Health Circles is a structured process in which employees hold facilitated meetings over a course of time to identify what’s holding their health back and what can be done to improve it – with an emphasis on job design and the psychosocial health risks at the workplace.
This excerpt from a webinar (hosted by Lumity) describes a multi-year, controlled study of hospital nurses and aides at a hospital Continue reading »
I agree with the position paper, Behaviour-Based Safety Programs, recently published by The International Union of Food, Agricultural, Hotel, Restaurant, Catering, Tobacco and Allied Workers’ Associations (IUF). An employer’s primary role in employee wellbeing is to protect employees from Continue reading »
If a job has high Motivating Potential, the jobholders are more likely to feel their work is meaningful, to exhibit high levels of motivation, performance, and job satisfaction. If a job has low Motivating Potential, jobholders are more likely to exhibit negative outcomes, like absenteeism, turnover, and sluggish performance.
Take a test drive of the Job Diagnostics Survey (learn more about the Job Characteristics Model, Job Diagnostics Survey, and Job Motivating Potential in my previous post). These 15 questions generate a “Motivating Potential” score — High Motivating, Moderately Motivating, or Low Motivating — for your job. You’ll get the results instantly, along with brief insights into the components of the score and how to design jobs that are motivating and supportive of employee well-being.
Note: This survey is still in development and is available for demo purposes only. The original Job Diagnostics Survey was designed to produce relevant aggregate data when completed by multiple employees. Its creators cautioned against having just just one individual complete it to assess a job.
Job Motivating Potential
Please answer all 15 questions. Be as objective as you can in deciding how accurately each statement describes your job — regardless of whether you like or dislike your job. For the first few questions, some of the answer choices don’t have statements beside them. Choose one of these “unlabeled” answers when your sentiment falls somewhere between two statements.
Pay attention to the science-backed workplace mental health frameworks that are taking shape outside the US, like those in Canada, Europe, and Australia.
In the US, the messaging of vendors and consultants tends to drown out science. Last year, for example, data from a meta-analysis — which included more than 120,000 research subjects — showed that job strain (the combination of high demands and low control at work) may lead to clinically diagnosed depression. This is consistent with a lot of other research that points us toward employer strategies for the primary prevention of mental health problems. But psychosocial risk and primary prevention are missing-in-action when we look at mental health resources made available by US employee wellness professional organizations and their vendors/consultant partners, .
Mental health crises — just like physical health crises — are mission critical, but this doesn’t mean we can’t prevent them before they happen and, what’s more, aspire to create workplace environments in which employee well-being flourishes.
Canada’s “Standard for Psychological Health and Safety in the Workplace” is a compelling example of a social strategy to promote mental health in all its stages — emphasizing primary prevention. Find out more about Canada’s Standard and other science-backed workplace mental health strategies on the Jozito mental health resources hub.
It’s easy to imagine how a white collar employee like a project manager or a data scientist might engage in job crafting. But what about, say, a machine operator or a restaurant server? Do they have enough flexibility to refashion the tasks, relationships, and other building blocks of work to more effectively match their strengths and needs?
Crafting any job presents challenges. But it can be successful across the full spectrum of occupations. Research I’ve previously described, as a matter of fact, included a wide variety of jobs: Silicon Valley tech workers, teachers, hospital housekeepers, chemical plant workers, police officers, and nurses, to name a few.
Less Flexibility May Mean More Job Crafting
Job crafting pioneers Justin Berg, Jane Dutton, and Amy Wrzesniewski tell us — in Job Crafting and Meaningful Work — why it can be easier for employees in highly structured, lower-status jobs to engage in crafting compared to those with more flexibility:
Since their jobs included tasks that had clear means and ends established (e.g., “you should service this machine using the following steps,” or “you must enter these data in this way”), it was easier for them to see the “white space” in their jobs—i.e., where they could fit in new tasks or relationships or drop tasks and relationships that were not very important.
Berg and company go on to describe, in contrast, the challenges of crafting a flexible, typically white-collar, job:
Lack of structure, combined with the continuous pressure to pursue their end goals, seemed to make it more difficult for [“higher-rank employees”] to recognize opportunities to craft their jobs. In other words, to color outside the lines of a job, one needs lines there in the first place.
We talk a lot about the importance of autonomy for employee wellbeing — and for job crafting, specifically. But more autonomy or less, at either extreme, may be suboptimal. The sweet spot lies somewhere in between.
