Cohort Profile: The PROspective Québec (PROQ) Study on Work and Health

Cohort Profile: The PROspective Québec (PROQ) Study on Work and Health Why was the cohort setup? Cardiovascular diseases (CVD) are the leading cause of mortality worldwide, accounting for 17.7 million deaths per year.1 CVD also rank first in terms of hospitalization costs in Canada,2 and are among the leading diagnoses for direct health expenditures in the USA.3 Mental health problems (MHP) are the first cause of disability worldwide.4 Their prevalence, long duration and high risk of recurrence5 place a considerable burden on health and social care systems and incur important productivity losses for employers.4 A number of prospective studies have documented the effects of adverse psychosocial work factors (work stressors) on CVD6,7 and MHP.8–11 To assess the exposure of psychosocial work factors, two theoretical models have mainly been used. The demand-control (DC) model suggests that workers simultaneously experiencing high psychological demands and low decision latitude, i.e. job strain, are more likely to develop stress-related health problems.12 The Siegrist’s effort-reward imbalance (ERI) model, proposes that efforts at work should be rewarded in various ways: income, respect and esteem, and occupational status control.13 Workers are in a state of detrimental imbalance when high efforts are accompanied by low reward, and are thus more susceptible to health problems. In industrialized countries, the proportions of working men and women exposed to these adverse factors at work have been found to be about 20–25%.14 The aim of The PROspective Québec (PROQ) Study on Work and Health is to further extend our comprehension of the effect of work stressors on cardiovascular and mental health, including a thorough examination of the pathways by which adverse psychosocial work factors accumulated over the working life could lead to higher risk of CVD and MHP at older ages. The PROspective Québec (PROQ) Study on Work and Health is a prospective cohort initiated in 1991-93, with two follow-ups 8 and 24 years later. Baseline (1991-93) and 8-year (1999-2001) follow-up data collections were funded by the Canadian Medical Research Council.15,16 The ongoing 24-year follow-up (2015-18) is supported by the Canadian Institutes of Health Research.17–20 This follow-up is a crucial phase, required to examine the effect of adverse psychosocial work factors exposure, accumulated over the working life, on: (i) the longitudinal progression of CVD and mental health outcomes assessed at earlier phases (blood pressure, psychological distress): (ii) CVD and MHP incidence before and after retirement; (iii) CVD and MHP social costs (health care costs and production losses costs) attributable to adverse psychosocial work factors exposure;20 and (iv) novel subclinical markers of disease risk (aortic stiffness, inflammatory markers, telomere length, cognitive function). These latter indicators intervene in the pathogenic process, leading to more severe form of diseases, and are therefore of great interest for early prevention. Who is in the cohort? All white-collar workers employed in 19 public and semi-public organizations were invited to participate in the study. These organizations were participating in an epidemiological study of job strain and cardiovascular diseases that was coupled (for the purposes of recruitment and data collection) with a cardiovascular health promotion programme led by the regional Public Health Centre. About half of the organizations were selected by the researchers based on an a priori impression of possible exposure to job strain (jobs involving repetitive tasks and semi-public insurance companies, income tax services). Other organizations were selected by the cardiovascular health promotion programme team. A personalized letter was sent to every worker of the organizations, inviting them to participate. At baseline (1991–93), 9189 white-collar workers aged 18 to 65 years participated (participation proportion: 75%). Sociodemographic characteristics of the population are described in Table 1. Their jobs encompassed the full range of white-collar occupations, including senior management (10.4%), professional (35.5%), technical (20.8%) and office (30.6%) workers. Education levels ranged from no high-school diploma to university degree. At the baseline data collection, participants were met at their worksite during working hours in a room especially set aside. Data collection included a self-reported questionnaire, a face-to-face interview, anthropometric and clinical measurements and administrative databases extraction (Table 2). Table 1 Sociodemographic characteristics of the PROspective Québec (PROQ) Study on Work and Health Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Table 1 Sociodemographic characteristics of the PROspective Québec (PROQ) Study on Work and Health Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Table 2 Measurements at each phase of the PROQ-Study on Work and Health Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X Table 2 Measurements at each phase of the PROQ-Study on Work and Health Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X How often have they been followed up? At the first follow-up 8 years later (1999–2001), 8121 agreed to participate again, corresponding to 89% of the initial sample. There were 117 deaths (1.2%) and 744 refusals (7.7%). For the ongoing 24-year follow-up (2015–18), 9020 of participants from the initial cohort (98.1%) were retraced. Approximately 63% of all participants are now aged over 60 years and about 70% of them are retired. Among retired participants, for whom data collection has already begun, a participation of 74% is actually attained. We expect to obtain a final proportion of ≥ 80% for questionnaires and anthropometric and clinical measures, and written consent of ≥ 95% of the cohort sample to access medico-administrative data for cardiovascular and mental health events. Retired participants are met in specially designed rooms at the Hospital du Saint-Sacrement du CHU de Québec (Québec City, Canada). Active workers are met at their workplace, during regular working hours. What has been measured? Table 2 summarizes all the variables measured at the three time points for each procedure, namely self-reported questionnaire, interview, biological variables and medico-administrative databases. Adverse psychosocial work factors exposure Karasek’s demand-control model Psychological demands (PD) and decision latitude (DL) were assessed with both 9-item scales of the Karasek’s Job Content Questionnaire.12 The results of previous studies have supported the psychometric properties (internal consistency, factorial validity and discriminant validity) of both the original English21 and French version of the questionnaire.22,23 PD refer to an excessive work load, very hard or very fast work, task interruption, intense concentration and conflicting demands. DL reflects opportunities for learning, autonomy and participation in the decision-making process. Psychological demands and decision latitude were computed according to the algorithms recommended by Karasek.12 Workers with PD scores of 24 or higher (the median for the general Québec working population) were classified as