adverse health effects of high-effort/low-reward conditions · adverse health effects of...

Journal of Occupational Health Psychology1996, %1.1, No. 1,27-41

Copyright 1996 by the Educational Publishing Foundation1076-8998/96V$3.00

Adverse Health Effects of High-Effort/Low-Reward Conditions

Johannes SiegristUniversity of Diisseldorf

In addition to the person-environment fit model (J. R. French, R. D. Caplan, & R. V. Harrison,1982) and the demand-control model (R. A. Karasek & T. Theorell, 1990), a third theoreticalconcept is proposed to assess adverse health effects of stressful experience at work: theeffort-reward imbalance model. The focus of this model is on reciprocity of exchange inoccupational life where high-cost/low-gain conditions are considered particularly stressful. Vari-ables measuring low reward, in terms of low status control (e.g., lack of promotion prospects, jobinsecurity) in association with high extrinsic (e.g., work pressure) or intrinsic (personal copingpattern, e.g., high need for control) effort independently predict new cardiovascular events in aprospective study on blue-collar men. Furthermore, these variables partly explain prevalence ofcardiovascular risk factors (hypertension, atherogenic lipids) in 2 independent studies. Studyingadverse health effects of high-effort/low-reward conditions seems well justified, especially in viewof recent developments of the labor market.

Remarkable progress has been achieved during thepast 20 years in the study of associations betweenwork and health in general, and between psychosocialhazards at work and adverse health outcomes inparticular (e.g., Cooper & Payne 1988, 1991; French,Caplan, & Harrison, 1982; Hackman & Oldham,1980; Hall, 1990; House, 1981; Johnson & Johann-son, 1991; Kahn, 1981; Karasek & Theorell, 1990; LaFerla & Levi, 1993; Sauter, Hurrell, & Cooper, 1989;Steptoe & Appels, 1989; Warr, 1987). These achieve-ments are impressive given the many difficulties thatare inherent in this type of research. However, acloser and more critical analysis of the current state ofart also reveals significant limitations. These limita-tions can be attributed to one or several of thefollowing challenges that still prevail in this field ofscientific inquiry.

The first challenge concerns the difficulty ofcomputing the knowledge from a wide range ofdisciplines dealing with the issue of work and health.In particular, material from diverse sources such associal, health, and organizational psychology; occupa-tional sociology; and epidemiology, psychosomatic,and behavioral medicine has to be integrated. Yet,integration requires more than just an additivecombination of available information. Ideally, aconcept is needed that links the following three types

I am grateful to my collaborator, Richard Peter, and toThomas Wilson for their helpful comments on this article.

Correspondence concerning this article should be ad-dressed to Johannes Siegrist, Institute of Medical Sociology,University of Diisseldorf, Postbox 101007, D-40001,Diisseldorf, Germany. Electronic mail may be sent viaInternet to [email protected].

of information in a comprehensive way: (a) sociologi-cal information describing the work setting orenvironment; (b) psychological information describ-ing relevant person characteristics (skills, copingprocesses, etc.); (c) biological information describingthe immediate or long-term health consequences.This integration calls for a theoretical approach (seebelow), and it requires the application of adequateresearch designs.

The development and testing of adequate researchdesigns in an area that is basically nonexperimentaldefines a second challenge: How can researchersmake sure that the cause-effect associations aretested, or that the time period of studying exposureimpact is adequate, or that relevant confoundingconditions are assessed? At different occasions,epidemiologist Kasl has discussed these challenges ina critical and seminal way (Kasl, 1989,1991,1993).

As mentioned, a third challenge concerns theory.Which critical components of the working life doaffect human health? To what extent are these effectsattributed to the extrinsic work environment, to theindividual person, or to a specific interaction betweenperson and environment? How is the intensity andchronicity of stressful experience maintained in aperson's job career, and how is it transduced intobodily dysfunction and disease (Weiner, 1992)?These are important questions that still wait fordefinite answers.

In this article I discuss these questions within aspecific theoretical framework, the framework ofhigh-effort/low-reward conditions at work. The expe-rience of an imbalance between high effort spent andlow reward received at work is assumed to be

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particularly stressful as this imbalance violates coreexpectations about reciprocity and adequate exchangein a crucial area of social life. This notion iselaborated in more detail below (see The Model ofEffort-Reward Imbalance at Work section) andempirical evidence on the effects of effort-rewardimbalance on human health, with particular referenceto cardiovascular health, is summarized (see Empiri-cal Evidence section).

The theoretical questions mentioned above havebeen dealt with previously in other, though relatedconceptual frameworks. The two most important andempirically most successful conceptual approachesare the person-environment fit model developed byFrench et al. (1982) and the demand-control modeldeveloped by Karasek (1979) and elaborated furtherby Karasek and Theorell (1990) and by Johnson andHall (1988). In the following section, I briefly discussthese models by pointing out their strengths as well aswhat I consider their open questions. However, thisdiscussion is restricted to a stress-theoretical perspec-tive dealing with links between the social environ-ment, the psychological characteristics, and processesof a person and the organism. Therefore, thediscussion does not adequately reflect the richimplications that are inherent in each one of thesemodels.

The Stressfulness of Incongruenceand Control at Work

The person-environment fit model has opened anew, important view on the role of work in human lifeby stressing the interplay between objective andsubjective components both of the work environmentand of the person. Two types of incongruence thatmay result from these components are of specialrelevance for health: the experience of an incongru-ence ("misfit") between a person's abilities and thedemands of his or her job, and the experience of anincongruence between a person's goals or aspirationsand the supplies offered by the work environment(French et al., 1982; Harrison, 1978; Kahn, 1981). Itis important to mention that the person's appraisal ofthis incongruence triggers his or her coping (ordefense) mechanisms and related strain reactions.This view is in accordance with a widely prevalentpsychological theory of stress (Lazarus, 1991).

The model has been elaborated to an impressivedegree, and the direct and indirect interactive effectsamong its crucial variables were specified. However,in a stress-theoretical perspective, several questionshave not yet been answered. One question concerns

the relevance of job dimensions involved. Does itmatter what components of the job environmentcontribute to the misfit experience? Is there anyimplicit association between the job componentsunder study and what is commonly considered acrucial strain dimension such as "control" or"threat"? Does the impact of the work environmenton strain experience vary from person to person?Another question relates to the chronicity of strainexperience: If "perceived misfit" is the importantcondition, then why do individuals not either altertheir environment or adapt their cognitions to thismisfit? Moreover, one may ask why this model doesnot specify those characteristics of personal copingthat critically enhance the intensity of strain reactionsand associated disease vulnerability.

