CSE Conferences and Meetings for 2010

The last meeting of the  California Work and Health Study Group was this past May, 2010 in Berkeley, California. These are regular meetings (three times/year) of colleagues in occupational health interested in discussing topical issues concerning the role of psychosocial factors at the workplace through the vehicle of the California Work and Health Study Group attended by 20 to 30 different researchers primarily from California.

As Chair of the ICOH Scientific Committee on Cardiology in Occupational Health 2005-2010 and as a current member of the ICOH Scientific Committee on Work Organization and Psychosocial Stressors Dr. Schnall chaired and helped organize several successful international meetings. He was invited to give several keynote addresses during 2010 at international conferences. He is also currently helping to organize a 3 day international conference to be held in Bogota, Colombia in October 2012 at the U. de los Andes sponsored by two Latin American research networks, RIPSOL and RIFAPT.

CSE Research Activities for 2010

The CSE’s research efforts are supported entirely by funds raised by contributions to the CSE or through contracts to evaluate worker health. The Center has developed and conducted occupational health projects with the support of 5 different unions and associated management groups over the last decade: HERE; UAW; CWA; IAFF; Orange County Fire Authority (Management).

CSE is finishing up a study conducted in November 2009 with Communications Workers of America (CWA) members employed as line-workers/technicians by Verizon in Southern California. Marnie Dobson (CSE Associate Director) prepared and presented a report to Verizon management and CWA representatives during a collective bargaining session in Southern Californiain March 2010. She also prepared a proposal outlining a study to be conducted in collaboration with Verizon Southern California and CWA to further study Verizon line workers and call-center workers. There has been no response from Verizon on this proposal. Marnie Dobson and Peter Schnall have published 2 abstracts presented at the November 2009 NIOSH Work and Health Conference in Puerto Rico describing the findings of work factors and health outcomes among CWA line workers.

The Center is currently involved in investigating work factors and their roles in obesity and hypertension among Orange County Firefighters (FF’s) in collaboration with the UCI Center for Occupational and Environmental Health.  Center staff at the UCI COEH recently wrote a successful two-year grant proposal to the CDC/NIOSH to study work characteristics, health behaviors and obesity risk in firefighters. The two-year study is currently underway at the UCI COEH as of November 2010 with collaboration from other CSE staff and is called the FORWARD project (Firefighter Obesity Research: Workplace Assessment to Reduce Disease)

FORWARD Project: Phase One of the project concluded with a last focus group (held on February 15th). The focus groups were conducted in order to revise/develop a firefighter work and health questionnaire. Phase Two to begin in May 2011 marks the beginning of recruitment and data collection. Our goal is to get 357 fire fighter respondents. Data collection is expected to take us into April of 2012. Phase Three is a sub-study, which begins sometime in June/July and takes us into December. It will include approximately 80 fire fighter participants who, for three days, will wear an accelerometer for physical activity monitoring and write what they eat in a food diary. Phase Four is ongoing and involves linking the WEFIT Clinical Data and the collection of BMI, body fat %, and CVD biological risk factors. OCFA archival data on call volume, etc., will also be collected. Phase Five, which will run between June and August of 2012 will involve holding new focus groups (to get feedback on the project and information collected therein), the submission of a final report to OCFA, along with an evaluation of the study and recommendations for prevention of obesity in OCFA fire fighters.

We have created a website for FF’s and the public to follow the progress of the project located at www.coeh.uci.edu/forward/index.htm. Please visit for more information and updates on our activities.


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California Work and Health Group – Meeting XXIV

The 24th Session of the California Work & Health Study Group was held at University of California on Friday May 14, 2010. The meeting was hosted by Paul Landsbergis and had three excellent presentations from June Fisher, Len Syme and Maria Hernandez. June Fisher presented her findings from the “MUNI Health & Safety Study” and talked about her international work on bus driver health. Len Syme & Maria Hernandez presented their work with CIGNA’s Communities for Health program and the development of Global Novations.

Introduction to Occupational Cardiology


Introduction By Karen Belkic MD, PhD, and Peter Schnall MD, MPH

Cardiologists and other clinicians handling hypertension and ischemic heart disease are routinely called upon to make a judgment about cardiovascular work fitness of their patients. Unfortunately, however, the more fundamental question has rarely been posed in the clinical context. Namely, is the work environment fit, or conducive to cardiovascular health?

