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OEM Online First, published on July 31, 2015 as 10.1136/oemed-2014-102664

Workplace

ORIGINAL ARTICLE

Non-communicable disease risk factor patterns

among mining industry workers in Papua, Indonesia:
longitudinal ndings from the Cardiovascular
Outcomes in a Papuan Population and Estimation
of Risk (COPPER) Study
Rodrigo Rodriguez-Fernandez,1,2 Ekowati Rahajeng,3 Francesca Viliani,4
Haripurnomo Kushadiwijaya,1,5 Rachel M Amiya,2,6 Michael J Bangs1
For numbered afliations see
end of article.
Correspondence to
Dr Rodrigo RodriguezFernandez, International SOS
Freeport Industrial Public
Health and Malaria Control,
Jalan Kertajasa 1,
Kuala Kencana, Mimika,
Papua 99920, Indonesia;
[email protected]
RMA and MJB contributed
equally to this work.
Received 29 October 2014
Revised 24 June 2015
Accepted 13 July 2015

To cite: RodriguezFernandez R, Rahajeng E,

Viliani F, et al. Occup
Environ Med Published
Online First: [ please include
Day Month Year]
doi:10.1136/oemed-2014102664

ABSTRACT
Objectives Non-communicable diseases (NCDs)
constitute an increasing slice of the global burden of
disease, with the South-East Asia region projected to see
the highest increase in NCD-related deaths over the next
decade. Mining industry employees may be exposed to
various factors potentially elevating their NCD risk. This
study aimed to assess the distribution and 5-year
longitudinal trends of key metabolic NCD risk factors in
a cohort of coppergold mining company workers in
Papua, Indonesia.
Methods Metabolic indicators of NCD risk were
assessed among employees (15 580 at baseline, 6496
prospectively) of a large coppergold mining operation
in Papua, Indonesia, using routinely collected 5-year
medical surveillance data. The study cohort comprised
individuals aged 1868 years employed for 1 year
during 20082013. Assessed risk factors were based on
repeat measures of cholesterol, blood glucose, blood
pressure and body weight, using WHO criteria.
Results Metabolic risk indicator rates were markedly
high and increased signicantly from baseline through
5-year follow-up ( p<0.001). Adjusting for gender and
age, longer duration of employment (10 years)
predicted raised cholesterol (adjusted OR (AOR)=1.13,
p=0.003), raised blood pressure (AOR=1.16, p=0.009)
and overweight/obesity (AOR=1.14, p=0.001) at
baseline; and persistent raised cholesterol (AOR=1.26,
p=0.003), and both incident (AOR=1.33, p=0.014) and
persistent raised blood glucose (AOR=1.62, p=0.044) at
3-year follow-up.
Conclusions Individuals employed for longer periods
in a mining operations setting in Papua, Indonesia,
may face elevated NCD risk through various routes.
Workplace health promotion interventions and policies
targeting modiable lifestyle patterns and environmental
exposures present an important opportunity to reduce
such susceptibilities and mitigate associated health risks.

INTRODUCTION
The last millennium saw a worldwide epidemiological transition, where chronic, non-communicable
diseases (NCDs)principally cardiovascular diseases
(CVDs), diabetes mellitus type 2, cancers and chronic
respiratory diseasesovertook infectious diseases
as the leading cause of morbidity and mortality.1 2

In 2011, 36 million (63%) of all premature deaths

globally were attributable to NCDs,2 with the vast
majority (85% of those between the ages of 30 and
70 years) occurring in low and middle income
countries (LMICs).3 Without appropriate action to
reduce NCD risk, the numbers will only continue to
rise, imposing major human, social and economic
costs.46
Notably, the highest increase in NCD-related
deaths over the next decade is expected in the
South-East Asia (SEA) region, which now accounts
for 22% of the global NCD burden.4 In this
region, between 2006 and 2015, mortality rates
from infectious diseases are projected to fall by
16%, while NCD-related mortalities are expected
to register a 21% increase.7 Of the approximately
7.9 million NCD deaths occurring in the SEA
region in 2008, Indonesia shouldered the secondhighest burden (13%).7 NCDs represent the
leading causes of mortality within the country,
accounting for around 71% of total deathsmore
than all other causes combined.8
Effective prevention and management of NCDs
hinges on addressing the root causes, which are
predominantly based on social and environmental
determinants.5 Across developed and developing
countries, expanding globalisation, increased life
expectancy and urbanisation, among other factors,
have facilitated a global increase in key NCD risk
factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. These
behavioural risk factors contribute to the development of biomedical or metabolic risk factors,
including raised cholesterol, blood glucose and
blood pressure, as well as overweight and obesity,
which can manifest through multiple and interrelated effects. For example, in addition to its
direct role in diabetes, raised fasting blood glucose
also increases the risk of cardiovascular deaths,
and has been estimated to directly contribute to
22% of coronary heart disease deaths and 16% of
stroke deaths.9 Similarly, overweight and obesity
are associated with increased risk for multiple
chronic diseases including cancer, type 2 diabetes,
asthma and CVDs.10 11 Raised blood pressure,
meanwhile, is perhaps the most powerful CVD
risk factor after adjusting for tobacco use,

