Tarani Chandola
CCSR
University of Manchester

SUMMARY OF PRESENTATION
- Whitehall II study
- Measures of psychosocial working conditions
- Effect on health
- Inequalities in psychosocial working conditions

SUMMARY OF PRESENTATION
Whitehall II study
- Measures of psychosocial working conditions
- Effect on health
- Inequalities in psychosocial working conditions

CHD Mortality Rate by Civil Service Employment Grade
Original Whitehall Study
7
6
5
4
3
2
1
0
Administrators Professional Clerical Other
Marmot et al. Lancet (1984)

Adjusted age + risk factors
5
4.08
4
2.75
3
2.07
1.75
1.77
1.52
2
1
*adjusted smoking, sbp, plasma cholesterol, glucose intolerance van Rossum et al, JECH 2000

Phase
3
4
5
1
2
6
7
8
9
Dates
1985-1988
1989-1990
1991-1993
1995-1996
1997-1999
2001
2003-2004
2006
2008-2009
Type
Screening / questionnaire
Questionnaire
Screening / questionnaire
Questionnaire
Screening / questionnaire
Questionnaire
Screening / questionnaire
Questionnaire
Screening / questionnaire
Participants
7,355
6,967
7,180
6,762
10,308
8,132
8,815
8,628
7,870

SUMMARY OF PRESENTATION
- Whitehall II study
Measures of psychosocial working conditions
- Effect on health
- Inequalities in psychosocial working conditions

Measures of work stressors and stress/health outcomes are separate
Measures of Work Stressors
- By questionnaire:
Job Demands/Control/Strain Model
Effort-Reward Imbalance Model
Organisational Justice Model
Job insecurity
- By external observer

Job Demands/Control/Strain Model

Job Demands/Control/Strain Model

Job Demands/Control/Strain Model

Job Demands/Control/Strain Model

Job Demands Question items
Do you have to work fast?
Do you have to work intensively?
Do you have enough time to do everything?
Do different groups at work demand things from you that you think are hard to combine?
4 Responses ranging from Often to Never

Job Control Question Items
Do you have a choice in deciding how you do your work?
Do you have a choice in deciding what to do in your work?
Others make decisions concerning my work
I have a good deal of say in decisions about work
I have say in my own work speed
My working time can be flexible
I can decide when to take a break
I have a say in choosing with whom I work
I have a great deal of say in planning my work environment

Supervisor support
My supervisor is concerned about the welfare of those under him
My supervisor pays attention to what I am saying
My supervisor is helpful in getting job done
My supervisor is successful in getting people to work together
Co-worker support
People I work with are competent in doing their jobs
People I work with take a personal interest in me
People I work with are friendly
People I work with are helpful in getting the job done

(Karasek and Theorell)
Job Demands
Low High
PASSIVE HIGH STRAIN
Strain
LOW STRAIN ACTIVE
Activity

Job demands
Low High
Passive High Strain
Collective Collective
Low strain Active
Collective Collective
W or k co n tr o l
High
Low
High work support
Passive High Strain
Isolated Isolated
Low Strain Active
Isolated Isolated
Low work support
Johnson and Hall, American Journal of Public Health 1988

The model of effort-reward imbalance at work
-(extrinsic) demands
-(intrinsic) obligations
-wage, salary
-esteem
-promotion/security effort reward
Expectancy
(overcommitment)
Siegrist, 1996
Expectancy
(overcommitment)

Job insecurity
“How secure do you feel in your present job?”
- Very Insecure
- Insecure
- Secure
- Very Secure

SUMMARY OF PRESENTATION
- Whitehall II study
- Measures of psychosocial working conditions
- Effect on health
(CARDIOVASCULAR DISEASE)
- Inequalities in psychosocial working conditions

Whitehall II study, men and women, 11 years follow-up
2
HR
1
0 low
CONTROL high low
Kuper and Marmot, JECH 2003 high
DEMANDS

