Stephen Stansfeld

Health inequalities among British civil servants: the Whitehall II study

The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10,314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall II study). Participants were asked to answer a self-administered questionnaire and attend a screening examination. In the 20 years separating the two studies there has been no diminution in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischaemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviours including smoking, diet, and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (eg, monotonous work characterised by low control and low satisfaction), and in social supports. Healthy behaviours should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.

Contribution of job control and other risk factors to social variations in coronary heart disease incidence

BACKGROUND The first Whitehall Study showed an inverse social gradient in mortality from coronary heart disease (CHD) among British civil servants--namely, that there were higher rates in men of lower employment grade. About a quarter of this gradient could be attributed to coronary risk factors. We analysed 5-year CHD incidence rates from the Whitehall II study to assess the contribution to the social gradient of psychosocial work environment, social support, coronary risk factors, and physical height. METHODS Data were collected in the first three phases of examination of men and women in the Whitehall II study. 7372 people were contacted on all three occasions. Mean length of follow-up was 5.3 years. Characteristics from the baseline, phase 1, questionnaire, and examination were related to newly reported CHD in people without CHD at baseline. Three self-reported CHD outcomes were examined: angina and chest pain from the Rose questionnaire, and doctor-diagnosed ischaemia. The contribution of different factors to the socioeconomic differences in incident CHD was assessed by adjustment of odds ratios. FINDINGS Compared with men in the highest grade (administrators), men in the lowest grade (clerical and office-support staff) had an age-adjusted odds ratio of developing any new CHD of 1.50. The largest difference was for doctor-diagnosed ischaemia (odds ratio for the lowest compared with the highest grade 2.27). For women, the odds ratio in the lowest grade was 1.47 for any CHD. Of factors examined, the largest contribution to the socioeconomic gradient in CHD frequency was from low control at work. Height and standard coronary risk factors made smaller contributions. Adjustment for all these factors reduced the odds ratios for newly reported CHD in the lowest grade from 1.5 to 0.95 in men, and from 1.47 to 1.07 in women. INTERPRETATION Much of the inverse social gradient in CHD incidence can be attributed to differences in psychosocial work environment. Additional contributions were made by coronary risk factors--mainly smoking--and from factors that act early in life, as represented by physical height.

Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study

Abstract Objective: To determine the association between adverse psychosocial characteristics at work and risk of coronary heart disease among male and female civil servants. Design: Prospective cohort study (Whitehall II study). At the baseline examination (1985-8) and twice during follow up a self report questionnaire provided information on psychosocial factors of the work environment and coronary heart disease. Independent assessments of the work environment were obtained from personnel managers at baseline. Mean length of follow up was 5.3 years. Setting: London based office staff in 20 civil service departments. Subjects: 10 308 civil servants aged 35-55 were examined-6895 men (67%) and 3413 women (33%). Main outcome measures: New cases of angina (Rose questionnaire), severe pain across the chest, diagnosed ischaemic heart disease, and any coronary event. Results: Men and women with low job control, either self reported or independently assessed, had a higher risk of newly reported coronary heart disease during follow up. Job control assessed on two occasions three years apart, although intercorrelated, had cumulative effects on newly reported disease. Subjects with low job control on both occasions had an odds ratio for any subsequent coronary event of 1.93 (95% confidence interval 1.34 to 2.77) compared with subjects with high job control at both occasions. This association could not be explained by employment grade, negative affectivity, or classic coronary risk factors. Job demands and social support at work were not related to the risk of coronary heart disease. Conclusions: Low control in the work environment is associated with an increased risk of future coronary heart disease among men and women employed in government offices. The cumulative effect of low job control assessed on two occasions indicates that giving employees more variety in tasks and a stronger say in decisions about work may decrease the risk of coronary heart disease. Key messages Low job control in the work environment contributes to the development of coronary heart disease among British male and female civil servants The risk of heart disease is associated with both objective low job control and perceived low job control. Increase in job control over time decreases the risk of coronary heart disease. This suggests that policies giving people a stronger say in decisions about their work or providing them with more variety in work tasks may contribute to better cardiovascular health

Work characteristics predict psychiatric disorder: prospective results from the Whitehall II Study.

