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!

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