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International Bus Driver Study Proposal

I. Introduction

Rationale – Bus drivers are well documented to have higher rates of bodily injury, psychological disorders and increased prevalence of hypertension. Yet, the specific causes of these health outcomes are still not well understood particularly with regard to obesity, and cardiovascular illnesses. Drivers are exposed to multiple risk factors on the job while driving that impact their health including noxious chemicals, demanding schedules, potentially dangerous environments including both driving and passengers, as well as a number of psychosocial work stressors such as job strain (work high in demands and low in control) inter alia. (See Special Issue of Studies of Urban Mass-Transit Operators of the Journal of Occupational Health Psychology Vol 3 Nº2, April 1998).

We are particularly interested in the role of work hours, scheduling, deadlines, constraints and organizational psychosocial stressors as they might contribute to fatigue, mental exhaustion, obesity, elevated blood pressure and safety issues. We believe the presence of many of these stressors negatively impacts on the drivers mental functioning and ability to carry out their jobs properly thus contributing to accidents.

I. Possible Goals of this proposed research project

1) To identify and compare the prevalence of accidents, cardio-metabolic risks factors and psychosocial work factors among the country participants
2) To examine the associations between work stressors, in particular psychosocial stressors and accidents, cardio-metabolic risks factors in bus drivers samples from Colombia, México, Switzerland, Poland and the USA.
3) To determine the statistical contribution of different aspects of work, individual factors, job stress (e.g. as explained by the job strain and effort-reward imbalance models) in accidents and cardio-metabolic indicators (e.g. obesity, blood pressure, heart rate) in bus drivers from different countries.

Question to discuss:

It is understood among us that the research goals in each country will reflect the specific problems and needs of each particular country. Nonetheless, the challenge for us is it possible to define a common goal (or goals) for all participant researchers that will allow valuable comparisons between countries. What exposures and outcomes as well as methods should be selected as common? This would be a central issue for discussion at our meeting Saturday am May 18th at 8am.

II. Possible Methods and Procedures

A common design for the International Study could be a cross-sectional study.

A, Outcomes of Interest:

1) Accidents. This variable could be measured by records of the organization or self-report of bus drivers
2) Fatigue and Emotional Exhaustion
3) Metabolic Syndrome: Includes Obesity, Blood Pressure, Glucose, Triglycerides and Cholesterol (depending of selected criteria). Self reported and objective measures of these variables should be discussed.
4) Hearth rate, HRV cardiovascular symptoms.
5) Self reported health and compensation and health insurance claims.

B. Exposures of interest:

1) Universal work place stressors: Job strain, ERI, Job insecurity
Specific work stressors: route, clerical requirements, type of passengers, etc.
2) Work hours
3) Scheduling
4) Shifts
5) Other

C. Methods of common interest

A. Qualitative methods including focus groups.
B. Ambulatory monitoring
One approach we wish to explore with transit drivers would involve ambulatory monitoring of bus drivers including measuring cortisol, blood pressure, heart rate, heart rate variability and activity with simple and inexpensive monitors that can be worn during working hours. 

For this procedure a feasibility study should be carried out or could be completed in sub-samples if it is not possible to do it in the complete sample.

Example of a Bus Driver Feasibility Pilot Study :

Goal: Demonstrate feasibility defined as safety and comfort of collecting ambulatory physiological data in a small group of firefighters.

Complete approvals

Ambulatory measures
1) Ambulatory bp (Spacelabs or Omron devices)
2) Cortisol (oral swab)
3) Activity monitor (worn on body)
4) Heart rate and heart rate variability (chest strap). This methodology is highly recojmmended due to ease of use and value of outcome data.

We would need 5-10 volunteers per project to wear equipment.

Key question. Can a Spacelabs ambulatory BP monitor be worn safely while driving?

1) Safety – automated monitor will grab and squeeze are for 45 seconds
2) Can Spacelab’s device obtain a reliable reading while driving?

Need 5-8 readings in a workday of blood pressure to get a reliable estimate of an individual’s bp.

