Citation: Divya S, Nimali S. Adverse Health Consequences - A Result of Long Work Hours: A Review of The Current Evidence. Indian J Nutri. 2016;3(1):125.

Abstract

Study background: Research evidence is mounting that link long work hours to a wide range of risk to health of the working population. In deference to thesedentary nature of work today and the invariably increasing stress levels, the risk of chronic disease amongst workforce has been greater than before. Thepurpose of this review paper is to give a concise summary of the possible negative health effects (with relevance to upcoming lifestyle diseases) of long workinghours that have been reported in the literature.

Method: Relevant papers for this review were identified using online open access databases (Pubmed, Google Scholar etc), internet searches, publishedstudies and journals covering the period from 1997 onwards. Where possible, the search was based on abstracts, titles and keywords to identify relevantpapers. Only those papers which referred to long working hours were considered, excluding shift work.

Results: The results indicate that the changing nature of work and its environment have made a noticeable impact on individual’s health and well being.

Conclusion: Although in recent years, interest in scientific research in health problems associated with various components of occupational exposure haveintensified, the number of studies concerning the different areas of health is still low and the results are often contradictory and inconclusive. No major workhas been done in India in the respective field. Nonetheless, it is agreed that the current evidence is sufficient to raise concerns about a possible link betweenlong work hours and lifestyle diseases, especially for hours exceeding 48 to 50 a week.

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Introduction

India’s population has crossed 1.21 billion according to the lastgovernment census carried out in 2011 [1]. The population in theworking age group of 15-64 years is constantly on the rise and isestimated to be 65.7 % according to World Bank Economic SurveyReport, 2014 [2]. Industrialization and globalizations are bringingabout drastic changes in the Indian occupational morbidity pattern.Traditionally labour-oriented markets are on change towardsmore automation and mechanization. According to World HealthOrganisation, in 2014, non communicable diseases are estimated tohave accounted for 60 % of the deaths in India. The probability of anIndian, in the age group of 30-70 years, dying from four main NCDs- diabetes, cancer, stroke and respiratory problems is 26 % [3]. The disease of plenty and prosperity or the modern diseases of mankindare all self inflicted and caused by sedentary lifestyle, of which,obesity, overeating, lack of activity and exercise, automated vehicles,stress and mental tension, alcohol, smoking and medication etc areall a way of life. They manifest themselves as high blood pressure,diabetes, cardiovascular and other ailments.

A large part of one’s adult life is spent at work. With the everchanging Indian economy, working long hours, has become acommon trend in India. Although the standard working hours wouldbe from 9 am to 6 pm, but this can vary a lot, depending not only onthe industry , but also on the international contracts. In the worldsoutsourcing capital, India, working hours are often tied to othertime zones and varies from 10-12 hours or more depending upon the assignment pressure [4]. A recent study by Das (2012) on softwareprofessionals in India, found that the average working hours per dayamounts to 10.5 hrs [5]. Also, the global survey findings [6] suggestedevidence that the days of 9-5 are gone, as over half of the Indianworkers work more than eight hours a day. The report also stated that10 % of the workers in India regularly work more than eleven hours aday for 6 days a week. A typical office though opens at 9:00 - 9:30 amand offically closes at about 19:00 hours, however it has been reportedthe staff and espcially the managers tend to stay late in office due toadditional work load.

Time at work is one of the most basic component of occupationalexposure and thus, long working hours have been and continue tobe of enormous concern for the health and well being of workingpeople. There are increasing epidemiological evidence from aroundthe world that states that long work hours are an important risk factorfor a number of acute and chronic health outcomes. Till date 8 majorreviews have been conducted on the relationship of long workinghours and workers health [7-14]. Collectively, they indicate thatalthough the facts regarding the relationship between long workinghours and health may not be consistent owing to several factors suchas definition of long work hours, measuremnet of outcomes, potentialcovariates and type of outcome under consideration, nevertheless,there are indications that excessive working hours cause serioushealth risks [15]. The evidence suggest that the workers compensatefor overtime related job stress by consuming more fatty and sweetfoods [16] and also long working time acts as a potential barrier toregular exercise by limiting the time available for non- work activity[17]. Thus, we certainly have a good reason to be concerend about thepossible adverse health effects of long work hours [18]. Working morethan 40 hours per week has been associated with poorer perceivedhealth, increased injury and illness rates and increased mortality, withpronounced effect in conjunction with extended work hours that arelonger than 8 hours [9].

What, therefore, is the current status of the scientific and medicalevidence corresponding to health effect of working long hours?Is there adequate information available in this area in India? Thepurpose of this paper is to give a concise summary of the possiblenegative health impacts (with relevance to upcoming lifestyle diseases)of long working hours that have been reported in the literature.Relevant papers for this review were identified using online databases(Pubmed, MEDLINE etc), internet searches, published studies andjournals covering the period from 1997 onwards. Where possible, thesearch was based on abstracts, titles and keywords to identify relevantpapers. Only those papers which referred to long working hours wereconsidered, excluding shift work.

