BEU, Alm.del - 2023-24 - Bilag 195: Orientering om nye forskningsresultater om sammenhæng mellem seksuel chikane på arbejdspladsen og risiko for hjertekarsygdom og/eller type 2-diabetes, fra beskæftigelsesministeren

Beskæftigelsesudvalget 2023-24
BEU Alm.del Bilag 195
Offentligt

European Journal of Preventive Cardiology (2024)

00,

1–10

https://doi.org/10.1093/eurjpc/zwae178

FULL RESEARCH PAPER

CVD risk factors

Exposure to workplace sexual harassment and

risk of cardiometabolic disease: a prospective

cohort study of 88 904 Swedish men and

women

Prakash KC

1,2,3

, Ida E.H. Madsen

4,5

, Reiner Rugulies

Hugo Westerlund

, Anna Nyberg

3,7,8

, Mika Kivimäki

and Linda L. Magnusson Hanson

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4,6

9,10

, Tianwei Xu

Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland;

Gerontology Research Center, Tampere University, Tampere, Finland;

Stress Research Institute,

Department of Psychology, Stockholm University, Albanovägen 12, 114 19 Stockholm, Sweden;

National Research Centre for the Working Environment, 2100 Copenhagen, Denmark;

The National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455 Copenhagen, Denmark;

Department of Public Health and Department of Psychology,

University of Copenhagen, Copenhagen, Denmark;

Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden;

Department of Public Health and Caring Sciences,

Uppsala University, Uppsala, Sweden;

Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland; and

UCL Brain Sciences, University College London, London, UK

Received 4 July 2023; revised 11 March 2024; accepted 2 May 2024; online publish-ahead-of-print 14 June 2024

Exposure to work-related sexual harassment may increase the risk for certain adverse behavioural and emotional outcomes

but less is known about its association with somatic diseases such as cardiovascular disease (CVD) and type 2 diabetes. This

study investigated the prospective association of work-related sexual harassment and risk of cardiometabolic diseases.

............................................................................................................................................................................................

Methods

This cohort study included 88 904 Swedish men and women in paid work who responded to questions on workplace sexual

and results

harassment in the Swedish Work Environment Survey (1995–2015) and were free from cardiometabolic diseases at base-

line. Cardiometabolic diseases (CVD and type 2 diabetes) were identified from the National Patient Register and Causes of

Death Register through linkage. Cox proportional hazard regression was used, adjusting for socio-demographic, work-

related psychosocial, and physical exposure at baseline. Overall, 4.8% of the participants (n

4300) reported exposure

to workplace sexual harassment during the previous 12 months. After adjustment for sex, birth country, family situation,

education, income, and work-related factors, workplace sexual harassment was associated with increased incidence of

CVD [hazard ratio (HR) 1.25, 95% confidence interval 1.03–1.51] and type 2 diabetes (1.45, 1.21–1.73). The HR for

CVD (1.57, 1.15–2.15) and type 2 diabetes (1.85, 1.39–2.46) was increased for sexual harassment from superior or fellow

workers, and sexual harassment from others was associated with type 2 diabetes (1.39, 1.13–1.70). The HR for both CVD

(1.31, 0.95–1.81) and type 2 diabetes (1.72, 1.30–2.28) was increased for frequent exposure.

............................................................................................................................................................................................

Conclusion

The results of this study support the hypothesis that workplace sexual harassment is prospectively associated with cardi-

ometabolic diseases. Future research is warranted to understand causality and mechanisms behind these associations.

Aims

Lay

summary

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We investigated if workers in Sweden who had experienced sexual harassment at work had a higher risk of developing car-

diovascular disease and diabetes than workers who had not experienced sexual harassment at work.

The experience of workplace sexual harassment was associated with an increased risk of both cardiovascular disease and

diabetes. The risk was highest among those workers who had frequently experienced sexual harassment.

Our results suggest that preventive measures directed towards elimination of sexual harassment may contribute to a

reduction in cardiovascular disease and diabetes in the population.

•

* Corresponding author. Tel: +46855378916, Email:

[email protected]

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits

non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] for reprints and

translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact

[email protected].

BEU, Alm.del - 2023-24 - Bilag 195: Orientering om nye forskningsresultater om sammenhæng mellem seksuel chikane på arbejdspladsen og risiko for hjertekarsygdom og/eller type 2-diabetes, fra beskæftigelsesministeren

P. KC

et al.

