The association between psychosocial characteristics at work and problem drinking: a cross-sectional study of men in three Eastern European urban populations

Background: Psychosocial factors at work are thought to influence health partly through health behaviours. Aims: To examine the association between effort-reward imbalance and job control and several alcohol related measures in three eastern European populations. Methods: A cross-sectional study was conducted in Novosibirsk (Russia), Krakow (Poland), and Karvina (Czech Republic). The participants completed a questionnaire that included effort-reward at work, job control, and a number of sociodemographic variables. Annual alcohol intake, annual number of drinking sessions, the mean dose of alcohol per drinking session, and binge drinking (⩾80 g of ethanol in one session at least once a week) were based on graduated frequencies in the questionnaire. Data were also available on problem drinking (⩾2 positive answers on CAGE questionnaire) and negative social consequences of drinking. All male participants in full employment (n = 694) were included in the present analyses. Results: After controlling for age and centre, all indices of alcohol consumption and problem drinking were associated with the effort-reward ratio. Adjustment for material deprivation did not change the results but adjustment for depressive symptoms reduced the estimated effects. Job control was not associated with any of the alcohol related outcomes. Conclusions: The imbalance of effort-reward at work is associated with increased alcohol intake and problem drinking. The association appears to be partly mediated by depressive symptoms, which might be either an antecedent or a consequence of men''s drinking behaviour.     

Psychosocial work environment and mental health: Job-strain and effort-reward imbalance models in a context of major organizational changes

This study explored the association between the two job-stress models, job-strain and effort-reward imbalance, and mental health outcomes in a working population exposed to major organizational changes. The cross-sectional study was based on 680 subjects, 504 men and 176 women. Psychosocial factors at work included: psychological demands, decision latitude, social support, effort, reward, and overcommitment. Mental health outcomes were depressive symptoms (CES-D) and psychiatric disorders (GHQ-12). Job strain, low decision latitude, effort-reward imbalance, and low reward (especially job instability) were found to be associated with depressive symptoms and/or psychiatric disorders among men. Overcommitment at work was a risk factor for both men and women. Social support at work played a role to reduce depressive symptoms for women. These findings emphasize the deleterious effects of psychosocial work environment on mental health during major organizational changes.     

Association between job stress and depression among Japanese employees threatened by job loss in a comparison between two complementary job-stress models.

OBJECTIVES: This study compared the separate effects produced by two complementary stress models--the job demand-control model and the effort-reward imbalance model--on depression among employees threatened by job loss. METHODS: A cross-sectional analysis was conducted to examine these associations among 190 male and female employees who responded to a self-administered questionnaire in a small Japanese plant with economic hardship. The employees were engaged in 2 job types--direct assembly line and indirect supportive tasks--and the latter was threatened by job loss because of downsizing. Independent variables were measured by the Japanese versions of Karasek's demand-control questionnaire and Siegrist's effort-reward imbalance questionnaire. Depression was assessed by the Center for Epidemiologic Studies Depression Scale. RESULTS: The employees with indirect supportive tasks (target for downsizing) were more likely to have depressive symptoms than direct assembly-line workers. Job strain, a combination of high demand and low control at work, was more frequent among the latter, while the combination of high effort and low reward was more frequent among the former. After adjustment for work environment factors, low control [odds ratio (OR) 4.7], effort reward imbalance (OR 4.1), and overcommitment (the person characteristic included in the effort-reward imbalance model) (OR 2.6) were independently related to depression. There is some indication that these effects were particularly strong in the subgroup suffering from potential job loss. CONCLUSIONS: This study confirms that the 2 job stress models identify different aspects of stressful job conditions. Moreover, effort-reward imbalance and low control at work are both associated with symptoms of depression.     

The psychosocial work environment and alcohol dependence: a prospective study

Aims: To examine whether a stressful psychosocial work environment predicts alcohol dependence.

Methods: Alcohol dependence of participants in the Whitehall II occupational cohort of London based civil servants (1985–88) was measured in 1991–93 using the CAGE questionnaire. The psychosocial work environment was measured by self report questions on the job demand-support-control model and on the model of effort-reward imbalance. Potential mediators including physical illness and poor mental health (GHQ) were measured at follow up in 1989.