OBJECTIVES: The impact of work on the risk of future psychiatric disorder has been examined in few longitudinal studies. This was examined prospectively in a large epidemiological study of civil servants. METHODS: In the Whitehall II study, a longitudinal, prospective cohort study of 6895 male and 3413 female London based civil servants, work characteristics measured at baseline (phase 1: 1985-8) and first follow up (phase 2: 1989) were used to predict psychiatric disorder measured by a 30 item general health questionnaire (GHQ) at phase 2 and phase 3 follow up (phase 3: 1991-3). Work characteristics and GHQ were measured at all three phases. RESULTS: Low social support at work and low decision authority, high job demands and effort-reward imbalance were associated with increased risk of psychiatric disorder as assessed by the GHQ at follow up adjusting for age, employment grade, and baseline GHQ score. CONCLUSIONS: Social support and control at work protect mental health while high job demands and effort-reward imbalance are risk factors for future psychiatric disorder. Intervention at the level of work design, organisation, and management might have positive effects on mental health in working populations.

Social inequality in coronary risk: central obesity and the metabolic syndrome. Evidence from the Whitehall ii study

SummaryThis report describes the social distribution of central obesity and the metabolic syndrome at the Whitehall II study phase 3 examination, and assesses the contribution of health related behaviours to their distribution. Cross-sectional analyses were conducted utilising data collected in 1991–1993 from 4978 men and 2035 women aged 39–63 years who completed an oral glucose tolerance test. There was an inverse social gradient in prevalence of the metabolic syndrome. The odds ratio (95 % confidence interval) for having the metabolic syndrome comparing lowest with highest employment grade was: men 2.2 (1.6–2.9), women 2.8 (1.6–4.8). Odds ratios for occupying the top quintile of the following variables, comparing lowest with highest grade, were, for waist-hip ratio: men 2.2 (1.8-2.8), women 1.6 (1.1-2.4); post-load glucose: men 1.4 (1.1-1.8), women 1.8 (1.2-2.6); triglycerides: men 1.6 (1.2-2.0), women 2.2 (1.5-3.3); fibrinogen: men 1.7 (1.4-2.3), women 1.9 (1.2-2.8). Current smoking status, alcohol consumption and exercise level made a small contribution (men 11%, women 9%) to the inverse association between socioeconomic status and metabolic syndrome prevalence. In conclusion, central obesity, components of the metabolic syndrome and plasma fibrinogen are strongly and inversely associated with socioeconomic status. Our findings suggest the metabolic syndrome may contribute to the biological explanation of social inequalities in coronary risk. Health related behaviours appear to account for little of the social patterning of metabolic syndrome prevalence.

Effects of chronic job insecurity and change in job security on self reported health, minor psychiatric morbidity, physiological measures, and health related behaviours in British civil servants: the Whitehall II study

Study objective: To determine the effect of chronic job insecurity and changes in job security on self reported health, minor psychiatric morbidity, physiological measures, and health related behaviours. Design: Self reported health, minor psychiatric morbidity, physiological measures, and health related behaviours were determined in 931 women and 2429 men who responded to a question on job insecurity in 1995/96 and again in 1997/99. Self reported health status, clinical screening measures, and health related behaviours for participants whose job security had changed or who remained insecure were compared with those whose jobs had remained secure. Setting: Prospective cohort study, Whitehall II, all participants were white collar office workers in the British Civil Service on entry to the study. Main results: Self reported morbidity was higher among participants who lost job security. Among those who gained job security residual negative effects, particularly in the psychological sphere were observed. Those exposed to chronic job insecurity had the highest self reported morbidity. Changes in the physiological measures were limited to an increase in blood pressure among women who lost job security and a decrease in body mass index among women reporting chronic job insecurity. There were no significant differences between any of the groups for alcohol over the recommended limits or smoking. Conclusion: Loss of job security has adverse effects on self reported health and minor psychiatric morbidity, which are not completely reversed by removal of the threat and which tend to increase with chronic exposure to the stressor.

Auditory and non-auditory effects of noise on health

Noise is pervasive in everyday life and can cause both auditory and non-auditory health effects. Noise-induced hearing loss remains highly prevalent in occupational settings, and is increasingly caused by social noise exposure (eg, through personal music players). Our understanding of molecular mechanisms involved in noise-induced hair-cell and nerve damage has substantially increased, and preventive and therapeutic drugs will probably become available within 10 years. Evidence of the non-auditory effects of environmental noise exposure on public health is growing. Observational and experimental studies have shown that noise exposure leads to annoyance, disturbs sleep and causes daytime sleepiness, affects patient outcomes and staff performance in hospitals, increases the occurrence of hypertension and cardiovascular disease, and impairs cognitive performance in schoolchildren. In this Review, we stress the importance of adequate noise prevention and mitigation strategies for public health.

