The Healthy Work Survey: A Standardized Questionnaire for the Assessment of Workplace Psychosocial Hazards and Work Organization in the United States.

OBJECTIVES: Work-related psychosocial stressors have been recognized as occupational hazards and assessed in workplaces in many countries for decades. Identifying tools to measure work-related psychosocial hazards to increase awareness in the United States about the impact on employees' health and safety is critical ( J Occup Environ Med. 2021;63:e245-e249). METHODS: We describe the development and psychometric validation of an online tool, the Healthy Work Survey, utilizing items from the National Institute for Occupational Safety and Health Quality of Work Life questionnaire. RESULTS: There are 55 items in the final core work section of the HWS. Factor analyses confirmed nine factors, and the subsequent multi-item scales had acceptable internal consistency. A user-friendly, online system and automated report compares individual's and organization's scores to distributions from a representative US working population (General Social Survey Quality of Work Life). DISCUSSION: The HWS is a reliable, valid tool for organizations and individuals to assess psychosocial work hazards.

The effect of exposure to long working hours on ischaemic heart disease: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing Joint Estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may cause ischaemic heart disease (IHD). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from IHD that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. OBJECTIVES: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on IHD (three outcomes: prevalence, incidence and mortality). DATA SOURCES: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including MEDLINE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. STUDY ELIGIBILITY AND CRITERIA: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged < 15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies which contained an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on IHD (prevalence, incidence or mortality). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors independently screened titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. Missing data were requested from principal study authors. We combined relative risks using random-effect meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using Navigation Guide and GRADE tools and approaches adapted to this project. RESULTS: Thirty-seven studies (26 prospective cohort studies and 11 case-control studies) met the inclusion criteria, comprising a total of 768,751 participants (310,954 females) in 13 countries in three WHO regions (Americas, Europe and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with administrative health records (30 studies) or self-reported physician diagnosis (7 studies). The outcome was defined as incident non-fatal IHD event in 19 studies (8 cohort studies, 11 case-control studies), incident fatal IHD event in two studies (both cohort studies), and incident non-fatal or fatal ("mixed") event in 16 studies (all cohort studies). Because we judged cohort studies to have a relatively lower risk of bias, we prioritized evidence from these studies and treated evidence from case-control studies as supporting evidence. For the bodies of evidence for both outcomes with any eligible studies (i.e. IHD incidence and mortality), we did not have serious concerns for risk of bias (at least for the cohort studies). No eligible study was found on the effect of long working hours on IHD prevalence. Compared with working 35-40 h/week, we are uncertain about the effect on acquiring (or incidence of) IHD of working 41-48 h/week (relative risk (RR) 0.98, 95% confidence interval (CI) 0.91 to 1.07, 20 studies, 312,209 participants, I2 0%, low quality of evidence) and 49-54 h/week (RR 1.05, 95% CI 0.94 to 1.17, 18 studies, 308,405 participants, I2 0%, low quality of evidence). Compared with working 35-40 h/week, working ≥55 h/week may have led to a moderately, clinically meaningful increase in the risk of acquiring IHD, when followed up between one year and 20 years (RR 1.13, 95% CI 1.02 to 1.26, 22 studies, 339,680 participants, I2 5%, moderate quality of evidence). Compared with working 35-40 h/week, we are very uncertain about the effect on dying (mortality) from IHD of working 41-48 h/week (RR 0.99, 95% CI 0.88 to 1.12, 13 studies, 288,278 participants, I2 8%, low quality of evidence) and 49-54 h/week (RR 1.01, 95% CI 0.82 to 1.25, 11 studies, 284,474 participants, I2 13%, low quality of evidence). Compared with working 35-40 h/week, working ≥55 h/week may have led to a moderate, clinically meaningful increase in the risk of dying from IHD when followed up between eight and 30 years (RR 1.17, 95% CI 1.05 to 1.31, 16 studies, 726,803 participants, I2 0%, moderate quality of evidence). Subgroup analyses found no evidence for differences by WHO region and sex, but RRs were higher among persons with lower SES. Sensitivity analyses found no differences by outcome definition (exclusively non-fatal or fatal versus "mixed"), outcome measurement (health records versus self-reports) and risk of bias ("high"/"probably high" ratings in any domain versus "low"/"probably low" in all domains). CONCLUSIONS: We judged the existing bodies of evidence for human evidence as "inadequate evidence for harmfulness" for the exposure categories 41-48 and 49-54 h/week for IHD prevalence, incidence and mortality, and for the exposure category ≥55 h/week for IHD prevalence. Evidence on exposure to working ≥55 h/week was judged as "sufficient evidence of harmfulness" for IHD incidence and mortality. Producing estimates for the burden of IHD attributable to exposure to working ≥55 h/week appears evidence-based, and the pooled effect estimates presented in this systematic review could be used as input data for the WHO/ILO Joint Estimates.

WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of exposure to long working hours and of the effect of exposure to long working hours on ischaemic heart disease.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of deaths and disability-adjusted life years of ischaemic heart disease from exposure to long working hours, to inform the development of the WHO/ILO joint methodology. OBJECTIVES: We aim to systematically review studies on occupational exposure to long working hours (Systematic Review 1) and systematically review and meta-analyse estimates of the effect of long working hours on ischaemic heart disease (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework. The selection of both, the exposure and the health outcome is justified by substantial scientific evidence on adverse effects of long working hours on ischaemic heart disease risk. DATA SOURCES: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, Medline, EMBASE, Web of Science, CISDOC and PsychINFO. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference list of previous systematic reviews and included study records; and consult additional experts. STUDY ELIGIBILITY AND CRITERIA: We will include working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State, but exclude children (<15 years) and unpaid domestic workers. For Systematic Review 1, we will include quantitative prevalence studies of relevant levels of exposure to long working hours (i.e. 35-40, 41-48, 49-54 and ≥55 h/week) stratified by country, sex, age and industrial sector or occupation. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the relative effect of relevant level(s) of long working hours on the prevalence of, incidence of or mortality from ischaemic heart disease, compared with the theoretical minimum risk exposure level (i.e. 35-40 h/week). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2. PROSPERO registration number: CRD42017084243.

Work organization, health, and obesity in urban transit operators: A qualitative study.

BACKGROUND: Urban transit operators have high rates of obesity, hypertension, and other cardiovascular risk-factors compared to other occupations. There have been few qualitative studies exploring the interrelationships between the organization of transit work, stress, and health including obesity, from the perspective of operators. METHODS: Five focus groups were conducted at five Divisions in a transit authority in Southern California and included 65 bus and rail operators. RESULTS: Operators reported a great deal of stress related to their work, including 1) time pressures and lack of recovery time; 2) long work shifts and overtime; 3) feeling unsafe when dealing with the public; 4) lack of respect from supervisors and management. Operators believed stressful working conditions negatively impacted their health and weight. CONCLUSION: This qualitative study yielded new as well as confirmatory data about stress and transit work organization, health, and weight in operators. This study will add to future survey research and interventions in this population.

A socioecological framework for research on work and obesity in diverse urban transit operators based on gender, race, and ethnicity.

Urban transit (bus and rail) operators, totaling nearly 700,000 persons, are one of the heaviest occupational groups in the United States (US). Little is known about occupational risk factors for weight gain and obesity and their interrelationship with health-related behaviors, particularly among female minority (African Americans and Hispanics) transit operators who are at greater risk for obesity. As a step towards developing successful obesity interventions among urban transit operators, this paper aims to present a new socioecological framework for studying working conditions, chronic strain, health-related behaviors, weight gain/obesity, and obesity disparity in diverse urban transit operators based on gender, race, and ethnicity. Our framework is a synthesis of several different theories and disciplines: the resource-work load model (work stress), occupational ergonomics, the theory of intersectionality, and worksite health promotion. The framework was developed utilizing an extensive literature review, results from our on-going research on obesity, input from focus groups conducted with Los Angeles transit operators as well as interviews and meetings with transit operator stakeholders (management, unions, and worksite transit wellness program), and ride-along observations. Our hypotheses highlighted in the framework (see Fig. 1) are that adverse working conditions, largely characterized as a combination of high demands and low resources, will increase the risk for weight gain/obesity among transit operators directly through chronic strain and hypothalamic dysfunction (hyper-and hypo-activations), and indirectly through health-related behaviors and injuries/chronic severe pain. We also hypothesize that the observed increase in adiposity among female minority operators is due to their greater exposure to adverse occupational and non-occupational conditions that reflect their intersecting social identities of lower social class and being a minority woman in the US. Our proposed framework could greatly facilitate future transit worksite obesity studies by clarifying the complex and important roles of adverse working conditions in the etiology of weight gain/obesity and obesity disparity among transit operators and other working populations.

