Annual Network Meeting Healthy Cities Horsens, March 16, 2015 Work and health in urban populations: How to reduce vulnerability Johannes Siegrist Senior Professor, Faculty of Medicine University of Duesseldorf. Germany
Annual Network Meeting
Healthy Cities
Horsens, March 16, 2015
Work and health in urban populations:
How to reduce vulnerability
Johannes Siegrist
Senior Professor, Faculty of Medicine
University of Duesseldorf. Germany
Structure of the presentation
1. Background: Urbanization and vulnerability
to stress and disease
2. Stressful work and employment conditions in
urbanized societies
3. What can be done locally and nationally to
reduce vulnerability in work and employment?
1. Background: Urbanization and urbanicity:
effects on population health and wellbeing?
•Source: © National Geographics, 2005
http://magma.nationalgeographic.com/ngm/0211/feature3/
Urbanization and
population
density in Europe
by NUTS 2
regions 2008.
Source: Eurostat regional
yearbook 2010
Does urbanization increase people‘s
vulnerability to stress and disease?
• Higher amount of poverty and poverty-
related morbidity/mortality
• Higher risks of traffic and pollution-
associated disorders
• Higher prevalence of mental disorders
(urban vs. rural)
– RR of depression 1.4
– RR of anxiety disorders 1.2
– RR of psychosis 2.0
Source: The Marmot Review, London 2010
Socioeconomic deprivation and disability-free
life expectancy (England 1999-2003)
Associations between
deprivation index and
mortality in 16 European
cities, men. Relative
Risk (RR).
Source: Borrell C et al. 2014 Scand J
Public Health 42. 245-254.
Urbanicity and increased stress
vulnerability: experimental evidence
Source: Lederbogen F et al. 2011. Nature 474:498-501
2. Stressful work and employment
conditions in urbanized societies
• Paid work: a core condition of economic independence,
welfare, autonomy and social identity in adult life
• Social inequalities in labour market entry and re-entry (skill
level. health status, migration, age, gender…)
• Social inequalities in quality of work among those in paid
work
• Substantial changes of working life in modern urbanized
societies
– increase of service and IT professions/occupations
– less physically strenuous work, more psychomentally and socio-
emotionally stressful work
– increase of flexibility of work arrangements, work-life interference
– Impact of economic globalization
Increased pressure of rationalisation
(mainly due to wage competition)
Downsizing, Merging, Outsourcing
Work Job Low wage /
intensification insecurity salary
Effects of economic globalisation: Labour
market consequences in developed countries
Increase in work intensity 2004-2010:
European Social Survey, 19 EU countries
Source: Gallie D (Ed.) (2013) ESS Topline Results Series 3, European Social Survey
Job insecurity 2004-2010
European Social Survey, 19 EU countries
Source: Gallie D (Ed.) (2013) ESS Topline Results Series 3, European Social Survey
Unemployment in Europe
http://health-gradient.eu/
employment/ NEWS
Declaration of the
Santiago de
Compostela
Conference, July 18,
2013: „Economy, Stress
and Health“
Job loss and risk of acute myocardial
infarction (HRS Study, USA; n = 1.351)
Source: Dupre, ME et al. 2012: Arch Intern Med, 172(22): 1731-1737, (p. 1734).
High work pressure (e.g. overtime work) and
job instability (e.g. downsizing) are unhealthy!
Examples of recent evidence from UK and Finland:
Overtime work (>11 hrs/day):
risk of severe depression: HR 2.4
risk of incident CHD: HR 1.7
(Virtanen M et al. PLoS One 2012, Eur Heart J 2010)
‚Surviving‘ severe downsizing:
risk of all-cause mortality: HR 1.4
risk of CHD mortality: HR 2.0(Vahtera J et al. BMJ 2004)
Work …
provides a source of regular income and related
opportunities
provides a source of personal growth and training of
capabilities/competencies
provides social identity, social status and related rewards
enables access to social networks beyond primary groups
Impacts on personal health and well being by exposure to
material and psychosocial stressors
Why is work of importance for health?
Psychosocial stress at work
Stress occurs if a person is exposed to a threatening demand(stressor) that taxes or exceeds her/his capacity of successful response risk of loss of control and reward
Dimensions of stress reactions:
• Cognitive evaluation of threat
• Negative emotions (anxiety, anger)
• Activation of stress axes in organism (SAM, HPA)
• Behavioural reaction (fight or flight) (restricted option!)
Critical for health:
• Chronic stressors requiring active coping allostatic load; risk of stress-related disorders (depression, CHD)
• Adverse work is a major chronic stressor in adult life
Theoretical models of work stress and
evidence of adverse health effects
Active
Passive
Low-
strain
High-
strain
Psychological Demands
De
cis
ion
la
titu
de
(c
on
tro
l)low high
low
hig
h
The demand-control model
(R. Karasek 1979)
Source: Karasek R, Theorell T: Healthy work, New York: Basic Books, 1990, p. 32.
effort
reward
demands / obligations
- labor income
- career mobility / job security
- esteem, respect
motivation
(‘overcommitment‘)
motivation
(‘overcommitment‘)
Extrinsic components
Intrinsic component
The model of effort-reward imbalance
(J. Siegrist 1996)
Source: Based on Siegrist, J (1996): J Occup Health Psychol, 1: 27-41.
