The Workplace and Cardiovascular Health: Conclusions and Thoughts for a Future Agenda (1)
By Karen Belkic, MD, PhD, Peter Schnall, MD, Paul Landsbergis, PhD, and Dean Baker, MD.
Reproduced with the permission of Hanley & Belfus, Inc., 210 South 13th Street, Philadelphia, PA, 19107. Phone: 215-546-7293.

Web site: www.hanleyandbelfus.com.
http://www.hanleyandbelfus.com/REVIEWS/om.html (1) Belkic KL, Schnall PL, Landsbergis PA, Baker D. Conclusions and thoughts for a future agenda regarding the workplace and cardiovascular health. In: Schnall PL, Belkic KL, Landsbergis PA, Baker DB, eds: The Workplace and Cardiovascular Disease. Occup Med 15(1), 2000, pp 307-321.



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).


We will need societal measures to support the above initiatives. Japan and much of Western Europe have taken the lead in passing legislation making certain forms of work stress illegal and mandating healthy work. An example is the Swedish Work Environment Act (Act No. 677, amended in 1991) which states:

· Working conditions shall be adapted to people’s differing physical and psychological circumstances.
· Employees shall be enabled to participate in the arrangement of their own job situations as well as in work changes and development that affect their jobs.
· Technology, work organization, and job content shall be arranged so that the employee is not exposed to physical or mental loads that may cause ill health or accidents.
· The matters to be considered in this context shall include forms of remuneration and the scheduling of working hours.
· Rigorously controlled or tied work shall be avoided or restricted.
· It shall be the aim of work to afford opportunities for variety, social contacts, and cooperation, as well as continuity between individual tasks.
· It shall further be the aim for working conditions to afford opportunities for personal and occupational development as well as for self-determination and occupational responsibility.

A prerequisite to implementing a “healthy work” policy is the establishment of a system of workplace surveillance to identify high-risk work environments. This, however, remains to be achieved on a broad scale.

Secondly, we may need legislation intended to provide companies with incentives to accomplish these goals. This could include a national tax on companies with excess levels of job-related risk factors and/or CVD outcomes (see Chapter 11). In this way, businesses would be encouraged to reassess their workplaces to lower job strain and other cardionoxious exposures.Finally, in the U.S. we will need national legislation mandating a healthy workplace, similar to the laws passed in Europe and Japan (see Chapter 12).

We concur with the conclusions of the European Heart Network on Social Factors, Work, Stress, and Cardiovascular Disease in the European Union that “the substantial scientific basis of the association of psychosocial factors and cardiovascular disease risk . . . (should) ensure that social, occupational, and individual factors will not be left off the health agenda.”(34) These protective steps are important to reduce the likelihood that working men and women are exposed to cardionoxious risk factors at the workplace. They recognize that today’s stressful jobs are the result of human design and thus amenable to change. But taken as a totality the steps outlined above are basically a defensive strategy which fails to address the human need for fulfilling work, work that satisfies human needs for dignity, creativity, and a sense of worth.

We have now reached the point where it is possible to design work that promotes health and well-being. It is not demanding work per se that is harmful, but work without control over how one meets the job demands or uses one’s skills. Tomorrow’s jobs will be deliberately crafted to allow the full development of the human spirit through work which encourages – not discourages – human potential. This means creating a work environment that is conducive to human mental and physical health. A key characteristic of a “health-liberating” work environment will be the full participation of all working people in the decision-making processes surrounding the organization of work.

Note: Some material adapted by permission from Landsbergis, et al; reference 36a. Copyright 1999 by the Educational Publishing Foundation.


