in health workers
Cristina Robaina Aguirre, M.D., 1
Rafaela Martínez Aguilera, M.D., 2
Fermín Robaina Aguirre, M.D., 3
Deisy Plunket Rowe, M.D.4
ABSTRACT: A cross-sectional study was conducted on the incidence of cardiovascular disorders that caused temporary disabilities in health workers of the Julio Trigo Hospital in Havana, between 1994 and 1996. Our main objective was to identify risk factors for such disorders among health workers at this hospital. Variables such as personal data (sex, age, etc.), job category and occupation were studied. Cardiovascular disorders were a health problem in this hospital, with an incidence of 10.64 per 100 workers. Hypertension had the highest incidence (6.31 per 100 workers), followed by ischemic heart disease (2.4 per 100 workers). Physicians, administrative workers and nurses were the most frequently affected by these disorders. The incidence was higher in men (11.53 per 100 workers) than in women (10.07 per 100 workers). There was a higher incidence in Black people (47.94%). The high prevalence of smoking (over 55%) and job-related stress (76.66%) seem to be the main risk factors for cardiovascular disorders among health workers in this hospital.
Cardiovascular disorders are a health problem worldwide. Therefore, control and prevention is a society-wide and governmental responsibility, not simply the job of public health authorities, as is sometimes
contemplated. According to the World Health Organization (WHO), cardiovascular disorders are the leading cause of death in Western countries. In Spain, myocardial infarction is the main cause of death, and
with other heart disease, accounts for over 50% of deaths.1 In Latin America, the number of deaths from cardiovascular disorders was estimated at 800,000 in
1990, accounting for 25% of all deaths. In the United States and Canada, these disorders accounted for almost 50% of deaths the same year. Cardiovascular disorders are the main cause of death in 31 of the 35
American countries studied by the WHO in 1990.2 In Cuba, heart disease has been the number-one cause of death since 1968. In 1995, 22,046 people died from
such disorders, which represented a mortality rate of 200.8 per 100,000 inhabitants. This rate has gradually increased from 148.6 in 1970, to 166.7 by 1980, and 200.3 in 1990. This means that during the last 25 years,
cardiovascular disorders have become one of the main health problems in Cuba Table 1.
Mortality Due to Cardiovascular Disorders in Cuba (1970 to 1995)
Mortality Rate/Year |
|||
Disorder |
1970 |
1980 |
1995 |
Ischemic Heart Disease |
9,748 |
13,347 |
17,792 |
Hypertension |
1,343 |
717 |
1,025 |
Chronic Rheumatic Diseases |
299 |
224 |
159 |
Other Cardiovascular Disorders |
1,314 |
2,015 |
3,070 |
Correlational epidemiological studies of cardiovascular disorders reveal a set of variables or
risk factors, correlated with a higher incidence of these disorders. Evidence indicates that the determinants for cardiovascular disorders are complex and multifactorial. Risk factors for
cardiovascular disorders include: age, sex, race, obesity, sedentary lifestyle, elevated dietary salt and fat intake, elevated consumption of alcohol and caffeine, smoking, stress, and psychological/behavioral factors.3
Some recent studies have shown a higher incidence of risk factors for cardiovascular disorders among certain sectors of the population, mainly professionals (among whom
intellectual activity is predominant). It is common knowledge, for example, that physicians in training and clinical practice are subjected to considerable stress, and acquire as a result a
number of habits that threaten their health.4 It is noteworthy that Spanish physicians, followed by their Italian and Portuguese colleagues, are considered the heaviest smokers in the
European Community. In Portugal, the percentage of physicians who smoke is higher than the percentage of smokers for the general population.
In his research on smoking, Abellaneda has emphasized the key influence health professionals have on anti-smoking programs, on the one hand due to their awareness of the
health-damaging effects of smoking, and on the other hand because they are responsible for warning their patients of the dangers of smoking for their health.5
Based on the theory that Cuban health professionals have a higher incidence of myocardial infarction due to higher secretion of adrenaline and noradrenaline than other sectors of the
population, a study was carried out by Dr. Ulacia among 233 specialists "on call" in Internal Medicine. Blood levels of these substances were measured both during normal working hours and nights and weekends "on call" (
Ed. Note: In Cuba, "on call" hours for both residents and specialists are spent on duty at the hospital itself, whether overnight or during
weekends). Results showed higher blood levels of adrenaline and noradrenaline during "on call" periods than during regular working hours. Dr. Ulacia also found that during "on call"
hours, residents had higher blood levels of adrenaline and noradrenaline than specialists, probably because they were less experienced in their work. (Ulacia Alfonso N. Efectos de
la guardia médica sobre la excreción de catecolaminas en especialistas y residentes de medicina interna. 1981. Havana. Institute of Occupational Medicine).
Stress has been reported as a related risk factor for cardiovascular disorders in health workers. In her article "El estrés de la guardia médica" (Stress During "On Call" Hours
), Dr. Reyes found that "on call" duties carry greater stress than physicians bear during normal working hours, and more than that borne by other professionals. She studied 20
physicians during "on call" duties, 20 physicians who were not "on call", and 20 professionals from other fields not related to medicine. (Reyes García ME. El estrés de la guardia médica.