Measurement of work stress models
Standardized self-administered questionnaires, available in
main languages across EU
• Psychometrically validated scales
> reliability, sensitivity to change
> discriminant validity
> criterion validity
> specificity and sensitivity of thresholds
• Partial validation by observational / administrative data
• Construction of job exposure matrices (DC model)
• More information on measurement:
DC model: www.jcqcenter.org
ERI model: www.uniklinik-duesseldorf.de/med-soziologie
COPSOQ model: www.arbejdsmiljoforskning.dk
Social gradient of work stress
0
5
10
15
20
25
30
35
40
Effort-Reward Imbalance Low control
Perc
en
t h
igh
str
essed
Very low
Low
Medium
High
Very high
Source: Wahrendorf M et al. (2013) European Sociological Review 29: 792-802
The social gradient of work stress in the European
workforce (age 50-64): SHARE-study
Mean level of work stress in 17 European countries
(SHARE, ELSA, n = 14 254, aged 50-64)
Source: T. Lunau et al. (2014): Unpublished results
.75 1 1.25Mean ERI
Hungary
Portugal
Czechia
Poland
Italy
Estonia
Slovenia
England
Spain
France
Germany
Austria
Belgium
Denmark
Netherlands
Sweden
Switzerland
3.5 4 4.5 5Mean Low Control
Poland
Hungary
Italy
Czechia
Spain
Austria
Estonia
England
France
Germany
Belgium
Slovenia
Portugal
Switzerland
Netherlands
Sweden
Denmark
Psychosocial Working Conditions
Does stress at work affect the health of
working people?
Three sources of evidence:
Epidemiological cohort studies of initially healthy
employees: exposure to stress> elevated relative risk of
stress-related disease
Experimental and naturalistic studies: monitoring stressful
situations and physiological reactions
Intervention studies: Reducing stress at work and
evaluatimg effects on health and wellbeing
„By the year 2020 depression
and coronary heart disease will be the
leading causes of premature death
and of life years defined by disability
(DALY‘s) worldwide.“
(Murray and Lopez 1996)
Focus on coronary heart disease and depression
Public health relevance of stress-related
disorders at work
• Depression:
• ~ 30 studies (Europe, USA, Canada, Japan):
People exposed to stress at work: mean increase of relative risk: 80% = OR 1.8 (95% CI 1.1-3.1) (PAR ca. 15%)
• Coronary heart disease:
• ~ 20 studies (Europe, USA):
People exposed to stress at work: mean increase of relative . risk: 40% = OR: 1.4 (95% CI 1.2-1.6) (PAR ca. 8%)
• Additional evidence of elevated health risks:
Metabolic syndrome / type II diabetes
Alcohol dependence
Musculoskeletal disorders
Scientific evidence from prospective cohort studies:
Demand-control and effort-reward-imbalance models
Source: Steptoe A, Kivimäki M 2012. Nat Rev Cardiol.9 ; Stansfeld SA ,Candy B 2006 Scand J WEH 32: 443
0,5
1
1,5
2
2,5
1 2 3 1 2 3
High demand / low control
Source: Based on Kivimäki, M, et al. (2002), BMJ, 325: 857, doi:/10.1136/bmj.325.7369.857.
High effort / low reward
Tertile (work stress):
1 = no
2 = low
3 = high
#adj. for age, sex, SEP,
smoking, phys. act.,
SBP, cholest., and BMI
**
Hazard
ratio
#Work stress and cardiovascular mortality:
Finnish Cohort Study, n = 812 employees
Decreases risk Increases risk
4/9
Source: Kivimaki, M, et al. Scand J Work Environ Health (2006): 32: 431-442, (p. 436).
Meta-analysis of cohort studies on relative risks of
coronary heart disease due to ’job strain’
Control at work and blood pressure
Mean ambulatory blood
pressure (low control vs.
high control).
N = 227 men and women
(47-59 years); Whitehall
Cohort Study
Low control
High control
Low control
High control
Systolic BP
Diastolic BP
Source: Based on Steptoe, A, et al. (2004), Journal of Hypertension, 22(5): 915-920.
Depression
• Serious public health problem worldwide
• Estimated life time prevalence: 13-16 %
• Severity due to high co-morbidity (esp.
cardiovascular diseases) and risk of suicide
• Manifestation in early adult life, compromised
work ability (sickness absence, disability pension)
• Massive direct and indirect costs
• Genetic, early life and other personal
determinants, but also role of work stress
Multivariate relative risiks* of the following components:
Women
• Low decision latitude RR 1.96 CI 1.10;3.47
• Low social support RR 1.92 CI 1.33;3.26
Men
• High job insecurity RR 2.09 CI 1.04;4.20
*adj. for age, depression at baseline and additional confounders
Source: R. Rugulies et al. (2006), Am J Epidemiol, 163: 877.
