Job strain is a particularly insidious form of stress that goes far beyond overflowing inboxes or tight deadlines. It is characterized primarily by organizational environments and job structure in which employees have high levels of demands placed on them and limited control over those demands (that is, low “decisional latitude”). This is the demand-control model that was originally described and measured by Robert Karasek. Other organizational and job-related factors that contribute to unhealthy job-related stress are effort-rewards imbalances, long work hours (sometimes including long commutes), job insecurity, and lack of social support on the job. Some researchers have categorized all of these stressors as job strain, others differentiate them. But most agree that these stressors — all related to organizations and job design and not to individual behavior — lead to negative health outcomes.
How unhealthy is job strain?
Job strain has been linked to hypertension and to heart disease. This is not a simple matter of people who have other risk factors, like pre-existing hypertension or what used to be called Type A personality, being drawn to stressful jobs. Research suggests a causal relationship between job strain and both hypertension and cardiovascular disease. (Some studies also have linked job strain to depression, musculoskeletal disorders, dyslipidemia, physical inactivity, obesity, and adverse birth outcomes.)
Blue collar workers are more prone to the effects of job strain compared to white collar workers, but no one is immune.
Not every study of job strain has confirmed this relationship, but most have. A 10-year prospective study of 22,086 female health professionals, published in 2012, revealed that women with active jobs (high demand, high control) and high levels of job strain (high demand, low control) were 38% more likely to experience a cardiovascular disease event (such as heart attack or diagnosis of atherosclerosis) compared to women reporting low job strain. During the study, there were 170 myocardial infarctions, 163 ischemic strokes, 440 coronary revascularizations, and 52 cardiovascular-disease-related deaths, reaffirming that cardiovascular disease is a major concern for employers and for public health.
A Finnish study of 812 employees, followed for more than 25 years, found that employees with high demands at work and low job control had a 2.2-fold increased cardiovascular mortality risk — independent of other risk factors — compared to their colleagues with low job strain.
Earlier this year, an Israeli study confirmed a link between job burnout and coronary heart disease. Job burnout was defined as physical, cognitive, and emotional exhaustion that results from stress at work. Factors contributing to burnout included most of those typically associated with job strain or job stress: heavy workload, lack of control over job situations, lack of emotional support, and long work hours. Over the course of the study, 8,838 male and female employees were followed for an average of 3.4 years. Each subject was measured for burnout, which, as it turned out, was associated with a 40% increased risk of developing heart disease. Of greatest concern, the 20% of participants with the highest burnout scores had a 79% increased risk of heart disease.
A British study of 6,014 workers, followed for an average of 11 years, found that three to four hours of overtime per day is associated with a 1.6-fold increase in coronary heart disease risk, independent of other risk factors. (More about overtime in a future post.)
Countless research studies have demonstrated the relationship between job strain and health.
Unlike many other countries (again…especially Scandinavian countries), American employers continue to insist on offering employees behaviorally based stress management programs, such as relaxation programs and time management seminars, rather than trying to address the program where the employer actually has the most control: the structure of the organization and the jobs within it.
Even the National Institute for Occupational Safety and Health declares, “Working conditions play a primary role in causing job stress” and it advises,
As a general rule, actions to reduce job stress should give top priority to organizational change to improve working conditions.
Check out the NIOSH page for some ideas about the type of organizational change that is needed.
Emphasis on the organization’s role, rather than the employee’s role, may have applications beyond stress. Fitness challenges, biggest loser contests, tobacco-free campuses, incentives, health risk assessments, coaching, health screenings, yoga classes, and even culture-of-health have limited potential to evoke meaningful population health improvement…as long as the roots of the problem persist.
[A version of this post was first published on Bob Merberg’s Health Shifting blog on December 20, 2014]