1.The Tokyo Declaration. J Tokyo Med Univ 56:760-767, 1998.
2.Alfredsson L, Spetz C, Theorell T: Type of occupation and near-future hospitalization for myocardial infarction and some other diagnoses. Int J Epidemiol 14:378-388, 1985.
3.Belkic K, Savic C, Theorell T, et al: Mechanisms of cardiac risk among professional drivers. Scand J Work Environ Health 20:73-86, 1994.
4.Berkman L: The role of social relations in health promotion. J Psychosom Res 57:245-254, 1995.
5.Bond JT, Galinsky E, Swanberg JE: The 1997 National Study of the Changing Workforce. New York, Families and Work Institute, 1998.
6.Bosma H, Peter R, Siegrist J, Marmot M: Two alternative job stress models and the risk of coronary heart disease. Am J Pub Health 88:68-74, 1998.
7.Brandt LPA, Nielson CV: Job stress and adverse outcome of pregnancy: A causal link or recall bias? Am J Epidemiol 135:302-311, 1992.
8.Cooper C: Working hours and health. Work Stress 10:1-4, 1996.
9.European Foundation: Time constraints and autonomy at work in the European Union. Dublin, European Foundation for the Improvement of Living and Working Conditions, 1997.
10.Falger PRJ, Schouten EGW: Exhaustion, psychologic stress in the work environment, and acute myocardial infarction in adult men. J Psychosom Res 36:777-786, 1992.
11.Falk A, Hanson BS, Isacsson SO, Ostergren PO: Job strain and mortality in elderly men: Social networks, support, and influence as buffers. Am J Public Health 82:1136-1139, 1992.
12.Ferrie JE, Shipley MJ, Marmot M, et al: The health effects of major organizational change and job insecurity. Soc Sci Med 46:243-254, 1998.
13.Forsman L: Individual and group differences in psychophysiological responses to stress with emphasis on sympathetic-adrenal medullary and pituitary-adrenal cortical responses. Stockholm, Department of Psychology, University of Stockholm, 1983.
14.Fredriksson M, Sundin O, Frankenhaeuser M: Cortisol excretion during the defense reaction in humans. Psychosom Med 47:313-319, 1985.
15.Gaillard AWK: Comparing the concepts of mental load and stress. Ergonomics 36:991-1005, 1993.
16.Genes N, Vaur L, Renault M, et al: Rythme circadien des infarctus du myocarde en France: resultats de l’etude USIK (Circadian patterns of myocardial infarction in France: Results of the USIK study). La Presse Medicale 26:603-608, 1997.
17.Gonzalez MA, Artalejo FR, Calero JR: Relationship between socioeconomic status and ischaemic heart disease in cohort and case-control studies:1960-1993. Int J Epidemiol 27:350Ð358, 1998.
18.Hallqvist J, Diderischsen F, Theorell T, et al: Is the effect of job strain on myocardial infarction due to interaction between high psychological demands and low decision latitude? Results from Stockholm Heart Epidemiology Program. Soc Sci Med 46:1405-1415, 1998.
19.Hayashi T, Kobayashi Y, Yamaoka K, Yano E: Effect of overtime work on 24-hour ambulatory blood pressure. J Occup Environ Med 38:1007-1011, 1996.
20.Henningsen GM, Hurrell JJ, Baker F, et al: Measurement of salivary immunoglobulin A as an immunologic biomarker of job stress. Scand J Work Environ Health 18 Suppl 2:133-136, 1992.
21.House JS, Landis KR, Umberson D: Social relations and health. Science 241:540-545, 1988.
22.International Labour Office: Key Indicators of the Labour Market 1999. Geneva, International Labour Office, 1999.
23.Johnson JV: Collective control: Strategies for survival in the workplace. Int J Health Services 19:469-480, 1989.
24.Johnson JV, Hall EM: Class, work, and health. In Amick B, Levine S, Tarlov AR, Walsh DC (eds): Society and Health. New York, Oxford University Press, 1995, pp 247-271.
25.Johnson JV, Hall EM: Job strain, workplace social support, and cardiovascular disease: A cross-sectional study of a random sample of the Swedish working population. Am J Public Health 78:1336-1342, 1988.
26.Johnson JV, Hall EM, Theorell T: Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working population. Scand J Work Environ Health 15:271-279, 1989.
27.Kaplan G, Pamuk E, Lynch JW, et al: Inequality in income and mortality in the United States: Analysis of mortality and potential pathways. Br Med J 312:999-1003, 1996.
