Effort-reward imbalance at work and recurrent coronary heart disease events: a 4-year prospective study of post-myocardial infarction patients

Development and validation of machine learning models based on stacked generalization to predict psychosocial maladjustment in patients with acute myocardial infarction

BACKGROUND

Psychosocial maladjustment threatens the recovery of patients with acute myocardial infarction (AMI), and early identification of patients with psychosocial maladjustment may facilitate provision of reference to targeted interventions. The aims of this study were to: (1) identify key factors influencing patient psychosocial maladjustment, and (2) develop a machine learning predictive model based on Stacked Generalization.

METHODS

Young and middle-aged patients with AMI (n = 734) were recruited from two tertiary hospitals (Center I and Center II) in Guangdong Province. Sociodemographic Characteristics, Perceived Stress Scale, Fear of Progression Questionnaire-Short Form, and Social Support Rating Scale data were collected before discharge, and psychosocial adjustment assessed one month after discharge using the Psychosocial Adjustment to Illness Scale. Six machine learning methods were trained on Center I to analyze the collected data and build a predictive model. Stacked Generalization was adopted to ensemble the models and build a final predictive model. Key factors and their contributions to the model were determined using SHapley Additive exPlanations (SHAP).

RESULTS

One month after discharge, psychosocial maladjustment incidence rates in Centers I and II were 59.2% and 58.3%, respectively. Eight key predictors of psychosocial adjustment were selected: employment status, exercise habits, diabetes, number of vascular lesions, chest tightness or chest pain, perceived stress, fear of disease progression, and social support. In the internal validation, Support Vector Classification (SVC) performed better in terms of Brier score, sensitivity, and negative predictive value; Decision Tree (DT) performed better in calibration slope, specificity, and precision; while Random Forest (RF) performed better in terms of area under the curve (AUC), Youden, and accuracy values. An LDS-R model stacked by SVC, logistic regression, DT, and RF, achieved the best comprehensive performance and generalization error, with accuracy = 0.834, AUC = 0.909, precision = 0.855, and calibration slope = 1.066 in external validation, indicating that the model is robust and the most suitable for promotion. SHAP provided insights into the model's predictions.

CONCLUSION

The LDS-R model is a practical tool for identifying patients at high risk for psychosocial maladjustment before discharge. Our identification of significant factors influencing psychosocial maladjustment may inform future development of interventions.

The burdens and benefits of managing and engaging: a diary study approach to person-centred risk assessment of top executives and works council members

The present diary study investigates the impact of daily effort-reward imbalance (ERI), subjective stress and the cortisol awakening response (CAR) as an objective measure on work engagement of top managers and high-level works council members (N = 45) on three consecutive working days. In the scope of psychosocial risk assessment, we argue that focusing on ERI as a generalized work characteristic might be more suitable for work re-design of higher leadership positions because of their highly dynamic and unpredictable psychosocial work characteristics, while at the same time having more access to job resources. The analyses reveal that both baseline and daily ERI, as well as subjective stress, influence work engagement. Our results suggest that interventions to reduce daily levels of ERI may improve the work environment of top managers and works councils by promoting work engagement and related positive health outcomes in the scope of person-centred risk assessment.

Burnout among diabetes specialist registrars across the United Kingdom in the post-pandemic era

Introduction

Burnout syndrome is a condition resulting from chronic work-related stress exposure and can be identified by the presence of one or more of the three classic dimensions of burnout, i.e., emotional exhaustion, depersonalization, and lack of personal accomplishment, which negatively impact physician health and productivity.

Objective

This study aimed to identify burnout among Diabetes and Endocrinology Specialty Training Registrars (DStRs) across the United Kingdom.

Design/setting

It was a Cross-sectional observational study after ethical approval ERSC_2022_1166, utilizing the gold standard Maslach Burnout Inventory to measure burnout syndrome, and to determine self-reported stressors and compare them with the results of our previous survey in 2018.

Participants

Over 430 DStRs across the United Kingdom were invited electronically through their deanery representatives and specialty training bodies.

Results

Using Google Forms™ to gather data, we were able to collect 104 completed surveys. Results revealed that 62.5% (n = 65) of participants have burnout (5% increase from the previous survey in 2018), 38.6% (n = 40) have high emotional exhaustion, and 44.2% (n = 46) feel a lack of personal accomplishment. "General Internal Medicine specific workload" was the most common self-reported stressor reported by 87.5% (n = 91) of participants, whereas bullying/harassment and discrimination at work were reported by 35.6% (n = 37) and 30.77% (n = 32) of participants, respectively. Using multivariable logistic regression model, personal stress (OR, 4.00; 95% CI, 1.48-10.86; p = 0.006) had significant, while Bullying/harassment (OR, 3.75; 95% CI, 0.93-15.12; p = 0.063) had marginal impact on the presence of burnout.

Conclusion

Diabetes and Endocrinology Specialty Training Registrars frequently experience burnout syndrome, which has increased over the last 4 years. However, organizational changes can help identify, prevent, and treat physician burnout.

Trial registration

NCT05481021 available at https://ichgcp.net/clinical-trials-registry/NCT05481021.

Impact of stress and stress mindset on prevalence of cardiovascular disease risk factors among first responders

BACKGROUND

Psychological stress is recognized as an important modifiable risk factor for cardiovascular disease (CVD). Despite its potential significance, few to no studies have evaluated the association between stress, stress mindset, and CVD risk factors among rural first responders. The objectives of this study were to identify relationships between general stress, stress mindset, and CVD risk factors.

METHODS

The study sample (n = 148) included those 18 years or older and who currently serve as a first responder, defined as either EMS, firefighter, or law enforcement. Questionnaires captured information on demographics, years of work experience as a first responder, multiple first responder occupations, general stress, stress mindset, and self-reported CVD risk factors. Data were analyzed using regression analyses.