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accounting for about 54% of stroke and 47% of ischaemic
heart disease globally.12
Evidence has demonstrated that NCDs are, to a great extent,
preventable and that, by targeting common risk factors, health
systems may effectively confront the ongoing epidemic.1315
These risk factors are measurable and largely modiable over
time, and thus continuing surveillance of their levels is of fundamental importance in NCD control. Yet, while the prevalence
and patterns of NCD risk in developed countries have been well
established, few data are available in the SEA region or in most
developing countries, where economic growth and associated
sociodemographic changes frequently translate to increased
prevalence of NCDs.7

The mining industry and NCD risk

Mining remains one of the most hazardous occupations in the
world, both in terms of short-term injuries and fatalities, and
through long-term exposure impacts such as cancers and
chronic respiratory conditions. Various mining-associated environmental hazards have been linked to the development of
NCDs. For instance, occupational exposure to noise and whole
body vibration, as well as particulate air pollution, have been
identied as risk factors for cardiovascular and respiratory morbidity and mortality.1618 Overall, high levels of occupational
stress, isolated living conditions, worksite food catering services,
nocturnal work shifts and other related factors have all been
shown to affect the development of NCD risk factors and consequent disease, reected as well in increased mortality risk due
to multiple related causes in miners compared with reference
populations.1922
Several studies in the past have presented snapshots of NCD
risk,23 but few have prospectively assessed the impact of
extended exposure to mining conditions over time or in a
South-Asian, developing country context. Hence, the present
study was undertaken with the objective of measuring the prevalences and prospective trends in major metabolic risk factors for
NCDs and their association with duration of employment in a
population of coppergold mine employees residing in the
Timika area of Mimika District, Papua Province, Indonesia.

METHODS
Study population and setting
This research forms a part of the ongoing Cardiovascular
Outcomes in a Papuan Population and Estimation of Risk
(COPPER) Study. The present study population was comprised
of both surface and underground workers aged 1868 years
who were employed by a multinational mining company and
participated in mandatory annual health examinations performed at two health facilities from January 2008 through
December 2013. Patient data are routinely collected as part of
normal clinical and public health practice, and stored electronically on a central server. In total, data were available for 15 580
workers (15 021 men, 559 women) at baseline (where baseline
is dened as the rst assessed health check-up, conducted in
2008) and 6496 workers (6320 men, 176 women) through
3-year, 4-year and 5-year follow-up surveillance points.
The COPPER Study is set in the Mimika District, located in
the southern part of Papua Province (formerly Irian Jaya),
Indonesia. The mining company operates one of the largest
gold and copper mine production sites in the world and is the
primary employer in the district. It directly or indirectly supports a primary and secondary hospital within the contract of
work area, together with ve community healthcare clinics and
seven mine-site health posts. The mine itself is located at
2

altitudes of up to 4200 m above sea level (asl) in one of the

most remote locations and working environments on the planet
the mountainous western-central highlands of Papua
Province. At the time of this study, the mining company
employed approximately 22 558 people, of whom 71% worked
at the highlands sites and 29% in the lowlands locations; males
made up 94% of the workforce, 70% were below the age of
45 years, and approximately 98% were Indonesian nationals.
Field workers, who constitute 63% of the total workforce,
work in timed shifts (of either 8 h or 12 h intervals), and must
engage in a signicant amount of strenuous physical activity.
Ofce workers comprise 37% of the total remaining workforce
and spend most of their working time sitting while doing deskbound activities, with minimal physical activity and no shift
work duties. All workers live on site, where food is provided by
the employer three times daily, with limited availability of external sources of intake.
To conduct the analyses, we secondarily used data that had
already been obtained through the routine annual health examination process conducted through the health facilities. Thus, it was
difcult to obtain informed consent retrospectively from the
employees who had participated. As only anonymous data are
used here, it was judged unnecessary to collect such consent for
the purposes of this study. Study protocols were reviewed and
approved by the Science Review Committee of International SOS.

