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1.  Psychosocial stress at work and perceived quality of care among clinicians in surgery 
Little is known about the association between job stress and job performance among surgeons, although physicians' well-being could be regarded as an important quality indicator. This paper examines associations between psychosocial job stress and perceived health care quality among German clinicians in surgery.
Survey data of 1,311 surgeons from 489 hospitals were analysed. Psychosocial stress at work was measured by the effort-reward imbalance model (ERI) and the demand-control model (job strain). The quality of health care was evaluated by physicians' self-assessed performance, service quality and error frequency. Data were collected in a nationwide standardised mail survey. 53% of the contacted hospitals sent back the questionnaire; the response rate of the clinicians in the participating hospitals was about 65%. To estimate the association between job stress and quality of care multiple logistic regression analyses were conducted.
Clinicians exposed to job stress have an increased risk of reporting suboptimal quality of care. Magnitude of the association varies depending on the respective job stress model and the indicator of health care quality used. Odds ratios, adjusted for gender, occupational position and job experience vary between 1.04 (CI 0.70-1.57) and 3.21 (CI 2.23-4.61).
Findings indicate that theoretical models of psychosocial stress at work can enrich the analysis of effects of working conditions on health care quality. Moreover, results suggest interventions for job related health promotion measures to improve the clinicians' working conditions, their quality of care and their patients' health.
PMCID: PMC3119178  PMID: 21599882
2.  Effort-reward imbalance and quality of life of healthcare workers in military hospitals: a cross-sectional study 
Taiwan’s National Defense Bureau has been merging its hospitals and adjusting hospital accreditation levels since the beginning of 2006. These changes have introduced many stressors to the healthcare workers in these hospitals. This study investigates the association between job stress, psychological morbidity and quality of life in healthcare workers in three military hospitals.
We posted surveys to 1269 healthcare workers in three military hospitals located in southern Taiwan. The surveys included the General Health Questionnaire (GHQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), and the Effort-Reward Imbalance (ERI) Questionnaire. High effort-reward (ER) ratio and overcommitment were defined when scores fell into the upper tertile of the total distribution.
The survey was completed by 791 healthcare workers. On average, women reported a higher ERI than men. High ERI was associated with younger age, higher psychological morbidity, and poor physical and psychological QOL domains in this population. High ER ratio and high overcommitment were associated with psychological morbidity and poor QOL in both sexes. However, high ER ratio was not significantly associated with the social QOL domain in either sexes or the physical QOL domain in males.
There was a clear association between ERI and QOL in the healthcare workers in the military hospitals under reorganization and accreditation in this study. We found ER ratio and overcommitment to be suitable indicators of job stress.
PMCID: PMC3471021  PMID: 22958365
Effort-reward imbalance; GHQ; Overcommitment; WHOQOL-BREF
3.  Adverse psychosocial working conditions and minor psychiatric disorders among bank workers 
BMC Public Health  2010;10:686.
In most countries, the financial service sector has undergone great organizational changes in the past decades, with potential negative impact on bank workers' mental health. The aim of this paper is to estimate the prevalence of minor psychiatric disorders (MPD) among Brazilian bank workers and to investigate whether they are associated with an adverse psychosocial working environment.
A cross-sectional study of a random sample of 2,500 workers in a Brazilian state bank in 2008. The presence of MPD was determined by the General Health Questionnaire.(GHQ). Psychosocial work conditions were assessed by means of the Effort-Reward Imbalance (ERI) and Job Content Questionnaire (JCQ). The presence and magnitude of the independent associations between MPD and adverse psychosocial working conditions were determined by Prevalence Ratios, obtained by Poisson regression.
From 2,337 eligible workers, 88% participated. The prevalence of MPD was greater among women (45% vs. 41%; p > 0.05). In the multivariate analysis, the prevalence of MPD was twice as high among bank workers exposed to high psychological demand and low control at work and under high effort and low reward working conditions. The lack of social support at work and the presence of over-commitment were also associated with higher prevalence of MPD. A negative interaction effect was found between over-commitment and effort-reward imbalance.
The prevalence of MPD is high among bank workers. The results reinforce the association between MPD and adverse psychosocial working conditions, assessed by the JCQ and ERI models. The direction of the interaction observed between over-commitment and ERI was contrary to what was expected.
PMCID: PMC2991297  PMID: 21062496
4.  The Use of Parsimonious Questionnaires in Occupational Health Surveillance: Psychometric Properties of the Short Italian Version of the Effort/Reward Imbalance Questionnaire 
The Scientific World Journal  2012;2012:372852.
