research paper about flight attendant

• Research article
• Open access
• Published: 23 March 2018

Estimating the health consequences of flight attendant work: comparing flight attendant health to the general population in a cross-sectional study

• Eileen McNeely 1 ,
• Irina Mordukhovich 1 ,
• Samuel Tideman 2 ,
• Sara Gale 1 &
• Brent Coull 2  

BMC Public Health volume  18 , Article number:  346 ( 2018 ) Cite this article

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Flight attendants are an understudied occupational group, despite undergoing a wide and unique range of adverse job-related exposures. In our study, we aimed to characterize the health profile of cabin crew relative to the U.S. general population.

In 2014–2015, we surveyed participants of the Harvard Flight Attendant Health Study. We compared the prevalence of their health conditions to a contemporaneous cohort in the National Health and Nutrition Examination Survey (NHANES 2013–2014) using age-weighted standardized prevalence ratios (SPRs). We also analyzed associations between job tenure and selected health outcomes, using logistic regression and adjusting for potential confounders.

Compared to the NHANES population ( n  = 2729), flight attendants ( n  = 5366) had a higher prevalence of female reproductive cancers (SPR = 1.66, 95% CI: 1.18–2.33), cancers at all sites (SPR = 2.15, 95% CI: 1.73–2.67 among females), as well as sleep disorders, fatigue, and depression, with SPRs ranging between 1.98 and 5.57 depending on gender and the specific condition examined. In contrast, we observed a decreased prevalence of cardiac and respiratory outcomes among flight crew relative to NHANES. Health conditions that increased with longer job tenure were sleep disorders, anxiety/depression, alcohol abuse, any cancer, peripheral artery disease, sinusitis, foot surgery, infertility, and several perinatal outcomes.

Conclusions

We observed higher rates of specific adverse health outcomes in U.S. flight attendants compared to the general population, as well as associations between longer tenure and health conditions, which should be interpreted in light of recall bias and a cross-sectional design. Future longitudinal studies should evaluate specific exposure-disease associations among flight crew.

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Flight attendants are an understudied occupational cohort, despite undergoing a wide and unique range of adverse job-related exposures. These workers are consistently exposed to cosmic ionizing radiation, circadian rhythm disruption due to night shift work and frequently crossing time zones, poor cabin air quality, elevated ozone levels, hypoxia, pesticides from cabin disinsection, high levels of occupational noise, heavy physical job demands, and verbal and sexual harassment [ 1 , 2 , 3 , 4 ]. Until 1998, they were also exposed in-flight secondhand tobacco smoke, especially before partial smoking bans were implemented in the year 1988 [ 5 ]. The long-term effects of this historical secondhand smoke exposure have not been well characterized.

Flight crew have historically been excluded from the Occupational Safety and Health Administration protections granted to most U.S. workers. Some limited protections were implemented in 2014 [ 6 ]. However, flight attendants’ exposure to ionizing radiation is not monitored, despite the National Council on Radiation Protection (NCRP) reporting that flight crew have the largest average annual effective dose of all U.S. radiation workers [ 7 , 8 ].

The literature regarding flight crew health is relatively sparse and of varying quality [ 2 ]. Results have been mixed, but overall point towards associations between in-flight exposures or job tenure and reduced respiratory health [ 9 ], increased rates of breast and skin cancers [ 10 ], adverse reproductive and perinatal outcomes [ 11 ], musculoskeletal injuries [ 2 ], health effects from contaminated cabin air [ 12 ], and higher rates of mental health conditions [ 1 , 13 ].

To address gaps in the existing literature (namely that (1) few U.S. studies have compared flight attendant health to that of the general population, especially for a comprehensive range of health outcomes, and (2) many previous studies of flight attendant health were of small sample size or prone to selection bias due to recruitment to investigate specific health issues), we launched the Harvard Flight Attendant Health Study (FAHS) in 2007 [ 14 ]. In the first wave of our study, we aimed to profile prevalent health conditions among cabin crew, compare the health of flight attendants to that of the general population, and evaluate associations between job tenure as a proxy for occupational exposures and prevalent health outcomes among cabin crew. This study reported elevated rates of reproductive cancers, respiratory and cardiovascular outcomes, and sleep and mental health conditions in flight attendants, some of which were related to job tenure [ 14 ]. We have since completed the second wave of the FAHS in 2014–2015, with new and returning participants. We aim to replicate our previous analysis with the goal of characterizing a possibly changing flight crew health profile given an older and more diverse work force, increased physical job demands, a longer time elapsed since the institution of in-flight smoking bans, and an updated fleet. We hypothesized that we would continue to observe associations between work as a flight attendant and a range of respiratory, cardiac, reproductive, perinatal, mental health and cancer outcomes.

Study population

Our participants were enrolled in the second wave of the FAHS, an ongoing study of flight crew health which was established in 2007 and originally enrolled 4011 flight attendants [ 14 ]. For the 2014–2015 wave of the FAHS reported in this manuscript, we recruited both new and returning flight attendants to participate through several channels, including a hard copy survey mailed to the 2007 participants and distributed at airport terminals between December 2014 and June 2015, and an online survey launched in December 2014. We supplemented our survey reach with in-person recruitment at five large airport hubs in the U.S. Our recruitment campaign also included announcements about the study from local unions and through social media. Survey participants could enter a lottery to win an iPad or Apple watch over an 18-month period.

Any current or former U.S. flight attendant was eligible to participate in the FAHS. We collected 1642 surveys from returning participants, which represents a 40% response rate from the original cohort with still-valid addresses. In total, the 2014–2015 FAHS cohort enrolled 5366 U.S. flight attendants with information on age and gender. These variables were among the last questions to be asked in the online questionnaire and are thus indicators of survey completeness. Our study was approved the Harvard T.H. Chan School of Public Health institutional review board, and all participants provided their written informed consent.

Our survey instrument included validated questions about self-reported health outcomes and symptomology, work experiences, and personal characteristics [ 14 ], taken from established surveys such as the Job Content Questionnaire and the National Health and Nutrition Examination Survey (NHANES) [ 15 , 16 ]. Participants were also asked to provide aviation employment history, including airlines, primary hubs, and dates of employment and leave.

Comparison to NHANES

We compared the prevalence of health conditions and symptoms reported in the 2014–2015 wave of the FAHS to equivalent information collected from a nationally representative sample from the NHANES during the years 2013–2014 [ 16 ]. The NHANES is administered by the Centers for Disease Control and Prevention, and collects demographic, health, dietary, and biomarker data from approximately 5000 U.S. residents each year. Most of the health conditions we compared had binary answer choices for prevalence (ever diagnosed: yes/no). For fatigue and depression, prevalence was based on symptoms reported in the past two weeks in both the FAHS and NHANES surveys: we considered symptoms occurring “nearly every day” as a “yes” for both conditions. We weighted the NHANES data by their two-year sample weights, primary sampling units, and strata based on analytic guidelines [ 17 ], and restricted respondents to adults who had a family income to poverty ratio of 1 or greater, at least a high school education, and were currently employed ( N  = 2729) in order to better match our study populations.

Statistical analyses

We calculated descriptive statistics for participant characteristics and health outcomes, and we compared participants taking hard copy and online questionnaires on key characteristics using Student’s t test and chi-square analysis. We then compared the prevalence of health behaviors, conditions and symptoms in the NHANES and FAHS using the Standardized Prevalence Ratio (SPR), an indirect method of standardization which compares observed and expected prevalence given rates in the reference study population, which in our case was NHANES [ 18 ]. The SPR was weighted by age category (18–39, 40–59, and 60+ years) and analyzed separately by gender.

To further increase the comparability of the study populations, we conducted a sensitivity analysis restricted to non-Hispanic white participants, who comprised 75% of our cohort and 43% of the NHANES population. We also conducted a secondary analysis evaluating the age-adjusted comparative prevalence of health conditions for flight crew exposed to high levels of historical occupational secondhand smoke, and we conducted sensitivity analyses which calculated SPRs for chronic bronchitis, coronary heart disease, reproductive cancer, and sleep disorders among participants taking hard copy surveys and among returning 2007 participants.

We also analyzed gender-stratified associations between net job tenure (total time working as a flight attendant minus any leave) and diagnosed health conditions using logistic regression and adjusting for potential confounders: age (continuous), current and past smoking status (yes/no), overweight status based on body mass index (25+ vs. < 25 kg/m 2 ), and educational attainment (high school, some college/trade certificate, and college degree or higher). Tenure was meant to serve as a proxy for the duration of occupational exposures [ 19 ]. We examined perinatal and reproductive outcomes in relation to tenure prior to age 45. Analyses were completed using STATA statistical software, version 14 (StataCorp, College Station, TX).

FAHS participants ( n  = 5366) presented with a mean age of 51.5 years (Table  1 ). The average net job tenure was 20.4 years and 81.4% were female. Only 8.1% of the participants reported being current smokers; 32.7% were former smokers. Over 90% of participants completed at least some college or post-high school vocational training. Participants taking hard copy surveys differed from online survey takers in terms of age, tenure, sex, smoking status, and ethnicity, and were similar in terms of overweight, race, education, and past smoking history (data not shown).

Acute and chronic health conditions reported by at least 15% of the FAHS population are presented in Table  2 . These conditions fall primarily into the following categories: respiratory, musculoskeletal, cardiovascular, and mental health. Over 15% of study participants had also been diagnosed with any cancer. Except for high cholesterol and hypertension, the prevalence of the profiled conditions was consistently slightly higher among the female participants.

We report SPRs comparing the prevalence of risk factors, mental health symptoms and health conditions in the FAHS and the NHANES in Table 3 . The flight attendants in our study had lower rates of overweight, obesity, and current smoking relative to employed NHANES participants of similar socioeconomic status. Cardiovascular and respiratory outcomes were also decreased among cabin crew relative to the general population. For example, SPRs among female flight attendants were 0.44 (95% CI: 0.39–0.50), 0.53 (95% CI: 0.29–0.96) and 0.82 (95% CI: 0.63–1.07) for hypertension, coronary heart disease, and chronic bronchitis, respectively. Results for cardiac and respiratory outcomes did not change meaningfully when we restricted our analysis to crew with high occupational secondhand smoke exposure (Additional file  1 : Table S1).

In contrast, we report a higher prevalence of two broad cancer outcomes in flight crew: “reproductive cancers” (breast, uterine, ovarian, and cervical) and “all cancers” (female reproductive, lung, oral, esophageal, prostate, testicular, colon, bladder, melanoma, non-melanoma skin, leukemia, thyroid, brain, lymphoma, liver, kidney, stomach, and pancreatic). The SPRs for reproductive and any cancers among females were 1.66 (95% CI: 1.18–2.33) and 2.15 (95% CI: 1.73–2.67), respectively, with slightly higher SPRs among those with high occupational secondhand smoke exposure (Additional file 1 : Table S1). The SPR for any cancer diagnosis was not elevated among male flight crew overall (SPR = 0.89, 95% CI: 0.69, 1.14), but was among those exposed to occupational secondhand smoke (SPR = 1.70, 95% CI: 1.10–2.63).

We also calculated SPRs for sleep disorders and fatigue and depression symptoms over the past two weeks (Table  4 ). These conditions were much more prevalent among flight attendants than in the general population. For example, the SPRs for sleep disorders and fatigue among females were 3.00 (95% CI: 2.45–3.69) and 2.18 (95% CI: 1.75–3.69), respectively.

SPRs for all health outcomes were similar when restricting the study populations to non-Hispanic white participants (data not shown). Participants taking the hard copy of the study questionnaire as well as returning 2007 participants did not show meaningful differences in SPRs for the four outcomes examined: bronchitis, coronary heart disease, reproductive cancers, and sleep disorders. However, comparing the entire 2007 wave of the FAHS to the 2013–2014 NHANES participants yielded elevated SPRs for bronchitis and heart disease (data not shown).

We found associations between each five-year increase in net job tenure and sleep disorders (OR = 1.18, 95% CI: 1.05, 1.31) and anxiety/depression (OR = 1.22, 95% CI: 1.08, 1.38) among male participants, and with alcohol abuse for both genders (female: OR = 1.25, 95% CI: 1.04, 1.49; male: OR = 1.37, 95% CI: 1.02, 1.85) (Table 4 ). Job tenure was also related to the prevalence of any cancer among males (OR = 1.14, 95% CI: 1.00, 1.32) and females (OR = 1.05, 95% CI: 1.00, 1.10), and to peripheral artery disease among females (OR = 1.37, 95% CI: 1.05, 1.79). Net tenure was related to sinusitis among males (OR = 1.17, 95% CI: 1.03, 1.32), and to foot surgery (OR = 1.09, 95% CI: 1.03, 1.16) among females (Table 4 ). Chronic back pain was marginally related to tenure among females (OR = 1.04, 95% CI: 1.00, 1.09). Because we are particularly interested in the effects of secondhand smoke on the prevalence of pulmonary embolism, peripheral artery disease, and transient ischemic attacks, we conducted a post-hoc analysis evaluating associations between tenure and these health outcomes among flight crew working prior to 1988; the ORs for pulmonary embolism and peripheral artery disease rose to 1.17 (95% CI: 0.90, 1.53) for males and 1.53 (95% CI: 0.93, 2.55) for females, and the OR for transient ischemic attack among females was 1.42 (95% CI: 0.79, 2.55).

Finally, we evaluated associations between five-year job tenure prior to age 45 years and several reproductive and perinatal outcomes: miscarriage, preterm birth, fetal abnormality, and infertility (Table  5 ). These conditions were all related to job tenure, with ORs of 1.33 (95% CI: 1.20, 1.46), 1.43 (95% CI: 1.17, 1.74), 1.64 (95% CI: 1.23, 2.18), and 1.45 (95% CI: 1.29, 1.64), respectively. The association between job tenure and infertility was attenuated slightly when restricting to parous women, but remained elevated at an OR of 1.34 (95% CI: 1.18, 1.52).

To our knowledge, we have conducted the largest study characterizing the overall health of flight attendants relative to the general population. Consistent with previous studies, we report a higher prevalence of fatigue, depression, anxiety, and sleep disorders, as well as reproductive and all cancers. This is striking given lower observed rates of overweight, smoking, and chronic respiratory and cardiovascular conditions among flight crew. We also report associations between job tenure and reproductive, perinatal, mental health, and cancer outcomes, as well as peripheral artery disease and sinusitis. Our study informs future research priorities regarding the health of this understudied group of workers, and raises the question of what can be done to minimize the adverse exposures and health outcomes common among cabin crew.

Our finding of a greater prevalence of reproductive and all cancers among flight crew is consistent with most of the epidemiologic literature on this topic [ 20 ]. We also observed that job tenure was associated with prevalence of cancer at all sites among males and females. While a recent study reported no evidence of increased breast cancer or melanoma mortality within a large cohort of U.S. flight attendants relative to the general population, this study was limited by reliance on cancer mortality rather than incidence data for cancers that have relatively low mortality rates, and by a short median employment tenure of 5.9 years [ 21 ]. The latter is problematic given the long induction and latency periods of cancers, especially solid tumors [ 22 ]. In contrast, the median tenure among participants in the FAHS was 19 years. Our results are also consistent with flight crews’ occupational exposures to ionizing radiation [ 2 , 8 ], circadian rhythm disruption and resulting sleep disorders [ 3 ], historical exposures to secondhand smoke [ 5 ], and ongoing exposures to other chemical agents [ 4 , 5 ], most of which are classified as confirmed or probable carcinogens in humans [ 23 , 24 , 25 ]. While beyond the scope of the study reported here, we plan to evaluate a wide range of specific cancers in a future investigation.

