Job Stress and Heart Disease: Evidence and Strategies for Prevention

For example, in 1984, Dr. Robert Karasek reviewed a film on stress produced by the Federal Aviation Administration and shown to all air traffic controllers. The film stated that stress depends on demands and the individual's coping style — control over the situation was not mentioned. To cope with stress, the film advised controllers to question that real world events are causes of stress, rather interpretations of events are the major cause. The film stated that employee expectations of fair treatment are often irrational in the modern setting, and that workers' misformed expectations of fairness are the source of problems. Finally, exclusively individual solutions (for example,“visualizations” of babbling brooks) were recommended. (2).

U.S. Congress. House. Committee on Public Works and Transportation, Hearing before the Subcommittee on Investigations and Oversight. Status of the Air Traffic Control System, 98th Congress, May 4; June 7; October 28, 1983; March 20,21,22,27,28,29; April 4; June 26,27, 1984; H. Rept. 98–83 pp. 785–787.

A number of recent developments suggest a growing awareness of the need to accord stress a major role in the occupational health agenda, including the publication of three essential books on this topic, by Karasek and Theorell (5), Johnson and Johannsson (51), and the International Labor Office. (36) Similarly, recent major conferences have focused on this topic: “Participatory Approaches to Improving Workplace Health,” Labor Studies Center, University of Michigan, June 3–5, 1991 (presentation summaries available), and the 1990 and 1992 job stress conferences sponsored by the National Institute for Occupational Safety and Health (NIOSH) and the American Psychological Association (APA). (Some presentations available in “Stress and Weil-Being at Work Assessments and Interventions for Occupational Mental Health,” Washington, DC: APA).

Sauter S. L. Murphy L. R. Hurrell J. J. Jr. “Prevention of Work-Related Psychological Disorders,” American Psychologist 45 (1990): 1146–1158.

Karasek R. Theorell T Healthy Work. New York: Basic Books, 1990.

The term “stress” is used in this paper to refer to the broad range of psychosocial factors and their resulting mechanisms that affect the worker due to impacts on behavioral, psychological, or physiological outcomes. Within the job stress research community, the term “strain” is typically used to indicate the short-term or intermediate effect of job stress (for example, alterations in the hormonal system of the body), which eventually lead to the development of disease. The terminology of “stress” leading to “strain” and then to disease is actually borrowed from the way these terms are used in engineering. In this paper, we use the term “job strain” in a more specific way — to refer to the objective workplace causes of “stress” described in the Karasek “job strain” model.

Johnson J. V. Hall E. M. Theorell T. “Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working population,” Scandinavian journal of Work, Environment and Health 15 (1989): 271–279.

Quinn M. M. Buiatti E. “Women Changing the Times,” New Solutions 1 (1991): 48–56.

Brandt B. “The Problem of Overwork in America Today,” New Solutions 2 (1991): 50–65.

Kasinsky R. G. “Sexual Harassment: A Health Hazard for Women Workers,” New Solutions 2 (1992): 74–83.

Spangler E. “Sexual Harassment: Labor Relations by Other Means,” New Solutions 3 (1992): 23–30.

Schnall P. L. Landsbergis P. A. Baker D. “Job Strain and Cardiovascular Disease,” Annual Review of Public Health, 1994 (under review).

Schurman S. J. Israel B. A. Hugentobler M. K. “Changing the Work Environment to Reduce Stress: Review of Interventions in the United States and Recommendations for Research and Practice,” in preparation.

American Heart Association. 1994 Heart and Stroke Facts. Dallas, TX: AHA, 1992.

This estimate of population attributable risk was derived from five studies in which multivariate models were used to calculate the association between “job strain” and heart disease. These models controlled for other risk factors (for example, age, education, cigarette smoking, serum cholesterol, and blood pressure) in many cases. To the extent that potential confounding was not adequately controlled for, the 23 percent figure may be an overestimate of the potential benefits of reducing “job strain.” However, to the extent that standard heart disease risk factors are in the causal pathway between “job strain” and heart disease, controlling for them provides a conservative estimate of risk — an underestimate of the true complete effect of exposure to “job strain.”

Alfredsson L Spetz C. L. Theorell T. “Type of Occupation and Near-future Hospitalization for Myocardial Infarction and Some Other Diagnoses,” International Journal of Epidemiology 14 (1985): 378–388.