Summer’s here, and it’s time to unstrap the Fitbit and track some physical inactivity — the kind, for example, that takes place while reading. Pictured here is a pile of books that I’d recommend, or almost recommend, to wonky wellness professionals who have been at it for a while and are still searching.
You may think it weird that some of these books are old or even out-of-print. What good does an out-of-print book recommendation do you? Well, sometimes the story of a book is worth telling just as much as the story inside it.
Starting at the bottom of the pile…
Making Health Communication Programs Work.
Can you imagine there was a time — from 1989-2004, to be exact — when the US government gave this health communication book away for free? All you had to do was call and ask. This was the authoritative source on health communication — with more of a public health bent rather than employee wellness — affectionately known to health communicators as “The Pink Book.”
The good news is that you can get the final version of the book as a pdf. Who cares if it doesn’t include the last 13 years of developments? Who cares if the last entry in the glossary is a definition of “World Wide Web”? The book still covers an evidence-based approach to health communication theory and practice, with some behavioral change theory thrown in to boot. Get on it.
I’ve been studying the Hawthorne experiments for the last couple of years, and have assembled quite the collection of yellowed, musty, out-of-print books, this being one of the most important and, published in 1993, the most recent. At the heart of the matter is the field study of workers, supplemented with detailed interviews of 23,000 workers, under different conditions at Western Electric’s Hawthorne plant outside Chicago, in the 1920s and early 1930s. It stands as one of the most important studies of workers, management, and productivity ever.
While the Hawthorne researchers weren’t committed to worker wellbeing as we think of it, they did recognize wellbeing as relevant to productivity. And much of what we believe today about management styles, leadership, employee engagement, and teamwork was rooted in the Hawthorne research. Forget the fact that it started as a study of lighting, or that it had an entire category of bias named after it. Most experts today believe that if there is such a thing as the Hawthorne effect — in which research subjects change their behavior simply as a response to being observed — it didn’t occur at Hawthorne.
Let’s get real… You’re not going to read an old book about a 90-year-old study. So take 9 minutes to listen to this peppy BBC podcast on the topic. Regardless of the Freakonomics interviewee drawing an unfounded explanation of the Hawthorne findings, the podcast may start to give you a sense of how important the Hawthorne experiments are to our understanding of work, motivation, and even research design.
Yup, out-of-print — I don’t know why, as this is a seminal classic about the relationship between work and health, in which Robert Karasek, one of the most important worker health researchers of our time, lays out the case for the demand/control model of job strain.
Healthy Work may be too technical for a lot of people, but if you can get your hands on a copy, it’s great to keep around and skim through whenever you have a chance. Healthy Work changed how managers, health agencies, and labor organizations around the globe think about worker health.
Health Behavior and Health Education.
Get the 2015 version (5th edition), which is called Health Behavior: Theory, Research, and Practice. Health behaviors aren’t the foundation of employee wellbeing. (Exposures are.) But whether you agree with me or are convinced that, like people always say, “it all comes down to behavior,” isn’t it important to understand what makes health behavior tick?
This book was published in 2000 predominantly for clinicians and other wonks. It gets highly technical — so it’s not something you’ll want to read at the beach. But I keep it handy on my desk. It’s a collection of evidence documenting the relationship between work, psychosocial job stressors, and health, and suggesting a causal relationship — that is, bad jobs lead to poor health. The rigor of the studies contrasts with the vendor- and employer-fueled quasi-science to which wellness professionals are customarily subjected.
Amazon usually sells The Workplace and Cardiovascular Disease, used, for less than 10 bucks. If you want something cheaper and more current, you can try to access the article, “Globalization, Work, and Cardiovascular Disease,” published in 2016 in the International Journal of Health Services. Two of the article’s authors, distinguished researchers Peter Schnall and Paul Landsbergis, were among the editors of the book.
The only thing I find more painful than hearing our industry called the “ignorati” is noticing that we often do ignore criticism. Sure, we’ve all been paying the price for Al Lewis’s book ever since it was published, but we can be thankful that someone cast skepticism on the claims of the wellness industry. I don’t know if this is Al’s goal, but it is mine: To get better at supporting the wellbeing of the American workforce. In order to achieve this, we need to be able to assess our practices critically, and this book rallies us to do just that.
