When John Froines proposed a statewide conference of "The Future of Psychosocial Stress Research" he opened the door to a dialog about what we as psychosocial stress researchers in California should be doing next. It seems to me there are a number of possibilities (not necessarily mutually exclusive).

1. Continue what we are doing now, with periodic discussions such as those held by the CWHSG
2. Reexamine our current research efforts to identify positives and negatives with the goal of redirecting our future research to answer new
questions
3. Begin research/prevention projects aimed at utilizing our new knowledge about the workplace and various health outcomes to improve work and health conditions (prevention and intervention activities). The SF Muni bus driver project would be a good example.
4. Begin sharing our knowledge with various stake holders who would normally have a vested interest in what we believe we know (such as health care providers, unions, etc.)
i. Educational courses such as our recent UCLA OHP course would be one example of this kind of activity while
ii. A "white paper" might be another. Here I am assuming that one of the purposes of a white paper is to contribute to a public consensus on the issues and potential solutions.

To target stakeholders implies we have a common knowledge base which generate an agreed upon agenda for the future. It is not clear to me (us) that this is the case. One way to go about exploring this issue is to attempt to write a "white paper" which would be a consensus statement on a wide range of relevant issues. A "white paper" probably should go beyond the "Tokyo Declaration" which was mainly a policy statement. The Tokyo Declaration assumed a shared set of research findings and conclusions. A "white paper" might include state of the art reviews of various topics (e.g., identified workplace risk factors, health outcomes affected by them, summaries of intervention findings, training needs, etc.). Key question for readers of this letter - How do we kick start this dialog? Do we start with another conference to discuss these issues in detail or hold a discussion utilizing email with a goal of trying to find a consensus prior to another general meeting. If the latter then one path would be to comment on the proposed white paper with the idea of identifying areas we
might wish to contribute to. In looking at the proposed "White Paper" outline below it occurs to me that since we have an OM:STAR already on this topic that the first section - what do we know - be quite short and in the form of a summary. Another approach would be a document along the lines of the Tokyo Declaration - updated to include new materials and goals as reflected in our current work in California. This would result in a much shorter document.

A proposed outline for a "White Paper"

Paul Landsbergis has suggested the following outline as the basis for a "white paper" on psychosocial stressors.

I. What do we know? Summary of scientific knowledge to date
A. Impacts of work stressors in health
1. Cardiovascular disease
2. Musculoskeletal disorders
3. Psychological distress
4. Social relationships/family
5. Other
B. Work stressors
1. Job strain, job demands, job decision
latitude
2. Effort-reward imbalance
3. Threat-avoidant vigilant work
4. Work schedules
a. Overtime
b. Shiftwork
5. Work stressors and social class
C. Physiological mechanisms
1. Cardiovascular disease
2. Musculoskeletal disorders
3. Other?
D. Secular trends in job characteristics, work hours - is
work stress increasing?
E. Economic impact of work stressors on health - estimates
for California
F. Intervention efforts - primarily in Scandinavia

II. What are the problems/issues?
A. Popular perception of stress as an important issue,
but...
B. Obstacles to widespread acceptance of this scientific
knowledge and prevention activities
1. Lack of acceptance of knowledge by
mainstream medicine
2. Anti-regulatory political climate
3. Weakness of labor movement
4. Other
C. Arguments made against this research
1. "It's all in your head"
2. Other
D. Risk communication
1. How to talk to workers, managers, unions,
govt about work stress and health?
2. Shaping the public discussion
a. Journal ists
E. Issues for clinicians
1. When to allow return to work after CHD,
WMSD?
2. "Modified duty" to include changes in job
characteristics?
F. Workers' compensation
G. Other

III. A proposed comprehensive plan for reducing disease burden, costs related to psychosocial work stressors in California
A. Research
1. Identification of workplace psychosocial risk factors
2. Proper characterization of each risk factor
3. Best form
4. Relationship to other variables
5. Causality argument (must traditional criteria be met - cigarette ex)
6. Determination of "etiologic fraction" (based on strength of
association) for each risk factor
7. Assessment of exposure rates in working populations - periodic
statewide surveys
8. Determination of "best place" to intervene to reduce risk
9. Pooling databases
10. Assessing ongoing changes in workplaces ("natural experiments")
11. Other
B. Service
1. Work site surveillance - identification of those at risk
2. Occult disease as major iceberg of industrial society (not in Tokyo
declaration)
3. Treatment
4. Develop clinical evaluation protocols and methodologies
5. Provide adequate clinical services to those at risk and to those
with occult disease
6. Surveillance and treatment goals require training of appropriate
professional staff
C. Professional Training
1. Graduate students in Public Health -? Role (to include
surveillance?)
2. Health Care providers (nurses, doctors, etc) to conduct evaluations
and provide treatment
ERCs
D. Public Education
1. Stake Holders
2. Labor, management, health care industry, public health
organizations, government, academia
3. How to get them involved
4. How to integrate various positions/understandings about work (e.g.,
academia with workers with management)
5. Prepare paper for each stakeholder group
E. Workplace Interventions
1. To confirm causality (Is this a necessary step)
2. To reduce exposures (population based)
3. To improve health of working people
4. Individual vs. group vs. workplace

Peter L. Schnall MD MPH
Associate Professor of Medicine
U. of California at Irvine
Director, Center for Social Epidemiology
710 Wilshire Blvd. Suite 525
Santa Monica, Ca 90401
(310) 319-6595