Falk A. Hanson B. S. Isacsson S-O. Ostergren P-O. “Job Strain and Mortality in Elderly Men: Social Network, Support, and Influence as Buffers,” American Journal of Public Health 82 (1992): 1136–1139.

Astrand N. E. Hanson B. S. Isacson S. O. “Job Demands, Job Decision Latitude, Job Support, and Social Network Factors as Predictors of Mortality in a Swedish Pulp and Paper Company,” British Journal of Industrial Medicine 46 (1989): 334–340.

Theorell T. Perski A. Orth-Gomer K. Hamsten A. deFaire U. The Effect of Returning to Job Strain on Cardiac Death Risk After a First Myocardial Infarction Before Age 45,” International Journal of Cardiology 30 (1991): 61–67.

LaCroix A. Z. High Demand/Low Control Work and the Incidence of CHD in the Framingham Cohort. Doctoral dissertation. Chapel Hill, NC: University of North Carolina, 1984.

Haan M. N. “Job Strain and Ischaemic Heart Disease: An Epidemiological Study of Metal Workers,” Annals of Clinical Research 20(1988): 143–145.

Green K. L. Johnson J. V. “The Effects of Psychosocial Work Organization on Patterns of Cigarette Smoking Among Male Chemical Plant Employees,” American Journal of Public Health 80 (1990): 1368–1371.

Mensch B. S. Kandel D. B. “Do Job Conditions Influence the Use of Drugs,” Journal of Health and Social Behavior 29 (1988): 169–184.

Pieper C. LaCroix A. Z. Karasek R. A. “The Relation of Psychosocial Dimensions of Work with Coronary Heart Disease Risk Factors: A Meta-analysis of Five United States Data Bases,” American Journal of Epidemiology 129 (1989): 483–494.

Theorell T. Perski A. Akerstedt T. Sigala F. Ahlberg-Hulten G. Svensson J. Eneroth P. “Changes in Job Strain in Relation to Changes in Physiological States,” Scandinavian Journal of Work, Environment and Health 14 (1988): 189–196.

Van Egeren L. F. “The Relationship Between Job Strain and Blood Pressure at Work, at Home, and During Sleep,” Psychosomatic Medicine 54 (1992): 337–343.

Blumenthal J. A. Siegel W. C. Phillips B. G. “Job Strain Affects Blood Pressure in the Laboratory and During Daily Life in Patients with Mild Hypertension,” Hypertension (in press).

Theorell T. deFaire U. Johnson J. Hall E. M. Perski A. Stewart W. “Job Strain and Ambulatory Blood Pressure Profiles,” Scandinavian Journal of Work, Environment and Health 17 (1991): 380–385.

Schnall P. L. Schwartz J. E. Landsbergis P. A. Warren K Pickering T. G. “The Relationship Between Job Strain, Alcohol and Ambulatory Blood Pressure,” Hypertension 19 (1992): 488–494.

Schnall P. L. Landsbergis P. A. Schwartz J. E. Warren K Pickering T. G. “The Relationship Between Job Strain, Ambulatory Blood Pressure and Hypertension,” Paper presented at the Ninth International Symposium on Epidemiology in Occupational Health, Cincinnati, OH, September, 1992.

Light K. C. Turner J. R. Hinderliter A. L. “Job Strain and Ambulatory Work Blood Pressure in Healthy Young Men and Women,” Hypertension 20 (1992): 214–218.

Theorell T. Knox S. Svensson J. Waller D. “Blood Pressure Variations During a Working Day at Age 28: Effects of Different Types of Work and Blood Pressure Level at Age 18,” Journal of Human Stress 11 (1985): 36–41.

Frankenhauser M Johansson G. “Stress at Work: Psychobiological and Psychosocial Aspects,” International Review of Applied Psychology 35 (1986): 287–299.

Schnall P. L. Pieper C. Schwartz J. E. Karasek R. A. Schlussel Y. Devereux R. B. Ganau A. Alderman M. Warren K. Pickering T. G. The Relationship Between “Job Strain,' Workplace Diastolic Blood Pressure, and Left Ventricular Mass Index: Results of a Case-control Study,” Journal of the American Medical Association 263 (1990): 1929–1935.

Karasek R. A. Gordon G. Pietrokovsky C Frese M. Pieper C. Schwartz J. Fry L. Schirer D. Job Content Instrument: Questionnaire and User's Guide. Los Angeles, CA: University of Southern California, 1985.