RESULTS

Findings suggest that first responders with a stress-is-negative mindset have significantly higher general stress levels (β = 2.20, p = 0.01). Of note, general stress was not a significant predictor of CVD risk factors (AOR = 1.00, 95%CI = 0.93, 1.08) included in our study. However, a negative stress mindset was statistically significant predictor of CVD risk factors (AOR = 2.82, 95%CI = 1.29, 6.41), after adjusting for general stress and other potential confounders.

CONCLUSIONS

Findings suggest that stress mindset is an independent predictor of stress and CVD risk factors among rural first responders. These results have the potential to inform educational and organization level interventions targeting stress appraisal for this vulnerable sub population of workers.

Occupational Health and Well-being Questionnaire (OHWQ): an instrument to assess psychosocial risk and protective factors in the workplace

OBJECTIVES

Psychosocial stressors at work have been identified as significant risk factors for several mental and physical health problems. These stressors must be compensated by psychosocial resources to prevent or reduce adverse effects on health. Questionnaires measuring these stressors and resources already exist, but none integrate digital stress, ethical culture, and psychosocial safety climate; factors that are increasingly linked to workers' health. This study aims to develop and establish the psychometric properties of one of the most comprehensive instruments measuring the psychosocial work environment to date: the Occupational Health and Well-being Questionnaire (OHWQ).

STUDY DESIGN

A cross-sectional validation study is proposed to develop the OHWQ and document its psychometric properties.

METHODS

The OHWQ was developed from validated instruments to which new items were added. The questionnaire includes psychosocial dimensions, along with indicators of psychological distress, musculoskeletal disorders, and well-being. It was administered to a sample of 2770 participants from a population working in the academic field. Exploratory and confirmatory factor analyses and the calculation of Cronbach's α coefficient were used to identify the variables, items, and, dimensions of the OHWQ and to document its main psychometric properties.

RESULTS

The acceptability of the measurement model was evaluated by the reliability of the items, internal consistency between the items, and the convergent and discriminant validity. Construct validity was assessed using exploratory and confirmatory factor analyses. Using factor analyses and cut-off rules, the new instrument has 124 items grouped into 22 dimensions. The OHWQ demonstrated satisfactory reliability and validity, as well as reasonable fit indices. The internal consistency of the scales was also good (Cronbach's α = 0.68-0.96, median = 0.85).

CONCLUSION

The OHWQ demonstrated good psychometric properties. It could be useful for both research purposes and for workplaces interested in developing concrete action plans aimed at improving the balance between psychosocial work stressors and resources.

Effort-Reward Imbalance at Work and Overcommitment in Patients with Acute Myocardial Infarction (AMI): Associations with Return to Work 6 Months After AMI

Purpose Stress-related factors influence the adaptation to life after acute myocardial infarction (AMI), including return to work. The goal of this study was to investigate the effect of work-related stress, (expressed by the effort-reward imbalance (ERI) model) on return to work after AMI. Methods A longitudinal study with AMI patients was conducted in order to assess associations between the independent variables effort, reward, ERI and overcommitment and the outcome return to work after AMI. Return to work was inquired at 6 months follow-up. Logistic regression models were applied in the analysis. The fully-adjusted model included demographic, clinical, social, stress-related and health-related quality of life (HRQOL) covariables. Results Of the 346 enrolled patients aged 31 to 82 years, 239 (69.1%) were included in the regression analysis. In the unadjusted model ERI presented an odds ratio (OR) of 1.72 (95% confidence interval (CI) 0.86-3.42). Associations for effort and overcommitment were 0.98 (95% CI 0.83-1.15) and 1.09 (95% CI 0.99-1.18). However, reward showed a significantly inverse association with return to work with an OR of 0.90 (95% CI 0.83-0.99). In the fully adjusted model the OR of ERI decreased to 1.20 (95% CI 0.49-2.96). Effort, reward and overcommitment also showed attenuated ORs without significant results in all models. Diabetes mellitus, current smoking, low physical and low mental HRQOL presented significantly negative relations with return to work. Conclusions Work-related stress appears less important than HRQOL and resilience in terms of return to work after AMI.

Effectiveness of a workplace intervention reducing psychosocial stressors at work on blood pressure and hypertension

Objectives

To assess the effectiveness of a workplace intervention reducing psychosocial stressors at work in lowering blood pressure and hypertension prevalence.

Methods

The study design was a quasi-experimental pre–post study with an intervention group and a control group. Post-intervention measurements were collected 6 and 36 months after the midpoint of the intervention. Participants were all white-collar workers employed in three public organisations. At baseline, the intervention and the control groups were composed of 1088 and 1068 workers, respectively. The intervention was designed to reduce psychosocial stressors at work by implementing organisational changes. Adjusted changes in ambulatory blood pressure and hypertension prevalence were examined.

Results

Blood pressure and hypertension significantly decreased in the intervention group while no change was observed in the control group. The differential decrease in systolic blood pressure between the intervention and the control group was 2.0 mm Hg (95% CI: −3.0 to –1.0). The prevalence of hypertension decreased in the intervention group, when compared with the control group (prevalence ratio: 0.85 (95% CI: 0.74 to 0.98)).

Conclusions

Findings suggest that psychosocial stressors at work are relevant targets for the primary prevention of hypertension. At the population level, systolic blood pressure reductions such as those observed in the present study could prevent a significant number of premature deaths and disabling strokes.

Factors associated with return to work following myocardial infarction: A systematic review of observational studies

OBJECTIVES

To identify and critically synthesise literature on return to work of patients following a myocardial infarction and to identify factors that are associated with this.

BACKGROUND

Understanding when patients return to work after myocardial infarction and what factors are associated with this may be helpful in designing person-centred treatment plans to facilitate patients' rehabilitation and return to work.

DESIGN

A narrative systematic review.

