Does Job Strain Increase the Risk for Coronary Heart Disease or Death in Men and Women?

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1 American Journal of Eidemiology Coyright 2004 by the Johns Hokins Bloomberg School of Public Health All rights reserved Vol. 159, No. 10 Printed in U.S.A. DOI: /aje/kwh127 Does Job Strain Increase the Risk for Coronary Heart Disease or Death in Men and Women? The Framingham Offsring Study Elaine D. Eaker 1, Lisa M. Sullivan 2,3, Margaret Kelly-Hayes 3,4, Ralh B. D Agostino, Sr. 2,3, and Emelia J. Benjamin 3,5 1 Eaker Eidemiology Enterrises, LLC, Chili, WI. 2 Deartment of Mathematics and Statistics, Boston University School of Public Health, Boston, MA. 3 The National Heart, Lung, and Blood Institute s Framingham Heart Study, Framingham, MA. 4 Deartments of Neurology and Cardiology, Boston University School of Medicine, Boston, MA. 5 Deartment of Cardiology, Boston University School of Medicine, Boston, MA. Received for ublication March 31, 2003; acceted for ublication December 4, Conflicting findings in the literature have made the relation between job strain and coronary heart disease (CHD) controversial. The effect of high job strain on the 10-year incidence of CHD and total mortality was examined in men and women articiating in the Framingham Offsring Study; 3,039 articiants, 1,711 men and 1,328 women, aged years, were examined between 1984 and 1987 and followed for 10 years. Measures of job strain, occuational characteristics, and risk factors for CHD were collected at the baseline examination. Before and after controlling for systolic blood ressure, body mass index, cigarette smoking, diabetes, and the total/high density liorotein cholesterol ratio in Cox roortional hazards models, the authors found that high job strain was not associated with mortality or incident CHD in either men or women over the follow-u eriod. Contrary to exectation, women with active job strain (high demands-high control) had a 2.8- fold increased risk of CHD ( : 1.1, 7.2) comared with women with high job strain (high demands-low control). For men, higher education, ersonal income, and occuational restige were related to decreased risk of total mortality and CHD. These findings do not suort high job strain as a significant risk factor for CHD or death in men or women. cohort studies; coronary disease; occuations; sychology; stress Abbreviations: CHD, coronary heart disease; CI, ; RR,. There has been longstanding interest in the imact of job strain on health outcomes. In 1970, Karasek (1) roosed a two-dimensional model for measuring sychosocial work conditions in which the combination of high job demands and low freedom to make job decisions (low control or low decision latitude) was found to be related to deression, exhaustion, and job dissatisfaction. Since then, a number of studies have used this aradigm to define job strain in relation to coronary heart disease (CHD) or risk factors for CHD (2 17). Another study used a comlementary concet of effortreward imbalance (18). Many of these studies, however, have serious limitations including reliance on revalence data (3, 8), failure to carefully measure and control for CHD risk factors (2, 4, 6, 11), oor confirmation of CHD (2, 4, 8), measurement of occuational strain after the event (4, 10, 12, 13), and no inclusion of women (7, 9, 12 14). Other roblems have included inconsistent definitions of outcomes ranging from self-reorted heart weakness to documented CHD death. In addition, job strain has been defined in various ways (9, 10, 12, 14, 19). These limitations have led to inconsistent findings. When the literature is limited to the seven studies with rosective data that controlled for CHD risk factors, five Rerint requests to Dr. Elaine D. Eaker, Eaker Eidemiology Enterrises, LLC, 8975 Country Road V, Chili, WI ( eakerei@tznet.com). 950 Am J Eidemiol 2004;159:

2 Job Strain and Coronary Heart Disease or Death 951 studies (14 18) (four from the same study oulation (15 18)) found some form of job strain to be associated with the incidence of some form of CHD. Two studies found no association between job strain and incident CHD or CHD mortality (7, 9). The Framingham Offsring Study can address these inconsistencies through a strong rosective cohort design, clinically verified disease incidence, the inclusion of both women and men, and direct measures of job strain based on Karasek s model. Other variables that might modify or confound the relations between job strain and incident CHD and death were also collected routinely. These variables included occuational restige, ersonal income, educational level, occuation, and the standard clinical risk factors for the develoment of CHD. The urose of this study was to test the hyothesis that high job strain is indeendently related to the 10-year incidence of CHD and total mortality in men and women in a well-defined cohort using standardized measures of occuational risk and disease. MATERIALS AND METHODS The Framingham Heart Study is a rosective longitudinal cohort study that began in In , the offsring (and souses) of the original Framingham Heart Study cohort were enrolled in the Framingham Offsring Study (20). A total of 5,135 ersons (75 ercent of all invitees) volunteered for the first examination cycle. At the third examination cycle