conversely, this relation has barely been investigated in rural areas where individual characteristics (demographic, socioeconomic, and psychosocial factors) and environmental co-exposures may differ. OBJECTIVE: We examined the association between prenatal exposure to traffic-related air pollution and PTB among pregnant women from the PELAGIE mother-child cohort (Brittany, France, 2002-2006) living in urban (n=1550) and rural (n=959) settings. METHODS: Women's residences were classified as either urban or rural according to the French census bureau rural-urban definitions. Nitrogen dioxide (NO2) concentrations at home addresses were estimated from adjusted land-use regression models as a marker of traffic-related pollution. Associations between NO2 concentrations and PTB were assessed with logistic regression models. RESULTS: Prevalence of PTB was similar among women living in urban (3.2%) and in rural (3.5%) settings. More positive socioeconomic characteristics and health behaviors but more single-parent families were observed among urban women. NO2 exposure averaged 20.8±6.6 µg m(-3) for women residing in urban areas and 18.8±5.6 µg m(-3) for their rural counterparts. A statistically significant increased risk of PTB was observed among women exposed to NO2 concentrations ≥16.4 µg m(-3) and residing in urban areas but not among their rural counterparts. DISCUSSION: The results of this study, conducted in a region with interspersed urban-rural areas, are in line with previous findings suggesting an increased risk of PTB associated with higher NO2 concentrations for women living in urban areas. The absence of association among their rural counterparts for whom exposure levels were similar suggests that environmental mixtures and psychosocial inequalities might play a role in this heterogeneity.

Can a deprivation index be used legitimately over both urban and rural areas?

BACKGROUND: Although widely used, area-based deprivation indices remain sensitive to urban-rural differences as such indices are usually standardised around typical urban values. There is, therefore, a need to determine to what extent available deprivation indices can be used legitimately over both urban and rural areas. METHODS: This study was carried out in Brittany, France, a relatively affluent region that contains deep rural areas. Among the 1,736 residential census block groups (IRIS) composing the Brittany region, 1,005 (57.9%) are rural. Four deprivation indices were calculated: two scores (Carstairs and Townsend) developed in the UK and two more recent French measures (Havard and Rey). Two standardisation levels were considered: all of the IRIS and only the urban IRIS of the region. Internal validity (Kappa coefficients and entropy values) and external validity (relationship with colorectal cancer screening [CCS] attendance) were investigated. RESULTS: Regardless of the deprivation measure used, wealthy areas are mostly clustered in the West and at the outskirts of major towns. Carstairs and Rey scores stand out by all evaluation criteria, capturing both urban and rural deprivation. High levels of agreements were found across standardisation levels (κ = 0.96). The distributions of deprivation scores were balanced across urban and rural areas, and high Shannon entropy values were observed in the capital city (≥0.93). Similar and significant negative trends were observed between CCS attendance and both deprivation indices, independent of the degree of urbanisation. CONCLUSIONS: These results provide support, despite potential sociological objections, for the use of a compromise index that would facilitate comparisons and interpretations across urban and rural locations in public health research.

Prevalence of occupational co-exposure to biomechanical factors and neurotoxic chemicals in French workers.

OBJECTIVES: Little is known about occupational co-exposure. The objective was to assess the prevalence of exposure and co-exposure to biomechanical factors and neurotoxic chemicals in French workers in 2017. METHODS: Data from the French representative survey SUMER 2017 (SUrveillance Médicale des Expositions aux Risques professionnels) were analyzed. A total of 25 118 workers were included. Exposure to 4 biomechanical factors (manual handling of loads, forceful joint exertion, repetitive movements, and hand-arm transmitted vibrations) and 18 neurotoxic chemicals (n-hexane, perchloroethylene, trichloroethylene, etc.) were assessed using a questionnaire during face-to-face interviews with occupational physicians. RESULTS: Among men, 22.9% were exposed to at least one biomechanical factor and 10.2% were exposed to at least one neurotoxic chemical, mainly single exposures. Among women, 10.8% were exposed to at least one biomechanical factor and 3.1% were exposed to at least one neurotoxic chemical, also mainly single exposures. Occupational co-exposure to biomechanical factors and neurotoxic chemicals was observed among 4.8% of men and 0.7% of women. Workers under 30 yr old, blue-collar workers and those working in small companies were more co-exposed than other workers. In men, the prevalence of co-exposure was higher in the construction sector compared to other economic activities. DISCUSSION: This study stresses the importance of considering multiple occupational exposures while the current prevention measures are designed to focus on preventing occupational factors individually.

School meals in French secondary state schools: Do national recommendations lead to healthier nutrition on offer?