Age adjusted odds ratios for the association between
Employment Grade (phase 1) and metabolic syndrome (phase 3) - Whitehall II
2
1.5
1
3
2.5
0.5
0
UG1- UG6 UG7 SEO HEO
Civil Service Employment Grades
Brunner et al. (1997) Diabetologia
EO Clerical

Odds Ratios of Metabolic Syndrome by Exposure to Work Stress- Whitehall II phases 1 to 5
5.00
4.00
3.00
2.00
Age, sex, emp grade adj.
Age, sex, emp. grade, behav. adj.
1.00
0.00
no exposures
(491/5178)
1 exposure
(134/1253)
2 exposures
(54/383)
Exposures to Iso-Strain
Chandola, Brunner & Marmot BMJ (2006)
3 or more exposures (41/220)

Work Stress and components of the Metabolic Syndrome
Whitehall II: Phases 1 and 2 to Phase 7
2.0
no report of Work Stress 1 report 2 reports
1.0
0.0
High Waist High
Triglycerides
High Fasting
Glucose
HDL cholsterol
Hypertension
Chandola et al. European Heart Journal (2008)

2
1.8
Work Stress and incident Obesity
Whitehall II: men, Phases 1 to 7
Age adjusted
Age and health behaviours adjusted
1.6
1.4
1.2
1
0.8
No exposure
1 exposure 2 exposures
3 or more exposures
Iso-strain
Brunner et al.
AJE (2006)

2.0
Work Stress and Health Behaviours
Whitehall II: Phases 1 and 2 to Phase 7 no report of Work Stress 1 report 2 reports
1.0
0.0
Poor Diet No Physical
Activity
No Alcohol Current smoker
Chandola et al. European Heart Journal (2008)

INDIRECT PATHWAY
Health behaviours
Psychosocial stressors e.g. smoking
Biological changes
CHD/
Diabetes
Biological changes
DIRECT PATHWAY

2 main biological stress mechanisms
- The autonomic nervous system: sympathetic and parasympathetic sympathetic systems
- The Hypothalamic-Pituitary-Adrenocortical (HPA) axis

Iso-strain and Poor Vagal Tone
0.00
-0.02
-0.04
-0.06
-0.08
-0.10
-0.12
-0.14
-0.16
* no report of iso-strain
1 report
2 reports
SD of NN intervals
* p<0.05
*
High
Frequency
Power
*
Low
Frequency
Power
Chandola et al.
European Heart Journal
(2008)

normal stressed
'burnout'
0 0.5
2.5
8
Hours since awakening
12 16

Mean Morning Rise and Average Day Levels of Cortisol by Iso-Strain
– Whitehall II Phase 7
30
25
20
15
10
5
0
Not Work Stressed
Work Stressed
Morning Rise Average Day Levels
Chandola et al.
European Heart Journal
(2008)

SUMMARY OF PRESENTATION
- Whitehall II study
- Measures of psychosocial working conditions
- Effect on health
(MENTAL HEALTH & SICKNESS ABSENCE)
- Inequalities in psychosocial working conditions

Risk of sickness absence (>7 days) by changes in working conditions
1.4
1.2
1
0.8
0.6
0.4
0.2
Increased
Stable
Decreased
0
Job control Job demands
Work social support
Head et al. Journal of Epidemiology and Community Health 2006

Risk of poor mental health by work stressors
2
1.5
1
0.5
High Medium Low
0
Job control
Stansfeld et al. (1999)
Job
Demands
Work
Social
Support

Risk of poor mental health by changes in work stressors
Beneficial change No change Adverse change
2
1.5
1
0.5
0
Job control
Stansfeld et al. (1999)
Job demands
Work social support

SUMMARY OF PRESENTATION
- Whitehall II study
- Measures of psychosocial working conditions
- Effect on health
(JOB INSECURITY & MENTAL HEALTH)
- Inequalities in psychosocial working conditions

