Prevalence and risk factors for work-related musculoskeletal pain among flight attendants: A comparative study

Abstract

Background

Flight attendants (FAs) are subject to unique occupational demands, increasing their risk of developing work-related musculoskeletal pain (WRMSP). WRMSP is influenced by physical, psychosocial, and demographic factors that may change over time due to evolving work environments and practices.

Objectives

Compare the prevalence of FAs’ WRMSP in 2016 vs 2024; Identify key physical and psychosocial predictors of WRMSP in each period; explore implications for ergonomic interventions and health promotion strategies tailored to the aviation work environment.

Methods

Two cross-sectional cohorts of FAs, from 2016 (n = 94) and 2024 (n = 89), completed identical, validated questionnaires using the same sampling frame. Surveys covered demographics, occupational tasks, region-specific pain, and psychosocial factors.

Results

Arm and hand pain were less prevalent in 2024. Logistic regressions showed higher odds of neck pain in 2024 associated with stress, attitudes, and satisfaction, but markedly lower odds of arm pain across psychosocial and task factors. Lower back pain was less predicted in 2024 when satisfaction was considered. Across both years, hand pain increased with workload and oven-loading but decreased with age and authority; finger pain rose with effort; upper back pain with BMI and time pressure; shoulder pain with dissatisfaction; elbow pain with standing.

Conclusions

Technological and organizational changes appear to have contributed to reduced arm and hand pain and to lower back pain being less predicted in 2024, while psychosocial stressors were linked to increased neck pain, underscoring the dual impact of ergonomic improvements and persistent organizational pressures on WRMSP.

Introduction

Due to their unique work environment, flight attendants (FAs) are exposed to various occupational health risks. Comparing the health of FAs to that of the general U.S. population reveals a higher prevalence of reproductive cancers, sleep disorders, fatigue, depression, and other health conditions, particularly as job tenure increases.^1,2 According to the Epidemiological Data on Work-Related Musculoskeletal Disorders (WRMSDs) in China from 2018 to 2020, flight attendants had the highest standardized prevalence rate of WRMSDs among occupational groups. ³ These findings highlight the demanding nature of their work, which includes prolonged standing, lifting, exposure to irregular sleep patterns, and low oxygen levels.^4,5

Work-related musculoskeletal pain (WRMSP) is a significant concern in many occupations, including those of FAs. These disorders encompass a range of inflammatory and degenerative conditions that cause pain and impair function, often resulting from sustained awkward postures, repetitive tasks, and poorly designed work environments. ⁶ For FAs, risk factors include handling luggage, operating carts, performing galley work, and dealing with cabin turbulence, which can lead to repetitive strain injuries and long-term musculoskeletal problems. ⁷ FAs report higher rates of work-related injuries than other professions, with a median of 27 lost workdays per year compared to 6–7 days in other female-dominated fields. ⁸

Several studies indicate a high prevalence of musculoskeletal pain among FAs. For instance, 82% of FAs reported pain in at least one body site, with foot pain being the most common (58%). ⁴ Other studies found significant pain in the lower back, shoulders, neck, and feet, with over 86% of FAs experiencing discomfort that affected their daily work.^7,9

The job of FAs is recognized as highly stressful due to the need for quick response times, maintaining concentration, dealing with difficult passengers, and managing emergencies.^10,11 High psychological demands, emotional labor, and chronic disruptions in circadian rhythms are everyday occurrences, contributing to anxiety, depression, and burnout, which may also impact the prevalence of WRMSD.^12,13

In addition, recent research underscores the multifaceted nature of FAs’ well-being and its influences. Kim et al. ¹⁴ examined social exchange relationships (leader-member exchange and team-member exchange) and job crafting (individual and team), finding that both factors significantly affect FAs’ occupational well-being. Strong interpersonal ties and proactive job shaping can foster better support structures, improving FAs’ overall satisfaction and mental health. Shin et al. ¹⁵ reported that salary reduction, career stagnation, social perception, and employment insecurity are associated with lower job self-esteem and satisfaction among cabin crew- highlighting psychosocial pathways pertinent to today's operations. Mulay et al. ⁶ explored the prevalence and risk factors for WRMSD among FAs, highlighting heavy physical demands, such as lifting, reaching, and prolonged standing, as primary contributors to pain and discomfort in the lower back, shoulders, and neck.