We report increased prevalence of adverse sleep and mental health outcomes among flight crew. We also observed associations between tenure, anxiety/depression, sleep disorders, and alcohol abuse. Our results are consistent with the existing literature, though ours is the only study population to have evaluated all of these conditions [ 3 , 13 ]. Studies also report elevated rates of suicide among cabin crew [ 21 ]. Previous research suggests risk factors for adverse mental health outcomes among flight crew, including long or irregular working hours, sexual harassment, and a lack of employer protections with respect to occupational exposures [ 26 ]. Flight attendants also anecdotally report work-related disruptions to their dietary intake and nutritional patterns, in terms of both meal timing and availability of nutritious food while traveling, which could potentially affect multiple health outcomes as well. Furthermore, it should be noted that sleep disorders, which can be related to Circadian rhythm disruption, are independent risk factors for adverse mental health outcomes, including suicide [ 27 , 28 ].

We observed positive associations between tenure as a flight attendant acquired during a woman’s reproductive years and infertility, miscarriage, preterm birth, and fetal abnormalities. Our results are consistent with the handful of studies that have examined reproductive and pregnancy outcomes among flight crew and passengers [ 11 , 29 ]. For example, a recent high-quality study observed associations between rates of miscarriage and circadian rhythm disruption, cosmic ionizing radiation exposure, and high physical job demands among flight attendants [ 11 ]. Our findings are also consistent with research linking adverse pregnancy outcomes to ionizing radiation exposure, shift work and physical job demands within other occupations [ 30 , 31 , 32 ]. Cabin crew have the largest annual ionizing radiation dose of all U.S. workers (e.g. 3.07 mSv vs. 0.59 mSv for U.S. Department of Energy workers) [ 8 ], and can easily exceed the prenatal ionizing radiation exposure guidelines released by the NCRP or the International Commission on Radiological Protection [ 8 , 33 ]. These exposures, which are not regulated among flight crew, may be particularly problematic for pregnant workers.

We report a lower prevalence of respiratory and cardiac conditions among flight crew relative to the general population, overall and when restricting to workers with high occupational secondhand smoke exposures prior to 1988. This contrasts with our findings from the previous wave of the FAHS [ 14 ]. While flight attendants in the 2007 wave reported lower rates of hypertension and asthma compared to the general population, they reported considerably higher rates of chronic bronchitis and heart disease. Flight attendants’ occupational exposures, such as noise and circadian rhythm disruption, have also been associated with cardiovascular outcomes in other study populations [ 34 , 35 ]. Furthermore, previous studies have reported associations between employment as a flight attendant and chronic bronchitis, though these were limited by low sample size, response rate, or a lack of participant blinding to study hypotheses [ 9 ]. We considered several explanations for our unexpected results, such as differences between hard copy and online questionnaire takers, 2007 and 2014–2015 FAHS participants, and the 2005–2008 and 2013–2014 NHANES study populations. Sensitivity analyses indicated that (1) chronic bronchitis and coronary heart disease rates were higher in the 2007 wave of the FAHS relative to the 2013–2014 NHANES participants, ruling out changes in prevalence within the NHANES as a contributing factor, (2) results were robust when restricting analyses to participants who filled out a hard copy questionnaire, and (3) 2007 participants who returned for the 2014–2015 wave had reduced rates of chronic bronchitis and heart disease. Given these findings, we suggest two possibilities explaining the difference in results between the waves of the FAHS, though we cannot rule out the possibility of random chance. First, working populations often exhibit lower mortality and morbidity rates than the general population due to the healthy worker effect [ 36 ]. This occurs because people with significant health issues may be unable to maintain employment, especially when the job is physically demanding. The resulting selection bias can obscure associations between occupational exposures and health outcomes. Chronic bronchitis and coronary heart disease are both severe and often deteriorating conditions that would significantly impair a flight attendant’s ability to perform their job duties, and participants reporting these diagnoses in 2007 may not have continued to work until 2015. Secondly, more time has elapsed since smoking bans were instituted on flights, and the risk of adverse respiratory and cardiac outcomes generally declines continually in the years after cessation of cigarette smoke exposure [ 37 ]. Hence, one can expect to see fewer incident cases of smoking-related bronchitis and heart disease among flight crew as time goes on, with a simultaneous increased rate of attrition for participants with these health outcomes due to an inability to sustain job demands. Interestingly, tenure as a flight attendant was related to the prevalence of peripheral artery disease in our study, especially among workers exposed to high levels of secondhand tobacco smoke. This is consistent with reports that former smoking has a more persistent effect on peripheral artery disease risk than on the risk of coronary heart disease [ 38 ].

Participants in the FAHS report a relatively high prevalence of sinonasal, ear and musculoskeletal symptoms, consistent with previous studies [ 2 , 9 , 14 ]. We also found positive associations between job tenure and sinusitis among males, foot surgery among females, and a marginal association with chronic back pain among females. Reasons underlying gender-specific associations are unclear, and these results should be considered preliminary given their lack of precision. However, the observed associations are consistent with the presence of respiratory irritants in the cabin environment, and with flight attendants’ physical job demands and exposures to noise and changes in barometric pressure [ 2 , 4 ]. Past studies have also identified work-related psychosocial factors related to musculoskeletal disorders among flight crew [ 39 ], which include psychological job demands, harassment, and job insecurity.

Limitations of our study include its cross-sectional design, which precludes inferences about causality. In addition, health outcomes in our study and in the NHANES were based on self-report; validation through medical records was not possible due to the scope and cost of this endeavor. Validity of self-reported health outcomes varies by study population and the outcome of interest. Sensitivity and specificity of self-reported outcomes relative to medical records or linkage to disease registries were found to be moderate to high for cancer, musculoskeletal disorders and mental health diagnoses, including in the NHANES [ 40 , 41 , 42 ]. Validity is often further improved among those with higher socioeconomic status [ 40 ]. Because flight attendants may differ from a representative sample of the general population in ways that could affect health, we restricted NHANES respondents to adults of comparable socioeconomic status (as measured by family income to poverty ratio, educational attainment, and employment status) in order to make the two cohorts more comparable. Nevertheless, we recognize that further health-related differences may exist between flight attendants and even a restricted general population survey. Hence, future studies should compare flight attendant health with that of U.S. workers in similar occupations, such as nursing or service industry professions.

An additional limitation of our study is the use of an online recruitment strategy, meaning that our response rate and the representativeness of our study with regard to the total population of U.S. cabin crew are unclear. Other limitations include reliance on job tenure as a surrogate for occupational exposures, lack of correction for multiple testing, and the use of a uniform set of potential confounders for evaluating all health outcomes. The goals of our study were to characterize the health of flight attendants relative to the general population and to identify future research directions. We plan to evaluate specific exposures and identify potential confounders for individual exposure-outcome analyses in future research efforts.

Strengths of our study include access to the resources of a large cohort of flight crew with information on a range of health outcomes, work experiences, and potential confounders. Our study presents the most comprehensive profile of cabin crew health to date, and the multiple waves of our cohort allow us to describe changes in the health of U.S. cabin crew over time. In addition, online questionnaires are an increasingly popular option in epidemiologic research, including high profile studies such as the Millennium Cohort and the Nurses’ Health Study 3 [ 43 ]. This mode of data collection allows for validation checks, reduced data entry and coding errors, personalized question administration, convenience to participants, equal or better validity compared to hard copy questionnaires, and the collection of metadata, such as date, time, and time to completion, which can be used for quality control and sensitivity analyses [ 43 ].

Our study findings contribute to the sparse literature on flight attendant health, which may also be applicable to passengers, especially frequent flyers or vulnerable subpopulations such as the elderly, those with preexisting health conditions, and pregnant women. Conducting high quality studies within this group of workers is important given the fact that U.S. flight crew are subject to fewer protections than most workers in this country and relative to flight attendants working in the European Union (EU). For example, the EU requires airlines to monitor radiation dose, organize schedules to reduce radiation exposure (e.g by rationing flight routes with higher radiation exposures, such as international or circumpolar flights), and inform workers of current studies and health risks [ 44 ]. Furthermore, studies consistently report fatigue and reduced mental health among cabin crew, which can affect worker quality of life and passenger safety. Possible interventions for improving quality of life among flight crew include altering the organization of work hours, providing more opportunities for rest and education regarding best sleep practices, and workplace policies for reducing sexual harassment [ 39 ].

Future studies should address the healthy worker effect through statistical methods. A more comprehensive assessment of cancer rates among cabin crew is warranted as well. It is also important to note that the lower prevalence of cardiac and respiratory disease among our participants does not rule out the possibility, even in the FAHS, of in-flight exposures being related to more subtle health markers, such as fluctuations in heart rate variability or reductions in pulmonary function, which could be important among susceptible crew and passengers. Hence, future studies could monitor subclinical cardiopulmonary changes in relation to flight.

To our knowledge, we have conducted the largest study of general flight crew health to date. Despite a strong observed healthy worker effect, we report that flight attendants have elevated rates of reproductive cancers, cancer at all sites, sleep disorders, and mental health conditions relative to the general U.S. population. The prevalence of adverse reproductive and perinatal outcomes, mental health and sleep disorders, musculoskeletal conditions, all cancers, peripheral artery disease, and sinusitis were related to tenure as a flight attendant. Our results provide new information to guide future research regarding the health of this understudied group of workers.

Abbreviations

Confidence interval

European Union

Flight Attendant Health Study

National Council on Radiation Protection

National Health and Nutrition Examination Survey

Standardized prevalence ratio

Ballard TJ, Romito P, Lauria L, Vigiliano V, Caldora M, Mazzanti C, et al. Self-perceived health and mental health among women flight attendants. Occup Environ Med. 2006;63(1):33–8.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Griffiths RF, Powell DM. The occupational health and safety of flight attendants. Aviat Space Environ Med. 2012;83(5):514–21.

Article   PubMed   Google Scholar  

Grajewski B, Whelan EA, Nguyen MM, Kwan L, Cole RJ. Sleep disturbance in female flight attendants and teachers. Aerosp Med Hum Perform. 2016;87(7):638–45.

Rayman RB. Cabin air quality: an overview. Aviat Space Environ Med. 2002;73(3):211–5.

CAS   PubMed   Google Scholar  

Repace J. Flying the smoky skies: secondhand smoke exposure of flight attendants. Tob Control. 2004;13(Suppl 1):18–9.

Google Scholar  

Occupational Safety and Health Administration. Applicability of certain OSHA standards to cabin crew members on Aircraft in Operation (2014). Accessed 17 Jan 2018.

The National Institute for Occupational Safety and Health. Aircrew Safety & Health (2017). Accessed 17 Jan 2018.

National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. Report No. 160. In: Recommendations of the National Council on radiation protection and measurements (NCRP). Bethesda, MD: National Council on Radiation Protection and Measurements; 2009.

Ebbert JO, Croghan IT, Schroeder DR, Murawski J, Hurt RD. Association between respiratory tract diseases and secondhand smoke exposure among never smoking flight attendants: a cross-sectional survey. Environ Health. 2007;6:28.

Article   PubMed   PubMed Central   Google Scholar  

Tokumaru O, Haruki K, Bacal K, Katagiri T, Yamamoto T, Sakurai Y. Incidence of cancer among female flight attendants: a meta-analysis. J Travel Med. 2006;13(3):127–32.

Grajewski B, Whelan EA, Lawson CC, Hein MJ, Waters MA, Anderson JL, et al. Miscarriage among flight attendants. Epidemiology. 2015;26(2):192–203.

Pinkerton LE, Hein MJ, Grajewski B, Kamel F. Mortality from neurodegenerative diseases in a cohort of US flight attendants. Am J Ind Med. 2016;59(7):532–7.

Feijo D, Luiz RR, Camara VM. Common mental disorders among civil aviation flight attendants. Aviat Space Environ Med. 2014;85(4):433–9.

McNeely E, Gale S, Tager I, Kincl L, Bradley J, Coull B, et al. The self-reported health of U.S. flight attendants compared to the general population. Environ Health. 2014;13(1):13.

Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. The job content questionnaire (JCQ): an instrument for internationally comparative assessments of psychosocial job characteristics. J Occup Health. 1998;3(4):322–55.

Article   CAS   Google Scholar  

National Health and Nutrition Examination Survey. Questionnaires, datasets, and related documentation. https://www.cdc.gov/Nchs/Nhanes/ . Accessed 10 January 2017.

Centers for Disease Control and Prevention: National Health and nutrition examination survey: analytic guidelines, 1999–2010. In vol. Series 2. Hyattsville, Maryland: U.S. Department of Health and Human Services; 2013.

Miettinen OS. Standardization of risk ratios. Am J Epidemiol. 1972;96(6):383–8.

Article   CAS   PubMed   Google Scholar  

Hammer GP, Zeeb H, Tveten U, Blettner M. Comparing different methods of estimating cosmic radiation exposure of airline personnel. Radiat Environ Biophys. 2000;39(4):227–31.

Buja A, Mastrangelo G, Perissinotto E, Grigoletto F, Frigo AC, Rausa G, et al. Cancer incidence among female flight attendants: a meta-analysis of published data. J Women's Health. 2006;15(1):98–105.

Article   Google Scholar  

Pinkerton LE, Waters MA, Hein MJ, Zivkovich Z, Schubauer-Berigan MK, Grajewski B. Cause-specific mortality among a cohort of U.S. flight attendants. Am J Ind Med. 2012;55(1):25–36.

Checkoway H, Pearce N, Hickey JL, Dement JM. Latency analysis in occupational epidemiology. Arch Environ Health. 1990;45(2):95–100.

IARC (International Agency for Research on Cancer). Radiation. IARC Monogr Eval Carcinog Risks Hum. 2012:100D.

IARC (International Agency for Research on Cancer). Painting, firefighting, and shiftwork. IARC Monogr Eval Carcinog Risks Hum. 2010;98:9–764.

IARC (International Agency for Research on Cancer). Tobacco smoke and involuntary smoking. IARC Monogr Eval Carcinog Risks Hum. 2004:83.

Gunnarsdottir HK, Sveinsdottir H, Bernburg JG, Fridriksdottir H, Tomasson K. Lifestyle, harassment at work and self-assessed health of female flight attendants, nurses and teachers. Work. 2006;27(2):165–72.

PubMed   Google Scholar  

Baglioni C, Nanovska S, Regen W, Spiegelhalder K, Feige B, Nissen C, et al. Sleep and mental disorders: a meta-analysis of polysomnographic research. Psychol Bull. 2016;142(9):969–90.

Escobar-Córdoba F, Quijano-Serrano M, Calvo-González JM. Evaluation of insomnia as a risk factor for suicide. Rev Fac Cien Med Univ Nac Cordoba. 2017;74(1):37–45.

Magann EF, Chauhan SP, Dahlke JD, McKelvey SS, Watson EM, Morrison JC. Air travel and pregnancy outcomes: a review of pregnancy regulations and outcomes for passengers, flight attendants, and aviators. Obstet Gynecol Surv. 2010;65(6):396–402.

Williams PM, Fletcher S. Health effects of prenatal radiation exposure. Am Fam Physician. 2010;82(5):488–93.

Stocker LJ, Macklon NS, Cheong YC, Bewley SJ. Influence of shift work on early reproductive outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2014;124(1):99–110.

Lee LJ, Symanski E, Lupo PJ, Tinker SC, Razzaghi H, Chan W, et al. Role of maternal occupational physical activity and psychosocial stressors on adverse birth outcomes. Occup Environ Med. 2016; https://doi.org/10.1136/oemed-2016-103715 .

International Commission on Radiological Protection (ICRP). Publication 103: recommendations of the international commission on radiological protection. Radiat Prot Dosim. 2008;129:500–7.

Gan WQ, Davies HW, Demers PA. Exposure to occupational noise and cardiovascular disease in the United States: the National Health and nutrition examination survey 1999-2004. Occup Environ Med. 2011;68(3):183–90.

Puttonen S, Harma M, Hublin C. Shift work and cardiovascular disease - pathways from circadian stress to morbidity. Scand J Work Environ Health. 2010;36(2):96–108.

Li CY, Sung FC. A review of the healthy worker effect in occupational epidemiology. Occup Med. 1999;49(4):225–9.

