Public Lecture at FIOCRUZRio de Janeiro

29 November 2011

Work stress and health in the era of economic globalisation

Johannes Siegrist, PhD

Professor and DirectorDepartment of Medical Sociology

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

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

fewer jobs defined by physical demands, more by mental and emotional demands

increase of service sector, computer-based job profiles

increase in flexible work arrangements, part-time work, de-standardized work arrangements

growing job instability / discontinuity; precarious work and unemployment

Segmentation of labour market; social gradient of quality of work and employment

Significant changes in the nature of work and labour market

Expansion of free market principles and technological innovations from high income to middle and low income countries

International organizations (WB, IMF, WTO)

Transnational corporations

Transnational capital flow

Globalized labor market

Neo-liberal policies (deregulation, disinvestment in welfare states, reduced impact of trade

unions)

Economic globalisation

Globalised production

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

Long-term unemployment

Physical/chemical hazards

Precarious work, job instability

Overtime/shift work

Stressful work in more privileged jobs

Work and health: What is known?

Source: M. Kivimäki et al. (2003), Am J Epidemiol, 158:663-668.

2,66

2,36

2,81

5,35

4,23

2,91

0

1

2

3

4

5

6

total cardiovascular external

men (n=15653/3858)

women (n=35770/3395)

Haz

ard

Rat

ioLong-term unemployment and mortality (10

yrs. follow up 1990-2000)

Key messages

1. Work stress is a risk factor of several major chronic disorders and contributes to social inequalities in health.

2. Scientific evidence is particularly strong in high income countries.

3. With economic globalisation this evidence extends to rapidly developing countries.

4. Evidence-based policy interventions at the organizational, national and international level are needed to reduce stressful work and employment and related health inequalities.

Work stress and health: evidence from high income countries

Definition of work stressA working person‘s reaction to a threatening

demand (stressor) that taxes or exceeds her/his capacity of successful response.

Negative emotions, e.g. anxiety, frustration, helplessness

Physiological stress responses (hormones, ANS)

Risk of stress-related disorders: Function of duration and intensity of stressor

Mental illness

Cardiovascular diseases

Musculoskeletal disorders

Reproductive hazards

Main diseases related to work stress

dominant subordinate

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

with without

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

stable unstableSocial group

Me

an

gro

wth

of

ath

ero

sc

lero

tic

pla

qu

es

(m

m2)

Beta-blocking agent(only unstable group)

Source: J.R. Kaplan et al. (1994), Am Heart J, 128: 1316.

Threat to control and social reward by experimental manipulation of social status in male macaques:

effects on coronary atherosclerosis

negative emotions

stress responsesstress-related disorders

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

A theoretical model...

reduces the complex reality at work to critical (‚toxic‘) components

allows for generalisation beyond single observations

provides an explanation of associations between work and health

serves as a guide for health-promoting interventions at work

Why do we need theoretical models?

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 the 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)

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)

DependencyThe working person has no alternative choice in the labour market: accepting contractual unfairness is preferred to job loss.

Strategic choiceThe working person accepts imbalance in order to improve future career development (anticipatory investment).

OvercommitmentThe working person exhibits a motivational pattern of excessive work-related commitment where investments often exceed gains. Overcommitment is either due to personality or due to pressure at work.

Why do people continue to work in ‚high cost – low gain‘ conditions?

DC Focus on job task: high

demands and low control

Threat to personal control / low self efficacy(cognitive appraisal)

Democracy, participation

ERI Focus on work contract:

non-reciprocity of efforts and rewards

Threat to social rewards / low self esteem (affective information processing)

Distributive justice, contractual fairness

Conceptual Differences between the Demand-Control (DC) and the Effort-Reward Imbalance Model (ERI)

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, procedural and relational justice only were measured with relevance to health and performance.