Flight attendants work in a demanding, safety-critical environment. Over the past eight years, the industry has undergone fleet upgrades, redesigned galleys, lighter service trolleys, and updated duty-time regulations,^16,17 all of which have altered daily job requirements. We therefore treated the years 2016 and 2024 as baselines and a current operational period, respectively, during which cabin service, equipment, staffing, and workflow have stabilized after industry-wide changes introduced during and after the pandemic. We used two well-separated waves, identical questionnaires, and the same sampling frame to identify changes over time in both the prevalence and predictors of region-specific musculoskeletal pain among FAs. By comparing these two groups under similar measurement conditions, we outline updated risk profiles that link pain outcomes with current physical and psychosocial exposures, which can inform targeted, mechanism-based prevention efforts in today's cabin operations.

Purpose and objectives

The purpose of this study was to characterize temporal changes in the prevalence and determinants of WRMSP among FAs by comparing two cross-sectional cohorts: 2016 (baseline) and 2024 (contemporary operations), both of which were surveyed using identical, validated questionnaires and the same sampling frame. The goal was to leverage two well-spaced measurements to detect long-term, system-level shifts in both outcomes and correlates.

The specific objectives of the study were to: (1) Assess differences in demographic and occupational characteristics of flight attendants between 2016 and 2024; (2) Evaluate the prevalence and anatomical distribution of WRMSP at both time points; (3) Identify key physical and psychosocial predictors of WRMSP in each period; and (4) Explore implications for ergonomic interventions and health promotion strategies tailored to the aviation work environment.

Hypotheses

We hypothesized that the prevalence, distribution, and severity of WRMSP among FAs have changed between 2016 and 2024. We also hypothesized that unique physical and psychosocial risk factors for WRMSP would emerge in the 2024 cohort. Furthermore, we predicted that these differences would reflect evolving occupational demands influenced by changes in flight operations.

Methods

Study design

We conducted two cross-sectional, comparative surveys in independent cohorts eight years apart (2016 baseline; 2024 contemporary operations), reported in accordance with STROBE. Both waves used the same sampling frame and recruitment channels (union email lists and closed FA social media groups), as well as an unchanged self-administered questionnaire battery. Replicating the protocol after eight years aimed to capture stabilized, industry-wide operational changes (e.g., fleet modernization, redesigned galleys, lighter service trolleys, updated crewing/duty-time rules, and staffing patterns) and to identify temporal shifts in the prevalence and predictors of region-specific WRMSP among flight attendants. We consider 2016 as a baseline and 2024 as a contemporary operational period.

Participants

The study involved flight attendants working for various airlines, focusing on those who are currently employed and actively flying. Participants were selected through a combination of random and convenience sampling methods to ensure a diverse group. The inclusion criteria included being actively engaged as a FA, having at least one year of experience, and being scheduled for at least 60 h of work in the past month. Exclusion criteria included retired flight attendants, those on long-term leave, and individuals who had surgery or a serious injury within the last six months. The survey was shared via social networks on Israeli flight attendant forums.

Data collection procedure

The survey link was shared electronically and completed anonymously on a secure platform. Participants first read and signed an informed consent page before completing the questionnaire (approximately 20 min). Data collection in 2024 followed the same procedures as in 2016; the earlier dataset had not been published.

Measures

Section A: Basic Demographics

This section collected data on participants’ age, seniority, flight hours per month, height, weight (used to calculate body mass index), current hours of leisure physical activity, and smoking status.

Section B: occupational Tasks

To identify the most physically demanding tasks that FAs face, six FAs participated in a focus group evaluation before the 2016 data collection. They were typically seasoned professionals with substantial experience in their roles. They were highly cooperative, willing to share their insights, actively engaged in discussions, and interested in improving work conditions and safety measures within their profession. The FAs were divided into three pairs, and each pair was given a list of 41 tasks that could be physically strenuous, based on a study by Lee et al.. ¹⁸ Each pair was asked to select 15 tasks they considered the most physically demanding. After all pairs completed the task selection, their results were compiled into a unified list containing the 10 tasks most frequently chosen by the three pairs.

The tasks included reaching and reorganizing bags in overhead bins, pushing to close overhead bins, handling full beverage carts while walking on an incline, pulling and moving carts to navigate the galley, shifting carts up and down stairs, loading food into ovens and retrieving it after cooking, carrying pitchers down the aisle during mealtime, operating aircraft doors, prolonged standing, and sleeping in the passenger seat in tourist class. Respondents were asked to select the five tasks they perceived as requiring the highest physical effort during their work.

