Challenges and support needs in psychological and physical health among pilots: a qualitative study

Abstract

Introduction
Physical and mental health problems among pilots affect their working state and impact flight safety. Although pilots’ physical and mental health problems have become increasingly prominent, their health has not been taken seriously. This study aimed to clarify challenges and support needs related to psychological and physical health among pilots to inform development of a more scientific and comprehensive physical and mental health system for civil aviation pilots.

Methods
This qualitative study recruited pilots from nine civil aviation companies. Focus group interviews via an online conference platform were conducted in August 2022. Colaizzi analysis was used to derive themes from the data and explore pilots’ experiences, challenges, and support needs.

Results
The main sub-themes capturing pilots’ psychological and physical health challenges were: (1) imbalance between family life and work; (2) pressure from assessment and physical examination eligibility requirements; (3) pressure from worries about being infected with COVID-19; (4) nutrition deficiency during working hours; (5) changes in eating habits because of the COVID-19 pandemic; (6) sleep deprivation; (7) occupational diseases; (8) lack of support from the company in coping with stress; (9) pilots’ yearly examination standards; (10) support with sports equipment; (11) respecting planned rest time; and (12) isolation periods.

Discussion
The interviewed pilots experienced major psychological pressure from various sources, and their physical health condition was concerning. We offer several suggestions that could be addressed to improve pilots’ physical and mental health. However, more research is needed to compare standard health measures for pilots around the world in order to improve their physical and mental health and contribute to overall aviation safety.

Full text

Frontiers in Public Health 01 frontiersin.org
Challenges and support needs in
psychological and physical health
among pilots: a qualitative study
WenXu
1,2, 3†, YuyanBao
1,2, 3†, LinZhang
4†, YunfeiLi
5,
ErliangZhang
6, HuilunLi
6, QingqingJin
4, YanChen
4,
QingqingDuan
4, FengShi
4, LinlinWang
4, ZiyangLu
3,
XuhuaChen
3, QijingGao
3, HangyuHan
3, BinRen
4*, YaSu
7* and
MiXiang
1,2, 6*
1 International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong
University, Shanghai, China, 2 Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China,
3 Shanghai Jiao Tong University School of Medicine, Shanghai, China, 4 CAAC East China Aviation
Personnel Medical Appraisal Center, Civil Aviation Shanghai Hospital, Shanghai, China, 5 Department
of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and
Medicine, Shinjuku, Japan, 6 School of Public Health, Shanghai Jiao Tong University, Shanghai, China,
7 School of Nursing, Shanghai Jiao Tong University, Shanghai, China
Introduction: Physical and mental health problems among pilots aect their
working state and impact flight safety. Although pilots’ physical and mental
health problems have become increasingly prominent, their health has not been
taken seriously. This study aimed to clarify challenges and support needs related
to psychological and physical health among pilots to inform development of a
more scientific and comprehensive physical and mental health system for civil
aviation pilots.
Methods: This qualitative study recruited pilots from nine civil aviation
companies. Focus group interviews via an online conference platform were
conducted in August 2022. Colaizzi analysis was used to derive themes from
the data and explore pilots’ experiences, challenges, and support needs.
Results: The main sub-themes capturing pilots’ psychological and physical
health challenges were: (1) imbalance between family life and work; (2) pressure
from assessment and physical examination eligibility requirements; (3) pressure
from worries about being infected with COVID-19; (4) nutrition deficiency
during working hours; (5) changes in eating habits because of the COVID-19
pandemic; (6) sleep deprivation; (7) occupational diseases; (8) lack of support
from the company in coping with stress; (9) pilots’ yearly examination standards;
(10) support with sports equipment; (11) respecting planned rest time; and (12)
isolation periods.
Discussion: The interviewed pilots experienced major psychological pressure
from various sources, and their physical health condition was concerning.
Weoer several suggestions that could beaddressed to improve pilots’ physical
and mental health. However, more research is needed to compare standard
health measures for pilots around the world in order to improve their physical
and mental health and contribute to overall aviation safety.
KEYWORDS
occupational health, mental health, physical health, qualitative study, pilots and cabin
crew, COVID-19
OPEN ACCESS
EDITED BY
Mardi A. Crane-Godreau,
Independent Researcher, Arlington, TX,
UnitedStates
REVIEWED BY
Leigh-ann Onnis,
James Cook University, Australia
Catherine Bodeau-Pean,
Independent Researcher, Paris, France
*CORRESPONDENCE
Bin Ren
1009080123@qq.com
Ya Su
suya@sjtu.edu.cn
Mi Xiang
xiang-sjtu@hotmai.com
†These authors have contributed equally to
this work and share first authorship
RECEIVED 06 December 2023
ACCEPTED 05 April 2024
PUBLISHED 16 April 2024
CITATION
Xu W, Bao Y, Zhang L, Li Y, Zhang E, Li H,
Jin Q, Chen Y, Duan Q, Shi F, Wang L, Lu Z,
Chen X, Gao Q, Han H, Ren B, Su Y and
Xiang M (2024) Challenges and support needs
in psychological and physical health among
pilots: a qualitative study.
Front. Public Health 12:1351568.
doi: 10.3389/fpubh.2024.1351568
COPYRIGHT
© 2024 Xu, Bao, Zhang, Li, Zhang, Li, Jin,
Chen, Duan, Shi, Wang, Lu, Chen, Gao, Han,
Ren, Su and Xiang. This is an open-access
article distributed under the terms of the
Creative Commons Attribution License
(CC BY). The use, distribution or reproduction
in other forums is permitted, provided the
original author(s) and the copyright owner(s)
are credited and that the original publication
in this journal is cited, in accordance with
accepted academic practice. No use,
distribution or reproduction is permitted
which does not comply with these terms.
TYPE Original Research
PUBLISHED 16 April 2024
DOI 10.3389/fpubh.2024.1351568