Graphical Abstract

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............................................................................................................................................................................................

Keywords

Cardiometabolic diseases

•

CVD

•

Type 2 diabetes

•

Workplace negative behaviours

•

Sexual harassment

•

Longitudinal studies

Introduction

Cardiovascular disease (CVD) was the underlying cause of one-third of

all deaths globally in 2019, i.e. an estimated 17.9 million deaths, making it

the leading cause of death and a major public health problem globally.

Likewise, diabetes mellitus is among the leading causes of death and dis-

ability, and its prevalence is rising worldwide.

The number of indivi-

duals affected by diabetes is projected to increase to 1.3 billion by

2050,

especially among those aged 50 or above. Cardiovascular disease

and diabetes have been found to share many lifestyle and environmental

risk factors and biological mechanisms connected to the cardiovascular

and metabolic system.

Especially people with diabetes are also more

prone to develop CVD compared with those without diabetes.

It has been acknowledged that a relatively large share of CVD deaths

is attributable to occupational risk factors such as long working hours,

probably increasing the risk for mortality and morbidity through psy-

chosocial stress.

Other psychosocial work characteristics such as sex-

ual harassment may also initiate stress reactions

and eventually lead to

diseases such as CVD and diabetes.

Harassment is usually regarded as

unacceptable or threat of unacceptable behaviour that aims at or re-

sults in harm.

Sexual harassment is usually regarded as unwanted or

unwelcome verbal or non-verbal behaviour of sexual nature, which is

experienced as intimidating, degrading, humiliating, hostile, or offensive

by those exposed. If this phenomenon occurs at work or in circum-

stances related to work, it may be considered as workplace sexual har-

assment.

8,9

Workplace sexual harassment is a problem affecting all

occupations, sectors, and countries around the globe. It is a widespread

but under-reported phenomenon.

Since the Me Too movement,

re-

porting and prevalence of sexual harassment in the working population

has received widespread attention. However, being a sensitive issue, the

estimation of exact prevalence is challenging. There are huge discrepan-

cies in the reported prevalence, with few reporting 1–20% and others

reporting 30% among men and no less than 80% among women, which

could be attributed to the measurement of harassment, the cultural

context of victims, the representativeness of the sample, and the

time frame of these different studies.

11,12

It is, however, clear that ex-

posure is common in occupations with client contact,

often leading to

an increased risk of job exit among the exposed. Previous studies have

reported higher prevalence, for instance among women and workers of

younger age and in occupations with an unequal sex ratio and industries

such as restaurants and hotels and workplaces with large power differ-

entials between men and women.

9,14

Work-related exposures such as long working hours, job strain, and

other adverse psychosocial working conditions and negative workplace

behaviours, such as bullying and violence, have been associated with an

increased risk of type 2 diabetes and CVD.

15–17

Previous studies have

reported workplace sexual harassment as a risk factor of several chron-

ic conditions and health outcomes

18–24

including high blood pressure,

poor sleep, depression, anxiety, sickness absence, chronic drinking be-

haviour, obesity, and suicide and suicide attempts. However, despite a

conceptual link between lifetime bullying and sexual violence with dia-

betes and CVD

16,25–28

and of workplace sexual harassment with car-

diovascular health,

substantial gaps of evidence exist.

21,26

A recent

systematic review and meta-analysis based on 830 579 adults reported

greater risk of CVD among those with a history of lifetime sexual vio-

lence relative to those without a history

; however, the articles consid-

ering assessment of sexual harassment were limited. Many studies have

also been based on lifetime sexual harassment, or adolescent sexual

harassment, or harassment among those in specific occupational sec-

tors or groups or convenience samples. Workplace sexual harassment

has previously been connected to cardiovascular risk factors such as

high blood pressure.

21,23

However, to the best of our knowledge, no

population-based longitudinal studies on workplace sexual harassment

and risk of CVD or type 2 diabetes have been reported yet. Further,

there is lack of evidence on the association between sexual harassment

and chronic conditions based on perpetrators of sexual violence.

Therefore, we aimed to investigate the prospective association be-

tween workplace sexual harassment and risk of CVD and type 2 dia-

betes among 88 904 Swedish men and women in paid work.