Data collection and denition of NCD risk indicators

As part of annual medical check-ups, all participants underwent
a physical examination including measurements of height (in
bare feet without headwear, using a measuring tape against a
wall), weight (in bare feet without heavy clothing, with standard
weighing scale) and blood pressure (at the midpoint of the arm,
with standard sphygmomanometer), as well as providing overnight (12 h) fasting blood samples. The associated blood tests
included serum total cholesterol and fasting plasma glucose. On
the basis of such measurements, metabolic risk factors for
NCDs were assessed and dened as follows based on WHO
criteria:24
Raised cholesterol: those aged 25 years or older having a
total cholesterol value 190 mg/dL.
Raised blood glucose: those aged 25 years or older having a
fasting plasma glucose value 126 mg/dL.
Raised blood pressure: those aged 25 years or older having
systolic blood pressure 140 mm Hg and/or diastolic blood
pressure 90 mm Hg.
Overweight/obesity: those aged 20 years or older having a
body mass index (BMI) 25 kg/m2 (with obesity dened as
BMI 30 kg/m2), where BMI is calculated as weight in kilograms divided by height in metres squared.
Data were also collected on each workers sex, birth date and
starting date of employment with the company.

Statistical analyses
Student t tests and analyses were used to compare baseline
characteristics between workers included in the longitudinal analyses and those excluded from such analyses due to incomplete
or missing follow-up data. Categorical data are presented as proportions, while numerical data are expressed as meansSD.
Separate one-way repeated measures analysis of variances
(ANOVAs) with Bonferroni-corrected post-hoc tests were conducted for each NCD risk indicator to examine the main effect
of time, comparing mean levels at baseline (T0), 3-year
follow-up (T3), 4-year follow-up (T4) and 5-year follow-up
(T5). Changes in prevalence of WHO-dened NCD risk

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indicators over time were further assessed using McNemars
test (paired test using Yates correction) for each time increment from baseline (ie, from T0 to T3, T4 and T5, respectively), with changes also depicted graphically by age bracket.
For investigating more directly the role of participants
employment as miners in the observed progression of NCD risk
over time, direct logistic regressions were performed to determine the impact of duration of employment (ie, time on site)
on the likelihood that respondents would exhibit each of the
measured metabolic risk indicators (ie, raised cholesterol, raised
blood glucose, raised blood pressure, overweight/obesity) crosssectionally at baseline and then, to account for possible reverse
causality, prospectively at 3-year follow-up. For the prospective
analyses, participants were analysed separately and outcomes
presented in two groups: (1) as risk incidence (ie, new cases of
elevated metabolic risk indicator levels) at 3-year follow-up
among those with indicator levels falling below the designated
risk threshold at baseline, and (2) as persistent risk (ie, continuing cases of elevated metabolic risk indicator levels) at 3-year
follow-up among those with indicator levels meeting or exceeding the designated risk threshold at baseline. Separate regressions were modelled for each risk indicator, with categorical
presence of the indicator (ie, raised vs normal) as the dependent
variable and duration of employment at baseline as the primary
independent variable of interest, tested in turn as both a categorical variable (10 vs<10 years) and as a continuous variable.
Each such analysis was adjusted for gender and age bracket
(2529, 3034, 3539, 4044, 45+ years) by inclusion of these
variables as additional independent variables in the regression
models.
Multicollinearity that might signicantly affect regression
results was ruled out by examining pairwise correlations, variation ination factors (VIFs) and tolerance values for each independent variable. All predictor intercorrelations and VIFs were
well below the conservative recommended cut-offs of 0.8025
and 2,26 respectively, and all tolerance values greater than
0.40,27 indicating no serious multicollinearity bias. In particular,
though age and duration of employment were signicantly correlated ( p<0.01), the degree was low-to-moderate (r=0.478).
Across all regression models, the highest VIF was 1.359 and the
lowest tolerance value 0.736.
Analyses involving assessments of metabolic risk were generally restricted to participants aged 25 years and older, in line
with WHO standard indicators. Independent variables were
entered into each regression analysis using a direct (simultaneous) entry method. All statistical tests were two-sided and evaluated as signicant at the p<0.05 level, using SPSS V.22.0 for
Windows (IBM SPSS Inc, Chicago, Illinois, USA).