having high PD. Workers with DL scores of 72 or lower (median of general Québec working population) were classified as having low DL.24 The passive group comprised workers with low PD and low DL, the active group comprised workers with high PD and high DL, and the job strain (high strain) group comprised workers with high PD and low DL. Other workers were classified as unexposed. Siegrist’s effort-reward imbalance model The effort-reward imbalance (ERI) model proposes that efforts at work should be rewarded in various ways: income, respect and esteem, and occupational status control. Workers are in a state of detrimental imbalance when high efforts are accompanied by low reward, and are thus more susceptible to health problems. Efforts and reward were respectively measured with 4 and 11 items on a 4-point Likert scale adapted from the original Siegrist’s questionnaire.13 The factorial validity and internal consistency of both the original English and the French versions of this instrument have been demonstrated.25,26 Scores of effort and reward were calculated with the sum of items, and the ERI ratio was obtained by divided the score of effort by the score of reward. Professional histories and annual exposure matrix Annual exposure to psychosocial work factors from the demand-control model will be defined using a job exposure matrix. This matrix will be created from the professional history of each subject and the average exposure scores per job title. Professional history covering the whole study period will be retrieved from registries of all organizations. Job title will be obtained for all occupied positions. Mean exposure scores will be computed using recommended methods, adjusting for age, gender and education.27 Annual exposure will be estimated using the job exposure matrix Cardiovascular health Blood pressure in the entire cohort Casual blood pressure was measured following the American Heart Association protocol.28 Workers’ blood pressure (BP) was measured at rest after they had been sitting for 5 min. The averages of two blood pressure measurements taken at baseline and three taken at follow-up, 1 to 2 min apart, was used as baseline and follow-up blood pressure levels. At the 24-year follow-up, BP was measured by trained personnel using a validated automated oscillometric device (Microlife Watch BP Office) to improve precision and validity.29 Moreover, blood pressure measurements were performed on both arms simultaneously for assessing inter-arm blood pressure differences. After the participant had been sitting for 5 min, three readings were taken on both arms and registered automatically on the Microlife software. Ambulatory blood pressure (subsample) Ambulatory blood pressure (ABP) was measured in a subsample composed of approximately 2200 workers from three public insurance institutions. They were contacted by the researchers to conduct a prospective examination within a shorter time span of the cumulative effect of adverse psychosocial work exposures on ambulatory blood pressure in middle-aged workers. More than half (N = 1240) were employed in an organization included in the main study sample, and workers from two other organizations also participated in this additional prospective examination. Workers from the main study sample and the ambulatory blood pressure subsample share the same distribution of sociodemographic factors, occupational characteristics and adverse psychosocial exposures at work. Data collection was performed at three time points in a distinct period: at baseline (2000–04), 3 years later (2004–06) and 5 years later (2006–09). At each measurement time, ABP was assessed by the Spacelabs 90207 oscillometric devices.30,31 The device was installed on the non-dominant arm if BP difference measured on both arms was inferior to 10 mmHg. Otherwise, it was installed on the arm showing the higher BP level. ABP was measured every 15 min during daytime working hours. ABP was defined as the mean of all readings taken during the working day. Information on blood pressure will be merged among workers participating in both samples, to provide additional insights on BP trajectories over the whole follow-up. Aortic stiffness Arterial stiffness is measured with carotid-femoral pulse wave velocity (PWV) according to actual recommendations,32 using the Complior Analyses Device.33 Carotid-femoral velocity was measured from the carotid-femoral distance and the transit time between the carotid and the femoral pulse, recorded simultaneously. In each participant, PWV was measured twice, and if the difference in velocity between the two measurements was larger than 0.5 m/s, a third measurement was taken. Inter- and intra-observor reproducibility was assessed in previous studies and found to be excellent.34,35 Incidence of CVD events CVD incidence is assessed using medico-administrative databases, including: the hospitalization (MEDECHO) database; the Québec medical claims database from the public health insurance system in Québec (RAMQ); and the death registry. Information on the following CVD events is retrieved: acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization. Mental health Psychological distress Psychological distress was measured using a validated 14-item version of the Psychiatric Symptom Index (PSI).36–38 The PSI assessed the presence and intensity of a range of symptoms: anxiety, depression, aggressiveness and minor cognitive impairment, during the previous week. The validity of the French version of the PSI has been demonstrated and has a good concurrent validity with four other mental health measures: consultation with a professional, hospitalization, suicidal ideation or suicide attempt and use of psychotropic medication.39 At the 24-year follow-up, we have included the K6 questionnaire, elaborated and validated by Kessler et al. Because of its brevity and good validity, it is now the main instrument used in major health surveys in Canada40 and specifically Québec.41 The K6 includes six questions covering the two most frequent distress symptoms, i.e. depressive symptoms and anxiety. Medically certified sickness absence Medically certified work absences were obtained retrospectively from computerized records from the employers’ unique insurance service. The covered period was from 1 year before study baseline to the end of follow-up. Data included the exact date of each work absence episode. The work absence policy was the same for each employer. For each episode of 3 days or more, workers had to provide a medical certificate from a physician to their employer. These data were rigorously verified by employers because they were used to pay indemnity to workers. Diagnoses on medical certificates are coded by a medical archivist using ICD-9 and ICD-10.42 Depression The prevalence of depression was measured at the 24-year follow-up (2015-18) using the validated French version of the Composite International Diagnostic Interview-Short Form (CIDI-SF). This instrument measures depression according to the definitions and criteria of the DSM-IV, and assesses the occurrence of symptoms of a major depressive episode within the past 12 months. The CIDI-SF was validated by the World Health Organization (WHO)43 and recently used in Canadian population-based studies.44,45 Depression