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Health Science Journal of Indonesia
Khrisnapandit et al.
64
Flight time, number of sectors and risk of low back pain among short and
medium haul commercial female ight attendants in Indonesia
Irma Khrisnapandit,1 Hepy Tapan,2 Miftahul Firdos,2 Bastaman Basuki3
1 Universitas Gunadarma, Jakarta
2Indonesian Institute for Aviation and Space Medicine (Lakespra Saryanto), Jakarta
3Universitas Indonesia, Jakarta
Corresponding Address: Dr. Irma Khrisnapandit
Email: khrisnapandit@yahoo.com
Received: October 4, 2015; Revised: March 22, 2016; Accepted: April 27, 2016.
Abstrak
Latar belakang: Nyeri pinggang bawah (NPB) sering dialami pramugari dan dapat membatasi tugas
serta tanggung jawab pramugari. Tujuan penelitian ialah untuk mengetahui hubungan antara jam terbang
dan faktor lainnya dengan NPB pramugari sipil penerbangan jarak dekat dan menengah di Indonesia.
Metode: Studi potong lintang dengan sampling purposif dilakukan pada pramugari sipil penerbangan
jarak dekat dan menengah yang melaksanakan pengujian kesehatan di Balai Kesehatan Penerbangan
tanggal 5-26 Mei 2014. Data demogra, pekerjaan dan NPB dikumpulkan dengan pengisian kuesioner
dan pemeriksaan sik. Denisi NPB ialah nyeri anamnesis yang pernah atau masih dirasakan pada
pinggang bawah 1 bulan terakhir, non-neural, dan tidak terkait cedera akut yang tidak berhubungan
pekerjaan. Analisis regresi Cox digunakan untuk mengidentikasi faktor risiko yang berhubungan NPB.
Hasil: Di antara 333 pramugari yang melaksanakan pengujian kesehatan, 287 orang bersedia
berpartisipasi, dan 240 di antaranya memenuhi kriteria inklusi. Sebanyak 37,9% pramugari menderita
NPB. Faktor dominan yang mempertinggi risiko NPB ialah jam terbang dan jumlah sektor 24 jam terakhir.
Pramugari dengan jam terbang 9 jam atau lebih dibandingkan dengan yang kurang dari 9 jam berisiko
82% lebih tinggi mengalami NPB [risiko relatif suaian (RRa) = 1,82; p = 0,000]. Ditinjau dari jumlah
sektor 24 jam terakhir, pramugari dengan 4 sektor atau lebih dibandingkan yang kurang dari 4 sektor
berisiko 53% lebih tinggi mengalami NPB (RRa = 1,53; p = 0,034).
Kesimpulan: Jam terbang 24 jam terakhir selama 9 jam atau lebih dan jumlah sektor sebanyak 24 jam
terakhir 4 sektor atau lebih meningkatkan risiko NPB. (Health Science Journal of Indonesia 2016;7:64-8)
Kata kunci: nyeri pinggang bawah, pramugari, jam terbang, jumlah sektor
Abstract
Background: Low back pain (LBP) often experienced by ight attendants could limit their duties and
responsibilities. Aim of this study was to determine the correlation between ight time and other factors with
LBP among short and medium haul commercial female ight attendants in Indonesia.
Methods: Cross-sectional study with purposive sampling among short and medium haul commercial female
ight attendants who conducting medical examination on May 5-26th 2014 at Civil Aviation Medical Center.
Demographic, job and LBP data collected using questionnaire and physical examination. Denition of LBP
was historically pain that ever or still felt in lower back in the last month, non-neural, and no non-working
related acute injury. Cox regression analysis used to identify risk factor associated LBP.
Results: Among 333 female ight attendants who were conducting medical examination, 287 attendants
willing to participate, and 240 meet inclusion criteria. There are 37.9% ight attendants experienced LBP. The
dominant factors increasing LBP risk were ight time and number of sectors in the last 24 consecutive hours.
Female ight attendant with 9 hours or more ight time compared with less have 82% higher LBP risk [adjusted
relative risk (RRa) = 1.82; p = 0.000]. Review from number of sectors in the last 24 consecutive hours, female
ight attendant with 4 sectors or more compared with less have 53% higher LBP risk (RRa = 1.53; p = 0.034).