As indicated, there is no doubt that the concept ofcontrol plays a crucial role in our understanding ofgeneral relationships between stressors and strainreactions. This was convincingly demonstrated inexperimental animal research (Henry & Stephens,1977) and in psychophysiologic studies in humans(Frankenhaeuser, 1979). Control is a major dimensionin the second theoretical concept to be discussed here,the influential demand-control model of work stress(Karasek, 1979; Karasek & Theorell, 1990). It is notalways clear, however, what "control" means in thiscontext. Kasl (1989) and Parkes (1989) pointed outthat interpretation of the control construct depends onthe particular focus of respective studies and theresearch tradition in which they are embedded.According to Parkes, at least three different ap-proaches to defining control in the work environmentcan be identified: "(1.) control as an objectivecharacteristic of the work situation, reflecting theextent to which the design of work tasks ... allowsopportunities for control; (2.) control as a subjectiveevaluation reflecting an individual's judgement aboutthe extent to which his or her work situation isamenable to control; and (3.) control as a generalizedbelief on the part of an individual about the extent towhich important outcomes ... are controllable"(Parkes, 1989, p. 21 f).

These three aspects are often not distinguished withsufficient clarity. Even approaches that clearly favorthe notion of control as an objective work characteris-tic tend to merge a variety of interrelated phenomenato one single conceptual scheme (for a detailedanalysis of this argument, see Kasl, 1989). Moreover,such approaches often tend to disregard the range ofunexplained phenomena when neglecting dimensionsof personal control.

For instance, the demand-control model explicitly

SPECIAL SECTION: HIGH EFFORT-LOW REWARD 29

restricts its notion of control to objective taskcharacteristics in terms of decision authority and skilldiscretion. By doing so, variations in physiologicalarousal remain unexplained, which may be due topersonal modes of coping with limited control. Suchmodes of coping include ways of changing one's levelof aspiration, modifying one's degree of job involve-ment, reducing the amount of effort spent anddistancing at the cognitive or emotional level.

In his thoughtful review of the demand-controlconcept, Kasl (1989) illustrated this point by quotinga number of research findings where elevated levelsof strain in otherwise homogenous working groupswere restricted to those individuals who exhibitedhigh work investments or to those who failed torealize their aspirations. The role of individualdifferences is further substantiated in studies summa-rized by Parkes (1989, 1991) and by Cooper andPayne (1991). Such findings call for a conceptualclarification of the relationship between control-limiting job conditions and those personal characteris-tics that influence the perception of and the search forcontrol.

In this respect, the concept "need for control" as adistinct individual pattern of coping with workdemands was developed (Matschinger et al., 1986,Siegrist & Matschinger, 1989). This concept evolvedfrom a critical analysis of the rather global pattern ofType A behavior. Need for control specifies thosecognitive, emotional, and motivational componentswithin the global concept of Type A behavior that aresuspected of triggering enhanced arousal in demand-ing situations: Individuals who score high onmeasures of need for control often tend to misjudge(i.e., overestimate or underestimate) demandingstimuli in their personal perception. It seems that bothtypes of misjudgement are instrumental in elicitingexcessive efforts and in providing opportunities toexperience approval, success, and dominance. Al-though self-rewarding and successful over a period ofyears in adult life, and especially so in occupationallife, high levels of need for control in the long runmay precipitate states of exhaustion and physiologicbreakdown (see below, see also Appels & Mulder,1989).

There is no doubt that the demand-control model,with its clear focus on the structure of task profilesand its impact on health, is of utmost importance. Alarge majority of empirical tests of this model weresuccessful, especially so with respect to cardiovascu-lar disease (Schnall, Landsbergis, & Becker, 1994),and the model proved to be helpful in implementingstructural changes of work organization in a number

of enterprises (Karasek & Theorell, 1990). Despitethese merits a further relevant question still remainsto be answered: How does exposure to a high-demand/low-control job elicit chronically stressful experi-ence? The authors themselves give the followinganswer: Lack of control over how to meet the job'sdemands and how one can use one's skills defines astate of arousal that inhibits learning; strain-inducedinhibition of learning, in turn, further increasesarousal by impairing confidence and self-esteem(Karasek & Theorell, 1990). However, one may askhow inhibition of learning is associated with long-term physiologic activation. Again, one obviousreaction to this situation would be to restrict one'samount of effort, to adapt cognitively, emotionally,and motivationally to this rather unfavorable taskprofile.

In conclusion, despite their undisputed merits, bothconceptual approaches, the person-environment fitmodel and the demand-control model, leave research-ers with some unresolved questions, especially thoseconcerning the chronicity of stressful experience, themeaning of "control," and the role of individualcoping characteristics. I do not claim to answer thesequestions, but I want to demonstrate how they can beapproached in a somewhat different conceptualframework.

The Model of Effort-RewardImbalance at Work

By studying adverse health effects of high-effort/low-reward conditions at work, I shift the focus ofanalysis from control to reward. What does this shiftmean in terms of stress theory? To answer thisquestion, the basic arguments of my approach need tobe developed. I maintain that the work role in adultlife defines a crucial link between self-regulatoryfunctions such as self-esteem and self-efficacy andthe social opportunity structure. In particular, theavailability of an occupational status is associatedwith recurrent options of contributing and perform-ing, of being rewarded or esteemed, and of belongingto some significant group (e.g., work collegues). Yetthese potentially beneficial effects of the work role onemotional and motivational self-regulation are contin-gent on a basic prerequisite of exchange in social life,that is, reciprocity. Effort at work is spent as part of asocially organized exchange process to which societyat large contributes in terms of rewards. Societalrewards are distributed by three transmitter systems tothe working population: money, esteem, and statuscontrol (see Figure 1). The model of effort-reward

30 SEGRIST

High Effort

Extrinsic(demands,obligations)

\Intrinsic(critical coping;e.g. need tor control)

Low Reward

MoneyEsteemStatus control

Figure 1. The effort-reward imbalance model at work.

imbalance claims that lack of reciprocity betweencosts and gains (i.e., high-cost/low-gain conditions),define a state of emotional distress with specialpropensity to autonomic arousal and associated strainreactions. Before explaining why sustained emotionaldistress is likely to occur under such conditions, theterm status control needs to be introduced in moredetail.