REVIEW METHODS

Six databases, MEDLINE, CINAHL, Academic Search Complete, EMBASE, SCOPUS and ProQuest Health and Medicine, and the search engine Google were searched to retrieve peer-reviewed articles published in English from January 2008-January 2020. In total, 22,217 papers were sourced and screened, with 18 papers retained for quality appraisal using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

The mean time to return to work varied between 46-192 days; about half the participants resumed work by 3 months. Patients who were male, younger, educated, non-manual workers or owned their own business, and those who evaluated their general and mental health highly, and had shorter hospitalisation, fewer comorbidities, complications and mental health issues were more likely to return to work after myocardial infarction.

RELEVANCE TO CLINICAL PRACTICE

Findings may help nurses detect patients at increased risk of failure to return to work and provide appropriate support to facilitate this.

Cardiometabolic risk in Algeria: past and present

Algeria, like all emerging countries, has been going through a health transition over the past 30 years or so, characterized by a drop in mortality rates, an increase in life expectancy and a change in the causes of death in favor of chronic non-communicable diseases. In the past, the country mainly faced infectious diseases such as typhoid, cholera and malaria. The prevalence of the latter has been significantly reduced thanks to the many social health and vaccination programs undertaken by the health authorities. As a result of this epidemiological transition, we are witnessing a growing increase in the incidence of non-communicable diseases, mainly represented by cardiovascular diseases, diabetes, obesity and cancer. According to the results of the latest national survey on the measurement of risk factors for non-communicable diseases (the Who StepWise approach), the prevalence of diabetes is close to 14.4% while the rate of obesity and overweight exceeds 50% of the population. High blood pressure has reached a prevalence rate of 23.6%. These diseases represent a real threat to our country's health, social and economic situation; they will lead to greater demands on health facilities and require more resources for intervention.

Differences between women and men in the relationship between psychosocial stressors at work and work absence due to mental health problem

OBJECTIVES

Women have a higher incidence of mental health problems compared with men. Psychosocial stressors at work are associated with mental health problems. However, few prospective studies have examined the association between these stressors and objectively measured outcomes of mental health. Moreover, evidence regarding potential differences between women and men in this association is scarce and inconsistent. This study investigates whether psychosocial stressors at work are associated with the 7.5-year incidence of medically certified work absence due to a mental health problem, separately for women and men.

METHODS

Data from a prospective cohort of white-collar workers in Canada (n=7138; 47.3% women) were used. We performed Cox regression models to examine the prospective association between self-reported psychosocial stressors at work (job strain model) at baseline and the 7.5-year HR of medically certified work absence of ≥5 days due to a mental health problem.

RESULTS

During follow-up, 11.9% of participants had a certified work absence, with a twofold higher incidence among women. Women (HR 1.40, 95% CI 1.01 to 1.93) and men (HR 1.41, 95% CI 0.97 to 2.05) exposed to high strain (high demands and low control) had a higher incidence of work absence compared with those unexposed. Among women only, those exposed to an active job situation (high demands and high control) also had a higher risk (HR 1.82, 95% CI 1.29 to 2.56).

CONCLUSIONS

Prevention efforts aimed at reducing psychosocial stressors at work could help lower the risk of work absence for both women and men. However, important differences between women and men need to be further studied in order to orient these efforts.

Physician Stress and Burnout

Tens (or hundreds) of thousands of Americans die each year as a result of preventable medical errors. Changes in the practice and business of medicine have caused some to question whether burnout among physicians and other healthcare providers may adversely affect patient outcomes. A clear consensus supports the contention that burnout affects patients, albeit with low-quality objective data. The psychological and physical impact on physicians and other providers is quite clear, however, and the impact on the physician workforce (where large shortages are projected) is yet another cause for concern. We have all heard the airplane safety announcement remind us to "Please put on your own oxygen mask first before assisting others." Unfortunately, like many airline passengers (very few of whom use oxygen masks correctly when they are needed), physicians often do not recognize symptoms of burnout or depression, and even less often do they seek help. We detail the causes and consequences of physician burnout and propose solutions to increase physician work satisfaction.

Resilience is strongly associated with health-related quality of life but does not buffer work-related stress in employed persons 1 year after acute myocardial infarction

PURPOSE

Resilience may facilitate the adaptation after experiencing a severe disease such as acute myocardial infarction (AMI) and attenuate the negative effects of stress on health-related quality of life (HRQOL). However, it is unclear so far whether resilience moderates a negative association between work-related stress and HRQOL in employed patients after AMI.

METHODS

Patients with confirmed AMI and regular paid employment admitted to a hospital in the study region of the MONICA/KORA Myocardial Infarction Registry, Germany (04/2014-06/2017) were included and completed questionnaires during their hospital stay and 6 and 12 months after discharge. The Resilience Questionnaire (RS-11) and the Effort-Reward Imbalance (ERI) Questionnaire were used to assess trait resilience and ERI, respectively. HRQOL was measured by the Short Form 36 Health Survey (SF-36) mental and physical component summary scales. Generalized estimating equations (GEE) adjusted for relevant potential confounding variables (demographic, social, stress-related, and clinical) were used to determine the association between resilience and HRQOL in the study course.

RESULTS

From the 346 patients enrolled in the study, 270 patients (78.0%) had completed all surveys. High baseline trait resilience was significantly and independently associated with high physical HRQOL (ß = 0.15, p < 0.0001) and high mental HRQOL (ß = 0.37, p < 0.0001) 1 year post AMI. No significant interaction effects between trait resilience and ERI were found in the physical HRQOL GEE model (ß = 0.05, p = 0.7241) and in the mental HRQOL model (ß = 0.05, p = 0.3478).

CONCLUSIONS

The results demonstrated that trait resilience is independently and strongly related with post-AMI HRQOL but does not moderate the association between ERI and HRQOL.

Work stress and risk of death in men and women with and without cardiometabolic disease: a multicohort study

BACKGROUND

Although some cardiovascular disease prevention guidelines suggest a need to manage work stress in patients with established cardiometabolic disease, the evidence base for this recommendation is weak. We sought to clarify the status of stress as a risk factor in cardiometabolic disease by investigating the associations between work stress and mortality in men and women with and without pre-existing cardiometabolic disease.

