Second Annual Conference „Occupational Disease Registry“ Sheba Hospital Tel Aviv, Feb. 27 2013 Health effects of an adverse psychosocial work environment:

Second Annual Conference „Occupational Disease Registry“ Sheba Hospital Tel Aviv, Feb. 27 2013

Health effects of an adverse psychosocial work environment:

Scientific evidence and implications for monitoring and prevention

Johannes Siegrist, PhDSenior Professor for Work Stress Research

University of Duesseldorf, Germany

Work … provides a source of regular income and related

opportunities provides a source of personal growth and training

opportunities provides social identity, social status and related rewards enables access to social networks beyond primary groups influences a person’s self efficacy and self esteem exposes a person to differential quality of work

environment

Importance of work for health

Importance of work for health (cont.)

• Job loss/ long-term unemployment is an established risk factor of elevated morbidity and mortality from addiction and stress-related disorders (esp. CVD, depression) (Gallo et al. 2004, Voss et al. 2004)

• Yet, among employees with poorest quality of work mental health is getting significantly worse over time than in the case among unemployed people (Butterworth et al. 2011)

Traditional focus: workplace

Modern focus: work organization and employment conditions

Chemical & physical hazards and specific ergonomic conditions reduce employees’ health and increase injury risk

Domain of occupational medicine and safety

Specific features enhance or reduce employees’ health through psychosocial stress-related mechanisms

Domain of ‚new‘ occupational health research and policy

Quality of work and health

Increase of work pressure, pace of work,and competition, including ‘high power work organization’ (impact of economic globalization)

High demand for flexibility, mobility, and adaption of workers to new taks/technologies

Fragmentation of occupational careers, de-standardized or atypical work, and growing job instability/insecurity

Increase of service and IT professions/occupations with high psychomental/emotional workload

Segmentation of labour market; social inequalities in quality of work and employment

Significant changes in the nature of work and labour market

Increased pressure of rationalisation

(mainly due to wage competition)

Downsizing, Merging, Outsourcing

Work Job Low wage / intensification insecurity salary

Effects of economic globalisation: Labour market consequences in developed countries

High work pressure (e.g. overtime work) and job instability (e.g. downsizing) are unhealthy!

Examples of recent evidence:

Overtime work (>11 hrs/day):

risk of severe depression: HR 2.4

risk of incident CHD: HR 1.7

(Virtanen M et al. PLoS One 2012, Eur Heart J 2010)

‚Surviving‘ severe downsizing:

risk of all-cause mortality: HR 1.4

risk of CHD mortality: HR 2.0(Vahtera J et al. BMJ 2004)

negative emotions

stress responsesstress-related disorders

Work stress: How to identify toxic components within complex environments?

Demand-control model (R. Karasek, 1979; R. Karasek & T. Theorell, 1990)

Effort-reward imbalance model (J. Siegrist, 1996; J. Siegrist et al., 2004)

Organizational justice model (J. Greenberg, 1990; M. Elovainio et al., 2002)

Features of job tasks

Features of work contracts

Features of organizational procedures

Three theoretical models of a health-adverse psychosocial work environment

active

passive

lowdistress

highdistress

Quantitative demandsS

cop

e o

f d

ecis

ion

/co

ntr

ol

low highlo

whi

gh

The demand-control model(R. Karasek 1979; R. Karasek & T. Theorell 1990)

Procedural justicePerceptions of consistent, accurate, unbiased and ethical rules of procedures

Relational justicePerceptions of polite, fair interactions from supervisors

Distributive justicePerceptions of appropriate distribution of job tasks and gains among employees

So far, mainly procedural and relational justice were measured with relevance to health and performance.

The Organizational Justice Model

effort

reward

demands / obligations

- labour income- career mobility / job security- esteem, respect

motivation(‘overcommitment‘)

motivation(‘overcommitment‘)

Extrinsic components

Intrinsic component

The model of effort-reward imbalance (J. Siegrist 1996)

Relevance of the effort-reward imbalance model

• It captures main features of modern work due to economic globalisation (competitive wages, high work pressure, low job security, lack of esteem).

