Annals of Occupational and Environmental Medicine

The Korean Society of Occupational & Environmental Medicine (대한직업환경의학회)
권호 표지

The Relationship between the Korean Occupational Stress Scale and Pulse Wave Velocity among Male Firefighters

일부 남성 소방공무원에서 한국인 직무스트레스 측정도구와 맥파전파속도와의 관계

  • Jeon, Hyun-Jun (Department of Occupational and Environmental Medicine, Dongsan Medical Center of Keimyung University) ;
  • Park, Sang-Jun (Department of Occupational and Environmental Medicine, Dongsan Medical Center of Keimyung University) ;
  • Shin, Dong-Hoon (Department of Occupational and Environmental Medicine, Dongsan Medical Center of Keimyung University) ;
  • Chung, In-Sung (Department of Occupational and Environmental Medicine, Dongsan Medical Center of Keimyung University) ;
  • Lee, Mi-Young (Department of Occupational and Environmental Medicine, Dongsan Medical Center of Keimyung University)
  • 전현준 (계명대학교 동산의료원 산업의학과) ;
  • 박상준 (계명대학교 동산의료원 산업의학과) ;
  • 신동훈 (계명대학교 동산의료원 산업의학과) ;
  • 정인성 (계명대학교 동산의료원 산업의학과) ;
  • 이미영 (계명대학교 동산의료원 산업의학과)
  • Published : 2011.12.31
⟨ Previous Next ⟩

Abstract

Objectives: The aim of this study was to investigate the relationship between job stress and the pulse wave velocity as an indicator of vessel stiffness among male firefighters in a metropolitan city. Methods: In November and December 2008, a total of 404 participants were analyzed. The questionnaire survey included the participants' general characteristics, job-related factors, health-related behaviors, and job stress. Job stress was measured using the Korean Occupational Stress Scale (KOSS). We merged the job stress data with clinical laboratory data and brachial-ankle Pulse Wave Velocity (baPWV) by conducting medical surveillance. We measured the relationship of job stress to baPWV by using a logistic regression analysis. Results: After adjusting for cardiovascular risk factors, the baPWV was significantly higher in the groups possessing high levels of job insecurity (OR=2.17, 95% CI=1.06~4.42). Conclusions: Our findings suggest that the level of job stress, especially in regards to job insecurity, was directly related to the baPWV. Therefore, further preventive efforts and studies in regards to firefighters are needed in order to reduce job stress and thereby help to prevent cardiovascular disease.

목적: 소방 공무원의 직무스트레스와 동맥경화성 병변과의 관련성을 KOSS와 동맥 경직성 지표인 맥파전파속도를 통해 확인하고자 한다. 방법: 2008년 11월부터 2008년 12월까지 건강진단을 목적으로 내원한 435명의 소방공무원 중 평가가 가능했던 404명의 남성 소방공무원을 대상으로 문진과 자가 기입식 설문지를 통해 일반적 특성, 직업적 특성 등에 대한 정보를 수집하였고, 공복상태에서 혈액검사를 시행하였다. 직무스트레스는 KOSS 기본형 43문항을 사용하였고, 동맥의 경직도는 상완 발목동맥 맥파전파속도를 이용해 측정하였다. 통계분석방법은 1.4 m/s을 기준으로 빠른 맥파전파속도 군과 느린 맥파전파속도 군으로 나누어 t-test, $x^{2}$-test를 시행하였고, 심혈관계 질환의 위험요인을 보정한 후 KOSS 하부영역이 맥파전파속도에 미치는 영향을 평가하기 위해 로지스틱 회귀분석을 시행하였다. 결과: 일반적 특성으로 연령의 증가, 비만, 고혈압, 공복혈당장애, 높은 총콜레스테롤 등의 경우에 빠른 맥 파전파속도 군에 속할 가능성이 유의하게 높았고, 교대근무자인 경우에 느린 맥파전파속도 군에 속할 가능성이 유의하게 높았다. 