The notion of status control evolved from myinterest in those aspects of occupational life thatthreaten a person's self-regulatory functions, his orher sense of mastery, efficacy, and esteem by evokingstrong recurrent negative emotions of fear, anger, orirritation. According to sociological theories of selfand identity (Mead, 1934; Schutz, 1962-1964) suchthreats are likely to occur if the continuity of crucialsocial roles is interrupted or lost. Under thesecircumstances, control over basic interpersonal re-wards is restricted, and as a consequence, self-esteemand emotional well-being are impared.

For a large part of the adult population, occupa-tional positions provide one such crucial social role.Threats to the continuity of occupational roles areassumed to produce sustained emotional distress.Most clearly, this is the case with job termination orjob instability. However, related conditions of lowreward and low security in occupational life may alsobe identified, such as forced occupational change,downward mobility, lack of promotion prospects, orjobs held with inconsistent educational background(status inconsistency). In all these conditions of lowoccupational status control in combination with higheffort, basic reciprocity of costs and gains is lacking.Therefore, having a demanding, but unstable job,achieving at high level without being offered anypromotion prospects, are examples of a particularlystressful working context.

With respect to the notion of status control, twoimportant differences between the effort-rewardimbalance model and the demand-control modelshould be noted here. First, in stress-theoreticalterms, a difference is likely to exist between the costsof adaptation to the two conditions of low control: It

seems less costly to cognitively adapt to a low level oftask control than to adapt to a low level of statuscontrol, simply because in the former condition fewerfundamental threats are involved. Second, in terms ofcurrent developments of the labor market in a globaleconomy, the emphasis on status control reflects thegrowing importance of fragmented job careers, of jobinstability, redundancy, and forced occupationalmobility. Under these conditions, concerns aboutstatus control among the labor force to some extentmay override concerns about task control.

In Figure 1, three dimensions of occupationalgratifications are distinguished: money, esteem orapproval, and status control. Although I discussed thedimension of status control in some detail, it isnevertheless obvious that inadequate payment andlack of esteem and approval in association with higheffort are similarly distressing experiences. In allthese instances, high-cost/low-gain conditions arelikely to elicit recurrent feelings of threat, anger, anddepression or demoralization, which in turn evokesustained autonomic arousal.

Although I have already answered the question ofwhy high-cost/low-gain conditions at work areconsidered particularly stressful, two additionalexplications need to be given. First, in line with theconcept depicted in Figure 1, I define two differentsources of high effort at work, an extrinsic source, thedemands on the job, and an intrinsic source, themotivations of the individual worker in a demandingsituation. In this latter regard, I have alreadyintroduced the concept of need for control as apersonal pattern of coping with the demands at work.It is likely that persons with high need for controlspend high costs in terms of energy mobilization andjob involvement even under conditions of relativelylow gain. This may be explained partly by thecharacteristics of their perceptual and attributablestyle, partly by the self-gratifying experience of"being in control" of a challenging situation.Therefore, an adequate assessment of the "high cost"part of the equation requires information about eithersource of effort, extrinsic and intrinsic.


The second explication concerns our answer to thequestion of why people should engage in suchunfavorable trade-offs in their working life. In fact, awell-known psychological theory predicts that effort-reward imbalance is not maintained over a longerperiod of time and, thus, may not be of pathophysi-ologic importance. I briefly discuss the argument. Theexpectancy value theory of motivation assumes thatrational choice operates in individuals to achieve andmaintain a balance between energy consumption andreward experience (Schonpflug & Batmann, 1989).High-cost/low-gain conditions are likely to be avoidedor dismissed to maximize one's profit. At least,reduced expectancy operates to minimize one'sefforts. This theory may be valid in many instances.Yet it does not take into account the social constraintsunder which individuals must take their decisions,especially the constraints associated with low occupa-tional status control.

For instance, blue-collar workers with reducedopportunities of changing jobs will not minimize theireffort at work even if their gain is low. The reason forthis behavior is obvious: The possible costs producedby disengagement (e.g., the risk of being laid off or offacing downward mobility) by far outweigh the costsof accepting inadequate benefits. Thus, I wouldmaintain that under defined conditions of lowoccupational status control, effort-reward imbalanceis maintained contrary to the prediction derived fromthe expectancy value theory of motivation.

A similar argument can be found in the classicalwritings of John Stuart Mill (1848/1965) whochallenged Adam Smith's theory of compensatorywage differentials by the following argument:

The really exhausting and the really repulsive labours,instead of being better paid than others, are almostinvariably paid the worst of all, because performed bythose who have no choice. The inequalities of wagesare generally in an opposite direction to the equitableprinciple of compensation erroneously represented byAdam Smith as the general law of the remuneration oflabour. The hardships and the earnings, instead of beingdirectly proportional, as in any just arrangements ofsociety they would be, are generally in an inverse ratioto one another (Mill, 1848/1965, p. 383).

To summarize: High-cost/low-gain conditions atwork are likely to occur in those groups of theworkforce that exhibit a low level of occupationalstatus control.

However, among higher status groups theseconditions may be prevalent as well. One exampleconcerns persons who for strategic reasons assumeextra work and additional responsibilities to competefor promotion prospects. Failed aspirations after yearsof excessive effort were shown to be a frequent

psychosocial risk constellation among victims ofpremature myocardial infarction (Siegrist, Dittman,Rittner, & Weber, 1982). In summary, the model ofeffort-reward imbalance applies to a wide range ofoccupational arrangements, most markedly to groupsthat suffer from a growing segmentation of the labormarket (Doeringer & Piore, 1971), to groups exposedto structural unemployment and rapid socioeconomicchange, to some extent also to groups that areinvolved in highly competitive career development.

A final point of my argument concerns thepathways of affective processing in high-cost/low-gain conditions. According to a widely discussedpsychological theory, the cognitive theory of emotiondeveloped by Lazarus (1991), cognitive appraisal orevaluation of an experienced stressor precedes anyform of emotional response. In this view, negativeemotions are the result of a multistage appraisalprocess, which includes the taxing of stressorproperties and of a person's coping repertoire underexposure. Negative affect is considered a commonreaction to conditions that exceed a person's copingabilities and thus threaten her or his self. Again, thistheory would predict cognitive and behavioraladjustment to a high-cost/low-gain condition as aconsequence of cognitive appraisal processes.