Godtfredsen NS, Prescott E. Benefits of smoking cessation with focus on cardiovascular and respiratory comorbidities. Clin Respir J. 2011;5(4):187–94.

Conen D, Everett BM, Kurth T, Creager MA, Buring JE, Ridker PM, et al. Smoking, smoking cessation and risk of symptomatic peripheral artery disease in women: a prospective study. Ann Intern Med. 2011;154(11):719–26.

Lee H, Wilbur J, Kim MJ, Miller AM. Psychosocial risk factors for work-related musculoskeletal disorders of the lower-back among long-haul international female flight attendants. J Adv Nurs. 2008;61(5):492–502.

Parikh-Patel A, Allen M, Wright WE. California teachers study steering committee. Validation of self-reported cancers in the California teachers study. Am J Epidmeiol. 2003;157(6):539–45.

Picavet HS, Hazes JM. Prevalence of self-reported musculoskeletal diseases is high. Ann Rheum Dis. 2003;62(7):644–50.

Sanchez-Villegas A, Schlatter J, Ortuno F, Lahortiga F, Pla J, Benito S, et al. Validity of a self-reported diagnosis of depression among participants in a cohort study using the structured clinical interview for DSM-IV (SCID-I). BMC Psychiatry. 2008;8:43.

van Gelder MM, Bretveld RW, Roeleveld N. Web-based questionnaires: the future in epidemiology? Am J Epidemiol. 2010;172(11):1292–8.

EURADOS. Exposure of air crew to cosmic radiation: a report of EURADOS Working Group 11, EURADOS Report 1996.01. In: Office for Official Publications of the European Communities; Luxembourg: European Commission Report Radiation Protection 85; 1996.

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Acknowledgments

We are grateful to all of the flight attendants who took the time and effort to complete the survey. Without their invaluable assistance, this study would not be possible.

The current study was funded by FAMRI grant CIA 150083. FAMRI had no role in the design of this study, in the collection, analysis, and interpretation of the data, or in writing the manuscript.

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The datasets generated and analyzed during the current study are not publicly available due to institutional review board specifications (but are available from the corresponding author on reasonable request).

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Eileen McNeely, Irina Mordukhovich & Sara Gale

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EM and SG designed and conducted the flight attendant health survey. EM, ST, BC, and IM conducted the study’s statistical analyses. EM and IM drafted the manuscript and all authors contributed to its contents. All authors read and approved the final manuscript.

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Correspondence to Irina Mordukhovich .

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Additional file 1:.

Table S1 . Comparative age-adjusted prevalence of health behaviors and conditions in the Harvard Flight Attendant Health Study (FAHS, 2014–2015) and NHANES (2013–2014), evaluating only flight attendants with occupational smoking exposure prior to the year 1988. (DOCX 21 kb)

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McNeely, E., Mordukhovich, I., Tideman, S. et al. Estimating the health consequences of flight attendant work: comparing flight attendant health to the general population in a cross-sectional study. BMC Public Health 18 , 346 (2018). https://doi.org/10.1186/s12889-018-5221-3

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• Published: 30 December 2021

Flight attendant occupational nutrition and lifestyle factors associated with COVID-19 incidence

• Jessica J. Yamamoto 1 ,
• Elizabeth T. Brandley 1 &
• Trina C. Ulrich 1  

Scientific Reports volume  11 , Article number:  24502 ( 2021 ) Cite this article

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• Occupational health
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• Risk factors

In the era of COVID-19, essential workers are plagued with unforeseen and obfuscated challenges. Flight attendants are a unique subgroup of essential workers who face a multitude of health risks attributed to occupational exposures that are accentuated by the COVID-19 pandemic. Such risks can be ameliorated with strategies that target factors which enhance COVID-19 risk, including modifiable factors of diet and lifestyle. The aim of this cross-sectional study is to detect occupational dietary and lifestyle factors which could increase COVID-19 incidence amongst flight attendants. To identify potential risk factors, a questionnaire was administered to eighty-four flight attendants and examined the participants’ diet and lifestyle, and COVID-19 incidence. Descriptive statistics and logistic regression indicated that the participants’ perceived dietary quality at work ( p  = 0.003), sleep disruptions which impacted their consumption of a healthy diet ( p  = 0.013), job tenure (OR: 0.67, 95% CI: 0.46:0.98) and frequency of reported cold/flu (OR: 1.49, 95% CI: 1.014–2.189) were all factors associated with confirmed/suspected COVID-19 incidence. This study also revealed that a lack of infrastructure for food storage and time limitations are considerable occupational barriers for flight attendants to consume healthy foods. Additional investigation can further elucidate these relationships and related solutions to mitigate COVID-19 risk in the future.

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Introduction.

In 2019, a novel coronavirus strain identified as SARS-CoV-2 emerged ushering in the beginning of the COVID-19 global pandemic 1 . COVID-19 is the coined name for the disease caused by the SARS-CoV-2 virus which causes a highly infectious respiratory illness that spreads rapidly from person to person via aerosols or droplets expelled by the mouth when coughing, talking, or breathing, or less commonly from contact with contaminated surfaces accompanied by subsequent facial contact 1 , 2 . This disease has been shown to disproportionately affect individuals with comorbid conditions such as heart disease, type 2 diabetes, hypertension, chronic obstructive pulmonary diseases, cancer, chronic kidney disease and obesity with age, race, gender, ethnicity, socioeconomic class, and residence in areas with higher air pollution being amongst other factors which have been identified to increase risks and/or severity for this infectious disease 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 . By mid-2021, the COVID-19 virus has impacted individuals and families across the globe with approximately 185 million confirmed cases, and approximately 4 million deaths according to the World Health Organization (WHO) 15 . These unprecedent times sent the global economy into a rapid halt in many occupational sectors due to lockdowns designed to prevent the spread of the virus 15 , 16 .

Essential workers were amongst those who were left on the frontlines despite global lockdowns due to their necessity in ensuring the continuing operation of critical infrastructure 17 . This unique group of workers span across a variety of professional fields including those working in health care, retail food industry, manufacturing, farming, mass transit such as buses, trains, airplanes, and beyond 17 . These professionals are often required to be in close proximity to others with frequent face-to-face interactions 18 . Additionally, they have a heightened exposure to infectious diseases and have environmental barriers which could interfere with performing healthy behaviors that mitigate illness or chronic disease 18 . Therefore, essential workers are a particularly vulnerable group 18 . Vigilant care and protection to reduce risks for infectious disease acquisition as well as the illumination of factors which may reduce risks for COVID-19 infection, including long-term complications, is needed.

Flight attendants are members of this vast group of essential workers who remain understudied yet are particularly vulnerable due to the increased rates of chronic illness compared to the general population and unique nature of their profession 19 , 20 . One study assessing flight attendants' health status compared to the general population from the National Health and Nutrition Examination Survey (NHANES), found both female and male flight attendants had three to five-fold greater incidence of sleep disorders, respectively 19 . This same study found that flight attendants had higher incidence of depression and fatigue symptoms 19 . Flight attendants are also at a higher risk for certain cancers 21 . In particular, a higher incidence of melanoma, non-melanoma skin cancer, and breast cancer have been found amongst female flight attendants with standard prevalence ratios being cited as 2.27, 4.09, and 1.51 respectively, compared to females from a similar socioeconomic spread 22 . The prevalence of heart disease is 3.5 times greater for female flight attendants when compared to the general public despite the fact that factors which often contribute to heart disease, such as higher biometric and metabolic markers (i.e. elevated weight and hypertension), are conditions that are reported to be lower in prevalence among flight attendants 19 . Furthermore, studies show a lower prevalence of smoking among flight attendants, yet this group is reported to have a greater incidence of chronic bronchitis and respiratory symptoms 19 , 20 . A recent study noted contradictory results regarding elevated chronic bronchitis risk, suggesting that this specific risk may be diminished due to removing unhealthy occupational exposures, such as mandating smoke-free environments onboard an aircraft and requires further examination 23 .

Given that COVID-19 incidence and severity rates are higher in individuals with comorbid conditions, including cancer, chronic obstructive pulmonary disease (including chronic bronchitis) and heart disease (all diseases disproportionately impacting flight attendants), it is critical to examine potential modifiable occupational factors and determinants for COVID-19 risk amongst flight attendants 24 , 25 , 26 , 27 .

It has been long established that healthy lifestyles that include adequate nutrition and physical activity are associated with longevity, well-being and reduced all-cause mortality; whereas lifestyles which consist of behaviors that can compromise health, such as inadequate diet, sedentary lifestyle, disordered sleep patterns, tobacco, and alcohol-use are associated with a higher incidence of a vast array of diseases and illnesses, including COVID-19 27 , 28 , 29 . Therefore, general recommendations for the management of COVID-19 risk have suggested adherence to healthy lifestyles 30 . Generally, adverse work life and environmental contributors to overall flight attendant health status have been cited to include noise, vibration, physical demands placed on flight attendants, and disruptions with circadian rhythm 19 . However, many of these factors may also interfere with flight attendants’ ability to consume a timely and nutrient-dense diet and adhere to healthier lifestyle patterns. The identification of areas where there is a lapse in healthy behaviors can be key to reduce one’s risks for COVID-19. Investigation into such areas of improvement in the health and wellbeing of flight attendants is lacking in current literature and warrants further attention.

To begin to address this gap in the literature, this study, to the best of the authors’ knowledge, is the first study to examine the potential occupational dietary and lifestyle determinants of COVID-19 incidence within a cohort of US based flight attendants. This study further explores the potential barriers associated with the consumption of healthy foods among flight attendants at work, compared to many of their habits at home and provides a few potential solutions. Reducing modifiable risk factors for chronic illnesses within the work environment, including targeting dietary and lifestyle measures, for the sake of the amelioration of COVID-19 risk and beyond is warranted.

Materials and methods

Research setting.

Data for this study were collected via a research survey using Qualtrics software. The criteria for inclusion in this study included respondents must be over the age of 18, be actively employed as a flight attendant, and reside in the U.S. The survey was piloted to a small sample of flight attendants. Upon receiving feedback from this group, the updated survey was shared to social media pages specific to flight attendants, posted on public social media posts and further disseminated through targeted advertising on social media. After initial survey dissemination, to address a low respondent rate, an approved IRB amendment for an infographic to be shared with participants at the end of the survey was provided as an incentive for participation. This infographic contained specific tips for healthy eating and lifestyle suggestions for flight attendants while working and away from typical daily amenities, such as refrigeration and cooking supplies.

Measures of variables

The survey combined a set of standardized questions (adapted and slightly modified from existing surveys), with questions specifically for flight attendants assessing their dietary needs, habits, barriers, and solutions to healthy food consumption 31 , 32 . The survey included questions related to demographic data and COVID-specific questions including categorical self-reported confirmed positive COVID test or suspected COVID incidence. Dietary-related questions inquiring about fruit, vegetable, and fish intake were reported in frequency ranges of daily/weekly intake. Whole grain consumption at home and at work was collected on a percentage scale from 0 to 100. The participants’ perceived dietary quality at home and at work was rated on a Likert scale from 1 to 5 (i.e., 1 = Poor, 2 = Fair, 3 = Good, 4 = Very good, and 5 = Excellent). Information on the participants’ diet type (e.g., carnivorous, vegetarian, vegan, etc.) was also collected. Additionally, information about changes in sleeping patterns when at work and the possible interference with the participants’ ability to consume a nourishing diet (i.e., “yes”, “no”, and “I don’t work in different time zones/I don’t layover in different time zones” responses) was also collected. Respondents were also asked to rate their perceived impact of the COVID-19 pandemic on their diet on a Likert scale of 1 to 5, where 1 = no effect and 5 = drastic effect. Finally, barriers associated with healthy eating at work were assessed using a list of potential responses along with a written response option.

Data analysis procedures

Following the four-month survey administration period, data analysis was performed using SPSS V26 software. The categorical data was coded into ordinal values and was analyzed primarily using descriptive statistics with a selected level of significance of ≤ 0.05. Researchers combined suspected COVID incidence with individuals who had a self-reported or confirmed positive COVID test when analyzing the influencing variables for COVID-19 onset. Theses variables were coded as a dichotomous variable and compared with other potential predictive variables. Potential predicative variables, including the participants’ demographics such as gender, age, and job tenure, were modeled and analyzed using logistic regression. Categorical and categorical ordinal variables such as ranges of dietary intake, diet type and perceived dietary quality at home and at work were analyzed using Pearson's chi-square and Fisher’s Exact tests. The annual frequency of cold/flu incidence was also examined using logistic regression. Factors which influenced the individuals’ perceived impact that COVID-19 had on their ability to consume a healthy diet when working were also analyzed. Results were assessed with descriptive statistics (i.e., Pearson’s Chi-square and Spearman’s Correlation) to check for association between job tenure and perceived COVID-19 occupational dietary impact.

Statement of ethical approval

This study was approved by the researchers’ university Institutional Review Board (IRB) and was performed in compliance with applicable regulations and requirements. All participants gave informed consent prior to participation.

Ethical statement

This article is a representation of the authors’ original work and research and has not been published elsewhere.

Demographics

A total of 84 surveys with varying completion rates were collected. As seen in Table 1 , the majority of the respondents identified as cisgender female (85.7%), and the mean age of respondents fell within the 35–44 year range. The average job tenure duration was between 0 and 10 years of flying, thus indicating a higher representative sample of flight attendants with a lower job tenure in our sample population. The average monthly hours flown were 86.46 h. Approximately one-third of individuals reported having a positive COVID-19 antibody test or suspected they had the COVID-19 virus (n = 28). Additionally, 40.5% of individuals reported having 2 or more colds/flu a year (n = 34).

Determinants which may increase COVID-19 risk

As demonstrated in Table 1 , there were 77 respondents who opted to give information regarding whether they had tested positive or suspected that they had COVID-19. Slightly over half of the respondents indicated that they had not tested positive nor suspected that they had COVID-19, whereas 13% of individuals indicated that they had at least one positive COVID-19 test (or antibody test), and 20% suspected that they had COVID-19 but did not have it confirmed via testing.

A statistically significant relationship between COVID-19 confirmed/suspected incidence and job tenure was seen. While holding gender and age constant, job tenure was found to be a statistically significant predictor of COVID-19 suspected/confirmed incidence ( p  = 0.04 , OR: 0.67, 95% CI: 0.46–0.98). Significant findings were not observed between the confirmed/suspected COVID-19 incidence and the respondents’ age ( p  = 0.562, logistic regression ) , fruit ( p  = 0.779, Fisher’s exact ) , vegetable ( p  = 0.15, Fisher’s exact), whole grain consumption at work ( p  = 0.883, logistic regression), and diet type ( p  = 0.669, Fisher’s Exact).

Table 2 highlights a statistically significant relationship between the respondents’ perceived diet quality at work with confirmed and suspected COVID-19 incidence ( p  = 0.003, Fisher’s exact). Those indicating a “poor” or “fair” perception of their diet at work accounted for 83% of all the positive/suspected positive COVID incidence, however, not a single participant with a suspected or confirmed COVID case rated their diet quality at work to be “very good” or “excellent”, despite respondents in these categories comprising 21% of the sample. Furthermore, although a relationship was observed between perceived dietary quality at work and COVID incidence, a statistically significant relationship was not observed between the perceived dietary quality at home and COVID incidence ( p  = 0.151, Fisher’s exact).

Table 3 shows a significant relationship was found between sleep disturbances cited at work and COVID incidence. Amongst individuals who reported changing time zones when working, individuals who indicated that their sleeping patterns at work impacted their ability to consume a healthy diet appeared to have a higher suspected/confirmed COVID incidence ( p  = 0.013, X 2  = 6.115, Cramer’s V = 0.293). Of the respondents who answered both queries and reported changing time zones at work, 72% of individuals confirmed or suspected to have experienced COVID-19 indicated that they also experienced an interference between their sleeping patterns/time zones when at work with their ability to consume a nourishing diet.

