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  Table of Contents    
Year : 2013  |  Volume : 15  |  Issue : 62  |  Page : 6-11
Environmental noise and sleep disturbance: Research in central, eastern and south-eastern Europe and newly independent states

1 Institute of Public Health, Department for Environmental Health, Skopje, 50 Divizija 6, 1000 Skopje, The Former Yugoslav Republic of Macedonia
2 European Commission's Joint Research Centre, Institute for Health and Consumer Protection, Chemical Assessment and Testing Unit, TP 281, Via E. Fermi, 2749, I-21027 Ispra (VA), Italy

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Date of Web Publication14-Feb-2013

Countries from South-East Europe (SEE), Central and Eastern Europe (CEE) and Newly Independent States (NIS) are in the process of harmonization with European environmental noise legislation. However, research work on noise and health was performed in some countries independently of harmonization process of adoption and implementation of legislation for environmental noise. Aim of this review is to summarize available evidence for noise induced sleep disturbance in population of CEE, SEE and NIS countries and to give directions for further research work in this field. After a systematic search through accessible electronic databases, conference proceedings, PhD thesis, national reports and scientific journals in English and non-English language, we decided to include six papers and one PhD thesis in this review: One paper from former Yugoslavia, one paper from Slovakia, one paper from Lithuania, two papers from Serbia and one paper, as also one PhD thesis from The Former Yugoslav Republic of Macedonia. Noise exposure assessment focused on road traffic noise was mainly performed with objective noise measurements, but also with noise mapping in case of Lithuanian study. Sleep disturbance was assessed with the questionnaire based surveys and was assumed from dose-effect relationship between night-time noise indicator (Lnight ) for road traffic noise and sleep disturbance (for Lithuanian study). Although research evidence on noise and sleep disturbance show to be sufficient for establishing dose response curves for sleep disturbance in countries where studies were performed, further research is needed with particular attention to vulnerable groups, other noise sources, development of laboratory research work and common methodology in assessment of burden of diseases from environmental noise.

Keywords: Environmental noise, noise sensitivity, road traffic noise, sleep disturbance

How to cite this article:
Ristovska G, Lekaviciute J. Environmental noise and sleep disturbance: Research in central, eastern and south-eastern Europe and newly independent states. Noise Health 2013;15:6-11

How to cite this URL:
Ristovska G, Lekaviciute J. Environmental noise and sleep disturbance: Research in central, eastern and south-eastern Europe and newly independent states. Noise Health [serial online] 2013 [cited 2022 Nov 30];15:6-11. Available from: https://www.noiseandhealth.org/text.asp?2013/15/62/6/107147

  Introduction Top

Urbanization, economic growth and motorized transport are some of the driving forces for increased environmental noise exposure and related health-effects. Conservative estimates, applied to the calculation using exposure-data from noise maps, give a total of 903,000 disability-adjusted life years lost from noise induced sleep disturbance for the European Union (EU) population living in towns of >250,000 inhabitants. [1] At present we have sufficient data for noise exposure of population in agglomerations with more than 250,000 inhabitants, delivered in accordance with the environmental noise directive (END) and available through the Noise Observation and Information Service for Europe. [2] Approximately 40% of the population living in the largest cities in the EU-27 may be exposed to long-term average road traffic noise levels exceeding 55 dB (A), and at night, almost 34 million people may be exposed to long-term average road noise levels exceeding 50 dB (A). [3],[4] The World Health Organization (WHO) night noise guidelines for Europe recommend that people should not be exposed to night noise level greater than 40 dB. Night time noise levels of 55 dB, described as "increasingly dangerous to public health", should be considered as an interim target in situations where the achievement of the guidelines is not yet feasible. [5]

When sleep is permanently disturbed and becomes a sleep disorder, it is classified in the International Classification of Sleep Disorders 2005 [6] as "environmental sleep disorder" and is listed in the category of "other sleep disorders." The diagnostic criteria for environmental sleep disorder are associated with the introduction of a physically measurable stimulus or environmental circumstance that disturbs sleep with physical properties, rather than the psychological meaning of the environmental factor, that accounts for the complaint. [7] The noise-induced sleep disturbance is not associated with another sleep disorder, medical or neurological disorder, mental disorder, medication use or substance use disorder. The prevalence of environmental sleep disorder is not known, but fewer than 5% of patients seen at sleep disorder centers receive this diagnosis. The disorder may occur at any age, although the elderly are at higher risk for developing this condition. [6]