An alternative a to Spacelab’s device would be an automated wrist device. This could be put on, triggered and bp collected in 60 seconds. Would need a repeated window during the day in which to obtain these readings. Drivers would need to be trained in its use. When do such opportunities present themselves during the day? Red lights, traffic jams, rest breaks (how many of these occur during the work day). If they occur every 2 hours this is not enough intervals to collect 5-8 readings.


Invitation to Participate in the California Local Organizing Committee

Also see our pages on LOC ParticipantsLOC Meeting Minutes and Panels.
California Colleagues,
As many of you know the 2013 Work Stress, and Health (WSH) Conference, co-sponsored by the American Psychological Association (APA), the Society for Occupational Health Psychology (SOHP), and the National Institute for Occupational Safety and Health (NIOSH) will be held in Los Angeles May 16-19th 2013 at the Westin Bonaventure Hotel and Suites.  The conference title is Work, Stress, and Health 2013: Protecting and Promoting Total Worker Health. The broad goal of this year’s conference is to highlight the concept of Total Worker HealthTM – a new approach to safeguarding the health and safety of workers. In accordance with this conference theme and in addition to usual conference topics (see below), the conference will give special attention to:
– Case reports and controlled studies on the effects of integrated health protection and health promotion interventions;
– Studies investigating the joint contribution of occupational and non-occupational factors to health and safety problems facing workers today;
– Strategies and best practices for implementing and evaluating integrated or holistic prevention programs;
– Merits, challenges, future directions, etc., relating to integrated prevention strategies;
– Training needs in order to advance research and practice relating to Total Worker HealthTM.
More information about the conference is available at http://www.apa.org/wsh/
The CSE has been asked by the conference planners to help organize a Local Organizing Committee (LOC). The charge to the local organizing committee is open-ended and below is a potential list of things to do that have been suggested by Gwen Keita, Ted Scharf and Wes Baker. 
This meeting gives us a wonderful opportunity to focus local, state and national attention on issues of occupational health and safety confronting Californians. 
We are planning several conference related activities and will use these to build a state-wide coalition of interested persons committed to improvements in occupational health in California.
Possible activities for the next year include:
                1) Identifying the occupational health needs of California now and for 2020
                2) Develop panels for inclusion in next year’s conference including:
                         A) Labor views on the workplace and occupational health
                         B) Minority needs
                         C) An occupational health agenda for 2020
                         D) A debate over Total Worker Health (the conference theme) and the best ways to introduce change at the workplace
                3) Expand and develop a network of individuals and companies committed to positive changes in California.
                        A) Examining the impact of austerity measures on California Occupational Health
                4) Work on items from the list below suggested by APA/NIOSH
We have held meetings in Southern California and  Northern California in conjunction with the California Work and Health Study Group to discuss these possibilities (see LOC Meeting Minutes). 
Please get back to me with your thoughts about all this and your interests.
Peter Schnall and Marnie Dobson for the CSE 

CWA Studies

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).

The CSE recently finished 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 Californian March 2010 and are in the mist of preparing a new proposal outlining a study to be conducted in collaboration with CWA and AT&T to further study line and call-center workers in Northern California. 

In 2011 the CSE submitted a proposal to Communications Workers of America (CWA) for a cross-sectional survey of AT&T technicians in California. We estimate the survey should be completed by approximately 600-800 technicians at 16-20 randomly selected worksites. This will give us sufficient statistical power to find credible associations between workplace stressors and self-reported health outcomes such as hypertension, cholesterol, obesity, burnout and psychological distress. We also recommend a random sample of N=200, among the participants of the survey population to collect physiological measurements such as work-site blood pressures, and height and weight. These “hard” outcomes are well established risk factors for CVD and are associated with work-related stressors and will add credibility to the study.

Our approach in previous research with CWA has included close consultation with CWA representatives and technicians and we strongly urge that this be repeated in a California study. Participatory Action Research (PAR) is an approach to conducting research which involves fostering a partnership between researchers and working people whereby the interests and knowledge of working people inform the research questions and process. PAR de-centers the research process to involve and empower those being studied to prioritize their concerns, gain knowledge about research processes from the academic researchers, foster successful participation among colleagues, and help interpret findings and develop recommendations for workplace change.

