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• Response to the Comments to the article by Savelieva E. et al “Psychological factors and indoor environmental quality in respiratory symptom reports of pupils: a cross-sectional study in Finnish schools”
  Kateryna Savelieva, Marko Elovainio, Jussi Lampi, Sari Ung-Lanki and Juha Pekkanen
  Published on: 23 December 2020
• Comments to the article by Savelieva E. et al “Psychological factors and indoor environmental quality in respiratory symptom reports of pupils: a cross-sectional study in Finnish schools”
  Tamara Tuuminen
  Published on: 5 December 2020

• Published on: 23 December 2020

  Response to the Comments to the article by Savelieva E. et al “Psychological factors and indoor environmental quality in respiratory symptom reports of pupils: a cross-sectional study in Finnish schools”

  • Kateryna Savelieva, PhD, postdoctoral researcher University of Helsinki, Finland
  • Other Contributors:
    • Marko Elovainio, PhD, professor
    • Jussi Lampi, MD, PhD, researcher
    • Sari Ung-Lanki, MA, researcher
    • Juha Pekkanen, MD, PhD, professor

  Poor indoor air quality in schools is a major problem in Finland that has increasingly been assessed using questionnaires to parents and pupils on symptoms and indoor air complaints. The fact that other factors beside indoor air quality may influence symptom reporting has, however, been largely neglected in the ongoing discussions also in Finland. Previous research has clearly established that symptoms which accompany indoor air problems are associated with both physical characteristics of the building environment and various psychosocial factors (1–3). The majority of the studies, however, were conducted among adults in office settings (4–6), and very little research was done among pupils in school setting. Our study (7) was conducted to fill this gap and examine whether, in addition to indoor environmental quality (IEQ) in schools, different psychosocial factors and other pupils’ individual and allergic characteristics are associated with symptom reporting.

  The main message of our study is the following: where high levels of symptoms are reported, both psychosocial factors and physical characteristics of indoor environment should be fully considered in the decision-making process of the indoor air quality in school buildings. Our paper (7), as well as our previous research (8,9), clearly demonstrates that our current findings cannot be used as a justification for ignoring physical environment in indoor air research. Below we provide our responses to the specific...

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  Poor indoor air quality in schools is a major problem in Finland that has increasingly been assessed using questionnaires to parents and pupils on symptoms and indoor air complaints. The fact that other factors beside indoor air quality may influence symptom reporting has, however, been largely neglected in the ongoing discussions also in Finland. Previous research has clearly established that symptoms which accompany indoor air problems are associated with both physical characteristics of the building environment and various psychosocial factors (1–3). The majority of the studies, however, were conducted among adults in office settings (4–6), and very little research was done among pupils in school setting. Our study (7) was conducted to fill this gap and examine whether, in addition to indoor environmental quality (IEQ) in schools, different psychosocial factors and other pupils’ individual and allergic characteristics are associated with symptom reporting.

  The main message of our study is the following: where high levels of symptoms are reported, both psychosocial factors and physical characteristics of indoor environment should be fully considered in the decision-making process of the indoor air quality in school buildings. Our paper (7), as well as our previous research (8,9), clearly demonstrates that our current findings cannot be used as a justification for ignoring physical environment in indoor air research. Below we provide our responses to the specific comments raised by Tuuminen and colleagues in their commentary to our article.

  First, for detailed discussion of the expert evaluation of indoor environmental quality, as well as the discussion of several challenges involved regarding measurement of IEQ, we refer the reader to our previous article (8). The assessment of IEQ in this study was also based on expert evaluation, during which the experts rated the schools based on several criteria previously defined by the Finnish Institute of Occupational Health, such as moisture and mould damage, insufficient ventilation, unsatisfactory temperature conditions, to name just a few. To validate the expert evaluation, several IEQ parameters were further independently assessed by two inspectors in a subsample of schools. At the moment of this study publication, the data only for moisture and mould damage was available, and a substantial agreement between experts’ and inspectors’ evaluations was found. All this information is provided in the Method section of the current article (7, p.3). Also, it was surprising to read from Tuuminen and colleagues that “There is no single mention on what data has been used…”, since the data collection process and the questionnaires are described in detail in both the current (7) and the previous study (8).

  Second, Tuuminen and colleagues raised concerns whether small children can reliably “analyse their feelings and attitudes”. In fact, there is repeated evidence that children can assess and report their feelings (e.g., 9,10). We have also shown the good repeatability of children’s questionnaire response, as compared to adults (12). In our study (7), 3-6 grade primary pupils (mean age 10.7), 7-9 grade pupils (mean age 14.2) and parents of primary pupils reported worry about school IEQ, and the result were consistent across the three samples. We additionally examined whether worry reported by primary school pupils is related to respiratory symptoms reported by parents of these primary pupils, and the results were similar to those based on solely primary pupils’ sample. All psychosocial factors (including worry) in the survey were assessed using a 5-point Likert scale, which is a frequently used psychometric tool in behavioural and social sciences.