Work and Health: an Overview

Work and health are intimately and dependably connected. Thechanging nature of jobs suggests that the threats to worker’s healthare dramatically different today than they were, a generation ago.People are prone to various diseases based on their way of living andoccupational habits. Chronic diseases account for a large number ofdeaths in developing countries where they take a disproportionatetoll during the ages of prime productivity [3,19].

Rising incomes and insecurity caused by the stress factors havecontributed to 24% cardio-vascular diseases (CVDs) which areprimarily centred on stroke and heart attack. Other leading riskfactor for mortality and morbidity primarily among the productiveage group budding as a result of changing lifestyle include bloodpressure (responsible for 13% of deaths globally), followed by tobaccouse (9%), raised blood glucose (6%), physical inactivity (6%), andoverweight and obesity (5%) [20].

An American survey, published in Occupational andEnvironmental medicine, concluded that long working hoursincreased an individual’s chances of illness and injury. It was notedthat for those doing 12 hours a day, there was a 37 % increase in riskas compared to those working fewer hours. Overtime and extendedwork schedules are associated with increased risk of hypertension,cardiovascular disease, fatigue, stress, depression, musculoskeletaldisorders, chronic infections, diabetes and other general healthcomplaints [21]. Similar results were obtained in much recent surveyby Gallup in 2014 in American workers which states that the average“40 hours workweek (standardized by the American labour law “)is actually 47-60 hours/ week which consequently showcase serioushealth repercussions in time starting with stress and depressionfollowed by other lifestyle disorders leading to increased absenteeismand missed work days as a result [22].

Long Working Hours

Generally, working time is defined as the amount of time spentby an individual to carry out a job or task [23]. Normal work time isusually taken to mean a working day with hours left for recreation andrest [24]. But the recent trends such as technological advancementsenabling teleworking have contributed to the creation of a “24-hoursociety” where line between work and non-work time is becomingincreasingly blurred.

The establishment of limits on daily and weekly working hourswas the subject of the very first International Labour Organization(ILO) Convention: the Hours of Work (Industry) Convention, 1919[25]. An interesting study (of more than 50 countries) carried outby ILO, says that 22 percent of the total workforce surveyed (614.2million people) worked more than 48 hours a week and that too incountries where the legal work-week was often far shorter - rangingfrom 35-48 hours. The ILO considers anyone working beyond48 hours a week as working “excessively”. But for work force in adeveloping country working 50-60 hours a week is a fact of life anddifficult to avoid [26].

Working Time and the Indian Labour Law

India has 16 laws related to working hours, condition of servicesand employment. The major legal provisions for the protection ofhealth and safety are contained in two acts: The Factories Act (1948)and the Mines Act (1952). According to the Factories Act 1948 (Actno. 63 of 1948), as amended by the Factories (amendment) Act 1987(Act 20 of 1987; Section 51 (Chapter IV on the maximum workinghours for adults), no adult worker shall be required to or allowed towork in a factory for more than forty eight hours in any week.

The hours of work convention, 1919 is an ILO convention established in 1919 having decided upon the adoption of certainproposals with regard to the application of the principle of 8 hoursworking day or of 48 hours work week. The Convention was rectifiedby India (as British India) on July 14, 1921 [27].

Reasons for Long Working Hours

Propensity to work for long hours is associated with severaldifferent aspects of employment. They are indeed varied andcomplex. Long working hours are more common among highearning professionals and among certain occupational groups, suchas academics, health care workers, business owners and managers,and emergency workers. Various reasons have been cited by differentresearchers for working long hours ranging from ability to increaseearnings, pressure of work, increased workload, job insecurity, jobdemand, to performance pressure [4,11,28-31]. The data also showedthat employees believed that by working longer hours they tendto set a good example by showing signs of commitment and as aresult successfully create an “ideal worker image” [32]. So, they doso as a matter of personal choice and pride, enjoying their work andregarding themselves as workaholics [28, 33-34].

A more recent Indian survey of over 1,200 executives, individualcontributors, managers and chief officers across the country in2014 done by American Society for Training & Development (ASTD)(sponsored by Dale Carnegie Training) partnered with NHRD inIndia revealed that 61% of the respondents of the surveyed Indianworkforce were willing to put in extra hours without more pay tocomplete a task to prove their engagement towards their company[35]. Another survey by Gobal Travel Agency - Expedia. Inc revealedthat India has the second highest number of overworked people (38%)working 41-50 hours a week on an average and it is 10th most vacationdeprived country as Indians do not tend to take leaves, just to be intheir boss’s good books and would like to be able, to be present inall the key descions of the company. Also, they would prefer gettingmoney in exchange of their unused holidays. The survey also pointedtowards the fact that even when indians are on holidays they arepractically never out of touch of work and keep checking their workemails etc[36].