Furthermore, as shown in Table 4 , there was a statistically significant relationship found between the annual frequency of reported cold incidence and COVID incidence ( p  = 0.042, OR: 1.49, 95% CI: 1.014–2.189).

A perceived influence of the COVID-19 pandemic on the respondents’ ability to consume healthy foods was also observed. Participants reported that the COVID-19 pandemic impacted their dietary habits at work with a mean score of 3.3 on a 0–5 scale, with 5 indicating a drastic effect. This data suggests a skewness of − 0.544 indicating that the data wavers more heavily towards a drastic effect, than a null effect.

Several barriers and solutions were also identified with regards to maintaining satisfactory dietary intake while working. When inquiring into the barriers associated with the consumption of healthy foods while working, the highest rated items were a lack of infrastructure, such as refrigeration space on the plane and on layovers, and time restrictions associated with the flight attendant work environment. Additional barriers are listed in Fig.  1 .

Perceived workplace barriers interfering with the introduction of healthier foods into participants’ diet.

This study suggests that there are modifiable dietary and lifestyle factors that can be addressed within or around flight attendants’ work environment to reduce the risk of COVID-19 and other illnesses. The significant findings between perceived influence of the COVID-19 pandemic on the quality of dietary consumption, perceived diet quality, and COVID-incidence suggests that the flight attendant workspace may be a key area for improvement among airlines to modify potential risks for COVID-19 that are rooted in sleep pattern disturbances, and/or are dietary in etiology.

It is well known that dietary intake is vital for optimal health. Eating a well-balanced diet is crucial to obtain all the daily nutrient recommendations necessary for enhanced immune health and improved overall health status 33 , 34 . The WHO has suggested an increased intake of fruit and vegetable consumption beyond pre-pandemic recommendations during this time period to lower the risk of potential infection 35 . However, studies assessing dietary habits during the pandemic have demonstrated that an increase in processed foods has occurred for many individuals instead 36 . Furthermore, other studies have shown that nutritional deficiencies can potentially contribute to COVID-19 infection and severity 37 , 38 , 39 . The findings from this study demonstrate similar results with perceived occupational dietary intake to be “poor” or “fair” being associated with positive COVID-19 incidence. Despite the workplace being a major venue for food consumption amongst working adults, there remain many questions surrounding the content of a flight attendant’s diet at work and how it supports the health of the worker 40 . One study of 5,222 adults found that nearly a quarter of all polled working adults consumed food at work, which was characteristically ripe with foods that are high in sodium and added sugars as well as solid fats 40 . These are all foods that can contribute to the onset of a variety of chronic illnesses when consumed in excess. In another study, over 30% of adults polled who purchase their meals at work, indicated that workplace cafeterias and vending machines were amongst their most frequented sites of food acquisition 41 . This suggests the potential for the worksite to be a powerful target location for the promotion of healthy behaviors which can support optimal immune function. Due to the fluid the nature of flight attendants’ work environment and limited access to healthy foods, especially during the pandemic and with their higher incidence of certain chronic diseases, it is imperative that this workgroup is supported in their efforts to consume a healthy diet to reduce risk from environmental exposures to infectious diseases and mitigate the development of chronic diseases. Since the present study is the first of its kind to illuminate occupational lifestyle factors associated with COVID-19 incidence, more research is warranted to add to the scare data on the topic to illuminate how the workplace can best be adjusted to support healthy behaviors.

Respondents reported the largest barrier preventing them from introducing more healthy foods into their diet while working was a lack of infrastructure for food storage. This highlights the need for ensuring access to reserved refrigerated storage. The solution to ensuring flight attendants have adequate storage space on board the airplane to accommodate fresh foods and meals is crucial to improving dietary intake during the pandemic and beyond. This is especially pertinent for flight attendants who have multi-day duty period and/or have extended duty period hours. Access to fresh foods at airports and even local shopping venues during layovers may be compromised due to drastic measures put in place in response to pandemic lockdown strategies, including reduced operational hours, and time for enhanced cleaning strategies 42 . Additionally, early restaurant and grocery store closures may also not be conducive to the flight schedules of late arriving flights and shorter layover durations, calling for the increased consideration on these occasions during the pandemic and in the future 43 . Additionally, early training to prepare flight attendants for certain dietary and lifestyle challenges associated with life “on the fly” in the absence of typical daily amenities is needed, however further research is warranted to investigate these health promotion efforts.

Another area of focus indicated by this study is the role of sleep disturbance connected to overall flight attendant health. This point is consistent with the current literature and presents a unique challenge to the flight attendant work group, as longer duty days and changing time zones may interfere with their ability to follow normal sleep schedules 44 , 45 . One study found that fatigue rooted in inadequate sleep or sleep disturbance is a common experience amongst flight attendants and affected about 84% of flight attendants polled over the course of their most recent bid period 43 . Of this group, 71% of flight attendants indicated fatigue impacting their safety-related duties. However, concerns associated with sleep and fatigue span beyond safety-related concerns. Another study which monitored the sleep habits of 202 flight attendants indicated that participants in this study had an average of 6.3 h of sleep at home, 5.7 h of sleep when working, and an even lower average when flying internationally 46 . Such sleep durations fall below the recommended 7–9 h that are suggested for optimal immune function for adults 47 . Research has demonstrated diet can impact sleep duration and quality significantly, while poor sleep can negatively influence dietary choices significantly. This is a point which was echoed by Perrin, et al. as their findings demonstrated that disruptions in circadian rhythm amongst flight attendants can subsequently interfere with established eating patterns 48 , 49 , 50 . Our study found similar findings between sleep disturbances interfering with diet quality and risks for positive COVID-19 incidence. Inadequate sleep has also been shown to be connected to reduced immunity function, which may also be a part of the explanation for those who had a higher incidence of confirmed or suspected COVID-19 occurrence also having a higher annual frequency of colds 51 . Solutions to these issues surrounding inadequate sleep may include a continuing focus during pandemic-times on the period of rest allotted to flight attendants during trips. This may also allow for greater opportunity to access healthy food options as after-hour food venues of convenience are often rich with energy-dense, nutrient-poor food options. Given that diet can play a role in sleep and sleep can impact dietary consumption, these two factors need to be addressed rapidly to combat the COVID-19 pandemic and beyond.

Although this study focuses on a small subset of modifiable factors with regards to COVID-19 risk amongst flight attendants, it is important to note that future studies could better inform the literature by further investigating the many factors which were not within the scope of the present paper. These established risk factors include one’s race, ethnicity and residence, factors which have been established to be risk factors for COVID-19 within the general population are of particular interest 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 . Further occupational factors, such as the temperate environment of airplanes, as well the air quality of selected layover destinations may also provide further information on possible risk factors for COVID-19 and subsequent measures of intervention. Temperature variation, humidity, and the presence of air pollution (especially when associated with lower wind speeds) are all factors which have been established to compromise immunity and potentially increase risks for COVID-19 13 , 14 , 52 , 53 . Strategic approaches to manage crisis should include preventative measures, such as the amelioration of related risk factors 54 . Therefore, the identification of further risk factors for flight attendants can help inform strategic approaches for future mitigating measures during the COVID-19 pandemic or a potential similar threat arise in the future.

Conclusions and limitations

The novel findings of this diet and lifestyle-focused study indicate that job tenure, sleep and dietary concerns are critical factors that could contribute to COVID-19 incidence within the flight attendant population. This study also found that time limitations and a lack of reliable infrastructure to support healthy habits are significant barriers for many flight attendants. Examination into these determinants warrant further investigation for the flight attendant work group. Future studies could better support the limited literature on the topic by including a broader sample size with wider accessibility. Although access to this study survey was widely available to flight attendants in the U.S. on flight attendant-focused social media pages, which allowed for a socially distant survey administration process that was optimally accessible to flight attendants who were both actively flying, on leave, or furloughed, flight attendants who do not have access to or do not use social media are likely underrepresented in the participant pool. A larger, broader participant pool may be possible by combining mass mailing and virtual survey administration strategies. Additional studies with larger sample sizes, which explore the connection between sleep patterns and dietary intake and food access could help further illuminate the relationship between flight attendant health status and disease risk (acute and chronic).

It would be furthermore advantageous to examine dietary factors expanding beyond a dietary recall and including methods such as a food journal coupled with a food frequency questionnaire administered by trained professionals. Information on the utilization of energy-dense food venues and other food outlets and/or company provided meals and meal planning strategies would be beneficial to further the limited understanding of dietary patterns and occupational needs. A great deal can be learned from flight attendant habits, lifestyle, and disease status that can be applicable to many essential workers. Other studies can also build upon the present findings by including other work groups classified as essential workers and/or other occupational groups that have similar environmental exposures and barriers to healthy behavior choices to ensure that healthy lifestyles which support optimal immune function are feasible and attainable within one’s workspace. Investigations into possible solutions, such as increased support and adequate infrastructure such as reliable at-work refrigeration to support healthy dietary patterns is also necessary. These findings would be particularly useful as airlines navigate their way beyond the COVID-19 pandemic and incorporate preventative measures and protocols should another pandemic arise in the future.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Hidalgo, J., Rodríguez-Vega, G. & Pérez-Fernández, J. in COVID-19 Pandemic (eds Hidalgo, J., Rodríguez-Vega, G., & Pérez-Fernández, J.) 1–21 (Elsevier, 2022).

Christophi, C. A. et al. Ambient temperature and subsequent COVID-19 mortality in the OECD countries and individual United States. Sci. Rep. 11 , 1–9 (2021).

Article   Google Scholar  

Hatef, E., Chang, H.-Y., Kitchen, C., Weiner, J. P. & Kharrazi, H. Assessing the impact of neighborhood socioeconomic characteristics on COVID-19 prevalence across seven states in the United States. Front. Public Health 8 , 571808 (2020).

Article   PubMed   PubMed Central   Google Scholar  

Wang, B., Li, R., Lu, Z. & Huang, Y. Does comorbidity increase the risk of patients with COVID-19: Evidence from meta-analysis. Aging (Albany NY) 12 , 6049 (2020).

Article   CAS   Google Scholar  

Nandy, K. et al. Coronavirus disease (COVID-19): A systematic review and meta-analysis to evaluate the impact of various comorbidities on serious events. Diabetes Metab. Syndr. 14 , 1017–1025 (2020).

Noor, F. M. & Islam, M. M. Prevalence and associated risk factors of mortality among COVID-19 patients: A meta-analysis. J. Community Health 45 , 1270–1282 (2020).

Article   PubMed   Google Scholar  

Cho, S. I., Yoon, S. & Lee, H.-J. Impact of comorbidity burden on mortality in patients with COVID-19 using the Korean health insurance database. Sci. Rep. 11 , 1–9 (2021).

Google Scholar  

Thakur, B. et al. A systematic review and meta-analysis of geographic differences in comorbidities and associated severity and mortality among individuals with COVID-19. Sci. Rep. 11 , 1–13 (2021).

Bajgain, K. T., Badal, S., Bajgain, B. B. & Santana, M. J. Prevalence of comorbidities among individuals with COVID-19: A rapid review of current literature. Am. J. Infect. Control 49 , 238–246 (2021).

Tieskens, K. et al. Time-varying associations between COVID-19 case incidence and community-level sociodemographic, occupational, environmental, and mobility risk factors in Massachusetts. Res. Sq. 3 , 237622 (2021).

Pan, A. P. et al. Disparities in COVID-19 hospitalizations and mortality among Black and Hispanic patients: Cross-sectional analysis from the Greater Houston Metropolitan Area. BMC Public Health 21 , 1–13 (2021).

Fang, X. et al. Epidemiological, comorbidity factors with severity and prognosis of COVID-19: A systematic review and meta-analysis. Aging (Albany NY) 12 , 12493 (2020).

Coccia, M. Effects of the spread of COVID-19 on public health of polluted cities: Results of the first wave for explaining the dejà vu in the second wave of COVID-19 pandemic and epidemics of future vital agents. Environ. Sci. Pollut. Res. 28 , 19147–19154 (2021).

Coccia, M. The effects of atmospheric stability with low wind speed and of air pollution on the accelerated transmission dynamics of COVID-19. Int. J. Environ. Stud. 78 , 1–27 (2021).

Organization, W. H. WHO Coronavirus (COVID-19) Dashboard , https://covid19.who.int/ (2021).

Verschuur, J., Koks, E. E. & Hall, J. W. Global economic impacts of COVID-19 lockdown measures stand out in high-frequency shipping data. PLoS ONE 16 , e0248818 (2021).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Lancet, T. The plight of essential workers during the COVID-19 pandemic. Lancet (London, England) 395 , 1587 (2020).

Kane, J. W. & Tomer, A. Valuing human infrastructure: Protecting and investing in essential workers during the COVID-19 era. Public Works Manag. Policy 26 , 34–46 (2021).

McNeely, E. et al. The self-reported health of US flight attendants compared to the general population. Environ. Health 13 , 1–11 (2014).

Whelan, E. A. et al. Prevalence of respiratory symptoms among female flight attendants and teachers. Occup. Environ. Med. 60 , 929. https://doi.org/10.1136/oem.60.12.929 (2003).

McNeely, E. et al. Cancer prevalence among flight attendants compared to the general population. Environ. Health 17 , 49. https://doi.org/10.1186/s12940-018-0396-8 (2018).

Tokumaru, O. et al. Incidence of cancer among female flight attendants: A meta-analysis. J. Travel Med. 13 , 127–132. https://doi.org/10.1111/j.1708-8305.2006.00029.x (2006).

McNeely, E., Mordukhovich, I., Tideman, S., Gale, S. & Coull, B. Estimating the health consequences of flight attendant work: Comparing flight attendant health to the general population in a cross-sectional study. BMC Public Health 18 , 346–346. https://doi.org/10.1186/s12889-018-5221-3 (2018).

Bae, S., Kim, S. R., Kim, M.-N., Shim, W. J. & Park, S.-M. Impact of cardiovascular disease and risk factors on fatal outcomes in patients with COVID-19 according to age: A systematic review and meta-analysis. Heart 107 , 373. https://doi.org/10.1136/heartjnl-2020-317901 (2021).

Article   CAS   PubMed   Google Scholar  

Wang, Q., Berger, N. A. & Xu, R. Analyses of Risk, racial disparity, and outcomes among US patients with cancer and COVID-19 infection. JAMA Oncol. 7 , 220–227. https://doi.org/10.1001/jamaoncol.2020.6178 (2021).

Centers for Disease Control and Prevention. COVID-19: People with Certain Medical Conditions , https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html (2021).

Willett, W. C. Diet and cancer. Oncologist 5 , 393–404 (2000).

Article   ADS   CAS   PubMed   Google Scholar  

Taheri, S. The link between short sleep duration and obesity: We should recommend more sleep to prevent obesity. Arch. Dis. Child. 91 , 881–884 (2006).

De Mello, M. T. et al. Sleep and COVID-19: Considerations about immunity, pathophysiology, and treatment. Sleep Sci. 13 , 199 (2020).

PubMed   PubMed Central   Google Scholar  

Balanzá-Martínez, V., Atienza-Carbonell, B., Kapczinski, F. & De Boni, R. B. Lifestyle behaviours during the COVID-19–time to connect. Acta Psychiatr. Scand. 141 , 399 (2020).

Territories, G. O. N. Healthy Eating Assesment , https://www.hss.gov.nt.ca/sites/hss/files/resources/healthy-eating-assessment.pdf

QuestionPro. Ethnicity Survey Questions for Questionnaires.

Willett, W. C. Diet and health: What should we eat?. Science (Am. Assoc. Adv. Sci.) 264 , 532–537. https://doi.org/10.1126/science.8160011 (1994).

Article   ADS   CAS   Google Scholar  

Lockyer, S. Effects of diets, foods and nutrients on immunity: Implications for COVID-19?. Nutr. Bull. 45 , 456–473 (2020).