Systematic review of evidence produced by epidemiological and experimental studies has developed the relationship between night noise exposure and health effects. [8] Below the level of 30 dB Lnight , no effects on sleep were observed except for a slight increase in the frequency of body movements during sleep due to night noise. [9] There is no sufficient evidence that the biological effects observed at the level below 40 dB (A) Lnight are harmful to health. [5] However, adverse health effects are observed at the levels above 40 dB (A) Lnight , such as self -reported sleep disturbance, environmental insomnia, and increased use of drugs and sedatives. Above 55 dB (A) the cardiovascular effects become the major public health concern, which are likely to be less dependent on the nature of the noise. [5] Lnight , is the night-time indicator for noise exposure, the A-weighted long-term average sound level, as defined in ISO 1996 - 2: 1987. It is determined over-all night periods of a year in which the night is 8 h (usually 23.00-07.00 local time). This indicator was already adopted and implemented in EU member states, as required by END. [10]

Countries from Central Europe (Czech Republic, Hungary, Poland, Slovakia, Slovenia) and some of the Eastern Europe and Newly Independent States (NIS) (Romania, Bulgaria, Lithuania, Latvia, Estonia) are members of EU, and they have already adopted European legislation for environmental noise, assessment of noise exposure indicators and indicators for noise effects to health and wellbeing. Most of the countries from South-East Europe (Albania, Bulgaria, Bosnia and Herzegovina, Croatia, The Former Yugoslav Republic of Macedonia, Montenegro, Serbia) and Newly Independent States (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russian federation, Tajikistan, Turkmenistan Ukraine, Uzbekistan) are in the process of harmonization with environmental noise legislation, but research work on noise and health was performed in some countries independently of this process of adoption and implementation for environmental noise. [11]

The aim of this review is to summarize available evidence focused on noise induced sleep disturbance in population of Central and Eastern Europe (CEE), South-East Europe (SEE) and NIS countries and to prospose directions for further research work in this field.

  Methods Top

For this review, we made literature search of all accessible medical and other databases (PubMed, Embase, Scopus, BioMed Central, Web of Science, Toxline, Scientia, Science Direct, etc.) using terms: Environmental noise, community noise, road traffic noise, transportation noise, noise sources, adults, sleep disturbance, as key words and country denomination. Authors reviewed scientific journals, conference proceedings, PhD thesis and local reports published in national languages as well. Inclusion criteria for review were research studies performed for the period from 1970 to 2011, focused on environmental noise and sleep disturbances in adult population. We found eleven titles, which were associated with the search methodology, but after reading of available abstracts we selected only six papers and one PhD thesis that met criteria for this critical review. The studies are listed in chronological order with following characteristics: The location (town and country where the study was carried out), the reference (first author, journal and year of publication), aim and the type of the study, the study subjects, sample size, exposure assessment/noise exposure indicator, outcome, confounding factors and findings. The table template was compiled in line with previous reviews on noise and health. [12]

  Results and Discussion Top

In this review, one paper from former Yugoslavia, [13] two papers from Serbia, [14],[15] one from Slovakia, [16] one paper, [17] and one PhD thesis [18] from The Former Yugoslav Republic of Macedonia and one paper from Lithuania [19] are included aiming to identify the level of sleep disturbance caused by environmental noise in urban adult population considering confounding factors for development of this effect. Results are presented in [Table 1].
Table 1: Evidence for sleep disturbance due to environmental noise exposure from studies selected for review

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Noise exposure assessment

In five studies in this review, we found that authors from former Yugoslavia, [13] Serbia, [14],[15] Slovakia [16] and The Former Yugoslav Republic of Macedonia [17] used objective noise exposure assessment with noise measurements on the residential site of the participants. Exposure indicator for night time noise was expressed as energy equivalent noise level for 24 hours (Leq24h ) and (Lnight ) [13],[14],[16] or maximum sound level (Lmax ). [15] In the study from former Yugoslavia [13] the equivalent continuous sound pressure levels (Leq ), and percentile sound pressure levels L1 and L99, were measured in three daily periods (9:00-10:30, 14:00-15:30, 18:00-19:30) and two nightly intervals (0:00-1:30 and 3:30-5:0). [13]

Lithuania, as a Member State of EU, has already prepared noise maps for the biggest cities and began to use them for health effect's assessment. Maciunas and Uscila used data from road traffic strategic noise maps of Vilnius and Kaunas city municipalities, looking for the number of people exposed to day, evening, night noise level indicator day-evening-night noise level (Lden ) and night-time noise level indicator Lnight . The strategic noise mapping results showed that 21% of Vilnius city population is exposed to Lnight that exceeds limit values of night-noise, and in Kaunas 16% of population is exposed to road traffic noise, exceeding limit values of Lnight . [19]

We found sufficient data for noise exposure assessment in Czech Republic, performed with objective measurements and noise mapping, and data for sleep disturbance assessed with a questionnaire based survey, published in summary reports for environmental health monitoring. [20] Strategic noise maps are available in Slovenia for the capital city of Ljubljana, but no epidemiological studies regarding noise effects on sleep disturbance were performed, until now. [2]

All studies included in this review were oriented to road traffic noise exposure, probably because of awareness in these countries that this source is the most disturbing in their environment. It seems that other sources were therefore underestimated in the research work.

