Colloque International de GESTES Paris, 10 June, Recognition and health at work: from scientific evidence to policy

Transcription

1 Colloque International de GESTES Paris, 10 June, 2013 Recognition and health at work: from scientific evidence to policy Johannes Siegrist, Ph.D. Senior Professor, Faculty of Medicine University of Duesseldorf. Germany

2 Main messages 1. Work is part of an exchange where workers efforts (E) are compensated by employers rewards (R). Rewards include salary/wage, job promotion/ job security, and appreciation ( recognition ). 2. Lack of recognition in terms of high E/low R is a frequent condition in current labour market (globalised economy; restructuring; precarious work etc.). 3. Chronic exposure to high E/low R at work contributes to a significant increase of stress-related mental and physical disorders (new scientific evidence!). 4. To improve healthy work (E/R balance) preventive efforts are needed at different policy levels (companies, national welfare policies, international regulations).

3 Significant changes in the nature of work and labor market Increase of work pressure and competition, including high performance work organization (impact of economic globalization) High demand for flexibility, mobility, and adaption of workers to new tasks/technologies Fragmentation of occupational careers, de-standardized or atypical work, and growing job instability/insecurity Increase of service and IT professions/occupations with high psychomental/emotional workload Segmentation of labor market; social inequalities in quality of work and employment

4 Effects of economic globalisation: Labour market consequences in developed countries Increased pressure of rationalisation (mainly due to wage competition) Downsizing, Merging, Outsourcing Work Job Low wage / intensification insecurity salary

5 High Performance Work Organization (HPWO) Gains: Functional flexibility, creativity Extended self-direction, increased responsibility Merging production and quality control Performance-based pay Costs: increased work pressure enhanced commitment close performance monitoring contextual vulnerability

6 Consequences of HPWO (P. Osterman 2000*) Empirical analyses of 683 establishments USA : Increased productivity But: No gains in real wages No reduction in layoffs Less managers due to flattening of hierarchies There is very little evidence that HPWOs have delivered on the promise of mutual gains. (p. 190f) HPWOs are therefore a risk constellation of chronic work stress *Source: Industrial and Labour Relations Review 53:

7 Downsizing and restructuring occurs frequently - in periods of slow economic growth (low demand, increased competition, rationalization) - in times of economic shocks (financial crisis, recession, major political upheaval) - in periods of rapid economic growth (enhanced privatization, trade liberalization, neoliberal labour and social policies)

8 Increase in job insecurity between 2005 and 2010, EU27 Survey Source: Eurofound (2010) Changes over time - First findings from the fifth European Working Conditions Survey, Dublin

9 Cumulative effect of unemployment on risk of myocardial infarction (HRS Study, USA; n = 1 351) Source: Dupre, ME et al. 2012: Arch Intern Med, 172(22): , (p. 1734).

10 High work pressure (e.g. overtime work) and job instability (e.g. downsizing) are unhealthy! Examples of recent evidence: Overtime work (>11 hrs/day): risk of severe depression: HR 2.4 risk of incident CHD: HR 1.7 (Virtanen M et al. PLoS One 2012, Eur Heart J 2010) Surviving severe downsizing: risk of all-cause mortality: HR 1.4 risk of CHD mortality: HR 2.0 (Vahtera J et al. BMJ 2004)

11 Scientific definition of stress Stress reactions occur if a person is exposed to an unescapable threatening demand (stressor) that taxes or exceeds her/his capacity of successful response. Four dimensions of stress reactions: Cognitive appraisal (evaluation of danger) Affective response (anxiety, anger) Activation of stress axes in organism (SAM, HPA) Behavioural patterns (fight or flight) Critical for health: Chronic stressors (work!) associated with active coping elevated risk of stress-related disorders

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

13 Three theoretical models of the psychosocial work environment 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

14 The demand-control model Psychological Demands low high Decision latitude (control) low high Passive Active Lowstrain Highstrain Source: Karasek: Healthy work, New York: Basic Books, 1990, p. 32.

15 The Organizational Justice Model 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, mainly procedural and relational justice were measured with relevance to health and performance.

16 The model of effort-reward imbalance Extrinsic components - labor income - career mobility / job security - esteem, respect demands / obligations reward effort motivation ( overcommitment ) motivation ( overcommitment ) Intrinsic component Source: Based on Siegrist, J (1996): J Occup Health Psychol, 1:

17 Why do people continue to work in high cost low gain conditions? 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.