Methods

Study population

The Swedish Work Environment Survey (SWES, 1995–2015), a biennial

cross-sectional survey, building on the Labor Force Survey is the data

Workplace sexual harassment and cardiometabolic disease

personal identification number. The patient register includes both inpatient

and outpatient data. We followed the respondents from the year of re-

sponse to SWES questionnaires to the year of either first registered

CVD, type 2 diabetes and death from another cause, emigration, or end

of follow-up (31 December 2015). We defined people with incident end-

point using versions eight, nine, and ten of the International Classification

of Diseases, including ICD-10 codes I20.0, I20.1, I21–I25 (excluding unspeci-

fied angina) and ICD-8/9 410–414 for the diagnosis of coronary heart dis-

ease (CHD) and ICD-10 I60–I69, and ICD-8/9 430–438 for the diagnosis of

cerebrovascular disease (CD). Total CVD included codes for either CHD

or CD. Myocardial infarction (MI) was based on the main diagnosis of

ICD-10 I21–22 or 410 in ICD-9 or ICD8 41 from the hospital registers

and the main cause of death in acute coronary death of ICD-10 I20–25,

or 410–414 in ICD-9, or ICD-8 410–414 from the death register.

Likewise, ischaemic stroke was based on the main diagnosis of ICD-10

I63 or ICD-9 433–434 or ICD8 433–434 from hospital and death registers.

Similarly, haemorrhagic stroke was based on the main diagnosis of codes

ICD-10 I61 and I62 or ICD-9 431 or ICD8 431 from hospital and death reg-

isters. Likewise, we considered those registered with codes ICD-8/9 250

and ICD-10 E11 in the National Patient Register to be cases of type 2

diabetes.

source of this study. These survey data were collected by simple random

sampling from the sample of 10 000–15 000 people aged 16–74 years

from the entire Swedish population, after stratification for sex, county,

and citizenship. The sample was first interviewed by phone, and a represen-

tative subsample of individuals aged 16–64 years and in paid work were sub-

sequently asked a range of questions related to their work as part of SWES

using additional self-completion questionnaire.

In the initial interviews,

non-participation in Labor Force Survey and SWES varied between 13%

(1995) and 42% (2015), respectively, and was 23% and 53% for the subse-

quent phone interviews and work situation questionnaire, respectively.

The SWES (1995–2015) collectively included 93 199 respondents

to self-completion questionnaires. The final analytical sample included

88 904 participants after excluding persons with missing data on workplace

sexual harassment and invalid data for the analyses on age at end of follow-

up. The final analytical sample did not differ from the eligible sample.

However, the excluded samples were slightly younger on average (42.5

vs. 43.2 years), consisting of a lower proportion of women (44 vs. 52%),

a higher proportion with foreign origin (17 vs. 10%), and a higher propor-

tion of singles (31 vs. 28%) than the analytical sample. Ethical approval was

obtained from the Regional Research Ethics Board in Stockholm, Sweden.

Participants received written information on the survey and response to

the survey indicated informed consent.

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Sexual harassment and covariates at baseline

After a brief definition of sexual harassment (‘sexual harassment refers to

undesirable advances or offensive references to what is generally associated

with sexual relations’), the respondents were asked to respond to two

questionnaire items about sexual harassment, which were used in this

study: ‘Are you subjected to sexual harassment in your workplace from

(i) superiors or fellow workers and (ii) other people (e.g. patients, clients,

passengers, students)?’ The response format was a 7-point Likert-type scale

ranging from not at all during the previous 12 months to every day. For the

analysis, we categorized the respondents into ‘exposed’ if they reported

that they were subjected to sexual harassment ‘once or twice during the

previous 12 months’, ‘sometimes during the last 3 months’, ‘a couple of

days a month (1 day of 10)’, ‘one day a week (1 day of 5),’ ‘a couple of

days a week (1 day of 2)’, or ‘every day’. We considered those reporting

not being subjected to sexual harassment at all during the previous 12

months to be ‘un-exposed’. We combined the responses on sexual harass-

ment by superiors, by fellow workers, or from other people into one vari-

able for the main analyses, indicating any exposure to workplace sexual

harassment during the previous 12 months. For exposure–response ana-

lyses, we created a variable with three categories (‘frequently’, every day

to sometimes during the last 3 months; ‘occasionally’, once or twice during

the last 12 months; and ‘never’, not at all during the last 12 months, and the

latter was used as the reference group).