• It is based on an evolutionary old principle of human exchange (social reciprocity between give and take) with important implications for health and wellbeing.

• It combines features of the work situation and of the working person.

• It provides robust comparative information on adverse health effects of work stress due to its wide application in international studies.

Both models are measured by a standardized self-assessed questionnaire which can be applied to a variety of different occupational groups:

- Job Content Questionnaire (JCQ) (R. A. Karasek)www.workhealth.org

- Effort-Reward Imbalance Questionnaire (ERI) (J. Siegrist)www.uniklinik-duesseldorf.de/Med-Soziologie

Both questionnaires fulfill criteria of psychometric quality (factorial structure of scales, reliability, discriminant and predictive validity etc.).

Both questionnaires are available in a number of languages and have been used in comparative international studies.

Measurement of the models

Scale ‚effort‘ (6 Likert-scaled items) = perceived demands (Cronbach‘s α = .72)

Scale ‚reward‘ (11 Likert-scaled items) = experienced or promised gratifications (Cronbach‘s α = .83)- 3 subscales: (a) salary and promotion, (b) esteem,

(c) job security- ‚ratio effort/reward‘ =

sum score ‚effort‘ / (sum score ‚reward‘ 6/11)

Scale ‚overcommitment‘ (6 Likert-scaled items) = pattern of coping with demands and rewards (Cronbach‘s α = .76)

For detailed information see: www.uniklinik-duesseldorf.de/Med-Soziologie

Measurement of effort-reward imbalance at work

Factorial structure of the ERI scales (confirmatory factor analysis)

.65-.33work stress

over-commitment

jobinsecurity

esteem

reward

effort

salary / promotion

ERI1

ERI2

ERI3

ERI4

ERI6

ERI7

ERI8

ERI9

ERI12

ERI13

ERI11

ERI14

ERI16

ERI15

ERI10

ERI17

OC1

OC2

OC3

OC4

OC5

OC6

.75(1)

.95

.82(1)

.49

.49

.64

.67(1)

.66(1).51

.58

.59

.55

.65

.54(1)

.80

.62

.80(1).76

.51(1)

.19

.74

.64

.86

.69

.75

.75

N=666 German employees

χ2/df

GFI

AGFI

CFI

RMSEA

Source: A. Rödel et al. (2004) Z diff diagn Psychol 25: 227-238

2.99

.91

.89

.90

.06

Explanatory contributions of single and combined scales, Swedish cohort study (SLOSH)

Association of ERI (2006) with self-rated health (2008):

• Effort (highest quartile) OR 2.60 (1.52-4.44)• Reward (lowest quartile) OR 2.25 (1.30-3.89)• E/R-Ratio (highest quart.) OR 4.43 (2.33-8.43)• Overcommitment ( „ „ ) OR 3.79 (2.06-6.94)

ORs adj. For age, sex, education, income, and baseline SRH

Source: C. Leineweber et al. Occup Environ Med 2010, 67: 526

Sensitivity and specificity of ERI scales: Cut-point of the ER-ratio

Source: D. Lehr et al. (2010) J Occup Organizat Psychol 83: 251-261

E/R

-rat

io

Social gradient of work stress

0

5

10

15

20

25

30

35

40

Effort-Reward Imbalance Low control

Per

cen

t h

igh

str

esse

d

Very low

Low

Medium

High

Very high

Source: Wahrendorf M et al. (2012) European Sociological Review, DOI: 10.1093/esr/jcs058,

The social gradient of work stress in the European workforce (age 50-65): SHARE-study

Methodological approaches: epidemiological and experimental

Epidemiological research: prospective observational cohort study (gold standard) cross-sectional and case-control-study (weaker

evidence) intervention study (limited options)

Experimental research: laboratory experiments (limited ecological validity) ambulatory monitoring at work (limited control)

What is the scientific evidence of a direct association of work stress with disease?

