Why this program?

1. Introduction to “Work and Health”: A Social Epidemiological Approach to the Workplace and Health Outcomes FacultyDr. Peter SchnallJune 18th 2009Universidad Javeriana

2. Why this program? • With the exception of occupationally related injuries the medical profession tends to neglect the role of work in disease. For example, a traditional medical history asks only one question about work – one’s job title. • The mainstream approach to stress and the workplace does not provide an adequate explanation for the epidemic of stress related diseases which we observe nor sufficient tools to prevent or alleviate stress(ors). • While there are courses on occupational health, health psychology and on occupational psychology in different departments there is little integration of the material in these different fields.

3. CourseObjectives: • To understand the principles of a social epidemiological approach as this pertains to the workplace. To appreciate the historical context from which modern production modes arise, illustrated by an examination of the introduction of Taylorism and its successor “lean production”. • To have a working familiarity with the leading work stress models—their theoretical basis, how they are operationalized in practice, and the strengths and weaknesses of the various assessment tools. To understand the concept of “triangulation” with regard to assessing workplace exposures. • To be familiar with the empirical evidence linking psychosocial workplace factors to mental health outcomes, hypertension, coronary artery disease and other health outcomes

4. Course Objectives cont: • To be able to describe some of the key physiological mechanisms by which work stressors affect the cardiovascular system and other target organs • To be able to describe the key psychological mechanisms by which work stressors and other psychosocial factors impact upon mental health and risk behaviors • To be able to take an occupational psychosocial history, to be able to use and interpret existing psychometric tools • To understand the principles and practical aspects involved in job redesign. To be able to develop a plan of action for short- and longer-term improvement in a given workplace • To be familiar with individual stress management approaches to stress at the workplace as well as health promotion

5. Course Objectives: Cont • To be familiar with key legislative measures which reduce employee exposure to workplace stressors • To develop an understanding of what constitutes healthy work

6. Practicum • The purpose of the course practicum is to familiarize students with work organizational characteristics that may act as work stressors and to give “hands-on” experience in evaluating occupational health exposures in working people using standardized and validated questionnaires and instruments. • Each student will complete THREE exercises which will prepare them to complete a Work History Report and the Take-Home midterm and final. • A participant-observation exercise • Administer a psychosocial questionnaire packet to a working person. • Complete the OSI questionnaire which will be combined with #2 in the Work History Report.

7. 1. Participant-Observation • Students will complete a participant-observation exercise to observe a worker unobtrusively in their work environment (e.g. retail, grocery store, public transport etc.) • The purpose of this exercise is to become familiar with work characteristics; e.g. pace, demands, responsibility, creativity etc. • Complete the worksheet during or after observation and turn in a ½ page report in Session 3 & discuss your observations in class.

8. 2. Psychosocial Questionnaire Packet • Each student will administer a psychosocial questionnaire packet & take an occupational history on one person who must have a current paid job. • The occupational work history will be of the most recent paid employment (can be summer/part-time employment). • Students will obtain informed consent. • The questionnaires and occupational history will have no identifying information (i.e., no names or social security numbers, etc). • The interviewed person should be a full time employed worker. • The information obtained should be about the current job.

9. 2. Psychosocial questionnaire packet cont. • The packet will contain the following – JCQ, ERI, GHQ and a short demographic questionnaire that determines education, age, race, gender and occupation. • There will be an instruction sheet for each psychometric instrument provided • The questionnaires will be scored by the students • National norms will be provided for Job Strain to which the students may make qualitative and quantitative comparisons. They will be asked to map the quadrant location for their subject re: job strain. • They will determine whether or not ERI is present. • Using the GHQ the students will determine the presence/absence of anxiety and depression, etc. • The completed and scored packet will be due in Session 3.

10. Work History Report (due Session 5) • Utilize the psychosocial questionnaires and the OSI to write up an occupational work history about the working person you have administered the questionnaires to. • Students will be challenged to interpret the psychosocial work exposure data in relation to the psychological outcomes taking into account the possibility that various issues such as denial or over-reporting may limit the inferences that can be made. • This narrative should be succinct (1 to 2 pages maximum) and complete such that other health professionals and other team members could use it for diagnosis and treatment. Optimally, this history would indicate areas in which workplace modifications might be feasible (course instructors will provide an example). • This body of information will form part of the basis for the take home midterm and final examinations for the course.

