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Long Working Hours and Occupational Stress-related Illness and Injury: Mini Review


DOI: 10.0000/JHSE.1000115 J Health Sci Educ Vol 1(3): 1-4
Long Working Hours and Occupational Stress-related Illness and
Injury: Mini Review
Persaud H and Williams S*
Department of Health Professions, School of Health Sciences and Professional Programs, City University of New York - York
College, USA
For decades, there have been concerns about long
working hours and the associated increased risk of injuries
and illnesses. Long hours can be defined as exceeding eight
hours per day at work or greater than a 40 hour work week.
Thousands of workers spend a significant amount of time at
their place of occupation exposing themselves to potentially
numerous workplace hazards. It is understood that in today’s
economy many people have to work multiple full time jobs to
“earn a living”, many of who do not know how these working
habits affect their health. According to the National Institute
for Occupational Safety and Health (NIOSH), the number of
annual hours worked in the United States has been on a steady
rise [1]. The US News and World Report found that the
majority of people between the ages of 22 and 65 spend more
than 40% of their time at work [3]. Since 1980, American
workers have been working additional hours, spending an
additional 1.5 hours per week at their place(s) of occupation.
It was estimated that hourly manufacturing workers are
working 25% more overtime when compared to 10 years ago
[2]. It was also estimated that work-related injuries and illness
cost the United States about $250 billion annually [3].
Multiple studies [4-7] have shown a strong association
between long working hours and the development of various
illnesses and injuries including, but not limited to,
hypertension, diabetes, cardiovascular disease,
musculoskeletal disorders, stress, fatigue, chronic infections,
and substance abuse. In addition, people working overtime are
subjected to a greater risk of adverse work-related outcomes
During the year 2007, it was estimated that deaths due
to occupational injuries and illnesses was higher than deaths
due to breast cancer, motor vehicle accidents or prostate
cancer [3]. This highlights the collective social need to reduce
occupational injuries and illnesses.
Long working hours is related to a myriad of adverse
health outcomes and injuries; however, the current
surveillance system does not fully capture every single
adverse work-related outcome, thus leading to an
underestimation of the true effects. For example, Rosenman et
al. [8], sought to enumerate the amount of work-related
injuries and illnesses that were missed by the national
surveillance system. Their findings suggest that up to 68% of
work-related injuries and illnesses were missed by the current
national surveillance system [8] begging the question: If this
information was more publically available and/or accessible,
would employers and employee make a preventative effort to
adjust work schedule(s)? This is an area yet to be explored
and a question that is very difficult to answer due to the
multitude and complexity of factors involved.
Literature Review
Dembe et al. assessed the impact of extended work
hours and overtime on illnesses and injuries via National
Longitudinal Survey of Youth (NLSY) [5]. A nationally
representative sample consisting of 10,793 working
Americans was used in the study between 1987 and 2000.
Journal of Health Science &
An open access journal
Mini Review
Workplace injuries and illnesses have been associated with long working hours. In the United States, working
overtime has been on the rise. It is estimated that American workers spend an extra 1.5 hours per week at their job, and for
those working in manufacturing-overtime has increased by 25% when compared to 10 years ago. Data suggests that working
greater than 12 hours in a single day was associated with a 37% (95% CI=1.161.59) increase in hazard rate (HR), while
working greater than 60 hour per week was associated with a 23% (95% CI=1.051.45) increase in HR. For those working
overtime, there was a 61% (95% CI=1.431.79) increase in HR when compared to jobs without overtime. Long working hours
carries a risk of 80% in developing Coronary Heart disease (CHD) (95% CI=1.422.29) after adjusting for age, sex and
socioeconomic status. More stringent restrictions found a risk for CHD to be 59% (95% CI=1.232.07). There is little known
on the effectiveness of strategies to address the association between long working hours and occupational stress-related injuries
and illnesses. Prevention strategies should address all levels in the hierarchy including individual, organizational and policy
levels. There is an urgency to support efforts that attempt to bring individuals, workplace and legislative policies together to
understand the adverse effects of working long hours and collaboratively work towards a solution.
Keywords: Working hours; Stress; Illness; Injuries
Persaud H, Williams S (2017) Long Working Hours and Occupational Stress-related Illness and Injury: Mini Review. J
Health Sci Educ 1: 115.