Organization, W. H. Nutrition advice for adults during the COVID-19 outbreak, http://www.emro.who.int/nutrition/news/nutrition-advice-for-adults-during-the-covid-19-outbreak.html (2020).

Bennett, G., Young, E., Butler, I. & Coe, S. The impact of lockdown during the COVID-19 outbreak on dietary habits in various population groups: A scoping review. Front. Nutr. 8 , 53 (2021).

Bleizgys, A. Vitamin D and COVID-19: It is time to act. Int. J. Clin. Pract. Esher 75 , e13748-n/a. https://doi.org/10.1111/ijcp.13748 (2021).

Butler, M. J. & Barrientos, R. M. The impact of nutrition on COVID-19 susceptibility and long-term consequences. Brain Behav. Immun. 87 , 53–54 (2020).

Kim, H. et al. Plant-based diets, pescatarian diets and COVID-19 severity: a population-based case–control study in six countries. BMJ Nutr. Prev. Health bmjnph-2021-000272 (2021).

Onufrak, S. J. et al. Foods and beverages obtained at worksites in the United States. J. Acad. Nutr. Diet. 119 , 999–1008. https://doi.org/10.1016/j.jand.2018.11.011 (2019).

Blanck, H. M. et al. Factors influencing lunchtime food choices among working Americans. Health Educ. Behav. 36 , 289–301 (2009).

Leone, L. A. et al. Healthy food retail during the COVID-19 pandemic: Challenges and future directions. Int. J. Environ. Res. Public Health 17 , 7397 (2020).

Article   CAS   PubMed Central   Google Scholar  

Avers, K. B., King, S. J., Nesthus, T. E., Thomas, S. & Banks, J. Flight Attendant Fatigue, Part 1: National Duty, Rest, and Fatigue Survey. (Federal Aviation Administration Oklahoma City OK Civil Aerospace Medical Inst, 2009).

Van Den Berg, M. J., Signal, T. L. & Gander, P. H. Fatigue risk management for cabin crew: the importance of company support and sufficient rest for work-life balance—A qualitative study. Ind. Health 2018-0233 (2019).

Perrin, S. L. et al. Timing of Australian flight attendant food and beverage while crewing: A preliminary investigation. Ind. Health 57 , 547–553. https://doi.org/10.2486/indhealth.2018-0070 (2019).

Roma, P. G., Mallis, M. M., Hursh, S. R., Mead, A. M. & Nesthus, T. E. Flight Attendant Fatigue Recommendation 2: Flight Attendant Work/Rest Patterns, Alertness, and Performance Assessment (Institute for Behavior Resources, 2010).

Hirshkowitz, M. et al. National Sleep Foundation’s sleep time duration recommendations: Methodology and results summary. Sleep Health 1 , 40–43. https://doi.org/10.1016/j.sleh.2014.12.010 (2015).

St-Onge M.P., Mikic A, Pietrolungo C.E. Effects of diet on sleep quality. Adv Nutr Sep 7 (5), 938–49 (2016).

Godos, J. et al. Association between diet and sleep quality: A systematic review. Sleep Med. Rev. 57 , 101430 (2021).

Peuhkuri, K., Sihvola, N. & Korpela, R. Diet promotes sleep duration and quality. Nutr. Res. 32 , 309–319 (2012).

Cirelli, C. & Tononi, G. The sleeping brain. Cerebrum 2017 , cer-07-17 (2017).

Coccia, M. How do low wind speeds and high levels of air pollution support the spread of COVID-19?. Atmos. Pollut. Res. 12 , 437–445 (2021).

Tan, J. et al. An initial investigation of the association between the SARS outbreak and weather: With the view of the environmental temperature and its variation. J. Epidemiol. Community Health 59 , 186–192 (2005).

Coccia, M. Pandemic prevention: Lessons from COVID-19. Encyclopedia 1 , 433–444 (2021).

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Acknowledgements

We would like to thank the flight attendants who shared and participated in this research and would like to acknowledge Dr. Mozghon Rajaee for useful discussions. We would also like to acknowledge the support of our department.

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The study was conceptualized by J.Y., and E.B., J.Y., E.B., T.U. developed the survey instrument and decided on study methodology. J.Y. administered the survey and recruited participants. E.B. organized the data and J.Y. performed data analysis and drafted visualizations. J.Y., E.B. prepared the original manuscript draft; J.Y., E.B., and T.U., all edited the final manuscript. All authors have read and approved the version to be published and agree to be accountable for all aspects of the work.

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Yamamoto, J.J., Brandley, E.T. & Ulrich, T.C. Flight attendant occupational nutrition and lifestyle factors associated with COVID-19 incidence. Sci Rep 11 , 24502 (2021). https://doi.org/10.1038/s41598-021-04350-0

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Fatigue and Sleep in Airline Cabin Crew: A Scoping Review

Candice c. y. wen.

1 John Trinder Sleep Laboratory, Melbourne School of Psychological Sciences, University of Melbourne, Parkville, VIC 3010, Australia

Darsh Cherian

Maya t. schenker, amy s. jordan.

2 Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC 3084, Australia

Associated Data

The data presented in this study are available on request from the corresponding author.

Airline cabin crew operate in dynamic work environments that are continuously changing, from unpredictable shift work hours to travelling through multiple time zones. These likely impact cabin crews’ overall health and may affect their performance on safety-related tasks. Research on this population has been limited; therefore, the aim was to summarise the relevant literature regarding fatigue, sleepiness and mental health of cabin crew. This review followed the PRISMA-ScR guidelines and conducted a systematic search utilising five databases. The initial search identified 1223 studies, and through vigorous screening processes, 27 studies were selected for this review. Over half of the selected studies focused on international or long-haul flights, and a large proportion of the sample participants were women. Findings suggested a high prevalence of fatigue and sleepiness as well as unsatisfactory sleep quality with elevated susceptibility to sleep disorders. Factors identified with health outcomes were associated with flight operations (e.g., rosters) and individual differences (e.g., age and coping strategies). Regarding mental health, cabin crews are potentially at a greater risk for depression and anxiety compared to the general public. This review draws attention to the importance of using a standardised approach, such as validated measures for fair and consistent inferences.

1. Introduction

In the aviation industry, shift work is considered the norm for the majority of employees. Shift work is associated with numerous adverse mental and physical health outcomes (outlined below). In addition to shift work, the two types of employees who work on aircraft, pilots (also known as flight deck or flight crew) and cabin crew (also commonly known as flight attendants), regularly experience jet lag. This further increases their risk of adverse health outcomes, particularly fatigue and sleepiness. Past research assessing fatigue and sleepiness in the airline industry has focused heavily on the pilot population. Therefore this scoping review aimed to gain a deeper understanding of the literature pertaining to the lesser-studied population: airline cabin crew.

1.1. Health Consequences of Shift Work

A large proportion of the working population around the world engages in shift work. Across Europe, 17% of employees were shift workers in 2005, and by 2015 this number increased to 21% [ 1 ]. In the United States, 26.6% of employees conducted shift work in 2015 [ 2 ], whereas in Australia, in 2021, 16% of the working population were shift workers [ 3 ]. Shift workers can be rostered with a permanent or a rotational shift pattern. Permanent shifts, as the name suggests, involve the employee always operating on the same shift schedule. This has traditionally been considered more manageable, as the employee can self-establish a consistent routine to accommodate this. For rotational shifts, the schedule is open to changes. The rotation can be clockwise (e.g., a morning shift followed by an afternoon shift), counter-clockwise (e.g., a morning shift followed by a night shift), or irregular shifts (no pattern to the roster). Rotational shifts are harder to manage with their continuous changes, thus not allowing one to form a routine to support it [ 4 ].

Despite the economic benefits that come with non-stop operations around the clock, shift work is not without consequences. Many health problems have been associated with shift work, including elevated risks for cardiovascular diseases [ 5 ], diabetes [ 6 , 7 ], obesity [ 8 ], sleep disorders [ 9 , 10 ], cancers [ 11 ], gastrointestinal issues [ 12 ] and poorer mental health [ 13 ]. Shift work can be difficult as, more often than not, work is performed out of synchrony with the circadian rhythm. The body’s circadian rhythm operates on an approximately 24 h basis and helps to regulate one’s sleep/wake cycle, cognitive performance and other physiological functions. When performing evening or overnight shift work, it is likely that part of the shift will overlap with one’s habitual sleep time, therefore making it difficult for the employee to stay alert and perform optimally. Further, workers often finish work at a time that coincides with their typical awake time (e.g., daytime) and, therefore, may have difficulty initiating sleep despite feeling tired. It is unsurprising that accidents are far more common amongst shift workers, especially night shift workers-research has found them associated with three times the reported occupational accidents compared to daytime/non-shift workers [ 14 ].

Fatigue and sleepiness are common complaints in shift workers. The feelings of fatigue and sleepiness can be similar, and the terms are often used interchangeably under the umbrella of feeling ‘tired’. However, the two are separate, distinct constructs. Fatigue stems from exertion, where one feels lethargic or exhausted from exerting energy or doing work [ 15 ]. For example, one may feel fatigued after a run; however, this does not necessitate sleep. Sleepiness, on the other hand, is related to one’s circadian rhythm and homeostatic sleep drive [ 16 ]; therefore, the longer one has been awake, the more ‘build-up’ of sleepiness one experiences. Unlike fatigue, the feeling of sleepiness can, fortunately, be relieved with sleep.

Fatigue and sleepiness have been linked to deterioration in both health and performance. The accumulative effect of fatigue and/or poor sleep can lead some shift workers to experience depressed moods, anxiety and stress [ 13 , 17 , 18 ]. Studies have also found fatigue and sleepiness can reduce cognitive and physical abilities that mimic alcohol intoxication with performance decrements. Moderate levels of fatigue and/or sleep deprivation decrease performance, equivalent to a blood alcohol concentration of 0.05–0.1%, which exceeds the legal alcohol limit in some countries [ 19 , 20 ]. In addition, another study found that loss of 2 h of sleep can negatively impact performance and alertness and increase the risk of errors and accidents [ 21 ]. Thus, shift work by itself likely contributes to at least some of the sleepiness, fatigue and poor mental and physical health observed in the aviation industry.

1.2. Specific Considerations for the Aviation Industry

Due to the unpredictable nature of flying (e.g., weather changes, air traffic), most pilots and cabin crew have a rotational (i.e., non-permanent) and often irregular roster, which, as noted above, is more difficult to manage compared to a permanent schedule. Pilots and cabin crew both experience the typical consequences of shift work; however, this is further complicated by time zone changes, also known as jet lag. As pilots are in charge of aircraft operations, past research has paid a lot of attention to this occupation, with pilot fatigue being documented as early as 1927 [ 22 ]. Past research found pilots regularly experienced fatigue and sleepiness [ 23 , 24 , 25 , 26 ], leading aviation policymakers and airlines to install provisions to negate fatigue and sleepiness. For example, controlled rest was implemented on the flight deck to allow a pilot to have a nap or rest (one at a time) during the cruise phase (after take-off, once the aircraft has levelled off and before landing)—this was designed for pilots to temporarily ‘switch off’ and to minimise fatigue [ 27 ]. Alternatively, on long-haul flights, two sets of pilots are scheduled to operate the aircraft; one operating and one augmenting crew. This allows one set of flight crew to rest for half of the flight duration and, therefore, reduces the risk of sleepiness during critical phases (take-off or landing).

Despite the extensive research that has been dedicated to pilots, their findings cannot be readily applied to cabin crew. Cabin crew work alongside pilots but have completely different job functions. Firstly, the cabin crew are in charge of the passengers. They are trained to evacuate passengers in an emergency situation, administer first-aid, fight fires, perform safety and security checks, restrain unruly passengers and, of course, provide in-flight services. Secondly, cabin crew have a more physical job and are on their feet for a large portion of the flight, whereas pilots have a greater mental workload and spend the majority of the flight seated inside the cockpit. Thirdly, the majority of the pilots are older and consist of a higher percentage of males, compared to cabin crew, who are more commonly female and have a wider age range with younger mean age than pilots. Cabin crew make up a large proportion of the airline industry; on a commercial flight, there are typically 2–4 pilots operating, whereas the number of operating cabin crew can range from 4–24, depending on the size of the aircraft. Therefore, understanding cabin crew experiences of fatigue and sleepiness is paramount.

In 2005, the United States Congress recognised there are unique issues surrounding cabin crew fatigue and directed the Civil Aerospace Medical Institute to address this. The National Aeronautics and Space Administration (NASA) Ames Research Centre’s Fatigue Countermeasure Group was recruited to investigate these issues further. Their results found most American cabin crews have operated while feeling fatigued and believe this is a common practice in the industry despite the crew appreciating that it is unsafe [ 28 , 29 ]. In America, the passenger workload for cabin crew is roughly one cabin crew member to 50 passengers [ 30 ]; thus, each cabin crew bears great responsibility for passenger safety and in case of an emergency. Yet 71% of cabin crew believe their fatigue affected their safety-related performance, and 60% felt their roles in looking after passengers were compromised, both in service and safety [ 28 ].

Technical reports from both American and European aviation commissions were interested in factors that may be associated with tiredness. NASA research found more than half of the cabin crew in their study have ‘nodded off’ recently whilst working [ 28 ] and identified workload, the work pace and schedule being main contributors. Reports for the European Aviation Safety Agency found that cabin crew reported the most contributing factors to fatigue were ‘long days,’ ‘early starts,’ ‘flying during hours when I would normally sleep,’ and ‘short recovery time between duties’ [ 31 ].

Past research that studied both pilots and cabin crew has found nearly 82% of participants have operated flights under the duress of fatigue [ 32 ]. This is alarming as only 26.8% felt comfortable enough to file a fatigue report, and two-thirds of the crew suggested no fatigue support was implemented within their airline [ 32 ]. A similar result was found with one study reviewing previously submitted fatigue reports, which found an average of 68 cases per 1000 person per year for cabin crew would submit a fatigue report, where 93% of those were stood down or were unable to attend work due to fatigue [ 33 ]. It seems the fatigue report was implemented as a solution for cabin crew; however, evidently, few felt encouraged to utilise it. Those who did use the report were in an extremely fatigued state.

With regards to the execution of cabin crew’s fatigue training, the aviation regulation states that fatigue training is mandatory for all crew members. However, retention of this information seems poor, with two-thirds of cabin crew not recalling ever having had fatigue training [ 28 , 32 ]. For those who did recall training, they found it to be useful only to a ‘limited extent’ or ‘not at all’ [ 28 ]. Therefore this training may be ineffective.

Although some regions in the world are commissioning technical reports to better understand the effect of fatigue and sleepiness on their cabin crew [ 28 , 29 , 31 ], to date, there is limited published research investigating this population. Hence, a systematic review is premature, given the current knowledge within the field.

The rationale for this scoping review is, therefore, to establish what is currently known about cabin crew fatigue and sleepiness, summarise current findings and identify gaps and limitations in the literature so future studies can abridge it.

1.3. Primary Objectives

• To summarise what is currently known in the literature on fatigue, sleepiness and other sleep-related constructs in cabin crew;
• To identify common factors that are associated with fatigue, sleepiness and other sleep-related constructs in cabin crew, e.g., operational factors such as rosters and flight routes or individual factors such as age and gender;
• To pinpoint existing gaps and limitations in the current literature on fatigue, sleepiness and other sleep-related constructs and to provide suggestions for future directions.

1.4. Secondary Objective

• 4. To summarise what is known about cabin crews’ mental health, specifically depression, anxiety and stress.

This scoping review followed the framework of PRISMA-ScR guidelines [ 34 , 35 ] ( Supplementary Table S1 ) and utilised the team method to develop the core concepts to extract data for the review [ 36 ]. This scoping review was not pre-registered with its protocol.

2.1. Eligibility Criteria

To be considered for the present scoping review, the document must be a published research paper that examined the experience of fatigue and/or sleepiness in commercial airline cabin crew. Further details of inclusion and exclusion criteria are listed in Table 1 .