Purpose. To perform a parsimonious measurement of workplace psychosocial stress in routine occupational health surveillance, this study tests the psychometric properties of a short version of the original Italian effort-reward imbalance (ERI) questionnaire. Methods. 1,803 employees (63 percent women) from 19 service companies in the Italian region of Latium participated in a cross-sectional survey containing the short version of the ERI questionnaire (16 items) and questions related to self-reported health, musculoskeletal complaints and job satisfaction. Exploratory factor analysis, internal consistency of scales and criterion validity were utilized. Results. The internal consistency of scales was satisfactory. Principal component analysis enabled to identify the model's main factors. Significant associations with health and job satisfaction in the majority of cases support the notion of criterion validity. A high score on the effort-reward ratio was associated with an elevated odds ratio (OR = 2.71; 95% CI 1.86–3.95) of musculoskeletal complaints in the upper arm. Conclusions. The short form of the Italian ERI questionnaire provides a psychometrically useful tool for routine occupational health surveillance, although further validation is recommended.
PMCID: PMC3425810  PMID: 22927780
5.  Association of work-related stress with mental health problems in a special police force unit 
BMJ Open  2013;3(7):e002791.
Law and order enforcement tasks may expose special force police officers to significant psychosocial risk factors. The aim of this work is to investigate the relationship between job stress and the presence of mental health symptoms while controlling sociodemographical, occupational and personality variables in special force police officers.
At different time points, 292 of 294 members of the ‘VI Reparto Mobile’, a special police force engaged exclusively in the enforcement of law and order, responded to our invitation to complete questionnaires for the assessment of personality traits, work-related stress (using the Demand–Control–Support (DCS) and the Effort–Reward–Imbalance (ERI) models) and mental health problems such as depression, anxiety and burnout.
Regression analyses showed that lower levels of support and reward and higher levels of effort and overcommitment were associated with higher levels of mental health symptoms. Psychological screening revealed 21 (7.3%) likely cases of mild depression (Beck Depression Inventory, BDI≥10). Officers who had experienced a discrepancy between work effort and rewards showed a marked increase in the risk of depression (OR 7.89, 95% CI 2.32 to 26.82) when compared with their counterparts who did not perceive themselves to be in a condition of distress.
The findings of this study suggest that work-related stress may play a role in the development of mental health problems in police officers. The prevalence of mental health symptoms in the cohort investigated here was low, but not negligible in the case of depression. Since special forces police officers have to perform sensitive tasks for which a healthy psychological functioning is needed, the results of this study suggest that steps should be taken to prevent distress and improve the mental well-being of these workers.
PMCID: PMC3717472  PMID: 23872288
Occupational & Industrial Medicine; Public Health
6.  Association of Job Demands with Work Engagement of Japanese Employees: Comparison of Challenges with Hindrances (J-HOPE) 
PLoS ONE  2014;9(3):e91583.
Recent epidemiological research in Europe has reported that two groups of job demands, i.e., challenges and hindrances, are differently associated with work engagement. The purpose of the present study was to replicate the cross-sectional association of workload and time pressure (as a challenge) and role ambiguity (as a hindrance) with work engagement among Japanese employees.
Between October 2010 and December 2011, a total of 9,134 employees (7,101 men and 1,673 women) from 12 companies in Japan were surveyed using a self-administered questionnaire comprising the Job Content Questionnaire, National Institute for Occupational Safety and Health Generic Job Stress Questionnaire, short 10-item version of the Effort-Reward Imbalance Questionnaire, short nine-item version of the Utrecht Work Engagement Scale, and demographic characteristics. Multilevel regression analyses with a random intercept model were conducted.
After adjusting for demographic characteristics, workload and time pressure showed a positive association with work engagement with a small effect size (standardized coefficient [β] = 0.102, Cohen’s d [d] = 0.240) while role ambiguity showed a negative association with a large effect size (β = −0.429, d = 1.011). After additionally adjusting for job resources (i.e., decision latitude, supervisor support, co-worker support, and extrinsic reward), the effect size of workload and time pressure was not attenuated (β = 0.093, d = 0.234) while that of role ambiguity was attenuated but still medium (β = −0.242, d = 0.609).
Among Japanese employees, challenges such as having higher levels of workload and time pressure may enhance work engagement but hindrances, such as role ambiguity, may reduce it.
PMCID: PMC3948913  PMID: 24614682
7.  Measuring Effort–Reward Imbalance in School Settings: A Novel Approach and Its Association With Self-Rated Health 
Journal of Epidemiology  2010;20(2):111-118.
We attempted to apply the model of effort–reward imbalance (ERI) to school settings in order to measure students’ psychosocial stress and analyze its association with self-rated health in adolescents.
