Total Worker Health Programs for Coronary Heart Disease, Stroke

Cardiovascular disease accounts for one in three deaths in the United States each year, and coronary heart disease and stroke account for most of those deaths. In an attempt to prevent one million heart attacks and strokes by 2017, the U.S. Department of Health and Human Services launched the Million Hearts initiative, promoting proven and effective interventions in communities and clinical settings.

In workplace settings, cardiovascular disease can be addressed through a Total Worker Health program, which integrates occupational safety and health protection with health promotion. To identify workers likely to benefit from such a program, the CDC analyzed data from the National Health Interview Survey (NHIS) for the period 2008 to 2012 to estimate the prevalence of a history of coronary heart disease or stroke (CHD/stroke) among adults under the age of 55 by selected characteristics, employment status, occupation category, and industry of employment.


The results of that analysis showed that 1.9% of employed adults under the age of 55 reported a history of CHD/stroke, compared with 2.5% of unemployed adults looking for work, and 6.3% of adults not in the labor force (e.g., unemployed adults who stopped looking for work, homemakers, students, retired persons, and disabled persons). Workers employed in service and blue collar occupations were more likely than those in white collar occupations to report a history of CHD/stroke.


Two industry groups also had significantly higher adjusted prevalence ratios for CHD/stroke: “Administrative and Support and Waste Management and Remediation Services” and “Accommodation and Food Service.” Workers in these occupation and industry groups might especially benefit from a Total Worker Health approach to reducing the risk for CHD/stroke.


NHIS collects information about the health of the non-institutionalized, civilian population in the United States, using nationally representative samples. Interviews are initiated in person with telephone follow-up when the interview cannot be completed in person. Questions about a history of CHD/stroke (defined as self-reported history of stroke or coronary heart disease [including angina and myocardial infarction] or both), employment status, industry, and occupation are asked of randomly selected adults. NHIS obtains verbatim responses from employed adult respondents (aged 18 or older) regarding their industry (employer's type of business) and occupation (employee's type of work). These responses are reviewed by U.S. Census Bureau coding specialists, who assign four-digit industry codes based on the 2007 North American Industrial Classification System.


For this analysis, an employment status variable was created with three categories: currently employed, unemployed, and not in the labor force. Adults were classified as unemployed if they reported that they were looking for work, whereas adults not in the labor force included unemployed adults who stopped looking for work, homemakers, students, retired persons, and disabled persons. Occupations were grouped into four categories: white collar, service (e.g., hairdresser, nurse's aide, and cook), blue collar (e.g., construction worker, factory worker, and truck driver), and farm.


The prevalence of a history of CHD/stroke among all adults under the age of 55 was estimated to be 2.8%, including 2.0% for coronary heart disease and 1.0% for stroke. The prevalence among employed adults was 1.9%. The prevalence was higher among both unemployed adults (2.5%) and adults not in the labor force (6.3%). Among adults who were employed, men and current and former smokers were significantly more likely than women and those who had never smoked to report a history of CHD/stroke. The prevalence of CHD/stroke among workers increased in each higher age group, and workers with a college degree were less likely than workers with less education to report a history of CHD/stroke.


The aim of this study was to identify workers with a greater potential to benefit from programs designed to reduce the risk for CHD/stroke. Because age, the strongest predictor of CHD/stroke, cannot be modified, the study focused on prevalence differences among workers under the age of 55 by selected characteristics, employment status, occupation category, and industry of employment. Occupational CHD/stroke risk factors can include work stress, shift work, exposure to particulate matter, noise, and secondhand smoke. Health professionals and employers should take these factors into account when planning workplace interventions to prevent CHD/stroke. These factors might have both direct physiologic effects on cardiovascular health and indirect effects by influencing behavioral risk factors such as smoking and obesity. Some evidence indicates that workplace hazards such as job strain might pose more potent risks to workers in lower-income households, perhaps because of an interaction with adverse exposures in the community, combined with fewer health-enhancing opportunities (e.g., health care, a healthy diet, and exercise facilities).


The industry and occupation categories found to be associated with a higher prevalence of CHD/stroke after adjustment for age and sex, “Administrative and Support and Waste Management and Remediation Services” and “Accommodation and Food Service” and service and blue collar occupations, are each characterized by multiple known CHD/stroke risk factors. For example, workers employed in “Administrative and Support and Waste Management and Remediation Services” industries (Including industries such as business support services, travel arrangements and reservation services, investigation and security services, services to buildings and dwellings (except cleaning during and immediately after construction), landscaping services, waste management, and remediation) have reported significantly higher rates of job insecurity, a common cause of job stress, compared with all workers combined. Workers employed in “Accommodation and Food Service” industries (including industries such as traveler accommodation, recreational vehicle parks and camps, rooming and boarding houses, restaurants and other food services, and bars) have been reported among those who are significantly more likely to work alternative shifts and significantly more likely to smoke. Conversely, workers in industry groups with lower prevalence of CHD/stroke compared with all other workers (e.g., “Education Services” and “Information”) might be more likely to have access to preventive services and less likely to be exposed to occupational CHD/stroke risk factors.


The findings in this report are subject to at least four limitations. First, all results are based upon self-report of a history of CHD/stroke, which was not validated with medical records. Second, the broad industry and occupation categories used for this analysis aggregate workers who likely have substantially different working conditions. Third, this is a cross-sectional study, and therefore, whether employment in any specific industry or occupation increases or decreases the risk for CHD/stroke cannot be determined. Finally, because the annual response rate was only 60.8%–66.3%, nonresponse bias might have affected the results.


Addressing the risk for CHD/stroke among workers might involve a Total Worker Health approach. Traditionally, health protection programs have focused squarely on safety, with the goal to reduce worker exposures to risk factors in the work environment, whereas workplace health promotion programs have focused exclusively on personal lifestyle factors. A growing body of science supports the effectiveness of combining these efforts through workplace interventions that integrate health protection with health promotion. The CDC has developed several resources that might help employers implement Total Worker Health programs in their worksites. This information is also important for clinicians, who should consider the potentially increased occupational risk for CHD/stroke in patients in certain industries and occupations and take their patients' work status, workplace, and occupation type into account when developing prevention and treatment plans.


See the CDC Report


See also Medical Risk Law, November 2013 Report: Diagnosis and Treatment of Heart Attacks: Liability Issues


See also Medical Risk Law, December 2013 Report: Thicker Than Water: Liability When Blood Clots Cause Injury or Death


See also Medical Risk Law, October 2013 Report: Brain Aneurysm and Subarachnoid Hemorrhage: Failure to Diagnose, Delayed Diagnosis, Misdiagnosis