To improve the dietary offering in schools, the French authorities published recommendations on nutrition in 1999, which were then revised in 2007. The aim of the present study was to assess the nutritional offering in secondary school meals and the extent to which the recommendations promote balanced nutritional offerings. In 2005, a national survey was conducted on a representative sample of secondary schools, either administrated by the Ministry of Education (ES) or the Ministry of Agriculture (AS). Information on school-catering organisation and twenty consecutive meals was collected from each of the 707 secondary schools surveyed. Nutritional composition was estimated according to the French food composition database. Univariate and multivariate analyses were used to investigate the impact of food-group frequency guidelines (FFG) on nutritional offering. It was found that 15 and 26 % of ES and AS schools, respectively, had high compliance with the FFG, at lunch. Macronutrient content was unbalanced in ES school lunches in which 42·8 % lipids, 21·5 % proteins and 35·7 % carbohydrates contributed to the energy. Nevertheless, proper offerings in Fe, Ca and vitamin C content were observed. In addition, a lower offering in lipids and a higher offering in proteins, Ca, vitamin C and Fe were found when the FFG were applied (P < 0·001). Similar results were found for AS schools. This paper confirms the effectiveness of FFG in providing nutritionally balanced school meals. However, others measures such as nutrition promotion and actions to improve children's food habits have to be introduced to make the recommendations more effective and easier to understand.

Return to work of breast cancer survivors: toward an integrative and transactional conceptual model.

PURPOSE: To propose a conceptual framework of the return to work (RTW) of breast cancer survivors (BCS) according to the transactional perspective. METHODS: The Technique for Research of Information by Animation of a Group of Experts was implemented. For each determinant in an initial list established from the literature, experts selected for the consensus exercise were firstly asked to indicate their agreement level individually, via an online questionnaire. Determinants obtaining an agreement level of 80% or over during this first phase were retained. Determinants obtaining an agreement level below 80%, and additional determinants proposed by the experts, were then discussed collectively. After discussion, experts voted via a new online questionnaire to retain (or not) each determinant. Determinants obtaining an agreement level of 80% or over after this second phase were retained. Based on the determinants selected, a conceptual model was developed following the transactional approach. RESULTS: Eleven experts participated in the study. Forty of the 51 determinants listed initially from the literature achieved an agreement level over 80%, and 20 were added after the individual consultation phase. Twenty-two of the 31 determinants discussed collectively were retained. In total, 62 determinants were selected to construct the conceptual model. CONCLUSIONS: This integrative, operational, and transactional conceptual model of the RTW of BCS, constructed following an expert consensus, will help to design more efficient patient-centered intervention studies. IMPLICATIONS FOR CANCER SURVIVORS: Identification of the 62 determinants associated with the RTW of BCS will help design tools that are easily used by all stakeholders involved in the RTW process.

Characteristics of energy under-reporting in children and adolescents.

Under-reporting (UR) of food intake is an issue of concern, as it may distort the relationships studied between diet and health. This topic has been scarcely addressed in children. The objective of the study was to assess the extent of UR in French children and investigate associated covariates. A total of 1455 children aged 3-17 years were taken from the nationally representative cross-sectional French étude Individuelle Nationale des Consommations Alimentaires (INCA2) dietary survey (2006-7). Food intake was reported in a 7 d diet record. Socio-economic status, sedentary behaviour, weight perception variables and food habits were collected by questionnaires. Weight and height were measured. Under-reporters were identified according to the Goldberg criterion adapted to children. Multivariate logistic regressions investigated the associations between UR and covariates. Rates of under-reporters were 4·9 and 26·0 % in children aged 3-10 and 11-17 years, respectively (P < 0·0001), without significant differences between boys and girls. Overall, UR was positively associated with a lower socio-economic status, overweight, skipping breakfast and dinner, a higher contribution of proteins to energy intake (EI), and a lower contribution of simple carbohydrates to EI. Under-reporters aged 3-10 years also had a higher sedentary behaviour and a lower snack-eating frequency. In adolescents, UR was also associated with a less-frequent school canteen attendance, a perception of being overweight, a wish to weigh less, and current and past restrictive diets. In conclusion, under-reporters differ from plausible reporters in several characteristics related to diet, lifestyle, weight status and socio-economic status. Therefore, it is important to consider this differential UR bias when investigating diet-disease associations in children.

Proposal for a neurotoxic classification for chemicals at work.

Many neurotoxic chemicals are used in the workplace but there is currently no database dedicated to neurotoxicity. We aimed to develop a classification method for neurotoxicity based on a weight-of-evidence approach, similar to the IARC classification for carcinogenicity. Human and animal lines of evidence were collected from recent toxicological profiles and a literature search and were combined into six groups from neurotoxic to potentially not neurotoxic. The method was tested on 26 chemicals, mixtures or group of products used in the workplace in France: 31% were considered neurotoxic, 31% probably and 11% possibly neurotoxic, and 27% not classifiable because of insufficient data. This operational method suggests that many chemicals used in the workplace are neurotoxic and that questionnaires used to collect data on occupational chemical exposure should propose items with more targeted compounds that have common chemical or toxic properties to improve risk assessment.