UCI Firefighter Obesity Research Project: Workplace Assessment to Reduce Disease (FORWARD)

Visit the FORWARD Study Website at: http://www.coeh.uci.edu/forward/

Firefighter Obesity Research: Workplace Assessment to Reduce Disease (FORWARD) is a 2-year project of the UCI-COEH, funded by the Center for Disease Control and Prevention/National Institute for Occupational Safety and Health (Award #: 1 R21 OH009911-01). The study will consider the unique working conditions and health behaviors of firefighters who work on a 24 hour-shift system. This will allow in the end to develop a firefighter-relevant work and health questionnaire along with several recommendations to reduce the obesity risk of firefighters. We propose this as an exploratory study which meets the public safety sub-sector strategic goals 1.4 and 1.5 of the National Occupational Research Agenda (NORA) and the Research to Practice (r2P) initiatives at the National Institute for Occupational Safety and Health.

NIOSH Exploratory and/or Developmental Grant Program (R21) 


PI: Choi, BongKyoo

Co-investigators: Schnall Peter MD, Leslie Israel MD, Marnie Dobson PhD, Pietro Galassetti MD, Dean Baker MD, Paul Landsbergis PhD (consultant).

Project Summary/Abstract

Among 41 male-dominated occupations, firefighters have the third highest prevalence rate of obesity. Few studies have examined the roles of working conditions and health behaviors of firefighters in obesity. In addition, few validated instruments — a methodological prerequisite for obesity studies in firefighters — are available that specifically assess the unique working conditions and health behaviors of firefighters who work on a 24 hour-shift system. Our long-term goals are to elucidate the roles of working conditions and health behaviors in the development of obesity among firefighters and to use this information to design and conduct intervention studies that lower CVD risk factors among firefighters by changing working conditions and health behaviors. The main aims of this proposal are a) to develop and validate a firefighter-relevant work and health questionnaire using qualitative and quantitative methods in firefighters enrolled in the Orange County Fire Authority (OCFA) Wellness Fitness (WEFIT) Program, b) to use this questionnaire in an epidemiological study to explore whether adverse working conditions and health behaviors are risk factors for obesity in firefighters, and c) to explore the interrelations between working conditions and health behaviors as they relate to obesity. A supplementary objective is to evaluate the strengths and weaknesses of Body Mass Index (BMI) as a measurement (commonly used as a surveillance measure of obesity in many WEFIT programs for firefighters) in comparison with skinfold-based body fat percent. For the purposes of this study, we will use a participatory action research (PAR) approach to build a work group of firefighters and researchers to develop and validate a questionnaire for assessing working conditions and health behaviors of firefighters. The developed questionnaire will be completed by about 350 OCFA firefighters over 15 months. A subsample of the firefighters (n=80) will be recruited to complete a 3-day food record and to wear an accelerometer during the same 3 days, and to fill in a short-form of the questionnaire for a one-week test and retest reliability. In addition, for analyses, the records of the WEFIT medical and fitness exams (Body Mass Indexes, body fat %, VO2 max, blood pressures, and blood lipid profiles) of the participants and archival records of 2004-2011 annual calls by each local OCFA fire station will be linked to the exposure profiles. At the end of this project a firefighter-relevant work and health questionnaire will have been developed, along with several recommendations to reduce the obesity risk of OCFA firefighters. We propose this as an exploratory study which meets the public safety sub-sector strategic goals 1.4 and 1.5 of the National Occupational Research Agenda (NORA) and the Research to Practice (r2P) initiatives at the National Institute for Occupational Safety and Health.

CSE Education Activities for 2010

CSE Staff and Consultants teach a Work and Health Course at UCLA one semester each year and have, over the last ten years, provided over 100 students with skills on conducting surveillance at the workplace and measurement of exposures and outcomes such as blood pressure.

The CSE sponsors a number of education activities including 1) a course at UCLA (Work and Health), 2) a course at UCI of Occupational Cardiology, 3) conferences and workshops in international settings, and 4) regular meetings of the  California Work and Health Study Group (last held this past May 2010 in Berkeley).

The Center is involved in the preparation and publication of scientific articles and books. CSE is proud to have had two books published during the past decade each with over 30 internationally recognized authors; the first, The Workplace and Cardiovascular Disease published by Hanley and Belfus in 2000 and the second, Unhealthy Work: Causes, Consequences, Cures published by Baywood in 2009. In 2010 book parties were held in Los Angeles and Berkeley to promote Unhealthy Work at which several of the books editors gave presentations.