Xu et al. 10.3389/fpubh.2024.1351568
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1 Introduction
It is known that pilots’ health aects their working state.
However, the serious risks posed by pilots’ working conditions,
including enclosed cabins that are exposed to ultraviolet radiation
at high altitudes for long periods (1) and isolation rooms during
the COVID-19 pandemic, mean that pilots’ physical and mental
health problems have become increasingly prominent; these health
problems may impact ight safety (1–4). Previous studies have
reported that compared with well-rested people, pilots who felt
tired from lack of sleep thought and reacted more slowly, had more
memory problems, and were more likely to make mistakes (5–7).
e PlaneCrashInfo.com database shows that approximately 50%
of ight accidents are related to pilots’ working state; this
proportion has not changed signicantly over time. ese data
conrm that pilots’ physical and mental health impact ight safety
by aecting their working state. erefore, improving pilots’
physical and mental health is necessary to improve aviation
safety (7).
Previous studies have shown that common health problems
among pilots include abdominal distension, headache, fatigue, and
depression, attributable to factors such as smoking, drinking, and
irregular diet and sleep (6, 8–10). Increased use of caeine, alcohol,
and drugs cannot prevent deterioration of physical and mental
conditions but increases the risk for insomnia and sleepiness,
whereas exercise can eectively improve pilots’ physical and mental
health (6, 11). Most previous studies on this topic were conducted
using questionnaires, which could not accurately capture pilots’
subjective feelings (1–6). Qualitative research in this area is
relatively scarce, meaning personalized information about pilots’
feelings remains largely unknown. In addition, most previous
studies have focused on physical or psychological evaluations.
However, both physical and mental health are important
components of overall health, and can inuence each other;
therefore, a discussion combining physical and mental health may
provide a more comprehensive perspective on pilots’ health issues.
Unfortunately, many unilateral studies could not eectively link
these two aspects to draw comprehensive conclusions. In contrast,
this study used a comprehensive qualitative approach with data
collected in interviews. is allowed us to pay attention to pilots’
real experiences, rather than constraining these experiences using
set response options. Additionally, using focus group interviews
meant that wecould analyze pilots’ perspectives of challenges and
support needs in relation to both physical and mental health
aspects, which allowed a comprehensive analysis.
In this qualitative study, we hoped to oer preliminary mind
mapping of pilots’ basic working conditions based on pilots’
experiences of their psychological and physical health through
interviews. Weaimed to analyze the experiences expressed by pilots
in relation to various factors, such as energy and time distribution
between work and life, exercise habits, diet and sleep regularity,
pressure conditions, and the impact of the pandemic on work content
and income. is allowed us to summarize pilots’ experiences of their
profession, examine their perspectives of their own health, and explore
their real support needs. e purpose of this series of qualitative focus
group interviews was to clarify the challenges faced by pilots relating
to both physical and mental health, and determine pilots’ needs and
suggestions from the perspective of balancing physical and mental
health. Ultimately, this study may provide guidance for follow-up
intervention research to improve the relevance and eectiveness of
strategies to improve pilots’ mental and physical health. Our
overarching purpose was to provide pilots with more appropriate
psychological and physical health support.
2 Materials and methods
Focus group interviews were carried out via the Tencent
conference platform. Interviewed participants’ statements about their
experiences on career-related topics were used as the data for analysis.
COREQ guidelines were used to guide this study (12).
2.1 Study sample
A purposive sampling method was used to select pilots from
nine civil aviation companies: two large, three medium-sized, and
three small civil aviation companies and one cargo airline (which
is a special type of civil aviation company). Werandomly selected
three or six pilots from each airline and conducted interviews in
batches of three participants. e reason for selecting three
participants for each focus group interview was that the privacy
and duration of the interviews would have been dicult to control
with more participants, and the information collected might have
been incomplete with fewer participants. Participant selection was
stratied by age and position (copilots: including pilot cadet and
second copilot, and captains or squadron leaders) to cover all
sub-groups of pilots. e inclusion criteria for this study were that
participants must beactively employed as pilots and reside in East
China. Any pilot that withdrew during the interview process was
excluded from the valid sample. Weconsidered the problem of
information saturation, and the sample size and interview content
were determined based on this principle. In total, weinterviewed
42 pilots (Table1). All participants provided informed consent
before their interviews.
Participants belonging to the same company were allocated to the
same interview group, with each group comprising three participants.
Overall, 14 groups were formed and interviewed successively.
2.2 Ethical considerations
is study was approved by the Ethics Committee of Civil
Aviation Shanghai Hospital (no. 2021-7). All ethics procedures and
governance requirements were adhered to for each interviewed
participant. All participants were advised that participation was
voluntary, they had the option to withdraw from the study, and the
interview session could end at any time they requested without
any repercussions.
2.3 Data collection
e interview outline was developed by the research team aer
reviewing relevant literature (13, 14), and reected our purpose of
improving pilots’ physical and mental health. e outline focused on