11. Session #1 – Intro lecture • Working people develop a wide variety of illnesses during their working lives, manifested by symptoms, psychological distress, time lost from work, disability, physical incapacity and ultimately morbidity and mortality. How/whether these manifestations are connected to work is a critically important issue for those in the fields of medicine, occupational and public health. • We will introduce the social epidemiologic approach, in which the workplace is viewed as a key leverage point for a wide variety of behavioral and health outcomes. The workplace can act relatively distally as well as proximately as a cause(s) of these outcomes. We view personality and individual factors as more proximal.

12. Session #1 – Intro lecture • During the 19th Century physical/chemical/infectious/nutritional exposures played a major role in health and illness. Urban areas/factories were associated with malnutrition, infectious diseases and shortened lifespan. • In turn, these conditions stimulated resistance/reform and amelioration of the most egregious insults (wages, housing, working conditions). Child labor laws were passed and an ecological model of causation developed.

13. Session #1 – Intro lecture • As living conditions in urban areas improved at the end of the 19th Century, such that major morbidity and mortality from infectious disease declined, workplace illnesses due to physical exposures such as Black lung disease gained increasing attention. • Nearly 30 years after the federal government began addressing the cause of black lung, the disease still hasn’t been eliminated. There is now recognition and protective legislation. • Progress has been made. Coal workers’ pneumoconiosis, commonly referred to as “black lung,” and the coal mine dust that causes it, are less prevalent than before. Available data show that miners' exposure to respirable dust in coal mines has been reduced more than 70 percent over the last two decades. The prevalence of black lung disease among surveyed miners has declined by more than two thirds.

14. Session #1 – Intro lecture • In the 20th Century another model emerged in contradistinction to an environmental or ecological model. The emphasis within modern medicine has been to focus upon biological disorders, sometimes resulting from individual traits, including genetic susceptibility, together with risk-behaviors (often referred to as the biomedical model).

15. Session #1 – Intro lecture • At the same time the nature of environmental exposures has been changing. While the proportion of workers exposed to toxic physical and chemical agents is on the decline in the modern workplace of post-industrial countries, the importance of another set of noxious exposures of a psychosocial nature has become increasingly recognized.

16. Session #1 – Intro lecture • In the case of physical occupational hazards the cause of injury/disease could be linked more directly to environmental exposures. • In contrast, for psychosocial risks the connections are more difficult to assess and document. The etiologic model becomes more complicated.

17. Two Views: • Social Epidemiology Model - negative health outcomes (illnesses) are due to the impact of social epidemiologic factors (in general class, work, race and gender), and in this case a focus on workplace stressors, acting on the individual => eliciting cognitive processes that result in physiological disturbance (e.g., depression and hypertension).

18. Predominant View • Biomedical Model - or is it the other way around with disease the result of disruption of psychological processes wherein subjective perceptions, behaviors and personality factors (e.g., neuroticism) are of primary importance (i.e., disease proceeds from the individual to the environment). This latter views work environment as tolerable to vast majority of humans but in some cases there is a lack of fit between the individual and their environment. Workplace stressors are frequently absent in this formulation.

19. The Role of Work (Job Characteristics) in Health and Disease • We will review throughout this course the developing evidence of the importance of workplace risk factors. • In this perspective, a key intellectual task becomes defining and measuring those psychosocial conditions of burden that surpass normal human capacity. • We use social epidemiological methods to identify those psychosocial stressors which impact on large populations of people (e.g. job strain, effort-reward imbalance, etc.).

20. The New York City Work Site Blood Pressure (BP) Study • Based at Weill Medical College of Cornell University- New York Hospital • Began in 1985 as a case-control study • 283 men initially enrolled at 8 large NYC work sites • Funding became available (after studying 7 sites) to: • conduct a prospective study (evaluate Ss every 3-4 yrs) • enroll women • Currently, 472 subjects enrolled at 10 sites (38% women) • maximum of 4 evaluations & 10 years of follow-up Work Site BP Study

21. The New York City Work Site BP Study: Eligibility criteria • aged 30-60 at recruitment • full-time employee (30+ hours/wk) • no second job requiring more than 15 hours/wk • no evidence of CHD • screening BPs less than 160/105 mm Hg • able to read and speak English • body mass index < 32.5 kg/m² at screening • at current worksite >3 yrs before recruitment and before Dx of high BP (only 1 yr at 8th site) Work Site BP Study

22. Job Strain and Work Ambulatory BP(men, Time 1 and Time 2) Time 1 Time 2 Time 1 Time 2 (n=195) (n=195) (n=195) (n=195) *** *** *** *** Systolic AmBP Diastolic AmBP controlling for age, education, body mass index, race, smoking, alcohol use, work site ***p<.001 Work Site BP Study Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.

