Selected Abstracts from the Whitehall II Study

Bosma H, Marmot MG, Hemingway H, Nicholson AG, Brunner E, Stansfeld A. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study. BMJ 1997;Volume 314:558-65.

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 (1985-98) 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 personnnel managers at baseline. Mean length of follow up was 5.3 years.
Setting: London based office staff in 20 civil service departments.
Subjects: 10308 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, has a higher risk of newly reported coronary heart disease during the follow up. Job control assessed in two occasions three years apart, although intercorrelated, had cumulative effects in newly reported disease. Subjects with low job control con both occasions has 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.
Conclusion: 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.

Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997;350:235-39.

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 analyzed 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 ischemia. The contribution of different factors to the socioeconomic differences in incident CHD was assessed by adjustment of odds ratio.
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 ischemia (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 socio-economic gradient in CHD frequency was from low control at work. Height and standard coronary risk factors made smaller contributions. Adjustments 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.

North FM, Syme LS, Feeney A, Shipley M, Marmot M. Psychosocial Work Environment and Sickness Absence among British Civil Servants: The Whitehall II Study. Am J Public Health 1996;86:332-340.

Objectives: This study sought to examine the association between the psychosocial work environment and subsequent rates of sickness absence.
Methods: The analyses were based on a cohort of male and female British civil servants (n=9072). Rates of short spells
( < 7 days) and long spells ( > 7 days) of sickness absence were calculated for different aspects of the psychosocial work environment , as measured by self-reports and personnel managers' ratings (external assessments).
Results: Low levels of work demands, control, and support were associated with higher rates of short and long spells of absence in men and, to a lesser extent, in women. The differences were similar for the self-reports and external assessments. After adjustment for grade of employment, the differences were diminished but generally remained significant for short spells. The combination of high demands and low control was only associated with higher rates of short spells in the lower grades.
Conclusions: The psychosocial work environment predicts rates of sickness absence. Increased levels of control and support at work could have beneficial effects in terms of improving the health and well-being of employees and increasing productivity.

Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, White I, Brunner E, Feeney A. Health inequalities among British civil servants: the Whitehall II study. The Lancet 1991; 337:1397-93.

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 10314 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 dimunition in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischemia, 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 behaviors including smoking, diet and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (e.g., monotonous work characterized by low control and low satisfaction), and in social supports.
Healthy behaviors 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.

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