EFFECTS OF JOB INSECURITY ON SELF RATED
HEALTH & DEPRESSION OVER 2 1/2 YEARS IN
THE LATE 1990s - WHITEHALL II
240
220
200
180
160
140
120
100
80
60 remained secure gained job security lost job security chronic job insecurity poor health - women poor health - men depression - women
Adjusted for age, grade and baseline health (Ferrie et al. 2001) depression - men

Distribution of Whitehall II participants working in a civil service department which was privatised, 18 months after privatisation

Odds of poor self-rated health, among Whitehall II civil servants,18 months after privatisation

Increase in Minor Psychiatric Morbidity (GHQ), among Whitehall II civil servants,18 months after privatisation

Odds of long standing illness, among Whitehall II civil servants,18 months after privatisation

SUMMARY OF PRESENTATION
- Whitehall II study
- Measures of psychosocial working conditions
- Effect on health
- Inequalities in psychosocial working conditions

the association of SES with perceived stress
Stress in last 4 weeks: wave 3 (higher score=more stress)
1
0.5
0
-0.5
-1
Unified
Grades 1-
6
Unified
Grade 7
Senior
Executive
Officer
Higher
Executive
Officer
Executive
Officer
Clerical and
Support
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

the association of SES with job demands
Job demands: wave 1 (higher score=more demands)
1
0.5
0
-0.5
-1
Unified
Grades 1-
6
Unified
Grade 7
Senior
Executive
Officer
Higher
Executive
Officer
Executive
Officer
Clerical and
Support
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

the association of SES with job control
Job control: wave 1 (higher score=more control)
1
0.5
0
-0.5
-1
Unified
Grades 1-
6
Unified
Grade 7
Senior
Executive
Officer
Higher
Executive
Officer
Executive
Officer
Clerical and
Support
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

the association of SES with job strain
Job strain: wave 1 (higher score=more stress)
1
0.5
0
-0.5
-1
Unified
Grades 1-
6
Unified
Grade 7
Senior
Executive
Officer
Higher
Executive
Officer
Executive
Officer
Clerical and
Support
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

the association of SES with change in job demands
Job demands: last wave-first wave (positive score=increased demands)
1
0.5
0
-0.5
-1
Unified
Grades 1-
6
Unified
Grade 7
Senior
Executive
Officer
Higher
Executive
Officer
Executive
Officer
Clerical and
Support
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

the association of SES with job strain (phase 5)
Jobstrain: last wave (higher score=more stress)
1
0.5
0
-0.5
-1
Unified
Grades 1-
6
Unified
Grade 7
Senior
Executive
Officer
Higher
Executive
Officer
Executive
Officer
Clerical and
Support
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

the association of SES with iso-strain
Unified Grades 1-6
Senior Executive Officer
Executive Officer
Unified Grade 7
Higher Executive Officer
Clerical and Support
1
0.5
0
-0.5
-1
Job strain, low est tertile of support: last w ave
Job strain, middle tertile of support: last w ave
Job strain, highest tertile of support: last w ave
Chandola and Marmot- forthcoming in Baum & Contrada
Handbook of Stress Science

Mean effort-reward imbalance at phases 1 and 5 and the difference score by employment grade
Chandola et al.
2005 OEM

To what extent do psychosocial working conditions explain social inequalities in health?

Evidence from other studies:
-Effect of psychosocial working conditions on CVD & mental health
-Social inequalities in psychosocial working conditions

Work stress in the etiology of coronary heart disease- a meta-analysis
Kivimaki et al. Scand J Work Environ Health 2006;32(6):431-442
3.5
3
2.5
2
1.5
1
0.5
0
High
Low
Job strain Effort Reward
Balance
Organisational
Justice

Evidence from other studies:
-Effect of psychosocial working conditions on CVD & mental health
-Social inequalities in psychosocial working conditions

Conclusions:
Stressful psychosocial working conditions negatively affect health and wellbeing
Lower socioeconomic-position is linked to more stressful psychosocial working conditions
Repeated measures of psychosocial working conditions over a working career is key

http://www.ucl.ac.uk/whitehallII/data_sharing/index.htm