  Third, the response rate of the parents was indeed very low, but this is a common problem with surveys of the present kind. What such low response rate of parents is telling us is that some new strategies are required during survey data collection to achieve adequate response rate (see our previous study for detailed discussion on this issue (8)).

  Forth, the associations between IEQ in schools with respiratory, lower respiratory, eye, skin, and general symptoms were shown in our previous article (8), to which we refer Tuuminen and colleagues. The present study (7) focuses only on respiratory symptoms for two reasons: in our previous article (8) we saw the strongest association of IEQ with respiratory symptoms, as many other previous studies, and for the sake of clarity. The present study already includes three samples (i.e., parents of primary school pupils, primary pupils, and secondary pupils), therefore, presenting the results for all symptoms would be an overload for one paper.

  Fifth, Tuuminen et al. can found the ethical approval in the ‘Ethical approval’ section at the end of the article (7, p.12).

  Sixth, as we have already mentioned in our article (7), as well as extensively discussed before (9), also our study is cross-sectional, and therefore no direction of associations can be stated. The sentence cited by Tuuminen et al. (“Psychosocial factors, especially worry about indoor air quality explained more of the variance between schools in respiratory symptoms than … ”) refers to the fact that the variance between schools in respiratory symptoms was low (0.6%–2.4%) to begin with, which indicates that the bigger share of variance in symptom reporting is explained by individual differences between pupils than school buildings’ characteristics. This is a common use of the word 'explain' in statistics.
  Tuuminen and colleagues are further speculating that “worries are more likely to be consequences because usually people cannot be afraid or worried of something if they never knew what to be afraid or worried about”. There is an extensive research on worry and other psychological factors influencing reporting of physical symptoms. At least the following sources should be consulted by anyone interested in the matter (13–15).

  Finally, as Tuuminen et al. have correctly pointed out, any misinterpretations of the research findings may be harmful, and we could not agree with this more. Our article highlights the importance of both physical school indoor environment and psychosocial factors in symptom reporting of pupils, which should be considered in the decision-making process of the indoor air quality of school buildings. We tried to write the results, conclusions, and potential implications as clearly and unambiguously as possible, so that any misinterpretation of them would be unlikely.

  References
  1. Lahtinen M, Huuhtanen P, Reijula K. Sick building syndrome and psychosocial factors – a literature review. Indoor Air. 1998;8:71–80.
  2. Lahtinen M, Lappalainen S, Reijula K. Multiprofessional teams resolving indoor-air problems—emphasis on the psychosocial perspective. SJWEH Suppl. 2008;4:30–4.
  3. Norbäck D. An update on sick building syndrome. Curr Opin Allergy Clin Immunol. 2009;9:55–9.
  4. Marmot AF, Eley J, Stafford M, et al. Building health: an epidemiological study of “sick building syndrome” in the Whitehall II study. Occup Environ Med. 2006;63:283–9.
  5. Stenberg B, Eriksson Ni, Höög J, et al. The sick building syndrome (SBS) in office workers. A case-referent study of personal, psychosocial and building-related risk indicators. Int J Epidemiol. 1994;23:1190–7.
  6. Eriksson N, Hoog J, Stenberg B, Sundell J. Psychosocial factors and the “sick building-syndrome”. A case-referent study. Indoor Air. 1996;6:101–10.
  7. Savelieva K, Elovainio M, Lampi J, et al. Psychosocial factors and indoor environmental quality in respiratory symptom reports of pupils: a cross-sectional study in Finnish schools. BMJ Open. 2020;10:e036873.
  8. Savelieva K, Marttila T, Lampi J, et al. Associations between indoor environmental quality in schools and symptom reporting in pupil-administered questionnaires. Environ Heal. 2019;18(1):115.
  9. Nissilä J, Savelieva K, Lampi J, et al. Parental worry about indoor air quality and student symptom reporting in primary schools with or without indoor air quality problems. Indoor Air. 2019;29:865–75
  10. Chorpita BF, Tracey SA, Brown TA, et al. Assessment of worry in children and adolescents: An adaptation of the Penn State Worry Questionnaire. Behav Res Ther. 1997;35:569–81.
  11. Stuijfzand S, Dodd HF. Young children have social worries too: Validation of a brief parent report measure of social worries in children aged 4–8 years. J Anxiety Disord. 2017;50:87–93.
  12. Lampi J, Ung-Lanki S, Santalahti P, et al. Test-retest repeatability of child’s respiratory symptoms and perceived indoor air quality – comparing self- and parent-administered questionnaires. BMC Pulm Med. 2018;18:32.
  13. Pennebaker JW. Psychological factors influencing the reporting of physical symptoms. In: Stone AA, Bachrach CA, Jobe JB, Kurtzman HS, Cain VS, editors. The science of self-report: Implications for research and practice. Taylor and Francis; 2000. p. 299–315.
  14. Davey GC, Wells A (Eds. ). Worry and its psychological disorders: Theory, assessment and treatment. In John Wiley & Sons; 2006.
  15. Rief W, Broadbent E. Explaining medically unexplained symptoms–models and mechanisms. Clin Psychol Rev. 2007;27:821–41.