Four additional questions were explicitly included for FAs in the 2024 data collection, focusing on satisfaction with the aircraft type, safety procedures, the company's handling of sexual harassment, and flight destinations.

Section C: Prevalence of Musculoskeletal Pain

The modified Nordic Questionnaire was used to assess the prevalence of WRMSP, aches, or discomfort lasting a day or longer in various body regions during the past 12 months, including the spine (neck, upper back, and lower back), upper limbs (shoulders, arms, elbows, wrists, and fingers), and lower limbs (hips, knees, and ankles). This questionnaire is recognized for reliability and validity ¹⁹ and has been validated for use in the Israeli population. ²⁰

Section D: Psychosocial Questionnaires

Workload, burnout, and job satisfaction were assessed using reliable and validated questionnaires.

For workload estimation, a six-item questionnaire was utilized, covering the aspects of workload level, work speed, working hours, workload intensity, perceived stress, and required effort. These items were rated on a 7-point Likert scale (1 = not at all; 7 = very much). ²¹

To assess burnout, the Shirom–Melamed Burnout Questionnaire, which consists of 10 items regarding feelings and attitudes, was used. Responses were rated on a 7-point Likert scale (1 = rarely; 7 = almost always).^22,23

Job satisfaction was evaluated using a 10-item questionnaire that covered the factors of responsibility, freedom to choose work methods, task variety, coworker relations, physical working conditions, utilization of abilities, salary, managerial recognition of good performance, and working hours. This scale was rated on a 7-point Likert scale (1 = very unsatisfied, 7 = very satisfied),.^24,25

Statistical analysis

Statistical analysis was performed to compare the demographic, occupational, and WRMSP characteristics of FAs between 2016 and 2024. Continuous variables, such as age, seniority, monthly working hours, and body mass index (BMI), were analyzed using independent samples T-tests to determine significant differences between the two groups. For categorical variables, including gender, hand dominance, physical exercise, smoking status, and pre-existing conditions, Chi-square tests were used to assess the differences between the two groups. Logistic regression analyses were conducted to predict the likelihood of experiencing WRMSP in different body regions over 12 months, considering physical and psychosocial factors as predictors. These models were adjusted for confounding variables, including age, BMI, years of work, and monthly working hours, and the results were presented as odds ratios. (Exp(B)) with 95% confidence intervals. Only statistically significant results (p < 0.05) were reported. Additionally, Chi-square analysis was used to compare the prevalence of pain in specific body regions between the two research groups. All statistical analyses were conducted using SPSS 23, and significance was set at p < 0.05.

Ethical considerations

The Ethical Committee of the Faculty of Health Sciences, Ben-Gurion University, Israel, approved the studies from 2016 and 2023 (28–2015 and 42–2023, respectively). All procedures were conducted in accordance with the ethical standards of the institutional committee, the 1964 Declaration of Helsinki, its subsequent amendments, and comparable ethical guidelines. All participants provided informed consent before participating in the study. Data were collected anonymously to protect confidentiality and privacy.

Results

183 FAs (94 from 2016 and 89 from 2024) were included in the study.

Table 1 compares the demographics and occupational continuous variables (seniority, monthly working hours, age, and BMI) of FAs between 2016 and 2024. Independent samples T-tests reveal significant differences in seniority (p < 0.001), monthly working hours (p = 0.007), age (p < 0.001), and BMI (p = 0.004) between the two years.

Table 1.

Demographics & occupational characteristics (continuous variables). Compare 2016 (n = 94) and 2024 (n = 89) Flight Attendants.

Variable	2016 (n = 94)	2016 Range	2024 (n = 89)	2024 Range	p-value
Seniority (years)	2.71 ± 2.26	0.5–14.0	6.52 ± 7.30	0.5–30.0	< 0.001
Monthly Working Hours	82.63 ± 10.70	50–150	88.23 ± 16.40	35–200	0.007
Age (years)	28.50 ± 6.59	21–58	43.07 ± 13.52	22–68	< 0.001
BMI	22.26 ± 2.69	10.73–29.74	23.66 ± 3.67	17.30–33.46	0.004

p-value analyzed by independent samples T-test

Table 2 presents categorical demographic and occupational variables for FAs between 2016 and 2024, shown as valid percentages. Chi-square tests indicate no significant differences between the two years.