Globalization, Work, and Cardiovascular Disease.

Cardiovascular disease (CVD), a global epidemic, is responsible for about 30% of all deaths worldwide. While mortality rates from CVD have been mostly declining in the advanced industrialized nations, CVD risk factors, including hypertension, obesity, and diabetes, have been on the increase everywhere. Researchers investigating the social causes of CVD have produced a robust body of evidence documenting the relationships between the work environment and CVD, including through the mechanisms of psychosocial work stressors. We review the empirical evidence linking work, psychosocial stressors, and CVD. These work stressors can produce chronic biologic arousal and promote unhealthy behaviors and thus, increased CVD risk. We offer a theoretical model that illustrates how economic globalization influences the labor market and work organization in high-income countries, which, in turn, exacerbates job characteristics, such as demands, low job control, effort-reward imbalance, job insecurity, and long work hours. There is also a growing interest in "upstream" factors among work stress researchers, including precarious employment, downsizing/restructuring, privatization, and lean production. We conclude with suggestions for future epidemiologic research on the role of work in the development of CVD, as well as policy recommendations for prevention of work-related CVD.

Twenty-four-hour work shifts, increased job demands, and elevated blood pressure in professional firefighters.

PURPOSE: To investigate whether working conditions (number of 24-h shifts, number of calls, sedentary work, job strain, effort-reward imbalance, and physical demands) are associated with elevated blood pressure and hypertension among professional firefighters. METHODS: A total of 330 (321 males and 9 females) firefighters were chosen for this study among the Southern California firefighters who participated in a work and obesity project. Working conditions were measured with a firefighter-specific occupational health questionnaire. Blood pressure was clinically assessed, and hypertension was defined according to the contemporary standard classification. RESULTS: About 11 % of the firefighters had hypertension. Fifty percent of the hypertensive firefighters (mostly mild hypertensive) had uncontrolled high blood pressure. Hypertension was more prevalent in male, older, and high-rank firefighters and firefighter who reported low numbers of daily calls. In male firefighters who were normotensive or hypertensive without taking anti-hypertensive medication, additional 24-h shifts in the past month increased the risk of elevated diastolic blood pressure (DBP) than those who reported a standard work schedule (eight to eleven 24-h shifts). Particularly, firefighters who reported sixteen 24-h shifts had 5.0 mmHg higher DBP (p < 0.01). Body mass index attenuated the association between number of shifts and blood pressure to some extent. Firefighters who reported "increased job demands over the past years" had 3.0 mmHg (p = 0.06) higher systolic blood pressure. Other working conditions were not associated with elevated blood pressure and hypertension. CONCLUSIONS: Many additional 24-h shifts and increased job demands were risk factors for elevated blood pressure in male firefighters. Optimal collective and individual workload and improved hypertension management are warranted for enhancing the cardiovascular health of firefighters.

24-hour work shifts, sedentary work, and obesity in male firefighters.

BACKGROUND: Little is known about the occupational risk factors for obesity in US firefighters. METHODS: 308 male California firefighters, who participated in a work and obesity project, were chosen. Working conditions were measured with a firefighter-specific occupational health questionnaire. Adiposity was clinically assessed using body mass index (BMI), waist circumference (WC), and body fat percent. RESULTS: In a multivariate analysis, the prevalence of obesity by all measures was significantly higher (PRs = 3.69-6.03, P < 0.05) in the firefighters who reported seventeen to twenty-one shifts than those who reported eight to eleven shifts in the past month. Prolonged sedentary work was also a risk factor for obesity by BMI (PR = 4.18, P < 0.05). Furthermore, there was a linear dose-response relationship of obesity by BMI and WC with the number of 24-hr shifts and sedentary work. CONCLUSIONS: Many additional 24-hr shifts and prolonged sedentary work substantially increased the risk for obesity in male firefighters. Am. J. Ind. Med. 59:486-500, 2016. © 2016 Wiley Periodicals, Inc.