DOI: 10.0000/JHSE.1000115 J Health Sci Educ Vol 1(3): 1-4
Multivariate analysis was performed adjusting for age,
gender, occupation, industry and region. Dembe et al. [5]
found that working greater than 12 hours in a single day was
associated with a 37% (95% CI=1.161.59) increase in hazard
rate (HR), while working greater than 60 hours per week was
associated with a 23% (95% CI=1.051.45) increase in HR.
For those working overtime, there was a 61% (95% CI=1.43
1.79) increase in HR when compared to jobs without
overtime. Overtime or long hours of any type was found to
have a HR of 38% (95% CI=1.251.51). In addition, a strong
dose-response relationship was found between injury rates
and long hours [5]. The top 5 injuries and illnesses in this
study across all job types were musculoskeletal disorders, cuts
and bruises, other traumatic injuries, other occupational
diseases, and fractures respectively. It must also be noted that
an increased risk of injury or illness does not necessarily mean
that a particular occupation is more risky. It is hypothesized
that the resulting affects merely stems from the stress and
fatigue subdued by the workers [5].
A study conducted by NIOSH in 2015 found that first
year medical residents who work continuously more than 24
hours are two times more likely to be in a car crash driving
after their work shift, and five times more likely to be in a
near-miss accident when compared to medical residents who
work shorter shifts [9]. Based on these findings, it is clear that
long hours are not only limited to injuries and illness within
the workplace, but also beyond.
Virtanen et al. conducted a systematic review and
meta-analysis using published studies and unpublished data
from individual participants to explore the association
between long working hours and alcohol use [7]. They found
statistically significant results between alcohol use and long
working hours with increased odds of 11% and 12% for cross-
sectional analysis and prospective studies, respectively. When
compared to those working standard weekly hours (35-40
hours), individuals who worked 49-54 hours and >55 hours
had an increased odds of alcohol use at 13% and 12%
respectively, both statistically significant at 95% alpha level.
No differences were found between gender, socioeconomic
status, geographic location, sample type or tendency for risky
alcohol use [7]. These findings suggest that individuals who
work long hours are more likely to drink alcohol resulting in
poor health outcomes versus those working shorter hours.
Another systematic review conducted by [4], exploring
the correlation between long working hours and health
outcomes also found statistically significant association with
long working hours and adverse health effects. These include,
but not limited to, diabetes, metabolic syndrome, circulatory
disease, anxiety and other psychological disorders, decreased
cognitive function, poor sleep and behavioral disorders [4].
Apart from working long hours, other factors such as,
time of day also play an important role in determining
exposure to work related illnesses and injuries. For example,
de Castro et al. [10] found that when nurses were exposed to
non-day shifts, their odds of sustaining a work related injury
and illnesses were 54% (95% CI=1.072.24) and 48% (95%
CI=1.022.16) respectively, after controlling for the number
of hours worked, the length of the shift and demographic
factors [10]. Consistent with other findings, there were
statistically significant results of 22% and 19% increased odds
of work related illnesses and injuries respectively, for nurses
working overtime [10].
A study conducted by Wirtz et al. [11] sought to assess
the relationship between gender, long working hours and
injuries and illnesses. Seven years of pooled data was
obtained from a nationally US representative sample (the US
National Health Interview Survey) and analysed. The results
showed that injuries were higher among men. However,
before any adjustments, it was found that, as working hours
increased, there was a direct correlation with injuries for both
men and women. After adjustments with logistic regression,
the results indicated that women who worked 41-50 hours per
week and >50 hours per week had statistically significant
odds of 51% and 69%, respectively, of being injured on the
job, when compared to those working 31-40 hours. These
trends were not observed for their male counterparts [11].
In addition to all the illnesses and work related injuries
mentioned above, it is important to note the relationship
between working long hours and heart disease. Coronary heart
disease (CHD), as we recall, is one of the leading causes of
death [6], including Karoshi (sudden death due to overwork)
[4]. Multiple studies have demonstrated a strong association
with CHD and working long hours. For example, one report
from the Annals of Internal Medicine showed that when
compared to a normal 8-hour day-shift, those working >11
hours per day have a significant increased risk of heart
disease, which could be as much as 67%. This population also
has a >50% risk of a recurrent MI [12]
A systematic review and meta-analysis was conducted
by Virtanen et al. [6], using data sources through Medline
from 1966 to 2011, and Web of Science through March 2011.
