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].”

NEW SYSTEMS OF WORK ORGANIZATION: IMPACTS ON JOB CHARACTERISTICS AND HEALTH

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.

Occupational Stress Index (OSI)

THE OCCUPATIONAL STRESS INDEX: AN INTRODUCTION By Dr. Karen Belkic August, 2000

A BRIEF BACKROUND

The Occupational Stress Index (OSI) is an additive burden model, which focuses on work stressors relevant to the cardiovascular system (Belkic 1995(a)). The OSI incorporates elements of the Job Strain Model (Karasek 1979), as well as other formulations of how stress leads to cardiovascular disease, such as features of work in high-risk occupations. However, in contrast to constructs such as Job Strain (Ibid.) and Effort-Reward Imbalance (Siegrist 1991, 1996), which are based heavily upon sociological theory, the OSI derives more from cognitive ergonomics and brain research, attempting to describe, in quantitative terms, the burden of work processes upon the human being. The underlying motivation for developing such an approach is to help pinpoint areas for intervention, by striving to reflect actual work experiences.

There have been two major approaches in occupational psychosocial research using self-report methods. One has been to develop occupation-specific questions. This can provide rich, detailed information useful in identifying key areas for intervention. However, these job-specific questionnaires generally cannot measure job stressors across various occupations. The other approach has been to measure generic job characteristics using questions of a general nature. However, “this approach is less useful for intervention studies, because questions are more ‘remote from actual work experiences'” (Landsbergis 2000). The OSI represents a potential means of bridging these two divergent approaches. As stated by Landsbergis and Theorell (Ibid): ” A recent innovative approach used occupation-specific questions (useful for workplace interventions), that are based on general questions. The Occupational Stress Index (OSI) can be tailored to specific occupations, thus allowing comparison among occupations of the stress burden faced by workers” (p. 164). We can make comparisons regarding the total burden, as well as in the nature of the occupational stress burden. These questions are of interest not only in the research setting, but are also those articulated by working people themselves.

OM:STAR Sections on SURVEILLANCE and INTERVENTIONS

SURVEILLANCE

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)

INTERVENTIONS

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

PREAMBLE

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.

Reviews of: THE WORKPLACE AND CARDIOVASCULAR DISEASE

Occupational Medicine: State of the Art Reviews
THE WORKPLACE AND CARDIOVASCULAR DISEASE

Edited by Peter Schnall, Karen Belkic, Paul Landsbergis and Dean Baker
Published by Hanley & Belfus, Inc. Occup Med 15(1), 2000

———————————————————————————————————————————————————-

REVIEWS by:

1. Anders Knutsson, MD
Scand J Work Environ Health 2000;26(5):455

2. Hazards: April/June 2000

3. Norman M. Kaplan in Hypertension

Why the Workplace and Cardiovascular Disease? – CHAPTER 1

WHY THE WORKPLACE AND CARDIOVASCULAR DISEASE? (1)

By Peter Schnall, MD, Karen Belkic, MD, PhD, Paul Landsbergis, PhD, 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

(1) Schnall PL, et al. Why the workplace and cardiovascular disease? In: Schnall PL, Belkic KL, Landsbergis PA,

Baker DB, eds: The Workplace and Cardiovascular Disease. Occup Med 15(1), 2000, pp 1-5.

Link to pdf of Chapter 1.

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in the industrialized world.* While there have been trends towards lowered rates of CVD mortality in North America and Western Europe, CVD still represents a significant public health problem – indeed, a pandemic. In the former Soviet Union and other eastern European countries, CVD morbidity and mortality have increased dramatically over the last 30 years.(7) Rising prevalence rates also have been observed in many developing countries. Thus, “it has been projected that CVD worldwide will climb from the second most common cause of death . . . in 1990, to first place, with more than 36% of all deaths in 2020.”(5)

In the U.S. alone, CVD is the cause of 41% of all deaths.(2) An estimated 250,000-350,000 people annually die suddenly of heart disease in the U.S.,(3,6,10,18,20,21) and at least the same number lose their lives more slowly due to manifest CVD from which they have chronically suffered.
The dominant focus of research and intervention in the medical community has been on individual traits, especially genetic susceptibility and risky behaviors (e.g., smoking, over-eating, sedentary lifestyle) as playing a primary role in the etiology of CVD. The underpinnings of this explanation of the CVD epidemic lie in the development of powerful engineering models. Modern advances in the physical sciences lend themselves particularly well to the study of the cardiovascular system. Namely, it has appeared that CVD could be characterized as a disturbance in hydraulic (hemodynamic) and/or electrical (electrophysiologic) function.(5) Coronary atherosclerosis (i.e., vascular obstruction) has been designated as the “prime mover” of cardiovascular disorders, such that a series of atherogenic risk factors were sought, and many were identified (e.g., hypercholesterolemia, hypertension, diabetes, obesity). According to this view, the CVD epidemic can be curtailed by: 1. better management of atherogenic risk factors, 2. use of available medical treatments and more technological advances, and 3. additional research into the molecular biology of atherogenic and other cardiodegenerative processes.

