Stopping Stress at Its Origins: Addressing Working Conditions
To the Editor:
A significant volume of research relates occupational stress to cardiovascular disease.1 Although a variety of methods exists for measuring occupational stress, a consistent feature of these measurements is a focus on environmental and work organization origins as opposed to individual characteristics and responses. This paradigm comes from occupational health with identifying exposure sources as distinct from measuring biological and/or behavioral response to exposure. Eliminating exposure is the preferred prevention, and personal protective equipment is an acceptable alternative when no other option exists. We equate job redesign with eliminating exposure and stress management to a personal protective equipment approach to occupational stress.2
We agree with Milani and Lavie3 regarding the importance and global impact of stress-related conditions; however, we do differ on the meaning of “stop stress at its origins.” We also disagree with calling exposure to work environment sources of stress as “lifestyle” stressors. We applaud the work praised by Milani and Lavie3 and performed by Lucini et al4 for furthering our understanding of autonomic dysregulation as a consequence of work stress and for testing the effectiveness of stress management. The relationship between environmentally measured job stressors and autonomic dysregulation has been documented,5 and the use of heart rate variability as a measurement strategy for assessing individual response and cardiac disease risk is recommended.
The best available evidence, based on several international job stress intervention reviews, shows that the most effective interventions to mitigate job stress and related adverse effects on health is a mixed strategy in which consideration is given to both work-directed and person-directed measures.2 Put another way, this means a combination of both primary and secondary prevention: job redesign coupled with “personal protective equipment” in the form of stress management programs.6 Stress management might need to precede attempts at job redesign to facilitate effective participatory action-based job redesign programs. Contrary to a behavior-based stress management program, the elimination of environmental sources of stress is more likely to result in lasting, sustainable stress reduction.6 It is unknown whether participants can sustain the practice of stress management programs in the face of ongoing job stress. Few stress management studies had a follow-up time >6 months, and approximately one third of participants fail to learn the techniques.6 In contrast, interventions that use systems approaches (emphasize primary prevention, integrate strategies, and include participation of targeted groups) tend to have longer intervention and evaluation follow-up times, usually on the order of months to years, and are the most effective in addressing both the organizational and individual impacts of job stress.6
Schnall PL, Belkic K, Landsbergis P, Baker D. The Workplace and Cardiovascular Disease. Occupational Medicine: State of the Art Reviews, vol 15. Philadelphia, PA: Hanley & Belfus, Inc; 2000.
Karasek RA. An analysis of 19 international case studies of stress prevention through work reorganization using the demand/control model. Bull Sci Technol. 2004; 24: 446–456.
Milani RV, Lavie CJ. Stopping stress at its origins. Hypertension. 2007; 49: 268–269.
Lucini D, Riva S, Pizzinelli P, Pagani M. Stress management at the worksite: reversal of symptoms profile and cardiovascular dysregulation. Hypertension. 2007; 49: 291–297.
LaMontagne AD, Shaw A, Ostry A, Louie AM, Keegel T: Workplace Stress in Victoria: Developing a Systems Approach. Melbourne, Australia: Victorian Health Promotion Foundation; 2006.