The focus was to assess the link between long working hours
and CHD. Relative Risk, Odds Ratio and Hazard Ratio were
calculated for any studies that did not contain statistical
measures. Pooled analyses were also performed using
adjusted risk estimates and their associated standard errors. In
addition, to determine whether or not there were variations
between different study designs, sub-group analyses were
performed. A total of 12 eligible studies (totalling 22,518
participants comprising of 53% males and 43% females) from
across the world, were found to meet inclusion criteria, of
which 7 were case-controlled, 4 were prospective cohort and
one was a cross-sectional [6]. After minimal adjustments
(adjusting for age, sex and socioeconomic status), it was
found that working long hours carries a risk of 80% of
developing CHD (95% CI=1.422.29). For studies utilizing
maximum restrictions using multivariate analyses, the risk of
CHD decreased to 59% (95% CI=1.232.07). When analysed
separately, the 7 case-controlled studies carried a risk of 143%
whereas; the 4 prospective cohort studies carried a risk of only
39%, both statistically significant at 95% alpha level. To
avoid confounding from shift work, studies were restricted to
only daytime work, of which the relative risk was calculated
to be 51%. Despite the vast difference in relative risks
Persaud H, Williams S (2017) Long Working Hours and Occupational Stress-related Illness and Injury: Mini Review. J
Health Sci Educ 1: 115.
DOI: 10.0000/JHSE.1000115 J Health Sci Educ Vol 1(3): 1-4
between the two studies, statistically significant results were
obtained. Since prospective cohort studies are more robust
and can show causality, we can with 95% certainty say that,
individuals working long hours have at least a 39% risk of
developing CHD. However, due to the fact that the data (when
combined together) were obtained from observational studies,
we cannot with 100% certainty attribute causality. The
authors [6] noted very little evidence of publication bias
between the studies. Regardless of some limitations (as stated
in the original article), this systematic review and meta-
analysis produced and accurate estimate between working
long hours the risk for coronary heart disease [6].
Intervention and prevention
A collective effort is required to prevent workplace
injuries and illnesses-changes need to be made at all levels in
the hierarchy. Policy implications are one such measure,
which should be implemented at the national level.
Regulatory organizations such as OSHA have already made
some impacts. Given the significant correlation between HR
and overtime work, policies targeting jobs with frequent
overtime, may help reduce the incidence of work related
illnesses and injuries. Some professions such as nursing have
made some progress limiting the number of hours nurses can
work. For example, in New York, a proposed bill
(A.2025/S.1380) states that “no hospital will permit or require
a registered nurse or licensed practical nurse to remain on
duty for longer than 16 hours except in an emergency, nor be
permitted or required to be on duty for more than 60 hours in
a seven-day period’ [2]. The Fair Labor Standards Act of
1938 (FLSA) is the organization responsible for regulating
overtime. Currently, there is no restriction on the amount of
overtime worked [2]. Given the premium pay of at least 1.5
times base salary, a most people would opt for optional
overtime to boost their salary. Regulation, to restrict the
amount of overtime worked in a day or week could be a way
of limiting long working hours.
At the workplace or organization level, some
strategies may include rest breaks, re-organization of work
schedules to avoid frequent overtime, employ more staff to
decrease job strain, active participation of unions, providing
ergonomic equipment, health promotion programs funded by
employers and frequent medical evaluation for employees in
high-risk jobs [5]. Although all of these will help alleviate the
problem, it is not always possible, as we know from history
most employers are concerned about production and their
bottom-line. It has been a challenge to change organizational
practices, which may continue if regulatory agencies do not
actively intervene.
Despite changes at policy or organizational levels,
individuals can also make some changes on their own to
preserve their well-being. Some of these practices include but
not limited to, eating a healthy diet, regular exercise, avoid
illicit drugs, tobacco and alcohol, get enough sleep (at least 8
hours per day) and close follow-ups with their primary care
provider to utilizing measures of preventative care [5].
Another area that ought to be explored is to recognize
working hours as a medical problem and incorporating
questions regarding this topic during medical visits. Primary
care physicians can screen patients at risk and implement
preventative strategies early to counteract the adverse effects
The literature provides a wide range of information
on the negative consequences of long working hours. This
expansive body of knowledge can serve as a catalyst for
change and alter the prevalence and incidence of occupational
stress-related illness and injury that are the result of long
working hours. What is yet to be understood is how to bring
individuals, workplace and legislative policies together to
understand the adverse effects of working long hours and
collaboratively work towards a solution. Yet, based on the
evidence provided, it is clear that working long hours on the
job is directly related to injuries and illnesses and overall
adverse health outcomes. Clearly, there is a lot that needs to
be done. However, despite hurdles and challenges, with
increased advocacy and awareness we can make some impact
towards eliminating this problem.