Conclusion: Nine hours or more ight time and 4 sectors or more in the last 24 consecutive hours have
higher risk of LBP. (Health Science Journal of Indonesia 2016;7:64-8)
Key words: low back pain, female ight attendant, ight time, number of sectors, short and medium haul ight
Vol. 7, No. 1, June 2016 Low back pain in female ight attendant 65
Low back pain is the leading cause of activity
limitation, work absence, and an enormous economic
burden on individuals, families, communities, indus-
try and governments.1 The lifetime prevalence of
low back pain is reported to be as high as 84%, with
11-12% of the population being disabled by it.2 Of
special importance for ight safety is the sudden,
and many times unpredictable, occurrence of acute
attacks of pain,3 which may result cabin crew may
not be able to provide appropriate cabin services,
but also their awareness of abnormal situations and
response ability will be weakened, and this may
render potential lethal risks to ight safety.
In United States (U.S.) ight attendants, the
lower-back was shown to be the body region most
commonly affected by musculoskeletal disorders,
as high as 85,9%.4 Up to 52% of total direct
workers’ compensation claim among Canadian ight
attendants related to low back problem.5 Result of
study in U.S. long haul female ight attendants was
no statistically signicant differences were found
between ight attendants with or without low-back
pain on years of service as a ight attendant, ight
hours, number of sectors, and body mass index.6
Flight time and number of sectors for cabin crew
have not been regulated in the Civil Aviation Safety
Regulations part 121. Prevalence of low back pain on
the ight attendants in Indonesia is unknown. Indonesia
is an archipelagic Island country, causing short and
medium ight dominates. The aim of this study was
to examine correlation of ight time, other risk factors
and low back pain among short and medium haul
commercial female ight attendants in Indonesia.
METHODS
This study used cross-sectional design with purposive
sampling among short and medium haul commercial
female ight attendants who conducting medical
examination on May 5-26th 2014 at Civil Aviation
Medical Center. The data was collected by subject
answering structured questionnaire and measurement
of body weight and height by researcher.
Subjects in this study were (1) commercial female
ight attendants who are still on active ight duty on
the airline in Indonesia; (2) age 19-45 years old; (3)
short-haul ight operation (with ight times of less
than 2 hours) or medium-haul ight operation (ight
times between 2 and 6 hours).7
Low back pain were denes as historically pain that
ever or still felt in lower back in the last month. This
was determined by a modied single question with
a yes/no response and a body map derived from
Nordic Musculoskeletal Questionnaire,8 which was
done by the study before.6 The positif low back pain
cases in this study were answering “Yes” from that
single question, but no non-work related acute injury
(e.g., motor vehicle accident, sports, home accident)
and non-neural origin.
Flight time in the last 24 consecutive hours were
the total elapsed time from the moment the aircraft
rst moves under its own power for the purpose of
take off, until the time it comes to rest at the end
of the ight with limit for 24 consecutive hours on
the last ight duty before the subjects lling out the
questionnaire (1-8 hours, 9-14 hours). While number
of sectors were total number of ight which has a
take-off and landing at different airports which are
not less than 50 nautical miles apart 24 consecutive
hours on the last ight duty before the subjects lling
out the questionnaire (1-3 sectors, 4-8 sectors).
A number of confounders categorized into: age (19-
29 years, 30-39 years, 40-44 years); educational
level (bachelor, diploma, high-school); marital status
(single, married, separated); height (158 cm-164 cm,
165-174 cm); body mass index (normal 18,5-24,9 kg/
m2, underweight < 18,5 kg/m2, overweight 25-29,9
kg/m2); leisure time physical activity (nothing, light,
moderate, high); smoking status (never, stopped,
current); years of service (1-5 years, 6-9 years, 10-
24 years); frequency of luggage lifting per ight (2-5
times, 6-10 times, 11-12 times).
The research protokol was approved by Research
Ethical Commission of Faculty of Medicine Uni-
versitas Indonesia and undertaken upon approval by
the Chief of the Civil Aviation Medical Centre.
Research analysis using Cox regression with a
constant time to calculate the relative risk (RR) for
low back pain. Calculations using STATA version 9.
Results were considered statistically signicant at a
5% (P < 0.05) signicance level.