1983. Havana. Institute of Occupational Medicine). Numerous studies, carried out mainly in Europe and the United States, have shown a higher
incidence of cardiovascular disorders in certain occupations, such as swing-shift workers; unskilled factory workers; bus, tractor, and taxi drivers; hotel workers; restaurant workers;
and sailors. Among the occupations with low incidence of cardiovascular disorders are: scholars and farmers.6-8
In 1995, T. Kristensen reported the existence of numerous epidemiological studies revealing substantial variations in the incidence of cardiovascular disorders according to social class
and occupation, and in particular showing that people of lower social strata in Europe, the United States and other industrialized countries tended to show a higher incidence of these disorders.9,10
In the same article, the author presented a methodological critique of R. Karasek et al's Demand-Control-Support model,11,12 which argues a correlation between the onset of
cardiovascular disorders and the demands of work, job decision latitude, and the individual's social support network. Kristensen added that the appearance of such disorders can also be
influenced by a worker's exposure to other factors such as noise, heavy physical labor and chemicals.13,14 Taking into consideration the importance of this field for the health of the Cuban population,
the Cuban Institute of Occupational Medicine, an agency of the Cuban Ministry of Public Health, has carried out this first epidemiological study on the incidence of cardiovascular disorders among health workers.
Methods
An epidemiological study was conducted on the incidence of cardiovascular disorders causing temporary disabilities in health workers of the Julio Trigo Clinical and Surgical
Hospital in Havana between 1994 and 1996. A total of 1,377 people work in this hospital (883 women and 494 men). For our study, we reviewed physicians' Medical Certificates
submitted by workers between 1994 and 1996, selecting those diagnosed with cardiovascular disorders. (Ed. Note: A Medical Certificate is issued to a Cuban worker by
the attending physician to justify a prolonged absence due to illness and ensure sick leave payments during that period. It includes both the diagnosis and the number of days needed
for recuperation.) A total of 338 Medical Certificates with a diagnosis of cardiovascular disorders were found for 146 workers, thus constituting the group under study.
Variables such as age, sex, race, occupation/profession, etc. were noted in each case, as was the specific diagnosis. Simple epidemiological analysis techniques were used to process data. Results were
presented in the form of percentages and rates per 100 workers. Relative risk (Rr) was also included in our results.
Results
Of the 1,377 workers of the Julio Trigo Clinical and Surgical Hospital, 31.73% are service workers, 31.15% nurses, 19.19% physicians, and 17.93% health technicians and
administrative workers. Of these, 146 were diagnosed with a cardiovascular disorder, representing a rate of 10.60 per 100 workers.
Our study of the incidence of cardiovascular disorders by profession showed that physicians have the highest rate (24.3 per 100 workers) followed by administrative workers (11.26 per 100 workers) and nurses (10.48 per 100 workers).
Figure 1 shows the distribution of cardiovascular disorders by sex and age. The age groups with the highest rates of cardiovascular disorders were 40-49 (43.83%) and 30-39
(34.24%). Women showed the highest number of cases in all age groups. Figure 1.
Distribution of Cardiovascular Disorders by Sex and Age. Table 2 shows the rate of temporary disabilities due to cardiovascular disorders by
occupation and sex. Women who carry out administrative work had the highest incidence (36.84 per 100 workers) followed by men physicians (26.25 per 100 workers) and women
physicians (20.83 per 100 workers). Women had the highest incidence in all occupational categories, except among physicians and health technicians. However, the overall rate by
sex shows a slightly higher incidence in men (11.53 per 100 workers) than in women (10.07 per 100 workers). Table 2. Temporary Disabilities from Cardiovascular Disorders by Occupation and Sex
|
Sex |
|||||
Male |
Female |
Total |
||||
No. |
Rate |
No. |
Rate |
Total |
Rate x 100 |
|
Physicians |
47 |
26.25 |
20 |
20.83 |
67 |
24.3 |
Nurses |
4 |
9.30 |
41 |
10.62 |
45 |
10.46 |
Health Technicians |
1 |
4.54 |
5 |
3.49 |
6 |
3.63 |
Service Workers |
4 |
2.02 |
16 |
6.69 |
20 |
4.57 |
Administrative Workers |
1 |
1.92 |
7 |
36.84 |
8 |
11.26 |
Total |
57 |
11.53 |
89 |
10.07 |
146 |
10.60 |
As shown in Table 2, physicians have the highest incidence of cardiovascular disorders. This
may be explained by the high degree of stress inherent in their profession. (Ed. Note: Since the early 1990s, the economic crisis in Cuba has imposed particularly harsh conditions on
hospital medical staff, working in many cases without essential equipment and supplies. It is generally understood that physicians have borne the brunt of this situation.) Table 3
compares the relative risk (Rr) of cardiovascular disorders for physicians with that for health technicians (Rr=6.71) and service workers (Rr=5.33). This means that physicians
are 5 to 6 times more likely to suffer from cardiovascular disorders than health technicians and service workers. However, the Rr for physicians compared to nurses (Rr=2.32) and
administrative workers (Rr=2.16) was considerably lower. Table 3. Relative risk (Rr) of Cardiovascular Disorders in Physicians and Other Personnel
With a Cardiovascular Disorder |
With No Cardiovascular Disorder |
Total |
|
(A) |
|||
Physicians |
67 |
208 |
275 |
Nurses |
45 |
384 |
429 |
(B) |
|||
Physicians |
67 |
208 |
275 |
Health Technicians |
6 |
159 |
165 |
(C) |
|||
Physicians |
67 |
208 |
275 |
Service Workers |
20 |
417 |
437 |
(D) |
|||
Physicians |
67 |
208 |
275 |
Administrative Employees |
8 |
63 |
71 |
(Julio Trigo Clinical Surgical Hospital, Havana) Table 4 shows the incidence of cardiovascular disorders in medical personnel at the Julio
Trigo Clinical and Surgical Hospital, with particular reference to differences especially among nurses and physicians in various job categories. Surgeons showed the highest percentages
among physicians (16.43%) followed by clinicians (12.32%). Among nurses, general nurses showed the highest incidence (17.12%) followed by intensive care nurses (6.84%). Table 4.
