Transcript The Changing Nature of Work - And its Implications for

The Changing Nature of Work –
And its Implications for Cardiovascular Disease
Fourth International Conference on Work
Environment and Cardiovascular Diseases
Southern California
March 9 – 11, 2005
Tage S. Kristensen
NIOH, Copenhagen
• Work and CVD
• The new challenges
• The new fatigue
• Family and private life
• Problems with methods and design?
• Conclusions
1. Work and CVD
General model for the relationship between work
environment and cardiovascular diseases
1
CVD risk factors:
2
diet obesity,
WORK
blood pressure,
CARDIO-
ENVIRON-
smoking etc.
VASCULAR
MENT
DISEASES.
3
The significance of work: 1 + 3
Causal network for CVD
SES
&
Occupation
Social &
Environmental
Factors
Individual
Behavior
Characteristics
Physiology
Precursors
Work environment
Physical
activity
Fitness
Cholesterol
Atherosclerosis
Social
isolation
Tobacco
Obesity
Blood
pressure
Thrombosis
Unemployment
Diet
Type A
Fibrinogen
Arrhythmia
Noise
Alcohol
Stress
Glucose
ECGchanges
….
Downstream
….
….
….
….
Upstream
CVD
The cardiovascular tradition from
Framingham and onwards
Risk factors are individual
Physiological:
Cholesterol
Fibrinogen
Triglycerides
Glucose
Blood pressure
Heart rate
Obesity
Behavioral:
Smoking
Physical inactivity
Type A
Salt intake
Diet
Alcohol
The occupational medicine tradition from
Ramazzini and onwards
Risk factors are environmental
Physical
Chemical
Psychosocial
Ergonomic
Biological
Etiological fractions of work environment for
cardiovascular diseases in Denmark
Proportion of CVD
Risk factor
“Sedentary” work
Men
Women
42%
42%
Job strain
6%
14%
Shift & night work
7%
7%
Noise
1%
1%
0-1%
0%
2%
2%
51%
16%
55%
22%
Chemical exposures
Passive smoking
All factors
All factors except sedentary work
Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10.
DK-2004-016
The significance of work environment for mortality
Estimates of etiologic fractions in Finland
Men
Women
Cardiovascular, total
14%
7%
IHD
19%
9%
Cerebrovascular
12%
8%
13%
2%
Mental disorders
7%
2%
Respiratory diseases
7%
1%
Accidents
4%
0%
Total
10%
2%
Cancer, total
Nurminen & Karjalainen. Scand J Work Environ Health 2001;27:161-213.
The significance of work environment for
hospitalisations
Estimates of etiologic fractions in Denmark
Men
Women
Circulatory
16%
18%
8%
3%
Nervous system
17%
12%
Respiratory
16%
12%
Accidents
17%
6%
Musculoskeletal
21%
19%
Total
15%
11%
Cancer
Tüchsen et al. Sci Total Environ 2004;328:287-294.
Etiologic fractions of psychosocial factors for acute myocardial infarctions:
The INTERHEART STUDY
11,119 cases and 13,648 controls from 52 countries
Etiologic
fractions*
Work stress
9%
Home stress
8%
Financial stress
11%
Life events
10%
Locus of control
16%
Depressive mood
9%
All psychosocial factors
* Adjusted for cardiovascular risk factors
Rosengren et al. www.thelancet.com
Sept. 3,2004:1-10
33%
Conclusion
CVD is one of the most important causes of
disease, disability, and mortality in the world.
The etiologic fraction of the work environment is
higher than for all other major diseases.
CVD is the most common and most serious of all
work-related diseases.
In spite of this, CVD plays a minor role in occuptional medicine,
and work plays a minor role in cardiology and cardiovascular
epidemiology.
2. The new challenges
Outsourcing, downsizing, privatization,
precarious work, job insecurity
Blood pressure and pulse among
Norwegian metal workers
(N = approx. 180)
Threat of closure
BP (mm Hg)
80
Pulse
160
150
140
130
142
SBP
129
130
145
143
135
129
70
69
120
110
Pulse
63
63
100
90
84
85
1982
1983
86
90
94
96
91
DBP
80
1984
1985
1986
1987
Erikssen et al. Tidsskr Nor Laegeforen. 1990;110:2873-7.
1988
78
76
74
72
70
68
66
64
62
60
58
Hospital admissions for CVD in a group of
unemployed men compared with a control group
1,8
1.8
1.60
1.6
1,6
1,4
1.4
1,2
1.2
11
0.8
0,8
1.04
0.80
0.6
0,6
0.4
0,4
0.2
0,2
00
Before factory
closure
(2 years)
During factory
closure
(3 years)
Iversen et al. BMJ 1989;299:1073-6.
After factory
closure
(3 years)
Threats to employment security among white-collar
workers in Whitehall
A five-year follow-up study
N=8354
RR
New cases of ischemia*
2
1.60
1
0
1.40
1.45
Men
Women
Total
Department under privatization
1.0
Control
departments
*ECG or angina
Ferrie et al. AJPH 1998;88:1030-1036.