incidence over the follow-up was measured using the hospitalization and medical claims databases as well as the employer’s registry of medically certified work absences for depression. Cognitive function Cognitive function was assessed using the Montréal Cognitive Assessment (MoCA). The MoCA test is designed to detect mild cognitive impairment (MCI).46 It is a global cognitive function 30-point short test which evaluates different domains: visuospatial abilities, executive functions, short-term memory recall, attention, concentration, working memory, language and orientation to time and space. The original validation study compared the MoCA with the Mini Mental State Examination (MMSE),- another test for global cognitive performance. The MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild Alzheimer’s disease group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively). Studies examining the individual MoCA domains with more comprehensive and commonly used neuropsychological measures showed further support for the use of the MoCA as a cognitive screen that reflects sconstructs similar to those measured by a comprehensive battery.47,48 Biomarkers Total cholesterol was measured at baseline using the Boehringer Mannaheim Reflotron Chemistry Analyser.49 Blood samples for measurements of inflammatory markers and telomeres were performed by a qualified research nurse using a standardized protocol, in 2015-18. Blood samples were collected in EDTA-treated tubes and in tubes with gel serum separator, processed and stored at −80°C until analysis. C-reactive protein (CRP) and interleukin 6 (IL-6) were measured following strict quality assurances procedures. CRP serum concentrations were measured using high-sensivity immunoturbidimetric assay on the Roche Modular analytical system (Roche Diagnostics, Indianapolis, IN). IL-6 serum concentrations were measured using enzyme-linked immunosorbent assay (ELISA), according to the manufacturer’s protocol (R & D Systems, Minneapolis, MN, USA) and the signal was measured using an automated fluorometer. For telomere measurement, leukocyte genomic DNA was extracted using QIAamp blood minikit (QIAGEN Inc., Missisauga, ON).50 Telomere length was measured using a highly reproducible quantitative polymerase chain reaction (PCR) method in peripheral white blood cells. This technique was validated by Southern blot.51,53 Glycated haemoglobin and urine in a subsample (N = 2300) Glycated haemoglobin will be measured in a subsample of active and recently retired workers using immunochemical assay on a Roche Diagnostics Integra platform [coefficient of variation (CV), 1.6%]. Serum creatinine will be dosed using the Jaffe method on a Siemens Advia 1800 automated analyser (CV 2.8%). Albuminuria [urine albumin/creatinine ratio (ACR)] will be measured using an immunoturbidimetric assay on a Siemens Advia 1800 analyser (CV 8.3%). Sodium/potassium ratio will be dosed in the urine sample using an ion-specific electrodes (ISE) method (CV 0.9%). Cost variables Costs data included are health care costs (direct costs) and indirect costs related to production losses (presenteeism, sickness absences, premature retirement and death) due to CVD and MHP, as measured from the societal perspective. Health care costs include medical visits and actions, medications, hospitalizations and emergency room visits deriving from the public health insurance databases in Québec (RAMQ). Indirect costs related to production losses will include medically certified work absences (see section above) and years of production lost because of premature death and retirement. Presenteeism at work is measured at the ongoing 24-year follow-up (2015-18) among active workers using the Work Productivity and Activity Impairment Questionnaire (WPAI).54 The WPAI measures productivity loss and costs for various health problems including CVD and depression.55 The estimation of the proportion of these CVD and MHP costs attributable to psychosocial work factors is based on attributable fractions estimates, which require adjusted relative risk and prevalence of exposure calculations using cohort data.56 Other measured variables Demographics included were age, gender, marital status, being a single parent and living alone. Body mass index was defined by weight (kg)/height (m2) and was measured by trained personnel. Waist-hip ratio was also measured as a proxy of adipose tissue distribution. Smoking status, family history of CVD, alcohol consumption, physical activity, diabetes, oral contraceptive use, social support outside work, social isolation and satisfaction toward family life were measured using the self-reported questionnaire.24 The following covariables were also assessed: social support at work,57 family responsibilities58 and personality.59,60 Several covariables were measured for the first time in the ongoing follow-up, including work-family conflicts, social participation, taking care of a sick or disabled parent and trust (toward others in general, toward the social system). In retired participants, working after the official retirement date was also measured. Diet was evaluated in 2015-18 using an online food frequency questionnaire, validated in a Québec population.61 Back pain was evaluated with a standardized and validated questionnaire.62 What has been found? Within the cohort, we have documented the validity of the French version of the instrument used to measure psychosocial work factors from the demand-control model.22,23 We have also demonstrated that the prevalence of these adverse psychosocial work factors was around 20%, which is comparable to that of the general population of Québec and of other industrialized countries, highlighting the public health importance of these exposures.14 We have shown that adverse psychosocial work factors are associated with an increased prevalence of known CVD risk factors such as smoking, obesity and sedentary behaviours.63 We have documented the adverse effect of job strain exposure on blood pressure,64 psychological distress65 and psychotropic drugs use.66 Within the subsample with ambulatory blood pressure measurements (N = 2200), we showed that job strain and effort-reward imbalance are associated with short- and mid-term (< 5 years) increases in ambulatory blood pressure,67–69 and with a higher prevalence of masked hypertension.70,–71 We have also shown that these adverse psychosocial exposures at work have an effect on psychological distress72 and medically certified sickness absence for mental health problems.73,74 Analyses conducted among women also documented the joint effect of adverse psychosocial work factors exposure and high family responsibilities on women’s blood pressure.75,76 What are the main strenghts and weaknesses? The cohort has some limitations. Blood pressure measures were based on a limited number of determinations, as is true of most large epidemiological studies. Second, there were three psychosocial work factors assessments over the 24-year period, possibly introducing exposure misclassification. The annual job exposure matrix will contribute to overcome this limitation. Finally, the study population was composed of white-collar workers, and thus the results may not generalize to other populations. However, the prevalence of exposure to adverse