Incidence of Cardiovascular Disorders by Occupation, Specialization and Post
Specialty/Post |
Sex |
|||
Male |
Female |
Total |
% |
|
Clinician |
13 |
5 |
18 |
12.32 |
Surgeon* |
8 |
6 |
24 |
16.43 |
Head of Medical Services |
8 |
6 |
14 |
9.58 |
Other Medical Specialties |
4 |
7 |
11 |
7.53 |
General Nurses |
4 |
21 |
25 |
17.12 |
Intensive Care Nurses |
- |
10 |
10 |
6.84 |
Surgery Nurse |
- |
3 |
3 |
2.05 |
Other Specialized Nurses |
2 |
5 |
7 |
4.79 |
Health Technicians |
1 |
5 |
6 |
4.10 |
Secretary |
1 |
6 |
7 |
4.79 |
Service Assistants |
- |
6 |
6 |
4.10 |
Other Service Workers |
4 |
3 |
7 |
4.79 |
Administrative Workers |
2 |
6 |
8 |
5.47 |
Total |
57 |
89 |
146 |
100.0 |
Specialists in Gynecology and Obstetrics are included in this group
Figure 2 shows that hypertension was the most prevalent cardiovascular disorder in our workers (59.58%) followed by ischemic cardiopathy (23.28%). There was a higher
incidence of hypertension (55.17%) and ischemic cardiopathy (50.00%,) in Black people. (Ed. Note: "Black people" is a subjective category in Cuba, denoting people of the darkest
shade in the population, followed by Mestizo representing a lighter shade—see Figure 2—and then white. This study separates Black and Mestizo into two categories, while other
studies group them together.) However, other cerebrovascular disorders were more prevalent in white people. Overall, Black people showed a higher incidence of cardiovascular disorders (47.94%) than white people (30.13%)
15,16 Figure 2. Incidence of Cardiovascular Disorders by Race.
In terms of sex, our study shows there was a higher number of hypertensive women (60). Women also showed the highest rate of hypertension (6.79 per 100 women). Nevertheless,
men showed the higher number of cases with ischemic heart disease (17) and a rate of 3.84 per 100 men. The two cases with myocardial infarction were men. In the case of other
cardiovascular disorders, men showed a higher incidence (1.82 per 100 workers) than women (1.58 per 100 workers). Hypertension was the cardiovascular disorder with the highest prevalence among the subjects
in our study (6.31 per 100 workers) followed by ischemic heart disease (2.46 per 100 workers).
Discussion
This study found that cardiovascular disorders constitute a health problem among workers at the Julio Trigo Clinical and Surgical Hospital,in Havana, among whom physicians were the
most seriously affected. Our analysis of the incidence of hypertension by race showed that it was more prevalent in Black people, a result similar to other studies carried out in Cuba.15-17
However our findings on the incidence of cardiovascular disorders by sex and age groups differ from previous studies, since we found women had the highest rates of these disorders.
Considering the high percentage of cardiovascular disorders in people between 30 and 39 years of age, and that myocardial infarction has a bleaker prognosis in young people, we
should reflect on the need to carry more preventive actions among health workers.
Conclusions
1. Cardiovascular disorders, among which hypertension was the most prevalent, constituted a health problem in health workers of the Julio Trigo Clinical and Surgical Hospital in the period studied. 2. Black people showed a higher tendency to suffer from these disorders than white people. 3. The incidence of cardiovascular disorders was slightly higher in men than in women.
4. According to our findings, physicians are the most vulnerable to these disorders, which can be explained by the greater degree of stress to which they are subject.
5. Surgeons and clinicians were the physicians with the highest incidence of cardiovascular disorders.
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This article originally appeared in Spanish in the Revista Cubana de Medicina General Integral, Vol. 15, No. 2, (pp. 115-22), 1999.