Table 2

Demographics and occupational characteristics (categorical variables). Comparison between 2016 (n = 94) and 2024 (n = 89) Flight Attendants (Data presented as valid percentages).

Variable	2016 (%)	2024 (%)	p-value
Female	88.3	86.5	NS
Male	11.7	13.5
Right Dominance	87.2	91.0
Left Dominance	12.8	9.0
Physical Exercise	48.9	59.6
Smoking Today	24.5	22.5
Smoked in the Past	12.8	6.7
Pre-existing Conditions	17.0	20.2

p-value analyzed by Chi-square. “NS” indicates not significant (p ≥ .05).

Figure 1 illustrates the prevalence of pain in various body regions among FAs in 2016 and 2024. Chi-square analysis shows statistically significant differences in arm (p = 0.002) and hand pain (p = 0.009), with a higher prevalence in the 2016 group.

Figure 1.

Comparison of 12-month pain prevalence in different body regions among flight attendants from 2016 vs 2024, analysed by Chi-Square.

Table 3 presents logistic regression analysis results to predict WRMSP over 12 months across different body regions, using demographics, physical, and psychosocial variables as predictors, adjusted for age, BMI, working years, and monthly working hours.

Table 3.

Logistic regression results predicting 12 months of musculoskeletal pain by demographics, physical, and psychosocial variables: Comparison of 2016 vs 2024 samples.

Body Region	Predictor	β	p	Exp(B)	95% CI	Model Fit
Neck	Years of Work	0.076	.026	1.079	1.009–1.154	R² = 0.09–0.24; χ² = 11.11–33.15
	Age	−0.038	.011	0.962	0.934–0.991
	Comparison (Stress)	0.897	.050	2.452	1.000–6.009
	Comparison (Attitudes)	0.931	.043	2.538	1.029–6.259
	Comparison (Satisfaction)	1.008	.049	2.741	1.003–7.490
Hands	Age	−0.031	.037	0.969	0.941–0.998	R² = 0.10–0.21; χ² = 13.20–30.05
	Too Much Workload	0.545	.005	1.725	1.180–2.522
	Maximum Authority (Attitudes)	−0.544	.007	0.580	0.391–0.861
	Load Food in Oven (Tasks)	1.086	.037	2.963	1.067–8.224
Fingers	Too Much Effort (Stress)	1.192	<.001	3.294	1.778–6.104	R² = 0.24; χ² = 21.49
Arms	Comparison (Stress)	−1.465	.011	0.231	0.074–0.717	R² = 0.18–0.30; χ² = 22.04–39.19
	Comparison (Attitudes)	−1.743	.006	0.175	0.051–0.604
	Comparison (Satisfaction)	−1.310	.027	0.270	0.084–0.862
	Comparison (Tasks)	−1.759	.003	0.172	0.053–0.555
Upper Back	Age	−0.048	.009	0.953	0.919–0.988	R² = 0.15–0.21; χ² = 18.60–27.78
	BMI	0.155	.006	1.168	1.046–1.305
	Not Enough Time (Stress)	0.357	.049	1.430	1.002–2.040
Shoulders	Dissatisfied with Responsibility (Satisfaction)	0.533	.004	1.703	1.188–2.442	R² = 0.25; χ² = 35.41
Elbows	Freedom to Choose (Satisfaction)	−0.605	.019	0.546	0.330–0.904	R² = 0.18–0.22; χ² = 16.28–20.21
	Prolonged Standing (Tasks)	1.303	.039	3.679	1.068–12.676
Lower Back	Determining the Work Rate (Attitudes)	0.523	.031	1.687	1.050–2.713	R² = 0.24–0.36; χ² = 23.52–35.02
	Comparison (Satisfaction)	−1.129	.042	0.323	0.109–0.960
	Physical Conditions (Satisfaction)	−0.458	.016	0.633	0.435–0.919
	Recognition (Satisfaction)	0.396	.012	1.485	1.091–2.022
	Flight Destinations (Assignments)	0.616	.048	1.852	1.005–3.413

• Exp(B): Odds ratio.

• 95% CI: Confidence interval for the odds ratio.

• R² references Nagelkerke's pseudo-R² from each block.