1. Center for Disease Control and Prevention (2015)
Overtime and extended work shifts: Recent findings on
illnesses, injuries and health behaviors.
2. Golden L, Jorgensen H (2002) Time after time: Mandatory
overtime in the U.S. economy.
3. U.S News and World Report (2012) U.S. work-related
injuries, illnesses take toll on the till.
4. Bannai A, Tamakoshi A (2014) The association between
long working hours and health: A systematic review of
epidemiological evidence. Scand J Work Environ Health
40(1): 5-18.
5. Dembe AE, Erickson JB, Delbos RG, et al. (2005) The
impact of overtime and long work hours on occupational
injuries and illnesses: New evidence from the United States.
Occup Environ Med 62(9): 588-597.
6. Virtanen M, Heikkilä K, Jokela M, et al. (2012) Long
working hours and coronary heart disease: A systematic
review and meta-analysis. Am J Epidemiol 176(7): 586-596.
7. Virtanen M, Jokela M, Nyberg ST, et al. (2015) Long
working hours and alcohol use: Systematic review and meta-
analysis of published studies and unpublished individual
participant data. BMJ 350: g7772.
8. Rosenman KD, Kalush A, Reilly MJ, et al. (2006) How
much work-related injury and illness is missed by the current
national surveillance system? J Occup Environ Med 48(4):
9. Center for Disease Control and Prevention (2005) Medical
interns' risk for car crashes linked with extended shifts in
NIOSH-funded study.
Persaud H, Williams S (2017) Long Working Hours and Occupational Stress-related Illness and Injury: Mini Review. J
Health Sci Educ 1: 115.
DOI: 10.0000/JHSE.1000115 J Health Sci Educ Vol 1(3): 1-4
10. De Castro AB, Fujishiro K, Rue T, et al. (2010)
Associations between work schedule characteristics and
occupational injury and illness. Int Nurs Rev 57(2): 188-194.
11. Wirtz A, Lombardi DA, Willetts JL, et al. (2012) Gender
differences in the effect of weekly working hours on
occupational injury risk in the United States working
population. Scand J Work Environ Health 38(4): 349-357.
12. BBC News Health (2011) Working long hours 'raises heart
attack risk'.
*Corresponding author: Shawn Williams, DC, PhD,
Department of Health Professions, School of Health Sciences
and Professional Programs, City University of New York -
York College, SCI 115B, USA, Tel: 718-262-2907; Email:
Received date: July 27, 2017; Accepted date: August 01,
2017; Published date: August 13, 2017
Citation: Persaud H, Williams S (2017) Long Working Hours
and Occupational Stress-related Illness and Injury: Mini
Review. J Health Sci Educ 1(3): 115.
Copyright: Persaud H, Williams S (2017) Long Working
Hours and Occupational Stress-related Illness and Injury:
Mini Review. J Health Sci Educ 1(3): 115.
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To analyse the impact of overtime and extended working hours on the risk of occupational injuries and illnesses among a nationally representative sample of working adults from the United States. Responses from 10,793 Americans participating in the National Longitudinal Survey of Youth (NLSY) were used to evaluate workers' job histories, work schedules, and occurrence of occupational injury and illness between 1987 and 2000. A total of 110,236 job records were analysed, encompassing 89,729 person-years of accumulated working time. Aggregated incidence rates in each of five exposure categories were calculated for each NLSY survey period. Multivariate analytical techniques were used to estimate the relative risk of long working hours per day, extended hours per week, long commute times, and overtime schedules on reporting a work related injury or illness, after adjusting for age, gender, occupation, industry, and region. After adjusting for those factors, working in jobs with overtime schedules was associated with a 61% higher injury hazard rate compared to jobs without overtime. Working at least 12 hours per day was associated with a 37% increased hazard rate and working at least 60 hours per week was associated with a 23% increased hazard rate. A strong dose-response effect was observed, with the injury rate (per 100 accumulated worker-years in a particular schedule) increasing in correspondence to the number of hours per day (or per week) in the workers' customary schedule. Results suggest that job schedules with long working hours are not more risky merely because they are concentrated in inherently hazardous industries or occupations, or because people working long hours spend more total time "at risk" for a work injury. Strategies to prevent work injuries should consider changes in scheduling practices, job redesign, and health protection programmes for people working in jobs involving overtime and extended hours.