Organisational downsizing and mortality
A 7.5 years’ follow-up study of 22.430 public employees
who kept their jobs.
RR*
Other
deaths
CVD
2.0
2.02
1.5
1.2
1.01
0
1.0
1.0
None
1.2
Minor
Major
None
Extent of downsizing
*Controlled for age, gender, SES, occupation
Vahtera et al. BMJ 2004;328:555-558.
Minor
Major
A simple model
Job insecurity, downsizing, outsourcing,
privatization
Loss of control, loss of social support,
loss of meaning, loss of predictability,
loss of rewards
Stress, uncertainty, hopelessness,
low self esteem
3. The new fatigue
The development of four different symptoms in the adult
Swedish population 1986 - 2001
Percent
Fatigue
Back trouble
Sleep trouble
Distress
Gustafsson & Lundberg, eds. Arbetsliv och hälsa, 2004.
Work-related burnout and sleeping problems
two years later
Results from the PUMA baseline and 2 years’ follow-up
Karolinska sleep
questionnaire (scale)
50
45
40
35
30
25.1
25
20
15
10
5
0
Low
44.6
32.6
34.4
Quartiles
N = 1014; Data from NIOH, Denmark
High
Work-related
burnout
Burnout as predictor of ischaemic heart diseas
A 4.2 years’ follow-up study of 3,877 Dutch male employees from Rotterdam
”Have you ever been burned out?”
No
Yes
RR* for IHD*
3
2.13
2
11
1
00
Yes
No
Burnout
* Controlled for age, BP, smoking, cholesterol. 59 cases.
Appels & Schouten. Behav Med 1991;Summer:53-59
74%
26%
Exhaustion and CHD
A 9.5 years’ follow-up study of 3,365 Dutch men.
Cases per 1000
50
50
45
40
40
30
30
30
26
20
20
10
10
00
None
Medium
High
Degree of exhaustion by the end of the working day.
Appels & Otten. Br J Clin Psychol 1992;31:351-356
Vital exhaustion, IHD and death
6 years of follow-up of 9,563 adults from Copenhagen
RR*
33
IHD
22
1.6
1.8
2.2
1.6
11
1
1.2
1.1
Mortality
00
0
0
1-4
1-4
5-9
5-9
10+
Vital exhaustion
10+
* Adjusted for 13 biological, behavioural and social factors
Prescott et al. Int J Epidemiol 2003;32:990-7
Sleep quality and myocardial infarction
3 years of follow-up of 416 middle-aged German blue-collar workers
RR
3.8
4
3
2.6
2
1.0
1.0
1
0
No
Yes
Wake up early
Siegrist. J Chron Dis 1987;40:571-578.
No
Yes
Difficulty
staying asleep
Psychological risk factors for CHD among homemakers
from Framingham
A 20-year follow-up study of 362 women
RR *
7.8
88
77
6.2
66
55
3.9
44
33
22
11
00
1.0
1.0
+
Tension
+
Symptoms
of anxiety
*Adjusted for CVD risk factors.
Eaker et al. Am J Epidemiol 1992;135:854-864.
1.0
+
Trouble
falling
asleep
Sleep and risk of IHD
A study of 71,617 American nurses followed for 10 years
2,0
Adjusted for 14 factors
Age-adjusted
2,5 RR
1.8
1.6
1,5
1.4
1.3
1.1
1,0
1.4
1.2
1.0
1.1
1.0
0,5
0,0
5
6
7
8 9
5
The Nurses’ Health Study
Ayas et al. Arch Intern Med 2003;163:205-9
6
7
8 9
CVD, sleep quality and ”need for recovery” after work
Results from 32 months of follow-up of the Maastrict Cohort Study on fatigue
RR
4
3.16
2.82
33
22
1
1
11
1.22
00
Good
Poor
Sleep quality
Low
Medium
High
Need for recovery
N=7,944 workers. 18-65 years. 42 cases.
Van Amelsvoort et al. Occup Environ Med 2003;60:83-87.
Long working hours and short sleep as risk factors for AMI
A case control study of working Japanese men 40-79 years of age
260 cases and 445 matched healthy controls
RR*
2.1
2
1.8
1.3
1
1
1.1
0
1
1
0
<40
41-60
61+
Working hours/week
past year
2+
Days/week with <5
hours of sleep
*Adjusted for smoking, alcohol, BMI, BP, DM, cholesterol, heart disease in family, job type and
sedentary job
Lin er al. Occup Environ Med 2002;59:447-51.
Depression and CHD
A meta-analysis
Relative risk among initially healthy subjects.
Analysis of 11 studies
RR
Clinical depression
2.69 (1.63-4.43)
Depressive mood
1.49 (1.16-1.92)
Overall estimate
1.64 (1.29-2.08)
Rugulies. Am J Prev Med 2002;23:51-61.
The new fatigue
Long working
hours
Fatigue
Family/
work
conflict
Shift work,
24 h society
Need for
recovery
Burnout
Stress
High emotional
demands
High work
pace
Withdrawal
Conflicts,
bullying
Depression
Sleep problems
Cardiovascular
disease
4. Family and private life
Is marriage worse than work?