Results: Effort-reward imbalance at work was associated with alcohol dependence in men after adjustment for employment grade and other baseline factors related to alcohol dependence. Although effort-reward imbalance predicted future longstanding illness, poor mental health and negative aspects of close relationships, the association between effort-reward imbalance and alcohol dependence in men was only partially mediated through these health and social support measures. In women, low decision latitude was related to alcohol dependence to some extent, but alcohol dependence among women was more prevalent in higher occupational grades. Men with high job demands or with low work social supports had a slightly reduced risk of alcohol dependence. No association was found between objectively assessed demands, job control, and alcohol dependence in either men or women.

Conclusion: A stressful psychosocial work environment in terms of effort-reward imbalance was found to be a risk factor for alcohol dependence in men. In view of the public health importance of alcohol dependence in working populations these findings call for more emphasis on psychosocial factors in occupational health research and prevention.

     

Psychosocial work characteristics and self rated health in four post-communist countries

STUDY OBJECTIVES: To examine whether psychosocial factors at work are related to self rated health in post-communist countries. DESIGN AND SETTINGS: Random samples of men and women in five communities in four countries were sent a postal questionnaire (Poland, Czech Republic and Lithuania) or were invited to an interview (Hungary). Working subjects (n=3941) reported their self rated health in the past 12 months (5 point scale), their socioeconomic circumstances, perceived control over life, and the following aspects of the psychosocial work environment: job control, job demand, job variety, social support, and effort and reward at work (to calculate a ratio of effort/reward imbalance). As the results did not differ by country, pooled analyses were performed. Odds ratios of poor or very poor health ("poor health") were estimated for a 1 SD increase in the scores of work related factors. MAIN RESULTS: The overall prevalence of poor health was 6% in men and 7% in women. After controlling for age, sex and community, all work related factors were associated with poor health (p<0.05). After further adjustment for perceived control, only two work related factors remained associated with poor health; the odds ratios (95% confidence intervals) for 1 SD increase in the effort/reward ratio (log transformed) and job variety were 1.51 (1.29, 1.78) and 0.82 (0.73, 1.00), respectively. Further adjustment for all work related factors did not change these estimates. There were no interactions between individual work related factors, but the effects of job control and social support at work differed by marital status, and the odds ratio of job demand increased with increasing education. CONCLUSIONS: The continuous measure of effort/reward imbalance at work was a powerful determinant of self rated health in these post-communist populations. Although the cross sectional design does not allow firm conclusions as to causality, this study suggests that the effect of the psychosocial work environment is not confined to Western populations.     

Effort-reward imbalance and depression in Japanese medical residents

The effort-reward imbalance is an important psychosocial factor which is related to poor health among employees. However, there are few studies that have evaluated effort-reward imbalance among medical residents. The present study was done to determine the association between psychosocial factors at work as defined by the effort-reward imbalance model and depression among Japanese medical residents. We distributed a questionnaire to 227 medical residents at 16 teaching hospitals in Japan at the end of August 2005. We asked participants to answer questions which included demographic information, depressive symptoms, effort-reward imbalance, over-commitment and social support. Depression was evaluated using the Japanese version of the Center for Epidemiologic Studies-Depression (CES-D) scale. The effort-reward imbalance and over-commitment were assessed by the Effort-Reward Imbalance (ERI) questionnaire which Siegrist developed. Social support was determined on a visual analog scale. Logistic regression analysis was performed to determine the associations between effort-reward imbalance and depressive symptoms. Depressive symptoms were found in 35 (29.2%) 1st-year residents and 21 (27.6%) 2nd-year residents. The effort-reward ratio >1 (OR, 8.83; 95% CI, 2.87-27.12) and low social support score (OR, 2.77, 95% CI, 1.36-5.64) were associated with depressive symptoms among medical residents. Effort-reward imbalance was independently related to depression among Japanese medical residents. The present study suggests that balancing between effort and reward at work is important for medical residents' mental health.     

Gender differences in job strain, effort-reward imbalance, and health functioning among Chinese physicians

To examine the association between work stress measured by job strain and effort-reward imbalance (ERI) and health functioning in a sample of hospital-based Chinese physicians, a self-reported survey with a standardized questionnaire was conducted in three hospitals in China, among 256 men and 266 women. It was found that both job strain and ERI were associated with impaired health functioning in men and women, but that ERI indicated a stronger association. Men's job control was significantly higher, and was related to men's physical health; whereas women perceived relatively higher job reward which predicted women's mental health. The findings provide evidence of the adverse effects on health functioning of both job strain and ERI, but ERI appears to have more explanatory power as a model of work stress in this sample of Chinese physicians. In addition, gender differences of work stress with respect to health are present.     

Socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven post-communist countries

This study examined the association between perceived control and several socioeconomic variables and self-rated health in seven post-communist countries (Russia, Estonia, Lithuania, Latvia, Hungary, Poland, Czech Republic). Questionnaire interviews were used to collect data on self-rated health in the last 12 months, education, marital status, perceived control based on nine questions, and material deprivation based on availability of food, clothing and heating. For each population, two ecological measures of material inequalities were available: an inequality score estimated from the survey data as the distance between the 90th and 10th percentiles of material deprivation, and Gini coefficient from published sources. Data on 5330 men and women aged 20-60 were analysed. Prevalence of poor health (worse than average) varied between 8% in Czechs and 19% in Hungarians. The age-sex-adjusted odds ratio for university vs primary education was 0.36 (0.26-0.49); odds ratios per 1 standard deviation increase in perceived control and in material deprivation were 0.58 (95% CI 0.48-0.69) and 1.51 (1.40-1.63), respectively. The odds ratio for an increase in inequality equivalent to the difference between the most and the least unequal populations was 1.49 (0.88-2.52) using the material inequality score and 1.41 (0.91-2.20) using the Gini coefficient. No indication of an effect of either inequality measure was seen after adjustment for individuals' deprivation or perceived control. The results suggest that, as in western populations, education and material deprivation are strongly related to self-rated health. Perceived control appeared statistically to mediate some of the effects of material deprivation. The non-significant effects of both ecological measures of inequality were eliminated by controlling for individuals' characteristics.     

Psychosocial work environment and myocardial infarction: improving risk estimation by combining two complementary job stress models in the SHEEP Study

OBJECTIVES: Associations between two alternative formulations of job stress derived from the effort-reward imbalance and the job strain model and first non-fatal acute myocardial infarction were studied. Whereas the job strain model concentrates on situational (extrinsic) characteristics the effort-reward imbalance model analyses distinct person (intrinsic) characteristics in addition to situational ones. In view of these conceptual differences the hypothesis was tested that combining information from the two models improves the risk estimation of acute myocardial infarction. METHODS: 951 male and female myocardial infarction cases and 1147 referents aged 45-64 years of The Stockholm Heart Epidemiology (SHEEP) case-control study underwent a clinical examination. Information on job stress and health adverse behaviours was derived from standardised questionnaires. RESULTS: Multivariate analysis showed moderately increased odds ratios for either model. Yet, with respect to the effort-reward imbalance model gender specific effects were found: in men the extrinsic component contributed to risk estimation, whereas this was the case with the intrinsic component in women. Controlling each job stress model for the other in order to test the independent effect of either approach did not show systematically increased odds ratios. An improved estimation of acute myocardial infarction risk resulted from combining information from the two models by defining groups characterised by simultaneous exposure to effort-reward imbalance and job strain (men: odds ratio 2.02 (95% confidence intervals (CI) 1.34 to 3.07); women odds ratio 2.19 (95% CI 1.11 to 4.28)). CONCLUSIONS: Findings show an improved risk estimation of acute myocardial infarction by combining information from the two job stress models under study. Moreover, gender specific effects of the two components of the effort-reward imbalance model were observed.     

Differential economic stability and psychosocial stress at work: associations with psychosomatic complaints and absenteeism

Stressful working conditions are well known to have a negative impact on the worker's health. We investigated this association in a Belgian study with a psychosocial health perspective, including individual work characteristics as well as firms' features. These data come from the first measure of the Somstress study. This is a 4 year project, initiated in 1999 and conducted in four different firms. The objective of this article is to investigate the relationships between stress, working conditions and absenteeism, self-reported health and psychosomatic complaints. Firms were selected according to their degree of structural environment and job stability. Among the four work sites, one can be considered as stable, one unstable and the remaining ones in an in-between situation. Stress is generally measured according to one of the following models: the job demands control model (Karasek) and the effort-reward imbalance model (Siegrist). We used here both models, along with the social support at work (Karasek) and overcommitment (Siegrist). Sex, age and education are important health determinants. After adjustment for those three variables and additionally for the work instability, it appeared that poor health outcomes (measured by the self-rated health, depression (SCL-90), anxiety (SCL-90), somatisation (SCL-90), chronic fatigue (Vercoulen) and reported absenteeism) are mainly associated with a low control, low social support at work, high overcommitment and high level of imbalance. Inversely, job demands do not make any significant contribution in the logistic regression models for the above-mentioned health outcomes.     

