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Workplace Stressors

A Brief Introduction to Work-Related Stress

“Work, so fundamental to basic survival and health, as well as to wealth, well-being, and positive social identity, has its darker and more costly side too.1 Work can negatively affect our health, an impact that goes well beyond the usual counts of injuries, accidents, and illnesses from exposure to toxic chemicals. The ways in which work is organized—particularly its pace, intensity and the space it allows or does not allow for control over one’s work process and for realizing a sense of self-efficacy, justice, and employment security—can be as toxic or benign to the health of workers over time as the chemicals they breathe in the workplace air. Certain ways in which work is organized have been found to be detrimental to mental and physical health and overall well-being, causing depression and burnout [1-2], as well as contributing to a range of serious and chronic physical health conditions, such as musculoskeletal disorders, hypertension, chronic back pain, heart disease, stroke, Type II diabetes, and even death [3-5]. Accordingly, many occupational health scientists refer to these particularly noxious characteristics of work as hazards or risk factors of the psychosocial work environment to which employees are exposed.”

Work-Related Psychosocial Stressors

“Researchers have thought about and measured work stressors in various ways over the last 30 years [54-57]. The most highly studied type of work stressor is “job strain,” that is, work which combines high psychological job demands with low job decision latitude or job control [11]. A more recently developed and important way of describing job stress is “effort-reward imbalance,” a “mismatch between high workload (high demand) and low control over long-term rewards” [58, p. 1128]. Low reward includes low “esteem reward” (respect and support), low income, and low “status control” (poor promotion prospects, employment insecurity, and status inconsistency). Another stressor, “organizational injustice,” has been defined in three ways: a) distributive injustice—is one unfairly rewarded at work?; b) procedural injustice—do decision-making procedures at work fail to provide for  input from affected parties, useful feedback, and the possibility of appeal, and are they not applied fairly, consistently, and without bias?; c) relational injustice— do supervisors fail to treat workers with fairness, politeness, and consideration [59]? In addition, research studies have examined “threat-avoidant” vigilant work, i.e., work that involves continuously maintaining a high level of vigilance in order to avoid disaster, such as loss of human life [56]. This is a feature of a number of occupations at high risk for CVD, e.g., truck drivers, air traffic controllers, and sea pilots. More recently, researchers have been investigating the health effects of employment insecurity and “downsizing” [60].”


1. Rugulies, R., U. Bultmann, B. Aust, and H. Burr, Psychosocial Work Environment and Incidence of Severe Depressive Symptoms: Prospective Findings from a 5-Year Follow-up of the Danish Work Environment Cohort Study, American Journal of Epidemiology, 163:10, pp. 877-887, 2006.

2. Rafferty, Y., R. Friend, and P. Landsbergis, The Association between Job Skill Discretion, Decision Authority and Burnout, Work and Stress, 15:1, pp. 73-85, 2001.

3. Belkic, K., P. Landsbergis, P. Schnall, and D. Baker, Is Job Strain a Major Source of Cardiovascular Disease Risk?, Scandinavian Journal of Work Environment and Health, 30:2, pp. 85-128, 2004.

4. Krause, N., D. R. Ragland, B. A. Greiner, S. L. Syme, and J. M. Fisher, Psychosocial Job Factors Associated with Back and Neck Pain in Public Transit Operators, Scandinavian Journal of Work Environment and Health, 23:3, pp. 179-186, 1997.

5. Krause, N. and D. R. Ragland, Occupational Disability Due to Low Back Pain: A New Interdiscipline Classification Based on a Phase Model of Disability, Spine, 19:9, pp. 1011-1020, 1994.

54. Schnall, P. L., P. A. Landsbergis, and D. Baker, Job Strain and Cardiovascular Disease, Annual Review of Public Health, 15, pp. 381-411, 1994.

55. Kristensen, T. S., M. Kronitzer, and L. Alfedsson, Social Factors, Work, Stress and Cardiovascular Disease Prevention, The European Heart Network, Brussels, Belgium, 1998.

56. Belkic, K., P. A. Landsbergis, P. Schnall, et al., Psychosocial Factors: Review of the Empirical Data among Men, in The Workplace and Cardiovascular Disease Occupational Medicine: State of the Art Reviews, Schnall, P., K. Belkic, P. A. Landsbergis, and D. Baker (eds.), Hanley and Belfus, Philadelphia, PA, pp. 24-46, 2000.

57. Belkic, K., P. Landsbergis, P. Schnall, and D. Baker, Is Job Strain a Major Source of Cardiovascular Disease Risk?, Scandinavian Journal of Work Environment and Health, 30:2, pp. 85-128, 2004.