빠른 맥파전파속도 군과 느린 맥파전파속도군에서 각각 KOSS 하부영역 중 직무불안정 43.96${\pm}$ 8.26과 44.39${\pm}$12.78, 직장문화 41.98${\pm}$12.45, 39.17 ${\pm}$15.02이었으나 통계적으로 유의한 차이는 없었다. KOSS 하부영역과 심혈관계 질환의 위험요인을 독립변수로 맥파전파속도를 종속변수로 하여 다중 로지스틱 회귀분석을 한 결과 빠른 맥파전파속도 군에 속할 위험은 연령이 1세 증가함에 따라 1.1배(OR=1.08, 95% CI=1.03~1.12), 고혈압 군이 정상 혈압 군에 비해 11.0 배(OR=11.00, 95% CI=4.43~27.35), 높은 중성지방군이 정상 중성지방 군에 비해 2.1배(OR=2.13, 95% CI=1.17~3.87), KOSS 하부영역 중 직무불안정이 높은 군이 낮은 군에 비해 2.2배(OR=2.17, 95% CI=1.06~4.42)이었다. 결론: KOSS 하부영역 중 직무불안정이 높은 군은 빠른 맥파전파속도 군에 속할 위험이 증가하였다. 심혈관계 질환의 예방을 위해 소방공무원의 직무스트레스 감소를 위한 노력이 필요하며, 특히 높은 직무 스트레스를 가지거나 빠른 맥파전파속도를 가진 소방공무원을 대상으로 적극적인 예방대책이 필요하다.

Keywords

References

  1. International Labour Organizations. International hazard datasheets on occupations: fire-fighter. Available: http://www.ilo.org/legacy/english/protection/safework/cis/products/hdo/pdf/firefightr.pdf[cited 23 September 2011].
  2. Guidotti TL. Human factors in firefighting: ergonomic-, cardiopulmonary-, and psychogenic stress-related issues. Int Arch Occup Environ Health 1992;64(1):1-12. https://doi.org/10.1007/BF00625945
  3. National Emergency Management Agency. Enforcement decree on the public service of firefighter. 2009. 4. 1. Available: http://law.go.kr/DRF/MDRFLawService.jsp?OC=njoy28&ID=003963[cited 23 September 2011]. (Korean)
  4. Seward JP, Larsen RC. Occupational Stress. In: LaDou J(eds) Current Occupational and Environmental Medicine. 4th ed. McGraw Hill. New York. 2007. pp 584-6.
  5. U.S. Centers for Disease Control and Prevention. Fatalities among volunteer and career firefighters: United States, 1994-2004. MMWR 2006;55(16):453-5.
  6. Hamer M, Malan L. Psychophysiological risk markers of cardiovascular disease. Neurosci Biobehav Rev 2010;35(1):76-83. https://doi.org/10.1016/j.neubiorev.2009.11.004
  7. Bataille R, Klein B. C-reactive protein levels as a direct indicator of the interleukin-6 levels in humans in vivo. Arthritis Rheum 1992;35(8):982-4. https://doi.org/10.1002/art.1780350824
  8. Seeman TE, McEwen BS, Rowe JW, Singer BH. Allostatic load as a marker of cumulative biological risk. MacArthur studies of successful aging. Proc Natl Acad Sci USA 2001;98(8):4770-5. https://doi.org/10.1073/pnas.081072698
  9. Dimsdale JE. Psychological stress and cardiovascular disease. J Am Coll Cardiol 2008;51(13):1237-46. https://doi.org/10.1016/j.jacc.2007.12.024
  10. Tennant C, McLean L. The impact of emotions on coronary heart disease risk. J Cardiovasc Risk 2001;8(3):175-83. https://doi.org/10.1097/00043798-200106000-00009
  11. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999;99(16):2192-217. https://doi.org/10.1161/01.CIR.99.16.2192
  12. Everson-Rose SA, Lewis TT. Psychosocial factors and cardiovascular disease. Annu Rev Public Health 2005;26:469-500. https://doi.org/10.1146/annurev.publhealth.26.021304.144542
  13. The National Institute for Occupational Safety and Health. Stress at work. Available: http://www.cdc.gov/niosh/docs/99-101/[cited 23 September 2010].