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participants’ working experience, living habits, and challenges in work
and life. To optimize timely data collection, the research team
conducted simulated interviews with two non-aviation practitioners
and then modied the interview outline as necessary to avoid
questions perceived as intruding on participants’ privacy or that had
unclear meanings.
TABLE1 Participants’ general information.
Serial
number
Gender age Date of
interview
Position Serial number
of company
Marital
status
Record of formal
schooling
Years of
flight
1Male 35 2022.8.8 Squadron leader 1 Married Undergraduate course 13
2Male 34 2022.8.8 Squadron leader 1 Married Undergraduate course 11
3Male 37 2022.8.8 Squadron leader 1 Married Undergraduate course 15
4Male 36 2022.8.9 Squadron leader 2 Married Undergraduate course 14
5Male 55 2022.8.9 Squadron leader 2 Married Undergraduate course 18
6Male 48 2022.8.9 Squadron leader 2 Married Undergraduate course 22
7Male 34 2022.8.9 Squadron leader 3 Married Undergraduate course 6
8Male 36 2022.8.9 Squadron leader 3 Married Undergraduate course 8
9Male 42 2022.8.9 Squadron leader 3 Married Undergraduate course 14
10 Male 40 2022.8.10 Squadron leader 4 Married Undergraduate course 14
11 Male 38 2022.8.10 Squadron leader 4 Married Undergraduate course 13
12 Male 39 2022.8.10 Squadron leader 4 Married Undergraduate course 13
13 Male 52 2022.8.10 Squadron leader 5 Married Undergraduate course 18
14 Male 40 2022.8.10 Squadron leader 5 Married Undergraduate course 18
15 Male 42 2022.8.10 Squadron leader 5 Married Undergraduate course 17
16 Male 30 2022.8.10 Copilot 6Married Undergraduate course 3
17 Male 27 2022.8.10 Copilot 6 Unmarried Undergraduate course 0.5
18 Male 30 2022.8.10 Copilot 6 Unmarried Undergraduate course 3
19 Male 30 2022.8.11 Copilot 4 Unmarried Undergraduate course 3
20 Female 29 2022.8.11 Copilot 4 Unmarried Undergraduate course 3
21 Male 26 2022.8.11 Copilot 4 Unmarried Undergraduate course 1
22 Male 43 2022.8.11 Squadron leader 7 Married Undergraduate course 22
23 Male 45 2022.8.11 Squadron leader 7 Married Undergraduate course 22
24 Male 43 2022.8.11 Squadron leader 7 Married Undergraduate course 22
25 Male 32 2022.8.11 Copilot 8Married Undergraduate course 6
26 Male 31 2022.8.11 Copilot 8Married Undergraduate course 3
27 Male 27 2022.8.11 Copilot 8 Unmarried Undergraduate course 3
28 Male 47 2022.8.15 Squadron leader 9 Married Undergraduate course 23
29 Male 42 2022.8.15 Squadron leader 9 Married Undergraduate course 20
30 Male 46 2022.8.15 Squadron leader 9 Married Undergraduate course 21
31 Male 40 2022.8.16 Squadron leader 7 Married Undergraduate course 19
32 Male 39 2022.8.16 Squadron leader 7 Married Undergraduate course 15
33 Male 40 2022.8.16 Squadron leader 7 Married Undergraduate course 19
34 Male 28 2022.8.16 Copilot 9 Unmarried Undergraduate course 5
35 Male 25 2022.8.16 Copilot 9 Unmarried Undergraduate course 5
36 Male 24 2022.8.16 Copilot 9 Unmarried Undergraduate course 3
37 Male 49 2022.8.17 Squadron leader 8 Unmarried Undergraduate course 23
38 Male 42 2022.8.17 Squadron leader 8 Unmarried Undergraduate course 17
39 Male 43 2022.8.17 Squadron leader 8 Unmarried Undergraduate course 20
40 Male 39 2022.8.17 Squadron leader 6 Married Undergraduate course 15
41 Male 42 2022.8.17 Squadron leader 6 Married Undergraduate course 17
42 Male 38 2022.8.17 Squadron leader 6 Married Undergraduate course 18

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2.3.1 Final interview outline
Q: Youmostly work in the cabin of an airplane. Do youfeel that
it interferes with your leisure and family life? Are there fewer
opportunities to exercise?
Q: In terms of diet, are your main meals served by the crew? Do
youget bored and want something else for a change?
Q: It appears that your working hours are largely limited
by the ight schedule. Is this a stressful working mode?
What is your schedule like? How do you feel about your
sleep? Have youexperienced a sleep disorder (e.g., diculty
falling asleep, waking up at night, waking up early in
the morning)?
Q: Does the stress from work interfere with your daily life?
Q: In the past 2 years, the airline industry was greatly aected by
COVID-19. What were the dierences between your working
pattern during that period and non-COVID-19 times? Has the
pandemic aected your income? Do you feel more stressed
and anxious?
Q: In such a unique period, did youhave a dierent view of work
than before? Could youshare your opinion on the measures taken
by your country or your company for COVID-19 prevention,
protection, and quarantine management? Does the company
provide psychological counseling and other interventions? How
does it work?
2.3.2 Research protocol
Before the interviews, one researcher (M.X.) had preliminary
contact with participants through WeChat and invited them to
participate in the online focus group interviews via the Tencent
conference platform. Only the research team members and
participants attended the group interviews. Before each interview
started, the interviewers introduced the research team members
(including the name, identity, and responsibilities of each
member) and the purpose of this qualitative research. The
research team’s commitment to confidentiality of the interview
data was also clearly stated. Consent was then obtained from all
participants. All interviews were conducted in Chinese and then
translated and reviewed by W.X. and Y.B. for inclusion in
this manuscript.
2.3.3 Interview process and reflection
As most participants were male, the interviews were mainly
conducted by two male interviewers (Y.B. and H.H.), supplemented
by questions from the supervising researcher. During interviews, the
interviewers and participants turned on their cameras and enabled
voice communication. e interviews were recorded to facilitate the
subsequent arrangement of the interview results. Each interview
lasted 45–90 min.
To improve the interview quality and ensure information
saturation, members of the interview team analyzed and reected on
the problems encountered in the interview process and put forward
practical suggestions aer each interview.
2.4 Data analysis
Step 1: aer the interviews, the researchers immediately
transcribed the recordings. Colaizzi’s 7-step method was used for data
analysis (15). Werepeatedly read the interview materials to understand
the general meaning.
Step2: weextracted statements of signicance and then coded
recurring, meaningful ideas.
Step3: wesummarized the encoded ideas, which was followed by
writing a detailed description without omissions.
Step 4: we then rened similar views and developed the
theme concept.
Step 5: the analysis results were returned to participants
for validation. In cases of disagreement, the research team
resolved problems through discussion to ensure the accuracy of
the results.
3 Results
Forty-two pilots from nine civil aviation companies (two large
civil aviation companies, three medium-sized civil aviation
companies, three small civil aviation companies, and one cargo
airline) participated in the interviews. Most participants were
captains (71%), and the remainder were copilots or ying cadets
(29%). e majority of participants were aged over 35 years (64%),
male (98%), married (71%), and had over 10 years of ying
experience (67%). All participants had completed their
undergraduate education (Table2).
We identified three major themes from the interview data
that covered the main types of issues reflected in participants’
narratives and the magnitude of their impact: (1)
psychological stress; (2) physical health; and (3) pilots’ needs
and suggestions.
3.1 Psychological stress
3.1.1 Imbalance between family life and work
Some participants expressed that their stress originated from the
lack of work-family balance. Pilots faced long-term absences from
their families because one cycle of their ying assignments usually
took several days (or more), and each interval between ying tasks was
relatively short.
“Even after returning home, Imay have to start a new round
after several days, and the number of days I can return
home might beonly dozens of days in a year. In these days,
there must bea lot of things to deal with. For people around
our age, the biggest worry is the health of the older adults and
children. Once they get sick, youcan only rely on your spouse
to take care of the four older adults and one child; even some
second-child families will have two children, which is a
greater pressure for the spouse. Some of our colleagues’
spouses will quit their jobs to bestay-at-home mothers for the
sake of their families, which is also unfair to their spouses.
They give up their careers for the sake of their families.”
(male, 36 years, captain)