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  Conflict of Interest:
  None declared.

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• Published on: 5 December 2020

  Comments to the article by Savelieva E. et al “Psychological factors and indoor environmental quality in respiratory symptom reports of pupils: a cross-sectional study in Finnish schools”

  • Tamara Tuuminen, Specialist in clinical microbiology, Adj professor Kruunuhaka Medical Center

  In Finland, the problem of bad indoor air in schools and other municipal buildings is a matter of a continuous public debate that pops up frequently and discussed in media. The problem has been acknowledged officially1,2. Because the problem of mold-infested public buildings cannot be solved quickly due to inadequate financial resources to replace all the old buildings which life cycle has come to an end (built in early seventies) there is a need to find alternative explanations above that of an inadequate environmental quality. Psychologization of the problems experienced by pupils, children in day care units or occupants of hospitals3 and other municipal buildings4 is a strategy of denial. This strategy is the switching of the responsibility of municipalities to children or their guardians who have imposed neuroticism on their offsprings and aggravate worries about the indoor air.
  Any good study on the impact of indoor air on the occupant’s health is welcome. Each study should have an aim of solving the problems and should be ethical. The paper by Savelieva et al was widely publicized by the Finnish media 5-7. It was eagerly reported that health problems experienced by the pupils are not explained only by the indoor air but by the psychological factors (the word explained is bolded by us; see the translations of titles of the publications in the Finnish media 5,6). Further popularization of the results of the paper of Savelieva et al. resulted in the misinterpret...

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  In Finland, the problem of bad indoor air in schools and other municipal buildings is a matter of a continuous public debate that pops up frequently and discussed in media. The problem has been acknowledged officially1,2. Because the problem of mold-infested public buildings cannot be solved quickly due to inadequate financial resources to replace all the old buildings which life cycle has come to an end (built in early seventies) there is a need to find alternative explanations above that of an inadequate environmental quality. Psychologization of the problems experienced by pupils, children in day care units or occupants of hospitals3 and other municipal buildings4 is a strategy of denial. This strategy is the switching of the responsibility of municipalities to children or their guardians who have imposed neuroticism on their offsprings and aggravate worries about the indoor air.
  Any good study on the impact of indoor air on the occupant’s health is welcome. Each study should have an aim of solving the problems and should be ethical. The paper by Savelieva et al was widely publicized by the Finnish media 5-7. It was eagerly reported that health problems experienced by the pupils are not explained only by the indoor air but by the psychological factors (the word explained is bolded by us; see the translations of titles of the publications in the Finnish media 5,6). Further popularization of the results of the paper of Savelieva et al. resulted in the misinterpretation of the message of the article. The problems experienced by pupils of the Finnish schools started to get an explanation through the prism of psychosocial factors (see the title of Mediuutiset and Helsingin Sanomat (HS)). The claim was that according to the results of the study numerous factors can aggravate the symptoms which are biological, psychological and social (HS). The paper of Savelieva et al. gave an impetus to present an alternative explanation by shifting the responsibility from the municipality to the families that impose worries on small children about the quality of indoor air.
  Here, we want to present a few comments on the paper.
  Firstly, the quality of indoor air has not been measured, and the results of these measurements have not been presented. The assessment “was based on all existing data from each school, and no special visits to the schools were done”. In other words, the title of the paper is misleading. There is no single mention on what data has been used and what were the parameters checked by the specialists whose data was used for the scientific article.
  Secondly, the questionnaire was addressed to small children who responded electronically with a help of teachers. We wonder how reliable the assessment of worries by small children is, and whether small children can analyse their feelings and attitudes. Such subjective data acquisition may not be reliable enough to draw scientific conclusions that are often the basis for political decisions. Importantly, the questions were not open but were introductory. We think that most persons utilizing municipal buildings in Finland and who may have so-called unexplained symptoms when asked whether they are worried about the indoor air would give a positive answer.
  Thirdly, the response rate from the parents was only 20% (year 2017) that dropped to 13% (2018) meaning that parents may not feel confident neither with the study design nor with a priori expectations, the purposes or aims of this study.
  Further, only respiratory symptoms were inquired in this study whereas there is extensive evidence that bad indoor air can cause systemic symptoms such as fatigue8, a plethora of neurological8, gastro-intestinal (and skin problems3,4,8,9.
  Also, the permission from an Ethical Committee was not mentioned in the paper.
  Most importantly, as the authors state in their article, the study was cross-sectional. This design may find out only association but not explanations. The word explanation points out causality. The Cambridge dictionary gives the meaning of the word explanation “the details or reasons that someone gives to make something clear or easy to understand”. As they state in their article ” cross-sectional design of this study does not allow to determine the direction of the association between psychosocial factors especially worries, and respiratory symptoms”. In the article the authors state correctly that it is not possible based on the found association to say whether worries are secondary to experienced respiratory symptoms or primary. However, they wrote “Psychosocial factors, especially worry about indoor air quality explained more of the variance between schools in respiratory symptoms than … ”. In our opinion, worries are likely to be consequences because usually people cannot be afraid or worried of something if they never knew what to be afraid or worried about.
  Based on what has been said above, we believe that it is harmful to misinterpret the findings of this paper. We hope that the responsible authors of this paper do their utmost best to correct the misleading information about the results of their article given by the Finnish media. We hope that the authors will emphasize that they found only association, not explanation. We also hope that the paper by Savielieva et al. will not lead away from the basic problem solution: each child whoever (s)he is with neuroticism or not and with any personality traits should be given a safe and clean working environment.