28.Kaplan GA, Keil JE: Socioeconomic factors and cardiovascular disease: A review of the literature. Circulation 88:1973-1998, 1993.
29.Karasek R, Theorell T: Healthy Work: Stress, Productivity, and the Reconstruction of Working Life. New York, Basic Books, 1990.
30.Karasek RA: Job demands, job decision latitude, and mental strain: Implications for job redesign. Adm Sci Q 24:285-308, 1979.
31.Karasek RA: Job socialization and job strain: The implications of two related psychosocial mechanisms for job design. In Gardell B, Johansson G (eds): Working Life. London, Wiley, 1981.
32.Kawachi I, Marmot M: What can we learn from studies of occupational class and cardiovascular disease? Am J Epidemiol 148:160-163, 1998.
33.Kennedy BP, Kawachi I, Prothrow-Stith D: Income distribution and mortality: Cross-sectional ecological study of the Robin Hood index in the United States. Br Med J 312:1004-1007, 1996.
34.Kristensen TS, Kronitzer M, Alfedsson L: Social factors, work, stress, and cardiovascular disease prevention. Brussels, The European Heart Network, 1998.
35.Landsbergis PA: Occupational stress faced by health care workers: A test of the job demand-control model. J Organiz Behav 9:217-239, 1988.
36.Landsbergis PA, Cahill J: Labor union programs to reduce or prevent occupational stress in the United States. Int J Health Services 24:105-129, 1994.
36a.Landsbergis PA, Cahill J, Schnall P: The impact of lean production and related new systems of work organization on worker health. J Occup Health Psychol 4:108-130, 1999.
37.Landsbergis PA, Hatch MC: Psychosocial work stress and pregnancy-induced hypertension [see comments]. Epidemiology 7:346-351, 1996.
38.Lown B: Sudden cardiac death: Biobehavioral perspective. Circulation 76 Suppl I:I186-I195, 1987.
39.Lynch J, Krause N, Kaplan GA, et al: Workplace demands, economic reward, and progression of carotid atherosclerosis. Circulation 96:302-307, 1997.
40.Marmot M, Rose G, Shipley M, et al: Employment grade and coronary heart disease in British civil servants. J Epid Commun Health 32:244-249, 1978.
41.Marmot MG, Bosma H, Hemingway H, et al: Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 350:235-239, 1997.
42.McIsaac SJ, Wilkinson RG: Income distribution and cause-specific mortality. Eur J Public Health 7:45-53, 1997.
43.Melin B, Lundberg U, Soderlund J, Granqvist M: Psychophysiological stress reactions of male and female assembly workers: A comparison between two different forms of work organization. J Organiz Behav 20:47-61, 1999.
44.Mishel L, Bernstein J: The state of working America. Washington, DC, Economic Policy Institute, 1998.
45.Moon SD, Sauter SL: Beyond Biomechanics: Psychosocial Aspects of Musculoskeletal Disorders in Office Work. London, Taylor & Francis, 1996.
46.Muller JE, Ludmer PL, Willich SN, et al: Circadian variation in the frequency of sudden cardiac death. Circulation 75:131-138, 1987.
47.Neerincx MA, Griffoen E: Cognitive task analysis: Harmonizing tasks to human capacities. Ergonomics 39:543-561, 1996.
48.Olsen O, Kristensen TS: Impact of work environment on cardiovascular diseases in Denmark. J Epidemiol Community Health 45:4-10, 1991.
49.Orth-Gomer K: International epidemiological evidence for a relationship between social support and CVD. In Shumaker SA, Czajowski SM (eds): Social Support and Cardiovascular Disease. New York, Plenum Press, 1994, pp 97-117.
50.Orth-Gomer K, Eriksson I, Moser V, et al: Lipid lowering through work stress reduction. Int J Behav Med 1:204-214, 1994.
51.Peter R, Hallqvist J, Reuterwall C, et al: Psychosocial work environment and myocardial infarction: Improving risk prediction by combining two alternative job stress models in the SHEEP Study. (Submitted), 1999.
52.Peter RW, McQuillan S, Resnick SK, Gold MR: Increased Monday incidence of life-threatening ventricular arrhythmias: Experience with a third-generation implantable defibrillator. Circulation 94:1346-1349, 1996.
53.Rabkin SW, Mathewson FAL, Tate RB: Chronobiology of cardiac sudden death in men. JAMA 44:1357-1358, 1980.
