Chronic Psychosocial Stress at Work and Cardiovascular Disease: The Role of Effort–Reward Imbalance

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Introduction

Over the past several decades, the nature of work in established market economies has undergone remarkable changes. Fewer jobs are defined by physical demands and more by psychological and socio-emotional demands. Fewer jobs are available in the industry sector, in particular in mass production, more in the service sector. More jobs are concerned with information processing due to computerization and automation. At the same time, job arrangements have undergone significant transformations, as there is now more flexibility in time schedules (e.g., part-time work) and workplaces (e.g., home work), but also an increase in mobility over one's occupational biography and an increase in job instability and structural unemployment. While the duration of working life is diminished and a substantial part of the workforce is faced with job loss, work and occupation nevertheless continue to play a crucial role in adult life in modern societies. This is mainly due to the fact that having a job is a principal prerequisite for continuous income opportunities and training for a job and achievement of occupational status are most important goals of primary and secondary socialization. Moreover, occupational positions define a relevant criterion of social stratification, and they provide essential means of experiencing successful self-regulation in a meaningful social context (see below). Thus, the importance of work for well-being and health goes beyond traditional occupational diseases. The challenge, then, consists in conceptualizing those aspects of the nature of current and near future work conditions that adversely affect human health. In addition, scientific evidence on adverse health effects produced by these working conditions needs to be demonstrated. Ways of reducing the burden of ill health, as far as it is attributable to the changing nature of work, need to be delineated.

This article presents one attempt toward facing these challenges, an attempt labeled “effort–reward imbalance.” Its focus is put on cardiovascular disease for the following reasons. First, cardiovascular disease, and in particular coronary heart disease (CHD), is a major cause of death, long-lasting disability, and reduced quality of life in midlife, that is, during the economically active life stage (Marmot & Elliott, 1992). Direct and indirect costs of cardiovascular morbidity are substantial, affecting the economy of advanced countries in several ways (Karasek & Theorell, 1990). Secondly, cardiovascular disease is considered a multifactorial disease where health-adverse behaviors and psychosocial stress, in addition to genetic and physico-chemical determinants, were shown to have a direct impact on the development of atherosclerosis and thrombosis (Beamish, Singal, & Dhalla, 1985), as well as on the development of important somatic risk factors, such as hypertension (Henry, 1997) and atherogenic lipids (Schneiderman & Skyler, 1996). This latter argument is of crucial importance as it opens a new perspective on how to analyze the interaction between the social environment (in particular, the psychosocial work environment), the individual person (in particular his or her ways of coping with job demands), and the organism (central nervous system-mediated cardiovascular dysfunction and pathology). In other words, cardiovascular disease is now considered a model disease within a biopsychosocial framework of transdisciplinary health research (Engel, 1977). Finally, focusing on cardiovascular disease is justified by the fact that most empirical research on the model outlined below was carried out so far with cardiovascular risk or disease as an outcome variable.

Section snippets

The Theoretical Model

Before introducing the model of effort–reward imbalance, it is useful to define some basic terms related to the concept of psychosocial stress. “Stressor” is defined as an environmental demand or threat that taxes or exceeds a person's ability to meet the challenge. Stressors—in particular, novel or dangerous ones—are appraised and evaluated by the person, and as long as there is some perception of agency on the part of the exposed person, efforts are mobilized to reverse the threat or to meet

Empirical Evidence

So far, five studies have reported findings with partial or full confirmation of the model's basic assumptions as related to cardiovascular risk or disease. An overview is given in Table 1. Concerning the study design, three studies are prospective. These are a German blue-collar study covering some 2,000 person years Siegrist, Peter, Junge, Cremer, & Seidel 1990, Siegrist et al. 1991, a British study comprising 8,695 men and 3,413 women, the so-called Whitehall II study directed by Michael

Practical Implications

This new information has several practical implications. In view of the fact that, according to the occupation under study, between 10 and 40% of the workforce suffer from some degree of effort–reward imbalance at work, and at least a third of them are characterized by severe chronic psychosocial stress, these findings deserve careful attention.

First, it is possible to identify dimensions of stressful experience at work that are relevant to health using standardized, well-tested questionnaires

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