METHODS

In this multicohort study, we used data from seven cohort studies in the IPD-Work consortium, initiated between 1985 and 2002 in Finland, France, Sweden, and the UK, to examine the association between work stress and mortality. Work stress was denoted as job strain or effort-reward imbalance at work. We extracted individual-level data on prevalent cardiometabolic diseases (coronary heart disease, stroke, or diabetes [without differentiation by diabetes type]) at baseline. Work stressors, socioeconomic status, and conventional and lifestyle risk factors (systolic and diastolic blood pressure, total cholesterol, smoking status, BMI, physical activity, and alcohol consumption) were also assessed at baseline. Mortality data, including date and cause of death, were obtained from national death registries. We used Cox proportional hazards regression to study the associations of work stressors with mortality in men and women with and without cardiometabolic disease.

RESULTS

We identified 102 633 individuals with 1 423 753 person-years at risk (mean follow-up 13·9 years [SD 3·9]), of whom 3441 had prevalent cardiometabolic disease at baseline and 3841 died during follow-up. In men with cardiometabolic disease, age-standardised mortality rates were substantially higher in people with job strain (149·8 per 10 000 person-years) than in those without (97·7 per 10 000 person-years; mortality difference 52·1 per 10 000 person-years; multivariable-adjusted hazard ratio [HR] 1·68, 95% CI 1·19-2·35). This mortality difference for job strain was almost as great as that for current smoking versus former smoking (78·1 per 10 000 person-years) and greater than those due to hypertension, high total cholesterol concentration, obesity, physical inactivity, and high alcohol consumption relative to the corresponding lower risk groups (mortality difference 5·9-44·0 per 10 000 person-years). Excess mortality associated with job strain was also noted in men with cardiometabolic disease who had achieved treatment targets, including groups with a healthy lifestyle (HR 2·01, 95% CI 1·18-3·43) and those with normal blood pressure and no dyslipidaemia (6·17, 1·74-21·9). In all women and in men without cardiometabolic disease, relative risk estimates for the work stress-mortality association were not significant, apart from effort-reward imbalance in men without cardiometabolic disease (mortality difference 6·6 per 10 000 person-years; multivariable-adjusted HR 1·22, 1·06-1·41).

INTERPRETATION

In men with cardiometabolic disease, the contribution of job strain to risk of death was clinically significant and independent of conventional risk factors and their treatment, and measured lifestyle factors. Standard care targeting conventional risk factors is therefore unlikely to mitigate the mortality risk associated with job strain in this population.

FUNDING

NordForsk, UK Medical Research Council, and Academy of Finland.

Psychosocial Hazard Analysis in a Heterogeneous Workforce: Determinants of Work Stress in Blue- and White-Collar Workers of the European Steel Industry

The European steel industry’s workforce is highly heterogeneous and consists of various occupational groups, presumably facing different psychosocial stressors. The few existing studies on the subject mainly focused on physical constraints of blue-collar workers, whereas the supposable psychosocial workload received only little research attention. This is remarkable considering the challenges associated with statutory required risk assessment of psychosocial hazards. Valid measures of hazard analysis must account for various stressors and reliably identify them, also between occupational groups. The present study, based on a sample of blue- and white-collar workers (N = 124) from the European steel industry, aims to provide a first insight into psychosocial stressors and strain at work in this rarely researched industrial sector. Furthermore, two well-known theoretical roadmaps in job analysis are examined regarding their utility for risk assessment in heterogeneous workforces: the German standard version of the Copenhagen Psychosocial Questionnaire (COPSOQ) and the short version of the effort–reward imbalance questionnaire. Hierarchical multiple regression analyses revealed that the COPSOQ was better suited to predict various strain indices in the present sample. Especially stressors relating to socioemotional aspects, such as work-privacy conflict, revealed a reasonable impact, indicating the need for comprehensive solutions at the organizational level instead of solutions focusing on single workplaces. To conclude, a broadly diversified and validated approach in psychosocial risk assessment is needed to adequately assess the variety of psychosocial factors at work and in different occupational groups.

Effects and mediators of psychosocial work characteristics on somatic symptoms six years later: Prospective findings from the Mannheim Industrial Cohort Studies (MICS)

OBJECTIVE

Ample evidence documented the adverse health effects of work stressors, and recent research has increasingly focused on somatic symptoms which are very common and costly. Prospective evidence is however sparse and yielded mixed findings. Furthermore, there is reason to assume that depression and anxiety might mediate the effects of adverse psychosocial work conditions on somatic symptoms. This study aimed to investigate longitudinal effects of work stressors on somatic symptoms and the potential mediation by anxiety and/or depression.

METHODS

Six year follow-up data from 352 individuals - free of potentially stress-related chronic disease - were utilized. Somatic symptoms were assessed by 19 items of an established list of complaints at baseline and follow-up. The effort-reward-imbalance (ERI) model measured adverse psychosocial work conditions and over-commitment (OC). Linear regressions adjusted for socio-demographics, social status, lifestyle, and baseline symptoms estimated the effects of the ERI ratio, effort, reward, OC, and the ERI ratio×OC interaction on somatic symptoms six years later. Furthermore, single and multiple mediation by anxiety and/or depression was investigated.

RESULTS

There was a strong longitudinal effect of the ERI ratio, as well as of its subcomponents, and OC on somatic symptoms (all Bs≥|0.49|; p-values ≤0.004). Moreover, the ERI ratio×OC interaction was significant (p-value=0.047). Multiple mediation analyses revealed especially anxiety to mediate the effect of work stressors on somatic symptoms (Sobel test=0.007).

CONCLUSION

Adverse psychosocial work conditions seem to longitudinally affect somatic symptoms, potentially moderated by OC, and mediated by anxiety.

Chronic exposure to adverse psychosocial work factors and high psychological distress among white-collar workers: A 5-year prospective study

OBJECTIVES

Prospective studies which evaluated whether the effects of chronic exposure to psychosocial work factors on mental health persisted over time are scarce. For the first time, this study evaluated: 1) the effect of chronic exposure to effort-reward imbalance over 5years on the prevalence of high psychological distress among men and women, and 2) the persistence of this effect over time.