Sleep disturbance

This review has shown that few studies were conducted for assessing sleep disturbance in several countries like former Yugoslavia, Serbia, The Former Yugoslav Republic of Macedonia, Slovakia and Lithuania in bigger agglomerations (Skopje, Nis, Belgrade, Bratislava, Kaunas and Vilnius), where noise was recognized as an environmental hazard for public health. Studies were designed as field research for subjective evaluation of sleep disturbance using questionnaires, developed according to international standards or scales. [21],[22] Two methodological approaches can be used in studies on noise and sleep disturbances: Laboratory experiments and field research. [23],[24] The advantage of field research is a possibility to identify sleep disturbance of exposed population in an everyday-life setting taking into account and habituation to noise. [24],[25] The main disadvantages of this method are that noise is commonly measured outdoors only, making it difficult to assess the sound pressure level of the noise to which the residents were actually exposed and the fact that noise -induced sleep disturbances are subjectively evaluated. [26] Laboratory experiments allow both the strict control of sound pressure level of a stimulus and the objective evaluation of noise-induced sleep disturbances by electroencephalography and polysomnography. [23]

Important factor influencing the effects of noise could be the habituation. Although some investigators claim that there is no habituation of sleep to road traffic noise, recent studies have provided some evidence that it exists. [9],[24] Some habituation to ambient noise occurs during sleep, and if the exposure is moderate, it is not infrequent to see progressive decrease or even disappearance of subjective annoyance after a few days or weeks. However, this habituation is not complete and the vegetative reactions observed during the sleep in response to the noises (more specifically the cardiovascular responses) are maintained over very long exposure periods. The lack of habituation in the cardiovascular domain during sleep may give a false idea to the sleeper who may feel that exposure to noise is not a problem anymore after being accustomed to it. [27]

Subjective noise sensitivity, defined as "a factor involving underlying attitudes towards noise in general," has been denoted as an important moderating factor for the psychological effects of noise. People sensitive to noise react to noise at a higher arousal level which may produce long-term health effects. Belojevic et al., confirmed the importance of subjective noise sensitivity for sleep disorders induced by environmental noise. [13] Consistency of their results with results from similarly designed studies indicated that noise sensitivity could be a strong predictor for the psychological and sleep disturbances induced by environmental noise. [23],[27]

Study from former Yugoslavia [13] performed in Belgrade confirmed scientific evidence based fact that living in "black acoustic zones" (Leq > 65 dB (A)) put an urban population in a high-risk category for numerous subjective effects of noise, including sleep disorders. Results of the sleep questionnaire showed that the population in the noisy streets had more difficulties in falling asleep, more night awakenings were identified, worse subjective sleep quality, and more pronounced tiredness after sleep, compared to the population from the control zone. Performed correlation analysis revealed a strong link between neuroticism, subjective noise sensitivity, psychological disturbances and noise induced sleep disturbance.

The same author's group continued with research on noise induced effects and they (Jakovljevic et al., 2006) found in their study in Belgrade that 48.7% of the respondents from noisy area (Leq > 65 dB (A)) had noise induced sleep disturbance, opposed to only 12.9% of respondents from quiet area, Leq < 55 dB (A) (χ2 = 12.014; P = 0.001). Noise was the most important cause of awakenings for 44.4% of respondents from noisy area, compared with 6.1% respondents from quiet area (χ2 = 22.57; P < 0.001). [14] Participants in this study reported traffic noise as the most disturbing source, but they lived in apartments along streets with heavy traffic.

