1. Public Lecture at FIOCRUZ Rio de Janeiro 29 November 2011 Work stress and health in the era of economic globalisation Johannes Siegrist, PhD Professor and Director Department of Medical Sociology University of Duesseldorf, Germany

2. 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

3. 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

4.  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

5. 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

6. Globalised production

7. 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

8. 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?

9. Source: M. Kivimäki et al. (2003), Am J Epidemiol, 158:663-668. Hazard Ratio Long-term unemployment and mortality (10 yrs. follow up 1990-2000)

10. 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.

11. Work stress and health: evidence from high income countries Definition of work stress A 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

12. Mental illness Cardiovascular diseases Musculoskeletal disorders Reproductive hazards Main diseases related to work stress

13. dominantsubordinate Social group Mean growth of atherosclerotic plaques (mm 2 ) 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

14. negative emotions stress responses stress-related disorders Work stress: How to identify toxic components within complex environments?

15. 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?

16.  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

17. active passive low distress high distress Quantitative demands Scope of decision/control lowhigh low high The demand-control model (R. Karasek 1979; R. Karasek & T. Theorell 1990)

18. 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)

19.  Dependency The working person has no alternative choice in the labour market: accepting contractual unfairness is preferred to job loss.  Strategic choice The working person accepts imbalance in order to improve future career development (anticipatory investment).  Overcommitment The 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?

20. 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)

21.  Procedural justice Perceptions of consistent, accurate, unbiased and ethical rules of procedures  Relational justice Perceptions of polite, fair interactions from supervisors  Distributive justice Perceptions 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

22.  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

23.  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

24. 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

25. „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

26. 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?

27. Source: M. Marmot & M.J. Shipley (1996), Brit Med J, 313: 1177. 40-64 years Mortality (rate ratio) 64-69 years70-89 years Mortality (rate ratio; 25 years) according to occupational position: the Whitehall-Study N=18.000)

28. 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

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

30. (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

31. Economic rewards Work demands 4-year increase In plaque height (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

32. 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)

33. 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 lowmediumhigh p <.05 0.12 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)

34. # adjusted for age, employment grade, baseline GHQ score Source: S.A. Stansfeld et al. (1999), Occup Environ Med, 56: 302-7. menwomen * * * Effort-reward imbalance and affective disorder (GHQ): Whitehall II-Study (odds ratios # ; N=6110, follow-up: 5.3 years)

35. 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.)

36. Source: N. Wege, N. Dragano, J. Siegrist (2008) JECH 62: 338-341 Risk of depression Odds 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)

37. 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)

38. 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]

39. 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

40. 10% 20% 30% 40% 50% 60% 70% 80% desire for early retirement ESFRITATGRDESEDKCHNL 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)

41. Increasing relevance of work stress in rapidly developing countries due to globalisation First studies applying the ERI-model in China, Taiwan, South Korea and Brazil  Reduced 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)

42. 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)

43. Multivariate prevalence odds ratio of hypertension Low reward3.09(1.21 - 7.92) Low job variety3.05(1.49 - 6.27) Conflict between work and family3.79(1.19 - 3.95) Smoking2.17(1.19 - 3.90) BMI ≥ 257.29(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 ♀ ; 38,8  8,1 y.)

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

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

46. 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

47. 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 context Job insecurity, Downsizing Precarious work New systems of work organization Job characteristics Low job control / reward High job demands / effort Stress response Physiological effects (e.g., BP  ) Psychological effects (e.g., burnout) Health behaviors Illness Evidence-based policy interventions at different levels

48.  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

49.  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

50. 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)

51. 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

52. 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)

53. 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.

54. 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

55. Effort-reward ratio (country) and women‘s employment rate (18 countries study) Source: unpublished findings T. Lunau, N. Dragano, J. Siegrist (2011)

56. 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.

57. 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

58. 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.“

59. Thank you!