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.

Evaluation of a computer-generated discharge summary for patients with acute coronary syndromes

The discharge summary from hospital to community physician contributes importantly to patient management, but deficiencies in its preparation are well documented. We sought to determine the preferences of general practitioners for standard dictated or computer-generated discharge summaries for patients with acute coronary syndromes. The majority (68.5%) of GPs preferred the computerized summary and particularly liked its comprehensive content, concise style, ease of access to relevant information, clarity and ease of reading. Most (66.9%) thought the computer-generated summary provided the clearer management plan and 70.8% recommended its use for other specialities. In addition, its speed of generation enables GPs to receive a summary within seven days of patient discharge.

Socio-economic status and blood pressure: an overview analysis

BACKGROUND

Mortality rates from hypertension related diseases such as coronary heart disease, hypertensive heart disease, stroke and end stage renal disease show an inverse association with socio-economic status (SES).

OBJECTIVES

To review the published literature in order to assess whether (i) there is an association between SES and blood pressure (BP), and if so whether this is explained by (ii) SES differences in treatment rates, or (iii) SES differences in established risk factors for hypertension, or (iv) psycho-social factors associated with SES.

METHOD

A narrative systematic review of published articles identified from a MEDLINE search from 1966-1996 and manual searching of the retrieved articles' bibliographies.

RESULTS

Lower SES was associated with higher mean BPs in almost all studies in developed countries. This inverse gradient was both stronger and more consistently found in women than in men. The magnitude of the association varied but generally was quite small, with age adjusted mean systolic BP differences of about 2-3 mm Hg between the highest and lowest SES groups. The finding of an SES gradient in BP, despite adjusting for treatment in some studies and the lack of consistent SES differences in hypertension treatment rates, makes differential treatment an unlikely explanation for the SES gradient in BP. A substantial part of the SES gradient was accounted for by the SES gradient in body mass index. Alcohol consumption across SES groups accounted for part of the association in men though few studies examined this issue specifically. In contrast, in undeveloped or developing countries a direct association between SES and BP has often been found which may reflect a higher prevalence of obesity, and higher salt and alcohol intakes among those of higher SES. The SES differences in BP were not detectable in most studies in children. There is little evidence that adverse psycho-social factors associated with low SES cause chronic elevations in BP.

CONCLUSION

A major challenge in reducing the SES gradient in BP is to understand and prevent the SES differences in obesity, which are particularly large in women. Future research should be directed to this question.

Current obesity, steady weight change and weight fluctuation as predictors of physical functioning in middle aged office workers: the Whitehall II Study

OBJECTIVES

(i) To investigate the effects of current obesity, steady weight change and weight fluctuation on physical functioning and (ii) to determine whether associations are independent of coronary heart disease.

DESIGN

Prospective cohort study with body mass index (BMI) measurements at four time points between the ages of 25 and 63 y.

SETTING

British civil servants based in London offices at baseline.

PARTICIPANTS

6895 men and 3413 women aged 35-55 y at baseline.

MAIN OUTCOME MEASURE

Physical functioning was assessed using the 10-item scale from the Short Form 36 Health Survey, with a score in the lowest quartile indicating poor physical functioning.

RESULTS

After adjustment for age and confounders (employment grade, smoking, alcohol, exercise and menopausal status), current BMI was monotonically associated with poor physical functioning in women whereas a threshold effect at a BMI of 27 kg/m2 was seen in men. The odds ratio of poor physical functioning was 1.55 (95% confidence interval (CI) 1.02-2.35) amongst women and 1.04 (95% CI 0.77-1.41) amongst men with BMI 23-24.9 kg/m2 compared to those with BMI < 21 kg/m2. Women in the upper, compared to the lower, tertile of steady weight change, had an odds ratio of poor physical functioning of 1.79 (1.24-2.60) after adjustment for age, confounders, current BMI and weight fluctuation. Women in the upper, compared to the lower, tertile of weight fluctuation had an odds ratio of poor physical functioning of 1.70 (1.23-2.34) adjusting for age, confounders, current BMI and steady weight change. Adjustment for the presence of coronary heart disease did not substantially alter any of these associations. Steady weight change and weight fluctuation had no independent effects in men.

CONCLUSION

Among women, current obesity, steady weight change and weight fluctuation are independently and monotonically associated with poor physical functioning. Development of overt coronary heart disease is unlikely to be the mechanism for these associations.

Is the SF-36 a valid measure of change in population health? Results from the Whitehall II Study

OBJECTIVE

To measure within-person change in scores on the short form general health survey (SF-36) by age, sex, employment grade, and disease status.

DESIGN

Longitudinal study with a mean of 36 months (range 23-59 months) follow up, with screening examination and questionnaire to detect physical and psychiatric morbidity.

SETTING

20 civil service departments originally located in London.

PARTICIPANTS

5070 male and 2197 female office based civil servants aged 39-63 years.

MAIN OUTCOME MEASURES

Change in the eight scales of the SF-36 (adjusted for baseline score and length of follow up) and effect sizes (adjusted change standard deviation of differences).

RESULTS

Within-person declines (worsening health) with age were greater than estimated by cross sectional data alone. General mental health showed greater declines among younger participants (P for linear trend < 0.001). Employment grade was inversely related to change; lower grades had greater deteriorations than higher grades (P < 0.001 for each scale in men; P < 0.05 for each scale in women except general health perceptions and role limitations due to physical problems). The greatest declines were seen among participants with disease at baseline, with the effects of physical and psychiatric morbidity being additive. Effect sizes ranged from 0.20 to 0.65 in participants with both physical and psychiatric morbidity.