Comparison of body mass index with waist circumference and skinfold-based percent body fat in firefighters: adiposity classification and associations with cardiovascular disease risk factors.

PURPOSE: This study aims to examine whether body mass index (BMI) overestimates the prevalence of overweight or obese firefighters when compared to waist circumference (WC) and skinfold-based percent body fat (PBF) and to investigate differential relationships of the three adiposity measures with other biological cardiovascular disease (CVD) risk factors. METHODS: The adiposity of 355 (347 males and eight females) California firefighters was assessed using three different measures. Other CVD risk factors (high blood pressure, high lipid profiles, high glucose, and low VO2 max) of the firefighters were also clinically assessed. RESULTS: The prevalence of total overweight and obesity was significantly (p < 0.01) higher by BMI (80.4 %) than by WC (48.7 %) and by PBF (55.6 %) in male firefighters. In particular, the prevalence of overweight firefighters was much higher (p < 0.01) by BMI (57.3 %) than by WC (24.5 %) and PBF (38.3 %). 60-64 % of male firefighters who were assessed as normal weight by WC and PBF were misclassified as overweight by BMI. When overweight by BMI was defined as 27.5-29.9 kg/m(2) (vs. the standard definition of 25.0-29.9 kg/m(2)), the agreement of the adiposity classification increased between BMI and other two adiposity measures. Obese firefighters had the highest CVD risk profiles across all three adiposity measures. Only when overweight by BMI was defined narrowly, overweight firefighters had substantially higher CVD risk profiles. Obesity and overweight were less prevalent in female and Asian male firefighters. CONCLUSIONS: BMI overestimated the prevalence of total overweight and obesity among male firefighters, compared to WC and skinfold-based PBF. Overweight by BMI needs to be more narrowly defined, or the prevalence of BMI-based overweight (27.5-29.9 kg/m(2)) should be reported additionally for prevention of CVD among male firefighters.

Recommendations for individual participant data meta-analyses on work stressors and health outcomes: comments on IPD-Work Consortium papers.

The IPD-Work (individual-participant data meta-analysis of working populations) Consortium has published several papers on job strain (the combination of low job control and high job demands) based on Karasek's demand-control model (1) and health-related outcomes including cardiovascular disease (CVD), cancer, obesity, diabetes as well as health-related behaviors, utilizing meta-analyses of a pooled database of study participants from 17 European cohorts. An IPD approach has some advantages over typical meta-analyses, eg, having access to all the data for each individual allows for additional analyses, compared to typical meta-analyses. However, such an approach, like other meta-analyses, is not free from errors and biases (2-6) when it is not conducted appropriately. In our review of the IPD-Work Consortium's (hereafter called the Consortium) publications of the last two years, we have identified and pointed out several conceptual and methodological errors, as well as unsubstantiated conclusions and inappropriate recommendations for worksite public health policies (6-15). However, the Consortium has not yet appropriately addressed many of the issues we have raised. Also several major errors and biases underlying the Consortium IPD meta-analysis publications have not been presented in a comprehensive way, nor have they been discussed widely among work stress researchers. We are concerned that the same errors and biases could be repeated in future IPD Consortium meta-analysis publications as well as by other researchers who are interested in meta-analyses on work stressors and health outcomes. It is possible that the inappropriate interpretations in the Consortium publications, which remained uncorrected to date, may have a negative impact on the international efforts of the work stress research community to improve the health of working populations. Recently, Dr. Töres Theorell, a principal investigator of the Consortium, responded in this journal (16) to some of our criticisms on the Consortium papers (17, 18). The purpose of this article is to discuss the methodological and substantive issues that remain to be resolved and how they could be addressed in future analyses. We provide recommendations for future IPD or typical meta-analyses on work stressors and health outcomes. Finally, we discuss the inappropriate conclusions and recommendations in the Consortium publications and provide alternative recommendations, including a comprehensive perspective on worksite intervention studies.

Short-term test-retest reliability of the Job Content Questionnaire and Effort-Reward Imbalance Questionnaire items and scales among professional firefighters.