DiMartino V. (Ed.) Conditions of Work Digest: Preventing Stress at Work. Geneva: International Labor Office, 1992.

Johnson J. V. “Collective Control: Strategies for Survival in the Workplace,” International Journal of Health Services 19 (1989): 469–480.

Israel B. A. Schurman S. J. House J. S. “Action Research on Occupational Stress: Involving Workers as Researchers,” International Journal of Health Services 19 (1989): 135–155.

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Hall E. M. “Double Exposure: The Combined Impact of the Home and Work Environments on Psychosomatic Strain in Swedish Men and Women,” International Journal of Health Services 22 (1992): 239–260.

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This section is based on a more detailed review in (13).

Examples are classic texts from this period: Lewin K. Field Theory in Social Science. New York: Harper, 1951; Walker C. R. Guest R. H. Man on the Assembly Line. Cambridge: Harvard University Press, 1952; MacGregor D. The Human Side of Enterprise. New York: McGraw-Hill, 1960; Kornhauser A. Mental Health of the Industrial Worker. New York: Wiley, 1965.

For recent critical reviews, see the series Woodman R. Pasmore W. (Eds.) Research in Organization Change and Development. Greenwich, CT: JAI Press, 1987.

Parker M. Inside the Circle. Boston: South End Press, 1985.

Gardell B. Gustavsen B. “Work Environment Research and Social Change: Current Developments in Scandinavia,” Journal of Occupational Behavior 1 (1980): 3–17.

Johnson J. V. Johannsson G. The Psychosocial Work Environment. Amityville, NY: Baywood, 1991.

Hanlon M. D. “Reducing Hospital Costs Through Employee Involvement Strategies,” National Productivity Review 5 (1986): 22–31.

Kopelman R. E. “Job Design and Productivity: A Review of the Evidence,” National Productivity Review 4 (1985): 237–255.

Gordon M. E. Burt R. E. “A History of Industrial Psychology's Relationship with American Unions: Lessons from the Past and Directions for the Future,” International Review of Applied Psychology 30 (1981): 137–156.

Buller P. F. Bell C. H. “Effects of Team Building and Goal Setting on Productivity: A Field Experiment,” Academy of Management Journal 29 (1986): 305–328.

Grenier G. J. “Twisting Quality Circles to Bust Unions,” AFL-CIO News, May 14, 1983.

Jones L. M. Bowers D. G. Fuller S. M. Report of Findings 1984: Task Force on Management and Employee Relationships. Washington, DC Federal Aviation Administration, November 7, 1984.

“APWU Settles USPS Company Union Charges,” AFL-CIO News, May 11, 1992.

“Partnership Sweetens Work at Nabisco Bakeries,” AFL-CIO News, April 29, 1991.

“Cooperative Successes Typified at Ohio Plant,” AFL-CIO News, June 22, 1992.

Whyte W. F. Participatory Action Research. Newbury Park, CA: Sage, 1990.

Karasek R. “Stress Prevention Through Work Reorganization: A Summary of 19 International Case Studies,” in DiMartino V. (ed.) Conditions of Work Digest, Preventing Stress at Work. Geneva International Labor Office, 1992: 23–41.

Jackson S. E. “Participation in Decision Making as a Strategy for Reducing Job Related Strain,” Journal of Applied Psychology 68 (1983): 3–19.

Golembiewski R. Hilles R. Daly R. “Some Effects of Multiple OD Interventions on Burnout and Worksite Features,” Journal of Applied Behavioral Science 23 (1987): 295–314.

Israel B. A. Schurman S. J. Hugentobler M. K. House J. “A Participatory Action Research Approach to Reducing Occupational Stress in the United States,” in DiMartino V. (Ed.) Conditions of Work Digest: Preventing Stress at Work. Geneva: International Labor Office, 1992: 152–163.

Heaney C. Israel B. Schurman S. House J. Baker B. Hugentobler M. “Evaluation of a Participatory Action Research Approach to Reducing Stress.” Paper presented at the APA/NIOSH Conference on Occupational Stress, Washington, DC, November, 1992.

Cahill J. “Computers and Stress Reduction in Social Service Workers in New Jersey,” in DiMartino V. (Ed.) Conditions of Work Digest: Preventing Stress at Work. Geneva: International Labor Office, 1992: 197–203.

Lemer M. Occupational Stress Groups and the Psychodynamics of the World of Work. Oakland, CA: Institute for Labor and Mental Health, 1985.