It is indisputable that this approach represents an invaluable advance in our battle against CVD. Millions of people have been protected by quitting smoking, eating a “heart-healthy” diet, and exercising. And countless patients with manifest coronary heart disease (CHD) have been saved by percutaneous transluminal coronary angioplasty and coronary artery by-pass surgery, not to mention the life-saving armamentarium of pharmacologic agents we now have at our disposal. Cardiac pacemakers and automatic implantable cardioverter defibrillators provide hope for a normal life to many patients suffering from life-threatening cardiac rhythm and conduction disturbances. Only 50 years ago, nearly all of these patients would have been doomed.

Despite the optimism engendered by these achievements, we believe that a closer look at the overall public health impact of this traditional medical approach to CVD is in order. While these methods of electrical and hemodynamic systems are highly sophisticated, the etiology and pathogenesis of CVD cannot be reduced to a series of disordered pumps and electrical circuits. Furthermore, the intimate connections between the social environment and the central nervous system (CNS), and the CNS and the cardiovascular system via the autonomic nervous system, compel one to look beyond the cardiovascular system in isolation to fully appreciate how CVD develops.

In point of fact, both our understanding of the etiology of CVD and our ability to manage the epidemic are still limited. For example, the Framingham Heart Study used epidemiologic techniques to identify important risk factors (smoking, diabetes, hypertension, and cholesterol). However, these traditional risk factors explained only part of the risk for CHD.11 In practical terms, this means that these standard risk factors fail to predict many of the new CHD cases. Note that one of these factors – essential hypertension – is of practically unknown etiology. Moreover, these traditional risk factors represent relatively “proximate” causes of CVD; each of them, in turn, has a complex set of determinants, many of which are of psychosocial origin.

New developments expand and challenge the focus on these traditional, proximate risk factors. One of these is the emergence of research into behavioral factors that might influence the development of CVD. A notable example has been the formulation of the concept of CVD-prone behavior – the Type A behavior pattern (TABP).(9) While initial study results from the Western Collaborate Group Study indicated that TABP was a strong independent predictor of CHD mortality,(24) subsequent research has failed to substantiate these findings.(22) More recently, hostility – a component of Type A behavior – has emerged as a possible risk factor for CVD.(30)

The importance of the TABP is not so much its contribution to the explanation of CVD, but its laying the groundwork for social psychology to examine the impact of the social and psychological environment on CVD. TABP was a stepping-stone to the investigation of the role of the workplace in CVD.

This formulation regarding TABP is complemented by a body of epidemiologic literature which documents the strong role of social experiences, beginning in childhood and extending through working life and beyond, in shaping human behavior. For example, recent research has demonstrated that characteristics of people’s jobs, such as high or low decision-making authority, are associated with the development of specific complex behaviors and personality attributes.(4,14-16,27)

Another development that has expanded traditional cardiovascular epidemiology has been the field of social epidemiology, which examines factors such as social networks, social support, and social class as potential causes or modifiers of disease processes.(8,17,23,28) For example, social epidemiologists have demonstrated that lower socioeconomic status is an important risk factor for CVD.(12,19) Nonetheless, even with the inclusion of these social and behavioral factors, there is still a large amount of unexplained variance in CVD, as well as in essential hypertension.

We wish to argue that to better understand the CVD epidemic, social epidemiology needs to incorporate, in a much more prominent manner, a heretofore relatively neglected realm of social life – the workplace. We briefly present the case of essential hypertension (EH) as an illustration of our argument. EH is a major risk factor not only for CHD, but also for left ventricular hypertrophy, stroke, renal disease, and many other major pathologic processes. This disease afflicts 60 million Americans and 600 million people worldwide. The identified risk factors (i.e., obesity, salt intake, genetics, age, alcohol intake) explain only a small part of the risk.

Unhealthy Work: Causes, Consequences, Cures

1. Schnall PL, Dobson M, Rosskam E. (eds.) Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

ICOH 2012 venue moved to Cancun, Mexico

Based on the concerns of several ICOH members and travel advices issued by some Government Institutions regarding security issues in the Monterrey area in Mexico, and in consideration of the analysis made by the ICOH Officers and the National Organizing Committee, ICOH Board decided during the meeting held on February 2, 2011 in Milan, to move the congress venue to the city of Cancun, Mexico.

The dates and the scientific program will remain the same. All the relevant information are online on ICOH 2012 Congress website.