Work and depression among women in the Federal Republic of Germany

A study was carried out to test the association between workplace stress and depression among working women and men in the Federal Republic of Germany (FRG). The data are from the 1984 German national health survey. The sample (N = 795) was composed of 319 working women and 476 working men. The hypothesis tested was that depression is related to high job demands and low job decision latitude. Correlation and multiple regression analyses supported the hypothesis for both women and men. However, the mean level of decision latitude was lower for women than men, as was the level of job demands. The mean depression score was higher for women, and correlations between depression and high job demands/low decision latitude were stronger for women than men. It was concluded that low decision latitude combined with high job demands, a condition experienced frequently by working women, contributes to depression among working women in the FRG. Study findings shed light on the health of employed women in the FRG and may also have implications for working women in other Western industrialized countries.     

Obesity and education in three countries of the Central and Eastern Europe: the HAPIEE study

The international pattern of obesity is only partly understood. While in developed countries the association between education and obesity is inverse, in the developing world social distribution of obesity is less predictable. We examined obesity patterns in three countries of Central and Eastern Europe (CEE): Russia, Poland and the Czech Republic, middle-income post-communist countries undergoing social and economic transition. The prevalence of obesity was inversely associated with education of individuals in our three samples of Central and Eastern European populations. In agreement with previous findings, the inverse socioeconomic gradient was more pronounced in the Czech Republic and Poland, countries with higher Gross National Product (GNP) than Russia. In addition, obesity was more common in Russian women than in Czech or Polish women while Russian men were less obese than Czech or Polish men. These findings are consistent with the hypothesis that the social gradient in obesity differs between populations--it is more likely to find a reverse association between socioeconomic position and prevalence of obesity in the more westernized countries with higher population income.     

Relationship between two job stress models and coronary risk factors among Japanese part-time female employees of a retail company

The objective of this study was to explore the associations between two major job stress models (job strain and effort-reward imbalance) and coronary heart disease (CHD) risk factors (blood pressure; total, high- (HDL) and low-density lipoprotein (LDL) cholesterol; and triglycerides) in Japanese part-time female employees of a retail company. The study population was either 35 yr old or between 40 and 63 yr old. Data collection was carried out in 2002; a total of 1,401 subjects participated in a medical examination and completed a questionnaire. After adjusting for other covariates (age, relative weight, tobacco use, alcohol consumption, lack of exercise, education, marital status, history of child bearing, medical treatment for disease, and occupation), a significant association was found between the effort-reward imbalance, a "high-cost and low-gain" condition at work, and a high prevalence of low HDL cholesterol (Odds ratio=4.4). A weak but unexpected association was found between job strain and low prevalence of low HDL cholesterol. In explanatory analysis with individual components of the two models, associations were evident between high extrinsic effort and high prevalence of low HDL cholesterol and low prevalence of high triglyceride, high job control and low prevalence of high systolic blood pressure, and high job demands and low prevalence of high systolic and diastolic blood pressure. In this cross-sectional study of Japanese part-time working women, a significant association was found between effort-reward imbalance and unfavorable HDL cholesterol profiles. The findings did not support the hypothesis that job strain is associated with CHD risk factors.     

Two alternative job stress models and the risk of coronary heart disease.

OBJECTIVES: This study examined the association between two alternative job stress models-the effort-reward imbalance model and the job strain model-and the risk of coronary heart disease among male and female British civil servants. METHODS: The logistic regression analyses were based on a prospective cohort study (Whitehall II study) comprising 6895 men and 3413 women aged 35 to 55 years. Baseline measures of both job stress models were related to new reports of coronary heart disease over a mean 5.3 years of follow-up. RESULTS: The imbalance between personal efforts (competitiveness, work-related overcommitment, and hostility) and rewards (poor promotion prospects and a blocked career') was associated with a 2.15-fold higher risk of new coronary heart disease. Job strain and high job demands were not related to coronary heart disease; however, low job control was strongly associated with new disease. The odds ratios for low job control were 2.38 and 1.56 for self-reported and externally assessed job control, respectively. Work characteristics were simultaneously adjusted and controlled for employment grade level, negative affectivity, and coronary risk factors. CONCLUSIONS: This is apparently the first report showing independent effects of components of two alternative job stress models-the effort-reward imbalance model and the job strain model (job control only)-on coronary heart disease.     

