1. In the name of ALLAH the most beneficent the most merciful

2. Masoud Lotfizadeh¹, Prof Dr Noor Hassim Ismail¹ And Dr Ehsan Habibi² ¹ Faculty of health, Shahrekord University of medical sciences, Iran and PhD candidate of UKM ¹ Department of community health, faculty of medicine, National University of Malaysia, UKM ² Faculty of Health, Esfahan University of medical sciences

3. 3

4. ESFAHAN (Isfahan) Historical cities of Iran: "The vast province of Isfahan, is located almost in the centre of Iran, there are several high mountains (Mount. Karkas at 3899m) and rivers that dominate its landscape...." 4

5. Esfahan steel company organization was established in 1959 and for constructing this company Russian and French experts were involved as consultant and finally selected an area about 45 Km southwest of Esfahan. Construction of different units started in 1967. The variety & quality of the ESCO products in Iran and Middle East are unique. 5

6. Work-related stress is estimated to be the highest occupational health problem in Iran, especially among industrial workers who appear to have a higher absence and sickness rate than other staff. Many workers now suffer from stress (Sadry, 1998). High rate of stress may be a reason for some of their problems and may threaten their health and thereby their efficiency. (Ahmadi & kolivand 2006) 6

7. The rate of job related injuries in Iran has so far been around 16.48 per 100 persons. The result of different studies in ESCO indicates that all the afflicted persons have been between 25-58 years old and married. The most common reasons of injuries are reported to be carelessness, technical defects as well as worn out equipment which account for 41% and 18.5% of injuries respectively (Amidi, Naghdi, and Joulazadeh,2005) 7

8. Justification The working environment and characteristics of materials in this company leads to increasing the incidence of stress in employees. Several studies in Iran showed that there is about 24% - 49.5% prevalence of stress, there is a realistic relation between stress and working accidents in the Iran companies. (soori 2005) Little is known about occupational stress study in ESCO IRAN. Therefore, this research will attempt to identification the cause of this problem. 8

9. This is one of premier studies on occupational stress and coping strategies with such a great distribution in our country. Consequently, ESCO is considering as an environment which result in work event and stress. Of course, eliminating such stress factors from workers society has great influence on improving socio-economic qualities between both workers society and economical situation of industry. 9

10. The word of stress comes directly from the ancient Latin language. It means force, pressure, or strain (Berger, 2002). stress Refers to events that are perceived as endangering ones physical or emotional wellbeing. (Selye, 1978) Life without stress is impossible. Without stress, there would be no change, no growth or no productivity. 10

11. Stress can affect employees at all levels. Stress has a high human cost but also a high financial cost – and it figures as one of the main causes of sick leave. World Health Organization (2007) states work-related stress may affect corporate performance due to costs associated with increased absenteeism and staff turnover, reduced performance and productivity, increased unsafe working practices and accident rates, increased complaints from clients/customers, replacement of absent workers, training of substitute workers, and so on. 11

12. Cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person Coping refers to the things people do in response to situations that put their adaptive capacities to test. (Lazarus & Folkman, 1984) 12

13. Harmful physical & emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. (National Institute for Occupational Safety and Health NIOSH). 13

14. Many researches note relationship between age and occupational stress Bridger. et al 2004 in their study show, the mean age was 31.05 years. Another study which was done in Taiwan most participants was aged between 40 and 49 years of age (Li. et al 2000). Studies which was done in Iran shows the mean age of people affected by stress is between 35.1 and 34.6 years. (Soori 2005and Marzabadi 2004) 14

15. Result from two different studies about job stress in Iran shows that around 45% of the samples have moderate or high level of stress. (Yousefy 2003 and Ahmadi & Kolivand,2006) Comparative study of perceived job stressor sources in American and Iranian managers showed: In US there was no relations between demographics and stressors, but for the Iranian, gender and marital was significantly related to stress. (Spector et al. 2002) 15

16. To determine prevalence and the factors causing occupational stress and the coping strategies among Esfahan steel company employees (Iran). 16

17. To determine the prevalence of stress among employees; To determine the reasons of stress among employees; To assess the association between demographic factors (age, current marital status, level of literacy, family income) and prevalence of stress; To identify types of coping strategies use by workers to prevent or control stress. 17

18. Prevalence of Stress is higher among younger employees. Prevalence of Stress is higher among employees with family income less than 600$ compare to employees with family income more than 600$. Married employees have less stress in compare to singles. Prevalence of Stress is higher among employees who work in rotational shift work compare to others who are working in constant shift. Prevalence of Stress is higher in employees with low level of literacy compare to high literacy employees. Stress among employees who use religion type of coping is lower in comparison with employees who do not. 18