The Center is excited to have just had Unhealthy Work translated by colleagues into Korean and Spanish. The Korean version was published in September 2010, Seoul, Korea by GyeChuk Mun Wha Sa (Publisher) while the University de Los Andes in Bogota, Colombia is publishing the Spanish version edited by Dr. Viviola Gomez, Department of Psychology.

During 2010, CSE consultants have prepared multiple abstracts, some based on a pilot web survey of Orange County Fire Authority (OCFA) firefighters conducted with colleagues at the UCI COEH. Several abstracts were accepted as oral presentations, a few others as poster presentations at the 4th International Conference of Occupational Health (ICOH) Work Organization and Psychosocial Stressors (WOPS) conference in Amsterdam in June 2010.

Paul Landsbergis, consultant to the CSE, with Peter Schnall, recently published a book chapter on job strain and cardiovascular disease for the second edition of the Handbook of Occupational Health Psychology. He is in the process of working on several new manuscripts, including a meta-analysis of job strain and ambulatory blood pressure (in collaboration with Marnie Dobson and Peter Schnall of the CSE) and a study of job strain and masked hypertension. Additionally, Paul authored papers for the 2010 Global Obesity Summit recently held in Jackson, Mississippi.

BongKyoo Choi, consultant to the CSE, published papers on work and obesity during 2010 in the American Journal of Industrial Medicine and the International Journal of Occupational Medicine and Environmental Health.. His other research on work and obesity using a US national dataset was well received at the 2010 ICOH-WOPS conference in Amsterdam, the Netherlands (Best Abstract Award and 2010 Global Obesity Summit, Jackson, MS (New Investigator Travel Award). In addition, he submitted a critical commentary to NIH on their draft strategies for research into obesity.

The Center also considers the education of the public one of its main goals. To support this aim, the Center’s Informations Systems Manager (ISM), Erin Wigger, moderates a network of health professionals through several listservs and manages a website using web design software (Dreamweaver).

Expansion of the ISM’s role at the Center includes broadening the Center’s fundraising efforts, the redesign of the Center’s Job Stress Network website as well as the creation and development of a blog and new website based on the Center’s recently published book, Unhealthy Work: Causes, Consequences, Cures, Baywood, 2009. This website represents the first of the Center’s efforts to begin presenting information on work and health to the lay-public.

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.

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.

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. 

California Work and Health Group (CWHG) Mission Statement

Drafted by: Karen Belkic, Paul Landsbergis and Peter Schnall

What is our purpose for doing research?

  • To prevent ill-health
  • To make healthy work a reality
  • To help humanize the workplace

How is this research to be conducted?

  • Based on sound scientific principles.
  • With rigorous criteria of reliability, validity and study design.
  • With ethics, ethics, ethics (explicate).
  • With recognition of the difficulties of the conduction of psychosocial stress research.
  • With participatory research which involves employees and employers in the research process & in their own salutogenesis.
  • Coordinated with other centers of research aiming toward multicenter intervention trials.
  • With researchers that are interactive and egalitarian.
  • With colleagues from other groups to co-author papers in their areas of expertise.
  • With an international perspective.
  • Collaboratively with trade unions, businesses and government agencies.

What are our responsibilities?

  • To all working people in their efforts to humanize the work place.
  • To enter public debate by the dissemination of our research findings through scientific journal articles and public education materials.
  • To oppose classism, sexism and racism in our own professional work.
  • To be prepared to debate social issues and challenge the systems that maintain the status quo at the expense of one group over another.
  • To exercise and/or develop scientific solidarity.
  • To maximize intellectual debate and dialog.
  • To provide support for each other and concrete aid in our efforts.
  • To be open on our parts to feedback.
  • To be honest about the limitations of our work.
  • To provide opportunities to discuss and reflect about difficult issues.
  • To review each others articles.
  • To acknowledgment each others reviews.
  • To respect each others work in progress (scientific integrity).
  • To challenge the dominant mode of doing research, where someone else’s success is a threat to ourselves.
  • On the contrary, To celebrate each others success.
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