from 1984 through 1987, 3,873 articiants aged years were examined. Subjects were mailed the self-administered sychosocial assessment forms that were collected at the scheduled clinic examination. A total of 3,682 articiants comleted a sychosocial questionnaire, 1,769 men and 1,913 women, comromising a 95 ercent resonse rate. Subjects were excluded from the resent study for the following indications: incomlete questionnaire (n = 191) or revalent CHD (n = 107). Included in the questionnaire were variables concerning job strain and occuational and job characteristics. Because this study was interested in job and occuational characteristics, we stratified the cohort into women (n = 1,328) and men (n = 1,711) who resonded that they had been emloyed outside the home most of their adult years (18 years of age or older). Data collected that related to job characteristics included Karasek s questions to assess the following items: decision authority (three scale items), skill discretion (six scale items), and job demands (five scale items). Questions that defined decision authority included being able to make decisions about one s own job, freedom to decide how to work, and having a lot to say about what haens on one s job. Questions that defined skill discretion included learning new things, being creative, and develoing one s own secific abilities on the job. Questions that defined job demands included excessive work, working fast, working hard, and conflicting job demands. These scales were measured according to established scoring algorithms. Each variable that contributes to a scale was scored on a Likert scale from 1 (strongly disagree) to 4 (strongly agree) and summed over the articular items constituting the job scale. Because there FIGURE 1. Definition of job strain. are no normative data for these scales, we used continuous scale scores to define the mean for men and women searately. A scale termed decision latitude was created by combining the two scales skill discretion and decision authority. This created scale of decision latitude in combination with job demands forms the basis to define job strain: 1) high strain, based on simultaneously high job demands (above the median score) and low job decision latitude (at or below the median score); 2) low strain, based on simultaneously low job demands and high job decision latitude; 3) assive, based on simultaneously low job demands and low decision latitude; or 4) active, based on simultaneously high job demands and high job decision latitude (2) (figure 1). The Census Bureau s six summary grous develoed from the 1980 Standard Industrial Classification were used for classifying occuations (21). In addition, scores were assigned to each occuation using the occuational restige ratings from the 1989 General Social Survey (22). Occuational restige ratings ranged from a high score of 86 for hysicians to 17 for miscellaneous food rearation. Several variables were collected and examined that could otentially confound the relations between job strain and the health outcomes of interest (e.g., being related to both job strain and the outcome). These variables included occuation, occuational restige, ersonal income, education, and housework resonsibilities. The choice of otential confounders was based on findings from revious research suggesting that these characteristics may exlain any observed relation between job strain and the outcomes of interest (23). The current research examined one s ersonal occuational status, job attributes, restige of one s own occuation, and educational level, not a comosite family score for standard of living. Therefore, total ersonal income was selected as a otential confounding variable, instead of total family income. The searate scales that defined job strain were also examined to see if they had a unique imact on health outcomes. Standard CHD risk factors were collected at the clinic examination and included systolic blood ressure, body mass index (weight (kg)/height (m) 2 ), current cigarette Am J Eidemiol 2004;159:

3 952 Eaker et al. smoking, the resence of diabetes (defined as a fasting blood glucose level of at least 126 mg/dl or on treatment), and the ratio of total to high density liorotein cholesterol. The two outcomes of interest included 10-year total mortality and incident CHD. The definition of CHD has been ublished reviously (24, 25); the manifestations of interest in these analyses included myocardial infarction (recognized and unrecognized), coronary insufficiency, and CHD death (both sudden and not sudden). Regarding statistical analyses, descritive statistics were generated in the first hase of the analysis for all study variables for the total samle and then for men and women, considered searately. Means, standard deviations, medians, and interquartile ranges were investigated for continuous variables, and relative frequencies were examined for discrete variables. Tests for differences in distributions of discrete variables were erformed using the chi-square test. Tests were erformed only for those ersons who were emloyed outside the home most of their adult life. In the next hase of the analysis, total mortality and CHD events were tallied for men and women searately according to secific levels of the redictor variables. Age-adjusted rates of total