Work stress (demand-control-model) and incidence
of severe depressive symptoms (5 years, N=4.133)
Psychosocial stress at work and depressive symptoms: 13.128
employed men and women 50-64 yrs. from 17 countries in three
continents (SHARE, ELSA, HRS, JSTAR)
0
0,5
1
1,5
2
2,5
USA (N=1560) Europa (N=10342) Japan (N=1226)
ERI
Low control
Source: J. Siegrist et al (2012) Globalization and Health 8:27.
* *
*
* *
Source: Juvani A et al. (2014): Scand J Work Environ Health, 40: 266-277.
Cumulative hazard curves of disability pension due to
depression by quartile of work stress (ERI) (n =51.874)
Work stress (ERI) and natural killer cells in 347
Japanese employees
Source: Nakata A et al (2011), Biol Psychol 88:270-279, (p. 277).
Summary
• Robust scientific evidence that manifestions of stressful
work (DC, ERI) are associated with increased risk of
stress-related disorders (esp. CHD, depression).
• Overall, every fifth working person is exposed to stressful
work, and associations with stress-related disorders
account for a relevant part of the work-related burden of
disease, especially among lower SES groups.
• Additional negative effects of stressful work due to
sickness absence, reduced productivity and disability
pension.
“Do something – do more – do better!”
3.1. The local level:
•Local initiatives to reduce (youth) unemployment
•Community-based programmes of health promotion
and primary prevention
• Healthy cities; healthy hospitals; healthy schools
• Healthy Workplaces Campaign/ Enterprise
Europe Networks
•Local programmes involving employers, community
services, NGOs etc. of improving return to work of
disabled/ chronically ill and other vulnerable groups
3. What can be done locally and nationally to reduce
vulnerability in work and employment?
Lessons learned from integrating young
unemployed people in urban settings
• Training should as far as possible be workplace, rather
than classroom, based, designed and commissioned
locally.
• It should reflect local labour market needs. There may be a
role for Local Enterprise Partnerships, Employment and
Skills Boards (where they exist) and local Chambers of
Commerce in specifying these.
• Employers should as far as possible play a role in the
design and delivery of provision.
Source: Wilson T (2013): Youth Unemployment. London. BIS
Effects of job coaching of homeless people
on gaining employment (BiTC „Ready to work“)
Source: Hoven H et al. (2015) Res Soc Welfare Practice (in press)
Effects of job coaching of homeless people
on sustaining employment (BiTC „Ready to work“)
Hoven H et al. (2015) Res Soc Work Practice (in press)
Improving return to work:
Challenges of mental illness and disability
• Lessons learned from successful practice:
– Develop and strengthen initiatives to provide early
return to work, in case of mental illness, e.g. by
Individual Placement and Support Models
– Involve social insurance agencies, rehabilitation clinics
and employers at an early stage of RTW programs, e.g
in case of injury-based disability
(cf. Swiss Paraplegic Rehabilitation: Comprehensive medical and
vocational rehabilitation program; financial incentives for
employers and SCI-disabled persons; high RTW rate of 63%)
Personal level: Stress prevention programs
Interpersonal level: Leadership training;
communication skills;
Structural level: Organizational/personnel
development (based on work stress models)
Job enrichment/ enlargement (autonomy, control, responsibility)
Skill utilization / active learning
Participation / team work and social support
Culture of recognition
Fair wages/ gain-sharing
Continued qualification/ promotion prospects
Healthy work: Initiatives at company level
Variable
Demand
Control
Social support
Reward
Effort-reward imbal.
Work-rel. burnout
Means at t2 adj. for t0
experimental - control hospital p
11.9
70.0
23.7
31.2
1.0
43.2
12.6
68.7
23.0
30.2
1.1
48.3
.008
.051
.011
.003
.001
.003
Source: R. Bourbonnais et al. (2011), Occup Environ Med, 68: 479-486.
*36 month-follow-up, two Canadian hospitals, N=248 (intervention) vs. 240
(control hospital) (ANCOVA, adj. for baseline values)
Organizational intervention in a Canadian hospital
vs. control hospital*
3.2. The level of national social and labour policies!
Source: Wahrendorf M, Siegrist J. (2014) BMC Public Health 14:849.
Association of
stressful work at
country level with
extent of national
labour policy
(SHARE study)
Conclusions
Urbanicity may increase people’s vulnerability to stress and stress-related disorders
This vulnerability adds to the burden of work-related stress in employed populations
Robust scientific evidence on adverse effects of unhealthy work calls for health-promoting and preventive action, especially for programmes at local level
Priority should be given to high risk groups (esp. young unemployed, migrants, homeless, disabled)
Local initiatives need to be supported by national/international social and labour policies
Thank you!