psychosocial work factors in the present cohort was similar to that of the Québec general working population, favouring external validity. This cohort has several important strengths: (i) it was conducted in a large sample of men and women; (ii) the participation proportion at baseline was 75%, the retention proportion was 89% at first follow-up and at the ongoing follow-up, 80% participation is expected for the in-person data collection and 95% for medico-administrative data; (iii) validated instruments were used to measure adverse psychosocial work factors; (iv) the repeated assessment of psychosocial work factors allowed cumulative exposure to be accounted for; (v) at mid-life or later life, a large number of CVD and mental health outcomes were measured as well as their major risk factors; and (vi) the costs of CVD and MHP attributable to adverse psychosocial work factors were assessed with a longitudinal design including a large set of direct and indirect costs components. Can I get hold of the data? where can I find more? Collaborations are highly welcome, please contact the corresponding author with any enquiries. Profile in a nutshell The aim of The PROspective Québec (PROQ) Study on Work and Health is to further extend our comprehension of the effect of work stressors on cardiovascular and mental health. The effect of adverse psychosocial work exposure, accumulated over the working life, will be investigated using multiple cardiovascular (CVD) and mental health problem (MHP) outcomes, measured before and after retirement, among men and women. The cohort is located in Québec City, Canada. Baseline data collection (1991-93) resulted in the recruitment of 9189 white-collar workers aged 18 to 65 years. At the first follow-up, 8 years later (1999-2001), 8121 agreed to participate again (89% of the initial sample). For the ongoing 24-year follow-up (2015-18), 9020 of participants from the initial cohort (98.1%) were retraced. We expect to obtain a final participation of ≥ 80% for questionnaires, anthropometric and clinical measures and participation (written consent) of ≥ 95% of the cohort sample, to access medico-administrative data. Available data include: adverse psychosocial work exposure (job strain, effort-reward imbalance), cardiovascular outcomes (blood pressure, arterial stiffness, CVD events), mental health outcomes (psychological distress, medically certified sickness absence, depression, cognition) and many covariates including main CVD and MHP risk factors. Collaborations are highly welcome, please contact the corresponding author Funding This work was supported by the Medical Research Council of Canada (grant number MA-11364) and the Canadian Institutes of Health Research (grants numbers 201109MOP-257818-PH2-CFBA-35698, 201309MOP-312916-PH1-CFBA-35698, 201403MOP-325244-BCA-CFBA-52569, 201603PJT-366272-PJT-CFBA-35698). Conflict of interest: All the authors declare no conflicts of interest. References 1 World Health Organization . Cardiovascular Diseases . (Fact sheet). Geneva : WHO , 2011 . 2 Canadian Institutes for Health Information . The Cost of Acute Care Hospital Stays by Medical Condition in Canada: 2004-2005 . Ottawa, ON : CIHI , 2008 . 3 Mozaffarian D , Benjamin EJ , Go AS et al. Heart disease and stroke statistics - 2015 update: a report from the American Heart Association . Circulation 2015 ; 131 : e29 – 322 . Google Scholar CrossRef Search ADS PubMed 4 Whiteford HA , Degenhardt L , Rehm J et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010 . Lancet 2013 ; 382 : 1575 – 86 . Google Scholar CrossRef Search ADS PubMed 5 Koopmans PC , Bultmann U , Roelen CA , Hoedeman R , van der Klink JJ , Groothoff JW. Recurrence of sickness absence due to common mental disorders . Int Arch Occup Environ Health 2011 ; 84: 193 – 201 . 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Google Scholar CrossRef Search ADS PubMed 73 Ndjaboue R , Brisson C , Vezina M , Blanchette C , Bourbonnais R. Effort-reward imbalance and medically certified absence for mental health problems: a prospective study of white-collar workers . Occup Environ Med 2014 ; 71 : 40 – 07 . Google Scholar CrossRef Search ADS PubMed 74 Ndjaboue R , Brisson C , Talbot D , Vezina M. Combined exposure to adverse psychosocial work factors and medically certified absence for mental health problems: A 5-year prospective study . J Psychosom Res 2017 ; 92 : 9 – 15 . Google Scholar CrossRef Search ADS PubMed 75 Gilbert-Ouimet M , Brisson C , Milot A , Vezina M. Double exposure to adverse psychosocial work factors and high family responsibilities as related to ambulatory blood pressure at work: a 5-year prospective study in women with white-collar jobs . Psychosom Med 2017 ; 79: 593 – 602 . Google Scholar CrossRef Search ADS PubMed 76 Brisson C , Laflamme N , Moisan J , Milot A , Mâsse B , Vézina M. Effect of family responsibilities and job strain on ambulatory blood pressure among white-collar women . Psychosom Med 1999 ; 61: 205 – 13 . Google Scholar CrossRef Search ADS PubMed Appendix 1. The PROspective Québec (PROQ) Study on Work and Health: Investigators and collaborators. Investigators (principal investigator followed by all investigators in alphabetical order) Brisson Chantal, PhD, Université Laval, Québec Bourbonnais Renée, PhD, Université Laval, Québec Breton Marie-Claude, PhD, Université Laval, Québec Dagenais Gilles R., MD, MSc, FRCP, Université Laval, Québec Dionne Clermont, PhD, Université Laval, Québec Diorio Caroline, PhD, Université Laval, Québec Giguère Yves, MD, PhD, FRCP, Université Laval, Québec Gilbert-Ouimet Mahée, PhD, Université Laval, Québec Laurin Danielle, PhD, Université Laval, Québec Lauzier Sophie, Université Laval, Québec Lesage Alain, MD, Université Laval, Québec Guénette Line, PhD, Université Laval, Québec Mâsse Benoît, PhD, Université de Montréal, Québec Maunsell Elizabeth, Université Laval, Québec Milot Alain, MD, MSc, FRCP, Université Laval, Québec Ndjaboué Ruth, MSc, Université Laval, Québec Niedhammer Isabelle, PhD, Sorbonne Universités, Paris Pearce Neil, PhD, London School of Hygiene and Tropical Medicine, London Sultan-Taïeb Hélène, Université du Québec à Montréal, Québec Trudel Xavier, PhD, Université Laval, Québec Vézina Michel, MD, MPH, FRCP, Université Laval, Québec Collaborators Chastang Jean-François, PhD, Institut National de la Santé et de la Recherche Médicale, Paris Kline Rex, PhD, Concordia, Montréal Lamarche Benoît, PhD, Université Laval, Québec © The Author(s) 2018; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Epidemiology Oxford University Press

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Oxford University Press
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© The Author(s) 2018; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association
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Abstract