RESULTS
Baseline characteristics of study participants
Characteristics of the 15 580 study participants at baseline,
stratied by gender, are presented in table 1. Relative to their
female counterparts, male employees skewed signicantly older
( p<0.001) and had been employed with the company for
longer periods of time ( p<0.001). Male employees were also
signicantly more likely to exhibit impaired (>100 mg/dL)
fasting blood glucose ranges ( p<0.001) and raised blood pressure, though less likely to be either underweight (BMI<18.5) or
obese (BMI30).
The total number of participants retained through all four
waves of data collection and thus included in the longitudinal
analyses was 6496, with a slightly higher retention rate in men
than in women ( p<0.001). Those excluded skewed younger

Table 1 Baseline demographic and metabolic risk characteristics

of male and female mining company employees
Characteristic

Total
(N=15 580)

Age, years, %*
1829
22.3
3034
21.9
3539
24.5
4044
18.3
4568
13.1
Mean (SD)
36.3 (7.4)
Duration of employment, years,
9.2 (4.0)
mean (SD)
Serum total cholesterol range, mg/dL, %
Normal (<190)
58.5
Raised (190240)
33.3
High (240+)
8.3
Mean (SD)
183.9 (40.4)
Fasting blood glucose range, mg/dL, %
Normal (70.2100)
90.0
Impaired (101125)
7.5
Raised (>125)
2.5
Mean (SD)
87.1 (20.8)
SBP range, mm Hg, %
Normal (<120)
52.3
Prehypertensive (120139)
42.3
Stage 1 hypertensive (140159)
4.6
Stage 2 hypertensive (160179)
0.5
Hypertensive emergency (180+)
0.2
Mean (SD)
113.9 (12.9)
DBP range, mm Hg, %
Normal (<80)
55.5
Prehypertensive (8089)
33.3
Stage 1 hypertensive (9099)
8.8
Stage 2 hypertensive (100109)
1.9
Hypertensive emergency (110+)
0.6
Mean (SD)
74.9 (9.4)
Raised blood pressure, %
11.9
(SBP140 mm Hg and/or
DBP90 mm Hg)
Body mass index range, kg/m2, %
Underweight (<18.5)
2.1
Normal (18.524.9)
57.0
Overweight (2529.9)
34.1
Moderately obese (3034.9)
6.1
Severely obese (3539.9)
0.6
Very severely obese (40+)
0.1
Mean (SD)
24.5 (3.6)

Males
(n=15 021)

Females
(n=559)

21.8
21.6
24.7
18.6
13.3
36.4 (7.4)
9.3 (4.0)

33.9
30.2
20.5
9.9
5.6
33.4 (6.8)
8.1 (3.8)

58.5
33.3
8.2
183.8 (40.4)

56.4
34.0
9.7
187.0 (40.9)

89.8
7.7
2.5
87.3 (20.8)

94.7
2.9
2.4
82.5 (18.0)

52.0
42.5
4.8
0.5
0.2
113.9 (13.0)

60.1
37.6
1.6
0.7
0
111.9 (11.3)

54.7
33.8
8.9
1.9
0.6
75.0 (9.4)
12.1

75.5
19.3
4.1
0.7
0.4
71.9 (8.6)
5.5

2.0
57.0
34.3
6.0
0.5
0.1
24.5 (3.6)

4.0
55.4
29.5
8.1
2.7
0.4
24.6 (4.3)

*Baseline data on age were missing for 55 participants.

Baseline data on serum total cholesterol were missing for 449 participants.
Baseline data on fasting blood glucose were missing for 604 participants.
Baseline data on blood pressure were missing for 36 participants.
Baseline data on body mass index were missing for 34 participants.
DBP, diastolic blood pressure; SBP, systolic blood pressure.

(p<0.001) and had slightly lower mean values for cholesterol

(p<0.001) and BMI (p<0.001).