List of Inclusion and Exclusion criteria for the present scoping review.

2.2. Information Sources & Search

The search strategy was developed in consultation with an experienced librarian to encompass all possible keywords and to search within relevant databases. Table 2 presents the databases and search strategies used. Reference lists from the database search were also screened for relevant papers.

Search resources and strategy used for this review.

2.3. Selection of Sources of Evidence

All findings from the search strategy were considered for abstract reviews. Two reviewers (C.W. and M.S.) independently screened the titles and abstracts. If the decision to keep or discard the abstract was not unanimous, this was resolved with a reviewer discussion on the disagreed abstract. With the shortlisted abstracts, a full article assessment was conducted with two independent reviewers (C.W. and D.C.). Similar to the abstract screening, any disagreement on this was first discussed among the two reviewers; however, when a consensus was not met, a third reviewer (A.J.) was invited to make the final decision.

2.4. Data Charting & Synthesis of Results

An excel spreadsheet was created to collate and chart the data. This chart followed the principles of Scoping Review [ 35 ] and focused on the three principal components: participant, context and concept. The spreadsheet was initially trialled and created by one author (C.W.) and was further tested by three independent reviewers (D.C., M.S. & A.J.) to confirm its efficacy prior to utilising it for the scoping review.

The following information was collected during the data extraction:

• Article information: author, year of publication, title, journal title, type of study and aim/objective of the study;
• Participant: sample size, cabin crew percentage in the sample, sample characteristics (age and sex), hierarchy and tenure;
• Context: location and type of routes (international versus domestic or long versus short haul);
• Concepts: Outcomes of interest to this scoping review; fatigue, sleepiness, other sleep-related constructs and mental health. With each outcome, the type of measure used, any associated factors and the reported prevalence were examined.

After data charting, information was grouped into one of the following outcomes: fatigue, sleepiness, mental health and relevant measures in search for common results and missing gaps in this area. The key characteristics of cabin crew (age, sex) and airline industry (type of route, sample percentage being cabin crew) were further assessed by their frequency and range.

Selection of Sources of Evidence

Of the initial 1223 studies identified, nearly half of the studies were duplicates. Of the 599 abstracts reviewed, 491 were deemed irrelevant as they did not meet the inclusion criteria (i.e., unrelated participants such as pilots and/or outcome measures such as no sleep or fatigue measure). Subsequently, 108 studies were selected for full-texts assessment, and 27 studies were considered eligible for the present scoping review (see Figure 1 ). The majority of the studies investigated multiple outcomes of interest; 17 studies looked at fatigue, eight sleepiness, 22 reported other relevant sleep measures and 11 explored mental health issues. One study investigated all four concepts [ 37 ]. Table 3 displays the publication details of the studies included in this scoping review.

PRISM Flowchart.

Research information of the 27 selected studies.

4. Characteristics of Sources of Evidence

Demographic characteristics.

Within the current scoping review, the study sample size ranged from 19 to 5366 cabin crew (five studies combined cabin and flight crew, and one paper combined cabin crew and teachers). Despite using specific keywords for the database search and stringent abstract screening to attain exclusive cabin crew samples, it is evident that research in this industry is strongly focused on airline pilots. At the full-text review stage, 16 papers were further excluded due to the sample consisting of pilots only, and an additional five papers were not eligible due to insufficient cabin crew sample percentage and/or not reporting results from cabin crew separately (see Figure 1 ). Of the 27 publications included in this scoping review, 78% of studies ( n = 21) were entirely conducted on cabin crew, and the remaining studies contained a combination of cabin crew and airline pilots, with two papers meeting the 70% cut-off criteria.

Being a cabin crew was traditionally a role predominantly performed by women. However, over the decades, this has evolved to involve both men and women. For this review, in 18 (72%) papers, the sample had more than 70% female participants, suggesting that the literature on this topic is dominated by research on women (see Figure 2 ).

Number of studies with different percentages of female cabin crew in the sample.

Despite no restrictions on publication dates, the 27 selected research papers for this scoping review were published between 1982–2021. This suggests the interest in cabin crew fatigue and sleepiness have been of increasing interest in the past decade. Twenty-three studies presented the age breakdowns of their cabin crew sample (mean, range or both). The range of crew within this review was 18–63 years old, with the average mean age of 38.7 years old (see Figure 3 ).

Age mean and range of each paper’s sample. [ 37 , 38 , 39 , 40 , 41 , 42 , 44 , 46 , 47 , 48 , 49 , 50 , 51 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ].

Twenty-two of the included papers presented the type of routes their cabin crew sample operated in. 54.5% operated in international or long-haul routes, 13.6% in domestic or short-haul and 31.8% serviced both operations or had crew samples from multiple airlines, which encompassed both international/domestic as well as long/short haul routes.

5. Concept Characteristics

5.1. fatigue.

Measures of fatigue were divided into validated scales, self-designed questionnaires and subscales (see Table 4 ). Seven papers [ 37 , 40 , 41 , 55 , 56 , 60 , 61 ] used four different validated fatigue measures, with the Samn-Perelli Crew Status Check (SP) [ 63 ] being the most commonly used tool. Another seven studies used non-validated, subjective fatigue questionnaires [ 39 , 43 , 50 , 51 , 53 , 57 , 62 ]. Two fatigue subscales were also used, which were retrieved from Profile of Mood States [ 64 ] and Liverpool Jet Lag Questionnaire [ 65 ].

Studies of fatigue in cabin crew—the measures used and its main findings.

5.2. Sleepiness

Sleepiness as a construct was not commonly measured in papers identified for this review, with only seven papers (26% of this scoping review) investigating it. Three validated sleepiness scales were used across the seven papers [ 37 , 46 , 47 , 48 , 56 , 60 , 61 ]. The Karolinska Sleepiness Scale (KSS) [ 66 ] was the most commonly used one and was reported by five of the seven papers (see Table 5 ). The KSS was developed as a scale measuring sleepiness [ 66 ]. However, one study reported this as a measure of fatigue [ 56 ]. For the purpose of this review, KSS results will be presented under sleepiness rather than fatigue.

Studies on sleepiness in cabin crew—the measures used and its main findings.

5.3. Other Relevant Measures

Thirteen other measures of sleep were considered relevant to this review (see Table 6 ), including objective measures (i.e., polysomnography, actigraphy, psychomotor vigilance task and neurobehavioural tests), validated scales (sleep quality, insomnia, shift work), subscales measuring sleep, sleep diaries and self-designed subjective questionnaires.

Studies with other sleep-related measures used and their main findings.

Self-designed subjective questionnaires varied from study to study. However, this method was most commonly used to measure sleep, with 11 studies utilising this method [ 38 , 39 , 41 , 43 , 44 , 46 , 50 , 51 , 55 , 57 , 58 ]. The next most common method was using a sleep/wake diary, with seven papers adopting this [ 38 , 41 , 42 , 44 , 46 , 56 , 61 ], followed by actigraphy in six papers [ 42 , 47 , 48 , 55 , 60 , 61 ].

5.4. Mental Health

The secondary objective of this scoping review was to review mental health measures in relation to sleepiness and fatigue, with a particular focus on depression, anxiety and stress experienced by cabin crew. Ten scales and subscales were used between 11 studies [ 37 , 40 , 45 , 46 , 48 , 49 , 50 , 51 , 52 , 55 , 57 ]. Self-designed questionnaires on anxiety and depression were the most commonly utilised method, with three studies adopting this approach [ 50 , 51 , 57 ], see Table 7 .

Studies on mental health in cabin crew—the measures used and its main findings.

6. Results of Individual Sources of Evidence

6.1. fatigue.

Table 4 provides a summary of the main findings from various fatigue measures in the reviewed papers. Fatigue was very commonly reported, with prevalence from validated scales ranging from 63.5% to 77.4% [ 37 , 40 , 55 ]. The high prevalence of fatigue was considered a health problem [ 39 , 43 , 62 ] and one of the biggest disadvantages of being a cabin crew member [ 39 ]. Compared to the general public, the prevalence of fatigue was double for cabin crew [ 50 ], with 21.4–36.8% of cabin crew having sought medical attention due to fatigue during the past 12 months [ 50 , 51 ].

While most measures found a high prevalence of fatigue, the occurrence of fatigue did differ based on the measures used. Interestingly, based on the fatigue subscale (single-item measure) of the Liverpool Jet Lag Questionnaire, nearly two-thirds of the cabin crew did not experiences fatigue [ 55 ]. The author raised the validity of a single-item measure; therefore, the results were interpreted with caution. The Chalder Fatigue Scale had two types of scoring processes; Binary and Likert methods. Large discrepancies were reported between the two scoring methods; the Binary scoring found 60.8% of the sample had substantial to maximum fatigue, yet the Likert scoring had only 26.5% reported abnormal to chronic levels of fatigue [ 55 ].

This review collated the common factors that were associated with the experience of fatigue. The factors were categorised into flight operations and individual variables.

6.2. Flight Operation Variables

Multiple flight operation variables were found to impact the level of fatigue. When reviewing a round trip, inbound flights were associated with greater reports of fatigue than outbound flights [ 60 , 61 ]. The cabin crew reported less fatigue during the pre-flight phase, grew progressively more fatigued during the flight [ 37 , 61 ], and were most fatigued on the commute home [ 37 ]. One study asked cabin crew how many hours they were able to work before tiring and found 61.1% would be fatigued from a 4–6 h work day [ 57 ]. It was, therefore, not surprising that cabin crew reported being ‘often’ or ‘always’ fatigued at the end of a flight [ 39 , 57 ]. Cabin crew also reported eastward flights ‘wear you out’ more than westward flights, and the subsequent sleep deficits continued into their rest days [ 49 ].

The common debate as to which flight route is more tiring (international versus domestic or long-haul versus short-haul) was not clarified by the findings of this review. Some studies found ultra-long-haul flights resulted in greater fatigue as the crew perceived to have greater workloads [ 60 ], and long-haul flights were found to be associated with greater health problems due to fatigue compared to short-haul flights [ 39 , 43 ]. Other studies report that being an international cabin crew predicted a higher risk for fatigue [ 37 ], and similarly, no fatigue was reported in one study from a short-haul operations cabin crew sample [ 41 ]. However, other research concluded that despite international crew having greater scheduled work hours than domestic cabin crew, fatigue was significantly higher amongst the latter [ 49 ]. One study explained this with domestic crew often required early morning starts and were scheduled with multiple take-offs and landings per work trip, which elevated fatigue [ 53 ]. Another study found fatigue was greater on shorter, non-ultra-long haul inbound flights than on ultra-long-haul outbound flights [ 61 ].

There were five studies in this review that compared cabin crew and pilots [ 41 , 43 , 48 , 52 , 56 ]. Fatigue was found to be more commonly reported by cabin crew than pilots [ 43 ], and cabin crew believed that airlines provided better support for fatigue management to pilots than cabin crew [ 59 ]. Through focus groups, cabin crews reported the overall safety training was excellent; however, the group found the fatigue management training they received to be insufficient [ 59 ]. In terms of hierarchy, one study found pursers (i.e., the highest-ranked cabin crew member) reported fatigue symptoms less frequently than cabin crew members [ 62 ].

6.3. Individual Variables

Fatigue was found to have a profound impact on cabin crews’ quality of life [ 40 ]. Families were often considered a supportive framework; however, through fatigue focus groups, families were reported to be an element of stress as they were considered a competing time demand [ 59 ]. With limited time resources, traditionally, women were considered more ‘time poor’ due to childcare and housework. However, the studies that compared genders found no differences between their fatigue levels [ 43 , 62 ]. This was further supported by studies with 100% female participants and other studies with greater male participants. Both reinforced that fatigue was a common and detrimental occurrence, which was not unique to women [ 49 , 53 , 59 ]. When considering age as a factor, younger age was found to be associated with greater fatigue [ 62 ].

7. Sleepiness

Although sleepiness was not commonly measured in the papers included in this review, the preliminary evidence was concerning (see Table 5 ), with one study reporting nearly half of the cabin crew to be ‘sleepy’ over the previous month [ 37 , 59 ].

Flight Operation Variables

Unsurprisingly, sleepiness (KSS scores) was worse on workdays than on rest days [ 46 , 48 ]. Cabin crew were most alert at the beginning of their outbound flights [ 47 , 60 ], and as the trip progressed, KSS scores increased (i.e., sleepiness increased) [ 47 , 61 ]. One study found that whist on layovers, cabin crew reported they had severely impaired levels of alertness due to sleepiness [ 48 ]. This elevated sleepiness was experienced for the remainder of the trip and would only start to return to the baseline level around the third recovery day [ 48 ].

Similar to the fatigue findings, conflicting results were found for the effect of route type on sleepiness. One study found ultra-long-haul flights increased sleepiness [ 60 ], whist another reported sleepiness was worse on shorter, non-ultra-long haul inbound flights compared to the longer ultra-long haul outbound flight [ 61 ]. This inconsistency may be explained by the factors found associated with sleepiness being the number of consecutive work days [ 37 ], early departure times [ 46 ] and the duration of awake time [ 60 ], whereby the type of route may not be a factor directly associated with sleepiness.

8. Other Relevant Measures

Table 6 provides a summary of the main findings from additional measures that were relevant to this review. Interestingly for cabin crew, the number of time zones travelled was not found to impact time spent in bed [ 58 ]; however, 78.1% of crews found it to have affected the quality and quantity of their sleep [ 57 ], with nearly 60% of the cabin crew reporting poor sleep quality [ 40 ]. Sleep duration was heavily impacted by flight duty, with the average sleep duration for workdays being 4.6 h, which was significantly lower than on rest days (7.2 h) and self-perceived sleep needs of 8.1 h sleep per day [ 54 ].

This review collated evidence that suggested cabin crew have poor sleep health. Amongst the general population, dissatisfaction with the quality of sleep has a prevalence between 16% and 21% [ 67 ], whereas more than half of the cabin crew reported sleep disturbances in the last year [ 41 ], and 27.1% have sought medical attention for it. Research also found insomnia had the greatest negative impact on cabin crew’s work ability [ 45 ], and 43.6–57.7% screened positive or at risk for it [ 37 , 45 ]. More than two-thirds of the cabin crew were found to be at risk for shift work disorder [ 37 ]. They experienced excessive sleepiness when the work schedule coincided with normal sleep time, yet, once off duty, they had insomnia symptoms of being unable to fall or maintain sleep. Another sleep concern, however, on the other end of the spectrum to insomnia, was a report of very short sleep onset latency. In cabin crew, the time it takes to fall asleep has been as little as 6.37 min, which is close to the cut-off time for excessive sleepiness on the multiple sleep latency test (<5 min) [ 55 ].

8.1. Flight Operation Variables

When cabin crew were operating a trip, the objective measures of vigilance (PVT) elicited better scores on the outbound compared with the inbound sector [ 60 , 61 ]. Unsurprisingly, attentional performance declined as the flight progressed [ 61 ], and with every additional flight sector, reaction times increased [ 41 ]. Flight delays were another operational variable that affected cabin crew. Flight delays were associated with poor sleep quality; with every delayed flight event, the likelihood of poor sleep quality increased [ 37 ].

The most commonly reported periods for sleep disturbances were the night before duty [ 41 ], on layovers [ 48 , 55 ] and the first night upon returning home [ 48 , 55 ]. Sleep tended to improve over subsequent rest days [ 55 ]. During layovers, cabin crew preferred to switch to local time despite staying on domicile time would reduce the effect of jet lag, whereby on the last day of layover, nearly three-quarters of the crew slept on a local night [ 61 ]. Looking at the effects of early rising, one study [ 46 ] reported that crew with early starts (duty commenced before 0630) went to bed earlier than non-early starts (duty commenced after 0830). However, the early start crew still had reduced total sleep time by almost two hours compared to the non-early start crew, and a reduction in polysomnography measured stage 2 and rapid eye movement (REM) sleep.

