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 Community and Preventive Medicine Mount Sinai School of Medicine, New York, NY Partnership for Heart Healthy Stroke Free Massachusetts Worcester, MA June 2, 2006
% of workers reporting “very stressful jobs” % of workers reporting “very stressful jobs” 40 50 40 29 26 30 % 20 10 0 Northwestern National Life 1992 Families and Work Institute 1997 Yale University 1997 NIOSH. Stress at work. DHHS (NIOSH) Publication No. 99-101, 1999. 2
What are the What are the sources of sources of stress on your stress on your job? job? 3
TYPICAL MEASURES OF JOB STRESSORS IN TYPICAL MEASURES OF JOB STRESSORS IN RESEARCH STUDIES RESEARCH STUDIES � 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 4
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THE CHANGING WORLD OF WORK: THE CHANGING WORLD OF WORK: What trends appear in the data? What trends appear in the data? � Work hours � Real income � Psychological job demands � Job decision latitude � Job strain 6
HOURS WORKED PER YEAR 2200 Japan 2100 USA 2000 1900 Spain 1800 1700 France 1600 Sweden 1500 1980 1990 1995 2000 7 Source: International Labour Organization, 2001
Changes in real wages, male workers, by wage percentile, 1973-2001 (2001 dollars) 40 35 90 th %ile 30 25 $/hr 70 th %ile 20 50 th %ile 15 30 th %ile 10 10 th %ile 5 0 1973 1979 1989 1995 2000 2001 Mishel L, Bernstein J, Boushey H. The State of Working America 2002/2003 . p. 130, Table 2.7. 8
Family income inequality, Gini coefficient,1947-00 0.43 Gini* 0.41 Trend in Gini 0.39 0.37 0.35 0.33 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.
“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. 10
European Foundation surveys: work intensity 70% % reporting "yes" 60% Tight Deadlines Very High Speed 50% 40% 1990 1995 2000 Pascal Paoli, Damien Merllié. Third European Survey on Working Conditions. European Foundation for the Improvement of Living and Working Conditions, 2001. 11
European Foundation surveys: job control (autonomy) 75% Control over: % reporting "yes" 70% Work Methods Speed Task Order 65% Break When Desired 60% 1990 1995 2000 Pascal Paoli, Damien Merllié. Third European Survey on Working Conditions. European Foundation for the Improvement of Living and Working Conditions, 2001. 12
U.S. national surveys: job demands 90% 80% % reporting "agree" Work Very Hard 70% Work Very Fast 60% Not Enough Time 50% 40% 1977 QES 1997 NSCW 13
HEALTH IMPACTS OF STRESSFUL WORK HEALTH IMPACTS OF STRESSFUL WORK ORGANIZATION: ORGANIZATION: � Most widely studied � Cardiovascular disease (including hypertension) � Existing evidence � Musculoskeletal disorders � Psychological disorders � Health behaviors � Sleeping problems � Injuries � More research needed on other outcomes � Immune system � Reproductive health 14
Job Demand- -Control Model Control Model Job Demand Combination of HIGH HIGH Psychological Job Demands Psychological Job Demands + + LOW LOW Job Job Combination of Decision Latitude (decision- -making authority and skill use) making authority and skill use) Decision Latitude (decision Decision Latitude Job Demands Job Strain Karasek R, Theorell T. Healthy work. New York: Basic Books, 1990. 15
Job Content Questionnaire Job Content Questionnaire (Karasek) (Karasek) Definition: Job Strain is the combination of HIGH HIGH Job Job Definition: Job Strain is the combination of Demands and and LOW LOW Job Decision Latitude Job Decision Latitude Demands Job Demands Job Demands 1. My job requires working very fast 1. My job requires working very fast 2. My job requires working very hard 2. My job requires working very hard 3. I am not asked to do an excessive amount of work * * 3. I am not asked to do an excessive amount of work 4. I have enough time to get the job done * * 4. I have enough time to get the job done 5. I am free from conflicting demands others make * * 5. I am free from conflicting demands others make * item reverse coded 16
Job Content Questionnaire Job Content Questionnaire Job Decision Latitude Job Decision Latitude Skill development Skill development 1. My job requires that I learn new things 1. My job requires that I learn new things 2. My job requires me to be creative 2. My job requires me to be creative 3. My job requires a high level of skill 3. My job requires a high level of skill 4. I get to do a variety of things on my job 4. I get to do a variety of things on my job 5. I have an opportunity to develop my own special abilities 5. I have an opportunity to develop my own special abilities 6. My job involves a lot of repetitive work (reverse coded) 6. My job involves a lot of repetitive work (reverse coded) Decision- -making authority making authority Decision 7. My job allows me to make a lot of decisions on my own 7. My job allows me to make a lot of decisions on my own 8. On my job, I am given a lot of freedom to decide how I do my work k 8. On my job, I am given a lot of freedom to decide how I do my wor 9. I have a lot to say about what happens on my job 9. I have a lot to say about what happens on my job 17
Typical occupations found in four quadrants of Typical occupations found in four quadrants of Karasek’s job strain model (1969- -1977 data) 1977 data) Karasek’s job strain model (1969 Psychological Job Demands Low High Forester Banker High Repairman Physician Dentist HS teacher Job Low Strain Active Low Strain Active Decision Janitor Assembler Latitude Watchman Waiter Low Billing Clerk Nurse aide Passive High Strain Passive High Strain 18
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Studies of Job Strain and Coronary Studies of Job Strain and Coronary Heart Disease Heart Disease 34 studies published between 1981 and 2002 34 studies published between 1981 and 2002 � � 16 from Sweden (many using national data bases) 16 from Sweden (many using national data bases) � � 7 from U.S. (2 using national data bases) 7 from U.S. (2 using national data bases) � � Also: Czech Republic, Denmark, England, Finland, Japan Also: Czech Republic, Denmark, England, Finland, Japan � � Significant Mixed positive Total positive and null # of associations associations studies Cohort studies 8 3 17 Case-control studies 6 0 9 Cross-sectional studies 4 0 8 PAR% = 10-30% Belki ć 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. 20
Job Strain and Work Ambulatory BP Job Strain and Work Ambulatory BP (men, Time 1 and Time 2) (men, Time 1 and Time 2) Time 1 Time 1 Time 2 Time 1 Time 1 Time 2 (n=285) (n=195) (n=195) (n=285) (n=195) (n=195) 14 12 *** *** 10 7.8 *** *** *** *** 8 *** *** *** *** 6.4 6.3 mm Hg 5 5 6 * * 4 2.6 2 0 Systolic AmBP Diastolic AmBP Systolic AmBP Diastolic AmBP controlling for age, education, body mass index, race, smoking, alcohol use, work site ***p<.001, *p<.05 ***p<.001, *p<.05 21 Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.
Job Strain change and Work Systolic Job Strain change and Work Systolic Ambulatory BP (n=195 men, Time 1 and 2) Ambulatory BP (n=195 men, Time 1 and 2) Strain- -T1: no T1: no no yes yes no no yes yes Strain yes yes no yes yes no no Strain- -T2: no yes no T2: no yes no yes no yes no yes Strain yes no yes no yes 142 140.7 139.6 140 138 136 133.6 mm Hg 134 131.5 132 130.2 130 130 128.5 128.3 128 126 Time 1 (p=.0017) Time 2 (p=.0015) Time 1 Time 2 (p=.0017) (p=.0015) controlling for age, education, body mass index, race, smoking, alcohol use, work site 22 Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.
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