A cross-sectional survey was conducted in Kunming, China among 1004 Chinese students (468 boys and 536 girls) in grades 7 through 12, using a 19-item effort–reward imbalance questionnaire.
Satisfactory internal consistencies for the scales for effort and reward were obtained; the value for the scale for overcommitment was acceptable. Factor analysis replicated the theoretical structure of the ERI construct in this sample of Chinese students. All 3 scales were associated with an elevated odds ratio for diminished self-rated health, and the effect was strongest for the effort–reward ratio, as predicted by the theory. Sex and grade differences were also observed.
The ERI questionnaire is a valid instrument for identifying sources of stressful experience, in terms of effort–reward imbalance, among adolescents in school settings.
PMCID: PMC3900809  PMID: 20037260
effort–reward imbalance; psychosocial school stress; self-rated health; adolescents
8.  The Gutenberg Health Study: measuring psychosocial factors at work and predicting health and work-related outcomes with the ERI and the COPSOQ questionnaire 
BMC Public Health  2013;13:538.
Several instruments have been developed to assess psychosocial workload. We compared two of these instruments, the Effort-Reward Imbalance (ERI) model and the Copenhagen Psychosocial Questionnaire (COPSOQ) with regard to congruent validity and internal validity.
This analysis is based on a population-based sample of the baseline examination of 2,783 employees from the Gutenberg Health Study (GHS). About half of the participants completed the ERI questionnaire (n = 1,342), the other half completed the COPSOQ (n = 1,441). First, the two samples were compared and descriptive analyses were carried out calculating mean values for both instruments in general, then separately for age, gender and main occupational groups. Second, we analyzed the relationship between ERI and COPSOQ scales on the workplace situation and on the workplace outcomes: job satisfaction, general health, burnout, satisfaction with life, by applying stepwise logistic regression analysis.
Results and discussion
For the majority of occupations, high effort as reflected by the ERI corresponded with high demands as reflected by the COPSOQ. Comparably, high reward (according to ERI) yielded a good agreement with high “influence and development” (according to COPSOQ). However, we could also find differences between ERI and COPSOQ concerning the intensity of psychosocial workload in some occupations (e.g., physicians/pharmacists or warehouse managers/warehousemen/transport workers). These differences point to differing theoretical concepts of ERI and COPSOQ. When the ability of ERI and COPSOQ was examined to determine the associations with health and work outcomes, burnout could be better predicted by the COPSOQ; this might be due to the fact that COPSOQ comprises the constructs “work-privacy conflict” and “emotional demand”, which are closely related to burnout. However, methodological differences between these instruments limit their direct comparability.
The ERI and COPSOQ instrument yielded similar results for most occupational groups. The slightly stronger association between psychosocial workload as assessed by COPSOQ and burnout might be explained by its broader approach. The ability of the ERI and COPSOQ instrument to reflect relevant risk factors for clinically manifest disorders (e.g., coronary heart disease) will be derived from subsequent prospective analyses of the GHS with the follow-up data.
PMCID: PMC3707767  PMID: 23734632
Psychosocial factors; Stress; Strain; COPSOQ; ERI
9.  Explaining global job satisfaction by facets of job satisfaction: the Japanese civil servants study 
Management of job satisfaction is of growing importance in terms of the maintenance of employees’ health. This study aimed to evaluate which and to what extent facets of job satisfaction contributed to global job satisfaction.
The participants were 4286 employees aged 18–69 years working in local government in Japan. A questionnaire survey was conducted in 1998–1999. Seven facets of job satisfaction were evaluated. Multiple logistic regression analysis was performed to evaluate which facets of job satisfaction contributed to global job satisfaction.
For all employees, all of the facets of job satisfaction significantly contributed to global job satisfaction. Among the facets of job satisfaction, ‘being satisfied with interests and skills involved in work’ and ‘how abilities were used’ contributed more strongly to global satisfaction than ‘being satisfied with how the section is running’, ‘co-workers’, ‘work prospects’, ‘physical working conditions’ and ‘payment’. The differing associations of facets of job satisfaction with global job satisfaction did not change substantially in stratified analysis by occupation, with one exception that only three facets of job satisfaction contributed to global job satisfaction in administrative workers.
Job satisfaction related to the intrinsic aspects of the job (i.e., ‘interests and skills involved in work’ and ‘how abilities were used’) contributed more to global job satisfaction than the other aspects of job satisfaction. Longitudinal research in employees with various occupations may be needed to confirm the results of this study.