METHODS

Overall, 1747 white-collar workers from three public organizations participated in a prospective study. Psychological distress and effort-reward imbalance were measured using validated questionnaires at baseline, and at 3- and 5-year follow-ups. Prevalence ratios (PRs) of high psychological distress were estimated using log-binomial regression according to baseline and repeated exposure.

RESULTS

Compared to unexposed workers, those with repeated exposure to effort-reward imbalance had a higher prevalence of high psychological distress. Workers exposed only at some time-points also had a higher prevalence. The deleterious effect of repeated exposure observed at the 3-year follow-up persisted at the 5-year follow-up among women (PR=2.48 95% confidence interval (CI) 1.97-3.11) and men (PR=1.91 95% CI 1.20-3.04). These effects were greater than those found using a single baseline measurement.

CONCLUSION

The current study supported a deleterious effect of repeated exposure to effort-reward imbalance on psychological distress, and a lack of adaptation to these effects over time among men and women. Since psychological distress may later lead to severe mental problems, current results highlight the need to consider exposure to these adverse work factors in primary and secondary preventions aimed at reducing mental health problems at work.

The Maugeri Stress Index - reduced form: a questionnaire for job stress assessment

INTRODUCTION AND OBJECTIVES

A multidimensional self-report questionnaire to evaluate job-related stress factors is presented. The questionnaire, called Maugeri Stress Index - reduced form (MASI-R), aims to assess the impact of job strain on a team or on a single worker by considering four domains: wellness, resilience, perception of social support, and reactions to stressful situations.

MATERIAL AND METHODS

The reliability of a first longer version (47 items) of the questionnaire was evaluated by an internal consistency analysis and a confirmatory factor analysis. An item reduction procedure was implemented to obtain a short form of the instrument, and the psychometric properties of the resulting instrument were evaluated using the Rasch measurement model.

RESULTS

A total of 14 items from the initial pool were deleted because they were not productive for measurement. The analysis of internal consistency led to the exclusion of eight items, while the analysis performed using structural equation models led to the exclusion of another six items. According to the Rasch model, item properties and the reliability of the instruments appear good, especially for the scales for wellness and resilience. In contrast, the scales for perception of social support and negative coping styles show a lower internal consistency.

CONCLUSIONS

The Maugeri Stress Index - reduced form provides a reliable and valid measure, useful for early identification of stress levels in workers or in a team along the eustress-vadistress continuum.

Work stress and the risk of recurrent coronary heart disease events: A systematic review and meta-analysis

Though much evidence indicates that work stress increases the risk of incident of coronary heart disease (CHD), little is known about the role of work stress in the development of recurrent CHD events. The objective of this study was to review and synthesize the existing epidemiological evidence on whether work stress increases the risk of recurrent CHD events in patients with the first CHD. A systematic literature search in the PubMed database (January 1990 - December 2013) for prospective studies was performed. Inclusion criteria included: peer-reviewed English papers with original data, studies with substantial follow-up (> 3 years), end points defined as cardiac death or nonfatal myocardial infarction, as well as work stress assessed with reliable and valid instruments. Meta-analysis using random-effects modeling was conducted in order to synthesize the observed effects across the studies. Five papers derived from 4 prospective studies conducted in Sweden and Canada were included in this systematic review. The measurement of work stress was based on the Demand- Control model (4 papers) or the Effort-Reward Imbalance model (1 paper). According to the estimation by meta-analysis based on 4 papers, a significant effect of work stress on the risk of recurrent CHD events (hazard ratio: 1.65, 95% confidence interval: 1.23-2.22) was observed. Our findings suggest that, in patients with the first CHD, work stress is associated with an increased relative risk of recurrent CHD events by 65%. Due to the limited literature, more well-designed prospective research is needed to examine this association, in particular, from other than western regions of the world.

Associations of Extrinsic and Intrinsic Components of Work Stress with Health: A Systematic Review of Evidence on the Effort-Reward Imbalance Model

Mainstream psychological stress theory claims that it is important to include information on people’s ways of coping with work stress when assessing the impact of stressful psychosocial work environments on health. Yet, some widely used respective theoretical models focus exclusively on extrinsic factors. The model of effort-reward imbalance (ERI) differs from them as it explicitly combines information on extrinsic and intrinsic factors in studying workers’ health. As a growing number of studies used the ERI model in recent past, we conducted a systematic review of available evidence, with a special focus on the distinct contribution of its intrinsic component, the coping pattern “over-commitment”, towards explaining health. Moreover, we explore whether the interaction of intrinsic and extrinsic components exceeds the size of effects on health attributable to single components. Results based on 51 reports document an independent explanatory role of “over-commitment” in explaining workers’ health in a majority of studies. However, support in favour of the interaction hypothesis is limited and requires further exploration. In conclusion, the findings of this review support the usefulness of a work stress model that combines extrinsic and intrinsic components in terms of scientific explanation and of designing more comprehensive worksite stress prevention programs.

Standardized assessment of psychosocial factors and their influence on medically confirmed health outcomes in workers: a systematic review

Previous studies of psychosocial work factors have indicated their importance for workers’ health. However, to what extent health problems can be attributed to the nature of the work environment or other psychosocial factors is not clear. No previous systematic review has used inclusion criteria based on specific medical evaluation of work-related health outcomes and the use of validated instruments for the assessment of the psychosocial (work) environment.

The aim of this systematic review is to summarize the evidence assessing the relationship between the psychosocial work environment and workers’ health based on studies that used standardized and validated instruments to assess the psychosocial work environment and that focused on medically confirmed health outcomes. A systematic review of the literature was carried out by searching the databases PubMed, B-ON, Science Direct, Psycarticles, Psychology and Behavioral Sciences Collection and the search engine (Google Scholar) using appropriate words for studies published from 2004 to 2014. This review follows the recommendations of the Statement for Reporting Systematic Reviews (PRISMA). Studies were included in the review if data on psychosocial validated assessment method(s) for the study population and specific medical evaluation of health-related work outcome(s) were presented.

