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Introduction to Surveillance

“In 1998, experts in Japan, Europe, and the United States called for a program of surveillance at workplaces and monitoring at national and regional levels in order to identify the extent of work-stress related health problems and to provide baselines against which to evaluate intervention efforts. They recommended that workplaces measure both workplace stressors and health problems known to result from such stressors [11].

In the United States, occupational and environmental medicine clinics can play a key role in such surveillance efforts. In addition to clinical care, such clinics conduct research, and provide patient education, industrial hygiene and ergonomics services, and social work and support groups [12]. Thus, a team approach is recommended in which epidemiologists work together with clinicians, health educators, ergonomists, psychologists, and other health professionals to identify high-risk workplaces and jobs, facilitate the provision of clinical care, and design and implement workplace interventions.

The surveillance team needs to discover whether the current occupation(s) is high risk; whether workers are exposed to any workplace physical, chemical, work schedule or psychosocial risk factors for disease; and whether any such have been increasing over time [13]. Questionnaires, such as the Job Content Questionnaire [14], the Effort-Reward Imbalance Questionnaire [15], and the Occupational Stress Index [16], can help measure job characteristics and job stressors. Workplace screenings should be conducted for biomedical risk factors, such as high blood pressure [17]. Such surveillance can help to identify clusters of work-related hypertension and help target work sites for primary and secondary prevention programs.

Another key part of surveillance is taking an occupational history of workers to see how long they have been facing workplace risk factors for disease, and what types of risk factors [18]. Such surveillance would be an important part of the newly developing field of occupational cardiology, which would link cardiologists, health promotion experts, and occupational health specialists. In addition to efforts described above, they would develop return-to-work guidelines for cardiac patients, including workplace modifications, and expand the use of ambulatory (portable) monitors to measure blood pressure or heart rate [19].”

Policy Statements Adopted by the Governing Council of the American Public Health Association, November 15, 2000

The American Public Health Association,

Recognizing that workers in the United States are taking fewer and shorter vacations, and are working more hours over the course of a year, surpassing even Japan as the leader among major developed nations in annual hours worked per person (1), and

Recognizing that 20% of American workers saw his or her job disappear during the 1980s, and downsizing and layoffs have continued through the end of the 1990s, despite an unprecedented economic boom, with income disparities rising to their highest levels in over a century (2), and

Recognizing that in the US, many previously secure and well-paying jobs in diverse manufacturing industries have been exported oversees, leaving workers in the US to take lower wage non-unionized jobs (4), and

Recognizing that more people in the US feel stressed now than in 1985, because of time urgency and worries about gaining a sense of control over their lives (4); most with job stress rooted in heavy workloads and job insecurity combined with a lack of control over schedules and other factors (4); jobs which constrict learning and skill development; and they are characterized by a lack of free time and reduced energy, resulting in individual isolation, passive, destructive behavior, increased drug use, as well as a decline in participation in social and political institutions (5); and

For example, finding that health care workers, particularly those working in managed care institutions, are now finding that their job latitude and control which include their use of personal judgment is being undermined; yet these factors are critical to job satisfaction and to their own and their patients’ health; and

Recognizing that how much control a person has over his or her work is important because it affects how well he or she copes with the demands of his job (6); and that jobs that offer restricted opportunity to use skills combined with high job demands result in a high strain situation with heavy psychosocial costs in physical and mental health (7). The so-called job demand-control hypothesis that high decision latitude and low-to-moderate work demands are good for health and that high job demands and low decision latitude are bad; similarly, the effort-reward hypothesis postulates that the risk of ill-health is increased by an imbalance between efforts and rewards (8); such poorly-designed jobs are associated with negative health effects, including increased blood pressure (9); heart disease (10,14), fatigue and sleep disturbance (15,16) musculoskeletal disorders (17), absenteeism, job turnover, and increased acute injury rates (18,19) and adverse effects on family and social life outside the workplace (5); and

Realizing that additional types of job strain, such as lean production, in particular, cutting the number of workers while at the same time speeding up production, are associated with increased injury rates (20); many of these involve non-standard shifts associated in some studies with adverse health outcomes including heart disease (21); and

Whereas APHA has previously recognized the right to a healthful working environment (22) and the need to increase occupational disease prevention and increasing worker and union rights (23); there-fore urges that,

1. Reducing job strain and providing quality jobs are key to improving the health of workers; and
2. Improved job design depends on sustainable principles of social equity instead of short-term profitability and “lean production” (24).
3. That the Congress provide for additional occupational safety and health funding to:

  • convene employers and other professional organizations to develop research strategies and intervention methods to reduce job stress;
  • conduct further research on job stress and the mechanism of the observed increase in cardiovascular disease;
  • support investigation into job stress and its relationship to depression;
  • evaluate occupational differences and gender and ethnic differences in prevalence of job stress and resulting adverse health affects.