„By the year 2020 depression and coronary heart disease will be the

leading causes of premature death and of life years defined by disability

(DALY‘s) worldwide.“

(Murray and Lopez 1996)

Focus on coronary heart disease and depression

Public health relevance of stress-related disorders

Source: H. Bosma et al. (1998), Amer J Publ Health, 88: 68-74

0.5

1

1.5

2

2.5

3

No workstress

Intermediatejob control

Low jobcontrol

0.5

1

1.5

2

2.5

3

No workstress

High effort orlow reward

High effortand lowreward

adjusted for age, sex, length of follow-up

+ alternative work stress model

+ grade, coronary risk factors, negative affect * p < .05

* *

Work stress (effort reward imbalance/job control) and CHD incidence, men and women: Whitehall II-Study

Decreases risk Increases risk

4/9

Source: Kivimaki et al. Scand J Work Environ Health (2006): 32: 431.

Meta-analysis of cohort studies on relative risks of coronary heart disease due to ’job strain’

0.33

0.27

0.26 0.27

0.2

0.25

0.3

0.35

low high

low

high

Economic rewardsW

ork d

emands

4-ye

ar i

ncr

ease

In

pla

qu

e h

eig

ht

(mm

)

Source: J. Lynch et al. (1997), Circulation, 96: 302

p = .04 (adj.)

Workplace demands, economic reward, and 4-year progression of carotid atherosclerosis

(plaque height) in 940 Finnish men

0

1

2

3

4

5

6

Effort-Reward Imbalance

lowmiddlehigh

Adjusted for age, and sex; Additionally adjusted for hypertension, diabetes mellitus, smoking, BMI, CHD family history, educational level, and marital status; *p<0.05; **p<0.01; ***p<0.001

Source: Xu W. et al (2009) J Occup Health 51: 107-113

Psychosocial stress at work in Chinese male coronary patients vs. healthy controls (N=388)

120

125

130

135

140

morning noon afternoon evening

mm

Hg

overcommitment +,occup. grade low

overcommitment +,occup. grade high

overcommitment -,occup. grade high

overcommitment -,occup. grade low

Source: A. Steptoe et al. (2004), Psychosomatic Medicine, 66: 323-329.

Mean systolic blood pressure (mmHg) in men over a working day according to overcommitment

and occupational grade (N=105)

Source: M. Hamer et al. (2006), Psychosom Med, 68: 408-413.

CRP change# (μg/ml) as function of effort-reward imbalance

# adjusted for age, BMI, baseline levels

effort-reward imbalance

low medium high

p < .050.12

0.10

0.08

0.06

0.04

0.02

0.00

Inflammatory response (CRP) during experimentally induced mental stress according to level of effort-

reward imbalance (N=92)

Demand-control model:

• 12 of 14 studies: OR varying from 1.2 to 3.4 (full model or components)

Effort-reward imbalance model:• 9 studies: OR varying from 1.5 to 4.6 (full model or

components)

Organisational justice model:• 11 studies: OR varying from 1.2 to 2.4 (single

components)

Evidence from prospective cohort studies: elevated risks of depression

Multivariate relative risiks* of the following components:

Women• Low decision latitude RR 1.96 CI

1.10;3.47• Low social support RR 1.92 CI

1.33;3.26

Men• High job insecurity RR 2.09 CI

1.04;4.20

*adj. for age, depression at baseline and additional confoundersSource: R. Rugulies et al. (2006), Am J Epidemiol, 163: 877.

Work stress (demand-control-model) and incidence of severe depressive symptoms (5 years, N=4.133)

1-year incidence on major depression and work stress quartiles (ERI) Canada (n = 2752, men and women)

Source: J Wang (2012): Am J Epidemiol 176: 52-59.

