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Work organization, stress, the Work organization, stress, the changing nature of work, and changing nature of work, and cardiovascular disease cardiovascular disease Paul Landsbergis, PhD, MPH paul.landsbergis@mssm.edu Department of
paul.landsbergis@mssm.edu Department of Community and Preventive Medicine Mount Sinai School of Medicine, New York, NY Partnership for Heart Healthy Stroke Free Massachusetts Worcester, MA June 2, 2006
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40 26 29 10 20 30 40 50 % Northwestern National Life 1992 Families and Work Institute 1997 Yale University 1997
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Work schedules
Long work hours Rotating, night shifts
Job characteristics
High job demands-low job control (“job strain”) High effort-low reward jobs Low social support Threat-avoidant vigilant work Piece-rate work
Workplace climate
Threat of violence Discrimination, harassment, bullying Lack of work-family programs Job insecurity
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HOURS WORKED PER YEAR
1500 1600 1700 1800 1900 2000 2100 2200
1980 1990 1995 2000 Source: International Labour Organization, 2001 Sweden France Spain Japan USA
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5 10 15 20 25 30 35 40
1973 1979 1989 1995 2000 2001
$/hr
Mishel L, Bernstein J, Boushey H. The State of Working America 2002/2003. p. 130, Table 2.7.
Changes in real wages, male workers, by wage percentile, 1973-2001 (2001 dollars)
10th %ile 30th %ile 50th %ile 70th %ile 90th %ile
Family income inequality, Gini coefficient,1947-00
0.33 0.35 0.37 0.39 0.41 0.43 1947 1950 1953 1956 1959 1962 1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001
*After 1993 the coefficients reflect a change in survey methodology leading to greater inequality. Source: U.S. Bureau of the Census. Gini* Trend in Gini
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“Time constraints” are similar to job pressures or job demands, and include deadlines and work speed. Time constraints and autonomy at work in the European Union. Dublin: European Foundation for the Improvement of Living and Working Conditions, 1997.
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40% 50% 60% 70%
1990 1995 2000
% reporting "yes" Tight Deadlines Very High Speed
Pascal Paoli, Damien Merllié. Third European Survey on Working Conditions. European Foundation for the Improvement of Living and Working Conditions, 2001.
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60% 65% 70% 75%
1990 1995 2000
% reporting "yes" Work Methods Speed Task Order Break When Desired
Pascal Paoli, Damien Merllié. Third European Survey on Working Conditions. European Foundation for the Improvement of Living and Working Conditions, 2001.
Control over:
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40% 50% 60% 70% 80% 90%
1977 QES 1997 NSCW
% reporting "agree" Work Very Hard Work Very Fast Not Enough Time
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Cardiovascular disease (including hypertension)
Musculoskeletal disorders Psychological disorders Health behaviors Sleeping problems Injuries
Immune system Reproductive health
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Combination of Combination of HIGH HIGH Psychological Job Demands Psychological Job Demands + + LOW LOW Job Job Decision Latitude (decision Decision Latitude (decision-
making authority and skill use)
Job Demands Decision Latitude Job Strain
Karasek R, Theorell T. Healthy work. New York: Basic Books, 1990.
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Definition: Job Strain is the combination of Definition: Job Strain is the combination of HIGH HIGH Job Job Demands Demands and and LOW LOW Job Decision Latitude Job Decision Latitude Job Demands Job Demands 1. 1. My job requires working very fast My job requires working very fast 2. 2. My job requires working very hard My job requires working very hard 3. 3. I am not asked to do an excessive amount of work I am not asked to do an excessive amount of work * * 4. 4. I have enough time to get the job done I have enough time to get the job done * * 5. 5. I am free from conflicting demands others make I am free from conflicting demands others make * *
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Job Decision Latitude Job Decision Latitude Skill development Skill development 1. 1. My job requires that I learn new things My job requires that I learn new things 2. 2. My job requires me to be creative My job requires me to be creative 3. 3. My job requires a high level of skill My job requires a high level of skill 4. 4. I get to do a variety of things on my job I get to do a variety of things on my job 5. 5. I have an opportunity to develop my own special abilities I have an opportunity to develop my own special abilities 6. 6. My job involves a lot of repetitive work (reverse coded) My job involves a lot of repetitive work (reverse coded) Decision Decision-
making authority 7. 7. My job allows me to make a lot of decisions on my own My job allows me to make a lot of decisions on my own 8. 8. On my job, I am given a lot of freedom to decide how I do my wor On my job, I am given a lot of freedom to decide how I do my work k 9. 9. I have a lot to say about what happens on my job I have a lot to say about what happens on my job
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Psychological Job Demands
Low High High Low
Job
Decision Latitude
Low Strain Low Strain Active Active Passive Passive High Strain High Strain Forester Repairman Dentist Janitor Watchman Billing Clerk Banker Physician HS teacher Assembler Waiter Nurse aide
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34 studies published between 1981 and 2002
16 from Sweden (many using national data bases)
7 from U.S. (2 using national data bases)
Also: Czech Republic, Denmark, England, Finland, Japan
PAR% = 10-30%
Belkić K, Landsbergis P, Schnall P, Baker D. Is job strain a major source of cardiovascular disease risk? Scandinavian Journal of Work Environment and Health 2004;30(2):85-128.