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3.1.2 Pressure from assessment and physical
examination eligibility requirements
Some participants who were ying cadets found it dicult to
complete their assessment to a high standard. e fear of making
mistakes created major pressure, which resulted in serious
psychological stress in the long term.
“When you’re in the cadet stage, the standard might beasking
youto nish 40% of the job correctly, but the faculty is asking
youto nish 60% of it correctly. ey themselves might beable to
do 90%, or even 100% of the job, without any mistakes. However,
this is actually very dicult for us. Suppose youwant to do 100
things, to make 10 to 20 mistakes is very easy, but if youallow
yourself to make only one mistake, or not make any mistakes, it
ends up being very dicult.” (male, 26 years, copilot)
Some participants emphasized that the physical examination,
which was an essential part of their yearly assessment, also caused
psychological stress. is was because failure to meet the physical
examination standards implied a potential signicant safety risk,
which would directly result in suspension of that pilot’s
medical certicate.
“We have a hard target to meet in our physical examination every
year. If wefail to meet the target, our work arrangement will
beaected.” (male, 30 years, copilot)
Given the stress caused by the various assessments, pilots reported
experiencing a heavy psychological burden, especially older pilots.
With all these stress from the various assessments, pilots reported
heavy psychological burden, especially in older pilots. is nding
provides a theoretical basis for the development of intervention to
improve the mental health of pilots.
3.1.3 Pressure caused by worries about being
infected with COVID-19
Most participants reported that the COVID-19 pandemic had a
huge inuence on the civil aviation industry and on pilots themselves.
ey noted that the pressure experienced during the COVID-19
pandemic originated from the economic pressure caused by the
decreased ying time, continuous isolation, and fear of contracting
the virus.
“Meanwhile, the ights have reduced a lot since the COVID-19
pandemic, and now about half of them are cancelled. Many
captains have a lot of pressure regarding mortgage payments
especially during the lockdown period. Now, to most of the young
people, even the captain, especially those whose home is not here
in Shanghai, the pressure is rather big. ere are so many family
members that they need to take care of, parents, children, and so
on. ey could probably handle it before the pandemic, but now
they lack condence.” (male, 48 years, captain)
“Another point causing anxiety for our pilots is COVID-19
because wehave to stop ying immediately when weare found to
beinfected in the physical examination. Wehave to wait until the
nucleic acid test is negative, then beobserved on the ground for 2
or 3 months and wait for the Civil Aviation Administration of
China (CAAC) to make a decision. e whole process may last for
6 months. (…) ough we’re all under close management, and
we’ve all taken precautions, Omicron is highly contagious with
many variants, so there’s still a lot of risk. And if weget infected,
westop ying, which makes us very anxious.” (male, 36 years,
captain)
3.2 Physical health
3.2.1 Nutrition deficiency during working hours
Most participants shared that prepared airline meals during ight
tasks created a serious problem regarding nutrition deciency. ey
noted that this problem originated from three phenomena: irregular
meal timings, imbalanced nutrition structure of prepared airline
meals, and limited choice.
Many participants reported they had an irregular diet during
ight tasks, which was closely related to the ight and landing times.
is made it dicult for pilots to get sucient nutrition when needed,
which may harm their health.
“e total life schedule of our occupation is irregular because it is
based on the time of the ight. For example, there are early or late
ights sometimes. Under such circumstances, maybe some of the
pilots do not follow the schedule in terms of diet. (…) For us,
especially when the ight time is right around lunch time or
dinner time, what wecan do is simply postpone the time to eat or
nish having meals in an extremely short time.” (male, 36 years,
captain)
Most participants claimed that the nutritional structure of the
airline meals could not beguaranteed. Although basic nutritional
factors (e.g., the amount of energy, vitamins) were considered carefully
TABLE2 Participants’ demographic characteristics.
Characteristics Numbers Percentage
Sex
Wom en 1 2%
Men 41 98%
Age, years
<35 27 64%
≥35 15 36%
Marital status
Married 30 71%
Unmarried 12 29%
Record of formal schooling
Undergraduate course 42 100%
Position
Captain 30 71%
Copilot 12 29%
Years of ight, years
<10 14 33%
≥10 28 67%