19. The design used in this study is Cross-sectional carried out during four months from March to July in 2008 on 200 ESCO employees. For selection, the first sample was chosen by using a random number (for example five) and then by continuing with 10 numbers (that is, 15) after the previous one (five). So by using this method, 200 samples from 2000 non-operational were chosen. If any of the participants (for instance number 25) were unavailable for long term leave, an alternative neighboring number (for example 26) was used. 19

20. As our study was a cross sectional study, the sample size determined based on the population proportion using single proportion formula with 95% confidence coefficient (Daniel.1987). Quantitative Instruments The first questionnaires originally in English were translated into Persian by using the back to back method by a group of professors in public health field at Esfahan and Shahr-e-Kord Medical University, Iran. 20

21. The Persian language version was used in the pilot study on a sample group of employees similar to those in the main study. The results of pilot study were analyzed by using SPSS version 16 for determining the reliability of each variable by using alpha cronbach test. In the pilot study, the reliability coefficient for the subscales was found 0.76 for JCQ, 0.89 for coping and the DASS showed high internal consistency (Cronbachs alpha = 0.95). 21

22. Inclusion criteria All employees who were working at the time of this study and agree to take part in this study. Exclusion criteria Employees with long term leave or absence 22

23. Dependent Variables : Stress Independent Variables: Age Educational level Marital status Income Shift work Task type Childrens problem Work environment Economical problem Colleague Relative Coping 23

24. Data analysis: The Statistical Package for the Social Sciences (SPSS) Version 16. Study limitation: Individuals perception of his own stressors and stress- coping mechanisms. Hesitancy by participants to reveal personal information related to their work environment. Tiring of participants because of long questionnaire. 24

25. 25 Methodology Methodology Plan for minimizing sampling and non-sampling errors The questionnaire will validate and modify by doing a pilot study and using alpha cronbach test. Any questionnaire with more than 20% missing data will be excluded from the study. Since the interview for each case may take more than 35 minutes and it can make the case tired and affect the answers subsequently, refreshment will provide in between.

27. Mean±std deviation MinimumMaximum Age35.3 ±7.22153 Number of Children Girls Boys 1.4 ±1.1 0.67 ±0.8 0.73 ±0.8 001001 533533 Total years of work experience11.8 ±7.6129

28. N% Marital status Single3316.5 Married16783.5 Educational level Primary &junior high school 189 High school168 Diploma & associated degree 12361.5 Bachelor and higher graduates 4321.5 Shift work Yes4020 No16080

31. Reasons RarelyAlways N%N% Task type13568.56231.5 Economical problem7940.311759.7 Colleagues14071.45628.6 Work environment14171.95528.1 Childrens problem17991.3178.7 Relatives17086.72613.3

32. No stress N (%) Stress N (%) p Age group <29 years30 (58.8)21 (41.2) 30-3941 (45.1)50 (54.9) 40-4939 (75)13 (25) >503 (50) 0.006 Marital status Single97 (58.1)70 (41.9) married16 (48.5)17 (51.5)0.3 Educational level Primary& Junior High school 7 (38.9)11 (61.1) High school 9 (56.2)7 (43.8) Diploma & Associate Degree 70 (56.9)53 (43.1) Bachelor and higher graduates 27 (62.8)16 (37.2)0.3

33. No stress N (%) Stress N (%) p Shift work No95 (59.4)65 (40.6) Yes18 (45)22 (55)0.1 Income $ per month <600$84 (57.1)63 (42.9) >600$39 (73.6)14 (26.4)0.03 Total years of work experience <5 years 33 (56.9)29 (43.1) 5-10 years 18 (42.9)24 (57.1) >10 years 62 (62)38 (38)0.1

34. Reason of stress No stress N (%) Stress N (%)P Task type Rarely85 (63)50 (37) Always26 (41.9)36 (58.1)0.0001 Economical problem Rarely57 (72.2)22 (27.8) Always53 (45.3)64 (54.7)0.0001 Colleagues Rarely82 (58.6)58 (41.4) Always28 (50) 0.27 Work environment Rarely91 (64.5)50 (35.5) Always19 (34.5)36 (65.5)0.0001 Children's problem Rarely86 (48)93 (52) Always4 (23.5)13 (76.5)0.05 Relatives Rarely103 (57.5)76 (42.5) Always7 (41.2)10 (58.8)0.19

35. Type of coping Yes or no stress Mean Std. Deviation tp Self distraction No5.11.6 Yes51.5-0.590.5 Active coping No6.71.5 Yes6.41.41.30.1 Denial No3.61.6 Yes3.91.3-1.60.1 Substance use No2.20.81 Yes2.20.820.0050.99 Emotional use No61.6 Yes51.5-4.70.001 Instrument support No61.5 Yes5.91.4-.620.5 Behavior disengagement No3.11.3 Yes4.31.7-5.50.001