PMCID: PMC3047668  PMID: 21432229
Job satisfaction; Occupation; Working environments; The JACS study; Japan
10.  Association between work-related health problems and job insecurity in permanent and temporary employees 
This research was conducted with an aim of determining the correlation between job insecurity and an employee’s work-related health problems among permanent and temporary workers.
Using the data from the First Korean Working Conditions Survey conducted in 2006, a total of 7,071 workers, excluding employers and the self-employed, were analyzed. Work-related health problems were categorized as backache, headache, abdominal pain, muscular pain, stress, fatigue, insomnia, anxiety or depression. Each problem was then analyzed for its relationship to job insecurity through logistic regression analysis.
Among the 7,071 workers, 5,294 (74.9%) were permanent workers and 1,777 (25.1%) were temporary workers. For the permanent workers, presence of high or moderate job insecurity appeared more closely linked to backache, headache, abdominal pain, muscular pain, stress, fatigue, insomnia, anxiety, and depression compared to absence of job insecurity. However, for the temporary workers, only depression appeared to be associated with the presence of high job insecurity.
The study showed that the presence of job insecurity is correlated with work-related health problems. The deleterious effects of job insecurity appeared to be stronger in permanent than temporary workers. Additional research should investigate ways to effectively reduce job insecurity.
PMCID: PMC3923339  PMID: 24472497
Job insecurity; Work-related health problems; Permanent workers; Temporary workers; Korean working conditions survey
11.  Associations of Job Stress Indicators with Oxidative Biomarkers in Japanese Men and Women 
Some researchers have suggested that oxidative damage may be one of the mechanisms linking job stress with coronary heart disease. The aim of this study was to investigate the association between job stress indicators and oxidative biomarkers. The study included 567 subjects (272 men, 295 women) who answered questionnaires related to their work and underwent a medical examination. Job stress evaluated using the demands-control-support model was measured using the Job Content Questionnaire. Effort-reward imbalance was measured using the Effort-Reward Imbalance Questionnaire. Urinary hydrogen peroxide (H2O2) and 8-hydroxy-2'-deoxyguanosine (8-OHdG) were measured by the modified ferrous ion oxidation xylenol orange version-1 method and enzyme-linked immunosorbent assay, respectively. In men, the changes in the odds ratios for high urinary H2O2 associated with a 1-standard-deviation (SD) increase in worksite social support were 0.69 (95% confidence interval (CI) 0.53, 0.91) univariately and 0.68 (95%CI 0.51, 0.90) after adjustment for covariates. The change in the odds ratio for high urinary H2O2 associated with a 1-SD increase in effort-reward ratio was 1.35 (95% CI 1.03, 1.78) after adjustment for covariates. In women, there were no significant associations of the two job stress indicators with urinary H2O2 and 8-OHdG levels after adjustment for covariates (p > 0.05).
PMCID: PMC3881133  PMID: 24317383
biomarkers; demands-control-support model; effort-reward imbalance model; oxidative stress; occupational health; psychological stress; sex factors
12.  Job Strain, Depressive Symptoms, and Drinking Behavior Among Older Adults: Results From the Health and Retirement Study 
To examine the relationship between job strain and two indicators of mental health, depression and alcohol misuse, among currently employed older adults.
Data come from the 2004 and 2006 waves of the Health and Retirement Study (N = 2,902). Multivariable logistic regression modeling was used to determine the association between job strain, indicated by the imbalance of job stress and job satisfaction, with depression and alcohol misuse.
High job strain (indicated by high job stress combined with low job satisfaction) was associated with elevated depressive symptoms (odds ratio [OR] = 2.98, 95% confidence interval [CI]: 1.99–4.45) relative to low job strain after adjusting for sociodemographic characteristics, labor force status, and occupation. High job stress combined with high job satisfaction (OR = 1.93) and low job stress combined with low job satisfaction (OR = 1.94) were also associated with depressive symptoms to a lesser degree. Job strain was unrelated to either moderate or heavy drinking. These associations did not vary by gender or age.
Job strain is associated with elevated depressive symptoms among older workers. In contrast to results from investigations of younger workers, job strain was unrelated to alcohol misuse. These findings can inform the development and implementation of workplace health promotion programs that reflect the mental health needs of the aging workforce.
PMCID: PMC3166196  PMID: 21427175
Aging workforce; Alcohol misuse; Depression; Job strain
13.  The psychosocial work environment and alcohol dependence: a prospective study 
Aims: To examine whether a stressful psychosocial work environment predicts alcohol dependence.
Methods: Alcohol dependence of participants in the Whitehall II occupational cohort of London based civil servants (1985–88) was measured in 1991–93 using the CAGE questionnaire. The psychosocial work environment was measured by self report questions on the job demand-support-control model and on the model of effort-reward imbalance. Potential mediators including physical illness and poor mental health (GHQ) were measured at follow up in 1989.