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when the meals were prepared to ensure that the pilots were well-
conditioned and make the ight safe, the quality of the meals varied
from company to company. Some participants reported high levels of
salt and oil in their airline meals.
Many participants reported a tendency to overeat when nishing
a ying task. Participants’ narratives emphasized that they tended to
choose unhealthy foods as a kind of “compensation” for the prolonged
intake of bland foods during ying tasks.
“Aer landing, most people really will go and overeat, and will
bemore likely to eat some food with strong avor, such as spicy
hot pot. Most of us know very well that this food is not healthy,
but wereally want to eat it.” (male, 27 years, copilot)
Some participants added that the limited choice of airline meals
was a major problem for many pilots with allergies. For example, if
airline meals happened to include allergens, most pilots had no choice
but to skip the meal, which resulted in inadequate energy and
nutrition intake, which could potentially damage the digestive system
in the long term (16).
“ere are a lot of people who are lactose intolerant, or allergic to
legumes or other foods, so for those people there is little choice.”
(male, 28 years, copilot)
Some participants expressed that it would benet their physical
and psychological health if the airline meals were more balanced in
terms of nutrition. A similar request was also made in relation to meals
provided during isolation periods because of the COVID-19 pandemic,
as meals during quarantine were oen provided by the airline for safety
reasons. Moreover, some participants noted that more personalized
meals or more choices in the daily meals may increase their desire to
eat airline meals, which would prevent the lack of nutrition resulting
from reluctance to eat airline meals. Several participants advised that
the taste of the airline meals could also beimproved to make pilots
more willing to eat these meals to guarantee sucient nutrition intake.
“All the quarantine hotels are short of vegetables. Because of the
epidemic, wecannot buy materials from the outside, so wehope
the company can intervene to provide us with some vegetables.
Now there is an imbalance between meat and vegetables, and
there is not much choice.” (male, 28 years, copilot)
3.2.2 Changes in eating habits because of the
COVID-19 pandemic
Some participants emphasized that their diet during the
COVID-19 pandemic differed from that before the pandemic. On
the one hand, the decreased flying time meant that pilots had
more time to spend at home, which resulted in the normalization
of daily diets. On the other hand, there were periods of isolation
after finishing flights. The meals during this period were supplied
by the company and were the same as the prepared airline meals,
so there were still problems such as nutrition imbalance and
limited choice.
“During the period of isolation, wemainly ate boxed lunches from
the hotel, which was also arranged by the company. Some of them
were greasy and not that healthy.” (male, 48 years, captain)
3.2.3 Sleep deprivation
Although some participants said that sleep problems were
within their range of self-regulation, about a half of the
participants acknowledged that sleep deprivation often occurred,
especially on morning and evening flights.
“There will be some cases of insomnia more or less. (…)
They may sleep at home during the day before the
flight so that they have more energy at night, but later they
find that it is not appropriate as they can’t sleep in the
morning after the night flight. Then some people will
stay up in the morning, so that they can sleep better at night,
but they still can’t make up for the lost sleep.” (male, 42 years,
captain)
Some participants from large civil aviation companies
with international airlines also reported that jet lag was a major
problem which affected the quality of their sleep (17).
“The body is used to it. It can’t sleep when it’s time to
sleep. It can’t rest when it’s time to rest.” (male, 52 years,
captain)
3.2.4 Occupational diseases
Participants expressed that the damage to their physical
health originated from multiple occupational diseases. Most
interviewed pilots had lumbar spondylosis and cervical
spondylosis, which they attributed to sitting for too long
and the discomfort of the cockpit seat. Several participants
believed that working at high altitude for long periods
of time could lead to various diseases such as heart
disease, attributed to changes in radiation and air pressure
at high altitude. A minority of participants reported they suered
from conditions such as hair loss, lithiasis, and high blood
pressure, which may be closely related to dietary limitations
during ight assignments. Two pilots reported that they
suered from shoulder arthritis, migraines, bloating, and
debilitating mental problems. A female pilot also reported
delayed menstruation.
“It’s not just sitting, it’s related extension issues, like cervical
spondylosis, noise, that actually have a physiological impact all the
time.” (male, 42 years, captain)
“e relative low pressure of the upper air and internal and
external pressure dierence may aect viscera organs and ear
pressure.” (male, 46 years, captain)
“High blood pressure, lithiasis and so on may have something to
do with ying, because for a long time on the plane wejust sit
there, rarely get up and do some activities, which may besome
objective factors. It is hard to say is directly caused, but also have
to say that this will bring about physical symptoms.” (male, 55
years, captain)
“Aer working for a certain time, sometimes youwill nd that
menstruation becomes delayed or irregular.” (female, 29 years,
copilot)

Xu et al. 10.3389/fpubh.2024.1351568
Frontiers in Public Health 07 frontiersin.org
3.3 Pilots’ needs and suggestions
3.3.1 Lack of support from the company in
coping with stress
Most participants claimed that they experienced difficulty in
releasing their psychological stress and required a workable
approach to handle this stress. Participants mentioned that they
worried about the impact on their career if they used psychological
support provided by the company, which reduced the effectiveness
of that support. That is, pilots wanted support options that did not
involve the company. Participants noted that pilots tended to have
a relatively small circle of friends, mainly limited to family and
colleagues, so it was hard for them to find someone to talk to when
dealing with psychological stress. In short, most participants
expressed a desire for more chances to communicate and release
their pressure without worrying that their complaint would
become known to the company and therefore influence their
career. This support was expected to beprovided by a third party
in the context of wider society.
“Many people may only be able to relieve stress through self-
adjustment or through some communication with their regular
colleagues. (…) Human beings are social animals. Ithink if wecan
have more opportunities to communicate and express our
pressure, the eect may bebetter.” (male, 45 years, captain)
3.3.2 Pilots’ yearly examination standards
One participant noted that the standards for physical examination
were still the same as they were decades ago, which did not reect the
changes in public health. erefore, he suggested updating the
physical examination standards based on pilots’ current general
health condition.
“e physical examination standards for pilots are still the same
as they were 30 or 40 years ago. Considering the human health
index has changed generally now, the standards should beadjusted
appropriately as well.” (male, 47 years, captain)
3.3.3 Support with sports equipment
Some participants reported a need for nancial support to buy
sports equipment, as the sports/activity facilities supported by the
company oen took too much time to access. Some participants
advised that the company could try dierent methods such as
providing gym cards or sports equipment vouchers.
“e company has some measures anyway. ere are gyms,
physical therapy rooms, and so on but youhave to use your
commute time to get there from home.” (male, 34 years, captain)
“I hope the company can reimburse a little sports equipment
every year, such as for basketball, volleyball, and so on.” (male, 34
years, captain)
3.3.4 Respect planned rest time
Participants noted the need for more rest time. Most companies
had adopted the “2-day rest aer 3-day ight” pattern, but participants
explained that during the “2-day rest” period, they were required to
handle extra work such as ight preparation and some administrative
work. ey expressed that the company required them to y as oen
as possible to earn more benets to the company, which resulted in
high fatigue conditions. Vacations rostered by the company were
usually inadequate for them to recover. However, because of their
income, they did not want to take extra leave to get a thorough rest.
erefore, they hoped that they could have more paid vacation time
that could give them the chance to relax completely.
“We usually y for 3 days and then have a rest for 2 days, but
westill have to go to work at the company during these two days,
because westill have a lot of groundwork and administrative work
to do, so it is still a busy situation. Sometimes Ifeel tired, but Istill
have to y for 3 days. Aer all, Idon’t get paid if Idon’t y.” (male,
47 years, captain)
“We hope that we can learn something from Western
management. Western countries have a system of paid vacation.
It seems very insignicant, but people can becompletely relaxed
in this situation.” (male, 40 years, captain)
3.3.5 Isolation periods
Moreover, as our interviews were conducted during the
COVID-19 pandemic period under a strict isolation policy, most
participants reported long isolation periods aer each ight, which
oen lasted for 2 weeks to several months. ese periods of isolation
during the COVID-19 pandemic were considered too long. Many
participants stated that the isolation could beshortened as the long-
term isolation directly led to their anxiety.
“I suggest that the isolation period bereduced appropriately and
the 4+3 mode (i.e., 4 days of centralized isolation and 3 days of
home isolation) beadopted.” (male, 48 years, captain)
4 Discussion
In this qualitative study, participating pilots described various
psychological and physical health challenges. ese challenges had
implications for pilots’ well-being and at last ight safety.
4.1 Psychological health
In our study, participants reported multifactorial stressors
related to the absence from their family, assessments, and the
COVID-19 pandemic. The main stressors among pilots varied
across different age groups. Stress among younger pilots mainly
originated from their financial situation, promotion opportunities,
and social interactions, whereas that among older pilots mainly
arose from concerns about their health and being absent from
their families. The differences in stressors between older and
younger pilots may bebecause an individual’s self-perception of
aging and their physical condition becomes worse with age, which
in turn leads to deterioration of health (18). In addition, older
pilots tended to attach more importance to family, meaning that
their absence from family life became a significant source of stress.
Our results were consistent with some previous studies that also
emphasized that stress among younger pilots mainly resulted from