  References
  1. Reijula K, Ahonen G, Alenius H, Holopainen R, Lappalainen S, Palomäki E ja Reiman M. [Rakennusten kosteus- ja homeongelmat]. Finnish parlia‑
  mentary audit committee, report 01/2012.
  2. Lampi J, Hyvärinen A, Erhola M, Haahtela T , Haukipuro K, Haverinen‑Shaughnessy U, et al , Healthy people in healthy premises:
  the Finnish Indoor Air and Health Programme 2018–2028. Clin Transl Allergy (2020) 10:4 https://doi.org/10.1186/s13601-020-0308-1
  3. Hyvonen S, Lohi J, Tuuminen T. Moist and mold exposure is associated with high prevalence of neurological symptoms and MCS in a Finnish hospital workers cohort. Saf Health Work 2020;11:173-177.
  4. Hyvönen S, Poussa T, Lohi J, Tuuminen T. High prevalence of neurological sequelae and multiple chemical sensitivity among occupants. Arch Environ Occup Health 2020 https://doi.org/10.1080/19338244.2020.1781034
  5. Helsingin Sanomat. Koulun sisäilman laatu selittää koululaisten oireilusta vain pienen osan. (The quality of indoor air at school explains the symptoms of pupils only to a small extend). STT, published 30.10. 2020 6.03
  6. Mediuutiset 30.10.2020 Sisäilmalaatu ei selitä koululaisten oireilua - Jo huoli sisäilmasta voi vaikuttaa oireisiin, (The quality of indoor air does not explain the symptoms of pupils. Worries about indoor air may cause the symptoms) update 30.102020 09:58
  7. Yle Uutiset, Uusimaa 30.10.2020 (minutes 03.08-03.28)
  8. Tuuminen T, Jääskeläinen T, Vaali K , Polo O. Dampness and mold hypersensitivity syndrome and vaccination as risk factors for chronic fatigue syndrome . Autoimm Rev 2019; 18:107-108
  9. Luosujärvi R A, Husman T M, Seuri M, Pietikäinen M A, Pollari P, Pelkonen J, Hujakka H T, Kaipiainen-Seppänen O A, Aho K. Joint symptoms and diseases associated with moisture damage in a health center. Clin Rheumatol 2003 22:381-5.

  Tamara Tuuminen, MD, specialist in clinical microbiology
  Adjunct Prof. in medical microbiology

  Ville Valtonen, Head (retired), Division of Infectious Diseases,
  Helsinki University Central Hospital, Helsinki, Finland
  professor, specialist in internal medicine and infectious diseases MD

  Kirsi Vaali, Adjunct Prof. in Pharmacology

  Jouni Lohi, MD, specialist and Adjunct Professor in general practice

  Tiina Tuomela, MD, PhD, pediatrician

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  Conflict of Interest:
  None declared.

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