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.


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