As recently summarized in The Workplace and Cardiovascular Disease: Occupational Medicine State of the Art Reviews (13), a large body of epidemiological as well as physiologic evidence has now accumulated implicating a number of workplace factors in the etiology of hypertension and ischemic heart disease (IHD). The evidence is particularly strong and consistent with respect to exposure to high strain work and risk of hypertension and IHD. Calculations of Population Attributable Risk (PAR%) indicate that between 20 and 30% of cases of hypertension among working men could be prevented by eliminating exposure to job strain. PAR% estimates suggest that possibly an even greater percentage of cardiovascular disease could be prevented by eliminating exposure to job strain, together with sedentary work, shift work and physical and chemical noxins. Current Trends in working life characterized e.g., by a rising level of exposure to job strain and long and irregular work hours, portend that work-related hypertension and IHD will become an increasingly important problem in the years to come.

A Proposal for an Agenda for Occupational Cardiology: How do we move from Epidemiological Evidence to Prevention-oriented Clinical Practice?

Karen Belkic and Peter Schnall

Epidemiological Evidence-Convergent Validation of the Role of Workplace Factors in the Etiology of Hypertension and IHD

There is a burgeoning body of empirical investigation concerning the role played by workplace factors in the risk of hypertension and of ischemic heart disease (IHD) morbidity and mortality. The epidemiological evidence is most abundant and convincing with respect to psychosocial factors, especially job strain or its major components: high psychological demands and low decision-making latitude, as reviewed in: Ref. (10, 18, 40, 68, 69, 118). The association between exposure to job strain and cardiovascular disease is particularly pronounced among those with lower occupational status (37,49b, 136). Consistent data are also found for work requiring intensive effort, but providing relatively few rewards (“effort-reward imbalance”) (10, 81, 124,141). Furthermore, the combined effects of exposure to job strain and to effort-reward imbalance appear to be much stronger than the separate effects of each model (96). Night shift work (17, 59, 61, 88), long work hours (38, 49a, 127), exposure to noise (22, 29, 72, 132), temperature extremes (77, 145), as well as chemicals such as carbon monoxide, lead and carbon disulfide (43, 45, 63, 89, 93), inter alia, are also implicated, on the basis of positive epidemiological studies, as possible risk factors for hypertension and/or IHD.

Certain occupational groups with exposure to a large number of workplace stressors are found to be at high risk for developing hypertension and IHD. Here the evidence is strongest with respect to professional drivers (9, 139, 148), whose work requires the maintenance of sustained vigilance, whereby an error or momentary lapse of attention can have serious, potentially fatal consequences (“threat-avoidant vigilant work”), and who face a heavy overall burden from potentially cardio-deleterious workplace factors (7). Rosengren, Anderson & Wilhelmsen (109) found that the increased risk of coronary heart disease was independent of standard risk factor status. After a mean of 11.8 years of prospective study, these authors reported an odds-ratio (OR) of 3.3 (95% Confidence Interval (CI)=2.0-5.5) for coronary heart disease among 103 middle-aged male mass transit drivers in Gothenberg with respect to 6596 men from other occupational groups. After accounting for age, serum cholesterol, blood pressure, smoking, body mass index, diabetes, positive parental history of CHD and physical activity, as well as socio-demographic factors, the risk decreased only slightly (OR=3.0, 95% CI=1.8-5.2).

Finally, epidemiological studies among working people reveal that systolic ambulatory blood pressure (AmBP) is on the average 5mmHg higher during the hours on the job compared to leisure time (33, 117, 120) and that mean 24-hour AmBP is lower on non-work days compared to work days (101, 102). There is also evidence of a septadian overrepresentation of acute cardiac events on Mondays (106, 147), and automatic implantable cardioverter-defibrillators are seen to fire significantly more on Mondays (97). These findings corroborate the statements of Lown (78) that “the stress of work after a weekend of respite may have been the precipitants of lethal arrhythmias” (p. I-188) and of Willich and colleagues (147) that “an increase in physical and mental burden from leisurely weekend activities to stressful work on Monday in the majority of working patients” could be causally related to the occurrence of acute MI (p.90).