Research evidence is mounting that link long work hours to awide range of risk to health of the working population. This indicatesthat long working hours impose cost to society through a drain of thehealth.

How Could Long Working Hours affect Health?

The association of long working hours is a frequently debatedtopic. Many researchers believe that the link is Stress, certainly withregard to the ill health outcomes associated with long working hours(Figure 1) [37].

Figure 1: How work shapes Health for workers; Issue 4: Work and Health, 2008

The effect of occupational stress on health is well establishedthrough a variety of studies [38]. Researches argue that long workinghours act as direct stressor and also an indirect stressor on employees.It acts as a direct stressor, increasing the demand on a person whoattempts to maintain performance level in the face of increasingfatigue. The indirect stressor mechanism means that working longhours lead to employees being exposed to other workplace stressors for longer [12,39].

Although this is somewhat equivocal as stress is measuredin a variety of ways, which has most likely influenced the lack ofconsensus within the literature [11]. The key is perhaps to ascertainwhy the employee is working long hours in the first place , as the wayan individual thinks about his job and the amount of control theyhave over their job will mediate the long hours- stress/ psychologicalhealth relationship.

More recently another study [40], through a 5 year follow upstudy on long working hours and development of stress concludedthat long working hours is a risk factor and in turn affect the healthof the employees in adverse ways. This result has been duly supportedby the work of Taris and his co-workers [41], who gave similarresults concluding that working overtime may in the long run lead tosubstantial increase in stress levels consequently affecting the workersbehavioural decisions / habits resulting in adverse health outcomes.

Adverse Health Consequences: A Result of Long Work Hours

Sparks et al. and White and Beswick did two comprehensivesurveys that review the relation between working hours and health[11,14].

Sparks and his fellow researchers reviewed the existing literatureon working hours both qualitatively and quantitatively, using metaanalysisto examine the relationship between the length of the workingweek and health symptoms. Results indicated small, but significantpositive mean correlations between overall health symptoms,physiological and psychological health symptoms, and hours of work[11]. Later White and Beswick in 2003 did another comprehensive survey and summarized the literature on the relationship betweenworking hours and fatigue, health and safety and work-life balanceoutcomes. They concluded that all studies suggest a positiveassociation between working long hours and fatigue, working timeand cardiovascular disorder [14].

Thereafter, several reviews and empirical studies havedemonstrated various negative health effects of extended work hoursand given us descriptive and in-depth results to believe that a strongconnection exists between long working hours and health relatedpractices and consequently adverse health conditions [41, 47-51, 52-54].

Several indicators (cardiovascular disease, diabetes, disabilityretirement, subjectively reported physical health, subjectivefatigue) have been used in different researches to provide evidencein this regard. Furthermore, some evidence exists for a linearassociation between long work hours and psycho vegetative changes(cardiovascular diseases, mental health, gastrointestinal disorders,sleep problems, musculoskeletal problems and immunologicparameters) [13,49,54,55]. Reduced sleep duration has been in turnreported to be a reason for increase in several other health problemssuch as cardiovascular diseases, overweight and impaired immunesystem [8,13, 18,50,57].

In 2005, Ruhm studied the effect of reducing working hours onhealth and found that a reduction in number of hours worked hasa positive impact on health among the United States population.More recently [58,59], while studying the effects of controlling orreducing working hours, concluded that working hours have a casualeffect on the health behaviour of an individual and that work hourreduction is associated with favourable health outcomes. Similarly,Berniell suggested that a reduction of working time increases theprobability of a significant drop in smoking, alcohol consumptionand an increase in physical activity, which in long term may bringabout a positive health change [60].

Long Working Hours and Chronic Diseases

Accounting for 63 % of the annual death challenge for developingcountries like India where they take a disproportionate toll on healthduring the prime ages of productivity; chronic diseases have becomea dominant reason for untold morbidity and disability [61].

Diabetes Type II

Globally, more than 285 million people were suffering from type2 diabetes in 2010 and its prevalence is predicted to increase to 439 by 2030 [62]. India has a highest number of people with diabetes -approximately 23 million in 2000, which is projected to rise to 57million by 2025 [63]. There are two major hypotheses suggesting anassociation between long working hours and risk of type II diabetes[54].

1. First hypothesis relates to stress as a contributory factor; longer working hours correlates to psychological stress and it has earlier been found to predict poor control among diabetic individuals.

2. Second hypothesis suggests that people with pre diabetes are usually advised to pay attention to their lifestyle, such as maintaining healthy diet and exercise, watching their weight and controlling excess alcohol consumption. It is possible that people who are working long hours are not able to be as dedicated in their adherence to advices as their colleagues with working standard hours.