Former Washington Post reporter turned work-life balance hunter, Brigid Schulte, endeavors to wake up America to the mess we’ve gotten ourselves into by putting obsessive “busyness” and profits ahead of our kids, our spouses, and ourselves. Schulte deconstructs an American culture driven by a destructive sense of individualism and machismo that puts us on a never-ending treadmill — the unhealthy kind — as well as the policies and gender inequality that keep us there. She draws upon the experience of her own work and family life, and visits Denmark where the possibility of a better way reveals itself to her.
Health is influenced by social status — specifically, our position in the spectrum of autonomy and of full participation in society. The workplace is a microcosm for this “social gradient.” Epidemiologist and author Sir Michael Marmot, who has devoted his career to spotlighting the social determinants of health, led the Whitehall studies — investigations into the work lives and the health of thousands of British civil service workers. Whitehall II is among the most important studies of worker health, but — as with much of the excellent research from Europe and other countries around the globe — is noncommercial and, consequently, infrequently discussed at American wellness conferences. Sir Michael once wrote in Lancet,
Healthy behaviors should be encouraged across the whole of society. More attention should be paid to the social environments, job design, and the consequences of income inequality.
Of all the books in my pile, this is the one I most enjoyed reading. If it’s nothing else to you, it’s a heart-wrenching story well told. Triangle also is filled with historical detail about working life that, for many, will continue to resonate today. The importance of the Triangle Factory fire — along with the events that preceded it and those that ensued — remind us of the context for worker wellbeing, and how it represents something more profound than lower health care costs or even improved morale.
Worthwhile reading, but not in my pile:
Workplace Wellness That Works, by Laura Putnam. At this point in my career, I learn most by delving into topics that are unrelated or only somewhat related to wellness. I don’t own Laura’s book, but I flipped through a co-worker’s copy and found it to be thorough and well-researched. This is the book I’d recommend to someone who’s looking for wellness ideas or trying to assess the evidence basis for employee wellness.
Quiet: The Power of Introverts in a World That Can’t Stop Talking, by Susan Cain. Quiet raises consciousness about what life is like for the large segment — perhaps the majority — of employees who consider themselves introverts. This is relevant as we plan our wellness programs and events and target our communications. Quiet isn’t on my pile because I lent it to someone and never got it back. I’d like to think that’s some sort of endorsement.
Any text on occupational health psychology. I like The Handbook of Work and Health Psychology, but others will do. Just as we should understand health behavior if we want to influence employees’ exercise and eating habits, we need to learn the science behind stress, burnout, adjustment to change, resilience, depression, motivation, and engagement.
Even if we don’t always understand the science of worker health, we benefit from recognizing that there is science to worker health.
For those interested in evidence-based approaches to wellness, reading these or similar books will be a breeze this summer.
Wellness experts emphasize the importance of sleep, and vendors promote sleep-tracking devices, apps, and programs. But little is said about the job conditions necessary to assure workers have the opportunity to get the sleep they need.
It’s hard to get eight hours of sleep if you’re only home for five or six hours between your evening shift and your morning shift. And that’s where “clopening” comes in. The term commonly applies to schedules in which part-time retail and fast food workers are required to close the store late in the evening and open early in the morning.
Clopening gained notoriety in a 2014 New York Times story about the life challenges a Starbucks employee faced as a result of “just in time” (last minute) scheduling that included clopening. In the minds of activists, unpredictable scheduling and insufficient rest periods between shifts have been linked ever since — appropriately so, as both practices tend to coincide and threaten employee wellbeing.
These scheduling practices also go hand-in-hand with schedule fluctuation (like working eight hours one week and 40 hours the next) and inflexibility. According to a report by the University of Chicago, unpredictable, fluctuating, and inflexible scheduling undermine almost every dimension of workers’ wellbeing, including the physical, mental, family, occupational, and financial realms. The report’s author, Susan Lambert, was quoted in a follow-up Times article as saying:
This particular form of scheduling — not enough rest time between shifts — is particularly harmful.
Through literature review, original data analysis, and focus groups, we find that the health and well-being of workers is undoubtedly compromised by unpredictable work schedules.
Even prior to the original New York Times exposé, and increasingly after it, municipalities have considered “secure scheduling” legislation to limit schedule unpredictability, fluctuation, and, yes, clopening.