In total, the search strategy yielded 10,623 references, of which 10 studies (seven prospective cohort and three cross-sectional) met the inclusion criteria. Most studies (7/10) observed an adverse effect of poor psychosocial work factors on workers’ health: 3 on sickness absence, 4 on cardiovascular diseases. The other 3 studies reported detrimental effects on sleep and on disease-associated biomarkers. A more consistent effect was observed in studies of higher methodological quality that used a prospective design jointly with the use of validated instruments for the assessment of the psychosocial (work) environment and clinical evaluation.

More prospective studies are needed to assess the evidence of work-related psychosocial factors on workers´ health.

Effect of Psychosocial Work Environment on Sickness Absence Among Patients Treated for Ischemic Heart Disease

INTRODUCTION

During the last decades mortality has declined in patients with coronary heart disease due to improvements in treatments and changes in life style, resulting in more people living with chronic heart disease. This implies that focus on rehabilitation and re-integration to the work-force becomes increasingly important. Previous studies among healthy workers suggest that the psychosocial working environment is associated with sickness absence. Whether the psychosocial working environment plays a role for patients with existing cardiovascular disease on return to work and sickness absence is less studied.

METHODS

A cohort of patients under 67 years and treated with percutaneous coronary intervention (PCI) was established in 2006. Three months after the procedure the patients (n = 625) answered a questionnaire about their psychosocial working environment. Patients were followed in registers for the following year. We examined the association between psychosocial working environment and sickness absence at 3 months, 1 year and new sick-listings during the first year with logistic regression.

RESULTS

A total of 528 patients had returned to work 3 months after the PCI, while 97 was still sick-listed. After 1 year one was dead, 465 were working and 85 were receiving health related benefits, while 74 had left the workforce permanently. A number of 106 patients were sick-listed during the whole first year or had left the workforce permanently. After the initial return to work, 90 experienced a new sickness absence during the first year while the remaining 429 did not. High work pace, low commitment to the workplace, low recognition (rewards) and low job control were associated with sickness absence at 3 months, but not after 1 year. Low job control as well as job strain (combination of high demands and low control) was associated with new sick-listings.

CONCLUSION

The psychosocial working environment was associated with sickness absence 3 months after the PCI, but not 1 year after.

Psychosocial Working Environment and Risk of Adverse Cardiac Events in Patients Treated for Coronary Heart Disease

INTRODUCTION

During the last decades a possible association between psychosocial working environment and increased risk of coronary heart disease (CHD) has been debated and moderate evidence supports that high psychological demands, lack of social support and iso-strain (the combination of high job strain and lack of social support) is associated with primary CHD. Whether psychosocial working environment plays a role as risk factor for new cardiac events and readmissions in patients with existing cardiovascular disease is less studied.

METHODS

A cohort of patients <67 years treated with percutaneous coronary intervention (PCI) was established in 2006. Three months after PCI patients answered a questionnaire about their psychosocial working environment. Patients were followed in the Danish National Patient Registry and the Danish Civil Registration System for 3+ years to identify adverse cardiac events and death. We analysed the association between psychosocial working environment and adverse cardiac events by Cox Regression.

RESULTS

A number of 528 patients had returned to work 12 weeks after PCI, while 97 were still sick-listed. We identified 12 deaths and 211 other events during follow-up. We found no statistically significant associations between psychosocial working environment and risk of adverse cardiac events and readmissions or mortality.

CONCLUSION

The psychosocial working environment was not associated with adverse cardiac events.

High-sensitivity CRP: possible link between job stress and atherosclerosis

BACKGROUND

Chronic inflammation may play an important role in linking job stress to atherosclerosis. We sought to investigate the relationship between job stress and high-sensitivity C-reactive protein (hs-CRP) among Chinese workers.

METHODS

A total of 731 subjects (506 men and 225 women) were analyzed. Job stress was evaluated by effort-reward imbalance (ERI) model.

RESULTS

Among men, after adjustment for confounders, effort, overcommitment, and ERI were significantly positively correlated with hs-CRP; and reward was significantly inversely related with hs-CRP; high level of effort, overcommitment, or ERI, respectively, significantly increased the odds of high hs-CRP with ORs of 2.0, 3.5, and 3.3 (all P<0.001), compared with the corresponding low level groups. Among women, high overcommitment or ERI also increased risk of high hs-CRP with ORs of 2.8, and 4.1 (P<0.05).

CONCLUSIONS

High effort, overcommmitment, and ERI were positively associated with hs-CRP. Inflammation indicated by hs-CRP may be one of important mediators linking job stress and atherosclerosis.

Psychosocial stress at work and cardiovascular diseases: an overview of systematic reviews

Purpose

Based on information reported in systematic reviews (SRevs), this study aimed to find out whether psychosocial stress at work leads to cardiovascular (CV) morbidity and mortality.

Methods

A systematic search in PubMed and EMBASE (until 2014) used a string based on PICOS components. A manual search was followed. Applying the predefined criteria, two reviewers independently screened the titles, abstracts, selected full texts, and validated their quality. Discrepancies were resolved by discussion between reviewers. Studies of low quality were excluded. Contents of enrolled SRevs were extracted by one reviewer; a second reviewer evaluated their accurateness.

Results

The search resulted in 462 records. Six SRevs based on 81 studies (total population: ~1,468,670) fulfilled the inclusion criteria, four of “very good” (++) and two of “good” (+) quality. Excluded records were filed, and reasons for exclusion were documented in all cases. Different stress models were used to measure the work-related stress; the “demand-control model” was most commonly used. The two enrolled meta-analysis confirmed a modest (1.32, 95 % CI 1.09–1.59; Virtanen et al. 2013) to moderate evidence (1.45, 95 % CI 1.15–1.84; Kivimäki et al. 2006), predominantly among men, for the association between psychosocial stress at work and CV outcomes. Due to lacking information, it was not possible to give evidence on the dose–response relationship.