International cabin crew were found to have a lower quality of sleep and a higher risk for insomnia than domestic crew [ 37 , 38 , 44 ]. For both cabin crew and pilots, more sleep problems were reported after long-haul flights than short-haul flights [ 43 ], with crew who operate ultra-long-haul flights obtaining 6.5 h sleep/day (sometimes three brief sleep periods/24 h), compared to 8 h/day (one solid sleep) for grounded crew [ 38 ]. Sleep quality was disturbed, with one-third of cabin crew reporting restless sleep prior to transmeridian flights, and upon the return flight, the number of restless sleep reports doubled [ 44 ]. This study further found for a 4-day transmeridian flight, it took, on average, 4 days to achieve full recovery in both sleep length and quality [ 44 ]. Flight directions were also found to have an impact, with eastward flights affecting cabin crew more negatively than westward flights [ 38 , 44 ]. Eastward travels were linked with greater sleep disturbances, longer sleep latency, lowered sleep quality, difficulty in waking and increased napping [ 48 ].

Some studies in this review compared cabin crew with pilots or teachers to gain further insight into this population. Despite both working on aircraft, the comparisons between pilots and cabin crew really highlighted their differences. Specifically, cabin crew had worse PVT performance on average than pilots [ 61 ] and reported higher mean values across all health complaints (the most prevalent were sleep problems and tiredness) [ 52 ]. Two studies found cabin crew to have, on average, 1 h less sleep than pilots. One of the studies found that 1 h sleep difference started from the night before the first duty day, and the findings suggested the reduced sleep may be due to earlier reporting times required for cabin crew compared to pilots [ 41 ]. Similar results were found in another study for rest days, where cabin crew slept on average 6.5 h per 24 h compared to pilots of 7.5 h of the same route [ 61 ]. Differences were also found with napping opportunities onboard, where on long night flights, 20% of cabin crew (vs 31% pilots) engaged in on-duty napping. Likewise, on short night flights, 8% of cabin crew (vs 11% pilots) napped. Overall, cabin crew had fewer opportunities to nap than pilots [ 56 ]. Comparing cabin crew with a non-shift working profession with a similar demographic (i.e., teachers), cabin crew, on average, slept longer than teachers (7.3 h versus 6.6 h). However, their nocturnal sleep was significantly impaired, with worse sleep efficiency and more wake-after-sleep onset than teachers [ 42 ].

8.2. Individual Variables

Cabin crew are more likely to have a diagnosed sleep disorder than the general population, with prevalence in the female and male cabin crew being 5.7 and 3.7 times greater, respectively, than in the general population [ 50 ]. Inconsistent results were found for gender in relation to sleep quality, whereby one study using actigraphy found women had longer and more efficient sleep than men [ 48 ]. Another study using a subjective questionnaire found men reported sleeping more restfully and experienced less sleepiness than women [ 39 ]. Age also influenced sleep, with older/higher seniority cabin crew perceiving their sleep quality, adaptation and recovery as worse than younger/less senior cabin crew [ 58 ], both at home and away from home [ 39 ].

Individual behaviours such as substance use were shown to have an impact on sleep. Studies found the majority of cabin crew (81–91%) consumed caffeinated drinks daily, with a good proportion consuming up to five servings per duty period or within 24 h [ 37 , 42 , 54 ]. One study found with every 1–2 servings of daily caffeine consumption, sleep quality decreased, and the likelihood of insomnia increased in cabin crew [ 37 ]. Further, the use of alcohol was not uncommon amongst cabin crew; compared to teachers, cabin crew were more likely to drink four or more times a week [ 42 ]. Another study found 76.4% of cabin crew drank ‘sometimes’ to ‘frequently’ [ 57 ], with 41.4% using alcohol to facilitate sleep [ 37 ]. Alcohol consumption was further found to be significantly higher on layovers (average 2–3 glasses/day) than at base (average 0.8 glasses) [ 44 ]. Drugs (e.g., herbal, cold/flu medication, painkillers, and other over-the-counter medication) have also been used to aid sleep [ 37 , 40 ]. One study found 9.2% of the cabin crew ‘almost always’ or ‘sometimes’ take sleeping pills to facilitate a good night’s sleep [ 57 ], with another reporting the use of alcohol and sleep-aid drugs (herbal and over-the-counter) to negatively affect sleep quality and increase the likelihood of insomnia [ 37 ].

In the studies that looked at chronotypes, more than half of the cabin crew showed no preference for either morningness or eveningness, and a greater proportion of the remainder tended to have a preference for morningness [ 39 , 55 ].

9. Mental Health

Psychological health was one of the domains measured for cabin crews’ quality of life, and it scored the worst compared to the other domains; physical health, social relationships and environment [ 40 ]. Fatigue was negatively correlated, and better sleep quality was positively correlated with quality of life [ 40 ]. Table 7 summarises the main findings on mental health for this review.

9.1. Depression & Anxiety

Mixed results were found for the prevalence of anxiety and depression amongst cabin crew. Two studies found anxiety and depression were relatively uncommon in the samples [ 45 , 49 ]. However, in other studies, a high occurrence or risk of depression was reported. Specifically, female cabin crew were reported to have twice the prevalence of depression compared to the general public, and male cabin crew five times the prevalence [ 50 , 51 ]. In another study, 40% of cabin crew were at risk for depression [ 37 ], and 36.3% had a medical diagnosis of depression and/or anxiety [ 50 ]. In addition to the high prevalence, the frequency of anxiety symptoms appeared high, with 16.4–20.0% reporting frequent symptoms of anxiety over the past week [ 50 , 51 ], and 14.3% of cabin crew reporting ‘usually’ feeling anxious before a flight, while 36.5% felt this way ‘sometimes’ [ 57 ].

Compared to pilots, cabin crew had more reports and higher mean values across the domain of psychological health complaints, including anxiety and depression [ 52 ], and international cabin crew had a greater risk for depression than domestic cabin crew [ 37 ]. Longer job tenure was found to increase the likelihood of depression and anxiety for both female and male cabin crew [ 50 , 51 ].

9.2. Stress

Significantly higher stress was reported for work days compared to rest days [ 46 ]. Stress at the workplace was not uncommon, and flying at high altitudes was certainly no exception. More cabin crew reported high levels of work stress compared to pilots; 25% of cabin crew compared to 15% of pilots [ 52 ]. Stress was commonly reported for parts of each flight [ 48 ], with higher reports of greater stress and mental strain on the inbound flight [ 48 , 55 ], and this elevated feeling of stress would carry across to the first recovery night [ 48 ].

10. Discussion

This scoping review aimed to understand the current literature on cabin crew and their experiences of fatigue, sleepiness and mental health. From analyses of 27 papers, the results found cabin crew had an alarmingly high prevalence of fatigue (ranging from 63.5% to 77.4%), and nearly half of the cabin crew experienced excessive sleepiness. Cabin crew were also found to have poor sleep quality and were vulnerable to sleep disorders, with elevated risks for insomnia and shift work disorder. With regard to mental health, both the symptoms and medical diagnoses for depression and anxiety were higher amongst cabin crew compared to the general public. Common factors relating to fatigue, sleepiness, sleep-related constructs and mental health in airline cabin crew are discussed further below. Figure 4 depicts the current literature in a word cloud [ 68 ], with the size of each keyword(s) denoting the frequency retrieved from the 27 abstracts selected for this scoping review.

Word Cloud of the current scoping review; summary keywords and common factors.

10.1. Flight Operations

Understandably both the experiences of fatigue and sleepiness were low at the beginning of a trip and increased as the flight progressed [ 37 , 47 , 60 , 61 ]. For a round trip, inbound flights consistently had greater reports of performance deficits than outbound flights [ 60 , 61 ], and the feeling of fatigue and sleepiness were reported at their peak at the top-of-descent on the inbound flight. Similar results were also found for alertness; the crew were most alert at the start of a trip and steadily declined as the trip progressed [ 41 , 61 ]. Unfortunately, a high proportion of cabin crew experienced fatigue on the commute home (77.4%) [ 37 ], and the feeling of sleepiness at the end of a trip was sometimes so severe that some cabin crew had reported falling asleep while driving home [ 59 ]. Therefore, not only endangering themselves but others on the road.

For some trips, layovers were implemented for cabin crew to rest before the inbound flight. However, cabin crew did not always capitalise on this opportunity to recharge, and this may partly be explained by jet lag and the constant changes to sleeping arrangements (such as different hotels and cities). This was reflected in the different sleep profiles when at home (average sleep of 7.7 h) compared with away from home (average sleep of 6.5 h) [ 28 ]. Despite advice to stay on domicile time, which assists in normalising sleep and reduces symptoms of sleepiness [ 61 ], many cabin crews opted not to do this in exchange for the opportunity to sightsee or to dine at local times. This is particularly the case with food, as it may not be readily available if cabin crew stay on domicile time [ 47 ]. Cabin crew considered the detriments of staying on domicile time to outweigh the benefits [ 47 ].

Understandably, cabin crew are required to work around the clock; however, fatigue complaints were often made on their roster with frequent early start times and late night finishes [ 39 , 53 ]. For domestic cabin crew, early starts and late night finishes were frequently paired together; which not only negatively affected their sleep architecture [ 46 ] but it also led to reduced rest periods or rest times at unfavourable circadian phases, which all increased the adverse effect on health [ 53 ]. The direction of transmeridian flights was further found to affect fatigue and sleep, with Eastward flights having a greater negative impact on cabin crew than Westward flights. As Eastward flights effectively shorten the day, therefore the ‘local night’ occurs earlier than the body clock is ready for. Thus, with insufficient homeostatic drive, sleep does not come easily, and yet when asleep, the quality is often disturbed [ 48 , 58 ].

With regard to the types of routes cabin crew fly, literature to date has shown conflicting results for both fatigue and sleepiness, suggesting more research could be done in this area. Alternatively, both routes may face the challenges of fatigue and sleepiness; however, their differences may not be easily compared. International or long-haul cabin crew will often travel great distances across multiple time zones per trip. Some may find this type of route to be more tiring as the typical workday often exceeds 12 h, and once at the destination, the crew must juggle with time differences. However, most long-haul flights have scheduled onboard rests and breaks that are built into the flight schedule to alleviate this. Within domestic or short-haul flights, there are different challenges.

Often on a work day, cabin crew operate in multiple sectors, therefore many take-offs and landings. This increases the workload with more passengers to service and multiple safety and security tasks for each flight. For a day with 5–6 flight sectors, cabin crew may look after 700 passengers [ 41 ]. Despite no consensus on fatigue and sleepiness with the type of routes, international and long-haul flights were found to affect one’s sleep and increase the likelihood of insomnia. Cabin crew travel multiple time zones annually; one study found the median annual time zone crossed was 93, ranging from 0–465 [ 42 ]—although these numbers vary between airlines and regions of the world, this may partly explain the increased risk of insomnia. Another potential explanatory factor may be the continuous changes to sleep environments that would affect one’s sleep on top of the myriad of complications associated with shift work.

Fatigue was found to increase with a greater physical workload [ 57 ]. The role of cabin crew changes with their hierarchy, where less physical responsibilities (e.g., delivering in-flight services) are associated with increased seniority. Therefore it was unsurprising that pursers, the highest ranked cabin crew, also known as the cabin crew managers reported the lowest fatigue compared to lower ranked cabin crew. Similarly, this could explain the greater fatigue experienced by cabin crew when compared with pilots; the workload of pilots is predominantly mental compared to the high physical workload of cabin crews. The definition of fatigue is being over-exerted; thus, less energy output from pursers and pilots could explain the lowered fatigue experience.

10.2. Individual Differences

No differences were found between gender for their fatigue experience, and results from sleep-related constructs had mixed findings. However, it is worth noting from the papers shortlisted in this review that the majority was dominated by female participants. Thus, the results may be skewed, meaning that conclusions could not be drawn accurately. As for age, the younger cabin crew members had greater reports of fatigue than the older cabin crew. However, as younger crew members are often less junior than the older, more experienced crew, one may question if this relationship was actually associated with age or operational hierarchy. On the other hand, the older/senior cabin crew members were found to have increased sleep disturbance compared to younger/junior cabin crew members. This finding may or may not be unique to cabin crew, as past research has found reduced sleep with ageing [ 69 , 70 ].

Looking at individual behaviours, cabin crews implemented several coping strategies to support their lifestyle. This review’s survey of the literature found high use of caffeine amongst cabin crew [ 37 , 42 , 54 ] and frequent consumption of alcohol and drugs to facilitate sleep [ 37 , 40 , 57 ]. Technical reports found that 39% of cabin crew reported using aids to assist them in sleeping when away from home. This ranged from prescription medication, over-the-counter medication and alcohol. Thirteen per cent of the cabin crew reported using at least two methods to achieve sleep [ 28 ]. Although not as prevalent, cabin crew also used the listed methods above to gain sleep when at home. Past research has established that caffeine, a stimulant, can increase wakefulness and reduce sleepiness, and alcohol, a sedative, can negatively affect sleep quality. Therefore, these behaviours suggested some cabin crew may be stuck in a vicious cycle due to the use of alcohol to facilitate sleep resulting in bad quality sleep, which subsequently requires more caffeine to stay awake the following day; and have this on repeat. Cabin crews would likely benefit from targeted education on coping strategies that can cast long-term efficiency rather than opting for short-term effects with overall negative consequences.

10.3. Mental Health

Mixed results were reported for cabin crews’ susceptibility to anxiety and depression. However, more results indicated cabin crew to be at greater risk for anxiety and depression than the general public, in particular men, with five times the prevalence. Interestingly, this review found international cabin crew had a higher risk for depression [ 37 ], and a longer tenure in the airline also increased cabin crews’ risk for depression and anxiety [ 50 , 51 ]. Stress was commonly found to be high amongst cabin crew.

11. Limitations

From this scoping review, it was evident that the concepts under investigation lacked consistent measures. The use of validated scales was infrequent, and the most popular method to measure fatigue, sleep-related constructs, and mental health were questions made up by their respective authors. If consistent and validated scales were used, more fair and justified inferences across studies could be made. Another limitation was that, on occasion, fatigue and sleepiness were assumed to be equivalent. For example, the Karolinska Sleepiness Scale (which was designed to measure sleepiness) was used in one study for fatigue [ 56 ]. There were several studies that used subscales of broader questionnaires to investigate their aims, understandably, as shorter measures would reduce participant burden; however, unless the subscale has been independently validated, this risks sacrificing the validity of the measure intended.

12. Limitations of the Current Review Process

Despite this scoping review following the PRISMA-ScR guidelines [ 34 , 35 ], there are some limitations that may have impacted the overall outcome. Firstly, it is worth noting the potential of author bias. Despite using four different authors across the selection process with stringent criteria, there may be bias from the authors regarding what was considered relevant for this review. For example, the process of selecting which methods to be further assessed under relevant sleep measures could potentially be influenced (for example, which neurobehavioral tests were considered to measure sleep-related constructs). Another limitation is the inclusion and exclusion criteria for cabin crew sample cut-off. This scoping review chose to include the paper for review if the cabin crew sample was more than 70% of the overall sample population. If less than 70%, the paper must present cabin crew data separately from the other occupation. Therefore some pilot results were included in this review. The stringent cut-off criteria or exclusive reports on cabin crew data would have excluded a significant number of papers from being reviewed and reduced the number of studies to be included in the outcomes. Lastly, no restriction on publication dates was included in the search strategy. This could possibly explain the widely varied methods used to measure fatigue, sleepiness, and mental health. With a range of 40 years between the first to last publication included in this review, scales and scoring processes to measure the same constructs have likely changed. Therefore, accurate and direct comparison between studies is difficult.