Longitudinal trends in metabolic risk factors

Table 2 shows the trajectories from baseline to 3-year, 4-year
and 5-year follow-up in mean levels of the assessed metabolic
NCD risk factors, including changes from baseline. One-way
repeated measures ANOVA analyses revealed large, signicant

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Table 2 Descriptive statistics for changes in metabolic risk factors across baseline and 3-year, 4-year and 5-year follow-ups
Risk factor
Serum total cholesterol (mg/dL) (N=6089)
Mean (SD)
Mean (SE) change from T0
95% CI for change
Fasting plasma glucose (mg/dL) (N=6240)
Mean (SD)
Mean (SE) change from T0
95% CI for change
Systolic blood pressure (mm Hg) (N=6684)
Mean (SD)
Mean (SE) change from T0
95% CI for change
Diastolic blood pressure (mm Hg) (N=6380)
Mean (SD)
Mean (SE) change from T0
95% CI for change
Body mass index (kg/m2) (N=6384)
Mean (SD)
Mean (SE) change from T0
95% CI for change

Baseline (T0)

3-Year follow-up (T3)

4-Year follow-up (T4)

5-Year follow-up (T5)

187.6 (37.9)

197.6 (37.7)
+10.0 (0.4)
(9.0 to 11.0)***

196.2 (38.2)
+8.5 (0.4)
(7.5 to 9.6)***

207.3 (40.2)
+19.7 (0.4)
(18.6 to 20.8)***

87.4 (20.3)

90.7 (23.7)
+3.4 (0.3)
(2.7 to 4.1)***

91.7 (24.4)
+4.4 (0.3)
(3.6 to 5.1)***

94.4 (27.7)
+7.1 (0.3)
(6.3 to 7.9)***

114.1 (13.3)

118.0 (14.6)
+3.9 (0.2)
(3.3 to 4.4)***

121.1 (15.6)
+7.0 (0.2)
(6.4 to 7.5)***

123.9 (16.3)
+9.8 (0.2)
(9.2 to 10.3)***

75.0 (9.5)

76.4 (10.6)
+1.4 (0.1)
(1.0 to 1.8)***

79.3 (10.9)
+4.3 (0.2)
(3.9 to 4.7)***

81.0 (11.2)
+6.0 (0.2)
(5.6 to 6.4)***

24.7 (3.7)

25.1 (3.6)
+0.4 (0.03)
(0.3 to 0.4)***

25.4 (3.7)
+0.7 (0.03)
(0.6 to 0.8)***

25.8 (3.7)
+1.1 (0.03)
(1.0 to 1.2)***

p Values are based on one-way repeated measures analysis of variance analyses.

*p<0.05, **p<0.01, ***p<0.001.

effects for time since baseline assessment for changes observed

in serum total cholesterol (F[3,6086]=803.83, p<0.001, multivariate partial 2=0.28), systolic blood pressure (F[3,6381]
=770.25, p<0.001, multivariate partial 2=0.27), diastolic
blood pressure (F[3,6377]=603.65, p<0.001, multivariate
partial 2=0.22) and BMI (F[3,6381]=544.53, p<0.001, multivariate partial 2=0.20); and a moderate, but signicant effect
for time since baseline assessment for fasting plasma glucose
(F[3,6237]=186.15, p<0.001, multivariate partial 2=0.08).
Assessed in terms of their clinically relevant, WHO-dened
indicators, signicant increases in prevalence rates from baseline
were observed at each successive follow-up of all metabolic risk
factors (ie, raised cholesterol, raised blood glucose, raised blood
pressure and overweight/obesity), based on the McNemars
test analyses ( p<0.001). Similar increasing trends were observed
in the age-stratied prevalence rates, as depicted in gure 1.

Analyses of association between duration of employment

and NCD risk indicators
Associations between duration of employment and metabolic
indicators of NCD risk were modelled both cross-sectionally
and longitudinally among participants aged 25 years and older.
The results of these adjusted analyses are shown in table 3. In
summary, workers employed for 10 years or longer at baseline
were 13% more likely at baseline and, among those with raised
cholesterol at baseline, 26% more likely at 3-year follow-up, to
exhibit persistent raised cholesterol; 33% more likely at 3-year
follow-up to exhibit newly raised blood glucose and, among
those with raised blood glucose at baseline, 62% more likely to
exhibit persistent raised blood glucose; 16% more likely at baseline to exhibit raised blood pressure; and 14% more likely at
baseline to be overweight or obese. Similar signicant associations were found when duration of employment was assessed as
a continuous variable, with signicant incremental increases in
NCD risk observed with each successive year of company
employment. Across all regression analyses, the full model
4

containing all predictors (employment duration, gender and

age) was statistically signicant based on both the Omnibus Tests
of Model Coefcients ( p0.001) and the Hosmer-Lemeshow
Goodness of Fit Test ( p>0.35). The models as a whole
explained between 0.48.3% (Cox and Snell R2) and 0.4
11.2% (Nagelkerke R2) of the variance in NCD risk indicator
status, and correctly classied 58.597.4% of cases (except in
the case of the two prospective models of overweight/obesity
status, in which none of the included predictors were signicant
and model t was thus poor).