Xu et al. 10.3389/fpubh.2024.1351568
Frontiers in Public Health 08 frontiersin.org
worries about income and promotion and led to mental health
issues (19, 20). Conversely, mental health issues among older
pilots tended to originate from being absent from their families.
A previous study highlighted the importance of being
accompanied by family members to improve mental health (21).
In addition, a study focused on stressors experienced by Chinese
pilots highlighted that the risk of income reduction, contracting
COVID-19, stress at work, and the risk for a delayed upgrade
schedule were major mental health stressors during the COVID-19
pandemic (20).
Various promising methods could be considered by civil
aviation companies to improve pilots’ mental health. For example,
given the nancial pressure pilots faced during the COVID-19
pandemic because of reduced ights, airlines could provide pilots
with more care focused on daily life (20, 22). In addition, measures
to guarantee pilots’ family security may oer a promising solution
to relieve mental health pressures caused by long periods of
absence from their families during the COVID-19 pandemic, such
as providing subsidies to families for daily necessities during
pilots’ isolation periods. Participating pilots mentioned that
various limitations still existed despite civil aviation companies
attempting to improve sta mental health, such as by establishing
psychological counseling rooms. Although most companies had a
counseling room, most pilots preferred not to use these services
because they feared doing so would negatively aect their future
careers. Instead of psychological support directly provided by the
companies, social support may provide an eective solution to
improve pilots’ psychological health, which was demonstrated in
a previous study (23). Economic support for pilots’ careers and
families and some appropriate social support may also help to
relieve their stress, thereby improving pilots’ mental health,
especially during the COVID-19 pandemic.
4.2 Physical health
Our ndings highlighted that a poor diet, poor sleep quality,
and occupational diseases were the main factors aecting pilots’
physical health based on their self-report. Participants commented
on the irregular and high-salt diet when completing ight tasks or
isolation periods, which they believed was harmful to their physical
health. Research shows that irregular diets can increase the risk for
esophageal and stomach cancer (22). e high-salt diet reported by
some participants increased the possibility of high blood pressure,
cardiovascular disease, and stroke (24). Sleep problems are common
among pilots; for example, a previous survey found 24.6% of short-
haul and 23.5% of long-haul pilots reported major sleep problems
8 nights a month (3). Furthermore, previous studies found that
pilots’ health problems were mainly in the cervical, shoulder, and
lumbar spine, such as cervical spondylosis, periarthritis of the
shoulder, reex shoulder, arm and hand pain, swelling and
numbness, back and leg pain, lumbar disc herniation, and lumbar
muscle strain (10, 25–28). ese factors were also reported in our
interviews. In addition to those diseases, our participants reported
problems such as hyperlipidemia, hypertension, dyspepsia, lithiasis,
endocrine dysfunction, and neurasthenia.
e emphasis on physical health problems reported by dierent
age groups also diered. Generally, younger pilots reported more cases
of diet problems, whereas older pilots reported more sleep problems.
Occupational diseases were common among pilots but more
pronounced among older pilots, which was consistent with the results
of a previous study (19). is may be because most occupational
diseases that pilots are prone to are chronic (29). For example, a study
on lipid status among pilots found that high triglycerides and total
cholesterol levels among pilots were related to older age and longer
ight time (30).
From a physical health perspective, most participants
expressed an urgent need for more choice of meals and more rest
time. It is worth noting that companies should place more
consideration on the cost of welfare measures (e.g., time and
convenience), which may inuence whether pilots are willing to
use these measures. For example, the company could organize
regular physical examinations for cardiovascular problems, which
are common among pilots, and oer medical care or convalescent
leave to pilots with poor results. Moreover, airlines could design
reasonable and scientic ight schedules to guarantee sucient
sleeping time. More attention should also bepaid to nutritional
composition when preparing airline meals.
4.3 Implications
Our results have some practical implications that may help
civil aviation companies and air transport management
departments to improve pilots’ physical and psychological
health. Currently, the aviation medical field lacks a
scientific and comprehensive assessment method for civil
aviation pilots (31–33), including factors such as physical health,
mental health, and healthy behaviors, as well as a dynamic
monitoring platform and health management system for
health data in this field. Many physical or psychological
assessment methods conducted for individuals or other
occupational groups are not suitable for pilots because pilots
receive special learning and training, and their working conditions
differ from those to which others may be exposed (31, 32).
Furthermore, relatively little research has been conducted on civil
aviation pilots’ physical and mental health, with a notable lack of
high-quality research (20, 34, 35). Most available studies
were based on scales, questionnaires, or standardized questions
(1–6). Therefore, weattempted to capture pilots’ perspectives of
their physical and mental health-related challenges and needs
through face-to-face conversations via qualitative interviews. This
allowed us to confirm information or seek clarity during the
interviews to ensure accuracy. Wecomprehensively collected the
information provided by participants during the interviews and
paid equal attention to each participants’ personalization,
meaning our results are rich and specific. Our study will provide
evidence to inform the development of a more scientific and
comprehensive physical and mental health evaluation system for
civil aviation pilots. This will help to achieve “early detection,
early prevention, early intervention, and early treatment.”
Through the development of all-round, multi-dimensional, and
different life cycle stages of “health portraits,” it is possible to
promote safer management of civil aviation pilots’ physical and
mental health and reduce the occurrence of physical and mental
health damage.