A recent debate on cognitive theory of emotionrevealed some limitations of this approach. There isgrowing evidence of rapid and direct pathways ofaffective information processing that bypass neocorti-cal-limbic structures and, thus, are not subjected toconscious awareness (LeDoux, 1987). Moreover,affective processing in limbic structures was shown tomodulate neocortically organized patterns of socialcognition in humans (Adolphs, Tranel, Damasio, &Damasio, 1994).

Therefore, it is likely that affective processing isquite different from conscious computational process-ing. Or, as Gaillard and Wientjes (1993) argued,

In contrast to computational processing we have nocontrol over the way in which emotional aspects of theinformation are processed. These processes are encap-sulated and are largely unconscious. Only the results ofthis processing reach our consciousness. We may evenfeel anxious although we do not know why... . It ishardly possible to disregard the signals that are sent byour emotions. Strong negative emotions, in particular,have 'control precedence' relative to other signalsreaching our consciousness (Gaillard & Wintjes, 1993,p. 26Sf).

In this perspective, negative affect associated withthe experience of effort-reward imbalance at workmay not necessarily be subjected to consciousappraisal, especially as it is a chronically recurrenteveryday experience.

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Empirical Evidence

In the first, major part of the Empirical Evidencesection, I summarize existing evidence in favor of theexplanatory power of the effort-reward imbalancemodel described above. This evidence is drawn froma series of studies conducted under my responsibilityas a principal investigator (Peter, Siegrist, Stork,Mann, & Labrot, 1991; Siegrist, Bernhardt, Feng, &Schettler, 1990; Siegrist, Peter, Junge, Cremer, &Seidel, 1990; Siegrist, Peter, Motz, & Strauer, 1992).Main criterion variables under study are newcardiovascular events (see Cardiovascular Diseasesection) and cardiovascular risk factors. In addition,associations between effort-reward imbalance andcardiovascular and hormonal reactions to an acutemental challenge are explored. In the second part (seeIndirect Evidence section), some indirect evidence isput together, that is, research findings from othergroups that did not explicitly measure the effort-reward imbalance model but that to some extent fitwith its core notions.

Direct Evidence

Before presenting results, I indicate how the modelwas measured and what types of studies wereperformed. In social science research on work andhealth, three sources of information are usuallyavailable: (a) contextual information derived fromindependent sources such as administrative data,objective measurements; (b) descriptive informationobtained from workers through structured interviewsor questionnaires; and (c) evaluative informationreflecting subjective appraisal (obtained throughinterviews and questionnaires). For two reasons, thismeasurement approach combines these three differentsources of information. First, the theoretical argumentrequires a combination of evaluative and descriptiveor contextual information to assess the extrinsic andintrinsic components of the model. Second, themethodological principle of triangulation is followedto secure the validity of these measures.

The following list of indicators defines the coremeasures of effort-reward imbalance at work.

Intrinsic effort. The coping pattern immersion ismeasured by a psychometric scale termed need forcontrol (Siegrist & Matschinger, 1989). This scalecontains 45 dichotomous items. By means ofconfirmatory factor analysis, two latent factors wererepeatedly found: "vigor" and "immersion." Accord-ing to my theoretical assumption, the latter factordefines a critical style of coping with demandsreflecting frustrated, but continued, efforts and associ-

ated negative feelings. A high score on the scalesmeasuring immersion indicates a critical stage ofintrinsic effort. This high score is defined as follows:upper tertile of the 29 items defining the total factorscore of immersion, or upper tertile of factor scoreson the following four subscales: (a) need for approval,(b) competitiveness and latent hostility, (c) impa-tience and disproportionate irritability, and (d)personal inability to withdraw from work obligations.

In addition to this pattern of critical coping withdemands, the following indicators of an emotionallydistressing state of effort were included: (a) feelingsof sustained anger during the past 12 months, (b)feelings of sustained hopelessness during the past 12months, and (c) aggravated sleep disturbanceswithout any obvious somatic background.

Extrinsic effort. Contextual information on extrin-sic effort varies according to the study population. Inthe blue-collar study piece work, shift work, overtimework, and increase of work load due to shortage oflabor force were major contextual indicators ofextrinsic effort (Siegrist, Peter, Junge, et al., 1990). Inthe study on middle managers, work pressure wasclosely associated with size of department, (i.e.,number of subordinates and coworkers to be super-vised; Peter, Siegrist, Stork, et al., 1991). Thus, thiscontextual measure was used in addition to thedescriptive measures (see below).

Descriptive and evaluative information on extrinsiceffort was obtained from ratings concerning fre-quency and stressfulness of experienced work pres-sure, interruptions, inconsistent demands, or facingdifficult problems.

Occupational rewards. In addition to contextualinformation on wages and salaries, the worker'sevaluation of payment was assessed. Esteem rewardwas measured by two items that asked about beingaccepted by supervisors or collegues and that askedabout receiving help in difficult conditions bysupervisors or collegues. Status control was measuredpartly by contextual information (e.g., amount ofredundancy in the workforce during observationperiod), partly by description and evaluation (forcedmobility, promotion prospects, status inconsistency,job insecurity).

Combinations of measures. In keeping with thecore assumption of the effort-reward imbalancemodel I focused the analysis on those conditionswhere at least one indicator of high extrinsic orintrinsic effort and one indicator of low occupationalreward were simultaneously present. These condi-tions were thought to trigger sustained distress and


activation and thus to impair the cardiovascularsystem in the long run.

Study samples. The two study samples fromwhich the following results were obtained and theresearch designed are as follows. First, we conducteda 6.5 year prospective study of a cohort of 416 maleblue-collar workers (ages 25-55, M = 40.8 ± 9.7).All men were free from overt coronary heart diseaseat entry. Medical and psychosocial data werecollected at entry and three times during follow-up.Baseline psychosocial measures were used to explainprevalence and change over time in major coronaryrisk factors and to predict new clinical events(Siegrist, Peter, Junge, et al., 1990; Siegrist, Peter,Motz, et al., 1992).

The second study to be reported was a cross-sectional analysis of associations between indicatorsof effort-reward imbalance at work and majorcoronary risk factors such as hypertension, elevatedfibrinogen, elevated atherogenic lipids, and smokingin a sample of male middle managers (n = 179; ages40-55; M = 48.5 ± 4.5). This sample was remark-ably homogeneous in terms of age and occupationalstatus, and it was representative of the total group ofmiddle managers of this age group in the enterprise(Peter, Siegrist, Stork, et al., 1991). In both studies,epidemiological and clinical information was com-bined with psychophysiological information derivedfrom a standardized psychomental stress test (Klein,1990,1995).