DISCUSSION
Findings from the COPPER Study point to an unmistakeable
heavy and mounting burden of NCD risk among those
employed in mining operations in Papua, Indonesia. Recorded
rates and upward-rising trends of metabolic risk factors reect
the wider context of changing disease epidemiology in
Indonesia, the SEA region and, more broadly, LMICs worldwide.1 3 Moreover, results suggest a markedly elevated level of
NCD risk specic to working and living in this isolated mining
community.
From baseline through 5-year follow-up, increasing trends in
NCD risk factors were observed in terms of both mean levels
and indicator prevalence rates. Changes were statistically as well
as clinically signicant. Even with regard to raw mean values for
the study sample, two of the risk factorstotal plasma cholesterol and BMIprogressed from being just below the
WHO-dened cut-off point at baseline to falling within the
designated high-risk range (progressing from 187.6 to
207.3 mg/dL for cholesterol and from 24.7 to 25.8 kg/m2 for
BMI) after 5 years. Moreover, based on Ketola et als28 classication using 19.33 mg/dL as the cut-off point for clinical
relevance in total cholesterol changes, the 19.72 mg/dL
individual-level change in total cholesterol observed from baseline to 5-year follow-up in the present study may be regarded as
both statistically and clinically meaningful.

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Figure 1 Age-stratied trends in metabolic risk factors from baseline to 3-year, 4-year and 5-year follow-up. T0, baseline; T3, 3-year follow-up;
T4, 4-year follow-up; T5, 5-year follow-up.
Over the past few decades, traditional societies in many developing countries have experienced rapid and poorly planned
urbanisation, leading to lifestyles characterised by unhealthy
nutrition, reduced physical activity and increased tobacco consumptionamong the primary behavioural risk factors contributing to NCDs.13 14 These risk factors are especially prevalent
in the SEA region, home to nearly 250 million smokers and an
equal number of smokeless tobacco users.7 29 The consequences
have been manifested clearly in NCD risk factor trajectories.
For example, a study using multicountry data between 1980 and
2008 has shown a decreasing trend of mean blood pressure in
western countries, but an increasing trend in SEA and
Oceania.30 Furthermore, obesity is rapidly increasing across
both developed and developing countries, particularly in urban
settings.31 In this sense, the observed prevalence rates and longitudinal trends seen in our study population are in line with
broader population-level transitions (Figure 2).

Yet the COPPER Study ndings further suggest that the high
and rising levels of NCD risk factors observed among the mine
employees extend beyond general population-level and
regional trends, indicating possible exposures specic to the
environment experienced by mining employees in Papua.
Compared with 2008 Indonesian national population prevalence estimates,14 baseline rates in the observed mine workers
were higher for raised cholesterol (41.6% vs 35.1%) and
nearly doubled for overweight/obesity indices (40.9% vs
21.0%). Moreover, our cross-sectional and longitudinal analyses found that the observed populations risk for raised cholesterol, raised blood glucose, raised blood pressure and
overweight/obesity increased with every year spent on site,
both cross-sectionally at baseline and prospectively at 3-year
follow-up. This result implies that participants employed for
longer durations experienced a longer duration of exposure to
conditions contributing to NCD risk. Although our data do

Table 3 Logistic regression results for the association of baseline employment duration (10 years) with metabolic risk indicators in
cross-sectional and prospective 3-year follow-up among participants aged 25 years and older, adjusted for gender and age
Incident at 3-year follow-up

Persistent at 3-year follow-up

Risk indicator

At baseline
N

AOR

(95% CI)

AOR

(95% CI)

AOR

(95% CI)

Raised cholesterol (190 mg/dL)

Raised blood glucose (126 mg/dL)
Raised blood pressure (SBP140 mm Hg
and/or DBP90 mm Hg)
Overweight or Obesity (25 kg/m2)