The Organizational Justice Model

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.uni-duesseldorf.de/MedicalSociology

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: http://www.uni-duesseldorf.de/MedicalSociology/

Measurement of effort-reward imbalance at work

• Languages:– German, English, Swedish, Dutch, French,

Italian, Spanish, Portuguese, Jaapanese, Chinese/Taiwanese, Korean, Thai

– The Brazilian version: • D. Chor et al. (2008) Cad Saude Publica 24:

219-224• R. Härter Griep et al. (2009) Int Arch Occup

Environ Health 82: 1163-1172

Psychometrically validated scales of the ERI questionnaire

„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

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?

Source: M. Marmot & M.J. Shipley (1996), Brit Med J, 313: 1177.

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

2,2administrativeprofessionalsclericalother

40-64 years

Mortality (rate ratio)

64-69 years 70-89 years

Mortality (rate ratio; 25 years) according to occupational position: the Whitehall-Study N=18.000)

0

20

40

60

80

0

10

20

30

men women

Effort-reward imbalance model:% imbalance between effort and reward

Demand-control model: % job strain (observer judgement)

high,

middle,

low occupational status

Source: Bosma et al. (1998), Am J Publ Health, 88: 70.

Social inequality of work stress in the Whitehall II-Study

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

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

No overtime1h2h3-4h

(N=6014 civil servants) followed over 11 years*;

* Hazard ratios adjusted for 21 risk factors

Source: Virtanen M et al. (2010) Eur Heart J: doi10.1093/eurheartj/ehq124

Mean daily overtime in hours (h) at baseline

Overtime work increases the risk of coronary heart disease: Whitehall II study

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

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)

# adjusted for age, employment grade, baseline GHQ score

Source: S.A. Stansfeld et al. (1999), Occup Environ Med, 56: 302-7.

0,5

1

1,5

2

2,5

3

low effort,high reward

high effort orlow reward

high effortand lowreward

0,5

1

1,5

2

2,5

3

low effort,high reward

high effort orlow reward

high effortand lowreward

men women*

**

Effort-reward imbalance and affective disorder (GHQ): Whitehall II-Study (odds ratios#; N=6110,

follow-up: 5.3 years)

0

10

20

3040

50

depression

anxiety

somatisation

t1 no -t2 no

t1 yes -t2 no

t1 no -t2 yes

t1 yes -t2 yes

effort-reward imbalance

%

Source: I. Godin et al. (2005), BMC Public Health, 5: 67.

Cumulative work stress and reduced mental health (SCL-90): Belgian Somstress-Study (N=920, 1 yr.)

0

1

2

3

4

5

6

7

8

low ERI / highposition

low ERI / lowposition

high ERI / highposition

high ERI / lowposition

Source: N. Wege, N. Dragano, J. Siegrist (2008) JECH 62: 338-341

Risk of depression

Od

ds

ratio

*

*

Synergy index: 1.99 (1.02-3.85)

Work stress (ERI), occupational position and depression (HNR Study; baseline; N=1811 men and

women aged 45-65)

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

Morning cortisol after dexametason-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 [in press]

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. 2011 (unpublished results based on SHARE release 2.3.0)

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

10

%2

0%

30

%4

0%

50

%6

0%

70

%8

0%

des

ire

fo

r ea

rly

reti

rem

ent

ES FR IT AT GR DE SE DK CH NL

low work stress

medium work stresshigh work stress

Source: Adapted from Siegrist et al. (2006). EJPH.

Work stress (effort-reward imbalance) and the desire for early retirement (SHARE Study; N=6,524)

Increasing relevance of work stress in rapidly developing countries due to globalisation

• First studies applying the ERI-model in China, Taiwan, South Korea and BrazilReduced health functioning in Chinese

physicians (Li et al. 2006)Elevated risk of menstrual disorders in Chinese

railway workers (Zhou et al. 2010)Elevated risk of depression in Taiwanese

engineers (Chen et al. 2010)Reduced health functioning in blue collars in

South Korea (Eum et al. 2008)

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)

Multivariate prevalence odds ratio of hypertension

Low reward 3.09 (1.21 - 7.92)Low job variety 3.05 (1.49 - 6.27)Conflict between work

and family 3.79 (1.19 - 3.95)Smoking 2.17 (1.19 - 3.90)BMI ≥ 25 7.29 (3.71 - 14.37)

Source: L.Y. Xu et al. (2000), Int J Behav Med, 7, S1: 10.