Results: Effort-reward imbalance at work was associated with alcohol dependence in men after adjustment for employment grade and other baseline factors related to alcohol dependence. Although effort-reward imbalance predicted future longstanding illness, poor mental health and negative aspects of close relationships, the association between effort-reward imbalance and alcohol dependence in men was only partially mediated through these health and social support measures. In women, low decision latitude was related to alcohol dependence to some extent, but alcohol dependence among women was more prevalent in higher occupational grades. Men with high job demands or with low work social supports had a slightly reduced risk of alcohol dependence. No association was found between objectively assessed demands, job control, and alcohol dependence in either men or women.
Conclusion: A stressful psychosocial work environment in terms of effort-reward imbalance was found to be a risk factor for alcohol dependence in men. In view of the public health importance of alcohol dependence in working populations these findings call for more emphasis on psychosocial factors in occupational health research and prevention.
PMCID: PMC1740737  PMID: 14985516
14.  Psychosocial work environment and myocardial infarction: improving risk estimation by combining two complementary job stress models in the SHEEP Study 
Objectives: Associations between two alternative formulations of job stress derived from the effort-reward imbalance and the job strain model and first non-fatal acute myocardial infarction were studied. Whereas the job strain model concentrates on situational (extrinsic) characteristics the effort-reward imbalance model analyses distinct person (intrinsic) characteristics in addition to situational ones. In view of these conceptual differences the hypothesis was tested that combining information from the two models improves the risk estimation of acute myocardial infarction.
Methods: 951 male and female myocardial infarction cases and 1147 referents aged 45–64 years of The Stockholm Heart Epidemiology (SHEEP) case-control study underwent a clinical examination. Information on job stress and health adverse behaviours was derived from standardised questionnaires.
Results: Multivariate analysis showed moderately increased odds ratios for either model. Yet, with respect to the effort-reward imbalance model gender specific effects were found: in men the extrinsic component contributed to risk estimation, whereas this was the case with the intrinsic component in women. Controlling each job stress model for the other in order to test the independent effect of either approach did not show systematically increased odds ratios. An improved estimation of acute myocardial infarction risk resulted from combining information from the two models by defining groups characterised by simultaneous exposure to effort-reward imbalance and job strain (men: odds ratio 2.02 (95% confidence intervals (CI) 1.34 to 3.07); women odds ratio 2.19 (95% CI 1.11 to 4.28)).
Conclusions: Findings show an improved risk estimation of acute myocardial infarction by combining information from the two job stress models under study. Moreover, gender specific effects of the two components of the effort-reward imbalance model were observed.
PMCID: PMC1732130  PMID: 11896138
15.  Predictive Power of Incidents Reporting Rate and Its Dimensions by Job Stress among Workers’ Isfahan Steel Company 
Iranian Journal of Public Health  2011;40(3):105-112.
There is long-term interest in the effects of stress on health, due to the strain that it places on individuals which can lead to an increased risk of disease. The present study examined degree of perceived job stress related to incidents reporting rate and its dimensions among workers’ Isfahan Steel Company.
A self-administered anonymous was distributed to 189 workers. The survey included demographic factors, incidents reporting rate and its components (physical symptoms, psychological symptoms and accidents) and the Job Stress Questionnaire. The data were analyzed by multivariate (MANOVA) and correlation techniques.
1) there was internal significant correlation between perceived job stress with incident reporting rate as well as with its two components namely physical symptoms and psychological symptoms; 2) there was not a significant relationship between perceived job stress and accident; 2) In multivariate analysis, perceived job stress respectively about 12%, 18% and 19% of the variance of variables of incidents reporting rate, physical and psychological symptoms significantly predicted (P< 0.05).
Perceived job stress influences to physical and psychological symptoms. Therefore, decreasing job stress can be important to prevent the development of stress-related diseases and to promote workers health.
PMCID: PMC3481651  PMID: 23113092
Perceived job stress; Incident reporting rate; Physical symptoms; Psychological symptoms; Accident
16.  Selection from fixed term to permanent employment: prospective study on health, job satisfaction, and behavioural risks 
Study objective: To examine health, job satisfaction, and behavioural risks as antecedents of selection from fixed term to permanent employment.
Design: Prospective cohort study of change in employment contract during a two year period. Self reported health, recorded sickness absence, job satisfaction, behavioural risks, demographics, and occupational characteristics were assessed at baseline.
Setting: Hospital staff in two Finnish hospital districts.