I restrict this review to the presentation of findingsfrom these two studies as they represent the researchthat fully assessed all relevant notions of thetheoretical model. It is well-known that in epidemio-logical studies a trade-off is needed between thesocial scientist's research interests and the constraintsof time, personnel, and money in conducting fieldstudies. In this respect, parts of these measures werealso included in two large-scale prospective studies,allowing only partial testing of the main researchhypotheses.

One such study was conducted in a cohort of some1,100 Chinese industrial workers in the city of Wuhanwho were followed over a period of 5 years.Measurements had to be largely restricted to contex-tual and descriptive information. Yet, this studyrevealed an interesting finding in terms of high-effort/low-reward conditions: systolic blood pressure andserum cholesterol significantly increased during the 5years in the subgroup of workers who were recentlyallowed to extend their working hours and were paidovertime and productivity bonuses. This augmentedpressure at work was associated with an increase in

job insecurity and uncertainty about further promo-tion prospects. The observed effects were adjusted forimportant confounders such as age, body weight,smoking, and alcohol consumption (Siegrist, Bern-hardt, Feng, et al., 1990).

A second prospective study that includes only apart of the measures was conducted in a cohort ofsome 4,000 industrial workers in Germany. Finalresults of this study are not yet fully published, butthey demonstrate an independent effect of highintrinsic effort at work (as measured by a shortversion of the "need for control" scale) on incidenceof coronary events in a 5-year observation period(Cremer et al., 1991, p. 59).

Cardiovascular Disease

A. relevant test of the explanatory power of atheoretical model concerns its ability to statisticallypredict disease manifestation. In prospectively de-signed epidemiological studies it is possible to predictincidence of clinical endpoints (e.g., as in this case,acute myocardial infarction, AMI, or sudden cardiacdeath, SCD; International Classification of Diseases410—414) by using baseline information on the modeland by adjusting the observed effects for importantconfounders such as age, smoking, blood pressure,cholesterol, or body weight. As a well-establishedstatistical procedure, logistic regression analysisserves to estimate the odds ratios of relevantpredicting variables. In these analyses, the model fitof the most parsimonious model is tested by thelikelihood ratio difference test (Hennekens & Buring,1987).

Table 1 presents a summary of findings derivedfrom the prospective blue-collar study. The predictivepower of indicators of high effort and low reward atwork is indicated in terms of multivariate odds ratiosand 95% confidence intervals of respective variables.I have analyzed these associations with threeinterrelated sets of outcome criteria: (a) AMI or SCD;(b) AMI or SCD and subclinical coronary heartdisease (CHD; i.e., CHD as documented by electrocar-diogram without meeting criteria of primary end-point, total cases n = 42); (c) AMI, SCD, or stroke.As the three groups are overlapping to some extent,findings cannot be interpreted as being independent.Rather, they underscore the relative consistency ofrespective results.

As can be seen from Table 1, two indicators of higheffort and two indicators of low reward at workindependently predict new coronary events (AMI orSCD). The magnitude of these odds ratios iscomparable although the confidence intervals are

34 SIEGRIST

Table 1Odds Ratios From Multivariate Logistic Regression Analysis ExplainingCardiovascular Disease by Indicators of Effort-Reward Imbalance at Work

Indicator Odds ratio

AMI or SCO

Work pressure (extrinsic effort) 3.45Immersion (intrinsic effort) 4.53Status inconsistency (reward, status control) 4.40Job insecurity (reward, status control) 3.41

AMI, SCO, or subclinical CHD

Work pressure (extrinsic effort) 2.54Immersion (intrinsic effort) 2.30Status inconsistency (reward, status control) 2.05Combined effect of effort-reward imbalance" 6.15

AMI, SCO, or stroke

Immersion (intrinsic effort) 3.57Status inconsistency (reward, status control) 2.86Combined effect of effort-reward imbalance" 8.24

95% CI

0.97-12.301.15-17.801.36-14.200.81-14.50

1.08-5.980.86-6.140.9(M.702.01-18.82

1.22-10.471.04-7.802.34-28.43

Note. At entry, n — 416 male blue-collar workers. CI = confidence interval; AMI = acutemyocardial infarction; SCD = sudden cardiac death; CHD = coronary heart disease."For detailed information and interpretation, see Direct Evidence section.

quite large. This latter fact may be due to the smallnumber of cases in this sample. Table 1 also containsinformation on the odds ratios of respective psychoso-cial predictors of clinical and subclinical CHD as wellas of CHD and stroke.

In keeping with the theoretical assumption, Iexplored the cumulative effect of a simultaneousmanifestation of high effort and low reward in CHDpatients versus people who remained free from CHD.This was done according to the following twoprocedures: First, I introduced respective interactionterms in multivariate logistic regression analysis. Thisapproach, in general, failed to produce expectedresults. A closer inspection revealed that the relativelysmall number of cases contributed to the productionof a series of "zero cells" in the calculations, whichmay have had an adverse impact on outcomes. Thesecond procedure consisted of computing an aggre-gate variable that combined all relevant predictinginformation regarding effort-reward imbalance ac-cording to the following three categories: (a) at leastone indicator of high effort and at least one indicatorof low reward is present; (b) either one (or more)indicator of high effort or one (or more) indicator oflow reward is present; (c) neither (a) nor (b) areobserved. I expected this three-categorial variable toproduce substantially elevated odds ratios in logisticregression analysis compared with the odds ratiosproduced by single predicting variables.

In Table 1, two examples of this latter strategy are

given. First, with respect to clinical and subclinicalCHD, the observed effect of the multivariate oddsratio produced by the aggregate measure (6.15) isclearly more powerful than the effects produced byrespective single psychosocial variables remaining inthe most parsimonious model. A second exampleconcerns CHD and stroke. Here again, the effect ofthe combined variable (multivariate odds ra-tio = 8.24) by far exceeds the odds ratios of the twosingle variables remaining in the model.

Of course, these examples need to be interpretedwith caution. The confidence intervals are large(which is why I did not include the results of theanalysis of the aggregate measure in the thirdexample, the AMI-SCO group, in Table 1). More-over, the magnitude of odds ratios cannot becompared directly between the different regressionmodels. Yet, given the relative consistency of thefindings and the observation that in all instancesconditions of high effort and of low reward at workpredict disease outcome, I think it is worth summariz-ing these results in the suggested way (for details, seeSiegrist, 1996; Siegrist, Peter, Junge, et al., 1990;Siegrist, Peter, Motz, & Strauer, 1992).