Psychosocial stress and hypertension among working women in Beijing (N=421 ♀; 38,88,1

y.)

School stress (ERI-S) and poor self-rated health in Chinese students

0

0,5

1

1,5

2

2,5

3

3,5

Boys Girls

ERI-S low

ERI-S middle

ERI-S high

N=1004 boys and girls; mean age: 15.9 +/-2.5: OR adj. for age, grade, health behaviours, family wealth

Source: J. Li et al. (2010) J Epidemiol 20: 111-118.

Work stress and poor self-rated health among Brazilian nurses in public hospitals (n=1307)

• Odds ratios* of poor self-rated health among nurses in public hospitals • * adj. For age, education, work contract, nr. of jobs, physical activity, smoking,

alcohol

0

0,5

1

1,5

2

2,5

3

ERI- and OC-

ERI+ and OC+

DC- and SocS-

DC+ andSocS+

Source: R. Härter Griep et al. (2011) Rev Saúde Publica 45:1-8.

• 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 / reward

High job demands / effort

Stress responsePhysiological effects (e.g., BP )

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

Illness

Evidence-based policy interventions at different levels

Job enrichment

Job enlargement (decision, control, responsibility)

Tasks with enhanced skill utilization / active learning

Increase of participatory activities

Strengthening social support at work

Extensive job training, requalification

Reduced status differences, flat hierarchies

Structural intervention at the level of single organisations: demand-control model

Compensatory wage differentials

Models of gain-sharing

Flexible time arrangements

Incentives for esteem / recognition

Enhanced leadership skills (managers)

Promotion prospects according to achievements

Extensive job training / requalification

Job security

Structural intervention at the level of single organisations: effort-reward imbalance model

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)

1. Employment security

2. Selective hiring of new personnel

3. Self-managed teams; decentralization of decision making

4. Comparatively high compensation contingent on performance

5. Extensive training

6. Reduced status distinctions and barriers

7. Extensive sharing of financial and performance information

Source: J. Pfeffer (1998). The Human Equation: Building Profits by Putting People First. Boston: Harvard Business School.

Seven practices of successful organizations: reconciling health promotion with economy

Structural interventions at national level:welfare state labour and social policies

• Hypotheses: – Mean level of stressful work and employment is

lower in countries with well developed welfare state labour and social policies than in countries with neoliberal policies.

– Reduced mean level of work-stress in these countries goes along with a reduced burden of work-related diseases.

• Cross-national multilevel analyses of comparable data sets (SHARE, ELSA, HRS)

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.

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

countries (SHARE study)

Macro indicator: national expenses on rehabilitation services as % of GDP.

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

Effort-reward ratio (country) and women‘s employment rate (18 countries study)

Source: unpublished findings T. Lunau, N. Dragano, J. Siegrist (2011)

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.

Policy recommendations at national/international levels I

• Invest in human capital and additional active labour market policies to improve quality of work and employment

• Increase employment protection by legislation/regulation prioritising vulnerable groups, and by providing high quality occupational safety and health services

• Strenghten primary prevention and establish national monitoring and risk management systems

Policy recommendations at national/international levels II

• Develop international networks to face global economic/financial and ecological threats (e.g. WHO, ILO, EU-OSHA)

Rio Political Declaration on Social Determinants of Health (21 October 2011)

„Strengthen occupational health safety and health protection and their oversight and encourage the public and private sectors to offer healthy working conditions so as to contribute to promoting health for all.“

Thank you!