Aircraft and road traffic noise and children's cognition and health: a cross-national study

BACKGROUND Exposure to environmental stressors can impair childrens health and their cognitive development. The effects of air pollution, lead, and chemicals have been studied, but there has been less emphasis on the effects of noise. Our aim, therefore, was to assess the effect of exposure to aircraft and road traffic noise on cognitive performance and health in children. METHODS We did a cross-national, cross-sectional study in which we assessed 2844 of 3207 children aged 9-10 years who were attending 89 schools of 77 approached in the Netherlands, 27 in Spain, and 30 in the UK located in local authority areas around three major airports. We selected children by extent of exposure to external aircraft and road traffic noise at school as predicted from noise contour maps, modelling, and on-site measurements, and matched schools within countries for socioeconomic status. We measured cognitive and health outcomes with standardised tests and questionnaires administered in the classroom. We also used a questionnaire to obtain information from parents about socioeconomic status, their education, and ethnic origin. FINDINGS We identified linear exposure-effect associations between exposure to chronic aircraft noise and impairment of reading comprehension (p=0.0097) and recognition memory (p=0.0141), and a non-linear association with annoyance (p<0.0001) maintained after adjustment for mothers education, socioeconomic status, longstanding illness, and extent of classroom insulation against noise. Exposure to road traffic noise was linearly associated with increases in episodic memory (conceptual recall: p=0.0066; information recall: p=0.0489), but also with annoyance (p=0.0047). Neither aircraft noise nor traffic noise affected sustained attention, self-reported health, or overall mental health. INTERPRETATION Our findings indicate that a chronic environmental stressor-aircraft noise-could impair cognitive development in children, specifically reading comprehension. Schools exposed to high levels of aircraft noise are not healthy educational environments.

Health effects of anticipation of job change and non-employment : longitudinal data from the Whitehall II study

Abstract Objective : To assess the effect of anticipating job change or non-employment on self reported health status in a group of middle aged male and female white collar civil servants. Design : Longitudinal cohort study (Whitehall II study). Questionnaire data on self reported health status and health behaviour were obtained at initial screening and four years later, during the period when employees of the department facing privatisation were anticipating job change or job loss. Setting : London based office staff in 20 civil service departments. Subjects : 666 members of one department threatened with early privatisation were compared with members of the 19 other departments. Main outcome measures : Self reported health status measures and health related behaviours, before and during anticipation of privatisation. Results : In comparison to the remainder of the cohort, the profile of health related behaviours of cohort members who faced privatisation was more favourable, both before and during anticipation of privatisation. There were no significant differences in the changes in health behaviours between cohort members moving into a period of job insecurity and the remainder of the cohort. Self reported health status, however, tended to deteriorate among employees anticipating privatisation when compared with that of the rest of the cohort. Conclusions : The application of a longitudinal design, allowing the same individuals to be followed from job security into anticipation, provides more robust evidence than has previously been available that anticipation of job loss affects health even before employment status has changed.

Psychosocial work characteristics and social support as predictors of SF-36 health functioning: the Whitehall II study.

Objective To assess whether work characteristics and social support are predictors of physical, psychological, and social functioning. Method Work characteristics (Karasek and Siegrist models) and social support at baseline were used to predict health functioning measured by the SF-36 General Health Survey 5 years later in a prospective cohort study of 10,308 British male and female civil servants. Results Effort-reward imbalance and negative aspects of close relationships predicted poor physical, psychological, and social functioning after adjustment for the potential confounding effects of age, employment grade, baseline ill health, and negative affectivity. These psychosocial characteristics seem to act in a similar way in the healthy and those with existing illness. Psychological demands at work in women, and low confiding/emotional support in men, also predicted poor functioning. Etiologically, these effects are not mediated through health-related behaviors. Conclusions Negative aspects of work (high demands and effort-reward imbalance) and negative aspects of close relationships are independent powerful predictors of poor health functioning. They may have an etiological role, which is independent of baseline illness.