In 2014, San Francisco enacted the Formula Retail [i.e “chain store”] Employee Bill of Rights, which requires covered employers to provide employees with two weeks’ notice of work schedules, advance notice of schedule changes, and additional pay for schedule changes made on less than seven days’ notice and unused on-call shifts.
Employers inevitably resist regulation. But if we are as committed to employee wellbeing as we say we are, we should evaluate and address scheduling practices proactively.
Leadership sometimes emerges where it’s least expected — in this case, Walmart. The mega-retailer recently phased in new processes — on the heels of improvements it made to compensation and occupational development — in order to make scheduling more flexible and predictable for workers. The Washington Post reported that, based on early results, workers with access to the new scheduling system experienced an 11% decline in absenteeism and a 14% drop in turnover, “which comports with what academic research has shown is possible with greater predictability and worker control.”
[This post is adapted from one originally posted by Bob Merberg on September 19, 2016 on the Healthshifting blog.]
The Robert Wood Johnson Foundation, as well as the Harvard T.H. Chan School of Public Health and National Public Radio, may have given a boost last week to advocates of employee wellbeing. Here, I refer to what I consider authentic wellbeing — based on workers’ exposure to harmful job conditions and environments — not the store-bought imitation based on wellness websites, apps, incentives, and medicalized interventions.
To promote the findings of their Workplace Health poll of 1,601 workers, these sponsoring organizations waged a publicity blitz that brought the “healthy work” perspective to a broad new audience. A Health in the American Workplace panel, streamed live on the web, served as a centerpiece of the campaign.
Workers’ Views on Jobs and Health
Poll results, according to panelists, revealed that many workers view their jobs as impediments to their wellbeing.
43% said their job has a negative impact on their stress level
28% said their job undermines their eating habits
27% reported that their job interfered with the ability to get a good night’s sleep
22% said their job has a negative impact on their weight.
Panelist Marjorie Paloma, director of RWJF, explained how job stress and health are influenced by workplace policies:
If you think about the stress a person feels whether because of their day to day work routines, or the stress they feel because of caring for a loved one while working a full time job, or workers who feel as if they have to go into work despite being sick…These are all stressors that influence health.
Succinctly describing the relationship between behaviors and the environment, Paloma stated:
The choices we make are as good as the choices we have.
She summarized this position with the catchy phrase:
Health shapes work, and work shapes health.
“Human Resource Failures”
Harvard Business School professor John Quelch described how workforce management and the intensification of work have been shown to influence health. Quelch bemoaned…
…the sheer overload that comes from downsizing and outsourcing and asking someone to do two jobs when previously they had to do one.
He cited an often overlooked source of stress:
It can also come from job ambiguity — the requirements of the job are not being clearly articulated by supervisors.
Quelch characterized these workforce management patterns as “fundamental human resource failures.”
Gloria Sorensen, from Harvard Chan, cited her team’s studies of health care workers, whose job conditions have been linked to health problems:
Risk of injury or musculoskeletal pain or accidents on the job increase…when we look at harassment on the job, inadequate staffing, bullying at work, high job demands, lack of control, and poor supervisor support.
Sorensen went on to say that these job conditions also have been linked to fatigue, sleep problems, and risk of obesity. She concluded…
The point is these conditions of work are critical when we look at a range of health outcomes for workers.
The panelists’ remarks revealed mixed feelings about conventional worksite wellness programs that focus on behavior change. The poll results showed that only half of workers have access to wellness programs, which at times the panelists, such as Harvard’s Robert Blendon, seemed to cite as an indictment of employers:
Almost half of people who work are at a workplace that has no workplace health program.…People go to work every day, and this is something they read about in a magazine, but they don’t see in their own job.
On the other hand, Paloma remarked…
Worksite wellness is insufficient if it’s not going hand in hand with efforts to improve the health of communities.
Blendon, director of the poll, said that the findings changed his mind about stress. He led an uncomfortable laugh at the expense of conventional stress management strategies, and noted…
Employers should have some responsibility for lowering the level of stress.
NPR’s Joe Neel, the panel’s moderator, summarized…
It’s all about conditions of the workplace and stress.
Kudos to Harvard Chan’s Sorensen, who introduces the audience to the study of job stress in San Francisco transit operators, in which changing the work — such as modifying schedules, training, staffing changes, and equipment upgrades — succeeded in reducing worker stress, whereas, according to Sorensen, previous efforts to change the workers (for example, with stress management programs) failed. For the curious: The research Sorensen cited has been incorporated into an in-depth analysis of stress prevention for bus drivers, available from the International Labour Organization.