14 208
14 063
14 569

1.13
1.10
1.16

(1.04 to 1.22)**
(0.88 to 1.39)
(1.04 to 1.30)**

7867
13 603
12 751

1.08
1.33
0.91

(0.97 to 1.21)
(1.06 to 1.68)*
(0.81 to 1.02)

6244
368
1808

1.26
1.62
0.96

(1.08 to 1.47)**
(1.01 to 2.58)*
(0.78 to 1.18)

14 569

1.14

(1.05 to 1.23)**

8352

1.03

(0.90 to 1.17)

6147

1.01

(0.83 to 1.22)

Logistic regression models all adjusted for gender and age bracket.
*p<0.05, **p<0.01, ***p<0.001.
Among those with indicator levels below the designated metabolic NCD risk threshold at baseline.
Among those with indicator levels meeting or exceeding the designated metabolic NCD risk threshold at baseline.
AOR, adjusted OR; DBP, diastolic blood pressure; NCD, non-communicable disease; SBP, systolic blood pressure.

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Workplace
not address specic causes, several possible dynamics might be
proposed based on previous studies and knowledge on
common behavioural risk factors for NCDs.
Compared with most other industries, the mining workforce
has been identied as having a high (though unqualied) proportion of chronic health problems.32 Chronic illnesses may be
caused through exposure to a range of physical, chemical, biological, ergonomic and psychosocial hazards common to mining
activities including shift work and nocturnal shifts, air pollution,
silica dust, high altitudes, and elevated trauma and stress levels
all of which may interact in complex ways leading to elevated cholesterol, blood glucose, blood pressure and BMI through diverse
pathophysiological mechanisms including direct physiological
effects, dysregulation of neuroendocrine pathways and behavioural
modication towards unhealthy lifestyle habits.1618 32 These
occupational hazards form part of a complex matrix of risk factors
that are a function of technological development as well as social,
economic and demographic factors, exacerbated by the regional
and remote location of sites and various organisational issues inuencing work demands.
The mining site in the present study provides a semicontrolled environment as far as lifestyle factors are concerned.
Importantly, studies under similar worksite conditions have
observed that obesity and unbalanced eating patterns increase
with eating in staff canteens, even after adjusting for demographic and socioeconomic variables,33 yet some studies have
also demonstrated the capacity for worksite canteens to increase
workers intake of fruits and vegetables,34 pointing to the potential for positive impact through workplace interventions.35
The continued role for the private sector in promoting workplace wellness was explicitly called for in the United Nations
Declaration on NCDs,36 providing opportunities such as peer
networks and employer incentives.37 At the same time, potential
negative aspects also need to be carefully considered including
the potential for faulting the workers, coercion and conicts of
interest.37
Particularly in the Indonesian/SEA region context, the private
sector may also play a critical role in addressing important gaps
in local knowledge and response systems.38 Reecting a growing
recognition of such widely untapped potential, the World
Health Assembly, in 2010, passed a resolution calling on countries to constructively engage the private sector in providing
essential health-care services.39 In remote and low-resource settings where health information systems and monitoring and
evaluation (M&E) mechanisms may be sparse or absent, companies with the resources and infrastructure to do so have the
opportunity to contribute quality up-to-date data on NCD risk
trends and pilot more innovative or resource-intensive initiatives
contributing to multiple objectives under the new WHO Global
NCDs Action Plan.40
There is now compelling evidence that workplace-based programmes incorporating health risk assessments used in combination with other interventions (eg, targeting dietary intake and
increased physical activity) are effective in relation to lowering
tobacco use, alcohol use, dietary fat intake, blood pressure,
cholesterol, and control of overweight and obesity, with concomitant improvements in medical parameters as well as in
psychological and physical well-being.35 4144 For the
employer, improved health outcomes may also lead to reduced
absenteeism and sick leave, increased productivity and reduced
healthcare expenditures.42
In view of the escalating burden of NCD risk factors observed
among mine workers residing in Papua, implementation of an
effective intervention programme is critical and timely. Building
6