Psychosocial stress at work and depressive symptoms: 13.128 employed men and women 50-64 yrs. from 17 countries in three

continents (SHARE, ELSA, HRS, JSTAR)

0

0,5

1

1,5

2

2,5

USA (N=1560) Europa (N=10342) Japan (N=1226)

ERI

Low control

Source: J. Siegrist et al (2012) Globalization and Health 8:27.

* *

*

* *

Moderation of effort-reward imbalance (ERI) on severe depressive symptoms by SES (N = 1729) ‚Danish Work

Environment Cohort‘ study

Logistic regression analysis: Model: adj. for gender, age, family status, survey method, health behaviours (smoking, heavy alcohol consumption, leisure time physical activity), self-rated health, sleep disturbances and non-severe depressive symptom score (53–100) at baseline

Source: Rugulies et al (2012) Eur J Public Health (in press)

Source: Wahrendorf M et al. 2013: Adv. Life Course Res 18:16-25.

N=8609: SHARELIFE

Source: Bellingrath S et al (2008) Biol Psychol 78: 104-113

Morning cortisol after dexamethasone-test in teachers with or without work stress (N=135)

Work stress (ERI) and natural killer cells in 347 Japanese employees

Source: Nakata A et al (2011) Effort-reward imbalance, overcommitment, and cellular immune measures among white-collar employees. Biol Psychol 88: 270-279

Reduced fatigue and depression is associated with retirement event (GAZEL-study)

Source: Westerlund H et al (2010) BMJ 341:c6149.

Employee work time control and risk of disability pension: the Finnish Public Sector Study.

Worktime control (self-assessed and co-worker assessed) from a survey in 2000-2001; 30 700 employees (78% women) aged 18-64 years. Information on disability pension during 4.4 y follow-up was collected from national registers.

1178 employees were granted disability pensions. Most common causes: musculoskeletal disorders (43% of all pensions) and mental disorders (25%).

A one unit increase in worktime control score was associated with a 41-48% decrease in risk of disabling musculoskeletal disorders in men and a 33-35% decrease in women.

This association was robust to adjustment for 17 baseline covariates

Source: Vahtera Occup Environ Med. 2010 Jul;67(7):479-85

Cumulative hazard of early retirement on health ground in general (upper part) and specifically due to musculosceletal disorders by quartile of worktime control. (Vahtera 2010)

• Challenging task profile providing autonomy, control and opportunities of personal development

• Appropriate material and non-material rewards in return to accomplished achievements

• Trusting, fair and supportive relationships at work

• Meaningful and secure employment

Summary: Main features of health promoting work

Legislation, Regulation, Social movements

Employer initiated new systems of work organization,Collective bargaining

Employer initiated job redesign,Labor-management committees,Action research

Health promotion, Stress management

Treatment, Rehabilitation, Return-to-Work programs

Economic, political context

Organizational contextJob insecurity, Downsizing

Precarious workNew systems of work organization

Job characteristicsLow job control / rewardHigh job demands / effort

Stress responsePhysiological effects (e.g., BP )

Psychological effects (e.g., burnout)Health behaviors

Illness

Actions towards strengthening a culture of prevention at different levels

Promoting a unified approach of validated measures towards effective management of psychosocial risks and of strengthening (mental) health and safety at the workplace

Cyclic process (assess, plan, act, evaluate, modify or establish)

Supported at level of enterprises by regulatory standards (e.g. national, EU), voluntary agreements and social partner dialogues

Initiate and promote models of good practice (e.g. Scandinavian countries, NE, UK)

Framework for psychosocial risk management at the workplace: PRIMA-EF (S. Leka, T. Cox 2008)

New strategy launched by the Danish Working Environment Authority in 2007 to strengthen and qualify primary prevention of work related stress

Trained WEA inspectors assess sector-specific guidance tools in all Danish enterprises as part of their regular work.