  14. Soteriades ES, Smith DL, Tsismenakis AJ, Baur DM, Kales SN. Cardiovascular disease in US firefighters: a systematic review. Cardiol Rev 2011;19(4):202-15. https://doi.org/10.1097/CRD.0b013e318215c105
  15. Everson SA, Lynch JW, Chesney MA, Kaplan GA, Goldberg DE, Shade SB, Cohen RE, Salonen R, Salonen JT. Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study. BMJ 1997;314(7080):553-8. https://doi.org/10.1136/bmj.314.7080.553
  16. Lynch J, Krause N, Kaplan GA, Salonen R, Salonen JT. Workplace demands, economic reward, and progression of carotid atherosclerosis. Circulation 1997;96(1):320-7.
  17. Libby P. The Pathogenesis, Prevention, and Treatment of Atherosclerosis. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J(eds) Harrison's Principles of Internal Medicine. 17th ed. McGraw Hill. New York. 2008. pp 1501-5.
  18. Ranjit N, Diez-Roux AV, Shea S, Cushman M, Seeman T, Tackson SA, Ni H. Psychosocial factors and inflammation in the multi-ethnic study of atherosclerosis. Arch Intern Med 2007;167(2):174-81. https://doi.org/10.1001/archinte.167.2.174
  19. Jennings JR, Kamarck TW, Everson-Rose SA, Kaplan GA, Manuck SB, Salonen JT. Exaggerated blood pressure responses during mental stress are prospectively related to enhanced carotid atherosclerosis in middleaged Finnish men. Circulation 2004;110(15):2198-203. https://doi.org/10.1161/01.CIR.0000143840.77061.E9
  20. Matthews KA, Zhu S, Tucker DC, Whooley MA. Blood pressure reactivity to psychological stress and coronary calcification in the coronary artery risk development in young adults study. Hypertension 2006;47(3):391-5. https://doi.org/10.1161/01.HYP.0000200713.44895.38
  21. Oliver JJ, Webb DJ. Noninvasive assessment of arterial stiffness and risk of atherosclerotic events. Arterioscler Thromb Vasc Biol 2003;23(4):554-66. https://doi.org/10.1161/01.ATV.0000060460.52916.D6
  22. Asmar R, Benetos A, Topuchian J, Laurent P, Pannier B, Brisac AM, Target R, Levy BI. Assessment of arterial distensibility by automatic pulse wave velocity measurements: validation and clinical application studies. Hypertension 1995;26(3):485-90. https://doi.org/10.1161/01.HYP.26.3.485
  23. Blacher J, Safar ME, Guerin AP, Pannier B, Marchais SJ, London GM. Aortic pulse wave velocity index and mortality in end-stage renal disease. Kidney Int 2003;63(5):1852-60. https://doi.org/10.1046/j.1523-1755.2003.00932.x
  24. Safar ME, Blacher J, Pannier B, Guerin AP, Marchais SJ, Guyonvarc'h PM, London GM. Central pulse pressure and mortality in end stage renal disease. Hypertension 2002;39(3):735-8. https://doi.org/10.1161/hy0202.098325
  25. Laurent S, Boutouyrie P, Asmar R, Gautier I, Laloux B, Guize L, Ducimetiere P, Benetos A. Aortic stiffness is an independent predictor of all-cause and cardiovascular mortality in hypertensive patients. Hypertension 2001;37(5):1236-41. https://doi.org/10.1161/01.HYP.37.5.1236
  26. Albaladejo P, Laurent P, Pannier B, Achimastos A, Safar M, Benetos A. Influence of sex on the relation between heart rate and aortic stiffness. J Hypertens 2003;21(3):555-62. https://doi.org/10.1097/00004872-200303000-00021
  27. Boutouyrie P, Tropeano AI, Asmar R, Gautier I, Benetos A, Lacolley P, Laurent S. Aortic stiffness is an independent predictor of primary coronary events in hypertensive patients: a longitudinal study. Hypertension 2002;39(1):10-5. https://doi.org/10.1161/hy0102.099031
  28. Shoji T, Emoto M, Shinohara K, Kakiya R, Tsujimoto Y, Kishimoto H, Ishimura E, Tabata T, Nishizawa Y. Diabetes mellitus, aortic stiffness, and cardiovascular mortality in end-stage renal disease. J Am Soc Nephrol 2001;12(10):2117-24.