on the COPPER Study ndings, further research will be needed

to more thoroughly explicate the vulnerabilities and needs of
the mining company employees, recognising the multifactorial
nature of NCD risk.
This study, despite its advantages of a large sample size and
historical prospective design, does present some methodological limitations that must be considered in interpreting the
present ndings. First, there is insufcient epidemiological evidence to draw meaningful conclusions about the existence of a
causal association between specic occupational exposures and
the development of NCD risk. Results do not, however, rule
out important associations in this direction, and the contributory evidence provided by multivariable regression analyses
and comparisons with national population prevalence points to
mechanisms that may link on-site exposures to such risk. Yet
the extent to which occupational exposures versus lifestyle or
environmental factors underlie these differences is not clear,
and the current study lacked data to directly explore or control
for either.
In a related vein, information collected on potential confounding risk factors was limited. We did not take into account,
for example, participants complete sociodemographic proles,
diversity across multiple work environments and job categories,
or detailed work histories, which may have explained a proportion of the variability in exposure. Consequently, competing
non-causal explanations are possible. For example, the effect of
duration of employment may be confounded by physical activity
requirements being greater in the workers with the least seniority, or by tendencies for sicker workers to remain with the
company in the interests of retaining health insurance benets.
Further studies incorporating a broader consideration of potential confounders as well as relevant control groups will be necessary to clarify the important exposures at play along with their
causal interactions.
As a further limitation, loss to follow-up may have introduced selection bias and limited somewhat the generalisability
of our ndings. Attrition analysis revealed that those participants who did not undergo follow-up measurements exhibited
signicant differences in gender, age, mean cholesterol and
mean BMI, though not in other key variables. Finally, comparison of the morbidity experience of an occupational cohort
to the general population may be biased and results of this
study thus diluted by the healthy worker effect,45 with
workers tending to exhibit lower rates of chronic disease than
the population at large. However, the longitudinal nature of
our analyses might be expected to counteract such biases, at
least partially, and rates of raised cholesterol and overweight/
obesity were still found to be higher than the general
population.

CONCLUSIONS
Our ndings, obtained from a large worksite cohort, highlight
high and upward-trending rates of NCD risk, and provide evidence of a potential relationship between mining community
residence and certain NCD risk factors in Papua, Indonesia.
Unfortunately, national health promotion activities are currently weak, leaving room for much positive action towards
improved and expanded prevention and control of NCDs
within the private sector. Primary and secondary prevention as
well as control strategies in the workplace are needed to
change unhealthy lifestyle habits such as poor diet and lack of
physical activity towards reducing heavy burdens of metabolic
risk factors among mine employees, particularly high cholesterol and overweight/obesity. To this end, evidence-based

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Workplace
interventions such as trafc light food labelling in company
cafeterias to promote better dietary habits,46 a portable patient
record for improved management of NCDs47 such as diabetes,
mHealth interventions for a range of NCDs prevention and
self-management aspects, and smoking cessation counselling
and therapy programmes, combined with regular M&E of relevant metabolic and behavioural risk indicators (eg, sodium
intake), should be explored for systematic on-site
implementation.

12

Author afliations
1
Public Health and Malaria Control, International SOS, Kuala Kencana, Papua,
Indonesia
2
NCD Asia Pacic Alliance, Tokyo, Japan
3
Non-Communicable Disease Control, Ministry of Health, Jakarta, Indonesia
4
Public Health Consulting Services and Community Health, International SOS,
Copenhagen, Denmark
5
Faculty of Medicine, Department of Public Health, Gadjah Mada University,
Yogyakarta, Indonesia
6
Department of Family Nursing, Graduate School of Medicine, The University of
Tokyo, Tokyo, Japan

17

Twitter Follow Francesca Viliani at @fravili

Contributors All the authors contributed to the various stages of this study. RR-F
conceptualised the topic, led the development of the manuscript and wrote the
original draft. ER and HK participated in the interpretation of the study ndings.
FV and MJB reviewed and edited the manuscript. RMA researched the literature,
performed all of the statistical analyses and revised the manuscript. All the authors
read and commented on the drafts, and approved the nal version of the
manuscript for submission.

13

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15

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20

21

22
23

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Funding PT Freeport, Freeport McMoRan Copper & Gold Inc.

Competing interests None declared.
Ethics approval Freeport Public Health and Malaria Control, International SOS,
Science Review Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/

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Non-communicable disease risk factor

patterns among mining industry workers in
Papua, Indonesia: longitudinal findings from
the Cardiovascular Outcomes in a Papuan
Population and Estimation of Risk (COPPER)
Study
Rodrigo Rodriguez-Fernandez, Ekowati Rahajeng, Francesca Viliani,
Haripurnomo Kushadiwijaya, Rachel M Amiya and Michael J Bangs
Occup Environ Med published online July 31, 2015

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