(For women)
A follow-up study of 292 female heart patients in Stockholm
Work stress
Marital Stress
RR* For new events
RR* For new events
2.8
3
2.9
3
22
22
1.7 (NS)
1.3 (NS)
1
11
11
00
Low
Moderate
Severe
00
1
Low
Moderate
* Adjusted for age, diagnosis, SBP, DM, smoking, lipids and estrogen status.
Orth-Gomér et al. JAMA 2000;284:3008-14.
Severe
Psychosocial factors and acute myocardial infarction: The
INTERHEART STUDY
11,119 cases and 13,648 controls from 52 countries
RR*
2.14
2.12
22
1.52
1.38
1.19
1
1
11
1.48
1.33
1.23
1
1
T
w
o
or
m
or
e
ne
O
e
N
on
od
er
at
e
Se
ve
re
L
ow
M
S
Pe om
rm e
an
en
t
e
N
on
S
Pe om
rm e
an
en
t
N
on
e
00
Work stress
Home stress
Financial stress
Rosengren et al. www.the lancet.com Sept. 3,2004:1-10
Life events
5.
Problems with methods and design?
Job strain and effort-reward imbalance as
predictors of CVD mortality
A 26 years’ follow-up of 812 Finnish employees
Effort-reward imbalance
Job strain
RR*
RR*
3
3
2.42
2.22
22
1
11
11
00
Low
Medium
1.91
22
1.64
High
00
1
Low
Medium
High
* Adjusted for smoking, physical activity, SBP, cholesterol, BMI, age and occupation. 73 cases.
Kivimäki et al. BMJ 2002;325:857-60.
Quantitative demands at work:
The two dimensions
Basic issue: The (mis)match between the amount of work
and the time available to do it.
Intensity
(pace)
Extensity
(hours)
Kristensen et al. Work & Stress 2004;18:305-322.
How should quantitative job demands be measured?
JCQ
Whitehall II
My job requires working very fast.
Intensive demands?
Do you have to work very fast?
Intensive demands?
My job requires working very hard.
Physical demands?
Do you have to work very intensively?
Cognitive demands?
I am not asked to do an excessive amount of
work.
Extensive demands?
Do you have enough time to do everything?
Extensive demands?
I have enough time to get the job done.
Extensive demands?
Do different groups at work demand
different things from you that you think are
hard to combine?
Role conflicts?
I am free from conflicting demands that
others make.
Role conflicts?
Each scale seems to measure four different dimensions.
We need better measures of job demands
“The basic measurement of the demand construct should be
improved”
(Johnson et al, 1996)
“Exposure measurement should be improved, especially for the
psychological demand variable”
(Steenland et al, 1997)
“The measures of psychological job demands need to be
refined”
(Theorell et al, 1998)
“The concept of demands may be too loosely defined”
(Hallqvist et al, 1998)
Kristensen et al. Work & Stress 2004;18:305-322.
How can we measure quantitative demands?
Model for the measurement of quantitative job demands.
Faster work pace
(Intensification)
Pressure for
increased
productivity
Mismatch between
the amount of work
to be done and the
time available
to do it
Basic scale for
quantitative demands at work
Pressure for
Longer working hours
(Extensification)
Processes at the
(global) labour
market.
Processes at the workplace and
job level.
Kristensen et al. Work & Stress 2004;18:305-322.
Scale for intensive
quantitative demands
Questions on formal
and actual working hours
Measures of
quantitative job
demands.
Job strain and CHD in Whitehall II
11 years of follow-up of 10,308 employees
Fatal CHD + non-fatal MI.
A positive study?
RR*
N.S.
N.S.
N.S.
N.S.
2
2.0
1.3
1
1.0
N.S.
1.9
1.0
1.3
1.0
1.0
0.9
1.3
1.2
1.14 1.16
1.0
1.0
1.0
0.71
0.7
0
0
H M
L
H M
L
Women
Men
Control
L
M H
Men
L
M H
Women
Demands
* Adjusted for other risk factors.
Kuper & Marmot. J Epidemiol Community Health 2003;57:147-153.
Job strain
Job strain & Whitehall II
90
Active
High
Strain
80
I
70
I
Demands
II
60
Women
50
III
II
Men
III
40
Low
Strain
Passive
30
30
40
50
60
Control
Kuper & Marmot. J Epidemiol Community Health 2003;57:147-153.
70
80
90
Extending our paradigms
Work
Individual
Demands
Control
Support
Rewards
(Di)stress
Hostility
Overcommitment
Job insecurity
Predictability
Meaning of work
Rate of change
Fatigue
Need for recovery
Depression
Sleep
Emotional demands
Role conflicts/ambiguities
Conflicts/bullying
Family/work conflicts
Long working hours
Irregular working hours
Conclusions
The association between work and CVD is a major –
but somewhat neglected – issue.
The new developments in the globalized economy
seem to increase CVD risk – at least in the rich
countries.
Fatigue, burnout, depression and sleep problems
seem to be increasing – and to increase CVD risk.
Our models, methods, and designs should be
improved.
The End
This presentation (and many others)
may be found at
www.ami.dk/presentations