The Changing Nature of Work

1
The Changing Nature of Work And its
Implications for Cardiovascular Disease
Fourth International Conference on Work
Environment and Cardiovascular Diseases
Southern CaliforniaMarch 9 11, 2005
Tage S. KristensenNIOH, Copenhagen
2

• Work and CVD
• The new challenges
• The new fatigue
• Family and private life
• Problems with methods and design?
• Conclusions

3
Work and CVD
4
General model for the relationship between work
environment and cardiovascular diseases
CVD risk factors diet obesity, blood
pressure, smoking etc.
WORK ENVIRON- MENT
CARDIO-VASCULAR DISEASES.
1
2
3
The significance of work 1 3
5
Causal network for CVD
6
The cardiovascular tradition fromFramingham and
onwards
Risk factors are individual
Physiological
Behavioral

• Smoking
• Physical inactivity
• Type A
• Salt intake
• Diet
• Alcohol

• Cholesterol
• Fibrinogen
• Triglycerides
• Glucose
• Blood pressure
• Heart rate
• Obesity

7
The occupational medicine tradition from
Ramazzini and onwards
Risk factors are environmental

• Physical
• Chemical
• Psychosocial
• Ergonomic
• Biological

8
Etiological fractions of work environment for
cardiovascular diseases in Denmark
Proportion of CVD Proportion of CVD
Risk factor Men Women
Sedentary work 42 42
Job strain 6 14
Shift night work 7 7
Noise 1 1
Chemical exposures 0-1 0
Passive smoking 2 2