• χ² references the model chi-square.

• Only p < .05 results are shown.

• “Comparison” (between the study groups) refers to differences between 2016 vs. 2024 flight attendants. Model fit (R², χ²) is summarized as ranges.

For the neck, longer years of work increased the odds of pain (OR = 1.08, 95% CI 1.01–1.15), while older age reduced the odds (OR = 0.96, 95% CI 0.93–0.99). Compared with 2016, the 2024 sample showed higher odds of neck pain associated with stress (OR = 2.45, 95% CI 1.00–6.01), attitudes (OR = 2.54, 95% CI 1.03–6.26), and satisfaction (OR = 2.74, 95% CI 1.00–7.49).

For the hands, older age reduced risk (OR = 0.97, 95% CI 0.94–0.998). High workload increased the odds (OR = 1.73, 95% CI 1.18–2.52), while having maximum authority (attitudes) was protective (OR = 0.58, 95% CI 0.39–0.86). Performing the task of loading food into ovens markedly increased risk (OR = 2.96, 95% CI 1.07–8.22).

For the fingers, reporting “too much effort” (stress) strongly predicted pain (OR = 3.29, 95% CI 1.78–6.10).

For the arms, the 2024 cohort showed significantly lower odds of pain compared with 2016, with protective effects observed for stress (OR = 0.23, 95% CI 0.07–0.72), attitudes (OR = 0.18, 95% CI 0.05–0.60), satisfaction (OR = 0.27, 95% CI 0.08–0.86), and tasks (OR = 0.17, 95% CI 0.05–0.56).

For the upper back, older age was protective (OR = 0.95, 95% CI 0.92–0.99), while higher BMI (OR = 1.17, 95% CI 1.05–1.31) and stress related to insufficient time (OR = 1.43, 95% CI 1.00–2.04) increased the odds.

For the shoulders, dissatisfaction with responsibility was a significant risk factor (OR = 1.70, 95% CI 1.19–2.44).

For the elbows, freedom to choose (satisfaction) reduced the odds of pain (OR = 0.55, 95% CI 0.33–0.90), while prolonged standing increased it (OR = 3.68, 95% CI 1.07–12.68).

For the lower back, determining one's own work rate increased the odds (OR = 1.69, 95% CI 1.05–2.71), while satisfaction-related comparisons between 2016 and 2024 showed significantly lower odds in 2024 (OR = 0.32, 95% CI 0.11–0.96). Poor physical conditions (satisfaction) were also protective (OR = 0.63, 95% CI 0.44–0.92). By contrast, lack of recognition increased the odds (OR = 1.49, 95% CI 1.09–2.02), as did flight destinations (assignments) (OR = 1.85, 95% CI 1.01–3.41).

Across all body regions, explained variance (Nagelkerke R²) ranged from 0.09 to 0.36, with chi-square tests indicating significant improvements in model fit.

Discussion

This study examines the prevalence, anatomical distribution, and predictors of WRMSP among flight attendants, highlighting the interaction of demographic, physical, and psychosocial factors. By comparing cohorts from 2016 (baseline) and 2024 (current operations) measured with identical tools, we identify both changes over time and consistent features that inform occupational health strategies.

Comparing 2016 and 2024 reveals time-sensitive patterns: a decrease in upper-limb pain (hand/arm) in 2024, which is consistent with the implementation of updated equipment and workflows, alongside persistent high levels of neck and lower-back pain that remain key targets for prevention. Psychosocial profiles also differ between the two periods; stress and time pressure continue to be significant factors, indicating that evolving procedures and duty mixes may shift biomechanical loads without entirely reducing spinal strain. These findings go beyond single-timepoint surveillance and outline long-term, system-level changes that support mechanism-based, targeted prevention.

Prevalence and risk factors for lower back pain

Our study found that the one-year prevalence of LBP among FAs in 2016 and 2024 was substantially higher (72%) than in the general population (38%). ²⁶ This disparity likely results from the unique occupational demands on FAs, including prolonged standing, lifting heavy objects, and exposure to turbulence. The nature of these physical tasks places significant strain on the lumbar region, contributing to higher LBP rates than other occupations.