Significant Mixed positive Total positive and null # of associations associations studies Cohort studies 8 3 17 Case-control studies 6 9 Cross-sectional studies 4 8
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(men, Time 1 and Time 2) (men, Time 1 and Time 2)
6.3 7.8 6.4 2.6 5 5 2 4 6 8 10 12 14 mm Hg
Time 1 Time 1 Time 2 Time 1 Time 1 Time 2 (n=285) (n=195) (n=195) (n=285) (n=195) (n=195) ***p<.001, *p<.05 ***p<.001, *p<.05 controlling for age, education, body mass index, race, smoking, alcohol use, work site
Systolic AmBP Systolic AmBP Diastolic AmBP Diastolic AmBP
*** *** *** *** *** *** *** *** *** *** * *
Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.
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128.3 130 133.6 140.7 128.5 131.5 130.2 139.6 126 128 130 132 134 136 138 140 142 mm Hg
controlling for age, education, body mass index, race, smoking, alcohol use, work site
Time 2 Time 2 (p=.0015)
(p=.0015)
Time 1 Time 1 (p=.0017)
(p=.0017)
Strain Strain-
T1: no no
no
yes yes yes yes no no no
no
yes yes yes yes Strain Strain-
T2: no yes no yes yes no yes no yes no yes no yes
Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.
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(n=213 men, age 30 (n=213 men, age 30-
60, 9 NYC work sites, 1985-
95, analysis restricted to 87 men with analysis restricted to 87 men with ≥ ≥25 yrs of employment) 25 yrs of employment)
4.8 7.9
0.8
2 4 6 8 10 mm Hg
adjusted for age, education, body mass index, race, smoking, alcohol use, winter season, standing position, work site, and job strain at entry into the study
Work Work Home Home Work Work Home Home
Landsbergis PA, Schnall PL, Pickering TG, Warren K, Schwartz JE. American Journal of Epidemiology 2003;157:998-1006.
Systolic AmBP Systolic AmBP Diastolic AmBP Diastolic AmBP
* * * *p<.05
p<.05
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effort reward
demands / obligations
motivation (‘overcommitment‘) motivation (‘overcommitment‘)
( (J.
Siegrist 1996) 1996)
Extrinsic components Extrinsic components Intrinsic component Intrinsic component
http://www.uni http://www.uni-
duesseldorf.de/MedicalSociology/
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#
Nmax Nmax=812 (73 deaths); mean follow =812 (73 deaths); mean follow-
up 25,6 years
0.5 1 1.5 2 2.5 1 2 3 1 2 3
High demand / low control
Tertiles 1 = low; 2 = intermediate; 3 = high
#adj. for age, sex,
smoking, physical activity, SBP, total chol., BMI Source: M. Kivimäki et al. (2002), BMJ, 325: 857
Effort-Reward Imbalance
* p < .05
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Source: T.G.M. Vrijkotte et al. (2000), Hypertension, 35: 880
low imbalance high imbalance
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Effort Effort-
reward imbalance and incident type 2 diabetes in the Whitehall II in the Whitehall II-
Study
(odds ratios (odds ratios#
#; N=8067, mean follow
; N=8067, mean follow-
up: 12.5 years)
Source: A. Kumari et al. (2004), Arch Intern Med, 164: 1873-80.
0.5 1 1.5 2
no work stress high effort or low reward high effort and low reward
# adjusted for age, employment grade, ethnic group, length of follow up, ECG abnormalities,
familiy history of diabetes, BMI, height, SBP, exercise, smoking, life events
0.5 1 1.5 2
no work stress high effort or low reward high effort and low reward
men women
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Jobs which require a high level of vigilance in order to avoid disasterous consequences, which could occur with a disasterous consequences, which could occur with a momentary lapse of attention or a wrong decision momentary lapse of attention or a wrong decision
Prominent feature of some high CVD risk jobs:
air traffic controllers
bus, taxi and truck drivers
sea pilots
Belkić K, Landsbergis P, Schnall P, Baker D, Theorell T, Siegrist J, Peter R, Karasek R. Psychosocial factors: Review of the empirical data among men. Occupational Medicine: State of the Art Reviews 2000;15(1):24-46.