Participants: A cohort of 526 hospital employees (54 men, 472 women) aged 20 to 58 years with a fixed term job contract at baseline.
Main results: During the follow up period, 137 became permanently employed. Men, employees in higher positions, full time workers, and those with five to eight years in the employ of the hospital were more likely to become permanently employed. After adjusting for these factors, obtaining a permanent job contract was predicted by self rated good health (odds ratio (OR) 3.90; 95% confidence intervals (CI) 1.34 to 11.36), non-caseness of psychological distress (OR 1.80; 95% CI 1.01 to 3.20), high job satisfaction (OR 1.86; CI 1.17 to 2.94), and non-sedentary life style (OR 2.64; CI 1.29 to 5.41), compared with the rest of the cohort.
Conclusions: Investigation of fixed term employees yields new information about selective mechanisms in employment mobility. Good health seems to promote the chances for a fixed term employee to reach a better labour market status. These results correspond to earlier research on selective mechanisms in other forms of employment mobility and provide a partial explanation for the socioeconomic gradient of health.
PMCID: PMC1732246  PMID: 12177087
17.  Musculoskeletal pain and effort-reward imbalance- a systematic review 
BMC Public Health  2014;14:37.
Musculoskeletal pain may be triggered by physical strains and psychosocial risk factors. The effort-reward imbalance model (ERI model) is a stress model which measures psychosocial factors in the working world. The question is whether workers with an effort-reward imbalance report musculoskeletal pain more frequently than those with no effort-reward imbalance. A systematic review using a best evidence synthesis approach was conducted to answer this question.
A literature search was conducted for the period from 1996 to 2012, using three databases (Pubmed, Embase and PsycINFO). The research criteria related to psychosocial, work-related stress as per the ERI model and to musculoskeletal pain. A quality score was developed using various quality criteria to assess the standard of the studies. The level of evidence was graded as in (Am J Ind Med 39:180–193, 2001).
After applying the inclusion criteria, a total of 19 studies were included in the review: 15 cross-sectional studies, three prospective studies and one case–control study. 74% of all studies exhibited good methodological quality, 53% collected data using the original ERI questionnaire, and in 42% of the studies, there was adequate control for physical working conditions. Furthermore, different cut-off points were used to classify exposed and non-exposed individuals. On the basis of 13 studies with a positive, statistically significant association, a moderate level of evidence was inferred for the association between effort-reward imbalance and musculoskeletal pain. The evidence for a role of over-commitment and for its interaction with effort-reward imbalance was rated as inconclusive - on the basis of eight and five studies, respectively.
On the basis of the available evidence, no reliable conclusion may be drawn about any association between the psychosocial factors ascertained using the ERI model and musculoskeletal pain. Before a reliable statement can be made on the association between ERI and musculoskeletal pain, additional longitudinal studies must be performed - with a standardised method for recording and classifying exposure, as well as control of physical confounders. Appropriate preventive measures can then be specified.
PMCID: PMC3898401  PMID: 24428955
Effort-reward imbalance; Musculoskeletal pain; Psychosocial work stress; Review
18.  Can labour contract differences in health and work-related attitudes be explained by quality of working life and job insecurity? 
Study aim
We hypothesise that due to a lower quality of working life and higher job insecurity, the health and work-related attitudes of temporary workers may be less positive compared to permanent workers. Therefore, we aimed to (1) examine differences between contract groups (i.e. permanent contract, temporary contract with prospect of permanent work, fixed-term contract, temporary agency contract and on-call contract) in the quality of working life, job insecurity, health and work-related attitudes and (2) investigate whether these latter contract group differences in health and work-related attitudes can be explained by differences in the quality of working life and/or job insecurity.
Data were collected from the Netherlands Working Conditions Survey 2008 (N = 21,639), and Hypotheses were tested using analysis of variance and cross-table analysis.
Temporary work was associated with fewer task demands and lower autonomy and was more often passive or high-strain work, while permanent work was more often active work. Except for on-call work, temporary work was more insecure and associated with worse health and work-related attitude scores than permanent work. Finally, the quality of working life and job insecurity partly accounted for most contract differences in work-related attitudes but not in health.
Especially agency workers have a lower health status and worse work-related attitudes. Job redesign measures regarding their quality of working life and job insecurity are recommended.
PMCID: PMC3440562  PMID: 22105652
Labour contracts; Quality of working life; Job insecurity; Health; Job attitudes
19.  Do changes in effort-reward imbalance at work contribute to an explanation of the social gradient in angina? 
Aims: To determine whether an increase in effort-reward imbalance over time increases the risk of angina, and whether such increases are associated with lower occupational position.