18 Relevance of the effort-reward imbalance model It captures main features of modern work due to economic globalisation (competitive wages, high work pressure, low job security, lack of esteem). It is based on an evolutionary old principle of human exchange (social reciprocity between give and take) with important implications for health and wellbeing. It combines features of the work situation and of the working person. It provides robust comparative information on adverse health effects of work stress due to its wide application in international studies.

19 Measurement of the DC and ERI models Both models are measured by a standardized selfassessed questionnaire which can be applied to a variety of different occupational groups: - Job Content Questionnaire (JCQ) (R. A. Karasek) - Effort-Reward Imbalance Questionnaire (ERI) (J. Siegrist) 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.

20 ERI Questionnaire: In addition to single scales, a ratio of effort/reward is constructed to quantify imbalance at individual level (e.g.swedish cohort study (SLOSH) Association of ERI (2006) with self-rated health (2008): Effort (highest quartile) OR 2.60 ( ) Reward (lowest quartile) OR 2.25 ( ) E/R-Ratio (highest quart.) OR 4.43 ( ) Overcommitment ( ) OR 3.79 ( ) ORs adj. For age, sex, education, income, and baseline SRH Source: C. Leineweber et al. Occup Environ Med 2010, 67: 526

21 The social gradient of work stress in the European workforce (age 50-65): SHARE-study Social gradient of work stress Percent high stressed Very low Low Medium High Very high 5 0 Effort-Reward Imbalance Low control Source: Wahrendorf M et al. (2012): Eur Sociol Rev, doi: /esr/jcs058 (results based on SHARE release 2.3.0)

22 What is the scientific evidence of a direct association of work stress with disease? 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)

23 Public health relevance of stress-related disorders at work Focus on coronary heart disease and depression 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)

24 Work stress (effort reward imbalance/job control) and CHD incidence, men and women: Whitehall II-Study 3 2,5 2 3 * * 2,5 2 1,5 1, ,5 No work stress High effort or low reward High effort and low reward 0,5 No work stress adjusted for age, sex, length of follow-up Intermediate job control Low job control + alternative work stress model + grade, coronary risk factors, negative affect * p <.05 Source: Based on Bosma, H, et al. (1998), Amer J Publ Health, 88: 68-74

25 Work stress and cardiovascular mortality: Finnish Cohort Study, n = 812 employees Hazard ratio # 2,5 2 1,5 1 * * Tertile (work stress): 1 = no 2 = low 3 = high # adj. for age, sex, SEP, smoking, phys. act., SBP, cholest., and BMI 0, High demand / low control High effort / low reward Source: Based on Kivimäki, M, et al. (2002), BMJ, 325: 857, doi:/ /bmj

26 Meta-analysis of cohort studies on relative risks of coronary heart disease due to job strain 4/9 Decreases risk Increases risk Source: Kivimaki, M, et al. Scand J Work Environ Health (2006): 32: , (p. 436).

27 Workplace demands, economic reward, and 4-year progression of carotid atherosclerosis (plaque height) in 940 Finnish men 4-year increase In plaque height (mm) 0,35 0,3 0,25 0,2 0,33 0,26 0,27 low high 0,27 low high Economic rewards p =.04 (adj.) Source: Based on Lynch, J., et al. (1997), Circulation, 96:

28 Psychosocial stress at work in Chinese male coronary patients vs. healthy controls (N=388) low middle high 1 0 Effort-Reward Imbalance 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: Based on Xu, W. et al (2009) J Occup Health 51:

29 Control at work and blood pressure Systolic BP Mean ambulatory blood pressure (low control vs. high control). N = 227 men and women (47-59 years); Whitehall Cohort Study Diastolic BP Low control High control Low control High control Source: Based on Steptoe, A, et al. (2004), Journal of Hypertension, 22(5):

30 Cardiovascular monitoring over 3 days in healthy male computer employees and work stress

31 Inflammatory response (CRP) during experimentally induced mental stress according to level of effortreward imbalance (N=92) CRP change # (μg/ml) as function of effortreward imbalance # adjusted for age, BMI, baseline levels p <.05 low medium high Effort-Reward Imbalance

32 Depression Serious public health problem worldwide Estimated life time prevalence: % Severity due to high co-morbidity (esp. cardiovascular diseases) and risk of suicide Manifestation in early adult life, compromised work ability (sickness absence, disability pension) Massive direct and indirect costs Genetic, early life and other personal determinants, but also role of work stress

33 Evidence from prospective cohort studies: elevated risks of depression Demand-control model: 12 of 14 studies: OR varying from 1.2 to 3.4 (full model or components) Effort-reward imbalance model: 10 studies: OR varying from 1.5 to 4.6 (full model or components) Organisational justice model: 11 studies: OR varying from 1.2 to 2.4 (single components)

34 1-year incidence on major depression and work stress quartiles (Effort-Reward Imbalance) Canada (n = 2752, men and women) Men Women Source: Wang, J (2012): Am J Epidemiol 176: 52-59, (p. 55).