13. Conclusions

Cabin crews across the world are tired, feeling fatigued, frequently experiencing poor sleep, and many are struggling with mental health issues. Due to the nature of the job for cabin crew, good sleep is not consistently achieved, and for some, it is a constant challenge. With flight operations impacting cabin crews’ experiences in fatigue, sleep and mental health, changes could be implemented to better support cabin crew, including more engaging fatigue training or increases in in-flight rests. With many cabin crew adopting coping strategies that are not necessarily beneficial to them (e.g., high caffeine consumption), further education or intervention programs on sleep management would be beneficial. Mental health awareness should also be raised, especially for international and longer-tenured cabin crew-for increased self-awareness and knowledge of how to seek help when needed. Cabin crews play an integral role in ensuring the safety and security of passengers high up in the sky. Therefore, equipping this population with better knowledge and tools to manage their physical and mental health will result in a safer environment for all.

Acknowledgments

We would like to thank Lindy Cochrane from the University of Melbourne Library for her assistance and support in the data-sourcing process.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph20032652/s1 , Table S1: Prisma ScR Checklist.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualisation, C.C.Y.W. and A.S.J.; methodology, C.C.Y.W., D.C., M.T.S. and A.S.J.; formal analysis, C.C.Y.W., D.C., M.T.S. and A.S.J.; writing—original draft preparation, C.C.Y.W.; writing—review and editing, C.C.Y.W., D.C., M.T.S. and A.S.J.; supervision, A.S.J. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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Flight Attendants’ Feedback on Tourism Curriculum Program: Inputs to Curriculum Improvement on Industry Needs

2016, Asia Pacific Journal of Academic Research in Social Sciences

– Flight Attendants or Cabin Crew are among the professional airline personnel whose primary responsibility is to ensure the safety and comfort of passengers aboard an aircraft. This paper is aimed to determine the alignment of the College of International Tourism and Hospitality Management’s Tourism Curriculum to the employment qualifications on both domestic and international flight attendants. The result of this study may be utilized to further enhance the existing curriculum to suit the employment standards of both local and international airline companies. Moreover, this study may serve as a guide for tourism students to confidently pursue a career of flight attendant in the future. A descriptive-correlation design was used in the conduct of the study. Questionnaire was used as main data gathering instrument utilizing percentage, frequency and weighted mean as statistical tool. A commercial airline is a company that transports passengers via air wherein professionals are hired to effectively deliver ultimate satisfaction to the traveling public. With the in depth training that each company provides, including service, safety and emergency, fist aid and others, trainees must be fully equipped with the right attitude and learning which could be acquired in a university offering quality education. As flight attendants are among the front liners of an airline company, one is expected to properly represent the company in the eyes of the public at all times.

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Asia Pacific Journal of Academic Research in Social Sciences

This study entitled “Airline Companies’ Feedback on Tourism Practicumers of Lyceum of the Philippines University Batangas: Basis for Enhanced Airline Practicum Program” intended to determine the profile background of the Tourism Students’ during 2010-2013 and their performance during their practicum. This study may be a great help for the continuous innovation, a continuous improvement with regards to the tourism practicum program. As LPUB gears towards the outcome based education- OBE it is but proper to improve the airline practicum program. Moreover, LPU garners series of recognition, most especially the College of International Tourism and Hospitality Management which is accredited as Center for Development for Tourism program. With this study, the researcher proposed an action plan that can be a basis for an enhanced practicum program for Tourism program. One is the Enhancement of module for pre-internship with emphasize on attitude and punctuality. There can also be a Simulation Area 1 - Laboratory with ground staff, this would be for the hands on experience working in the airport before the students would be deployed.

Nusantara Science and Technology Proceedings

chandra gultom

Paramita Suklabaidya

Purpose: Tourism Education, a professional course, must impart knowledge and skill sets suitable for immediate employment in the tourism industry. This study aims to explore the expectations of tourism educators and industry, with respect to the important skill sets and knowledge required by the tourism students. Further, the study compares the views of tourism educators and industry representatives on the knowledge and skills imparted by tourism educational institutes in the country. Design/Methodology/Approach: This is a Descriptive study wherein both qualitative and quantitative approaches were used. For this study, data was collected from both primary and secondary data sources. In-depth interviews and questionnaires were the tools used to collect primary data while the secondary data have been collected from various university websites, journals, and tourism magazines. Findings: The major finding of the study showcases that there exists a difference of opinion between the touri...

Andrew Fernandes

With the ASEAN unification looming, passengers will be flying in and out of the region at an unprecedented pace due to the open policies on business and employment. The tourism industry will be one of the major benefactors of this trend, and the airline sector in particular, will benefit the most. The Philippines has reflected the global trend of customers supporting low-cost carriers and have become as uncompromising as ever on safety and service demands despite the incongruent tradeoff of expenses and benefits. Airline staff have become increasingly in demand, however, there seems to be a disconnect with the knowledge, skills and abilities of graduates of Bachelor of Science in Travel Management as they are commonly bypassed by other prospective employees from different disciplines and backgrounds. Consulting with airline managers, the author desires to put together empirical proof on the expected knowledge, skills and abilities, and in particular the most in demand of them, to make BSTM graduates highly employable in the airline industry’s servicescape. This paper gives perspective on assessing which frontliner attributes do airline managers value and how can this input be factored in to improve BSTM graduates at not only entry into the aviation industry but enjoy long term success and productivity.

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Asia Pacific Journal of Education Perspective

This work was intended to assess the Airline Internship of Tourism Graduates of LPU-B from the school year 2010-2013. Specifically, the study also described the demographic profile of the respondents who have undergone the Airline internship; assessed the knowledge and skills they gained in the Airline internship; determined the level of effectiveness of the Airline internship to Tourism graduates; and found out that the employment of the respondents was paralleled to the course they completed. The descriptive method was used by the researchers in order to gather the needed information of the study. The researchers found out that the respondents of the study were dominated by single female young adults whose employment was coupled with the necessary trainings, and with work experience of less than one year. Based on the survey, the knowledge and skills gained by the respondents in the Airline Internship were both very good and the Airline Internship to Tourism Graduates of 2010-2013 was highly effective. Lastly, the Internship Program of the majority of the respondents is aligned to their current jobs.

Expectations of Tourism Industry on Competencies and Tourism Education

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Generally tourism and hospitality courses/qualifications equip the holder with skills and knowledge for the tourism and hospitality industry in a holistic approach. However, the current literature evaluation on the hospitality and tourism education and training denotes a number of differences from the tourism and hospitality manpower needs. This bolsters the industrialists’ outcry that the tourism and hospitality programmes/courses are not addressing the needs of both the tourism sector and the hospitality sector within the Tourism and Hospitality industry, especially in Zimbabwe. This paper probes the misunderstanding of the current situation concerning tourism and hospitality graduates, hospitality skills, travel/ tourism skills and both areas’ competencies and career development within the combined discipline. Literature points out that for the implementation of curricula there is a need to connect with industries and make the best use of the social resources which will contribut...

Challenges of Tourism Education: Conformity of Tourism Curriculum to Business Needs

This study was conducted in the fourth largest tertiary education institution in Latvia, which also provides higher education in the field of tourism. The purpose of the research is to study stakeholder needs and to evaluate the knowledge of tourism students, as well as the level of skills and abilities necessary for work in tourism business and to determine opportunities for curriculum development. The study is comprised of three stages: context analysis; a survey of 262 tourism students and 192 employers applying a similar Likert Scale questionnaire; comparing findings with the findings obtained in similar studies in other countries and elaborating conclusions and suggestions regarding curriculum improvement. A quantitative approach conducting primary data analysis (descriptive statistics) and secondary data analysis (Levene’s Test for Equality of Variances, Anova test) is applied to study stakeholder opinion. Findings of the study reveal the knowledge, skills and abilities necessary to succeed in tourism business. It indicates that the present curriculum corresponds to the requirements of the industry and student needs. Students highly value the knowledge acquired and the skills and abilities developed during their studies. The employers’ high evaluation of student knowledge, skills, and abilities verifies this fact. The curriculum might be improved by creating modules of related courses, applying a cross-disciplinary approach to studies, using corresponding teaching-learning methods and creating a supportive learning environment, initiating autonomous learning for the students and motivating them for studies. Key words: tourism curriculum; knowledge; skills; abilities

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Southwest Flight Attendants Score New Contract, to Be Among Highest Paid

Meghna Maharishi , Skift

April 24th, 2024 at 4:10 PM EDT

After overwhelmingly rejecting a previous contract in December, this one will make Southwest flight attendants some of the most highly paid in the industry.

Meghna Maharishi

Southwest flight attendants ratified a new four-year contract that will offer them a 22.3% raise, the Transport Workers Union announced Wednesday. 

The contract also offers flight attendants $364 million in retroactive wages and will make them some of the most highly paid flight attendants in the industry. The retroactive wages will be paid out based on how much flight attendants had been flying during negotiations. 

The 22.3% raise kicks in May 1. 

“This is a significant victory for Flight Attendants industrywide and the TWU has once again proven that we are an incredibly effective voice for Flight Attendants,” said TWU president John Samuelsen in a statement. 

The contract includes provisions for additional compensation for extra time spent on the ground and premium pay for extended shifts. The contract also includes protections for flight attendants who experience injuries while on the job and provides holiday pay for the Fourth of July, Memorial Day and Labor Day. 

Flight attendants will also receive paid maternal and paternal leave that the union described as “industry-first.” The contract includes healthcare coverage for flight attendants taking care of a newborn child. 

The newly ratified contract also includes 3% raises in 2025, 2026 and 2027 on top of the 22.3% pay increase. And after the 2022 holiday meltdown, the contract also includes a revised reserve system that would end the 24-hour on-call system so flight attendants can get more rest. 

“This agreement rewards our Flight Attendants and includes provisions that strengthen Southwest’s operation,” said Adam Carlisle, Southwest’s vice president of labor relations.

A Major Deal

The Southwest flight attendants’ union is one of the first to reach a landmark deal with its carrier. Previously, negotiations reached a contentious point when Southwest flight attendants overwhelmingly rejected a contract in December. 

The new contract was approved by 81% votes in favor, with 93% of eligible flight attendants participating. 

Flight attendants at American Airlines, United Airlines and Alaska Airlines are also in the midst of contract negotiations. 

United flight attendants picketed at LaGuardia Airport and other major U.S. and U.K. airports April 11. Alaska flight attendants held a similar protest in February. And American flight attendants previously voted to authorize a strike that was then struck down by mediators. 

A major flash point during negotiations has been issues with pay structure. Flight attendants are typically only compensated for the time worked inside the plane. Boarding and any other work on the ground is not compensated. 

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Tags: association of flight attendants , flight attendants , southwest airlines , transport workers union , TWU

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Luckily for flyers, it’s gonna be May very soon.

“May and September are great months to travel, as they’re before and after peak summer here in the US,” flight attendant Bernice Padilla, 29, confided to SWNS .

“You have less crowds and more affordable prices, but the weather is still nice,” she continued. “Every country has their specific shoulder season, so I recommend doing some research before booking.”

Padilla, a flight attendant for six years who has visited 44 countries, is sharing tricks of the travel trade — from flights to book to countries to explore.

The Dallas-based flight attendant , who boasts 144,300 followers on TikTok , said that while Europe is a hot destination for American travelers, it’s best to book holidays in “overlooked” destinations.

“Everyone loves to go to London, Rome, Paris and Barcelona,” she explained. “ I am going to Argentina in a few weeks, for example. I think it is good to book places that aren’t as popular with tourists.”

She added: “Even [if] people are still wanting to visit Europe, there are so many places that aren’t as popular, like Albania and countries on the coast.”

Padilla also revealed her preference for booking the earliest possible flight to avoid delays.

“ If there are any delays , it ends up being a domino effect. Say there is a delay in California due to the weather — then my flight here can’t take off until that flight takes off,” she reasoned. “Everything trickles down, whereas if you fly early, your plane will be there from the night before.”

And when it comes to packing, Padilla recommends traveling with carry-on luggage , especially in the summer.

If that’s not possible, she relies on compression packing cubes .

“I still have a problem with overpacking, but I try not to overpack as much,” she confessed. “I always travel with compression cubes — that way you can fit more into your suitcase.”

Her travel must-haves include a reusable water bottle , a sweater or blanket , a pen to fill out any forms that might be needed at arrival, noise-canceling headphones , and a portable charger .

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I'm a flight attendant - these are the best times to travel if you want to avoid price hikes AND delays

• Bernice Padilla, from Dallas, Texas, has been a flight attendant for six years 
• The 29-year-old  has travelled to more than 44 countries on thousands of flights
• She shared invaluable insight about both booking a holiday and packing well

A flight attendant has revealed the best time of the day to catch a plane - as well as the best months to travel to avoid delays and price hikes. 

Bernice Padilla, 29, has been a flight attendant for six years and has travelled to 44 countries on thousands of flights. 

The travel expert, from Dallas, Texas , has now shared her invaluable insight about both booking a holiday and packing appropriately.

She began by recommending people book holidays for the 'shoulder seasons' - which are May or September - to get the best deal.   

Flight attendant's top travel items

• Take a reusable water bottle
• Take a sweater or blanket
• Take a pen to fill out any forms that might be needed when you arrive
• Pack noise-cancelling headphones
• Take a portable charger 

Bernice explained: 'May and September are great months to travel as they're before and after peak summer here in the US.

'You have less crowds and more affordable prices but the weather is still nice.

'Every country has their specific shoulder season so I recommend doing some research before booking.'

She also urged holiday-goers to book the earliest flight possible because these are much less likely to encounter a delay.

'I always take the earliest flight possible so there are fewer delays. If there are any delays it ends up being a domino effect.

'Say there is a delay in California due to the weather then my flight here can't take off until that flight takes off.

'Everything trickles down, whereas if you fly early your plane will be there from the night before.'

Elsewhere, the frequent flier revealed that Europe is a hot destination for American travelers in the US but said people should try to book holidays in places that are 'overlooked.'

She said: 'Everyone loves to go to London, Rome, Paris and Barcelona.

'I think there are a lot of great places people can go to that are overlooked.

'I am going to Argentina in a few weeks, for example, I think it is good to book places that aren't as popular with tourists.

'Even people are still wanting to visit Europe there are so many places that aren't as popular like Albania and countries on the coast.'

But Bernice's tips did not stop there because, when it comes to packing, she recommended people travel light with just carry-on luggage.

If that is not possible, Bernice lives by using compression cubes.

She said: 'I still have a problem with overpacking but I try not to overpack as much.

'What I do recommend is trying to travel with a carry, especially in the summer.

'If that is not possible, I always travel with compression cubes, that way you can fit more into your suitcase.

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Southwest Airlines flight attendants ratify a contract that will raise pay about 33% over 4 years

Associated Press

DALLAS – Flight attendants at Southwest Airlines have ratified a contract that includes pay raises totaling more than 33% over four years, as airline workers continue to benefit from the industry's recovery since the pandemic.

The Transport Workers Union said Wednesday that members of Local 556 approved the contract by a margin of 81% to 19%. The union's board rejected a lower offer last summer, and flight attendants voted against a second proposal in December.

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Southwest has about 20,000 flight attendants. They will get raises of more than 22% on May 1 and annual increases of 3% in each of the following three years.

The union said the contract provides record gains for flight attendants and sets a standard for other flight attendants. Cabin crews at United Airlines and American Airlines, which are represented by other unions, are still negotiating contracts.

The union said the deal gives Southwest crews the shortest on-duty day and highest pay in the industry, compensation during disruptions like the Southwest meltdown in December 2022, and industry-first paid maternity and parental leave. Workers will also split $364 million in ratification bonuses, according to the union.

Dallas-based Southwest, the nation's fourth-biggest airline, said the contract includes changes in scheduling and will help the airline's operation.

Pilot unions at Delta, United, American and Southwest approved contracts last year that raised pay by more than one-third over several years. This week, Delta said its flight attendants and other nonunion workers will get 5% raises .

Copyright 2024 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed without permission.