23. Job Strain Change Variable Time 1 Time 2 (baseline) (3 years later) Yes (n=15) (chronic strain) Yes Job Strain No (n=25) Yes (n=17) No No (n=137) (referent) Work Site BP Study

24. Job Strain change and Work Systolic Ambulatory BP (n=195 men, Time 1 and 2) Strain-T1: no no yes yes no no yes yes Strain-T2: no yes no yes no yes no yes Time 1 (p=.0017) Time 2 (p=.0015) controlling for age, education, body mass index, race, smoking, alcohol use, work site Work Site BP Study Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.

25. Job Strain change and 3-yr Work Ambulatory BP change (n=195 men, Time 1-2) Strain-T1: no no yes yes no no yes yes Strain-T2: no yes no yes no yes no yes Ref ** * Systolic AmBP Diastolic AmBP controlling for age, race, body mass index, smoking, alcohol use, work site Work Site BP Study p<.05, **p<.01, (vs Ref group) Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Psychosomatic Medicine 1998;60:697-706.

26. Job Strain and Work Ambulatory Systolic BP by Occupational Status (n=283 men, Time 1) Job StrainNo Job Strain White-collar Clerical Blue-collar White-collar Clerical Blue-collar * * Ref INTERACTION TERM: p=.13 controlling for age, body mass index, race, smoking, alcohol use and work site #p<.10, *p<.05 (vs Ref group) Landsbergis et al. In Adler, NE, Marmot M, McEwen BS, Stewart J (eds.) Socioeconomic status and health in industrialized nations (pp. 414-6). New York: New York Academy of Sciences, 1999.

27. The Importance of Psychosocial Factors in Hypertension: Findings from the Cornell U.M.C. Work Site Ambulatory Blood Pressure Project • Case-Control Study – Job Strain and Hypertension – Odds Ratio = 2.7 • Cross-Sectional Study – Job Strain and Ambulatory SBP = + 6.6 mm Hg • Job Strain and Ambulatory DBP = + 4.0 mm Hg • Longitudinal Study – Repeated exposure Job Strain and AmSBP = +12 mm Hg • Repeated exposure Job Strain and AmDBP = +9 mm Hg • Population Attributable Risk % = 27% 1 • 1calculation based on OR of 2.7 and prevalence rate of Job strain of 20%

28. The Role of Work (Job Characteristics) in Health and Disease (continued) • The social epidemiologic model moves from left to right  1) psychosocial stressors  2) cognitive processing can be influenced by a) personality factors, b) coping mechanisms, c) other neurological factors  3) physiological arousal as well psychological disturbances. • There is now evidence of the mechanisms by which the brain mediates these stressors – this is the field of cognitive ergonomics. • Tony Gaillard 1993 article has elegantly linked psychosocial factors and job strain into the realm of brain mechanisms of attention and mental load and how this plays out in terms of stress. (Session # 4)

29. The Role of Work (Job Characteristics) in Health and Disease (continued) • This approach leads to a description/identification of health outcomes that are most likely especially associated with modern production - repetitive motion injuries, hypertension, cvd and a number of psychological conditions. Here is where we again find Charlie. He could be a statistic, one of millions, but in Modern Times he is the Canary in the Coal Mine who gives a human face to the consequences of modern working life. • In understanding psychosocial stressors in terms of their social origins we argue that the work organizations under modern conditions of production are driven for economic reasons to maximize human productivity and often this will be at the expense of the human nervous system. • At all times this process is limited by the constraints of biological vulnerability and social and political resistance.

30. Two Differing Views - Two Different Sets of Interventions • Social Epidemiologic Model - focuses on the organization of work. • Biomedical model – focus is on the individual via stress management models and drug therapy. • These are not necessarily contradictory positions. Both these types of interventions may be useful and complementary (prevention and treatment)

31. The Importance of OHP • The new field of OHP is incorporating this kind of social epidemiologic approach. • OHP practitioners are potentially key players in identifying workplace risk factors which can impact negatively on individuals. • They can play key leadership role in health promotion/protection at the worksite by liasoning among other related concerned individuals. • OHP practitioners can help develop new strategies to create a healthy workplace. • Or perhaps we should train industrial hygienists, OHN’s, and others for this role.

32. End Hour #1