Xu et al. 10.3389/fpubh.2024.1351568
Frontiers in Public Health 09 frontiersin.org
4.4 Limitations
ere were some limitations in this study. First, because of the
serious imbalance in the male to female ratio in the occupational
group of pilots, only one female participant was interviewed;
therefore, our study might not berepresentative of the experience
of female pilots. However, only 0.44% of airplane pilots in China
are women, as reported in the Annual Report of Chinese Civil
Aviation Pilot Development (36); therefore, our study provided
relatively robust evidence regarding the challenges of pilots’
psychological and physical health. Second, because the interviews
were mainly conducted in groups, some questions, especially those
that touched on participants’ privacy, could not be explored
in-depth. A further study using individual interviews is needed to
resolve this issue. ird, the purpose of our study was to investigate
pilots’ health conditions; therefore, comparisons among companies
were relatively weak and more evidence is needed. For example,
wedid not explore the dierences in welfare benets between
companies, so wecould not determine the relationship between
dierences in these benets and pilots’ various needs. Weintend
to conduct further research in this area. Finally, our study
investigated pilots’ health challenges and needs through focus
group interviews. Although this method meant that personalization
was emphasized compared with questionnaire surveys, the results
could not bequantied, and it was not possible to analyze the
correlations between various factors and the results or the
correlations between various factors. In addition, this study was
based on self-reported information, and the results obtained may
be biased because of individual dierences in expression.
Obtaining accurate data (e.g., physical examination results) was
also dicult. erefore, we need to combine other research
methods in a further study to improve the accuracy of the results.
5 Conclusion
In this study, we interviewed 42 pilots and found that they
experienced a large amount of psychological pressure from various
factors. eir physical health condition was also worrying, and pilots
had several suggestions in relation to improving their physical and
mental health. Although pilots are generally satised with the
working environment, they are aware that the schedule and content
of their work can have a negative impact on their physical and mental
health. In addition, the COVID-19 pandemic situation and the lack
of suitable professional assessment are also health-related problems
that remain to beresolved. Civil aviation companies, air transport
management departments, and aviation hospitals pay insucient
attention to pilots’ physical and mental health. erefore, it is
necessary to establish a systematic, scientic, and personalized
medical intervention system for pilots going forward. rough this
qualitative study, weidentied pilots’ perspectives of challenges and
support needs in relation to psychological and physical health, and
also laid a foundation for subsequent research. Wehope to attract
more researchers to conduct comparative studies of standard health
measures for pilots in dierent parts of the world. is will provide a
reference for civil aviation companies and governments worldwide to
support improvement of pilots’ working conditions, which will
ultimately improve pilots’ physical and mental health and contribute
to overall aviation safety.
Data availability statement
e raw data supporting the conclusions of this article will
bemade available by the authors, without undue reservation.
Ethics statement
e studies involving humans were approved by the Ethics
Committee of Civil Aviation Shanghai Hospital (no. 2021-7). e
studies were conducted in accordance with the local legislation and
institutional requirements. e participants provided their written
informed consent to participate in this study. Written informed
consent was obtained from the individual(s) for the publication of any
potentially identiable images or data included in this article.
Author contributions
WX: Data curation, Writing – review & editing, Writing – original
dra. YB: Data curation, Writing – review & editing, Writing – original
dra. LZ: Data curation, Writing – review & editing. YL: Data curation,
Writing – review & editing. EZ: Data curation, Writing – review &
editing. HL: Data curation, Writing – review & editing. QJ: Data
curation, Writing – review & editing. YC: Data curation, Writing –
review & editing. QD: Data curation, Writing – review & editing. FS:
Data curation, Writing – review & editing. LW: Data curation, Writing
– review & editing. ZL: Data curation, Writing – review & editing. XC:
Data curation, Writing – review & editing. QG: Data curation, Writing
– review & editing. HH: Data curation, Writing – review & editing. BR:
Data curation, Writing – review & editing. YS: Data curation, Writing
– review & editing. MX: Data curation, Supervision, Writing – review
& editing, Investigation, Project administration.
Funding
e author(s) declare nancial support was received for the
research, authorship, and/or publication of this article. e study was
funded by Civil Aviation Safety Capacity Building Project (no.: 251),
Shanghai Science and Technology Development Funds (no.:
21QA1405300), and the Science Foundation of Ministry of Education
of China (no.: 22YJAZH116).
Conflict of interest
e authors declare that the research was conducted in the
absence of any commercial or nancial relationships that could
beconstrued as a potential conict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their aliated organizations,
or those of the publisher, the editors and the reviewers. Any product
that may be evaluated in this article, or claim that may be made by its
manufacturer, is not guaranteed or endorsed by the publisher.