Cardiovascular Risk Factors

Although there is considerable evidence availableon direct effects of sustained distress-induced auto-nomic activation on atherogenesis and its further


course (Manuck et al., 1991), theoretical models inthis area should also be able to contribute to theexplanation of main pathways leading to CHD, theestablished cardiovascular risk factors. The substanceof these risk factors is quite heterogeneous, rangingfrom genetic to lifestyle influences. In the context ofthis research, I am mainly interested in effects ofdistress-induced autonomic activation on somatic riskfactors such as atherogenic lipids, hypertension, andelevated fibrinogen. Given the fact that such patho-physiological mechanisms are currently discussed ingreat detail (Henry, 1992; Markovitz & Matthews,1991), the following question is raised: Is it possibleto demonstrate associations between components ofthe effort-reward imbalance model and these riskfactors at the level of statistical analysis bothcross-sectionally and longitudinally?

I answer this question by using two differentstatistical techniques: (a) logistic regression analysisand (b) linear structural equation modeling. I firstrefer to the approach introduced in the previoussection where the construction of an aggregatevariable as a proxy measure of high-cost/low-gainconditions at work was explained. It was argued thatpronounced effects of this variable should consis-tently result from logistic regression analysis what-

ever criterion variable (disease endpoints, riskfactors) was of interest.

In Table 2, results of logistic regression analyseswith three different cardiovascular risk factors aresummarized. These risk factors are (a) hypertension(defined according to World Health Organizationcriteria), (b) atherogenic lipid level (low densitylipoprotein cholesterol >160 mg/dl), and (c) thecomanifestation of hypertension and of high athero-genic lipids. This latter condition was shown toelevate the risk of CHD over and above the risksproduced by its single components (Castelli &Anderson, 1986).

As can be seen from Table 2, the crucial predictingvariables to some extent differ from analysis toanalysis, but it is always the combination of at leastone indicator of high effort and of at least oneindicator of low reward that produces the observedstrong effect, irrespective of whether data from theblue-collar study or the white-collar study areanalyzed.

These findings were adjusted for a number ofrelevant confounders, and their robustness wasfurther explored by additional analyses, including apartial replication using a different data set (Peter,1991; Siegrist, 1996, Siegrist, Peter, Georg, et al.,

Table 2Odds Ratios From Multivariate Logistic Regression Analysis ExplainingCardiovascular Risk Factors by Indicators of Effort-Reward Imbalance at Work

Indicator Odds ratio 95% CI Criterion

Combined effect of effort-reward imbalance

Overtime work (e)Cutdown of personnel (r)Fear of job loss (r)Job instability (r)

Blue-collar workers

3.29 1.11-9.77 Comanifestation of hyperten-sion and atherogenic lipids

Middle managers


Work pressure (e)Frequent interruptions (e)Lack of reciprocal support (r)

3.33 1.22-9.21 Atherogenic lipids (LDL cho-lesterol > 160 mg/dl)


Frequent interruptions (e)Forced job change (r)

Middle managers

6.81 1.70-26.60 Hypertension (SBP > 160mmHg and/or DBF a90mmHg)

Note, n = 179 male middle managers and n = 416 male blue-collar workers. CI =confidence interval; e = effort; r = reward; SBP = systolic blood pressure; DBF = diastolicblood pressure.

36 SIEGRIST

1991). Moreover, components of the model success-fully explained level of fibrinogen in the middlemanagers study (Peter, Siegrist, Cremer, et al., 1995)and were associated with cigarette smoking (Peter etal., 1991). Nevertheless, these are cross-sectionaldata, and the results are based on rather crudebiomedical variables. Thus, in conclusion, they canbe regarded as supporting the general line of researchwhile calling for more detailed consecutive studies.

A second statistical approach was applied in searchof a modeling technique that would seem moreappropriate to the theoretical model outlined: linearstructural equation analysis (LISREL; Joreskog &Sorbom, 1979). LISREL represents a statisticalprogram which by combining factor analysis and pathanalysis allows a confirmatory test of a set of effectsbetween latent and manifest variables in differentpopulations. Furthermore, one can test the model fitunder certain restrictions for model parameters suchas the restriction of invariance of parameters betweendifferent groups of observation.

Working with data from the blue-collar study,Siegrist and Matschinger (1989) defined two concep-tually different, although empirically not totallyindependent conditions of low occupational statuscontrol: (a) forced piecework (defining blue-collarswho for reasons of maintaining their standard ofliving had to continue piecework) and (b) unskilled orsemiskilled job qualification. According to myhypothesis, these conditions describe two powerfulsocial contexts that modulate the intensity ofeffort-related experience of distress at work. In otherwords, they postulated an identical structure of effectsamong variables measuring distress at work for thetwo respective subgroups of the study sample(workers with forced piecework vs. workers withoutforced piecework and unskilled or semiskilledworkers vs. higher qualified workers, respectively),but they postulated explanatory power of the modelconcerning its most endogenous criterion, level ofblood pressure, in the presence only of the stressfulcontext.

Although a detailed presentation of respectivefindings is beyond the scope of this review (Siegrist &Matschinger, 1989), major results can be summarizedas follows:

1. A model composed by the two latent factors ofthe construct need for control, by the variablesworkload, social support at work, sustained anger andhopelessness, and the confounding factors of age,body weight, and cigarette smoking was tested withrespect to the amount of explained variance ofsystolic blood pressure. In the group of workers

suffering from forced piecework, the amount ofexplained variance was 44% compared with 14% inthe remaining group.

2. An identical model was tested in the two groupsof unskilled or semiskilled workers versus higherqualified workers. Here again, the amount ofexplained variance of systolic blood pressure wassubstantially higher in the group with low occupa-tional status control: 54% compared with 27% in theless-distressed, higher status group.

3. A third linear structural model was tested in closeassociation with the first one described above (forcedpiecework). Yet, in this model, blood pressuremeasures from two different screenings of theprospective blue-collar cohort were integrated. Again,an acceptable model fit was observed, and unstandard-ized beta and gamma coefficients were alwayssignificant in the stressed group while insignificant inthe nonstressed group.