Association between job characteristics and plasma fibrinogen in a normal working population: a cross sectional analysis in referents of the SHEEP Study. Stockholm Heart Epidemiology Program

STUDY OBJECTIVE: To explore the association between job characteristics and plasma fibrinogen concentrations. DESIGN: Cross sectional design. SETTING: The Greater Stockholm area. SUBJECTS: A total of 1018 men and 490 women aged 45-70 who were randomly selected from the general population during 1992-1994. They were all employed and had no history of myocardial infarction. MAIN RESULTS: The self reported job characteristics were measured by a Swedish version of the Karasek demand-control questionnaire. For inferred scoring of job characteristics, psychosocial exposure categories (job control and psychological demands) were assigned by linking each subject's occupational history with a work organisation exposure matrix. Job strain was defined as the ratio between demands and control. In univariate analyses, expected linear trends were found in three of four tests of association between high plasma fibrinogen and low control (the self reported score for women and the inferred score for both sexes), in one of four tests of association between high plasma fibrinogen and high demands (the inferred score for women) and in two of four tests of association between high plasma fibrinogen and job strain (the inferred score for both sexes). Multiple logistic regression analyses showed that men in the inferred job strain group have an increased risk of falling into the increased plasma fibrinogen concentration group (above median level of the distribution) (odds ratio (OR) 1.2; 95% CI 1.0, 1.5) after adjustment for the variables that were associated with plasma fibrinogen in the univariate analyses. In women, low self reported control, high inferred demand, and inferred job strain were significantly associated with increased plasma fibrinogen concentration (OR 1.3; 95% CI 1.0, 1.8, OR 1.5; 95% CI 1.0, 2.2, OR 1.5; 95% CI 1.1, 2.2, respectively). CONCLUSIONS: These results indicate that adverse job characteristics may be related to plasma fibrinogen concentrations and this relation is more relevant in female workers. The clearest evidence for psychosocial effects on plasma fibrinogen seems to be with job control and the associations are clearer for the objective than for the self report variables.     

Psychosocial work characteristics and incidence of newly diagnosed depression: a prospective cohort study of three different models

This study explored the association between psychosocial work characteristics and incidence of depression as indicated in three complementary models (the Job Strain Model, the Team Climate Model, and the Procedural Justice Model). Participants were 4815 Finnish hospital personnel (4278 women and 537 men) free from diagnosed depression at entry into the study. A baseline survey in 1998 measured psychosocial work characteristics, health-related behaviours, psychological distress, and doctor-diagnosed depression. The factor analysis of pooled questionnaire items on psychosocial work characteristics supported a five-factor solution with the following distinct dimensions: team climate, relational justice, procedural justice, job control, and job demands. Items in these dimensions were used as scales and job strain was modelled as a combination of job demands and job control. A follow-up survey in 2000 identified 225 incident cases of depression. After adjustment for age, sex and income, poor team climate, low procedural justice, and low relational justice were associated with a higher risk of new depression, the odds ratios (ORs) 1.58 (95% confidence interval (CI) 1.11-2.24), 1.45 (95% CI 1.03-2.04), and 1.39 (95% CI 1.00-1.96), respectively. After additional adjustment for lifestyle factors and exclusion of those with psychological distress at baseline, there was still an association between poor team climate and risk of depression (ORs 1.55 and 1.75, respectively). Job control, work demands, and job strain did not predict the 2-year incidence of depression, and the effects of all psychosocial work characteristics were attenuated when entered simultaneously in the model. In conclusion, work unit social factors seem to be predictive of subsequent doctor-diagnosed depression, but other aspects of psychosocial work environment may also be important.     