The disconnect between the “healthy work” approach and the behavior change emphasis in the panel’s videos, if anything, highlights the need for an acceleration of credible worker health research, which is exactly what NIOSH’s Total Worker Health initiative has set out to do .
In the interim, watch the full one-hour panel here:
On June 19, 2015, while the U.S. federal government was determining how much employers should be allowed to fine workers for high blood pressure and cholesterol, the United Kingdom’s quasi-governmental National Institute for Health and Care Excellence (NICE) was doing something beneficial for employee wellness. NICE issued evidence-based guidelines for management practices and policies that support employee health.
In the U.S., where we lean on behavioral programs and medicalized approaches to try to manipulate worker health, NICE’s focus on workforce management and policy may seem…um…foreign. But as often mentioned in this blog, much of the rest of the economically advanced world long ago realized that management practices — especially those relating to job design and work environment — are the foundation of employee health. Voluntary behavioral programs play a potentially important but supporting role.
In fact, a recent Stanford study, described in a previous post here, determined that low job control, unemployment, long work hours, and work-family conflict had a greater affect on mortality than second hand smoke. And more than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce.
The NICE guidance includes recommendations like…
“Encourage employees to be involved in the design of their role to achieve a balance in the work demanded of them. Allow them to have a degree of control, appropriate to their role, over when and how work is completed.”
“Value and acknowledge employees’ contribution across the organisation. If practical, act on their input and explain why this action was taken.”
“Create a supportive environment that enables employees to be proactive to protect and enhance their own health and wellbeing.”
“Ensure any unfair treatment of employees is addressed as a matter of priority.”
“Proactively challenge behaviour and actions that may adversely affect employee health and wellbeing.”
“If possible and within the needs of the organisation be flexible about work scheduling, giving employees control and flexibility over their own time.”
In the U.S., we seek “disruption” in the form of new wellness programs, gizmos, and websites. But these aren’t disruptive and in some cases they aren’t even improvements. They’re just new tricks for old dogs.
Even if behavior is the underpinning of health, as we insist on believing, employers have little influence over it, and may do some damage in the process of trying.
Employers do influence the workplace and the work, and that’s where they can have the most impact on wellness. Hence the tagline of this Health Shifting blog…
It may be hard to get your brain around abstract models of stress, especially when they don’t line up with the usual fright-or-flight illustrations or seem remediable by the relaxation tips commonly sold as solutions. But if we care about workers, and how employers may be able to help them, we can’t ignore the harmful effects of effort-reward imbalance.
Think back to Psych 101 and you’ll remember that most human transactions are based on our expectation of an even exchange, or social reciprocity. It’s like an unwritten contract. We’re hard-wired for evenhandedness, and when we get — or believe we’ve gotten — a raw deal, we suffer from physical and emotional stress.
In the workplace, employees trade their currency — effort — for the employer’s currency, rewards, which include:
job security and prospects for promotion
respect and prestige within the organization
The balance — or imbalance — of effort and reward may be influenced by an employee’s motivational style, especially for employees who are intrinsically driven to overextend their effort independent of rewards, often to fulfill their underlying longing for approval. This surfaces as “overcommitment” in the effort-reward imbalance model.
When physical and or mental job effort outweigh the reward — or employees perceive the balance to be out of whack — the result is chronic stress and, over time, the physical and mental problems that stress can lead to.
This understanding of work stress was first conceptualized by medical sociologist Johannes Siegrist.
The model of effort rewards imbalance claims that lack of reciprocity between costs and gains (i.e., high-cost/low-gain conditions), define a state of emotional distress with special propensity to autonomic arousal and associated strain reactions.
Siegrist’s theory was put to the test in Britain’s classic “Whitehall II Study,” which followed more than 10,000 civil service workers for 11 years. Results showed that effort-reward imbalance led to increased risk of cardiovascular disease, as well as declines in overall physical and mental health. Study subjects who were lower on the organizational chart and those with less workplace social support had the highest levels of risk among those with effort-reward imbalance. Since then, research has shown even more pronounced effects of effort-reward imbalance, especially on the risk of heart disease and depression — based on rigorous studies of employees in a wide range of occupations working in countries across the globe.