  29. Cruickshank K, Riste L, Anderson SG, Wright JS, Dunn G, Gosling RG. Aortic pulse-wave velocity and its relationship to mortality in diabetes and glucose intolerance: an integrated index of vascular function? Circulation 2002;106(16):2085-90. https://doi.org/10.1161/01.CIR.0000033824.02722.F7
  30. Meaume S, Benetos A, Henry OF, Rudinichi A, Safar ME. Aortic pulse wave velocity predicts cardiovascular mortality in subjects >70 years of age. Arterioscler Thromb Vasc Biol 2001;21(12):2046-50. https://doi.org/10.1161/hq1201.100226
  31. Amar J, Ruidavets JB, Chamontin B, Drouet L, Ferrieres J. Arterial stiffness and cardiovascular risk factors in a population-based study. J Hypertens 2001;19(3):381-7. https://doi.org/10.1097/00004872-200103000-00005
  32. van Popele NM, Grobbee DE, Bots ML, Asmar R, Topouchian J, Reneman RS, Hoeks AP, van der Kuip DA, Hofman A, Witteman JC. Association between arterial stiffness and atherosclerosis: the Rotterdam study. Stroke 2001;32(2):454-60. https://doi.org/10.1161/01.STR.32.2.454
  33. Meaume S, Rudnichi A, Lynch A, Bussy C, Sebban C, Benetos A, Safar ME. Aortic pulse wave velocity as a marker of cardiovascular disease in subjects over 70 years old. J Hypertens 2001;19(5):871-7. https://doi.org/10.1097/00004872-200105000-00006
  34. Choi KM, Lee KW, Seo JA, Oh JH, Kim SG, Kim NH, Choi DS, Baik SH. Relationship between brachialankle pulse wave velocity and cardiovascular risk factors of the metabolic syndrome. Diabetes Res Clin Pract 2004;66(1):57-61. https://doi.org/10.1016/j.diabres.2004.02.014
  35. Nam JS, Park JS, Cho MH, Jee SH, Lee HS, Ahn CW, Lowe WL Jr, Kim KR. The association between pulse wave velocity and metabolic syndrome and adiponectin in patients with impaired fasting glucose: cardiovascular risks and adiponectin in IFG. Diabetes Res Clin Pract 2009;84(2):145-51. https://doi.org/10.1016/j.diabres.2009.02.002
  36. Xu L, Jiang CQ, Lam TH, Yue XJ, Cheng KK, Liu B, Jin YL, Zhang WS, Thomas GN. Brachial-ankle pulse wave velocity and cardiovascular risk factors in the non-diabetic and newly diagnosed diabetic Chinese: Guangzhou Biobank Cohort Study-CVD. Diabetes Metab Res Rev 2010;26(2):133-9. https://doi.org/10.1002/dmrr.1059
  37. El Feghali R, Topouchian J, Pannier B, Asmar R. Ageing and blood pressure modulate the relationship between metabolic syndrome and aortic stiffness in never-treated essential hypertensive patients. A comparative study. Diabetes Metab 2007;33(3):183-8.
  38. van Trijp MJ, Uiterwaal CS, Bos WJ, Oren A, Grobbee DE, Bots ML. Noninvasive arterial measurements of vascular damage in healthy young adults: relation to coronary heart disease risk. Ann Epidemiol 2006;16(2):71-7.
  39. Na SH, Kim YS, Bae JH, Nah DY, Kim YK, Lee MM, Kim HY, Rhee MY. Effects of physical activity and aerobic exercise capacity on aortic stiffness in patients with untreated hypertension. Korean Circ J 2009;39(2):52-6. (Korean) https://doi.org/10.4070/kcj.2009.39.2.52
  40. Sung J, Yang JH, Cho SJ, Hong SH, Huh EH, Park SW. The effects of short-duration exercise on arterial stiffness in patients with stable coronary artery disease. J Korean Med Sci 2009;24(5):795-9. (Korean) https://doi.org/10.3346/jkms.2009.24.5.795
  41. Trzos E, Kurpesa M, Rechcinski T, Wierzbowska- Drabik K, Krzeminska-Pakula M. The influence of physical rehabilitation on arterial compliance in patients after myocardial infarction. Cardiol J 2007;14(4):366-71.