OBJECTIVE: To quantify the association between long working hours and alcohol use. DESIGN: Systematic review and meta-analysis of published studies and unpublished individual participant data. DATA SOURCES: A systematic search of PubMed and Embase databases in April 2014 for published studies, supplemented with manual searches. Unpublished individual participant data were obtained from 27 additional studies. REVIEW METHODS: The search strategy was designed to retrieve cross sectional and prospective studies of the association between long working hours and alcohol use. Summary estimates were obtained with random effects meta-analysis. Sources of heterogeneity were examined with meta-regression. RESULTS: Cross sectional analysis was based on 61 studies representing 333,693 participants from 14 countries. Prospective analysis was based on 20 studies representing 100,602 participants from nine countries. The pooled maximum adjusted odds ratio for the association between long working hours and alcohol use was 1.11 (95% confidence interval 1.05 to 1.18) in the cross sectional analysis of published and unpublished data. Odds ratio of new onset risky alcohol use was 1.12 (1.04 to 1.20) in the analysis of prospective published and unpublished data. In the 18 studies with individual participant data it was possible to assess the European Union Working Time Directive, which recommends an upper limit of 48 hours a week. Odds ratios of new onset risky alcohol use for those working 49-54 hours and >/= 55 hours a week were 1.13 (1.02 to 1.26; adjusted difference in incidence 0.8 percentage points) and 1.12 (1.01 to 1.25; adjusted difference in incidence 0.7 percentage points), respectively, compared with working standard 35-40 hours (incidence of new onset risky alcohol use 6.2%). There was no difference in these associations between men and women or by age or socioeconomic groups, geographical regions, sample type (population based v occupational cohort), prevalence of risky alcohol use in the cohort, or sample attrition rate. CONCLUSIONS: Individuals whose working hours exceed standard recommendations are more likely to increase their alcohol use to levels that pose a health risk.
Many studies have investigated the association between long working hours and health. By focusing on differences in the definition of long working hours and the influence of shift work, we attempt to explain why the results of these studies remain inconclusive. We defined long working hours as working time greater than around 40 hours per week or 8 hours per day. Since previous studies have indicated that shift work is detrimental to health, we minimized the influence of shift work in the studies. We also placed importance on the existence of reference groups since this made the results clearer. Based on these points, we analyzed previous studies to clarify the epidemiological evidence regarding the association between long working hours and health. We established inclusion criteria and carried out a systematic search for articles published in the Medline and PsycINFO databases between 1995-2012. We identified a total of 17 articles and 19 studies (12 prospective cohort and 7 cross-sectional studies). The outcomes were all-cause mortality, circulatory disease, diabetes mellitus, metabolic syndrome, depressive state, anxiety, other psychological disorders, sleep condition, cognitive function, and health-related behavior. Long working hours had significant adverse effects on most health outcomes. We concluded that working long hours is associated with depressive state, anxiety, sleep condition, and coronary heart disease. However, further studies that appropriately deal with the definition of long working hours and shift work are needed.
We sought to estimate the undercount in the existing national surveillance system of occupational injuries and illnesses. Adhering to the strict confidentiality rules of the U.S. Bureau of Labor Statistics, we matched the companies and individuals who reported work-related injuries and illnesses to the Bureau in 1999, 2000, and 2001 in Michigan with companies and individuals reported in four other Michigan data bases, workers' compensation, OSHA Annual Survey, OSHA Integrated Management Information System, and the Occupational Disease Report. We performed capture-recapture analysis to estimate the number of cases missed by the combined systems. We calculated that the current national surveillance system did not include 61% and with capture-recapture analysis up to 68% of the work-related injuries and illnesses that occurred annually in Michigan. This was true for injuries alone, 60% and 67%, and illnesses alone 66% and 69%, respectively. The current national system for work-related injuries and illnesses markedly underestimates the magnitude of these conditions. A more comprehensive system, such as the one developed for traumatic workplace fatalities, that is not solely dependent on employer based data sources is needed to better guide decision-making and evaluation of public health programs to reduce work-related conditions.
Medical interns' risk for car crashes linked with extended shifts in NIOSH-funded study
  • Disease Center
  • Control
  • Prevention
Center for Disease Control and Prevention (2005) Medical interns' risk for car crashes linked with extended shifts in NIOSH-funded study.
Working long hours 'raises heart attack risk
  • Bbc News
  • Health
BBC News Health (2011) Working long hours 'raises heart attack risk'.