Shift Work and CVD

“People working evening, night, or rotating shifts have a slightly higher risk of heart disease [39]. Research on long work hours (overtime work) point to a wide variety of health effects, including increases in work accidents and injuries, musculoskeletal disorders, fatigue, psychological symptoms, unhealthy behaviors (such as smoking or alcohol use), cardiovascular risk factors (such as high blood pressure), and CVD [40-43]. Prolonged exposure to work may act to increase fatigue thereby increasing heart disease risk while rest breaks, days off, and vacations all provide relief and lower risk. The stress of returning to work after a weekend off increases risk as increased heart disease deaths have been reported for Mondays compared to other days of the week [44]. Beginning in 1958, research has suggested that long working hours may increase risk of heart disease [45-50]. Much research has been conducted in Asia, beginning with the interest in Japan about Karoshi—“sudden death from overwork” [51]. The impact of overtime on health may be greater for workers in stressful jobs, such as professional drivers [52], shift workers [43], and older workers [41, 53].”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

39. Steenland, K., Shift Work, Long Hours, and CVD: A Review, Occupational Medicine: State-of-the-Art Reviews, 15:1, pp. 7-17, 2000.

40. Spurgeon, A., J. M. Harrington, and C. L. Cooper, Health and Safety Problems Associated with Long Working Hours: A Review of the Current Position, Occupational and Environmental Medicine, 54:6, pp. 367-375, 1997.

41. Sparks, K., C. Cooper, Y. Fried, and A. Shirom, The Effects of Hours of Work on Health: A Meta-Analytic Review, Journal of Occupational and Organizational Psychology, 70, pp. 391-408, 1997.

42. van der Hulst, M., Long Workhours and Health, Scandinavian Journal of Work Environment and Health, 29:3, pp. 171-188, 2003.

43. Caruso, C., E. Hitchcock, R. Dick, J. Russo, and J. Schmit, Overtime and Extended Work Shifts: Recent Findings on Illnesses, Injuries, and Health Behaviors, NIOSH, Cincinnati, OH, pp. 1-49, 2004.

44. Barnett, A. and A. Dobson, Excess in Cardiovascular Events on Mondays: A Meta-Analysis and Prospective Study, Journal of Epidemiology and Community Health, 59:2, pp. 109-114, 2005.

45. Russek, H. I. and B. L. Zohman, Relative Significance of Heredity, Diet, and Occupational Stress in Coronary Heart Disease of Young Adults, American Journal of Medical Science, 235, pp. 266-275, 1958.

46. Theorell, T. and R. H. Rahe, Behavior and Life Satisfactions of Swedish Subjects with Myocardial Infarction, Journal of Chronic Disease, 25, pp. 139-147, 1972.

47. Alfredsson, L., C. Spetz, and T. Theorell, Type of Occupation and Near-Future Hospitalization for Myocardial Infarction and Some Other Diagnoses, International Journal of Epidemiology, 14, pp. 378-388, 1985.

48. Falger, P. R. J. and E. G. W. Schouten, Exhaustion, Psychologic Stress in the Work Environment and Acute Myocardial Infarction in Adult Men, Journal of Psychosomatic Research, 36, pp. 777-786, 1992.

49. Liu, Y. and H. Tanaka, Overtime Work, Insufficient Sleep, and Risk of Nonfatal Acute Myocardial Infarction in Japanese Men (the Fukuoka Heart Study Group), Occupational and Environmental Medicine, 59, pp. 447-451, 2002.

50. Sokejima, S. and S. Kagamimori, Working Hours as a Risk Factor for Acute Myocardial Infarction in Japan: Case-Control Study, British Medical Journal, 317, pp. 775-780, 1998.

51. Nishiyama, K. and J. V. Johnson, Karoshi—Death from Overwork: Occupational Health Consequences of Japanese Production Management, International Journal of Health Services, 27:4, pp. 625-641, 1997.

52. Raggatt, P., Work Stress among Long-Distance Coach Drivers: A Survey and Correlational Study, Journal of Organizational Behavior, 12, pp. 565-579, 1991.

March 5, 2008 Woodrow Wilson Presentation given by Dr. Peter Schnall

On March 5, 2008, participants from health, economic, academic, labor, and other sectors gathered at the Woodrow Wilson Center to discuss work’s contribution to public health and national economic costs. Research shows that employees facing high demands at their job, combined with low control over the work process or little reward, are more likely to die of heart disease and suffer from mental health problems than workers without such job stressors. The panelists of this event presented data on the relationship between work and health in order to illustrate its global impact. 