Occupational co-exposure to biomechanical factors and neurotoxic chemicals in a representative sample of French employees.

OBJECTIVES: Musculoskeletal disorders, mainly carpal tunnel syndrome, represent a leading cause of compensation claims of workers worldwide. Despite this, and the fact that occupational exposures to biomechanical factors and neurotoxic chemicals have been individually associated with peripheral nerve damage, the prevalence of occupational co-exposure to biomechanical factors and neurotoxic chemicals has rarely been explored. Therefore, our aim was to assess the prevalence of occupational co-exposure to biomechanical factors and neurotoxic chemicals in a national representative sample of the French working population. METHODS: The study was based on the French representative cross-sectional survey SUMER 2010. A total of 47 983 employees who had worked in their current job for at least one year were included. Occupational exposure to biomechanical factors and neurotoxic chemicals within the previous week of work were assessed using a questionnaire during face-to-face interviews with occupational physicians. RESULTS: Approximately 5% of male employees and 1% of female employees were co-exposed to biomechanical factors and neurotoxic chemicals. This prevalence was up to 10% among male blue-collar workers and 13%, 8%, and 6%, respectively, among male employees in the construction, agriculture, and industry sectors. Male employees under 30 years old, in apprenticeships, and working in small companies were more co-exposed to biomechanical factors and neurotoxic chemicals than their counterparts. CONCLUSIONS: Occupational co-exposure to biomechanical factors and neurotoxic chemicals was observed in a significant proportion of French male employees, suggesting that further studies are required to investigate its potential adverse effects on peripheral neuropathies.

Do Women and Men Have the Same Patterns of Multiple Occupational Carcinogenic Exposures? Results from a Cohort of Cancer Patients.

Complex exposure situations are frequent at the workplace, but few studies have characterized multiple occupational carcinogenic exposures (MOCE) and their gendered differences across jobs' characteristics. We assessed MOCE separately in male and female jobs and identified patterns of MOCE at job level. Participants (834 men and 183 women) were cancer patients recruited between March 2002 and December 2010 in the ongoing SCOP93 cohort study, Seine-Saint-Denis department, France. Job histories were collected through personal interviews, and carcinogenic exposures were assessed by a multidisciplinary expert committee using a list of 53 carcinogens. Proportion of MOCE (i.e. ≥2 carcinogens) was assessed for male and female jobs separately. Principal component analysis combined with hierarchical ascendant classification was used to identify patterns of MOCE. Among the 5202 male jobs and 885 female jobs, respectively 42 and 9% were multi-exposed. Blue-collar workers and jobs in the construction and industry sectors had the highest rates of MOCE, contrasting with jobs held in recent periods (≥1997) and by patients aged ≥45 years at job start. A gradient of MOCE was also observed according to occupational segregation for both men and women. Eight patterns of MOCE were identified among male jobs: widespread carcinogens, mixed silica dust, heavy metals/combustion products, organic compounds/radiation, metal working, solvents/heavy metals, wood dust/formaldehyde/pesticides, and fuel exhausts. Three patterns of MOCE were found among female jobs: biological/organic compounds, industrial working, and fuel exhausts. Some patterns of MOCE were job-specific, whereas other patterns were found across different occupations. These results suggest that patterns of MOCE partly differ between men and women. They stress the importance of gendering multiple exposure assessment studies and point out the inadequacy of occupational disease compensation systems based on a single factor and non-gendered approach of carcinogenesis, ignoring differences between men and women in complex occupational exposure situations.

Multiple Exposures and Coexposures to Occupational Hazards Among Agricultural Workers: A Systematic Review of Observational Studies.

BACKGROUND: Workers may be exposed to various types of occupational hazards at the same time, potentially increasing the risk of adverse health outcomes. The aim of this review was to analyze the effects of multiple occupational exposures and coexposures to chemical, biomechanical, and physical hazards on adverse health outcomes among agricultural workers. METHODS: Articles published in English between 1990 and 2015 were identified using five popular databases and two complementary sources. The quality of the included publications was assessed using the methodology developed by the Effective Public Health Practice Project assessment tool for quantitative studies. RESULTS: Fifteen articles were included in the review. Multiple chemical exposures were significantly associated with an increased risk of respiratory diseases, cancer, and DNA and cytogenetic damage. Multiple physical exposures seemed to increase the risk of hearing loss, whereas coexposures to physical and biomechanical hazards were associated with an increased risk of musculoskeletal disorders among agricultural workers. CONCLUSION: Few studies have explored the impact of multiple occupational exposures on the health of agricultural workers. A very limited number of studies have investigated the effect of coexposures among biomechanical, physical, and chemical hazards on occupational health, which indicates a need for further research in this area.