Cardiovascular and Hormonal Reactions

One of the three crucial questions raised in theintroductory section was stated as follows: How isstressful experience transduced into bodily dysfunc-tion and disease? Traditionally, epidemiologic studiesin the field of psychosocial occupational health arerestricted to the analysis of statistical associationsbetween predicting variables measuring work stressand outcome criteria measuring health. Yet, it iscrucial to obtain additional information on thebiological mechanisms underlying these associations.Ambulatory monitoring techniques and standardizedmental stress tests define two methodological tradi-tions in this regard, despite the many restrictionsinvolved in either approach. As mentioned before, wecombined mental stress testing with epidemiologicexplorations in the blue-collar study as well as in themiddle managers study. This combination was givenhigh priority for theoretical reasons, which are brieflysummarized as follows (for details, see Klein, 1995;Siegrist, 1996).

1. In the long run, recurrent autonomic activationfollowing the experience of effort-reward imbalanceat work is expected to tax the cardiovascular andhormonal systems involved in these responses.

2. As a consequence of long-term taxing, cardiovas-cular and hormonal reactions to acute challenges maybe compromised (i.e., reduced rather than elevatedmaximal responsiveness is expected to occur).Reduced responsiveness may be modulated peripher-


ally (e.g., via down regulation of beta receptors) orcentrally at control sites within the brain.

3. In a cohort of workers of roughly the same age,where additional confounders are controlled for,exposure to high level of chronic effort-rewardimbalance at work is associated with reducedmaximal cardiovascular and hormonal responsive-ness to acute mental stress. This association givessome limited (cross-sectional study design) indirectevidence on (at least one of the) biological processesthat may mediate chronically stressful experience tobodily dysfunction.

In fact, Klein (1990, 1995) and Siegrist (1996)found support for systematic associations betweenmeasures of chronic stress at work (in terms of higheffort-low reward) and reduced responsiveness to astandardized mental stressor (a modified version ofthe Stroop color-word conflict task) in either study.

Measures of responsiveness in the blue-collarstudy were restricted to heart rate and blood pressureresponses (differences between baseline and maximalstress). After carefully adjusting for a number ofconfounding factors, significant effects were ob-served for the following indicators of chronic workstress: (a) high demand in combination with low jobsecurity; (b) worsening of job conditions; (c)cumulative workload (Klein, 1990).

In the middle managers study, hormonal measurescould be assessed in addition to measures ofcardiovascular reactivity. Moreover, it was possible tocompute a summary index of high-effort/low-rewardexperience at work (not including, however, the scaleof need for control). Again, results showed the sametrend: Middle managers in the upper fertile of chronicwork stress were found to react with significantlyreduced heart rate, adrenalin, and cortisol reactions tomental challenge if compared with managers definedby lower levels of work stress. Main effects ofanalysis of variance were adjusted for age, bodyweight, medication, cigarette smoking, physicalinactivity, baseline level of reactivity measure, coffeeconsumption before test, and diurnal time. Resultscould not be attributed to test performance or differenttest evaluation (Klein, 1995).

Although the pathophysiological significance ofthese results is far from clear, it nevertheless adds tothe consistency of reported findings: In addition topredicting cardiovascular events and to explainingprevalence of selected cardiovascular risk factors,measures of high-effort/low-reward conditions atwork are consistently associated with reduced reactiv-ity to acute mental challenge. These latter observa-

tions may be interpreted in the framework oflong-term effects of exposure to chronic stressors onautonomic nervous system regulation.

Indirect Evidence

A considerable part of published findings insocial-epidemiologic studies on work stress andhealth to some extent can be interpreted in the frameof the described model. The problem inherent in arespective reinterpretation consists in the selectivityof available information and, of course, in the ex-postnature of respective arguments. Therefore, I restrictthis section to a very limited number of studiesshowing both the limits and the gains of such anenterprise.

In his excellent review, Theorell (1992) recentlyquoted a number of studies in the field of socialepidemiology of CHD whose results at least partly fitwith the above mentioned model. For instance,Kornitzer, Kittel, Dramaix, and de Backer (1982)found increased CHD incidence among clerks of aprivate bank where increase of workload in combina-tion with reduced job security was obvious. In a morerecent study, Mattiasson, Lindgarde, Nilsson, andTheorell (1990) observed elevated levels of athero-genic lipids in shipyard employees who werethreatened by unemployment. Another example isdrawn from a recent study of Johnson and Stewart(1993). When putting together demand-control char-acteristics in a lifetime perspective in a cohort ofworkers, Johnson and Stewart observed a decrease indecision latitude-control levels 2-3 years beforeCHD manifestation in future victims but not inworkers who remained free from manifest CHD. Thisdecrease may be analyzed in terms of threats to or lossof occupational status control.

Some but not all earlier studies on occupationaldownward mobility and forced job change found anelevated risk of CHD (for overview, see Siegrist,1996). The particular case of job termination andunemployment is difficult to evaluate in this context.First, until recently, there were few studies thatconformed to the methodological requirements in thisarea of research. This has changed recently where atleast two independent prospective studies docu-mented an adverse effect of (involuntary) unemploy-ment on cardiovascular health (Martikainen, 1990;Moser, Goldblatt, Fox, & Jones, 1987). Second,however, virtually no information is available fromthese studies concerning the effort component of thepre-unemployment job career. Again, I hypothesize

38 SffiGRIST

that the predictive power in these studies could beimproved if this information was available.

Concluding Remarks

In this review, three relevant questions concerningthe links between psychosocial occupational stressand health were discussed.

The first question asked how to identify thosecomponents within the global psychosocial occupa-tional environment that are of critical importance tohealth. It was argued that the help of theory is neededto analytically define those critical components. Inthis regard, two theoretical models were brieflyreviewed, the person-environment fit model and thedemand-control model.

The second question asked how chronicallystressful experience is maintained in individuals whoare exposed to the psychosocial stressors identified intheoretical models. To answer this question, thenotions of threat, status control, and reciprocity ofexchange in occupational life were introduced. Basedon these notions, a third theoretical concept wasintroduced: the model of effort-reward imbalance atwork.

The third question related to the adverse healtheffects of chronically stressful experience in terms ofhigh effort and low reward. Here the focus was put oncardiovascular health, and the three answers given tothis question summarized major findings from twosocial epidemiologic and psychophysiologic studieson middle aged men conducted in the group. First, thepredictive power of components of the model withrespect to the incidence of cardiovascular events wasdemonstrated in terms of multivariate odds ratios (seeCardiovascular Disease section and Table 1). Sec-ond, associations of indicators of high effort and lowreward with cardiovascular risk factors were pre-sented (see Cardiovascular Risk Factors section andTable 2). Finally, within the limits of cross-sectionalpsychophysiologic studies, I explored the effects ofchronic exposure to high-cost/low-gain conditions atwork on cardiovascular and hormonal reactions to astandardized acute mental challenge (see Cardiovas-cular and Hormonal Reactions section).