Covariates were sex, family situation, birth country, educational level, in-

come, and work characteristics, as these factors have been found to be as-

sociated with workplace sexual harassment and risk factors for chronic

diseases.

18,19,21,22

The source of information about sex, family situation,

birth country, education, and income was the longitudinal integration

database for health insurance and labour market studies (LISA). We used

educational level as a categorical variable with three categories (≤9 years,

10–12 years, and

≥13

years). We categorized baseline family situation as

single (living alone, divorced, separated, or widowed) without children, sin-

gle with children, married or living with partner without children, or married

or living with partner with children. Birth country was divided into ‘Swedish’

and ‘Foreign’. Baseline work characteristics included job demands and con-

trol, measured by indices for demands and control based on four items each

scored from 0 to 4. We also used an index for job support measured with

two separate questions about support from superiors and fellow workers,

scored from 1 to 4, and physical strain at work measured with question on

frequency of physical strain, which was assessed on a scale from not at all to

every day and divided into three categories, namely low (not at all or rarely

the last 3 months), moderate (1 day per week or 2 days per month), and

high (2 days per week or every day).

Statistical analyses

We estimated the risk of cardiometabolic diseases by using Cox propor-

tional hazard regression analyses. Assuming that the participants are enter-

ing the risk set at the age they entered the survey, we used age as the

underlying time scale, which takes entry age and exit age into account. In

this study, the entry age is the age at first response to SWES questionnaire,

and exit age is the age of being censored (i.e. first registered cardiometabolic

diseases, death from cardiometabolic disease, death from another cause,

emigration, or age at end of follow-up). We tested the proportional hazard

assumption for all Cox models by using log–log plots and testing the inter-

actions of exposure with time (logarithmically transformed), and we found

no significant deviations from proportionality (see

Supplementary material

online,

Table S1).

We fitted separate models assessing the associations of

workplace sexual harassment with risk of CVD and risk of type 2 diabetes.

All people with full information on exposure and outcome were included in

the analyses. The main analyses were adjusted for sex, family situation, birth

country, educational level, and income. In additional analyses, we adjusted

for baseline work characteristics.

We checked for interaction between sex and sexual harassment by in-

cluding an interaction term in the model and stratified the analyses by

sex. Likewise, we presented the results separately for sexual harassment

from superior or fellow workers and sexual harassment from other people

than the fellow workers (e.g. patients, clients, passengers, and students).

Similar sets of results are also presented for CHD, any CD, MI, and stroke

as separate outcomes. We also present exposure–response analyses for

CVD and type 2 diabetes according to the frequency of exposure to work-

place sexual harassment. We used SAS Statistical Software 9.4 for all

analyses.

Patient and public involvement

No patients were involved in setting the research question or the outcome

measures, nor were they involved in developing plans for recruitment, de-

sign, and implementation of the study. No patients were asked for advice on

interpretation or writing up of results. However, part of the research and

dissemination strategy at the Stress Research Institute is developed with pa-

tient and public involvement.

Results

Overall, 4.8% (4300/88 904) of the included study population reported

workplace sexual harassment during the previous 12 months. The

corresponding prevalence was 1.9% (815/42551) in men and 7.5%

(3485/46353) in women. Those who were not exposed to workplace

sexual harassment differed from the exposed group of the study popu-

lation in terms of several baseline socio-economic and work-related

characteristics (Table

1).

There was a higher proportion of women,

Cardiometabolic diseases at follow-up

We identified CVD and type 2 diabetes from the National Patient Register

and Causes of Death Register through linkage based on the Swedish

P. KC

et al.

Table 1

Distribution of socio-demographic factors and chronic diseases among participants of Swedish Work

Environment Survey (1995–2015) according to exposure to workplace sexual harassment

Characteristics

Total (n, 88 904)

Un-exposed

(n, 84 604)

Exposed

(n, 4300)

P-value

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........................