Why was the cohort setup? Cardiovascular diseases (CVD) are the leading cause of mortality worldwide, accounting for 17.7 million deaths per year.1 CVD also rank first in terms of hospitalization costs in Canada,2 and are among the leading diagnoses for direct health expenditures in the USA.3 Mental health problems (MHP) are the first cause of disability worldwide.4 Their prevalence, long duration and high risk of recurrence5 place a considerable burden on health and social care systems and incur important productivity losses for employers.4 A number of prospective studies have documented the effects of adverse psychosocial work factors (work stressors) on CVD6,7 and MHP.8–11 To assess the exposure of psychosocial work factors, two theoretical models have mainly been used. The demand-control (DC) model suggests that workers simultaneously experiencing high psychological demands and low decision latitude, i.e. job strain, are more likely to develop stress-related health problems.12 The Siegrist’s effort-reward imbalance (ERI) model, proposes that efforts at work should be rewarded in various ways: income, respect and esteem, and occupational status control.13 Workers are in a state of detrimental imbalance when high efforts are accompanied by low reward, and are thus more susceptible to health problems. In industrialized countries, the proportions of working men and women exposed to these adverse factors at work have been found to be about 20–25%.14 The aim of The PROspective Québec (PROQ) Study on Work and Health is to further extend our comprehension of the effect of work stressors on cardiovascular and mental health, including a thorough examination of the pathways by which adverse psychosocial work factors accumulated over the working life could lead to higher risk of CVD and MHP at older ages. The PROspective Québec (PROQ) Study on Work and Health is a prospective cohort initiated in 1991-93, with two follow-ups 8 and 24 years later. Baseline (1991-93) and 8-year (1999-2001) follow-up data collections were funded by the Canadian Medical Research Council.15,16 The ongoing 24-year follow-up (2015-18) is supported by the Canadian Institutes of Health Research.17–20 This follow-up is a crucial phase, required to examine the effect of adverse psychosocial work factors exposure, accumulated over the working life, on: (i) the longitudinal progression of CVD and mental health outcomes assessed at earlier phases (blood pressure, psychological distress): (ii) CVD and MHP incidence before and after retirement; (iii) CVD and MHP social costs (health care costs and production losses costs) attributable to adverse psychosocial work factors exposure;20 and (iv) novel subclinical markers of disease risk (aortic stiffness, inflammatory markers, telomere length, cognitive function). These latter indicators intervene in the pathogenic process, leading to more severe form of diseases, and are therefore of great interest for early prevention. Who is in the cohort? All white-collar workers employed in 19 public and semi-public organizations were invited to participate in the study. These organizations were participating in an epidemiological study of job strain and cardiovascular diseases that was coupled (for the purposes of recruitment and data collection) with a cardiovascular health promotion programme led by the regional Public Health Centre. About half of the organizations were selected by the researchers based on an a priori impression of possible exposure to job strain (jobs involving repetitive tasks and semi-public insurance companies, income tax services). Other organizations were selected by the cardiovascular health promotion programme team. A personalized letter was sent to every worker of the organizations, inviting them to participate. At baseline (1991–93), 9189 white-collar workers aged 18 to 65 years participated (participation proportion: 75%). Sociodemographic characteristics of the population are described in Table 1. Their jobs encompassed the full range of white-collar occupations, including senior management (10.4%), professional (35.5%), technical (20.8%) and office (30.6%) workers. Education levels ranged from no high-school diploma to university degree. At the baseline data collection, participants were met at their worksite during working hours in a room especially set aside. Data collection included a self-reported questionnaire, a face-to-face interview, anthropometric and clinical measurements and administrative databases extraction (Table 2). Table 1 Sociodemographic characteristics of the PROspective Québec (PROQ) Study on Work and Health Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Table 1 Sociodemographic characteristics of the PROspective Québec (PROQ) Study on Work and Health Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Baseline (1991–93) 8-year follow-up (1999–2001) n = 9188 N (%) N (%) Gender  Women 4581 (49.9) 4000 (49.3)  Men 4607 (50.1) 4120 (50.7) Age (years)  ≤ 34 2419 (26.3) 395 (4.9)  35–44 4098 (44.6) 2666 (32.8)  45–54 2088 (22.7) 3355 (41.3)  ≥ 55 583 (3.4) 1704 (21.0) Means (SD) 40.2 (8.7) 47.8 (8.5) Education  < College degree 2715 (29.8) 2170 (27.0)  College degree 2564 (28.1) 2233 (27.8)  University degree 3835 (42.1) 3634 (45.2) Occupation  Office workers 2993 (32.7) 1779 (26.1)  Technician 1807 (19.7) 1619 (23.8)  Professionals 3121 (34.1) 2589 (38.0)  Managers 950 (10.4) 676 (9.9)  Others 292 (3.2) 143 (2.1)  Retired 1080 Income  < 30,000$ 1345 (14.9) 791 (9.87)  30–39,999$ 1098 (12.1) 914 (11.4)  40–49,999$ 1236 (13.6) 732 (9.1)  50–59,999$ 1647 (18.2) 1250 (15.6)  60–69,999$ 1197 (13.2) 1035 (12.9)  ≥ 70,000$ 2537 (28.0) 3296 (41.1) Table 2 Measurements at each phase of the PROQ-Study on Work and Health Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X Table 2 Measurements at each phase of the PROQ-Study on Work and Health Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X Variables Availability 1991–93 1999–2001 2015–18 A) SELF-REPORTED QUESTIONNAIRE Sociodemographics Gender, age, education, occupation, income, marital status, number of children X X X Lifestyle factors Smoking status, alcohol intake, meditation practice X X X Physical activity X X X General health indicators Morning tiredness X X X Self-rated health Physical health problem Low back pain X Self-reported CVD risk factors Blood pressure, cholesterol, triglyceride, diabetes, CVD, family history of CVD, medication X X X Mental health problems Psychological distress X X X Depressive symptoms X Self-reported MHP risk factors Family history of depression and dementia X Eudemonic happiness Presenteeism (subsample N = 1800) X Medication for MHP X X X Other health conditions Head trauma, inflammatory disease, migraine X Self-reported medication Vaccine, anti-inflammatory X Work characteristics Employment status, number of working hours, type of work X X X Physical constraints X Psychosocial work factors Decision latitude X X X Psychological demands Co-worker support Supervisor support X X Effort, reward, over-commitment X X Work-family conflict X Other psychosocial factors Social support, relation with children and spouse, care giving, stressful life events X X X Personality scale X X X Women health Pregnancy, menopausal status, hormonal medication X X X Diet Food frequency questionnaire (online) X B) INTERVIEW Cognitive function Global cognitive function X C) BIOLOGICAL VARIABLES Anthropometrics Weight, height, waist-hip circumference X X X Blood pressure Sphygmomanometer (T1-T2) X X X BP-TRU (T3) Ambulatory BP(subsample N = 2200) Spacelabs 90207 2000–04 2004–06 2006–09 Arterial stiffness Complior X Blood sample CRP X IL-6 X Telomere length X Glycated haemoglobin (subsample = 2300) X Total cholesterol X Urine (subsample N = 2300) Albuminuria (creatinine serum) X Potassium sodium ratio X Glomerular filtration rate (GFR) X D) MEDICO-ADMINISTRATIVE DATABASES CVD Acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization and related health care costs. X X X MHP Diagnosed depression and related health care costs X X X Other diseases Diabetes, kidney disease X X X How often have they been followed up? At the first follow-up 8 years later (1999–2001), 8121 agreed to participate again, corresponding to 89% of the initial sample. There were 117 deaths (1.2%) and 744 refusals (7.7%). For the ongoing 24-year follow-up (2015–18), 9020 of participants from the initial cohort (98.1%) were retraced. Approximately 63% of all participants are now aged over 60 years and about 70% of them are retired. Among retired participants, for whom data collection has already begun, a participation of 74% is actually attained. We expect to obtain a final proportion of ≥ 80% for questionnaires and anthropometric and clinical measures, and written consent of ≥ 95% of the cohort sample to access medico-administrative data for cardiovascular and mental health events. Retired participants are met in specially designed rooms at the Hospital du Saint-Sacrement du CHU de Québec (Québec City, Canada). Active workers are met at their workplace, during regular working hours. What has been measured? Table 2 summarizes all the variables measured at the three time points for each procedure, namely self-reported questionnaire, interview, biological variables and medico-administrative databases. Adverse psychosocial work factors exposure Karasek’s demand-control model Psychological demands (PD) and decision latitude (DL) were assessed with both 9-item scales of the Karasek’s Job Content Questionnaire.12 The results of previous studies have supported the psychometric properties (internal consistency, factorial validity and discriminant validity) of both the original English21 and French version of the questionnaire.22,23 PD refer to an excessive work load, very hard or very fast work, task interruption, intense concentration and conflicting demands. DL reflects opportunities for learning, autonomy and participation in the decision-making process. Psychological demands and decision latitude were computed according to the algorithms recommended by Karasek.12 Workers with PD scores of 24 or higher (the median for the general Québec working population) were classified as having high PD. Workers with DL scores of 72 or lower (median of general Québec working population) were classified as having low DL.24 The passive group comprised workers with low PD and low DL, the active group comprised workers with high PD and high DL, and the job strain (high strain) group comprised workers with high PD and low DL. Other workers were classified as unexposed. Siegrist’s effort-reward imbalance model The effort-reward imbalance (ERI) model proposes that efforts at work should be rewarded in various ways: income, respect and esteem, and occupational status control. Workers are in a state of detrimental imbalance when high efforts are accompanied by low reward, and are thus more susceptible to health problems. Efforts and reward were respectively measured with 4 and 11 items on a 4-point Likert scale adapted from the original Siegrist’s questionnaire.13 The factorial validity and internal consistency of both the original English and the French versions of this instrument have been demonstrated.25,26 Scores of effort and reward were calculated with the sum of items, and the ERI ratio was obtained by divided the score of effort by the score of reward. Professional histories and annual exposure matrix Annual exposure to psychosocial work factors from the demand-control model will be defined using a job exposure matrix. This matrix will be created from the professional history of each subject and the average exposure scores per job title. Professional history covering the whole study period will be retrieved from registries of all organizations. Job title will be obtained for all occupied positions. Mean exposure scores will be computed using recommended methods, adjusting for age, gender and education.27 Annual exposure will be estimated using the job exposure matrix Cardiovascular health Blood pressure in the entire cohort Casual blood pressure was measured following the American Heart Association protocol.28 Workers’ blood pressure (BP) was measured at rest after they had been sitting for 5 min. The averages of two blood pressure measurements taken at baseline and three taken at follow-up, 1 to 2 min apart, was used as baseline and follow-up blood pressure levels. At the 24-year follow-up, BP was measured by trained personnel using a validated automated oscillometric device (Microlife Watch BP Office) to improve precision and validity.29 Moreover, blood pressure measurements were performed on both arms simultaneously for assessing inter-arm blood pressure differences. After the participant had been sitting for 5 min, three readings were taken on both arms and registered automatically on the Microlife software. Ambulatory blood pressure (subsample) Ambulatory blood pressure (ABP) was measured in a subsample composed of approximately 2200 workers from three public insurance institutions. They were contacted by the researchers to conduct a prospective examination within a shorter time span of the cumulative effect of adverse psychosocial work exposures on ambulatory blood pressure in middle-aged workers. More than half (N = 1240) were employed in an organization included in the main study sample, and workers from two other organizations also participated in this additional prospective examination. Workers from the main study sample and the ambulatory blood pressure subsample share the same distribution of sociodemographic factors, occupational characteristics and adverse psychosocial exposures at work. Data collection was performed at three time points in a distinct period: at baseline (2000–04), 3 years later (2004–06) and 5 years later (2006–09). At each measurement time, ABP was assessed by the Spacelabs 90207 oscillometric devices.30,31 The device was installed on the non-dominant arm if BP difference measured on both arms was inferior to 10 mmHg. Otherwise, it was installed on the arm showing the higher BP level. ABP was measured every 15 min during daytime working hours. ABP was defined as the mean of all readings taken during the working day. Information on blood pressure will be merged among workers participating in both samples, to provide additional insights on BP trajectories over the whole follow-up. Aortic stiffness Arterial stiffness is measured with carotid-femoral pulse wave velocity (PWV) according to actual recommendations,32 using the Complior Analyses Device.33 Carotid-femoral velocity was measured from the carotid-femoral distance and the transit time between the carotid and the femoral pulse, recorded simultaneously. In each participant, PWV was measured twice, and if the difference in velocity between the two measurements was larger than 0.5 m/s, a third measurement was taken. Inter- and intra-observor reproducibility was assessed in previous studies and found to be excellent.34,35 Incidence of CVD events CVD incidence is assessed using medico-administrative databases, including: the hospitalization (MEDECHO) database; the Québec medical claims database from the public health insurance system in Québec (RAMQ); and the death registry. Information on the following CVD events is retrieved: acute myocardial infarction, unstable angina, acute stroke, atrial fibrillation, peripheral vascular diseases and revascularization. Mental health Psychological distress Psychological distress was measured using a validated 14-item version of the Psychiatric Symptom Index (PSI).36–38 The PSI assessed the presence and intensity of a range of symptoms: anxiety, depression, aggressiveness and minor cognitive impairment, during the previous week. The validity of the French version of the PSI has been demonstrated and has a good concurrent validity with four other mental health measures: consultation with a professional, hospitalization, suicidal ideation or suicide attempt and use of psychotropic medication.39 At the 24-year follow-up, we have included the K6 questionnaire, elaborated and validated by Kessler et al. Because of its brevity and good validity, it is now the main instrument used in major health surveys in Canada40 and specifically Québec.41 The K6 includes six questions covering the two most frequent distress symptoms, i.e. depressive symptoms and anxiety. Medically certified sickness absence Medically certified work absences were obtained retrospectively from computerized records from the employers’ unique insurance service. The covered period was from 1 year before study baseline to the end of follow-up. Data included the exact date of each work absence episode. The work absence policy was the same for each employer. For each episode of 3 days or more, workers had to provide a medical certificate from a physician to their employer. These data were rigorously verified by employers because they were used to pay indemnity to workers. Diagnoses on medical certificates are coded by a medical archivist using ICD-9 and ICD-10.42 Depression The prevalence of depression was measured at the 24-year follow-up (2015-18) using the validated French version of the Composite International Diagnostic Interview-Short Form (CIDI-SF). This instrument measures depression according to the definitions and criteria of the DSM-IV, and assesses the occurrence of symptoms of a major depressive episode within the past 12 months. The CIDI-SF was validated by the World Health Organization (WHO)43 and recently used in Canadian population-based studies.44,45 Depression incidence over the follow-up was measured using the hospitalization and medical claims databases as well as the employer’s registry of medically certified work absences for depression. Cognitive function Cognitive function was assessed using the Montréal Cognitive Assessment (MoCA). The MoCA test is designed to detect mild cognitive impairment (MCI).46 It is a global cognitive function 30-point short test which evaluates different domains: visuospatial abilities, executive functions, short-term memory recall, attention, concentration, working memory, language and orientation to time and space. The original validation study compared the MoCA with the Mini Mental State Examination (MMSE),- another test for global cognitive performance. The MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild Alzheimer’s disease group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively). Studies examining the individual MoCA domains with more comprehensive and commonly used neuropsychological measures showed further support for the use of the MoCA as a cognitive screen that reflects sconstructs similar to those measured by a comprehensive battery.47,48 Biomarkers Total cholesterol was measured at baseline using the Boehringer Mannaheim Reflotron Chemistry Analyser.49 Blood samples for measurements of inflammatory markers and telomeres were performed by a qualified research nurse using a standardized protocol, in 2015-18. Blood samples were collected in EDTA-treated tubes and in tubes with gel serum separator, processed and stored at −80°C until analysis. C-reactive protein (CRP) and interleukin 6 (IL-6) were measured following strict quality assurances procedures. CRP serum concentrations were measured using high-sensivity immunoturbidimetric assay on the Roche Modular analytical system (Roche Diagnostics, Indianapolis, IN). IL-6 serum concentrations were measured using enzyme-linked immunosorbent assay (ELISA), according to the manufacturer’s protocol (R & D Systems, Minneapolis, MN, USA) and the signal was measured using an automated fluorometer. For telomere measurement, leukocyte genomic DNA was extracted using QIAamp blood minikit (QIAGEN Inc., Missisauga, ON).50 Telomere length was measured using a highly reproducible quantitative polymerase chain reaction (PCR) method in peripheral white blood cells. This technique was validated by Southern blot.51,53 Glycated haemoglobin and urine in a subsample (N = 2300) Glycated haemoglobin will be measured in a subsample of active and recently retired workers using immunochemical assay on a Roche Diagnostics Integra platform [coefficient of variation (CV), 1.6%]. Serum creatinine will be dosed using the Jaffe method on a Siemens Advia 1800 automated analyser (CV 2.8%). Albuminuria [urine albumin/creatinine ratio (ACR)] will be measured using an immunoturbidimetric assay on a Siemens Advia 1800 analyser (CV 8.3%). Sodium/potassium ratio will be dosed in the urine sample using an ion-specific electrodes (ISE) method (CV 0.9%). Cost variables Costs data included are health care costs (direct costs) and indirect costs related to production losses (presenteeism, sickness absences, premature retirement and death) due to CVD and MHP, as measured from the societal perspective. Health care costs include medical visits and actions, medications, hospitalizations and emergency room visits deriving from the public health insurance databases in Québec (RAMQ). Indirect costs related to production losses will include medically certified work absences (see section above) and years of production lost because of premature death and retirement. Presenteeism at work is measured at the ongoing 24-year follow-up (2015-18) among active workers using the Work Productivity and Activity Impairment Questionnaire (WPAI).54 The WPAI measures productivity loss and costs for various health problems including CVD and depression.55 The estimation of the proportion of these CVD and MHP costs attributable to psychosocial work factors is based on attributable fractions estimates, which require adjusted relative risk and prevalence of exposure calculations using cohort data.56 Other measured variables Demographics included were age, gender, marital status, being a single parent and living alone. Body mass index was defined by weight (kg)/height (m2) and was measured by trained personnel. Waist-hip ratio was also measured as a proxy of adipose tissue distribution. Smoking status, family history of CVD, alcohol consumption, physical activity, diabetes, oral contraceptive use, social support outside work, social isolation and satisfaction toward family life were measured using the self-reported questionnaire.24 The following covariables were also assessed: social support at work,57 family responsibilities58 and personality.59,60 Several covariables