58. Siegrist, J., R. Peter, A. Junge, P. Cremer, and D. Seidel, Low Status Control, High Effort at Work and Ischemic Heart Disease: Prospective Evidence from Blue Collar Men, Social Science and Medicine, 31, pp. 1127-1134, 1990.

59. Kivimaki, M., M. Virtanen, M. Elovainio, A. Kouvonen, A. Vaananen, and J. Vahtera, Work Stress in the Etiology of Coronary Heart Disease—A Meta-Analysis, Scandinavian Journal of Work Environment and Health, 32:6(Special Issue), pp. 431-442, 2006.

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.


A Brief Introduction to Job Strain

Peter Schnall M.D., M.P.H.

Research conducted since the end of WWII into the causes of hypertension and coronary heart disease has identified a number of important risk factors that contribute to the development of these illnesses such as excessive caloric and fat intake leading to obesity and elevated blood cholesterol, cigarette smoking, high blood pressure, and diabetes, all of which contribute to atherosclerosis. Unfortunately, the cause(s) of high blood pressure have proven more difficult to identify, though being overweight has long been recognized as a risk factor for hypertension. Recently, attention has focused on the workplace as a potential source of stressors that might contribute to the development of hypertension.

A number of specific stressful working conditions, such as repetitive work, assembly-line work, electronic monitoring or surveillance, involuntary overtime, piece-rate work, inflexible hours, arbitrary supervision, and deskilled work, have been studied. Over the last 15 years, a new model of job stress (see figure) developed by Robert Karasek has highlighted two key elements of these stressors, and has been supported by a growing body of evidence. Karasek’s “job strain” model states that the greatest risk to physical and mental health from stress occurs to workers facing high psychological workload demands or pressures combined with low control or decision latitude in meeting those demands. Job demands are defined by questions such as “working very fast,” “working very hard,” and not “enough time to get the job done.” Job decision latitude is defined as both the ability to use skills on the job and the decision-making authority available to the worker. In some recent studies, this model was expanded to include a third factor – the beneficial effects of workplace social support. While there are a variety of models of “job stress, the “job strain” model emphasizes the inter-action between demands and control in causing stress, and objective constraints on action in the work environment, rather than individual perceptions or “person-environment fit.” Karasek’s model emphasizes another major negative consequence of work organization; how the assembly­line and the principles of Taylorism, with its focus on reducing workers’ skills and influence, can produce passivity, learned helplessness, and lack of participation (at work, in the community, and in politics). The “job strain” model (see figure) has two components – increasing risk of heart disease following arrow A, but increasing activity, participation, self esteem, motivation to learn, and sense of accomplishment following arrow B. Thus, this model provides a justification and a public health foundation for efforts to achieve greater worker autonomy as well as increased workplace democracy.

Considerable evidence exists linking ‘job strain’ to hypertension and coronary heart disease. Over the last decade more than 40 studies on “job strain” and heart disease and 20 studies on “job strain” and heart disease risk factors have been published throughout the world providing strong evidence that “job strain” is a risk factor for heart disease1. Of the eight studies where an ambulatory (portable) blood pressure monitor was worn during a work day, five showed strong positive associations between “job strain” and blood pressure, while three others provided mixed results. Since ambulatory blood pressure is both more reliable (since there is no observer bias and the number of readings is greatly increased) and more valid (since blood pressure is measured during a person’s normal daily activities including work) than casual measures of blood pressure, we feel confident in placing more emphasis on the ambulatory blood pressure results.

The issue of job stress is of utmost importance to the public health community and working people. The economic costs of job stress in general (absenteeism, lost productivity) are difficult to estimate but could be as high as several hundred-billions/per year (2, p. 167-8). Most importantly, there is the potential for preventing much illness and death. More than 50 million Americans have high blood pressure, and, in 95 percent of cases, the cause is unknown. While estimates of the proportion of heart disease possibly due to “job strain” vary greatly between studies, Karasek and Theorell (5, p. 167) calculate that up to 23 percent of heart disease could potentially be prevented (over 150,000 deaths prevented per year in the U.S.) if we reduced the level of “job strain” in jobs with the worst strain levels to the average of other occupations.

1 Schnall PL, Landsbergis PA, Baker D. Job Strain and Cardiovascular Disease. Annual Review of Public Health; 15:381-411,1994.Schnall PL, Landsbergis PA, Schwartz JE, Pickering TG. Job Strain and Hypertension.
2 Karasek RA, Theorell T. 1990. Healthy Work. New York: Basic Books
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