RESULTS
In making interpretations of this study need to be
considered: purposive sampling in a short time, and
subjectivity because no special physical examination
for the diagnosis of low back pain. In this study, low
back pain caused by musculoskeletal system and
the study was performed on short and medium haul
commercial female ight attendants only.
Health Science Journal of Indonesia
Khrisnapandit et al.
66
During the 16 days of the study there were 333
female ight attendants who perform periodic health
examination in Civil Aviation Medical Center. A
total of 287 female ight attendants are willing to
participate in this study and of whom 47 people were
excluded for analysis. From 240 short and medium
haul commercial female ight attendants that t the
inclusion criteria there were 91 attendants having
low back pain.
Table 1 shows that both the female ight attendants
with and without low back pain similarly distributed by
age, education level, marital status, height, body mass
index and leisure time physical activity. Female ight
attendants who are still smoking compared with never
smoking appears to have a higher risk of having low
back pain.
Table 2 shows that both the female ight attendants
with and without low back pain similarly distributed
on years of service and frequency of luggage lifting
per ight.
Table 3 shows that the two dominant factors (ight
time and the number of sectors in the last 24
consecutive hours) correlate with the risk of low
back pain. Female ight attendant with 9 hours or
more ight time in the 24 consecutive hours had a
82% higher probability of experiencing low back
pain compared with less than 9 hours. While 4
sectors or more in the last 24 consecutive hours had
a 53% higher probability of experiencing low back
pain compared with less than 4 sectors.
Table 1. Several socio demographic, health behavior characteristics and risk of low back pain
Low back pain
Crude relative risk 95% Condence interval P
No
(n = 149) Yes
(n = 91)
n % n %
Age
19-29 years 124 63.6 71 36.4 1.00 Reference
30-39 years 23 56.1 18 43.9 1.21 0.72-2.02 0.478
40-44 years 2 50.0 2 50.0 1.37 0.33-5.60 0.668
Education level
Bachelor 14 58.3 10 41.7 1.00 Reference
Diploma 17 48.6 18 51.4 1.23 0.57-2.67 0.594
High-school 118 65.2 63 34.8 0.84 0.43-1.63 0.597
Marital status
Single 124 63.9 70 36.1 1.00 Reference
Married 19 51.4 18 48.6 1.35 0.80-2.26 0.258
Separated 6 66.7 3 33.3 0.92 0.29-2.93 0.893
Body weight
43-53 kg 66 64.7 36 35.3 1.00 Reference
54-68 kg 83 60.1 55 39.9 1.13 0.74-1.72 0.571
Body height
158-164 cm 86 65.2 46 34.8 1.00 Reference
165-174 cm 63 58.3 45 41.7 1.20 0.79-1.80 0.394
Body mass index
Normal 132 63.8 75 36.2 1.00 Reference
Underweight 16 53.3 14 46.7 1.29 0.76-2.38 0.385
Overweight 1 33.3 2 66.7 1.84 0.46-7.57 0.395
Leisure time physical activity
Heavy 861.5 5 38.5 1.00 Reference
Moderate 45 70.3 19 29.7 0.77 0.29-2.07 0.606
Light 48 53.9 41 46.1 1.19 0.47-3.03 0.703
Nothing 48 64.9 26 35.1 0.91 0.35-2.38 0.853
Smoking status
Never 112 65.9 58 34.1 1.00 Reference
Stopped 16 55.2 13 44.8 1.31 0.72-2.40 0.374
Current 21 51.2 20 48.8 1.43 0.86-2.38 0.168
Vol. 7, No. 1, June 2016 Low back pain in female ight attendant 67
Table 2. Several work related factors and risk of low back pain
Low back pain
Crude relative risk 95% Condence interval P
No
(n = 149) Yes
(n = 91)
n % n %
Years of service
1-5 years 107 62.2 65 37.8 1.00 Reference
6-9 years 21 60.0 14 40.0 1.06 0.59-1.89 0.847
10-24 years 21 63.6 12 36.4 0.96 0.529-1.78 0.902
Frequency of luggage lifting per ight
2-5 times 101 63.9 57 36.1 1.00 Reference
6-10 times 29 56.9 22 43.1 1.19 0.73-1.95 0.476
11-12 times 19 61.3 12 38.7 1.07 0.58-2.00 0.824
Table 3. Relationship between ight time in the last 24 consecutive hours, number of sectors in the last 24 consecutive
hours and risk of low back pain
Low back pain
Adjusted relative risk* 95% Condence interval P
No
(n = 149) Ye s
(n = 91)
n % n %
Flight time in the last 24 consecutive hours
1-8 hours 131 68.9 59 31.1 1.00 Reference
9-14 hours 18 36.0 32 64.0 1.82 1.34-2.46 0.000
Number of sectors in the last 24
consecutive hours
1-3 74 74.0 26 26.0 1.00 Reference
4-8 75 53.6 65 46.4 1.53 1.03-2.26 0.034
*Adjusted each other between variables listed on this table
DISCUSSION
This study found 91 (37.9%) short and medium haul
commercial female ight attendant experiencing low
back pain. This is lower than U.S. long-haul female
ight attendant where 85.9% of those experiencing
low back pain.4 The difference is caused by the
difference in determined the kriteria for diagnosis.