To watch Dr. Peter Schnall’s presentation visit the Woodrow Wilson Center page here.

The Physical Manifestations of Unhealthy Work

Dr. Peter Schnall, director of the Center for Social Epidemiology, opened the event by stating that “global epidemics are not natural”. Rather, they are products of globalization, the labor-intensive work organization it fosters, and increasing social inequality. “Globalization is contributing to a changing nature of work . . . which is contributing to poorer health of many peoples worldwide,” said Schnall. He described stress as a social process related to societal and occupational organization. The physical manifestations of stress and musculoskeletal disorders are caused by the high demands, long hours, job strain, effort-reward imbalance, and hazardous conditions of many work environments. Thus, the culpability of poor health outcomes, such as cardiovascular disease and mental health conditions, should not be placed on genes or individuals, but rather unhealthy working conditions. 

Schnall also noted that cardiovascular disease is currently the leading cause of death worldwide and its prevalence rate continues to rise in both developed and developing countries. According to the American Heart Association, cardiovascular disease causes around 40 percent of all U.S. deaths. Globally, 900 million people suffer from hypertension; approximately 60-80 million of them live in the United States. Schnall used his own research to demonstrate the relationship between job strain and cardiovascular disease, showing that blood pressure is elevated during work hours and sharply rises when demanding or stressful activities are performed. 

The Global Impact of Unhealthy Work Organization

Paul Landsbergis, associate professor of Community and Preventive Medicine at the Mount Sinai School of Medicine, continued the discussion by outlining the global impact of unhealthy work conditions. He focused on recent trends in work organization including, privatization, de-regulation, lean production techniques, income inequality, increasing contingent work, and longer work hours. “These overriding pressures force workers to work harder and longer,” said Landsbergis, as well as weaken job control and security, deteriorate social support, and elevate stress levels. He also explained that as developed countries strive to attract foreign capital, many businesses have adopted longer hours and more deadline pressures, often emphasizing quantity and speed over quality and safety. These conditions, along with forced and child labor, have made job conditions detrimental to workers’ health and family dynamics. 



The Mental Health Consequences of Work
Marnie Dobson, associate director of the Center for Social Epidemiology, addressed the mental health consequences of work, which are increasing along with health care and productivity costs. Currently, 9.6 percent of U.S. adults suffer from depression within a 12 month period. “Changes resulting from globalization and from work are key

contributing factors to depression and mental disorders,” stated Dobson. She also linked effort-reward imbalance and occupational position to depression and exposure to work stressors to mental fatigue, psychological distress, and sleep disorders. Dobson emphasized the importance of addressing the role that work plays, especially since the World Health Organization projects depression to be the second greatest contributor to the global disease burden by 2020. 

Finally, Dobson described how work-related illnesses have direct and indirect economic consequences including, high health insurance premiums, worker’s compensation costs, production losses due to sick and disability leave, and employee turnover. The top contributors to these costs include hypertension, heart attacks, and depression. She referred to one study that found that depression cost U.S. employers $44 billion in one year. Nevertheless, “business has really yet to focus on the deleterious effects of the workplace as a way to deter productivity losses and heath problems in their employees,” said Dobson.

Adopting Systematic Reform

Ellen Rosskam, public policy scholar at the Woodrow Wilson Center, called for the re-organization of work to protect employee health, and offered legislative strategies to reverse the grave trends outlined by the panelists before her. The presented solutions included more participatory action research, job re-design centered on reducing job strain, collective bargaining based on workplace democracy, and collaborative interventions that increased employee job control. Rosskam noted t

hat, “collaborative approaches in interventions have led to improved co-worker relations, better employment security, and stronger social support, which is an important buffer against job strain”. She also advocated for establishing a universal floor for basic social protection to promote health within the workplace. For the United States, this floor would include minimum staffing levels, bans on mandatory overtime, limits on work hours, and guaranteed paid family, vacation, and sick leave. 

Third Forum of the Americas on Psychosocial Factors

“Stress and Mental Health at Work”

October 14 – 16, 2010

Mexico City, Mexico

ICOH – WOPS Conference

“The Changing World of Work”

Driven by technological innovations, globalisation and demographic changes, the world of work is changing.

June 14 – 17, 2010

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