(%)

Sex

Male

Female

Mean (SD) age in years

Birth country

Sweden

Foreign

Family situation

Married/living with partner with children

Married/living with partner without children

Single/divorced/separated/widowed with children

Single/divorced/separated/widowed without children

Mean (SD) income from work, SEK

Education (n

88 341)

Primary and lower secondary

Upper secondary

University

Mean (SD) job demands, scale 0–4

Mean (SD) job control, scale 0–4

Mean (SD) job support, scale 1–4

Physical strain at work (n

88 199)

Low (not at all, rarely the last 3 months)

Moderate (1 day/week or 2 days/month)

High (2 days/week or every day)

CVD

Yes

Type 2 diabetes

Yes

85 280

3624

84 686

4218

42 551

46 353

43.2 (11.9)

80 050

8854

41 376

16 180

6786

24 550

.......................

<0.0001

.........................................................................................................................................................

41 736

42 868

43.6 (11.8)

76 262

8342

39 612

15 777

6287

22 917

815

3485

37.3 (11.5)

3788

512

1764

403

499

1633

<0.0001

12 657

42 644

33 040

1.7 (1.3)

2.5 (1.3)

1.6 (0.9)

54 498

13 663

20 038

12 294

40 446

31 335

1.7 (1.3)

2.6 (1.3)

1.6 (0.9)

52 404

12 824

18 701

80 497

4107

81 108

3496

363

2198

1705

2.1 (1.3)

1.9 (1.3)

1.7 (0.9)

2094

839

1337

4189

111

4172

128

<0.0001

0.0002

<0.0001

2 525 894 (1 582 097)

2 547 288 (1 597 219)

2 104 916 (1 170 9372)

CVD, cardiovascular disease; SD, standard deviation.

P-value

for hypothesis testing that one group is different from other based on chi-square test for categorical and analysis of variance for continuous characteristics of the study population.

single/divorced/separated, people with foreign background, people

with high job demands, and low controls among exposed than among

un-exposed. Moreover, the population exposed to workplace sexual

harassment were relatively younger than the un-exposed population.

A higher proportion of exposed had university education, but the ma-

jority had low income from their work and had no supervisory duties.

Of all study population born outside Sweden, 5.8% were exposed

to workplace sexual harassment (512/8854), which was slightly higher

than in the total study population born in Sweden (4.7%, 3788/80050).

Workplace sexual harassment and risk of

CVD and type 2 diabetes

We followed the study population for a total of 989 512 person-years

(mean follow-up 11 years, standard deviation 6 years). In total, 4218

(4.7%) persons had been diagnosed with CVD during the follow-up

(rate: 4.3 cases per 1000 person-years), 111 (2.6%) among those

exposed to any workplace sexual harassment, and 4107 (4.9%) among

those un-exposed. A total of 3624 (4%) persons were diagnosed with

type 2 diabetes during the follow-up (rate: 3.6 cases per 1000 person-

years), 3% among exposed, and 4% among un-exposed study popula-

tion. In total, 2784 (3.1%) person had been diagnosed with CHD

(2.8 cases per 1000 person-years), 1935 (2.2%) were diagnosed with

CD (1.9 cases per 1000 person-years), 1776 (2.0%) were diagnosed

with MI (1.8 cases per 1000 person-years), and 1488 (1.7%) were diag-

nosed with stroke (1.5 cases per 1000 person-years) during the follow-

up (Table

Supplementary material online,

Tables S1

and

S2).

In the Cox regression analysis (Figure

1),

the hazard ratio (HR) for

CVD was 1.27 (95% confidence interval 1.05–1.54) for any workplace

sexual harassment in the sex-adjusted model. Neither adjustment for

birth country, family situation, education, and income nor additional

adjustment for work-related factors (job demands, job control, job

support, and physical strain) substantially changed the HRs (1.26,

1.04–1.53, 1.25, and 1.03–1.51, respectively). Excess risk estimates

Workplace sexual harassment and cardiometabolic disease

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Figure 1

Results from Cox regression analyses on workplace sexual harassment stratified by sex and presented separately for sexual harassment

from superiors/fellow workers and others, presented as hazard ratios and 95% confidence intervals with and without adjustment for cardiovascular

disease. CI, confidence interval; HR, hazard ratio.

were detected in both men and women, although most risk estimates

were not statistically significantly increased in stratified analyses, and

there was no statistically significant interaction between workplace sex-

ual harassment and sex for CVD.

In total, 1.5% reported being exposed by superiors or fellow work-

ers, and 3.8% were exposed by other people, which include patients,

clients, passengers, and students. Excess risk of CVD was detected

for the exposure to sexual harassment from both superiors and

fellow workers (1.57, 1.15–2.15), while the risk estimate for exposure

from other people was weaker and not statistically significant

(1.16, 0.93–1.45) in the fully adjusted model.