May L. “A Union Programme to Reduce Work and Family Stress Factors in Unskilled and Semi-Skilled Workers on the East Coast of the United States,” in DiMartino V. (Ed.) Conditions of Work Digest: Preventing Stress at Work. Geneva: International Labor Office, 1992: 164–171.

Landsbergis P. A. Silverman B. Barrett C. Schnall P. L. “Union Stress Committees and Stress Reduction in Blue and White Collar Workers,” in DiMartino V. (Ed.) Conditions of Work Digest: Preventing Stress at Work. Geneva: International Labor Office, 1992: 144–151.

Mergler D. “Worker Participation in Occupational Health Research: Theory and Practice,” International Journal of Health Services 17(1987): 151–167.

Thus, it is analogous to the role proposed for workers in making industrial hygiene more effective, that is, involving workers in inspections, assessment of hazards and health symptoms; problem-solving; and changing work practices and organization as well as technical improvements ( Senn E “Playing Industrial Hygiene To Win,” New Solutions (1991): 72–81).

Hugentobler M. K. Robins T. G. Schurman S. J. “How Unions Can Improve the Outcomes of Joint Health and Safety Training Programs,” Labor Studies journal 15 (1990): 16–38.

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Cahill J. “Economic and Non-Economic Sources of Job Satisfaction in Higher Education,” Paper Presented at the American Association for Higher Education, Washington, D.C., March, 1994.

Israel B. Schurman S. “Social Support, Control and the Stress Process,” in Glanz K. Lewis F. Rimer B. (Eds.) Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass, 1990: 187–215.

“Moving Towards Worker-Oriented Participatory Research,” Panel at the American Public Health Association, San Francisco, CA, October, 1994.

Bongers P. M. deWinter R. R. Kompier M. A. J. Hildebrandt V. H. “Psychosocial Factors at Work and Musculoskeletal Disease: A Review of the Literature,” Scandinavian Journal of Work Environment and Health (in press).

Brett K. Strogatz D. Savitz D. “Occupational Stress and Low Birth Weight Delivery.” Presented at the 24th Annual Meeting of the Society of Epidemiological Research, Buffalo, NY, June 1991. American Journal of Epidemiology 134 (1991): 722–723.

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Unions have also developed valuable worker education materials on job stress that use the Small Group Activity Method and the principles of empowerment education. Sources include the Communications Workers of America, District 1; District 65, UAW; and the Labor Institute, in New York City; 9 to 5, National Association of Working Women, Cleveland, OH; and the Workers Health and Safety Centre, Kingston, Ontario.

Landsbergis P. “Occupational Stress Among Nurses: New Developments in Theory and Prevention,” in Humphrey J. R. (Ed.) Human Stress: Current Selected Research (Vol. 3). New York: AMC Press, 1989: 173–195.

AFL-CIO News, January 26, 1985; May 23, 1988; July 8, 1989; February 1, 1994; Labor Notes, December 1985; October, 1989.

Bunis Dena , personal communication, February, 1994.

Bernard B. “Psychosocial Factors for Musculoskeletal Disorders,” Paper to be Presented at the American Public Health Association, San Francisco, CA, October, 1994.

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“The Electronic Supervisor,” op. cit., p. 39, 46–48, 57; Massachusetts Coalition on New Office Technology, “Electronic Monitoring in the Workplace: Supervision or Surveillance?” Boston, 1989.

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Cases of similar physical symptoms among a group of workers without an identifiable pathogen (known as “epidemic psychogenic illness,” EPI) have been extensively analyzed by NIOSH and others. (For example: Colligan M. Pennebaker J. Murphy L. (Eds.) Mass Psychogenic Illness: A Social Psychological Analysis. Hillsdale, NJ: Lawrence Erlbaum, 1982.) Work organization in workplaces where EPI has occurred has been characterized as repetitive or boring work with rigid pacing and high job pressures, strict rules, and a lack of communication and social interaction. While EPI can therefore be regarded as a desperate reaction to excessive “job strain,” another explanation is that low-level chemical exposure and stress may have synergistic effects.

DeCarlo D. T. Gruenfeld D. H. Stress in the American Workplace. Fort Washington, PA: LRP Publications, 1989: 11.

California Workers' Compensation Institute, “Mental Stress Claims in California Workers' Compensation — Incidence, Costs and Trends,” San Francisco: California Workers' Compensation Institute, 1990.

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