Xu et al. 10.3389/fpubh.2024.1351568
Frontiers in Public Health 10 frontiersin.org
References
1. McNeely E, Mordukhovich I, Tideman S, Gale S, Coull B. Estimating the health
consequences of ight attendant work: comparing ight attendant health to the general
population in a cross-sectional study. BMC Public Health. (2018) 18:346. doi: 10.1186/
s12889-018-5221-3
2. McNeely E, Gale S, Tager I, Kincl L, Bradley J, Coull B, et al. e self-reported
health of U.S. ight attendants compared to the general population. Environ Health.
(2014) 13:13. doi: 10.1186/1476-069X-13-13
3. Venus M, Holtforth MG. Short and long haul pilots rosters, stress, sleep problems,
fatigue, mental health, and well-being. Aerosp Med Hum Perform. (2021) 92:786–97. doi:
10.3357/AMHP.5812.2021
4. Wang Y, Yuan X. Analysis of psychological treatment of aviation illness in ight
personnel. World Latest Med Inform Abstracts. (2017) 17:76+79. doi: 10.3969/j.
issn.1671-3141.2017.43.040
5. Goeng EM, Wagsta A, Nordby K-C, Meland A, Goeng LO, Skare Ø, et al. Risk
of fatigue among airline crew during 4 consecutive days of ight duty. Aeros Med Hum
Perform. (2019) 90:466–74. doi: 10.3357/AMHP.5236.2019
6. Wen CCY, Nicholas CL, Clarke-Errey S, Howard ME, Trinder J, Jordan AS. Health
risks and potential predictors of fatigue and sleepiness in airline cabin crew. Int J Environ
Res Public Health. (2020) 18:13. doi: 10.3390/ijerph18010013
7. Lin J., Tang R., You X.. Psychological factors inuencing aviation safety: a textual
analysis based on ASRS. e 23rd National Psychology Academic Conference. (2021).
8. Omholt ML, Tveito TH, Ihlebæk C. Subjective health complaints, work-related
stress and self-ecacy in Norwegian aircrew. Occup Med (Oxford). (2017) 67:135–42.
doi: 10.1093/occmed/kqw127
9. Wang J. Investigation and analysis on the ment al health status of pilots in an airline.
Psychol Monthly. (2020) 15:29–30. doi: 10.19738/j.cnki.psy.2020.07.019
10. Lindgren T, Norbäck D. Health and perception of cabin air quality among Swedish
commercial airline crew. Indoor Air. (2005) 15:65–72. doi: 10.1111/j.1600-0668.2005.00353.x
11. Liu T, Qiu B, Zhang C, Deng M, Liang Z, Qi Y. Health-related quality of life in
pilots of a Chinese commercial airline. Arch Environ Occup Health. (2021) 76:511–7. doi:
10.1080/19338244.2020.1863765
12. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative
research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual
Health Care. (2007) 19:349–57. doi: 10.1093/intqhc/mzm042
13. Zhang Y. Model study on the relationship between job satisfaction, job burnout
and turnover intention of doctors in urban public medical institutions. Fudan Univ.
(2011) 11:235. doi: 10.1186/1472-6963-11-235
14. Tang Q, Cheng Z, Yuan A, Deng Y. Application and analysis of SCL-90in China.
Chin J Clin Psych. (1999) 1:19–23. doi: 10.16128/j.cnki.1005-3611.1999.01.005
15. Englander M. e phenomenological method in qualitative psychology and
psychiatry. Int J Qual Stud Health Well-being. (2016) 11:30682. doi: 10.3402/qhw.v11.30682
16. Kelly P. Starvation and its eects on the gut. Adv Nutr. (2021) 12:897–903. doi:
10.1093/advances/nmaa135
17. Herxheimer A. Jet lag. BMJ. Clin Evid. (2014) 2014:2303.
18. Wurm S, Diehl M, Kornadt AE, Westerhof GJ, Wahl HW. How do views on aging
aect health outcomes in adulthood and late life? Explanations for an established
connection. Dev Rev. (2017) 46:27–43. doi: 10.1016/j.dr.2017.08.002
19. Yu F, Li X, Yang J. Investigation of pilots' mental health and analysis of inuencing
factors in China: based on structural equation model. BMC Public Health. (2022)
22:1352. doi: 10.1186/s12889-022-13764-y
20. Wang L, Zou Y, Li S. Analysis of the stressors and mental status of civil aviation
pilots under the background of the major infectious disease. Chin J Indus Hyg Occup Dis.
(2022) 40:688–93. doi: 10.3760/cma.j.cn121094-20210802-00381
21. Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before
and during the COVID-19 pandemic: a longitudinal probability sample survey of the
UK population. Lancet. Psychiatry. (2020) 7:883–92. doi: 10.1016/
S2215-0366(20)30308-4
22. Chen W, He Y, Sun X, Wen D, Chen Z, Zhao D. Analysis of risk factors for upper
gastrointestinal cancer in China: a multicentric population-based case-control study.
Chin J Prev Med. (2011) 45:244–8. doi: 10.3760/cma.j.issn.0253-9624.2011.03.011
23. Zhang C, Qing N, Zhang S. e impact of leisure activities on the mental health
of older adults: the mediating eect of social support and perceived stress. J Healthc Eng.
(2021) 2021:1–11. doi: 10.1155/2021/6264447
24. Malta D, Petersen KS, Johnson C, Trieu K, Rae S, Jeerson K, et al. High
sodium intake increases blood pressure and risk of kidney disease. From the science
of salt: a regularly updated systematic review of salt and health outcomes (august
2016 to march 2017). J Clin Hypertens (Greenwich). (2018) 20:1654–65. doi: 10.1111/
jch.13408
25. Wilson D, Driller M, Johnston B, Gill N. e prevalence of cardiometabolic health
risk factors among airline pilots: a systematic review. Int J Environ Res Public Health.
(2022) 19:4848. doi: 10.3390/ijerph19084848
26. Rutledge P. A comparison of health data from river forth pilots in Scotland: in 1988
and 2012. Int Marit Health. (2014) 65:43–6. doi: 10.5603/IMH.2014.0010
27. Wilson D, Driller M, Johnston B, Gill N. The prevalence and distribution of
health risk factors in airline pilots: a cross-sectional comparison with the
general population. Aust N Z J Public Health. (2022) 46:572–80. doi:
10.1111/1753-6405.13231
28. Alaminos-Torres A, Martínez-Álvarez JR, López-Ejeda N, Marrodán-Serrano MD.
Atherogenic risk, anthropometry, diet and physical activity in a sample of Spanish
commercial airline pilots. Int J Environ Res Public Health. (2022) 19:4128. doi: 10.3390/
ijerph19074128
29. Lei F, Cheng S, Deng M. Investigation and intervention measures of chronic
diseases in civil aviation pilots. Mod Diagn Treatment. (2016) 27:2974–297.
30. Liu A, Wang Q. Investigation on blood lipid prole of pilots. Chin J Aeros Med.
(2005) 16:280–7.
31. Lord D, Conlon HA. Cardiovascular risk factors in airline pilots. Workplace Health
Saf. (2018) 66:471–4. doi: 10.1177/2165079917751478
32. Zhao C, Liu F, Qi Y, Xu K. Psychological assessment of Chinese airline pilot
students with MMPI-2. Space Med Med Eng. (2015) 28:249–52. doi: 10.16289/j.
cnki.1002-0837.2015.04.004
33. Donnelly D. A study of environmental factors that aect the physical and mental
health of airline pilots: A systematic review with Metasynthesis. Nova Southeastern
University ProQuest Dissertations Publishing (2018).
34. Pasha T, Stokes PRA. Reecting on the Germanwings disaster: a systematic review
of depression and suicide in commercial airline pilots. Front Psych. (2018) 9:86. doi:
10.3389/fpsyt.2018.00086
35. Griffiths RF, Powell DM. The occupational health and safety of flight
attendants. Aviat Space Environ Med. (2012) 83:514–21. doi: 10.3357/
ASEM.3186.2012
36. Department of Flight Standards, Civil Aviation Administration of China. China
Civil Aviation Pilot Development Annual Report (2021).