mortality and CHD over 10 years were then comuted for each level of each variable using Cox roortional hazards regression. Finally, using a sex-secific Cox roortional hazards regression analysis, we estimated the s of total mortality and CHD for each job-related and demograhic variable in the age-adjusted analyses. These analyses were adjusted for standard CHD risk factors and were erformed on the individuals emloyed outside the home most of their adult life. Relative risks for continuous measures were comuted relative to a 1 standard deviation change in the continuous measure. It should be noted that high strain is the referent category, since the hyothesis being tested is that eole scoring in this quadrant will have the greatest risk comared with others in the other three quadrants. RESULTS Among those reorting having been emloyed outside the home most of their adult life, most men (31.1 ercent) were in the active category of job strain, and the greatest ercentage of women (35.6 ercent) were in the assive job strain category (table 1; figure 1). With regard to occuation, the highest roortion of men was in management/rofessional occuations (42.6 ercent), and the highest roortion of women was in technical/sales ositions (42.9 ercent). Tables 2 and 3 resent the relations between measures of job strain and the searate scales used to define job strain as risk factors for CHD and total morality for men and women, resectively. Men (table 2) reorting assive job strain were significantly older and had higher systolic blood ressure. Men reorting active strain were younger and had the lowest systolic blood ressure. When the scales that comrise job strain were examined, decision latitude, skill discretion, decision authority, and job demands were inversely and significantly related to age. With the excetion of decision authority, these scales were also significantly and inversely related to systolic blood ressure. Women (table 3) reorting active job strain were significantly younger and had lower systolic blood ressure and ratio of total to high density liorotein cholesterol levels. Women with active job strain were less likely to be smokers or to have diabetes. When the scales that comrise job strain were examined, decision latitude, skill discretion, and decision authority were all significantly and inversely related to age, systolic blood ressure, and the ratio of total to high density liorotein cholesterol. Table 4 resents the age-adjusted 10-year incidence rates for total mortality and CHD by job strain variables and otential confounding variables (i.e., those variables related to both job strain and the outcome of interest). For men, job strain was not associated with either incident CHD or total mortality over the 10 years of follow-u. A higher educational level and a higher ersonal income were related to lower risk of both the develoment of CHD and total mortality. Men emloyed as oerators/laborers had the highest rates of both death and CHD, and those emloyed in management/rofessional or farming/forestry occuations had the lowest rates. Women in service or construction occuations had the highest total mortality rates, and those in management/rofessional or technical/sales occuations had the highest 10-year CHD rates. Although the association of occuation with both outcomes was significant in men and women, there were no events in some of the categories (e.g., farming/forestry). In age-adjusted models, with regard to the job characteristics (table 5), higher occuational restige was associated with significantly lower total mortality ( (RR) = 0.73, 95 ercent (CI): 0.62, 0.86) and 10- year incidence of CHD (RR = 0.81, 95 ercent CI: 0.68, 0.97) in men. None of the other searate job characteristic scales that define job strain was significantly associated with total mortality or CHD in men. In women, the comosite scale of decision latitude (made u of both skill discretion and decision authority) (RR = 1.62, 95 ercent CI: 1.09, 2.42) and the single scale of high decision authority (RR = 1.55, 95 ercent CI: 1.05, 2.29) were associated with significantly higher age-adjusted risk of CHD. Job demands were not associated with either total mortality or the 10-year incidence of CHD in women. Occuational restige did not reach statistical significance with either the develoment of CHD or total mortality in women in this samle. Table 6 resents the multivariable analyses for the 10-year follow-u for total mortality and incident CHD. Each jobrelated or demograhic variable was entered into a Cox roortional hazards model with age, systolic blood ressure, the ratio of total cholesterol to high density liorotein cholesterol, body mass index, cigarette smoking, and diabetes. Job strain was significantly associated with the 10-year incidence of CHD in women. Contrary to our hyothesis, however, women with increased job demands and increased decision latitude (those in the active job strain quadrant in figure 1) had significantly higher risk of develoing CHD over the 10 years of follow-u comared with women reorting decreased decision latitude and increased job demands (those in the high job strain quadrant in figure 1). When the individual scales that define job strain were exam- Am J Eidemiol 2004;159:

4 Job Strain and Coronary Heart Disease or Death 953 TABLE 1. Demograhic and sychosocial characteristics of articiants emloyed outside the home most of their adult life, Framingham Offsring Study, Men (%) (n = 1,711) Women (%) (n = 1,328) Characteristic Education (years) Job strain Active High strain Low strain Passive Personal income ($) 0 9, ,000 19, ,000 29, ,000 49, , Occuation Management/rofessional Technical/sales Service Farming/forestry Production/craft Construction Oerators/labors Mean (SD*) Median Mean (SD) Median Occuational scales Occuational restige 48.9 (12.6) (12.9) 46.0 Decision latitude 75.0 (12.1) (12.6) 70.0 Skill discretion 18.0 (3.0) (3.3) 17.0 Decision authority 19.4 (3.6) (3.7) 18.0 Job demands 31.5 (6.0) (6.0) 32.0 * SD, standard deviation. ined searately in the multivariable analyses, decision latitude and the subscales of decision authority and skill discretion were significantly and ositively related to the 10- year incidence of CHD in women. To determine if the effect of active job strain on the 10-year incidence of CHD in women could be confounded by occuational level, occuation was included in the multivariable equation with the standard risk factors. The s for each category comared with high strain after adjustment for standard risk factors and occuation were as follows: active job strain (RR = 2.97, = 0.02), low job strain (RR = 1.93, = 0.23), and assive job strain (RR = 0.43, = 0.15). Family income and education were also entered into the model with job strain in women, and the results were not changed. It is ossible that the association between high decision authority/high decision latitude and CHD in women might be exlained by the strain of household resonsibilities. However, this hyothesis does not seem to be the case, as the number of children a woman had, housework resonsibilities, and housework as a big strain were not related to the age-adjusted 10-year incidence of CHD in women emloyed most of their adult years (data not shown). Among men, educational level and ersonal income were inversely and significantly related to death and CHD (table Am J Eidemiol 2004;159:

5 954 Eaker et al. TABLE 2. Relation between occuational characteristics and risk factors related to coronary heart disease and total mortality: men emloyed outside the home most of their adult life, Framingham Offsring Study, Age years) SBP* mmhg) BMI* kg/m 2 ) Total/HDL* cholesterol ratio ) * SBP, systolic blood ressure; BMI, body mass index; HDL, high density liorotein. Decision latitude is a combination of skill discretion and decision authority. Cigarette smoking (%) Diabetes mellitus (%) Job strain < High strain Active Passive Low strain Decision latitude < Below median Above median Skill discretion < Below median Above median Decision authority < Below median Above median Job demands < Below median Above median TABLE 3. Relation between occuational characteristics and risk factors related to coronary heart disease and total mortality: women emloyed outside the home most of their adult life, Framingham Offsring Study, Age years) SBP* mmhg) BMI* kg/m 2 ) Total/HDL* cholesterol ratio ) * SBP, systolic blood ressure; BMI, body mass index; HDL, high density liorotein. Decision latitude is a combination of skill discretion and decision authority. Cigarette smoking (%) Diabetes mellitus (%) Job strain < < High strain Active Passive Low strain Decision latitude 0.01 < Below median Above median Skill discretion 0.04 < < Below median Above median Decision authority Below median Above median Job demands < Below median Above median Am J Eidemiol 2004;159:

6 Job Strain and Coronary Heart Disease or Death 955 TABLE 4. Age-adjusted 10-year rates of total mortality and coronary heart disease among eole emloyed at least half of their adult years, Framingham Offsring Study, from to Characteristics Total mortality* Coronary heart disease Men (n = 1,711) Women (n = 1,328) Men (n = 1,624) Women (n = 1,316) Ageadjusted rate Ageadjusted rate Ageadjusted rate * Total mortality: no. of events among men = 160 and among women = 54. Coronary heart disease: no. of events among men = 118 and among women = 31. Ageadjusted rate Job strain Active High strain Low strain Passive Education (years) Occuation <0.001 < <0.001 Management/rofessional Technical/sales Service Farming/forestry Production/craft Construction Oerators/laborers Personal income ($) , ,000 19, ,000 29, ,000 49, , ). Comared with men in management/rofessional ositions, men who were oerators/laborers had over twice the risk of death or CHD over the 10 years of follow-u. With regard to the job characteristic scales, occuational restige was significantly rotective in men against both death and CHD over the 10 years of follow-u. To further exlore the relation between occuational restige and total mortality, we entered both educational level and occuational restige TABLE 5. Age-adjusted s er 1 standard deviation change in each scale for total mortality and incident coronary heart disease by job characteristics for men and women, Framingham Offsring Study, from to Job characteristics * Significant ( 0.05). Age-adjusted Am J Eidemiol 2004;159: Total mortality Coronary heart disease Men Women Men Women Age-adjusted Age-adjusted Age-adjusted Occuational restige 0.73* 0.62, 0.86* , * 0.68, 0.97* , 1.74 Decision latitude , , , * 1.09, 2.42* Skill discretion , , , , 2.19 Decision authority , , , * 1.05, 2.29* Job demands , , , , 1.35