All factors 51 55
All factors except sedentary work 16 22
Olsen Kristensen. J Epidemiol Community Health
1991454-10.
DK-2004-016
9
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
Cancer, total 13 2
Mental disorders 7 2
Respiratory diseases 7 1
Accidents 4 0
Total 10 2
Nurminen Karjalainen. Scand J Work Environ
Health 200127161-213.
10
The significance of work environment for
hospitalisations
Estimates of etiologic fractions in Denmark Men Women
Circulatory 16 18
Cancer 8 3
Nervous system 17 12
Respiratory 16 12
Accidents 17 6
Musculoskeletal 21 19
Total 15 11
Tüchsen et al. Sci Total Environ 2004328287-294.
11
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 33
Adjusted for cardiovascular risk factors
Rosengren et al. www.thelancet.com Sept.
3,20041-10
12
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.
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The new challenges
Outsourcing, downsizing, privatization,precariou
s work, job insecurity
14
Blood pressure and pulse amongNorwegian metal
workers
Erikssen et al. Tidsskr Nor Laegeforen.
19901102873-7.
15
Hospital admissions for CVD in a group of
unemployed men compared with a control group
Iversen et al. BMJ 19892991073-6.
16
Threats to employment security among white-collar
workers in Whitehall
A five-year follow-up studyN8354
RR
New cases of ischemia
1.60
1.45
1.40
1.0
Control departments
Men
Women
Total
Department under privatization
ECG or angina
Ferrie et al. AJPH 1998881030-1036.
17
Organisational downsizing and mortality
A 7.5 years follow-up study of 22.430 public
employeeswho kept their jobs.
RR
CVD
Other deaths
2.0
2.0
1.5
1.2
1.2
1.0
1.0
1.0
0
None
Minor
Major
None
Minor
Major
Extent of downsizing
Controlled for age, gender, SES, occupation
Vahtera et al. BMJ 2004328555-558.
18
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
19
The new fatigue
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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.
21
Work-related burnout and sleeping problemstwo
years later
Results from the PUMA baseline and 2 years
follow-up
Karolinska sleep questionnaire (scale)
44.6
34.4
32.6
25.1
Work-related burnout
Low
High
Quartiles
N 1014 Data from NIOH, Denmark
22
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 74 Yes
26
RR for IHD
2.13
2
1
1
0
Yes
No
Burnout
Controlled for age, BP, smoking, cholesterol.
59 cases. Appels Schouten. Behav Med
1991Summer53-59
23
Exhaustion and CHD
A 9.5 years follow-up study of 3,365 Dutch men.
Appels Otten. Br J Clin Psychol 199231351-356
24
Vital exhaustion, IHD and death
6 years of follow-up of 9,563 adults from
Copenhagen
Adjusted for 13 biological, behavioural and
social factors
Prescott et al. Int J Epidemiol 200332990-7
25
Sleep quality and myocardial infarction
3 years of follow-up of 416 middle-aged German
blue-collar workers
RR
3.8
2.6
1.0
1.0
No
No
Yes
Yes
Wake up early
Difficulty staying asleep
Siegrist. J Chron Dis 198740571-578.
26
Psychological risk factors for CHD among
homemakers from Framingham
A 20-year follow-up study of 362 women
Tension
Symptoms of anxiety
Trouble falling asleep
Adjusted for CVD risk factors.Eaker et al. Am
J Epidemiol 1992135854-864.
27
Sleep and risk of IHD
A study of 71,617 American nurses followed for 10
years
Adjusted for 14 factors
Age-adjusted
RR
1.8
1.6
1.4
1.4
1.3
1.2
1.1
1.1
1.0
1.0
? 5
6
? 9
7
8
? 5
6
7
8
? 9
The Nurses Health Study
Ayas et al. Arch Intern Med 2003163205-9
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CVD, sleep quality and need for recovery after
work
Results from 32 months of follow-up of the
Maastrict Cohort Study on fatigue
RR
3.16
2.82
3
2
1.22
1
1
1
0
Good
Poor
Low
Medium
High
Need for recovery
Sleep quality
N7,944 workers. 18-65 years. 42 cases.
Van Amelsvoort et al. Occup Environ Med
20036083-87.
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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
1.8
1.3
1.1
1
1
lt40
41-60
61
0
1
2
Working hours/week past year
Days/week with lt5 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 200259447-51.
30
Depression and CHD A meta-analysis
Relative risk among initially healthy
subjects. Analysis of 11 studies
RR RR
Clinical depression Clinical depression 2.69 (1.63-4.43)
Depressive mood Depressive mood 1.49 (1.16-1.92)
Overall estimate Overall estimate 1.64 (1.29-2.08)
Rugulies. Am J Prev Med 20022351-61.
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The new fatigue
Long working hours
Fatigue
Family/ work conflict
Need for recovery
Shift work, 24 h society
Burnout
Stress
High emotional demands
High work pace
Depression
Withdrawal
Conflicts, bullying
Sleep problems
Cardiovascular disease
32
Family and private life
33
Is marriage worse than work? (For women)
A follow-up study of 292 female heart patients in
Stockholm
Marital Stress
Work stress
RR For new events
RR For new events
2.9
2.8
2
2
1.7 (NS)
1.3 (NS)
1
1
1
1
0
0
Low
Moderate
Severe
Low
Moderate
Severe
Adjusted for age, diagnosis, SBP, DM, smoking,
lipids and estrogen status.
Orth-Gomér et al. JAMA 20002843008-14.
34
Psychosocial factors and acute myocardial
infarction The INTERHEART STUDY
11,119 cases and 13,648 controls from 52 countries
RR
2.14
2.12
2
1.52
1.48
1.38
1.33
1.23
1.19
1
1
1
1
1
0
Work stress
Home stress
Financial stress
Life events
Rosengren et al. www.the lancet.com Sept.
3,20041-10
35
Problems with methods and design?
36
Job strain and effort-reward imbalance as
predictors of CVD mortality
A 26 years follow-up of 812 Finnish employees
Job strain
Effort-reward imbalance
RR
RR
2.42
2.22
1.91
2
2
1.64
1
1
1
1
0
0
Low
Medium
High
Low
Medium
High
Adjusted for smoking, physical activity, SBP,
cholesterol, BMI, age and occupation. 73 cases.
Kivimäki et al. BMJ 2002325857-60.
37
Quantitative demands at workThe 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 200418305-322.
38
How should quantitative job demands be measured?
JCQ
Whitehall II
My job requires working very fast.
Do you have to work very fast?
Intensive demands?
Intensive demands?
My job requires working very hard.
Do you have to work very intensively?
Physical demands?
Cognitive demands?
I am not asked to do an excessive amount of work.
Do you have enough time to do everything?
Extensive demands?
Extensive demands?
I have enough time to get the job done.
Do different groups at work demand different
things from you that you think are hard to
combine?
Extensive demands?
I am free from conflicting demands that others
make.
Role conflicts?
Role conflicts?
Each scale seems to measure four different
dimensions.
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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 200418305-322.
40
How can we measure quantitative demands?
Model for the measurement of quantitative job
demands.
Processes at the workplace and job level.
Measures of quantitative job demands.
Processes at the (global) labour market.
Kristensen et al. Work Stress 200418305-322.
41
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.
N.S.
1.9
2.0
1.3
1.3
1.3
1.2
1.16
1.14
1.0
1.0
1.0
1.0
1.0
1.0
0.9
1.0
0.71
0.7
0
M
L
M
H
M
H
H
M
L
H
L
L
Low
Active
High
Passive
Men
Women
Women
Men
Control
Demands
Job strain
Adjusted for other risk factors.
Kuper Marmot. J Epidemiol Community Health
200357147-153.
42
Job strain Whitehall II
Kuper Marmot. J Epidemiol Community Health
200357147-153.
43
Extending our paradigms
Work Demands Control Support Rewards Job
insecurity Predictability Meaning of work Rate of
change Emotional demands Role conflicts/ambiguiti
es Conflicts/bullying Family/work
conflicts Long working hours Irregular working
hours
Individual (Di)stress Hostility Overcommitment
Fatigue Need for recovery Depression Sleep

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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.

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The End
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