In conclusion, high-cost/low-gain conditions atwork must be considered a risk constellation forcardiovascular health. Indirect support of this notioncame from several related studies that were per-formed without explicit reference to the model (seeIndirect Evidence section).

This analysis also revealed a number of restrictionsand open questions, and these should direct future

research efforts in this area. In these final remarks, Idiscuss those restrictions and open questions thatseem most important and urgent.

A first set of open questions concerns theoperational status of the effort-reward imbalancemodel. To justify the use of the term model, therelations between the three sets of variables delin-eated in Figure 1 (extrinsic effort, intrinsic effort,reward) need to be specified further. The summaryindices of (or ratios between) variables measuringhigh effort and low reward, or constructed variablescontaining combined information to estimate thepostulated effects of imbalance on health, wascomputed. The multiplicative interaction terms inlogistic regression analysis was also tested, but thisfailed to find consistent trends in the relatively smallsamples. A further statistical approach, linear struc-tural equation modeling, was discussed, and respec-tive findings were summarized.

The relative importance of extrinsic versus intrin-sic effort was not specified a priori in this model. Itwas argued that either component was capable ofelevating the risk of stress-related disease if combinedwith low occupational reward. Similarly, the relativeimportance of the three reward components was notspecified in advance although threats to status controlwere assumed to produce highest intensity of stressfulexperience. This assumption was supported by thefindings in the blue-collar study (Siegrist, Peter,Junge, et al., 1990). However, in the middle managersstudy, under conditions of relatively high statuscontrol, the two remaining reward componentsproduced similarly powerful statistical effects (Peteret al., 1991; Peter et al., 1995).

The small number of empirical tests performed sofar with the effort-reward imbalance model must beconsidered a second limitation. Evidence so far isrestricted to middle-aged working men in advancedwestern societies. One single study so far hasanalyzed in part its applicability to a differentsociocultural context of Chinese blue-collar workers(Siegrist, Bernhard, Feng, et al., 1990). Severalstudies are now under way that include employedwomen and occupational groups belonging to theservice sector (e.g., bus drivers, hospital nurses,computer specialists). Specification of measurementsaccording to these occupational contexts in generalhas not proven to be particularly difficult, and a seriesof preliminary findings indicate that, in principle, themodel is working under these conditions as well.

A discussion of the contribution of the effort-reward imbalance model to explanations of the socialgradient of CHD (Marmot, Shipley, & Rose, 1984) is


beyond the scope of this article (see Siegrist 1991,1996). Yet, it is interesting to note that predictionbased on this model, although particularly strongwithin a blue-collar sample, is not restricted toblue-collar workers but can be extended at least toone group with a higher socioeconomic standing(middle managers). Thus, this offers the opportunityof analyzing differences in CHD both between andwithin socioeconomic status groups.

A third limitation of this work is its diseasespecificity. On one hand, having an objective andclear-cut measurement of a relevant endpoint isimportant because it rules out some of the problemsof causal sequence that are prevalent in the area ofwork stress and mental health. Moreover, researchbased on the effort-reward imbalance model isexpected to contribute to the development oftransdisciplinary theories of health and diseasebecause it may offer opportunities to combinebiological, psychological, and sociological informa-tion within a comprehensive approach. On the otherhand, I may have missed information on thepredictive power of the model due to the narrow focusof the defined endpoints. In fact, a series of currentlyunpublished findings indicate that a high ratio ofeffort-reward imbalance is associated with high levelof symptom reporting in bus drivers and with highscores on two out of three "burn out" measures inhospital nurses (Siegrist, 1996). I also have resultsfrom the middle managers study showing that somemeasures of sickness absence are associated with lowreward but not with high effort at work (Siegrist,1996).

This latter observation is of special interest becauseit may indicate differential predictive power of themodel: The specific intensity of negative affectresulting from high effort in combination with lowreward may directly result in autonomic arousal andstress-related physiological responses, whereas nega-tive affect associated with low reward only mayinfluence mood, motivation, and behavioral decisionmaking (e.g., the decision to stay away from work). Interms of scientific development, there exists a debateon whether it is desirable for a concept to extend itsscope of application to a wide range of phenomena orwhether it is more promising to deepen its explana-tory potential by restricting the range of phenomenaunder study.

Some strong arguments are now evolving insupport of the latter strategy as new insights into basicregulatory processes of the human organism arebecoming available (Weiner, 1992). For instance,Williams (1994) recently pointed to the heuristically

fruitful links that start developing between cellularand molecular biology and psychosomatic medicine.More specifically, he pointed to the alteration ofmacrophage activation following the neurohormonaland immunological changes that are induced byexcessive hostility (Williams, 1994). Altered macro-phage activation, in turn, may play a role in thepathogenesis of atherosclerosis and in some forms ofcancer development.

Another example concerns possible links betweenstress and endogenous oxidative DNA damage in thehuman organism. There is now evidence that suchdamage contributes to atherosclerosis, cancer develop-ment, and aging (Ames & Shigenaga, 1993).

These examples challenge the traditional clinicaltaxonomies and ask for new strategies to definemeaningful sets of outcome variables in stress-relatedstudies. Moreover, new markers and mediatingprocesses need to be considered. The potential ofthese innovations for stress-related research on workand health to researchers' knowledge has not yet beenexplored.

Finally, coming back to the core question ofchronicity of stressful experience raised earlier, moreinformation on the cumulative effects of work-relatedand extra-work related distress in terms of experienc-ing high-cost/low-gain conditions is clearly needed.In this context, beneficial effects of rewardingexperiences in private and social life on work-relateddistress should be explored. In a salutogenic perspec-tive, theories on social support (e.g., Berkman &Syme, 1979; House, Landis, & Umberson, 1988;Johnson & Johansson, 1991) and theories onhealth-promoting aspects of psychosocial workingconditions (Karasek & Theorell, 1990; Siegrist, 19%)still wait for a cross-fertilization.

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Received March 8, 1995Revision received May 21, 1995

Accepted May 23, 1995 •

adverse health effects of high-effort/low-reward conditions · adverse health effects of...

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