The results from Cox regression were similar for type 2 diabetes

(1.51 and 1.26–1.80 in the sex-adjusted model), with a HR of 1.45

(1.21–1.73) in the fully adjusted model (Figure

2).

Excess risk estimates

P. KC

et al.

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Figure 2

Results from Cox regression analyses on workplace sexual harassment stratified by sex and presented separately for sexual harassment

from superiors/fellow workers and others, presented as hazard ratios and 95% confidence intervals with and without adjustment for covariates for

type 2 diabetes. CI, confidence interval; HR, hazard ratio.

were detected for both sexes (1.63 and 1.20–2.21 for men and 1.34 and

1.08–1.68 for women in the fully adjusted model), and there was no

statistically significant interaction between workplace sexual harass-

ment and sex. An excess risk of type 2 diabetes was also indicated

for both exposure to sexual harassment from both superiors and fellow

workers (1.85, 1.39–2.46) and from other people (1.39, 1.13–1.70) in the

fully adjusted model.

An exposure–response relationship according to the frequency of

exposure to workplace sexual harassment was present for both

CVD (P

trend

0.0001) and diabetes (P

trend

0.001) (Figure

3).

The exposure–response analysis based on frequency of exposure to

workplace sexual harassment showed that the risk of CVD was slightly

higher among those who were frequently exposed (1.31, 0.95–1.54)

than those who were occasionally exposed (1.21, 0.96–1.54) to

Workplace sexual harassment and cardiometabolic disease

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Figure 3

Results from Cox regression analyses on the frequency of workplace sexual harassment presented as hazard ratios and 95% confidence

intervals with and without adjustment for covariates for cardiovascular disease and type 2 diabetes. CI, confidence interval; CVD, cardiovascular disease;

HR, hazard ratio.

workplace sexual harassment. The risk of type 2 diabetes was also high-

er among frequently exposed (1.72, 1.30–2.28) than those who were

occasionally exposed (1.31, 1.05–1.65).

The results from Cox regression for CHD (1.26, 0.99–1.91) and CD

(1.31, 1.00–1.70) were borderline statistically significant in the sex-

adjusted model but attenuated when fully adjusted, and the risk esti-

mates for MI (1.29, 0.95–1.75) and stroke (1.11, 0.80–1.55) were not

significant throughout (see

Supplementary material online,

Figure S1).

In addition, we did not note any statistically significant excess risk esti-

mates in sex-stratified analyses for women and men for CHD, CD, MI, and

stroke (see

Supplementary material online,

Figure S2).

However, we ob-

served a moderately higher HR for CHD development (1.68, 1.15–2.46)

and a two-fold higher HR for MI development (2.04, 1.33–3.15) among

those exposed to workplace sexual harassment from superiors or fellow

workers, in the fully adjusted model (see

Supplementary material online,

Figure S3).

The estimates for other exposure–outcome associations

were not statistically significantly increased.

Discussion

This population-based cohort study of Swedish paid workers aged 16–

64 years showed an association between workplace sexual harassment

and cardiometabolic diseases.

Our study finding on higher risk of CVD and diabetes

16,17,26–29

among those exposed to workplace sexual harassment is in line with

findings from previous studies on exposure to sexual harassment in

general or sexual abuse during childhood or inter-personal violence

or lifetime abuse. Four of the previous studies were either systematic

review or meta-analysis,

16,17,26,27

and another study was based on life-

time abuse.

The results from a systematic review by Suglia

et al.

in-

dicated high risk of CVD among the victims of child abuse; however, the

authors did not find a tangible risk of CVD outcomes among the victims

of adulthood violence exposure. This conclusion relied mostly on

cross-sectional studies included in their study, and the authors asked

for further research based on violence exposure across the life course.

Our findings on higher risk of CVD among those exposed to workplace

sexual harassment corroborate the findings reported by another re-

cently conducted systematic review.

However, the exposure variable

used in our study was any workplace sexual harassment compared with

any sexual violence used in the previous systematic review. A multi-

cohort meta-analytical study using four different studies carried out

in Nordic countries reported a higher diabetes risk among those ex-

posed to violence or threat of violence,

which is in line with our find-

ings of an association between any workplace sexual harassment and

type 2 diabetes. Those who experienced workplace violence had a sig-

nificantly higher risk of CVD as compared with the un-exposed group in

a study of working men and women from Sweden and Denmark by Xu

et al.

