Tage S. Kristensen

Psychosocial DepartmentNational Institute of Occupational Health

Copenhagen, Denmark

27th International Congress on Occupational Health

Iguassu Falls, Brazil

L:\PSA01\8. PERSONLIGE ARKIVER\LNA\Forskere\Tage

ICOH-Symposium on Psychosocial Factors

Cardiovascular mortality for Danish men.

FarmersArchitectsMilitary officersProfessorsGardenersDoctors

All employed men

JournalistsSailorsBus driversCooksWaitersSalvage corps driversRestaurant ownersTaxi drivers

676869717577

100

121122127135150150162185

SMR

Heart disease and work

”Little is known about occupational risks

for coronary heart disease”

Kyle Steenland. NIOSH. Am J Ind Med 1996;30:495-9

The connection betweenwork and CVD

General model for the relationship between work environment and cardiovascular

diseases

WORKENVIRON-

MENT

CARDIO-VASCULAR DISEASES

CVD risk factors:Diet obesity,

blood pressure,smoking etc.

3

1 2

THE SIGNIFICANCE OF WORK: 1+3

Work and deathHow many deaths are due to working conditions?

Men Women Total

Death, all causes 10% 2% 7%

Heart disease 19% 9% 17%

Stroke 12% 8% 11%

Cancer 14% 2% 8%

Respiratory diseases 7% 1% 4%

Accidents, violence 4% 0.4% 3%

All proportions apply to Finland

Nurminen & Karjalainen. Scand J Work Environ Health 2001;27:161-213.

The impact of work on cardiovascular diseases

Etiologic fraction Men 16%

Women 22%

Etiologic fraction IHD 17%

Stroke 11%

Nurminen & Karjalainen. Scand J Work Environ Helath 2001;27:161-213.

Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10

Empirical evidence

Etiological fractions of work environment for cardiovascular diseases in Denmark

(Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10)

Proportion of CVD

Risk factor Men Women

”Sedentary” work 42% 42%

Job Stressors 6% 14%

Shift & night work 7% 7%

Noise 1% 1%

Chemical exposures 0-1% 0%

Passive smoking 2% 2%

All factors 51% 55%

All factors except sedentary work 16% 22%

100

193215

168 172

0

50

100

150

200

250

Day Night Lateevening

24 hourrosters

Otherirregular

(4 years of follow-up. N=407,000)

Standardized Hospitalization Ratios (SHR’s) for IHD among Danish men aged 20-59 years

(Tüchsen. Int J Epidemiol 1993;22:215-21)

SHR

Relative risk of IHD among shift workers15 years of follow-up

0

0,5

1

1,5

2

2,5

3

0 2-5 6-10 11-15 16-20 21+

Years of shift work

1

1.5

22.2

2.8

0.4

RR

(Knutsson et al. Lancet 1986;II:89-92

3

2.5

2

1.5

1

0.5

0

Work noise and AMI

0

0,5

1

1,5

2

2,5

3

3,5

4

Type writer El. lawn mower El. drill Road drillNoise level:

OR (adjusted)

A case control study of 395 cases and 2,148 controls from Berlin.

Ising et al. Soz Präventivmed 1997;42:216-22.

1.0

1.4

2.0

3.84

3.5

3

2.5

2

1.5

1

0.5

0

The two main psychosocial models on work and CVD

The job strain model

– demands– control– support

The effort reward imbalance model

– effort (extrinsic)

– rewards (money, esteem, career opportunities)– personality (instrincis effort – overcommitment)

Good – but not excellent – empirical support for the two models

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

Hospital admission for CVD in a group of unemployed men compared with a control group

0.80

1.04

1.60

(Iversen et al. BMJ 1989;299:1073-6)

1.6

1.4

1.2

1

0.8

0.6

0.4

0

RR

0.2

Beforefactory closure

(2 years)

Duringfactory closure

(3 years)

Afterfactory closure

(3 years)

Issues in research

and prevention

The cardiovascular tradition from Framingham and onwards.

Physiological:

• Cholesterol

• Fibrinogen

• Triglycerides

• Glucose

• Blood pressure

• Heart rate

• Obesity

Behavioral:

• Smoking

• Physical inactivity

• Type A

• Salt intake

• Diet

• Alcohol

Risk factors are individual.

The individualistic bias of cardiovascular epidemiology and prevention

Sampling: Representative samples of individuals

Variables: Physiological and behavioral factors

Risk factors: Individual characteristics (e.g. high cholesterol) or behaviors (e.g. smoking)

Preventionstrategies: Interventions aiming at the individual:

High risk intervention or mass intervention

The missing connection between cardiovascular and occupational medicine

Occupational medicine

focuses on:

Cancer Lung diseases Musculoskeletal disorders Reproductive disorders Allergies– but not CVD

Preventive cardiology

focuses on:

Tobacco Cholesterol Blood pressure Physical activity Diet– but not work environment

The basic dimensions of stressors at work

The ”Copenhagen Stress Model”

• Influence (with regard to the conditions of daily work)

• Meaning(purpose and connection to the overall production)

• Predictability(relevant information about future changes and events)

• Social support(from supervisors and colleagues)

• Rewards(salary, appreciation, and possibilities for a good and secure future)

• Demands(quantitative and qualitative)

Kristensen. Scand J Work Environ Health 1999;25:550-557.

Topics for future research

Human service work:

New organisations:

Unstable labour markets:

Emotional demands

Burnout fatigue

CVD

Work without limits

Workaholism

CVD

Downsizing, unemployment, temporary work

Uncertainty, stress

CVD

?

?

?

?

?

?

Causal network for CVD

Social &Environmental

FactorsBehavior Physiology Precursors

Individual

characteristics

Upstream

Downstream

Tobacco

Job strainPhysicalactivity

Fitness CholesterolAthero-sclerosis

Social isolation

ObesityBlood

pressureThrom-

bosis

Unem-ployment

Diet Type A FibrinogenArr-

hythmia

Noise Alcohol Stress GlucoseECG-

changes

SES&

OccupationCVD

Integrated prevention at the workplace

Healthpromotion

Workenvironment

improvementsWorkplace

rehabilitation

This presentation can be found at:www.ami.dk/presentations