7 956 Eaker et al. TABLE 6. Multivariable-adjusted s for total mortality and incident coronary heart disease over 10 years among eole emloyed at least half of their adult years, men and women, Framingham Offsring Study, from to Characteristic Adjusted Total mortality Coronary heart disease Men Women Men Women Adjusted Adjusted Adjusted Job strain Active , , , * 1.09, 7.17* High strain Referent Referent Referent Referent Low strain , , , , 4.67 Passive , , , , 1.33 Education (years) 12 Referent Referent Referent Referent , , , , * 0.41, 0.94* , * 0.35, 0.94* , 4.33 Occuation Management/rofessional Referent Referent Referent Referent Technical/sales , , , , 1.91 Service , , , 3.16 Farming/forestry Production/craft , , 3.34 Construction , , , , 5.44 Oerators/laborers 2.02* 1.24, 3.29* , , 3.78 Personal income ($) 0 9,000 Referent Referent Referent Referent 10,000 19, , , , , ,000 29, * 0.26, 0.71* , , , ,000 49, * 0.38, 0.91* , , , , * 0.24, 0.75* 0.34* 0.16, 0.73* , Occuational restige 0.77* 0.65, 0.91* , * 0.66, 0.98* , 1.05 Decision latitude , , , * 1.26, 3.10* Skill discretion , , , * 1.03, 1.37* Decision authority , , , * 1.21, 2.85* Job demands , , , , 1.06 * Significant ( 0.05). Adjusted for age, systolic blood ressure, the ratio of total cholesterol to high density liorotein cholesterol, body mass index, cigarette smoking, and diabetes. into the same multivariable equation with the standard risk factors. A man s educational level or income level did not account for the relation observed between occuational restige and total mortality (data not shown). DISCUSSION These findings from the Framingham Offsring Study failed to suort the notion that high job strain, as defined by high job demands and low decision latitude, was a significant risk factor for the develoment of CHD or total mortality over a 10-year eriod in either men or women. Contrary to our hyothesis, women reorting active job strain, as defined by high job demands and high decision latitude, were significantly more likely (2.8 times) to develo CHD comared with those reorting high job strain in their work setting (figure 1). This was true after adjustment for the standard risk factors associated with CHD. The adverse effect of active job strain on the 10-year incidence of CHD in women seems to be not the result of high job demands er se but the result of higher levels of decision latitude and/or decision authority or skill discretion. It is of interest that women (as well as men) in the active job strain category actually have lower levels on most of the standard risk factors measured in this study (tables 2 and 3). The otential mechanisms for this increased risk may be through characteristics not measured in this study, such as Am J Eidemiol 2004;159:

8 Job Strain and Coronary Heart Disease or Death 957 hemostasis and thrombosis, coronary vasoconstriction, latelet aggregation, or laque ruture. The question arises as to why we observed a counterintuitive relation in our data in which increased authority and latitude in one s job were related to increased risk of develoing CHD in women. One seculative exlanation involves historical shifts in social status and roles. In exlaining the shift in the relation between social status and CHD in men over time, Morgenstern (26) observes that there are new demands from a new social environment where individuals need to develo new s, attitudes, and atterns of behaviors. In the ast, a woman s social status was most likely a reflection of the income and occuation of her husband, not of her own role in society. In the current study, we see women with jobs associated with autonomy, authority, and control at higher risk for the develoment of CHD. For women, the adotion of new social roles may be articularly difficult because of cultural resistance to the change in women s roles (27). It could be argued that women in the mid-1980s who were in ositions of authority and control were at the cutting edge of a social transition. As women broke into ositions of authority, the social ressures and reactions to women in a man s role may have had deleterious effects on women s risk of CHD. For examle, discrimination and disarities with regard to wages comared with men may have had an effect. As recently as 2001, the General Accounting Office reorted that full-time female managers earned less than their male counterarts in all 10 industries studied in 1995 and In 2000, women managers in the communications industry made 73 cents for every dollar earned by a man (28). It is imortant for future research to exlore issues and characteristics of working women and the work environment that may roduce a highrisk situation for the develoment of CHD. There have been seven studies (four from the same oulation) of job strain and risk of CHD that were rosective in design and controlled for CHD risk factors (7, 9, 14 18). One study found high job strain to be marginally rotective in a oulation of men of Jaanese ancestry in Hawaii (7). Another study found that the combined effect on incidence of CHD of high job demands and low resources was mitigated by income level (14). When decision latitude (job control) was examined searately in the Western Electric Study (9), it was not a significant redictor of CHD death but was more ronounced (rotective) for white-collar than for blue-collar workers. Job demands were also not associated with CHD death in the Western Electric Study. Contrary to these findings, the Whitehall Study found low job control to be significantly associated with an increased risk of CHD disease in both men and women regardless of emloyment grade and CHD risk factors (15). Job demands and social suort were examined in this reort from the Whitehall Study and found not to be related to CHD. Two more recent ublications from the Whitehall II Study examined the combined effects of high job demands and low job control (job strain) (17) and the imbalance between effort and reward (18) on the incidence of CHD. The former study found that job strain was significantly related to the incidence of all CHD (hazard ratio = 1.38, 95 ercent CI: 1.10, 1.75) but not to the hard endoints of fatal CHD/nonfatal myocardial infarction (hazard ratio = 1.16, 95 ercent CI: 0.78, 1.71). In the study of effort-reward imbalance, a similar finding was reorted: A high ratio of effort to rewards was related to all CHD but not to fatal CHD/nonfatal myocardial infarction. The outcome of all CHD included otential cases of myocardial infarction and angina (18,. 778). An imortant similarity between the Whitehall Study and the Framingham Offsring Study is that, when definite CHD was the outcome of interest, job strain was not a significant risk factor after otential confounders were controlled in either men or women. We know from revious research of sychosocial risk factors in the Framingham data that inclusion of definite angina ectoris as an outcome for coronary heart disease can result in significant findings that are not observed when only hard endoints are observed (29). The imortance of the distinction between findings related to definite or hard endoints and those related to otential CHD endoints cannot be overemhasized. In a study of the validation of the London School of Hygiene (Rose) Questionnaire, Garber et al. (30) found a oor relation between Rose Questionnaire angina and exercise thallium-201 scintigrahy, an objective measure of myocardial ischemia. In this study, the Rose Questionnaire resulted in a false ositive rate of 75 ercent in females and 27 ercent in males. Among men, the work characteristics that were related to their health in a ositive way were increased occuational restige and management/rofessional occuational level. Perhas men are socially and sychologically rewarded for being in occuational ositions of higher restige. Women in similar ositions may not be afforded the same benefits as men. In addition, a work environment that encourages and rewards authority and control may be counter to an environment of cooeration and that may be more conducive to women s health. Similar findings have been reorted by Bassuk et al. (31), who found that education, household income, and occuational restige were associated with lower mortality in men, but only household income was rotective in women. The strengths of the Framingham Offsring Study include direct measures of occuational characteristics, rosective design, inclusion of both men and women, a stable cohort, carefully assessed endoints, and information on standard risk factors. A limitation of this articular study is that the Framingham cohort is redominantly Caucasian and was redominantly middle aged at the time of the study; the findings may not be generalizable to other ethnicities and the elderly. In addition, the resent study had a greater ower to detect redictors of mortality and CHD in men than in women. For instance, when comaring two similarly sized emloyed grous, the study had ower exceeding 80 ercent to detect a for total mortality of at least 2.0 in emloyed women and a of 1.6 in emloyed men. Hence, one should be cautious in interreting our negative findings in women. It should be noted, however, that this is one of the larger data sets with rosective data on women. In summary, this research did not suort the hyothesis that high job strain is associated with the incidence of CHD or total mortality in men and women. Women in occuational ositions with high decision latitude and/or high authority over their work were adversely affected for the occurrence of definite CHD. For men, low education, low occuational res- Am J Eidemiol 2004;159:

9 958 Eaker et al. tige, and low income adversely affected their health. The mechanisms by which these variables oerate are comlex and require additional investigation. Similar studies in other multiethnic cohorts are also warranted. ACKNOWLEDGMENTS This research was suorted by the following grants from the National Heart, Lung, and Blood Institute: 1 R03 HL and N01-HC REFERENCES 1. Karasek R. Job demands, job decision latitude, and mental strain: imlications for job redesign. Admin Sci Q 1979;24: Karasek R, Baker D, Marxer F, et al. Job decision latitude, job demands, and cardiovascular disease: a rosective study of Swedish men. Am J Public Health 1981;71: Karasek RA, Theorell T, Schwartz JE, et al. Job characteristics in relation to the revalence of myocardial infarction in the US Health Examination Survey (HES) and the Health and Nutrition Examination Survey (HANES). Am J Public Health 1988;78: Hammar N, Alfredsson L, Johnson JV. 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