Interestingly, psychosocial factors such as job satisfaction and stress were also found to be associated with LBP. According to typical findings where low job satisfaction correlates with higher musculoskeletal disorders, ²⁷ our study showed that satisfaction-related comparisons indicated significantly lower odds of reporting lower back pain in 2024 compared with 2016. This reduction may suggest that changes occurring between 2016 and 2024, such as fleet upgrades, redesigned galleys, lighter service trolleys, and updated duty-time regulations, contributed to lowering physical workload and improving satisfaction with certain job aspects, thereby mitigating lower back strain. At the same time, other risk factors (e.g., lack of recognition, specific assignments) continued to elevate risk, highlighting that the improvement was not uniform across all domains.

Upper back pain and workload stressors

Our findings suggest that upper back pain among FAs is closely associated with job-related stress, including insufficient time to complete tasks. This aligns with prior research indicating that high job demands, low job control, and monotonous work significantly increase the risk of musculoskeletal symptoms, particularly in the upper back^28,29 Stress-induced mechanisms, including the release of cortisol and adrenaline, cause muscle tension in the upper back, which reduces blood flow and amplifies pain sensitivity. This “dysfunctional mechanism” hypothesis explains how stress can amplify pain by disrupting sensory processing and altering physical behaviors, such as maintaining poor posture or prolonged muscle tension. ³⁰

Given these findings, addressing work-related stress through interventions such as workload management and improving job control may reduce upper back pain in FAs. Ergonomic interventions to reduce muscle strain during stressful tasks could further alleviate this issue.

Neck and shoulder pain: The role of age and experience

The study revealed an inverse relationship between age and the prevalence of neck and shoulder pain, with younger FAs reporting more pain than their older counterparts. This could be explained by the “healthy worker effect,” where those more susceptible to WRMSP are more likely to leave the profession over time, leaving a workforce composed of those who have adopted or are less prone to musculoskeletal disorders.^31,32 Additionally, younger and less experienced FAs may face higher stress during their adjustment period, leading to increased musculoskeletal strain due to unfamiliarity with energy-efficient task performance.

Interventions focusing on ergonomic training and stress management, particularly for newer FAs, could help mitigate this risk. Implementing training programs that teach energy-efficient work practices may help reduce neck and shoulder pain in this cohort.

Upper limb pain: Trends and task-related strain

The study found a notably high prevalence of hand and arm pain in 2016 (53% for hand pain and 33.3% for arm pain), with a marked decline in 2024 (33.7% for hand pain and 13.3% for arm pain). This improvement may be attributed to changes in work methods, equipment, or the introduction of new aircraft. Modifications in passenger service protocols, such as reduced beverage service frequency, may have also contributed to a decrease in physical strain on FAs’ upper extremities.

Moreover, longer periods of standing were associated with increased elbow pain, consistent with the literature linking repetitive movements and awkward postures to conditions such as lateral epicondylitis. ³³ These findings suggest that ergonomic improvements, such as adjusting task loads and minimizing repetitive strain, could reduce WRMSD in the upper extremities.

Psychosocial factors: Job control, satisfaction, and pain

Psychosocial elements, such as job dissatisfaction, lack of decision-making autonomy, and high-stress levels, were significantly associated with WRMSP in 2016; however, these associations were less pronounced in 2024. This shift may reflect changes in workplace culture or management strategies that have improved job satisfaction and autonomy over the years, reducing the influence of psychosocial factors on pain outcomes.

Research consistently shows that psychosocial factors, including job dissatisfaction, lack of autonomy, and high stress, are key contributors to musculoskeletal pain. Specifically, dissatisfaction with job responsibilities and limited decision-making control are strongly associated with increased pain, particularly in the shoulders and upper limbs. For instance, one study found that low job satisfaction mediates the relationship between work stress and both mental health issues and physical symptoms, including WRMSD. ³⁴

In our study, dissatisfaction with responsibility levels was associated with increased shoulder pain, while limited freedom to choose work methods contributed to more elbow pain. These findings underscore the importance of fostering a supportive work environment that enables flight attendants to have greater autonomy over their tasks and responsibilities. Giving greater autonomy and job satisfaction can decrease upper extremity pain and enhance overall well-being. ²⁸

Impact of technological advancements on WRMSP

Recent advances in aircraft design and regulatory frameworks have reshaped the ergonomic environment of flight attendants. Cabin redesigns incorporating enlarged overhead bins, optimized galley layouts, and lighter service trolleys have been proposed to reduce manual handling demands and improve workflow efficiency. ¹⁶ At the same time, revised flight time limitation rules have been shown to influence fatigue and workload management, with implications for musculoskeletal health. ¹⁷ Together, these technological and organizational developments may partly explain observed differences in WRMSP across time.