Conclusions

Same to a SRev, an overview of SRev is used to summarize literature and identify areas in which research is needed. This overview can be used to: (a) Disseminate an up-to-date information on work-related stress as a risk factors for CV morbidity and mortality to government, health care providers, workers, and other stakeholders; (b) Encourage governments to better regulate the working conditions and consider work-related psychosocial stress as a hazardous factor that leads to CV diseases or mortality; and (c) Analyze gaps in the literature and provide a summary of research needs.

The effort-reward imbalance work-stress model and daytime salivary cortisol and dehydroepiandrosterone (DHEA) among Japanese women

We examined the influence of work-related effort-reward imbalance and overcommitment to work (OC), as derived from Siegrist's Effort-Reward Imbalance (ERI) model, on the hypothalamic-pituitary-adrenocortical (HPA) axis. We hypothesized that, among healthy workers, both cortisol and dehydroepiandrosterone (DHEA) secretion would be increased by effort-reward imbalance and OC and, as a result, cortisol-to-DHEA ratio (C/D ratio) would not differ by effort-reward imbalance or OC. The subjects were 115 healthy female nursery school teachers. Salivary cortisol, DHEA, and C/D ratio were used as indexes of HPA activity. Mixed-model analyses of variance revealed that neither the interaction between the ERI model indicators (i.e., effort, reward, effort-to-reward ratio, and OC) and the series of measurement times (9:00, 12:00, and 15:00) nor the main effect of the ERI model indicators was significant for daytime salivary cortisol, DHEA, or C/D ratio. Multiple linear regression analyses indicated that none of the ERI model indicators was significantly associated with area under the curve of daytime salivary cortisol, DHEA, or C/D ratio. We found that effort, reward, effort-reward imbalance, and OC had little influence on daytime variation patterns, levels, or amounts of salivary HPA-axis-related hormones. Thus, our hypotheses were not supported.

Occupational stress and subclinical atherosclerosis: a systematic review

BACKGROUND

Stress is a common hazard in the work environment and is associated with multiple adverse health effects. The association between work-related stress (WRS) and cardiovascular disease has been established in a number of epidemiological studies.

METHODS

A systematic review was conducted according to the PRISMA statement of the English literature involving WRS and carotid artery intima media thickness (CIMT).

RESULTS

Four cohorts and six cross-sectional studies of occupational stress and CIMT were identified. All cohorts and five of the cross-sectional studies reported a significant positive association, while one reported an inverse association of WRS and CIMT.

DISCUSSION

The weight of the evidence that we were able to identify suggests that occupational stress results in an increased risk of atherosclerosis, assessed via CIMT. Studies that include longitudinal measures of stress and intermediate cardiac endpoints, with adequate accounting for confounders, are needed. Interventional studies should also be conducted to determine whether CIMT progression can be prevented with workplace stress reduction.

Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

Work stress and quality of life in persons with disabilities from four European countries: the case of spinal cord injury

BACKGROUND

Evidence on the adverse effects of work stress on quality of life (QoL) is largely derived from general populations, while respective information is lacking for people with disabilities. We investigated associations between work stress and QoL and the potentially moderating role of socioeconomic circumstances in employed persons with spinal cord injury (SCI).

METHODS

Cross-sectional data from 386 employed men and women with SCI (≥18 work h/week) from the Netherlands, Switzerland, Denmark, and Norway were analyzed. Work stress was assessed with the 'effort-reward imbalance' (ERI) model and the control component of the 'demand/control' model. QoL was operationalized with five WHOQoL BREF items. Socioeconomic circumstances were measured by years of formal education and perception of financial hardship. We applied ordinal and linear regressions to predict QoL and introduced interaction terms to assess a potential moderation of socioeconomic circumstances.

RESULTS

Multivariate analyses showed consistent associations between increased ERI and decreased overall QoL (coefficient -1.55, p < 0.001), domain-specific life satisfaction (health -1.32, p < 0.001; activities of daily living -1.28, p < 0.001; relationships -0.84, p = 0.004; living conditions -1.05, p < 0.001), and the QoL sum score (-2.40, p < 0.001). Low job control was linked to decreased general QoL (0.13, p = 0.015), satisfaction with relationships (0.15, p = 0.004), and QoL sum score (0.15, p = 0.029). None of the tested interaction terms were significant.

CONCLUSION

ERI was consistently related to all indicators of QoL, while associations with job control were less consistent. Our results do not support the notion that unfavorable socioeconomic circumstances moderate the association between work stress and QoL among persons with SCI.

Psychosocial risk factors for coronary heart disease

In 2003, the National Heart Foundation of Australia published a position statement on psychosocial risk factors and coronary heart disease (CHD). This consensus statement provides an updated review of the literature on psychosocial stressors, including chronic stressors (in particular, work stress), acute individual stressors and acute population stressors, to guide health professionals based on current evidence. It complements a separate updated statement on depression and CHD. Perceived chronic job strain and shift work are associated with a small absolute increased risk of developing CHD, but there is limited evidence regarding their effect on the prognosis of CHD. Evidence regarding a relationship between CHD and job (in)security, job satisfaction, working hours, effort-reward imbalance and job loss is inconclusive. Expert consensus is that workplace programs aimed at weight loss, exercise and other standard cardiovascular risk factors may have positive outcomes for these risk factors, but no evidence is available regarding the effect of such programs on the development of CHD. Social isolation after myocardial infarction (MI) is associated with an adverse prognosis. Expert consensus is that although measures to reduce social isolation are likely to produce positive psychosocial effects, it is unclear whether this would also improve CHD outcomes. Acute emotional stress may trigger MI or takotsubo ("stress") cardiomyopathy, but the absolute increase in transient risk from an individual stressor is low. Psychosocial stressors have an impact on CHD, but clinical significance and prevention require further study. Awareness of the potential for increased cardiovascular risk among populations exposed to natural disasters and other conditions of extreme stress may be useful for emergency services response planning. Wider public access to defibrillators should be available where large populations gather, such as sporting venues and airports, and as part of the response to natural and other disasters.

