Continuing on with my Code Pink theme from earlier this week, I want to comment on the Nurses’ Health Study (female nurses only—sorry guys there is no male nurses’ health study that I know of). Today I was invited to join Nurses’ Health Study III by Karen Daley, President of the American Nurses Association.

If you don’t already know, the Nurses’ Health Study was started in 1976 by epidemiologists from the Harvard Medical School and Brigham and Women’s Hospital. Originally it was a prospective cohort study looking at the possible risks of oral contraceptives for development of ovarian and breast cancer in women. Funded by the NIH, the researchers targeted nurses because they were mostly female, they knew enough medical terminology to be able to answer questionnaires with accuracy, and they were likely to be compliant with research study parameters. Expanded in 1989 with the Nurses’ Health Study II, they have 238,000 “dedicated nurse participants” and have had a 90% follow-up rate. The questionnaires include questions on reproductive health, family history, environmental exposure, diet/supplement use, physical activity, screening history, disease outcome, medication use and psychosocial issues. A scan of the questionnaire/long form reveals these interesting questions: 1) how often (each day) do you apply lipstick?, 2) how many natural teeth do you have?, 3) how many moles do you have on your left arm >3mm?, and 4) how do you feel about your social standing in US society and in your community? (picture a ladder, where participant is asked to mark the rung on which they perceive themselves to be, once for US and community). According to the study website, quality of life questions were added in 1992 at the request of nurse participants. The questions include social support, perceived support by job supervisors, participation in religious activities, shift work, and global rating of overall health.

More than 100 scholarly journal articles are published every year based on results from this study. As the ANA President says, “These studies have taught us much of what we currently know about how foods, exercise, and medications can affect women’s risk of developing cancer and other serious health conditions.” She goes on to say, “However, there is still a great deal that we do not know, especially among women from diverse ethnic backgrounds.

 The goal of the Nurses’ Health Study 3 is to investigate how women’s lifestyles (including diet, exercise, birth control, pregnancy, work exposures etc.) during their 20’s, 30’s and 40’s can influence their health and disease risk later in life.” They started to recruit female nurse participants in the Summer 2010 and have a goal of recruiting 100,000 nurses.

I did a PubMed search on all of the published journal articles related to the Nurses’ Health Study. They are listed in the categories of breast cancer, diabetes, cardiovascular disease, physical activity and vitamins. I found no published journal articles related to job stress, perceived social standing and health outcomes. The closest are studies linking night shift work and bone loss and/or pregnancy loss. To make sure I wasn’t missing something, I asked Dr. Susan Hankinson, RN, ScD, Principal Investigator for the study if she knew of any current/unpublished studies on these issues. She told me that they have some new people looking at the relationships between stress and ovarian cancer and diabetes, but that it will be a few more years before they have those results. She added in a follow-up e-mail that they were looking at the relationship between stress (experience with violence and PTSD) and health (asthma, diabetes, coronary heart disease).

A missed opportunity. First, let me state clearly that I applaud this study and have personally benefited from it. For instance, when I was in my late 20s, I was reassured by study results indicating that use of oral contraceptives was not likely to increase my risk of breast or ovarian cancer. However, I am struck by the lack of research attention on stress—and particularly on work-related stress for women (and nurses in this case) on health outcomes. Gender and class issues come to mind here. As does the fact that for the first time in recorded US history, female life expectancy rates in parts of the US have started to decline. Majid Ezzati and colleagues in 2008 published an article, “The Reversal of Fortunes, Trends in County Mortality and Cross-County Mortality Disparities in the United States.” Between 1982-2001 they found that for 19% of the US female population there was a significant decline or stagnation in overall life expectancy. This reversal of the epidemiologic transition was most apparent for low-income white women in Appalachia and the Mississippi Valley. I wonder how many of these women are nurses and how many are reflected in the Nurses’ Health Study.

There is growing recognition that social determinants of health have a much bigger part to play in terms of health inequities than do behavioral health factors like diet and exercise. The socioeconomic ladder is strongly associated with gradations in health outcomes. The Nurses’ Study asks about perceived social standing, which I would imagine has a close association with nurses’ socioeconomic ranking. I hope that some researchers begin to examine these data, as well as the relationship between work-related stress and overall perceived health status. So, all of you female nurses ages 22-45, consider joining the Nurses’ Health Study III and count how many times per day you apply lipstick. And all of you epidemiologists please consider looking at the social determinants of health—including work-related stress—for female nurses.