One possible explanation for the reported decline in upper limb pain between 2016 and 2024 is the adoption of newer aircraft technologies and ergonomic equipment. Over the past decade, many airlines have introduced lightweight galley carts, overhead bins with assisted opening and closing mechanisms, and more streamlined cabin layouts, all aimed at reducing repetitive, forceful exertions. Additionally, some carriers have updated their service protocols to minimize pushing or pulling heavily loaded carts. Although the data do not directly measure these innovations, the observed decrease in upper-limb musculoskeletal complaints, which coincides with industry-wide technological upgrades, suggests that modernized equipment and revised procedures may help decrease repetitive strain injuries. Future research could strengthen this link by collecting direct observational evidence (e.g., comparing older versus newer aircraft) to better understand how ergonomic developments impact WRMSP.

Despite advances in equipment design, from lighter galley carts to improved overhead bins, long-term research linking these enhancements to a measurable decrease in WRMSD risks among FA remains limited. Much of the current literature continues to focus on pinpointing high-risk tasks and baseline WRMSD prevalence rather than assessing the long-term effects of ergonomic innovations. Therefore, while recent technological and procedural changes appear promising, the field lacks comprehensive, real-world studies that definitively show whether these improvements lead to sustained occupational health benefits for cabin crews.

The present study provides important insights across four key objectives. First, by comparing flight attendants surveyed in 2016 and 2024, we identified significant changes in demographic and occupational characteristics, including age, seniority, and working hours, reflecting broader shifts in workforce dynamics over time. Second, we observed a notably high prevalence of WRMSP at both time points, with the neck, lower back, and shoulders remaining the most affected anatomical regions, suggesting ongoing ergonomic strain. Third, distinct physical and psychosocial predictors of WRMSP were identified for each cohort, with increased workload, perceived stress, and low job satisfaction emerging as consistent contributors. Ultimately, these findings highlight the pressing need to tailor ergonomic interventions and health promotion strategies to the evolving demands of the aviation industry, ensuring they address both physical and organizational risk factors pertinent to various time periods.

Study limitations

While this study offers valuable insights into WRMSP among FAs, several limitations should be acknowledged: (1) Cross-Sectional Design: The study's cross-sectional approach limits our ability to determine causal relationships between identified risk factors and WRMSP. (2) Self-Reported Data: Dependence on self-reported questionnaires may introduce recall or response bias, as participants might have overestimated or underestimated the severity of their symptoms and work-related risk factors. (3) Limited Generalizability: The sample was restricted to FAs from specific airlines, which may not reflect the broader FA population worldwide. Differences in airline policies, flight routes, and work environments could affect the applicability of the findings. (4) Small Sample Size for Certain Analyses: Some subgroup analyses, especially those focusing on specific body regions or less common risk factors, may have been underpowered due to limited sample sizes. (5) Effect of the 2024 Security Emergency: Data for the 2024 wave were collected during a period of missile attacks and sirens, but threat exposure was not quantified. Psychosocial risks such as fear and urgency may have impacted pain reports, making it impossible to isolate the emergency's influence or generalize the results to airlines outside conflict zones.

Conclusion and recommendations

This study demonstrates that both physical and psychosocial factors significantly shape WRMSP among flight attendants. The decline in arm and hand pain in 2024 suggests that technological and organizational changes, such as fleet upgrades and modified workflows, may have eased some upper limb demands. In contrast, logistic regression showed that neck pain risks increased with psychosocial stressors, while satisfaction factors offered only partial protection against lower back pain. These findings highlight persistent challenges. The findings emphasize the need for targeted ergonomic and organizational interventions addressing workload, recognition, task design, and psychosocial pressures to complement technological improvements and ensure long-term musculoskeletal health in this safety-critical workforce.

Future studies should examine longitudinal cohorts to confirm whether technological and organizational changes translate into sustained reductions in WRMSP. Cross-national comparisons could clarify the role of different fleet configurations, routes, and duty-time regulations. In addition, intervention studies targeting psychosocial exposures, such as workload, recognition, and job satisfaction, are needed to complement ergonomic improvements and to address persistent risks for neck and lower back pain.