Effort-reward imbalance at work and pre-clinical biological indices of ill-health: the case for salivary immunoglobulin A

Physiological indices of stress and ill-health (cortisol and salivary immunoglobulin A) were assessed to determine if they were predicted by Siegrist's effort-reward imbalance model (ERI) with an aim of identifying employees at risk of illness. Male Australian dairy farmers (N=66) completed the Perceived Stress Scale, Work related Questions II & III, Eysenck Personality Questionnaire Revised--Short and demographic questions and provided morning saliva samples (at awakening and 30 min post awakening) on a working day, which were subsequently analysed for cortisol and salivary immunoglobulin A (sIgA) concentration levels. A high percentage (45.5%) of the sample reported an imbalance between efforts and rewards in the workplace that may place them 'at risk' for ill-health. After controlling for disposition, sIgA scores were more successfully predicted by the ERI than the cortisol assessments. Although both efforts and rewards were significantly associated with sIgA, efforts were most strongly associated. The dispositional trait overcommitment, did not moderate the experience of stress on the physiologic indices. The current investigation supports the continued use of sIgA in studies that use biomarkers to assess occupational stress. ERI ratio scores >1 aligned with previous findings that suggest elevated risk of illness for these employees.

Pressure pain sensitivity: a new method of stress measurement in patients with ischemic heart disease

BACKGROUND

Chronic stress is prevalent in patients with ischemic heart disease (IHD) and worsens the long-term prognosis. Chronic stress is vaguely defined, but is associated with depressive symptoms, reduced psychological wellbeing, and reduced quality of life (QOL). Stress seems to induce hyperalgesia.The aim of the present study was to evaluate hyperalgesia by pressure pain sensitivity (PPS) in patients with IHD, and compare PPS to questionnaires measuring depressive symptoms, reduced psychological wellbeing, and QOL as markers of stress. Design. A cross-sectional study of 361 subjects with IHD.

METHODS

PPS was measured on the sternum, and compared to the questionnaires: Clinical stress symptoms score (CSS), Major Depression Inventory (MDI), WHO-5 Wellbeing Index, and SF-36 QOL score.

RESULTS

PPS correlated to CSS (r = 0.20, p < 0.001), MDI (r = 0.14, p = 0.02), SF-36 mental component summary score (MCS) (r = - 0.10, p = 0.049), SF-36 physical component summary score (PCS) (r = - 0.17, p = 0.001), and self-perceived stress level (r = 0.15, p = 0.006). CSS correlated similarly (r = 0.5-0.7, all p < 0.001). Comparing subjects within the lowest vs. highest tertiles of PPS and CSS, the mean MDI score was 4 vs. 15, WHO-5 was 77 vs. 53, SF-36 PCS was 53 vs. 43, and SF-36 MCS was 58 vs. 46; all p < 0.001.

CONCLUSIONS

PPS reflected to a modest degree markers of chronic stress in IHD. PPS and CSS together might be useful as easy-to use tools for evaluating these markers in IHD patients.

Stress and cardiovascular disease

The physiological reaction to psychological stress, involving the hypothalamic-pituitary-adrenocortical and sympatho-adrenomedullary axes, is well characterized, but its link to cardiovascular disease risk is not well understood. Epidemiological data show that chronic stress predicts the occurrence of coronary heart disease (CHD). Employees who experience work-related stress and individuals who are socially isolated or lonely have an increased risk of a first CHD event. In addition, short-term emotional stress can act as a trigger of cardiac events among individuals with advanced atherosclerosis. A stress-specific coronary syndrome, known as transient left ventricular apical ballooning cardiomyopathy or stress (Takotsubo) cardiomyopathy, also exists. Among patients with CHD, acute psychological stress has been shown to induce transient myocardial ischemia and long-term stress can increase the risk of recurrent CHD events and mortality. Applications of the 'stress concept' (the understanding of stress as a risk factor and the use of stress management) in the clinical settings have been relatively limited, although the importance of stress management is highlighted in European guidelines for cardiovascular disease prevention.

Effort-reward imbalance at work and psychological distress: a validation study of post-myocardial infarction patients

OBJECTIVES

To examine whether the psychometric properties of the effort-reward imbalance (ERI) at work scales could be replicated with post-myocardial infarction (post-MI) patients and to measure the criterion validity through its association with psychological distress.

METHODS

A cross-sectional survey was conducted among 814 patients (739 men and 75 women) who had returned to work after their first MI and who were followed up by telephone at an average of 2.2 years after their baseline interview (1998-2000). The psychological demands scale of the Karasek Job Content Questionnaire was used to measure effort. Reward was measured with nine items from the original reward scale by Siegrist plus two proxy items. Exploratory and confirmatory factor analyses were used to test the theoretical structure of ERI. Using log-binomial regression models, we evaluated the association between ERI scales and psychological distress measured with the 14-item Psychiatric Symptom Index.

RESULTS

ERI scales and subscales demonstrated adequate internal consistencies. Exploratory factor analysis using oblique (promax) rotation yielded a three-factor solution with items representative of extrinsic effort (Factor 1) and reward subscales (Factors 2 and 3). Confirmatory factor analysis demonstrated a good fit with the data. The internal consistencies and discriminant validities of the ERI scales were satisfactory. Furthermore, effort, reward, and ERI ratio were significantly associated with psychological distress (adjusted prevalence ratio [PR] = 1.71, 95% confidence interval [CI] = 1.26-2.31; PR = 1.63, 95% CI = 1.16-2.29; and PR = 1.70, 95% CI = 1.17-2.47, respectively).

CONCLUSIONS

The psychometric properties of the ERI scales were generally reproduced among post-MI patients. The associations with psychological distress supported the criterion validity of the ERI scales in this population.