The hypothesis was found to be significant in the light ofseveral prominent research studies that indicated that people in theproductive age group who work more than 50 hours/ week havebeen found to show significant association with incidence of type IIdiabetes [64-67]. Another research by Davilla et al., on US populationsuggested that adult’s working over 40 hours were more likely to havesuboptimal glycaemia control compared to those lesser number ofhours [68]. There are many contradictions to the above said theoriesand researches vary on various aspects, but the evidence in favouris mounting and is a cause of concern. In yet another much recentcontradiction a Meta analysis was conducted on 2, 22,120 individuals’.Data was stratified by socioeconomic status to investigate the effectof long work hours as a risk factor for diabetes; after adjustment ofage, sex, obesity and physical activity and exclusion of shift workers,the results indicated that this relationship existed only in case ofindividuals from lower socioeconomic status. The reason for the sameis yet unknown [69].

Cardiovascular Diseases

Cardiovascular diseases (CVDs) are the most prominent cause ofdeath and disability worldwide in the chronic disease cluster [70]. TheCVD burden in India is expected to increase in the next two decades,making it the single largest cause of death and second largest cause ofdisability, thereby making India the world’s CVD capital by the year2020 [71-73]. According to recent reviews regarding the prevalenceof CVDs in India, the trends indicate that the disease has escalatedin the younger age groups in the last decade and is further expectedto go up significantly for people between ages 25-69. The reviews alsopinpoint the fact that age standardised CVD death rates in people30-69 years is highest in India with 405 deaths per 100000 [74-75].One of the plausible causes of the alarming increase in heart diseasesseems to be linked to changes in lifestyle and diet, rapid urbanizationand globalization resulting in a nutritional swing, causing rise ofunhealthy food intake coupled with reduced physical activity whichhas given rise to intermediate risk factors such a hypertension andobesity [70,76]. Long work hours has only made the situation worseby giving the productive age group an excuse to allow the above saidcauses to intervene with their daily routine coupled with other geneticand biological factors.

Several studies provide sufficient evidence of the possible links between long working hours and risk of significant health outcomesincluding CVDs [12,40,77-82]. The main biological explanation forimpaired cardiovascular health from long working hours encompassincreased sympathetic nervous activity during work , causing aprolonged elevation of heart rate and mean blood pressure [12,83].Few other studies also relate long working hours along with shortsleep duration as an independent risk factor for CVD [84,85].

It is established through mounting evidence that long workinghours is one of the major sources of occupational stress. Hence, it isreasonable to expect an association between long working hours andCVDs.

Hypertension

Hypertension, according to the World Health Organization, isestimated to affect more than one in three adults aged 25 and overglobally [86,87]. It is one of the most important precipitators of heartdisease and stroke - there by making is the most potential cause ofpremature deaths and disability around the world.

As for the association between long work hours and bloodpressure, the influence is related to sympathetic nervous activity andconcentration of counter regulatory hormones that accompaniespsychological stress [87].

Although hypertension related to long work hours has been amatter of immense concern for a long period of time yet the scientificevidence is inconclusive [12]. A handful of relevant studies includingthe recent researches can be quoted from Japan that were conductedon people in the productive age group and found positive evidencelinking long working hours to hypertension [88-91]. Yet othersstrongly indicated results that were contrary to what is normallyperceived [81,92].

In India, diabetes and hypertension are often termed as twinepidemic. A Recent screening done by Joshi, Vadivale, Dalal and Dasin 2011, presents a grim picture of the current situation. According tothe data collected, 60 % of Indians (three out of every five), have either of the diseases or sometimes both [93].

Obesity

Obesity can be seen as the first wave of a defined cluster of noncommunicable diseases called “new world syndrome”. Obesityarises from complex social and biological phenomenon, but is oftenperceived as a result of the individual behaviour. There is increasingevidence that suggest that it may be related in part to adverse workconditions. In particular, the risk increases in high demand andlow control environment and for those who work long hours asthis is perceived to affect their dietary pattern, behavioural habits(smoking and alcohol consumption) and activity pattern [94,95].Epidemiological studies often prove positive association betweengreater BMI and long work hours and job stress [96].

A recent systematic review found positive associations betweenlong work hours, working overtime and weight gain [97]. Similarly,another study on long working hours in 1086 transit workers whowere working more than 50 hours per week also found a strongcorrelation between long working hours and higher BMI levels due to erratic diet patterns , lesser physical activity and increased dependenceon calorie dense food available at the workplace [98]. This is partlyin concurrence to the results of a previous study conducted in2009 [99]. Another study established that working hours and sleepduration have a trade off relationship and inadequate sleep habits canpotentially cause health problems such as obesity [100]. This view wassupported by Jang et al who used “sleep hours per day “as cofoundersfor the association between work hours and obesity [101].