The Whitehall researchers, led by social determinants of health pioneer Sir Michael Marmot, felt their results showed that cardiovascular disease and other stress-related illnesses could be prevented by improving work conditions. Their work led to a campaign to encourage employers to:
Improve rewards by recognizing good job performance
Encourage job-skill and professional development
Foster social support at the workplace
Siegrist has proposed additional solutions:
Leadership development among supervisors, emphasizing the importance of esteem, recognition and appropriate feedback.
Building upon non-monetary rewards, like flexible work options, more effectively matching job status to achievements, and fostering job security.
Effort-reward imbalance is one of the two most influential frameworks for understanding job stress, alongside the demand-control model of job strain. In fact — despite our preoccupation with other models that push accountability for stress solely on workers — regarding both demand-control and effort-reward imbalance, Siegrist wrote in 2014:
Empirical evidence on their health-adverse effects is far broader than is currently the case for any other stress-theoretical model related to work and employment.
Ultimately, most elements of the psychosocial work environment can be plugged into one or both of these models.
Whether effort-reward imbalance is a product of employee perception or actual work conditions remains a topic of debate. Most likely, both play a role. Certainly, job demands and job control have been validated as causes of cardiovascular disease and high blood pressure, in contrast to trendy notions that stress is a mindset or is a good thing and that employees are on their own to address it. The role of personal interventions is to help employees with problem-solving skills that can help them advocate for themselves, assess their level of effort as objectively as possible and, in some cases, moderate overcommitment. Stress management and resilience programs may play a supporting role.
The workplace demons that threaten employee health include long work hours, job insecurity, low job control, high job demands, shift work, effort/reward imbalances, role ambiguity, work-family conflict, inadequate workplace social support, and unfair treatment. These can be bucketed in various ways, but whatever you call them, they are the work conditions — controllable by employers — that research has consistently shown to influence employee health and well-being.
Now, along comes a study out of Stanford University that not only endeavors to quantify the burden — in terms of health outcomes, cost, and mortality — of these demons (what the researchers called “stressors” and I sometimes refer to as the workplace determinants of health), but also puts it into context relative to other, more commonly recognized, health issues.
Spoiler alert: More than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce, according to this analysis. The mortality rate for these stressors, plus another the researchers found to have significant impact — lack of health insurance — was on par with the fourth and fifth largest causes of death in the U.S.: heart disease and accidents. It was greater than mortality resulting from diabetes, Alzheimer’s, or influenza.
Exposure to the following stressors was found to be more harmful than secondhand tobacco smoke:
Lack of health insurance
Low organizational justice (fairness)
High job demands
And — again, using secondhand smoke as a benchmark — the conditions that had a greater affect on mortality are:
Low job control
Long work hours
Lack of health insurance
The Stanford researchers concluded,
Employers may not make appropriate decisions concerning workplace management if they are unaware of the link between management decisions and employee health and healthcare costs. Our analysis suggests that for such organizations, paying attention to the structure of the workplace and the associated job stressors experienced by their employees may be a fruitful way to reduce unnecessary healthcare costs.
But they acknowledge that employers may have limited motivation to address these issues if, indeed, they’re not on the hook for the costs of health care — for example, in the cases of employees who have been laid off or who are not offered health insurance. The study didn’t delve into associations between stress and productivity.
The analysis was conducted by Joel Goh, Jeffrey Pfeffer, and Stefanos A. Zenios and published in Management Science. Goh is now on the faculty of Harvard Business School.
The researchers are conservative yet insightful in their expectations regarding the implications of their work:
While we stop short of claiming that employer decisions have a definite effect on these outcomes and costs, denying the possibility of an effect is not prudent either. Analyzing how employers affect health outcomes and costs through the workplace decisions they make is incredibly important if we are to more fully understand the landscape of health and well-being.
And what of our current approach to employee well-being, with its slaphappy embrace of screenings, health risk assessments, health coaching, apps, wearables and incentives? How does it jibe with the real determinants of worker health? Not very well, according to study co-author Jeffrey Pfeffer. In his YouTube interview for the Stanford Graduate School of Business, he says,
Employers worry mostly about individual decisions: eating, exercise, smoking, drinking…things like that. Or about policy issues like how we pay for health care. A lot of their excess health care costs come from what happens to people every day in the work environment… Things that employers could fix, if they wanted to.
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]