Methods: Effort-reward imbalance (ERI) at work was measured in the Whitehall II occupational cohort of London based civil servants at baseline (1985–88) and in 1997. Coronary heart disease was measured in a self-reported health questionnaire by combining the Rose Angina Questionnaire with doctor diagnosed angina in 2001.
Results: Among men, increase in ERI over time was associated with an increased risk of incident angina. Moreover, as increases in ERI were more common among lower grade civil servants, change in imbalance, to some extent, contributed to explaining the social gradient in angina. Among women, increases in imbalance were not associated with risk of angina, and therefore did not contribute to the explanation of the social gradient.
Conclusions: Reductions in effort-reward imbalance at work may reduce the risk of coronary heart disease among men.
PMCID: PMC1740994  PMID: 15778254
20.  Is There an Association between Work Stress and Diurnal Cortisol Patterns? Findings from the Whitehall II Study 
PLoS ONE  2013;8(12):e81020.
The evidence on whether there is work stress related dysregulation of the hypothalamic-pituitary-adrenal axis is equivocal. This study assessed the relation between work stress and diurnal cortisol rhythm in a large-scale occupational cohort, the Whitehall II study.
Work stress was assessed in two ways, using the job-demand-control (JDC) and the effort-reward-imbalance (ERI) models. Salivary cortisol samples were collected six times over a normal day in 2002–2004. The cortisol awakening response (CAR) and diurnal cortisol decline (slope) were calculated.
In this large occupational cohort (N = 2,126, mean age 57.1), modest differences in cortisol patterns were found for ERI models only, showing lower reward (β = −0.001, P-value = 0.04) and higher ERI (β = 0.002, P-value = 0.05) were related to a flatter slope in cortisol across the day. Meanwhile, moderate gender interactions were observed regarding CAR and JDC model.
We conclude that the associations of work stress with cortisol are modest, with associations apparent for ERI model rather than JDC model.
PMCID: PMC3849138  PMID: 24312516
21.  Better Off Jobless? Scarring Effects of Contingent Employment in Japan 
Previous research fails to address whether contingent employment benefits individuals’ careers more than the alternative they often face: being without a job. Using work history data from Japan, this study shows that accepting a contingent job delays individuals’ transition to standard employment more than remaining jobless. Moreover, having a contingent job, rather than having no job, leads Japanese men to have lower occupational status after they transition back to standard employment. I argue that in a highly segmented labor market like Japan’s, the strict separation of labor pools for standard and contingent jobs makes being labeled as a contingent worker particularly detrimental. Meanwhile, the legacy of Japan’s welfare corporatism alleviates the stigma of unemployment, making individuals better off jobless than having a contingent job. This research thus demonstrates the importance of labor-market contexts in shaping the scarring effects of contingent work arrangements.
PMCID: PMC3408094  PMID: 22859864
22.  A cross-sectional study of the relationship between job demand-control, effort-reward imbalance and cardiovascular heart disease risk factors 
BMC Public Health  2012;12:1102.
This cross-sectional study explored relationships between psychosocial work environment, captured by job demand-control (JDC) and effort-reward imbalance (ERI), and seven cardiovascular heart disease (CHD) risk factors in a general population.
The sampled consists of randomly-selected men and women from Gothenburg, Sweden and the city’s surrounding metropolitan areas. Associations between psychosocial variables and biomarkers were analysed with multiple linear regression adjusted for age, smoking, education and occupational status.
The study included 638 men and 668 women aged 24–71. Analysis between JDC and CHD risk factors illustrated that, for men, JDC was associated with impaired scores in several biomarkers, especially among those in high strain jobs. For women, there were no relationships between JDC and biomarkers. In the analysis of links between ERI and CHD risk factors, most associations tested null. The only findings were raised triglycerides and BMI among men in the fourth quartile of the ERI-ratio distribution, and lowered LDL-cholesterol for women. An complementary ERI analysis, combining high/low effort and reward into categories, illustrated lowered triglycerides and elevated HDL-cholesterol values among women reporting high efforts and high rewards, compared to women experiencing low effort and high reward.
There were some associations between psychosocial stressors and CHD risk factors. The cross-sectional design did not allow conclusions about causality but some results indicated gender differences regarding sensitivity to work stressors and also how the models might capture different psychosocial dimensions.
PMCID: PMC3541343  PMID: 23259757
Psychosocial work environment; Cardiovascular heart disease risk factors; Job demand-control; Effort-reward imbalance; Gender
23.  Psychosocial work characteristics and self rated health in four post-communist countries 
STUDY OBJECTIVES—To examine whether psychosocial factors at work are related to self rated health in post-communist countries.