  42. Aoyagi Y, Park H, Kakiyama T, Park S, Yoshiuchi K, Shephard RJ. Yearlong physical activity and regional stiffness of arteries in older adults: the Nakanojo Study. Eur J Appl Physiol 2010;109(3):455-64. https://doi.org/10.1007/s00421-010-1357-2
  43. Chen CC, Shiu LJ, Li YL, Tung KY, Chan KY, Yeh CJ, Chen SC, Wong RH. Shift work and arteriosclerosis risk in professional bus drivers. Ann Epidemiol 2010;20(1):60-6. https://doi.org/10.1016/j.annepidem.2009.07.093
  44. Cho JJ, Kim JY, Byun JS. Occupational stress on risk factors for cardiovascular diseases and metabolic syndrome. Korean J Occup Environ Med 2006;18(3):209-22. (Korean)
  45. Hwang CK, Koh SB, Chang SJ, Park CY, Cha BS, Hyun SJ , Park JH, Lee KM, Cha KT, Park WJ, Jhun HJ. Occupational stress in relation to cerebrovascular and cardiovascular disease: longitudinal analysis from the NSDSOS project. Korean J Occup Environ Med 2007;19(2):105-11. (Korean)
  46. Kuper H, Marmot M. Job strain, job demands, decision latitude, and risk of coronary heart disease within the Whitehall II study. J Epidemiol Community Health 2003;57(2):147-53. https://doi.org/10.1136/jech.57.2.147
  47. Siegrist J. Effort-reward imbalance at work and cardiovascular diseases. Int J Occup Med Environ Health 2010;23(3):279-85.
  48. Utsugi M, Saijo Y, Yoshioka E, Sato T, Horikawa N, Gong Y, Kishi R. Relationship between two alternative occupational stress models and arterial stiffness: a cross-sectional study among Japanese workers. Int Arch Occup Environ Health 2009;82(2):175-83. https://doi.org/10.1007/s00420-008-0319-z
  49. Kang KH, Lee KS, Kim SI, Meng KH, Hong HS, Jeong CH. The relationship between alcohol use and job stress among firemen. Korean J Occup Environ Med 2001;13(4):401-12. (Korean)
  50. Kim KH, Kim JW, Kim SH. Influences of job stressors on psychosocial well-being, fatigue and sleep sufficiency among firefighters. Korean J Occup Environ Med 2006;18(3):232-45. (Korean)
  51. Yoon SH, Choi SJ, Shin DH, Chung IS, Ha JS. Job stressors in subway workers and firemen. Korean J Occup Environ Med 2007;19(3):179-86. (Korean)
  52. Kwon SC, Song JC, Lee SJ, Kim IH, Koh JW, Ryou HC, Kim SH, Kim DH, Jung SA. Posttraumatic stress symptoms and related factors in firefighters of a firestation. Korean J Occup Environ Med 2008;20(3):193-204. (Korean)
  53. Ha JH, Kim DI, Seo BS, Kim WS, Ryu SH, Kim SG. Job stress and psychosocial stress among firefighters. Korean J Occup Environ Med 2008;20(2):104-11. (Korean)
  54. Donovan R, Nelson T, Peel J, Lipsey T, Voyles W, Israel RG. Cardiorespiratory fitness and the metabolic syndrome in firefighters. Occup Med(Lond) 2009;59(7):487-92. https://doi.org/10.1093/occmed/kqp095
  55. Holder JD, Stallings LA, Peeples L, Burress JW, Kales SN. Firefighter heart presumption retirements in Massachusetts 1997-2004. J Occup Environ Med 2006;48(10):1047-53. https://doi.org/10.1097/01.jom.0000235909.31632.46
  56. Saijo Y, Ueno T, Hashimoto Y. Twenty-four-hour shift work, depressive symptoms, and job dissatisfaction among Japanese firefighters. Am J Ind Med 2008;51(5):380-91. https://doi.org/10.1002/ajim.20571
  57. Kong JO, Koh SB, Chang SJ, Cha BS, Chung HK, Choi HR, JungChoi KH, Jeon SJ. Relationship between job stress and pulse wave velocity as a cardiovascular risk factor. Korean J Occup Environ Med 2004;16(4):450-8. (Korean)