Given the similarity in the nature of the exposure variable, our

study findings are in line with that of the previous study.

Moreover,

previous studies have also reported an association between workplace

sexual harassment and behavioural risk such as alcohol mis-use,

18,30

de-

pressive symptoms,

post-traumatic stress disorder (PTSD),

6,19

and

hypertension,

21,23

which may in turn aggravate the risk of CVD and dia-

betes through physical dysregulation. However, to the best of our

knowledge, this is the first study to investigate the association of work-

place sexual harassment and cardiometabolic disease using a prospect-

ive cohort of a large population-based sample.

In line with the study by Xu

et al.,

we also found an exposure–

response association with CVD and diabetes that strengthens the prob-

ability of a causal association. With regard to biological plausibility, it has

been found that sexual harassment may induce reactions such as help-

lessness and fearfulness that often lead to increased risk of distress and

PTSD.

Previous studies have also reported an association of work-

place sexual harassment with an increased risk of distress and

PTSD.

6,19

The cumulative burden of chronic stress reactions and stress

symptoms and life events could result in physiological dysregulation,

also referred to as allostatic load,

which is a potential pathway to mani-

festation of chronic diseases,

especially related to metabolic

and in-

flammatory system.

Such physiological dysregulation may include

obesity, an increase in metabolic risk factors, cardiovascular risk factors,

and inflammatory response, which may in turn increase the risk for dis-

eases such as diabetes and CVD.

Psychosocial stressors may also trig-

ger diseases such as CVD among individuals already at high risk for

disease, for instance by accelerating the atherosclerotic process among

people with an already high atherosclerotic plaque burden.

The prevalence of any workplace sexual harassment is high among

women,

which was also true in our sample, and the risk for cardiome-

tabolic disorders may differ according to sex due to sex hormones and

sex-specific molecular mechanism that has an influence on cardiac en-

ergy metabolism.

We, therefore, conducted sex-specific analyses.

However, the lack of significant interaction between sex and workplace

sexual harassment in the analyses of CVD and type 2 diabetes risk sug-

gest that there were no obvious differences in associations by sex. We

further analysed sexual harassment separately for harassment from

superiors/fellow workers and others (clients, patients, etc.) and found

that sexual harassment from superiors or fellow workers was most

clearly associated with CVD and type 2 diabetes. Similarly, a previous

prospective study on Danish workers reported sexual harassment

P. KC

et al.

from superiors and colleagues as a stronger predictor of depressive

symptoms as compared with harassment from other customers or cli-

ents.

Sexual harassment from superiors or fellow workers may be

more difficult to cope with than harassment from others such as pa-

tients, especially from superiors who are in a power situation

and since

it may more frequently entail sexual coercion. Exposure from superiors

or fellow workers may also be more frequently occurring and thereby

have more severe consequences. However, few studies have to date

looked at different types of workplace sexual harassment, which is

why more knowledge is needed.

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Strengths and limitations of the study

A large sample representative of Swedish workforce prospectively fol-

lowed for several years is one of the major strengths of this study.

Compared with other observational studies, prospective cohort stud-

ies deliver stronger evidence of an association. This contributes to fill

the gap in the previous body of research as suggested by some of the

latest systematic reviews projecting cardiovascular health effects of sex-

ual harassment.

26,27,37

There are some potential limitations of this study, and one of the ma-

jor limitations is a risk that information on any sexual harassment at

workplace is under-reported. As sexual harassment was self-reported

and diseases were ascertained in the register objectively, the

mis-classification of the exposure is very likely to be non-differential

and independent, which may contribute to an under-estimation of

associations. It is likely that the single-item self-reported measurement

is not very sensitive in terms of capturing different types of sexually

harassing behaviours. The methods with multiple items may better cap-

ture different behaviours that can constitute workplace sexual harass-

ment compared with single-item strategies of assessing sexual

harassment,

12,38

thus yielding higher prevalence.