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Occupations at increased risk of either acute MI or CHD Occupations at increased risk of either acute MI or CHD mortality or morbidity in >1 study mortality or morbidity in >1 study MEN MEN
Air traffic controllers Air traffic controllers Bakers Bakers Bus drivers Bus drivers Butchers Butchers Cannery workers Cannery workers Cooks Cooks Fire fighters Fire fighters Fishermen Fishermen Foundry workers Foundry workers Hairdressers Hairdressers Lorry drivers Lorry drivers Paper workers Paper workers Police Police Prison wardens Prison wardens Rubber and plastics Rubber and plastics workers workers Sea pilots Sea pilots Taxi drivers Taxi drivers Waiters Waiters Warehousemen, Warehousemen, storekeepers storekeepers
WOMEN WOMEN
Bus drivers Bus drivers Cleaners Cleaners Home help Home help Rubber and plastics workers Rubber and plastics workers Paper workers Paper workers Self Self-
employed in hotel and catering catering Taxi drivers Taxi drivers Unskilled workers in tube, Unskilled workers in tube, sheet, steel construction sheet, steel construction Waitresses Waitresses
Tuchsen F. High risk occupations for cardiovascular disease. Occupational Medicine: State of the Art Reviews 2000;15(1):57-60.
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Professional drivers: Most consistent evidence of elevated CVD r Professional drivers: Most consistent evidence of elevated CVD risk isk
34 of 40 studies confirm increased risk of CHD + HTN among professional drivers, particularly urban transit operators: professional drivers, particularly urban transit operators:
Bus drivers greater risk of CHD as conductors on same routes
Gothenberg, Sweden
3x increased risk of heart disease compared to men in other jobs
Denmark
high vs low traffic intensity 2.7x increased risk of acute MI 2.7x increased risk of acute MI
San Francisco
HTN (≥ ≥160/95) associated with experts 160/95) associated with experts’ ’ ratings of objective stressors: ratings of objective stressors: job barriers, time pressure job barriers, time pressure
Tuchsen F. High risk occupations for cardiovascular disease. Occupational Medicine: State of the Art Reviews 2000;15(1):57-60. Belkic K, Emdad R, Theorell T. Occupational profile and cardiac risk: possible mechanisms and implications for professional
Tse JLM, Flin R, Mearns K. Bus driver well-being review: 50 years of research. Transportation Research Part F 9 (2006) 89–114.
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Van Van der Hulst der Hulst et al et al. Scand J Work Environ Health 2003;29(3):171-88. Harma M. Scand J Work Environ Health 2003;29(3):167-9.
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City of Fukuoka, 260 cases, 445 controls, 1996 City of Fukuoka, 260 cases, 445 controls, 1996-
1998
1 1.2 1.9 1 2 3
Odds Ratio
41 41-
60 hrs <41 hrs <41 hrs Past week Past week: :
Liu Y, Tanaka H. Occupational and Environmental Medicine 2002;59:447-451.
>60 hrs >60 hrs
Controlling for smoking, alcohol, overweight, hypertension, diabetes, hyperlipidemia, parental heart disease, job type, sedentary job
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121 127 110 115 120 125 130
mm Hg
Busy period Busy period Slow period Slow period
Hayashi T, Kobayashi Y, Yamaoka K, Yano E. Journal of Occupational and Environmental Medicine 1996;38:1007-11.
Average Average: : 51 hrs/week 51 hrs/week 64 hrs/week 64 hrs/week
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Van Van der Hulst der Hulst et al et al. Scand J Work Environ Health 2003;29(3):171-88. Harma M. Scand J Work Environ Health 2003;29(3):167-9.
Work
Physical hazards
Noise Heat Cold
Toxic chemicals
Tobacco smoke Carbon monoxide Carbon disulphide Nitroglycerin Lead
Physical activity
Sedentary work Static load Heavy physical exertion
Schedules
Shiftwork Long work hours
Psychosocial stressors
Job strain Low job control Social isolation Effort-reward imbalance Danger potential
Cardiovascular disease
(+ other injuries, illnesses)
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Data from Jackson, MS, Forsyth County, NC, Minneapolis suburbs, Washington County, MD. Source: Rosamond et al. NEJM 1998;339:861-7.
(NHANES III: 24% NHANES IV: 29%)
Singh GK, Siahpush M. Increasing inequalities in all-cause and cardiovascular mortality among US adults aged 25-64 years by area socioeconomic status, 1969-1998. International Journal of Epidemiology 2002;31:600-613.
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Low SES Cardiovascular Disease, Hypertension Job strain; effort-reward imbalance
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0.8 1 1.2 1.4 1.6 OR High Intermediate Low
Men Men Women Women
Adjusted for: Age Standard Low job All Age Standard Low job All RF control; RF control; effort-reward effort-reward imbalance imbalance Marmot et al. Lancet 1997;350:235-239.
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Job Strain; Effort-reward imbalance Low SES Cardiovascular Disease, Hypertension
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n=283 men, Time 1)
3.4 8.6 11.8
1.8
2 4 6 8 10 12 14 mm Hg
Job Strain Job Strain No Job Strain No Job Strain
White White-
collar Clerical Blue-
collar White White-
collar Clerical Blue-
collar controlling for age, body mass index, race, smoking, alcohol use and work site *p<.05 (vs Ref group) *p<.05 (vs Ref group)
* * * *
Ref Ref
Landsbergis P, Schnall P, Pickering T, Warren K, Schwartz J. Lower socioeconomic status among men in relation to the association between job strain and blood pressure. Scandinavian Journal of Work, Environment and Health 2003;29(3):206-215.