Important findings from studies performed in former Yugoslavia, and Serbia are personality traits like noise sensitivity, neuroticism, and extroversion and their influence on sleep disturbance. [13],[14],[15] These findings have shown that personal characteristics should be included in investigation of noise induced sleep disturbance and other health effects. These factors were identified as an important predictor for the occurrence of difficulties with falling asleep ( P = 0.010), difficulties with falling back to sleep ( P = 0.041), being woken up at night by noise ( P < 0.001) and sleeping by closed windows ( P < 0.001). Living in the noisy area, exposed to Lnight above 45 dB (A) increased the risk of complaints of poor sleep quality ( P = 0.027) and tiredness after sleep ( P = 0.027). [15] Self evaluated participants with higher noise sensitivity and higher level of neuroticism had significantly poorer sleep quality. [28]

Study conducted in The Former Yugoslav Republic of Macedonia has shown that 26% of whole sample had sleep disturbance, and dominant sources were neighborhood noise and road traffic noise. [17],[18] The findings have shown similarity with the findings of LARES study. [22] Summary results from the LARES study, organized by WHO and conducted in eight European countries, has shown that 23% of whole sample had sleep disturbance, and dominant noise source were traffic noise (including road traffic, railway and aircraft noise) and neighborhood noise. [22] Questionnaire based survey conducted in 19 cities in Czech Republic showed that 37% of respondents have noise induced sleep disturbance. Awakening from sleep was a more frequent mechanism of sleep disturbance than problems with falling asleep. In the noisiest localities where the noise marker L den threshold 70 dBA was exceeded, 66% of respondents reported sleep disturbance. [20]

In the noisiest localities where subjects were exposed to Lden > 70 dB (A), 66% of respondents reported sleep disturbance. [20] Surveys conducted in 1998 and 2003 in Netherlands have shown that at 18% residents in 1998 and 25% in 2003 sleep disturbance was identified. The main sources for noise induced sleep disturbance were road traffic noise, neighborhood noise and aircraft noise. [29] In Valencia, about 49% of adults complained of night awakenings by traffic noise in the 1990s. Residents of Gothenburg, who lived near a highway, with 24 h Leq of 72 dB (A) reported worse sleep quality and more pronounced tiredness after sleep than people from a quiet area exposed to 24 h Leq = 56 dB (A). [14],[25],[26],[30] This is another confirmation that investigation or field study should be performed for assessment of sleep disturbance in exposed population for several reasons. Case by case research is the most appropriate way to identify the noise sources to take into account specific environmental conditions and non-acoustical factors in the community response to noise. [24]

Sleep disturbance was evaluated using the dose-effect relationships: The relation between Lnight for road traffic noise and sleep disturbance by Maciunas and Uscila. [19] Percentage of people experiencing sleep disturbance caused by road traffic noise at night, in Vilnius and Kaunas were similar. According to the strategic noise mapping results, in Vilnius city, 7% of population at night suffered from high level of sleep disturbance, 5.9% suffered from moderate sleep disturbance, and 11.2% from light sleep disturbance. In Kaunas 2.6% of population at night suffered from high sleep disturbance, 5.9% from moderate sleep disturbance, and 11.5% from light sleep disturbance. Dose response curves for environmental noise and sleep disturbance are based on analysis of the 15 datasets with more than 12,000 individual observations of exposure response combinations from 12 studies. Self-reported noise induced sleep disturbance has curvelinear relation with age, with highest reaction found at 51 years. Different curves are available for no other influencing factors, taking into account bedroom orientation and bedroom insulation. [24] Study of Maciunas and Uscila has proven data applicability from strategic maps, and dose response curves in assessment of sleep disturbance and further planning and implementation of preventive measures. [19]

  Conclusions Top

Research work on noise and sleep disturbance is sufficient for obtaining evidence for noise effects in countries, like former Yugoslavia, Serbia, The Former Yugoslav Republic of Macedonia, Slovakia, Czech Republic and Lithuania where it was performed. At the same time, findings from these studies give strong support for policy-making and implementation of noise legislation in order to protect human health. Sleep disturbance could be assessed using already derived dose response curves according to noise source and night time noise exposure data, but we still need field research on sleep disturbance. This kind of questionnaire based surveys could provide reliable data that cannot be derived from the models. Maybe we will discover new sources of noise as predominant in the environment, like neighborhood noise or construction activities, which are usual reasons for complaints in this region. Laboratory research on sleep disturbance using objective methods could be developed in these countries through the collaboration with already developed centers for experimental research. Research on sleep disturbance in countries from Central, Eastern Europe, South East Europe and Newly Independent States should be stimulated and developed by national responsible bodies or international organizations, like initiative from WHO Europe and European Commission's Joint Research Centre (EC, JRC) for developing methodology for assessment of burden of diseases from environmental noise.

  Acknowledgment Top

The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement No 226442.

  References Top

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Correspondence Address:
Gordana Ristovska
Department for Environmental Health, Institute of Public Health, Skopje, 50 Divizija 6, 1000 Skopje
The Former Yugoslav Republic of Macedonia
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Source of Support: European Union’s Seventh Framework Programme (FP7/2007-2013) under grant agreement No 226442.,, Conflict of Interest: None

DOI: 10.4103/1463-1741.107147

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