Collection of data in combination with information on available preventive activities; data analysis in collaboration with NRCWE in Copenhagen

Feedback to enterprises and discussion of implementation, together with experts and social partners

Models of good practice: the case of Denmark(M.Bogehus Rasmussen et al. (2011) Safety Science 49:565-74)

WHO Global Framework of Healthy Workplaceshttp://www.who.int/occupational_health/publications/healthy_workplaces_model.

pdf

Adj. rel. SA-risk (during 28 months)

Work stress (ERI) + Control of daily work schedule

23 %

Work stress (ERI) + Lack of control of daily work schedule

39 %

Work stress (ERI) + Control of free days at work

12 %

Work stress (ERI) + No control of free days at work

43 %

Source: Ala Mursala L. et al. (2005) J Epidemiol Community Health 59: 851-857; N=16.000)

Improved control and autonomy over work time and sickness absence (SA)

Variable

Demand

Control

Supervisor support

Coworker support

ERI

Psychol. distress

Work-rel. burnout

Means at t1 adj. for t0

experimental - control hospital p

12.08

68.59

10.82

12.49

1.10

21.17

46.66

12.68

68.06

10.42

12.26

1.15

22.43

49.03

.015

.382

.028

.056

.002

.205

.034

Source: R. Bourbonnais et al. (2006), Occup Environ Med, 63: 335.

Work stress and health problems after structural intervention*

*12 month-follow-up, two Canadian hospitals, N=302 (intervention) vs. 311 (control hospital) (ANCOVA, adj. for baseline values)

Source: Siegrist J., Wahrendorf M. (2011) in: The Individual and the Welfare State (ed. A. Börsch-Supan et al.) Springer Heidelberg

Macro indicators of national labour and social policies and mean level of work-stress in 13 European

countries (SHARE study)

Macro indicator: Percentage of workers participating in further education.

National welfare state programs

Association between employment rate of women and quality of work (ratio effort and reward)

Results from four national aging studies (SHARE, ELSA, HRS, JSTAR)

Source: unpublished results (2013) T. Lunau, N. Dragano, J. Siegrist

0

1

2

3

socialdemocratic

conservative liberal socialdemocratic

conservative liberal

Effort-Reward imbalance Low conctrol

Od

ds

rati

o

no

yes

Effects of stressful work on depressive symptoms: variation according to welfare system (SHARE)?

Stressful work: Tertiles, effort-reward ratio or low control

Depressive symptoms: Odds ratios adjusted for SEP, age and gender.

Source: Dragano N et al (2011) J Epidemiol Community Health 65: 793-799.

Conclusions I

• Robust scientific evidence of elevated risks of CHD and depression among employees exposed to stressful psychosocial work (DC, ERI, OJ)

• Additional studies demonstrate associations of stressful work with musculoskeletal disorders, sleep disturbances, poor health functioning, alcohol dependence, sickness absence, and disability pension

• Even if the relative attributable risk of each of these health outcomes with regard to stressful work is rather small (e.g. CHD: 5% - 15%; depression: 10% - 20%), a significant part of this burden of disease could theoretically be prevented by strengthening healthy work

Conclusions II

• Given substantial direct and indirects costs of the burden of disease attibutable to unhealthy work, increased investments into evidence based primary and secondary preventive programs at work are strongly recommended

• Preliminary findings from intervention trials point to a business case, i.e. relevant return on investment within 3 to 4 years

• Improving quality of work among occupations with high prevalence of exposure to health-adverse working conditions: – strengthening occupational health services and respective

monitoring and risk management activities– enforcing regulations and voluntary agreements between social

partners– supporting the implementation of best practice models of healthy

work. • Promoting return-to-work programmes, availability of

appropriate rehabilitation services and sufficient benefits for disabled workers and other groups who are excluded from regular work, without compromising principles of basic social protection.

.

Recommendations of strengthening prevention at work (WHO-Euro Review 2013)

Thank you!