  58. Koh SB, Chang SJ, Park JK, Park JH, Son DK, Hyun SJ, Cha BS. Occupational stress and risk factors for cardiovascular diseases. Korean J Occup Environ Med 2005;17(3):186-98. (Korean)
  59. Lucas DL, Brown RA, Wassef M, Giles TD. Alcohol and the cardiovascular system. J Am Coll Cardiol 2005;45(12):1916-24. https://doi.org/10.1016/j.jacc.2005.02.075
  60. Chang SJ, Koh SB, Kang DM, Kim SA, Kang MG, Lee CG, Chung JJ, Cho JJ, Son M, Chae CH, Kim JW, Kim JI, Kim HS, Roh SC, Park JB, Woo JM, Kim SY, Kim JY, Ha M, Park J, Rhee KY, Kim HR, Kong JO, Kim IA, Kim JS, Park JH, Huyun SJ, Son DK. Developing an occupational stress scale for Korean employees. Korean J Occup Environ Med 2005;17(4):297-317. (Korean)
  61. Alexander K, Michael AP, Daniel JF. Appendix: Laboratroy Values of Clinical Importance. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J(eds) Harrison's Principles of Internal Medicine. 17th ed. McGraw Hill. New York. 2008. pp A1-A15.
  62. Yamashina A, Tomiyama H, Arai T, Hirose K, Koji Y, Hirayama Y, Yamamoto Y, Hori S. Brachial-ankle pulse wave velocity as a marker of atherosclerotic vascular damage and cardiovascular risk. Hypertens Res 2003;26(8):615-22. https://doi.org/10.1291/hypres.26.615
  63. Lee JM. A study on the financial structure for public fire services and the alternatives to expand revenue sources. J Korean Assoc for Local Finace 2007;12(2):33-64. (Korean)
  64. Ctnews. Fire administration budget assigned to local government resulted in poor financial status. Available: http://www.ctnews.co.kr/sub_read.html?uid=12308§ion=sc21 [cited 10 October 2011]. (Korean)
  65. Lee YS. A Study on Effective Ways of Firefighting Affairs: the National Emergency Management Agency's 5 Years, What's the problem? (tanslated by Jeon HJ). National Assembly of the Republic of Korea. Seoul. 2008. pp 99-104. (Korean)
  66. Lee HY, Oh BH. Aging and arterial stiffness. Circ J 2010;74:2257-62. https://doi.org/10.1253/circj.CJ-10-0910
  67. Heerkens EH, Izzard AS, Heagerty AM. Integrins, vascular remodeling and hypertension. Hypertension 2007;49(1):1-4.
  68. Cecelja M, Chowienczyk P. Dissociation of aortic pulse wave velocity with risk factors for cardiovascular disease other than hypertension. Hypertension 2009;54(6):1328-36. https://doi.org/10.1161/HYPERTENSIONAHA.109.137653
  69. Hartley J. Models of job insecurity and coping strategies of organizations. WHO Reg Publ Eur Ser 1999;81:127-49.
  70. Witte HD. Job insecurity and psychological well-being: review of the literature and exploration of some unresolved issues. European Journal of Work and Organizational Psychology 1999;8(2):155-77. https://doi.org/10.1080/135943299398302
  71. Hellgren J, Sverke M, Isaksson K. A two dimensional approach to job insecurity: consequences for employee attitudes and well-being. European Journal of Work and Organizational Psychology 1999;8(2):179-95. https://doi.org/10.1080/135943299398311
  72. Roskies E, Louis-Guerin C. Job insecurity in managers: antecedents and consequences. Journal of Organizational Behavior 1990;11(5):345-59. https://doi.org/10.1002/job.4030110503
  73. Vivien KG, Lim. Job insecurity and its outcomes: moderating effects of work-based and nonwork-based social support. Human Relations 1996;49(2):171-94. https://doi.org/10.1177/001872679604900203
  74. Kasl SV, Cobb S. Blood pressure changes in men undergoing job loss: a preliminary report. Psychosom Med 1970;32(1):19-38.