Relatively little is known about the short-term test-retest reliability of the Job Content Questionnaire (JCQ) and Effort-Reward Imbalance Questionnaire (ERIQ). Seventeen JCQ and six ERIQ items were qualitatively reviewed by 19 firefighters in focus groups. The items were then administered twice to 81 firefighters with a time interval of 1-8 weeks. The short-term reliability of the JCQ and ERIQ items and scales with the four-point Likert item responses was at least fair or moderate with several complementary statistical methods. It improved substantially when the four-point responses were simplified into the two ('agree' or 'disagree') responses. The JCQ psychological demands and the ERIQ effort scales were among the least reliable scales and their items were most frequently indicated by the firefighters to be clarified. The responses of professional firefighters to the JCQ and ERIQ items and scales were stable during an 8-week period, particularly when dichotomous item responses were used.

Very Long (> 48 hours) Shifts and Cardiovascular Strain in Firefighters: a Theoretical Framework.

Shift work and overtime have been implicated as important work-related risk factors for cardiovascular disease (CVD). Many firefighters who contractually work on a 24-hr work schedule, often do overtime (additional 24-hr shifts) which can result in working multiple, consecutive 24-hr shifts. Very little research has been conducted on firefighters at work that examines the impact of performing consecutive 24-hr shifts on cardiovascular physiology. Also, there have been no standard field methods for assessing in firefighters the cardiovascular changes that result from 24-hr shifts, what we call "cardiovascular strain". The objective of this study, as the first step toward elucidating the role of very long (> 48 hrs) shifts in the development of CVD in firefighters, is to develop and describe a theoretical framework for studying cardiovascular strain in firefighters on very long shifts (i.e., > 2 consecutive 24-hr shifts). The developed theoretical framework was built on an extensive literature review, our recently completed studies with firefighters in Southern California, e-mail and discussions with several firefighters on their experiences of consecutive shifts, and our recently conducted feasibility study in a small group of firefighters of several ambulatory cardiovascular strain biomarkers (heart rate, heart rate variability, blood pressure, salivary cortisol, and salivary C-reactive protein). The theoretical framework developed in this study will facilitate future field studies on consecutive 24-hr shifts and cardiovascular health in firefighters. Also it will increase our understanding of the mechanisms by which shift work or long work hours can affect CVD, particularly through CVD biological risk factors, and thereby inform policy about sustainable work and rest schedules for firefighters.

Working conditions and masked hypertension.

INTRODUCTION: Masked hypertension, i.e., normal clinic blood pressure but elevated blood pressure during normal daily activities as measured by ambulatory monitoring, is a common problem and a serious cardiovascular risk factor. Given previously reported associations between work stressors and ambulatory blood pressure, an inquiry into the relationship between work stressors and masked hypertension is warranted. OBJECTIVE: To assess the relationship between working conditions and masked hypertension. DESIGN: Cross-sectional study. SETTING: Hospital and home care employers in New York City. STUDY PARTICIPANTS: Forty-five male and 119 female hospital and home care employee volunteers wore an ambulatory blood pressure monitor during working hours. MAIN OUTCOME MEASURES: Masked hypertension was defined as work systolic ambulatory blood pressure ≥135 mmHg or diastolic ambulatory blood pressure ≥85 mmHg, and casual blood pressure <140/90 mmHg with no use of antihypertensive medications. Associations between work stressors and masked hypertension were tested by multiple logistic regression. RESULTS: Masked hypertension, observed in 24.0% of males and 17.6% of females with normal casual office obtained blood pressure, was associated with evening, night or rotating shiftwork (odds ratio (OR) 8.25, 95% confidence interval (CI) 2.11-40.31) and with the combination of job strain and effort-reward imbalance (OR 2.97, 95% CI 1.02-8.60) after controlling for age. Associations remained substantial, and statistically significant for shiftwork, after individual adjustment for each of 10 potential confounders. Masked hypertension was not associated with total weekly work hours. CONCLUSIONS: Masked hypertension is a significant individual and public health concern. Additional research is needed to clarify the role of work-related risk factors in the development of masked hypertension, and to develop an appropriate clinical and public health strategy for diagnosis, treatment and prevention.