The forms of work-

place sexual harassment could vary from inappropriate verbal remarks

to very severe physical acts such as rape. There is a probability that re-

spondents only consider severe forms of sexual harassments when re-

sponding to explicit inquiries about sexual harassment,

which might

be one of the relevant explanations for robust associations between

any workplace sexual harassment and cardiometabolic diseases found

in our study. Nonetheless, the assessment of workplace sexual harass-

ment was based on the frequency, which we believe could serve as an

indicator of severity of harassment. It is possible that part of our sample

was too young for CVD development, and the follow-up time was too

short. An earlier review on psychosocial work characteristics noted

more pronounced associations with heart disease among younger

age groups and an increased risk only among studies with a long follow-

up (10 years or more).

However, in our previous work on workplace

violence/bullying, the risk of CVD appeared to be higher among those

50 years of age or older, and the results did not differ according to the

length of follow-up.

16,17

Socio-economic characteristics and work-

related physical and psychosocial exposures were used to adjust for po-

tential confounding, as suggested in previous literatures.

18,19,21

These

factors partly explained the associations between any workplace sexual

harassment and CVD as well as type 2 diabetes, but the associations

persisted with adjustment for these factors. However, some

unmeasured work exposures such as sitting and standing at work are

other possible factors that could be considered as potential covariates

in future studies. Exposure to these factors vary according to the type

of work, and more importantly, the risk of heart disease has been found

to differ among occupations that required lengthy sitting and lengthy

standing.

We believe that the adjustment for job control, job de-

mands, and physical strain at work partly satisfies the requirement of

adjustment with sitting and standing at work. Yet, we are aware of

the potential for a slight over-estimation due to the lack of other factors

such as shift work and other hazardous nature of employment. Thus,

residual confounding as an explanation for the present findings cannot

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be excluded. Furthermore, due to the unavailability of information, we

were also unable to account for smoking and risky alcohol consumption

that may act as potential confounders for the association between work-

place sexual harassment and CVD. However, sexual harassment is likely

to be associated with stress responses that could lead to smoking and

alcohol abuse, which may in turn be associated with cardiometabolic dis-

ease; therefore, factors such as smoking and risky alcohol consumption

may be seen as mediators rather than confounders. Also, the estimates

of prevalence and risk in our study might have been affected by the de-

creased response rate in SWES, which impacts the generalizability of the

results of our study. We have seen an increase in attrition in SWES over

time, majority of the non-responders being young people with low in-

come and low education levels and immigrants. Nonetheless, we had a

long follow-up and pragmatically no loss to follow-up that we regarded

as another major strength of our study.

This study supports prospective association between workplace sexual

harassment and increased risk of cardiometabolic diseases. If the observed

associations were causal, then our findings indicate that prevention of sex-

ual harassment at workplace through interventions targeted towards so-

cial environment and behaviours might contribute to decreased burden of

type 2 diabetes as well as CVD. Given the importance of this association

from the public health point of view, future research is warranted to clarify

the causality and mechanisms behind these associations considering the

severity of sexual harassment at workplace.

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Supplementary material

is available at

European Journal of Preventive

Cardiology.

Author contributions

Concept and design: L.L.M.H., P.K.C., and H.W. Acquisition of data:

L.L.M.H., I.E.H.M., R.R., T.X., H.W., M.K., and A.N. Analysis of data: P.K.C.

Interpretation of data: P.K.C., L.L.M.H., I.E.H.M., R.R., T.X., H.W., M.K., and

A.N. Drafted the manuscript: P.K.C. Critical revision of the manuscript for im-

portant intellectual content: P.K.C., L.L.M.H., I.E.H.M., R.R., T.X., H.W., M.K.,

and A.N. Obtained funding: L.L.M.H., H.W., I.E.H.M., T.X., R.R., M.K., and A.N.

Agreed to be accountable for all aspects of work and given final approval of

the submission: P.K.C., L.L.M.H., I.E.H.M., R.R., T.X., H.W., M.K., and A.N.

Funding

This study was supported by the Swedish Research Council for Health,

Working Life and Welfare (grant number #2019-01318) to the project

led by L.L.M.H. The funders had no role in the study design and conduction

of the study; data collection, management, analysis, and interpretation; and

drafting, review, or approval of the manuscript.

Conflict of interest:

none declared.

Data availability

SWES data are not publicly available due to legislative and ethical restric-

tions but can be requested for research directly from Statistics Sweden,

while linked health records can be requested from the Swedish National

Board of Health and Welfare.

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