  75. Ferrie JE, Shipley MJ, Marmot MG, Stansfeld S, Smith GD. Health effects of anticipation of job change and non-employment: longitudinal data from the Whitehall II study. BMJ 1995;311(7015):1264-9. https://doi.org/10.1136/bmj.311.7015.1264
  76. Lee S, Colditz GA, Berkman LF, Kawachi I. Prospective study of job insecurity and coronary heart disease in US women. Ann Epidemiol 2004;14(1):24-30. https://doi.org/10.1016/S1047-2797(03)00074-7
  77. Siegrist J, Peter R, Junge A, Cremer P, Seidel D. Low status control, high effort at work and ischemic heart disease: prospective evidence from blue-collar men. Soc Sci Med 1990;31(10):1127-34. https://doi.org/10.1016/0277-9536(90)90234-J
  78. Kim SH, Kang SJ, Jeong HJ, Noh SC, Park JB, Yoon SB. A Study on Reformation of Government Employee's Wage and Human Rsources System (translated by Jeon HJ). The Korean Government Employee's Union, Korea Contingent Workers Center, The Worker's Institute Industrial Labor Policy. Seoul. 2009. pp 1-2, 22-25. (Korean)
  79. Chang SJ, Koh SB, Kang DM, Kim SA, Kang MG, Lee CG, Chung JJ, Cho JJ, Son M, Chae CH, Kim JW, Kim JI, Kim HS, Roh SC, Park JB, Woo JM, Kim SY, Kim JY, Kim HR, Kong JO, Kim IA, Kim JS, Park JH, Huyun SJ, Son DK. Standardization of job stress measurement scale for korean employees(the 2nd Year Project). Occupationl Safety and Health Research Institute. Incheon. 2004. pp 62. (Korean)
  80. Haupt CM, Alte D, Dorr M, Robinson DM, Felix SB, John U, Volzke H. The relation of exposure to shift work with atherosclerosis and myocardial infarction in a general population. Atherosclerosis 2008;201(1):205-11. https://doi.org/10.1016/j.atherosclerosis.2007.12.059
  81. Puttonen S, Kivimaki M, Elovainio M, Pulkki-R?back L, Hintsanen M, Vahtera J, Telama R, Juonala M, Viikari JS, Raitakari OT, Keltikangas-Jarvinen L. Shift work in young adults and carotid artery intima-media thickness: the cardiovascular risk in young Finns study. Atherosclerosis 2009;205(2):608-13. https://doi.org/10.1016/j.atherosclerosis.2009.01.016
  82. Black PH. Stress and the inflammatory response: a review of neurogenic inflammation. Brain Behav Immun 2002;16(6):622-53. https://doi.org/10.1016/S0889-1591(02)00021-1
  83. Bertovic DA, Waddell TK, Gatzka CD, Cameron JD, Dart AM, Kingwell BA. Muscular strength training is associated with low arterial compliance and high pulse pressure. Hypertension 1999;33(6):1385-91. https://doi.org/10.1161/01.HYP.33.6.1385
  84. Miyachi M, Donato AJ, Yamamoto K, Takahashi K, Gates PE, Moreau KL, Tanaka H. Greater age-related reductions in central arterial compliance in resistancetrained men. Hypertension 2003;41(1):130-5. https://doi.org/10.1161/01.HYP.0000047649.62181.88
  85. Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, Grassi G, Heagerty AM, Kjeldsen SE, Laurent S, Narkiewicz K, Ruilope L, Rynkiewicz A, Schmieder RE, Boudier HA, Zanchetti A. 2007 ESH-ESC practice guidelines for the management of arterial hypertension: ESH-ESC task force on the management of arterial hypertension. J Hypertens 2007;25(9):1751-62. https://doi.org/10.1097/HJH.0b013e3282f0580f
  86. Persu A, De Plaen JF. Recent insights in the development of organ damage caused by hypertension. Acta Cardiol 2004;59(4):369-81. https://doi.org/10.2143/AC.59.4.2005202
  87. Kim IA, Sung JC. Occupational health and fitness for work of firefighters. J Korean Med Assoc 2008;51(12):1078-1086. (Korean) https://doi.org/10.5124/jkma.2008.51.12.1078