High cumulative risk of lung cancer death among smokers and nonsmokers in Central and Eastern Europe

The authors have calculated cumulative risks of lung cancer from a case-control study conducted between 1998 and 2002 involving 2,633 lung cancer cases and 2,884 controls in Hungary, Poland, the Czech Republic, Slovakia, Romania, and Russia. The odds ratios for smoking history were combined with national lung cancer mortality rates to obtain the cumulative risk of lung cancer. The cumulative risk of death from lung cancer by the age of 75 years among current male smokers was 14.6% in Romania and Russia and 15.8% in Poland, similar to levels reported in Western Europe, although higher risks were found in the Czech Republic (19.8%), Hungary (21.9%), and Slovakia (28.2%). Cumulative risks of lung cancer death among never smokers of over 1% were observed in Hungary among both men and women and among men in Poland. The effect of quitting smoking on the lifetime cumulative risk was substantial, with between 67% and 83% of lung cancer risk among men being avoided by quitting before the age of 50 years. This substantial reduction in risk among former smokers confirms that lung cancer mortality in Central Europe over the next three decades will be determined by the extent to which current smokers can successfully quit smoking.     

工作付出—回报失衡对公立医院医生职业心态的影响

目的:探讨付出—回报失衡对公立医院医生职业倦怠、工作满意度和离职意向的影响。方法:利用课题组编制的医生工作感受量表,按照分层随机抽样原则,根据经济发展水平从山东省抽取济南、潍坊、德州3市的1 910名公立医院医生进行调查,采用描述性统计分析、相关分析、分层回归分析等分析方法。结果:医生工作付出—回报失衡,工作付出是工作回报的1.54±0.74倍。工作付出—回报失衡对职业倦怠有正向预测作用,对工作满意度有负向预测作用,对离职意向有正向预测作用。结论:管理者应从改善医生付出—回报比例入手,以稳定医生职业心态,提升其工作积极性。     

Work characteristics predict psychiatric disorder: prospective results from the Whitehall II Study

OBJECTIVES: The impact of work on the risk of future psychiatric disorder has been examined in few longitudinal studies. This was examined prospectively in a large epidemiological study of civil servants. METHODS: In the Whitehall II study, a longitudinal, prospective cohort study of 6895 male and 3413 female London based civil servants, work characteristics measured at baseline (phase 1: 1985-8) and first follow up (phase 2: 1989) were used to predict psychiatric disorder measured by a 30 item general health questionnaire (GHQ) at phase 2 and phase 3 follow up (phase 3: 1991-3). Work characteristics and GHQ were measured at all three phases. RESULTS: Low social support at work and low decision authority, high job demands and effort-reward imbalance were associated with increased risk of psychiatric disorder as assessed by the GHQ at follow up adjusting for age, employment grade, and baseline GHQ score. CONCLUSIONS: Social support and control at work protect mental health while high job demands and effort-reward imbalance are risk factors for future psychiatric disorder. Intervention at the level of work design, organisation, and management might have positive effects on mental health in working populations.

 

     

Effort-reward imbalance at work is predicted by temporal and energetic characteristics of behavior: A population-based study

Objective

Personality dispositions may influence perceptions of work stress. The paper examines the relationship between temperament in terms of Strelau’s Regulative Theory of Temperament and the effort-reward imbalance and its components.

Material and Methods

There were 890 participants (360 men) aged 37.9 years on average. Temperament traits of briskness and perseveration (temporal characteristics of behavior), sensory sensitivity, emotional reactivity, endurance and activity (energetic characteristics of behavior) were measured by Strelau & Zawadzki’s Formal Characteristics of Behavior-Temperament Inventory (FCB-TI) in 1997 and 2001. Effort and reward at work were assessed with the original effort-reward imbalance (ERI) questionnaire of 2007.

Results

Higher ERI at work was predicted by higher emotional reactivity, higher perseveration, lower briskness, and lower endurance. Higher effort and lower rewards at work were predicted by higher perseveration and lower endurance. The FCB-TI temperament characteristics accounted for 5.2%, 4.8% and 6.5% of the variance in the ERI, effort and reward, respectively. Lower emotional reactivity, lower perseveration, higher briskness and higher endurance predicted higher esteem at work, job promotion and job security.

Conclusions

Individual differences in arousability, reflected in temporal and energetic characteristics of behavior, may predispose to or to protect from an effort-reward imbalance at work. Individual differences should be acknowledged in work stress prevention and developing interventions.