Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis

The global financial crisis (GFC) has without doubt taken its toll on workforces globally. It resulted in uncertain employment prospects, leading to the perception of job insecurity. On this note, Virtanen and colleagues performed a meta-analysis, and determined that there was modest association between perceived job insecurity and incident coronary heart disease (CHD) attributed to unfavourable socioeconomic situation and risk factor profiles.

With regard to risk factors, the authors found that insecure patients tend to be less physically active, have higher prevalence of hypertension and hypercholesterolaemia than secure participants. In the discussion of limitations of the study, they acknowledged the possibility of mental disorders such as depression, which could be confounding factors. The latter could impact the job insecurity-CHD association in different ways. Under the heading “interpretation of findings”, the authors hypothesised possible mechanisms, first of which is health risk behaviours such as smoking, heavy alcohol consumption, physical inactivity and being overweight, all of which are associated with low socioeconomic status (SES). A second underlying mechanism is biological risk factors whereby the authors found a higher prevalence of hypertension, type 2 diabetes and hypercholesterolaemia among patients who reported job insecurity.

Job insecurity and its perception thereof is a situation in the patient’s immediate social environment. A better way to frame the question is, given the perception of job insecurity, how does the patient cope with the situation? Does the patient have adaptive or maladaptive coping strategies? It could be entirely possible that the patient already has non-modifiable and modifiable risk factors for CHD before he perceived job insecurity, but if we are interested in the association of job insecurity with CHD, then specifically, we should be concerned with how a patient responds to his social environment at the workplace, when he finds out his job is insecure.

In this old study by Lindquist and colleagues, they found no direct association between work stress and blood pressure, and that there is no direct effect of the former on the latter. However, they found that the way individuals coped with stress were directly related to their blood pressures. [1] Vogenberg and Cutts examined the impact of the GFC on healthcare decision-making in a Pharmacy and Therapeutics journal article where they discussed how financial decisions made by patients affected their healthcare, whereby the latter reported fewer visits to their physicians, and not taking medications as prescribed as this would extend the supply of medications and reduce number of pharmacy visits. [2]

The mechanisms suggested by Virtanen and colleagues are reasonably feasible, however, a more unifying mechanism should be the biopsychosocial model, which incorporates biological risk factors , on the social side - health behaviours and lastly, psychological response. In this suggested model, the biological risk factors can be sub-divided into modifiable and non-modifiable biological risk factors. For the psychological section, besides depression, anxiety disorders are also associated with poor prognosis in patients with CAD. [3] Thus, an outline of the biopsychosocial model is shown below. The list provided is non-exhuastive.

1)Bio
i) Non-modifiable: Age, Sex, Family history of cardiovascular disease, ethnic origin
ii) Modifiable: High cholesterol, hypertension, cigarette smoking, diabetes mellitus, obesity, lack of physical activity, metabolic syndrome [4]

2)Psychological: Mental stress, anxiety, depression, negative moods

3)Social: Low SES, smoking or/and increasing cigarette consumption to deal with stress, alcohol or/and increased alcohol consumption, poor diet/eating fast food/unhealthy food, non-compliance with medications, not visiting physicians/primary care practitioners on a regular basis, not exercising regularly

Hence, when the patient comes in through the door and states that he has job security issues, although it is reasonable to tell him that there is moderate association between his perception and CHD, what is more crucial is his baseline (from before) and current biological risk factors both modifiable and non-modifiable which can be based on the Framingham Heart Study for instance [5], and his response to job insecurity, which involves exploration of pertinent psychological and social issues, knowing fully well that those can impact his biological risks.

For patients who are cutting down on physician visits due to financial issues, i.e. from the low SES group, they can be a challenge from the population screening point of view. There is high likelihood of missing incidental CHD in these people, leading to catastrophic events in the future, such as myocardial infarction. A possible solution is opportunistic screening, e.g. blood pressure, lipids profile, blood glucose/HbA1c and BMI/waist circumference measurement, funded by state or philanthropic sources.

1. Lindquist TL, Beilin LJ, Knuiman MW. Influence of lifestyle, coping, and job stress on blood pressure in men and women. Hypertension. 1997 Jan;29(1 Pt 1):1-7.

2. Vogenberg FR, Cutts S. Economic instability and its impact on decision making in health care. P T. 2009 Jan;34(1):24-5.

3. Bunevicius A, Staniute M, Brozaitiene J, Pop VJ, Neverauskas J, Bunevicius R. Screening for anxiety disorders in patients with coronary artery disease. Health Qual Life Outcomes. 2013 Mar 11;11:37.

4. Boudi, Brian F. "Risk Factors for Coronary Artery Disease ." Risk Factors for Coronary Artery Disease. Medscape, n.d. Web. 16 Oct. 2013. .

5. "Coronary Heart Disease (10-year Risk) Framingham Heart Study." Coronary Heart Disease (10-year Risk) Framingham Heart Study. National Heart, Lung and Blood Institute & Boston University, n.d. Web. 16 Oct. 2013. .