were measured for the first time in the ongoing follow-up, including work-family conflicts, social participation, taking care of a sick or disabled parent and trust (toward others in general, toward the social system). In retired participants, working after the official retirement date was also measured. Diet was evaluated in 2015-18 using an online food frequency questionnaire, validated in a Québec population.61 Back pain was evaluated with a standardized and validated questionnaire.62 What has been found? Within the cohort, we have documented the validity of the French version of the instrument used to measure psychosocial work factors from the demand-control model.22,23 We have also demonstrated that the prevalence of these adverse psychosocial work factors was around 20%, which is comparable to that of the general population of Québec and of other industrialized countries, highlighting the public health importance of these exposures.14 We have shown that adverse psychosocial work factors are associated with an increased prevalence of known CVD risk factors such as smoking, obesity and sedentary behaviours.63 We have documented the adverse effect of job strain exposure on blood pressure,64 psychological distress65 and psychotropic drugs use.66 Within the subsample with ambulatory blood pressure measurements (N = 2200), we showed that job strain and effort-reward imbalance are associated with short- and mid-term (< 5 years) increases in ambulatory blood pressure,67–69 and with a higher prevalence of masked hypertension.70,–71 We have also shown that these adverse psychosocial exposures at work have an effect on psychological distress72 and medically certified sickness absence for mental health problems.73,74 Analyses conducted among women also documented the joint effect of adverse psychosocial work factors exposure and high family responsibilities on women’s blood pressure.75,76 What are the main strenghts and weaknesses? The cohort has some limitations. Blood pressure measures were based on a limited number of determinations, as is true of most large epidemiological studies. Second, there were three psychosocial work factors assessments over the 24-year period, possibly introducing exposure misclassification. The annual job exposure matrix will contribute to overcome this limitation. Finally, the study population was composed of white-collar workers, and thus the results may not generalize to other populations. However, the prevalence of exposure to adverse psychosocial work factors in the present cohort was similar to that of the Québec general working population, favouring external validity. This cohort has several important strengths: (i) it was conducted in a large sample of men and women; (ii) the participation proportion at baseline was 75%, the retention proportion was 89% at first follow-up and at the ongoing follow-up, 80% participation is expected for the in-person data collection and 95% for medico-administrative data; (iii) validated instruments were used to measure adverse psychosocial work factors; (iv) the repeated assessment of psychosocial work factors allowed cumulative exposure to be accounted for; (v) at mid-life or later life, a large number of CVD and mental health outcomes were measured as well as their major risk factors; and (vi) the costs of CVD and MHP attributable to adverse psychosocial work factors were assessed with a longitudinal design including a large set of direct and indirect costs components. Can I get hold of the data? where can I find more? Collaborations are highly welcome, please contact the corresponding author with any enquiries. Profile in a nutshell The aim of The PROspective Québec (PROQ) Study on Work and Health is to further extend our comprehension of the effect of work stressors on cardiovascular and mental health. The effect of adverse psychosocial work exposure, accumulated over the working life, will be investigated using multiple cardiovascular (CVD) and mental health problem (MHP) outcomes, measured before and after retirement, among men and women. The cohort is located in Québec City, Canada. Baseline data collection (1991-93) resulted in the recruitment of 9189 white-collar workers aged 18 to 65 years. At the first follow-up, 8 years later (1999-2001), 8121 agreed to participate again (89% of the initial sample). For the ongoing 24-year follow-up (2015-18), 9020 of participants from the initial cohort (98.1%) were retraced. We expect to obtain a final participation of ≥ 80% for questionnaires, anthropometric and clinical measures and participation (written consent) of ≥ 95% of the cohort sample, to access medico-administrative data. Available data include: adverse psychosocial work exposure (job strain, effort-reward imbalance), cardiovascular outcomes (blood pressure, arterial stiffness, CVD events), mental health outcomes (psychological distress, medically certified sickness absence, depression, cognition) and many covariates including main CVD and MHP risk factors. Collaborations are highly welcome, please contact the corresponding author Funding This work was supported by the Medical Research Council of Canada (grant number MA-11364) and the Canadian Institutes of Health Research (grants numbers 201109MOP-257818-PH2-CFBA-35698, 201309MOP-312916-PH1-CFBA-35698, 201403MOP-325244-BCA-CFBA-52569, 201603PJT-366272-PJT-CFBA-35698). Conflict of interest: All the authors declare no conflicts of interest. 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Effect of family responsibilities and job strain on ambulatory blood pressure among white-collar women . Psychosom Med 1999 ; 61: 205 – 13 . Google Scholar CrossRef Search ADS PubMed Appendix 1. The PROspective Québec (PROQ) Study on Work and Health: Investigators and collaborators. Investigators (principal investigator followed by all investigators in alphabetical order) Brisson Chantal, PhD, Université Laval, Québec Bourbonnais Renée, PhD, Université Laval, Québec Breton Marie-Claude, PhD, Université Laval, Québec Dagenais Gilles R., MD, MSc, FRCP, Université Laval, Québec Dionne Clermont, PhD, Université Laval, Québec Diorio Caroline, PhD, Université Laval, Québec Giguère Yves, MD, PhD, FRCP, Université Laval, Québec Gilbert-Ouimet Mahée, PhD, Université Laval, Québec Laurin Danielle, PhD, Université Laval, Québec Lauzier Sophie, Université Laval, Québec Lesage Alain, MD, Université Laval, Québec Guénette Line, PhD, Université Laval, Québec Mâsse Benoît, PhD, Université de Montréal, Québec Maunsell Elizabeth, Université Laval, Québec Milot Alain, MD, MSc, FRCP, Université Laval, Québec Ndjaboué Ruth, MSc, Université Laval, Québec Niedhammer Isabelle, PhD, Sorbonne Universités, Paris Pearce Neil, PhD, London School of Hygiene and Tropical Medicine, London Sultan-Taïeb Hélène, Université du Québec à Montréal, Québec Trudel Xavier, PhD, Université Laval, Québec Vézina Michel, MD, MPH, FRCP, Université Laval, Québec Collaborators Chastang Jean-François, PhD, Institut National de la Santé et de la Recherche Médicale, Paris Kline Rex, PhD, Concordia, Montréal Lamarche Benoît, PhD, Université Laval, Québec © The Author(s) 2018; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal of EpidemiologyOxford University Press

Published: Mar 9, 2018

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