In that study, the diagnosis was low back pain in
the last 12 months regardless of the cause so that
the estimated prevalence is higher. Long-haul ight
attendant is known to have risk of low back pain
greater that short-haul ight attendant.9
Our research shows that 9 hours or more ight time
in the last 24 consecutive hours had higher low back
pain risk when compared with less than 9 hours ight
time in short and medium haul commercial female
ight attendantS. Similar result were not obtained
in study conducted on U.S. long-haul female
ight attendants, which no statistically signicant
differences were found between ight attendants
with or without low-back pain on ight time.6 On
long-haul ights, the ight is only done 1 time a day
with more than 6 hours ying per segment and was
followed by a break at least 24 hours.
The longer ight hours on short and medium haul
ight attendant, more and more physical loading is
done. In Galipault study, 27.6% of ight attendants
thought seven-nine hours the duty length induced
tiredness. This study also found that short duration
ights with beverage or snack service produce large
increases in end-of-duty fatigue.10 Ono’s study on
Japanese ight attendant found that the ying hours
9 hours or more shown to correlate with stress and
fatigue symptoms include low back pain.11
Low back pain on the ight attendant can be related
to physical burden associated with their work tasks,
including manual material handling (for example,
long standing and frequent bending).5 In Morley
and Grifths’s study, high workload demands were
reported by 83% of ight attendants.12 In another
workload-related study with 118 female ight
attendants, the total average number of steps taken
per ight attendant during ights of an approximate
duration of 10.6 hours was 10,742.8, or 14.0 steps/
min.13
Health Science Journal of Indonesia
Khrisnapandit et al.
68
Other risk factors were signicantly related to lower
back pain in this study is the number of sectors in
the last 24 consecutive hours. In this study, female
ight attendant with 4 sectors or more in the last 24
consecutive hours had higher risk of low back pain
compared to less than 4 sectors. Similar result were
not obtained in the study conducted on U.S. long-
haul female ight attendant, which no statistically
signicant differences were found between ight
attendants with or without low-back pain on ight.6
Short and medium haul ight crew work with
more often take off and landing. On each ight
there are working cycle begin of the entry of
passengers to the aircraft, passenger seat, baggage
storage, passenger brieng, distribution of food and
beverages, cleaning up, preparation for landing,
and clearing the passengers off the plane, to be
completed on each sector down the route. In long-
haul ight operation, there is only one full cycle to
be completed each rostered duty period. Therefore
it takes recommendations to the airline and Civil
Aviation Medical Center regarding ight time and
sector number in the last 24 consecutive hours
regulation for the cabin crew.
Overweight appears to increase the risk of low back
pain compared with normal body mass index ight
attendants but not signicantly correlated. This may
occur because slightly number of overweight ight
attendants.
It is also seen on the risk factors of smoking, where
smoking appears to increase the risk of low back
pain compared with non-smoking ight attendants
but it is not signicantly correlated. Little female
ight attendants who are still smoking.
Lifting luggage did not correlate signicantly with
risk of low back pain. This happen because the
weight of passengers luggage only about 7 kg and if
necessary, the ight attendants will lift the luggage
with the other.
In conclusion, 9 hours or more ight time and 4
sectors or more in last 24 consecutive hours increased
the risk of low back pain.
Acknowledgments
The authors acknowledge all female ight attendants
who participated in the study. We also would like
to thank Chief of Civil Aviation Medical Center for
allowing this study.
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