35 Moderation of effort-reward imbalance (ERI) on severe depressive symptoms by SES (N = 1729) Danish Work Environment Cohort study Logistic regression analysis: Model: adj. for gender, age, family status, survey method, health behaviours (smoking, heavy alcohol consumption, leisure time physical activity), self-rated health, sleep disturbances and non-severe depressive symptom score (53 100) at baseline Source: Rugulies et al (2012) Eur J Public Health (in press)

36 Psychosocial stress at work and depressive symptoms: employed men and women yrs. from 17 countries in three continents (SHARE, ELSA, HRS, JSTAR) 2,5 * * 2 * 1,5 1 * * ERI Low control 0,5 0 USA (N=1560) Europa (N=10342) Japan (N=1226) Source: J. Siegrist et al (2012) Globalization and Health 8:27.

37 Work stress (ERI) and natural killer cells in 347 Japanese employees Source: Nakata A et al (2011), Biol Psychol 88: , (p. 277).

38 Summary Robust evidence from epidemiological and experimental research that lack of recognition at work (ERI) is a risk factor of stress-related disorders. Overall, with a mean prevalence of 25% among employees, exposure to ERI is associated with a twofold elevated disease risk. Additional negative effects of stressful work due to sickness absence, reduced productivity and early exit from labour market.

39 Evidence-based policy interventions at different levels Legislation, Regulation, Social movements Employer initiated new systems of work organization, Collective bargaining Economic, political context Organizational context Job insecurity, Downsizing Precarious work New systems of work organization Employer initiated job redesign, Labor-management committees, Action research Health promotion, Stress management Treatment, Rehabilitation, Return-to-Work programs 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

40 Policy implications and conclusions 1. The level of firms/ organizations Strengthen main features of health-promoting work: Jobs offering some degree of autonomy, control for personal development Regulations against excessive demands, overtime work, stressful work pace/-load Productivity-related rewards, fair wages, appropriate recognition from superiors, satisfying career prospects, including job security Regulations against non-standard, precarious work and employment

41 What can be done at company level? Provide evidence of a business case Provide shared commitment from management and employees Provide available expertise (e.g. occupational safety & health) and equipment Monitor working conditions and employees health Develop and implement programmes, invest in improvements, consult models of best practice Ensure continuity, evaluate outcomes, build networks

42 Improved control and autonomy over work time and sickness absence (SA) Adj. rel. SA-risk (during 28 months) Work stress (ERI) + Control of daily work schedule Work stress (ERI) + Lack of control of daily work schedule Work stress (ERI) + Control of free days at work Work stress (ERI) + No control of free days at work 23 % 39 % 12 % 43 % Source: Ala Mursala L. et al. (2005) J Epidemiol Community Health 59: ; N=16.000)

43 Models of best practice: the case of Denmark (M.Bogehus Rasmussen et al. (2011) Safety Science 49:565-74) New strategy launched by the Danish Working Environment Authority in 2007 to strengthen primary prevention of work related stress Trained WEA inspectors assess sector-specific guidance tools in all Danish enterprises as part of their regular work. Centralized data analysis in collaboration with national research institute Feedback to enterprises; discussion of improvements with social partners

44 Policy implications and conclusions: 2. Initiatives at national and international level Apply legal frameworks (national, international) Enforce fair work standards in trade contracts Promote voluntary agreements between employers and trade unions Support social movements (e.g. EU: Corporate Social Responsibility) Maintain and develop distinct national labor and social policies Welfare regimes securing basic social and economic protection, access to health care, further education, etc.

45 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. Source: Siegrist J., Wahrendorf M. (2011) in: The Individual and the Welfare State (ed. A. Börsch-Supan et al.) Springer Heidelberg, , p. 174.

46 Effects of stressful work on depressive symptoms: variation according to welfare system (SHARE) 3 2 Odds ratio no yes 1 0 social democratic conservative liberal social democratic conservative Effort-Reward imbalance Low conctrol liberal Stressful work: Tertiles, effort-reward ratio or low control Depressive symptoms: Odds ratios adjusted for SEP, age and gender. Source: Based on Dragano N et al (2011) J Epidemiol Community Health 65:

47 Conclusion In times of economic threats and challenges it is essential to preserve a population s basic level of social and health protection and to strive for healthy work by strengthening recognition at all available policy levels! Thank you!