36. Type of coping Yes or no stressMeanStd. Deviationtp VentingNo5.51.6 Yes4.81.3-3.20.001 Positive reframingNo6.31.6 Yes5.81.52.30.02 PlanningNo6.31.5 Yes6.11.3-0.950.34 HumorNo3.61.4 Yes3.31.6-1.60.09 AcceptanceNo61.5 Yes5.81.50.10.3 ReligiousNo6.11.6 Yes6.51.2-1.60.09 Self blameNo4.41.5 Yes5.61.7-50.001

37. On the basis of the present study results, it can be said that around half of the employees suffer from stress. This result concurs with the findings in other similar studies in Iran but internationally and in comparison with industrial countries, Iranian people have a much higher level of stress. This study on stress reveals high stress levels in the population, which justify appropriate planning and community-based interventions, to make better lifestyle and reduce stress.

38. References Ahmadi, KH & Kolivand, A. 2006. Stress and Job Satisfaction among Air Force Military Pilots. Journal of Social Sciences. 2 (4): 121-124. Amidi, M. Naghdi, H. Joulazadeh, M. H. 2006. Occupational accident in Esfahan Steel Company. The eleventh Iranian annual congress of metallurgy engineering association. Arnold, J. Cooper, C. & Robertson T. (1995) Work Psychology, 2nd ed. Pitman. Arsenault, A. Dolan S.1983. The role of personality, occupation and organization in understanding the relationship between job stress, performance and absenteeism. J Occup Psych.56:227-240. Baker, D. B. 1985. The study of stress at work. Annual Review of Public Health. (6) 367– 381. Bartlett, D. 1998 Stress, Perspectives and Processes. Health psychology Series. Chapter 1. Stress and Health, OUP, Buckingham, pp. 1–21. Bourbonnais, R. Comeau, M. Vezina M. 1999. Job strain and evolution of mental health among nurses. J. Occup. Health Psychol. 4: 95–107. Boyle, A. Crap, M. Younger, J. Thornby, D. 1991. Personality hardiness, ways of coping, social support and burnout in critical care nurses. J. Adv. Nurs. 16: 850–857. Brooks, E. Wilkinson, J. Bott, M. Tauton, R. 1993. Situational supports and job stress: A correlational study. Nursing connections. 6: 39–45. Breznitz, S. and L. Goldberger.1993. Stress Research at a Crossroads. In L. Goldberger and S. Breznitz, eds. The Handbook of Stress. 2nd edition, New York: The Free Press. Chapman, J. 1993. Collegial support linked to reduction of job stress. Nurs. Manage. 24: 52– 54. 38

39. Carver, C.S. pozo, C. Harris, S, D. Noriega V. Scheier, M, F. Robinson, D, S. Ketchman, A, S. Kimberley, C, C. 1993. How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of personality and social psychology. 65 (2) 375-390. Cheng, Y. Kawachi, I. Coakley, E. Schwartz, J. Colditz, G. 2000. Association between psychosocial work characteristics and health functioning in American women: Prospective study. BMJ 320: 1432–1436. Clancy, J. & McVicar, A. 2002. Physiology and Anatomy: A Homeostatic Approach, 2nd edn. Chapter 22: Stress. Arnold, London, pp. 611–633. Cobb, S. 1979. Social support and health throughout the life course. In M.W. Riley (Ed), Aging from birth to death. Boulder, CO: Westview Press. Cohen, S. & Wills, T. 1985. Stress, social support, and the buffering hypothesis. Psychological Bulletin. 98: 310-357. Collins M. 1996.The relation of work stress, hardiness and burnout among full-time hospital staff nurses. J. Nurs.Staff Dev. 12: 81–85. Cooper, C.L. 1986. Job Distress: Recent Research and the Emerging Role of the Clinical Occupational Psychologist. Bulletin of the British Psychological Society. 39:325-331. 39

40. Thank you 40

41. 41

42. 42

43. 43 CONSENT FORM Study Title "occupational stress and coping strategies among the workers of Esfahan Steel Company, Iran. Please tick () to confirm you have read and understood the following: I have received verbal information on the above study and have read that attached written information sheet. I have been given the chance to discuss the study and ask questions. I consent to take part in the study and I am aware my participation is entirely voluntary. I understand that I may withdraw at any time without giving a reason and without this affecting my future care. Signing this information and consent form, I agree that my personal data, including data relating to my results, physical or medical condition, may be used as described in this attached written information sheet. Signature of responder Date of Signature I have explained the nature and the purpose of the study to the subject named above. Witness name employee name researcher name signature Signature signature