According to the authors of the recent Tokyo Declaration, we need to institute a program of “surveillance at individual workplaces and monitoring at national and regional levels in order to identify the extent of work-related stress health problems and to provide baselines against which to evaluate effects at amelioration. They recommend that workplaces assess both workplace stressors and health outcomes known to result from such exposures . . . on an annual basis.”(1)

Worksite screening should obtain prevalence data on cardionoxious exposures (e.g., job strain) and on work-related CVD. Worksite point estimates of BP (see Chapter 7) would be particularly useful, being inexpensive and relatively simple to obtain, with ambulatory BP monitoring performed whenever possible. Holter monitoring is needed to survey the prevalence of silent myocardial ischemia, and to assess other sensitive, noninvasive parameters such as heart rate variability. Carotid ultrasound is also an invaluable screening tool. The incidence of CVD events and standard cardiac risk factors should be systematically registered. Since many large companies require annual physical exams and collect much of the relevant data, it should be a relatively simple task to enter this information into a database and make it available to those concerned with worker health. Appropriate precautions to protect employee confidentiality must always be observed.(63)


Worksites identified as high risk for CVD should be targeted for interventions (see Chapter 13). Primary interventions would focus on creating a healthy workplace. For example, high-strain jobs could be redesigned to provide optimal levels of employee decision-making latitude and skill discretion, and workloads could be realistic, compatible with human capacity. Since the workplace appears to be a “leverage point” with regard to standard CVD risk factors (see Chapter 10), such interventions could have the additional benefit of lowering these risk factors.

A number of worksite intervention studies have specifically focused on reducing stressful features of work organization, and several have measured changes in CVD risk factors. Two Swedish studies exemplify interventions with some successes:
1. Employees of a large government agency participated in an intervention which included worker committees that developed and carried out action plans to reduce sources of workplace stress. A significant decrease in apolipoprotein B/apolipoprotein AI ratio occurred in the intervention group but not in the control group, an effect which could not be explained by smoking, eating, exercise, weight or other lifestyle factors. Stimulation from and autonomy over work significantly increased in the intervention group but remained the same in the control group.(50)
2. Researchers examined a new auto assembly work organization which contained small autonomous work groups having much greater opportunities to influence the pace and content of their work than either traditional assembly work or the Japanese management method of “lean production”. Workers in the flexible sociotechnical systems organization did not show increases in systolic BP, heart rate, and adrenaline during their work shift as did workers on a traditional assembly line. In addition, catecholamines showed more rapid “unwinding” (toward non-workday baseline levels) after work in the flexible organization, particularly for female workers.(43)

The workplace is also a good setting for interventions aimed directly at traditional risk factors, e.g., dietary interventions by improved nutrition in cafeterias, exercise programs, and medical treatment (e.g., for hypertension).

The Tokyo Declaration


The “triangular” Conference on “Work-Related Stress and Health in Three Postindustrial Settings – the European Union, Japan and the United States” – was held in Tokyo on 31 October – 1 November 1998 and sponsored by Tokyo Medical University and co-sponsored by the World Health Organization, International Labor Office, the European Commission, Japan Ministry of Labor, Japan Ministry of Health and Welfare, Tokyo Metropolitan Government, the United States National Institute of Occupational Safety and Health, Karolinska Institute, Japan National Institute of Industrial Health, Japan Industrial Safety and Health Association, Tokyo Citizens’ Council for Health Promotion, The Japanese Association of Stress Science, Japan Society for Occupational Mental Health, and the Section of Occupational Psychiatry of the World Psychiatric Association. Its 28 international scientists (Annex 1) from all three settings and relevant disciplines described and discussed:

o present conditions of work, stress and occupational health,

o foreseeable trends,

o needs for action, and

o needs for research, education, and information.

Discussions focused on the similarities and differences in all these respects between the three postindustrial settings. Agreement was reached concerning a number of conclusions and recommendations, including options for continued information exchange and concerted actions.

The conference participants are fully aware of the enormous environmental and health burden carried by workers in countries at earlier phases of industrial development. We envisage that their corresponding problems and solutions need to be given consideration.

This declaration is based on the philosophy of Investment for Health. According to a common dictionary the verb invest is defined as a commitment (of money or capital, technology, human resources, etc.) in order to gain a return, to spend or devote for future advantage or benefit. Consequently, an investment for health refers to a commitment of resources in order to gain a health and social return. Seen in such a way, the investment does not constitute a burden, rather an opportunity for increasing returns.

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