CONCLUSIONS

Health functioning, as measured by the SF-36, changed in hypothesised directions with age, employment grade, and disease status. These changes occurred within a short follow up period, in an occupational, high functioning cohort which has not been the subject of intervention, suggesting that the SF-36 is sensitive to changes in health in general populations.

The impact of socioeconomic status on health functioning as assessed by the SF-36 questionnaire: the Whitehall II Study

OBJECTIVES

This study measured the association between socioeconomic status and the eight scale scores of the Medical Outcomes Study short form 36 (SF-36) general health survey in the Whitehall II study of British civil servants. It also assessed, for the physical functioning scale, whether this association was independent of disease.

METHODS

A questionnaire containing the SF-36 was administered at the third phase of the study to 5766 men and 2589 women aged 39 through 63 years. Socioeconomic status was measured by means of six levels of employment grades.

RESULTS

There were significant improvements with age in general mental health, role-emotional, vitality, and social functioning scale scores. In men, all the scales except vitality showed significant age-adjusted gradients across the employment grades (lower grades, worse health). Among women, a similar relationship was found for the physical functioning, pain, and social functioning scales. For physical functioning, the effect of grade was found in those with and without disease.

CONCLUSIONS

Low socioeconomic status was associated with poor health functioning, and the effect sizes were comparable to those for some clinical conditions. For physical functioning, this association may act both via and independently of disease.

Association of angiotensin-converting enzyme gene I/D polymorphism with change in left ventricular mass in response to physical training

BACKGROUND

The absence (deletion allele [D]) of a 287-base pair marker in the ACE gene is associated with higher ACE levels than its presence (insertion allele [I]). If renin-angiotensin systems regulate left ventricular (LV) growth, then individuals of DD genotype might show a greater hypertrophic response than those of II genotype. We tested this hypothesis by studying exercise-induced LV hypertrophy.

METHODS AND RESULTS

Echocardiographically determined LV dimensions and mass (n=140), electrocardiographically determined LV mass and frequency of LV hypertrophy (LVH) (n=121), and plasma brain natriuretic peptide (BNP) levels (n=49) were compared at the start and end of a 10-week physical training period in male Caucasian military recruits. Septal and posterior wall thicknesses increased with training, and LV mass increased by 18% (all P<.0001). Response magnitude was strongly associated with ACE genotype: mean LV mass altered by +2.0, +38.5, and +42.3 g in II, ID and DD, respectively (P<.0001). The prevalence of electrocardiographically defined LVH rose significantly only among those of DD genotype (from 6 of 24 before training to 11 of 24 after training, P<.01). Plasma brain natriuretic peptide levels rose by 56.0 and 11.5 pg/mL for DD and II, respectively (P<.001).

CONCLUSIONS

Exercise-induced LV growth in young males is strongly associated with the ACE I/D polymorphism.

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.

Social class, spoken language and pattern of care as determinants of continuity of carer in maternity services in east London

BACKGROUND

The Government's policy of Changing childbirth gives priority to user-oriented outcomes, such as continuity of carer. It has been assumed that the organization (or pattern) of maternity care is the main determinant of continuity, with relatively little attention paid to sociodemographic factors. The aim of this study was to assess the relative contribution of social class, spoken language and pattern of care in determining continuity of carer.

METHOD

Postal questionnaires were sent 14 days after delivery to East London and the City Health Authority residents delivering within a three-week period in May 1994. Bilingual interviews were carried out for non-English-speaking women. Pattern of care was assigned by the midwife as either hospital or community (including team based care, 'domino' and home births). The main outcome measure was self-reported continuity of carer in antenatal, delivery and postnatal care.

RESULTS

The response rate was 69 per cent (370/533). The community pattern of care affected only antenatal continuity (62 per cent community vs 50 per cent hospital, p < 0.05). Women whose main spoken language was English or whose social class was I-IIIn reported higher levels of continuity at each phase of care, although this effect was largely confined to the community pattern of care. The odds ratios (95 per cent confidence intervals) for the effect of social class (I-IIIn vs other) on antenatal, labour and postnatal continuity within the community pattern of care were 3.64 (1.09-12.18), 3.08 (1.09-8.74) and 4.93 (1.48-16.46), respectively.

CONCLUSION

Spoken English and high social class were associated with continuity of carer, although this effect was mainly confined to women with a community pattern of care. Achievement of national targets for continuity of carer may not be possible in east London without explicit consideration of sociodemographic factors.

Sickness absence from back pain, psychosocial work characteristics and employment grade among office workers

OBJECTIVES

The relation between psychosocial work characteristics, employment grade, and sickness absence due to back pain was studied among office workers.

METHODS

Base-line questionnaire data and sickness absence data collected continuously with a mean of 4 years of follow-up were analyzed. The subjects were 6894 men and 3414 women aged 35 to 55 years at recruitment. The main outcome measures were short (< or = 7 days) and long (> 7 days) absences due to back pain.

RESULTS

There was a strong inverse association between employment grade and rate of absences due to back pain (P for linear trend < 0.001); for example, the rate ratio for short absences among the men in a comparison of lowest versus highest employment grade was 8.21. The age adjusted rate ratio for the effect of low versus high control over work among the men was 2.22 [95% confidence interval (95% CI) 1.77-2.79] for short and 1.61 (95% CI 1.01-2.58) for long absences due to back pain. For short absences due to back pain among the men in high grades of employment, the rate ratio for low control was 3.42 compared with 0.78 for the lower grades (P for interaction < 0.001). For the women the corresponding rate ratios were 0.80 and 1.35, respectively (P for interaction 0.08).

CONCLUSIONS

Absence from work due to back pain was strongly inversely related to employment grade. The effects of psychosocial work characteristics-particularly control-differed by grade and gender in magnitude and direction. The psychosocial work environment represents a potentially reversible cause of ill health.

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

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.