DESIGN AND SETTINGS—Random samples of men and women in five communities in four countries were sent a postal questionnaire (Poland, Czech Republic and Lithuania) or were invited to an interview (Hungary). Working subjects (n=3941) reported their self rated health in the past 12 months (5 point scale), their socioeconomic circumstances, perceived control over life, and the following aspects of the psychosocial work environment: job control, job demand, job variety, social support, and effort and reward at work (to calculate a ratio of effort/reward imbalance). As the results did not differ by country, pooled analyses were performed. Odds ratios of poor or very poor health ("poor health") were estimated for a 1 SD increase in the scores of work related factors.
MAIN RESULTS—The overall prevalence of poor health was 6% in men and 7% in women. After controlling for age, sex and community, all work related factors were associated with poor health (p<0.05). After further adjustment for perceived control, only two work related factors remained associated with poor health; the odds ratios (95% confidence intervals) for 1 SD increase in the effort/reward ratio (log transformed) and job variety were 1.51 (1.29, 1.78) and 0.82 (0.73, 1.00), respectively. Further adjustment for all work related factors did not change these estimates. There were no interactions between individual work related factors, but the effects of job control and social support at work differed by marital status, and the odds ratio of job demand increased with increasing education.
CONCLUSIONS—The continuous measure of effort/reward imbalance at work was a powerful determinant of self rated health in these post-communist populations. Although the cross sectional design does not allow firm conclusions as to causality, this study suggests that the effect of the psychosocial work environment is not confined to Western populations.

Keywords: self rated health; psychosocial work characteristics; effort-reward imbalance
PMCID: PMC1731970  PMID: 11511640
24.  Effort-reward imbalance and overcommitment in employees in a Norwegian municipality: a cross sectional study 
The aim of this study was to validate a Norwegian version of the Effort-Reward Imbalance Questionnaire (ERI-Q).
One thousand eight-hundred and three employees in a medium-sized Norwegian municipality replied to the ERI-Q, and health-related variables such as self-reported general health, psychological distress, musculoskeletal complaints, and work-related burnout were examined.
Sound psychometric properties were found for this Norwegian version of the ERI-Q. When the two dimensions of ERI and overcommitment were analyzed in four types of employees, the results showed that employees characterized by a combination of high values on ERI and overcommitment had more unfavorable health scores than others. Employees with low effort-reward and overcommitment scores had more favorable health scores. Employees with scores on the overcommitment and the effort-reward scales that are supposed to have opposite effects on health (that is, the combination of low overcommitment with a high effort-reward score and vice versa), had health scores somewhere in between the two other groups.
Satisfactory psychometric properties were found for most of the latent factors in the ERI-Q. The findings also indicate that it may be fruitful to explore health conditions among employees with different combinations of effort-reward and overcommitment.
PMCID: PMC2405796  PMID: 18447923
25.  Folate intake and depressive symptoms in Japanese workers considering SES and job stress factors: J-HOPE study 
BMC Psychiatry  2012;12:33.
Recently socioeconomic status (SES) and job stress index received more attention to affect mental health. Folate intake has been implicated to have negative association with depression. However, few studies were published for the evidence association together with the consideration of SES and job stress factors. The current study is a part of the Japanese study of Health, Occupation and Psychosocial factors related Equity (J-HOPE study) that focused on the association of social stratification and health and our objective was to clarify the association between folate intake and depressive symptoms in Japanese general workers.
Subjects were 2266 workers in a Japanese nationwide company. SES and job stress factors were assessed by self-administered questionnaire. Folate intake was estimated by a validated, brief, self-administered diet history questionnaire. Depressive symptoms were measured by Kessler’s K6 questionnaire. “Individuals with depressive symptoms” was defined as K6≧9 (in K6 score of 0–24 scoring system). Multiple logistic regression and linear regression model were used to evaluate the association between folate and depressive symptoms.
Several SES factors (proportion of management positions, years of continuous employment, and annual household income) and folate intake were found to be significantly lower in the subjects with depressive symptom (SES factors: p < 0.001; folate intake: P = 0.001). There was an inverse, independent linear association between K6 score and folate intake after adjusting for age, sex, job stress scores (job strains, worksite supports), and SES factors (p = 0.010). The impact of folate intake on the prevalence of depressive symptom by a multiple logistic model was (ORs[95% CI]: 0.813 [0.664-0.994]; P =0.044).
Our cross-sectional study suggested an inverse, independent relation of energy-adjusted folate intake with depression score and prevalence of depressive symptoms in Japanese workers, together with the consideration of SES and job stress factors.
PMCID: PMC3439709  PMID: 22521003

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