54.Richardson D, Loomis D: Trends in fatal occupational injuries and industrial restructuring in North Carolina in the 1980s. Am J Public Health 87:1041-1043, 1997.
55.Rosamond WD, Chanbless LE, Folsom AR, et al: Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994 [abstract]. New Engl J Med 339:863, 1998.
56.Rozanski A, Blumenthal JA, Kaplan J: Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 99:2192Ð2217, 1999.
57.ÊSchnall PL, Landsbergis PA, Baker D: Job strain and cardiovascular disease. Annu Rev Public Health 15:381-411, 1994.
58.Schnall PL, Landsbergis PA, Schwartz J, et al: A longitudinal study of job strain and ambulatory blood pressure: Results from a 3-year follow-up. Psychosom Med 60:697-706, 1998.
59.Schnall PL, Pieper C, Schwartz JE, et al: The relationship between job strain, workplace diastolic blood pressure, and left ventricular mass index. Results of a case-control study [published erratum appears in JAMA 1992 Mar 4;267(9):1209]. JAMA 263:1929-1935, 1990.
60.Siegrist J: Threat to social status and cardiovascular risk. Psychother Psychosom 42:90-96, 1984.
61.Siegrist J, Peter R: Measuring effort-reward imbalance at work: Guidelines. Dusseldorf, University of Dusseldorf, 1996.
62.Stansfeld SA, North FM, White I, Marmot MG: Work characteristics and psychiatric disorder in civil servants in London. J Epidemiol Commun Health 49:48-53, 1995.
63.Stokols D, Pelletier KR, Fielding JE: Integration of medical care and worksite health promotion. JAMA 273:1136-1142, 1995.
64.Sytkowski PA, D’Agostino RB, Belanger A, Kannel WB: Sex and time trends in cardiovascular disease incidence and mortality: The Framingham Heart Study, 1950-1989. Am J Epidemiol 143:338Ð350, 1996.
65.Theorell T, de Faire U, Johnson J, et al: Job strain and ambulatory blood pressure profiles. Scand J Work Environ Health 17:380-385, 1991.
66.Theorell T, Karasek R: Should heart attack patients return to stressful jobs? Stress Med 11:219-220, 1995.
67.Tofler GH: Triggering and the pathophysiology of acute coronary syndromes. Am Heart J 134:S55-S61, 1997.
68.Tuchsen F: Working hours and ischaemic heart disease in Danish men: A 4-year cohort study of hospitalization. Int J Epidemiol 22:215-221, 1993.
69.Tuchsen F, Endahl LA: Increasing inequality in ischaemic heart disease morbidity among employed men in Denmark 1981-1993: The need for a new preventive policy. Int J Epidemiol 28:640-644, 1999.
70.Uehata T: Long working hours and occupational stress-related cardiovascular attacks among middle-aged workers in Japan. J Human Ergol 20:147-153, 1991.
71. U.S. Departments of Labor and Commerce: Fact Finding Report. Commission on the Future of Worker-Management Relations. Washington, DC, U.S. Departments of Labor and Commerce, 1994.
72.Vahtera J, Kivimaki M, Pentti J: Effect of organizational downsizing on health employees. Lancet 350:1124-1128, 1997.
73.Walters D: Health and safety strategies in a changing Europe. Int J Health Services 28:305-331, 1998.
74.Weinberg D: A brief look at postwar U.S. income inequality. Washington, DC, U.S. Census Bureau, Current Population Reports, 1996.
75.Wilkinson RG: Unhealthy Societies: The Afflictions of Inequality. London, Routledge, 1996.
76.Willich SN, Lewis M, Lowel H, et al: Physical exertion as a trigger of myocardial infarction. Triggers and mechanisms of myocardial infarction study group. N Engl J Med 329:1684-1690, 1993.
77.Willich SN, Lowel H, Lewis M, et al: Weekly variation of acute myocardial infarction: Increased Monday risk in the working population. Circulation 90:87-93, 1994.
78.Wilson PWF, D’Aostino RB, Levy D, et al: Trends in coronary heart disease: A comparison of the original (1956-1968) and offspring Framingham Study cohorts. Anaheim, CA, American Heart Association, 1991.
79.Wing S, Dargent-Molina P, Casper M, et al: Changing association between community structure and ischaemic heart disease mortality in the United States. Lancet 2:1067-1070, 1987.
80.Wolff E: Top heavy: A study of wealth inequality in America. New York, Twentieth Century Fund Press, 1995.

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