The European Journal of Public Health Advance Access originally published online on February 16, 2007
The European Journal of Public Health 2007 17(5):471-476; doi:10.1093/eurpub/ckm004
Prevention |
Leadership in workplace health promotion projects: 1- and 2-year effects on long-term work attendance
Lotta Dellve, Katrin Skagert and Rebecka VilhelmssonDepartment of Public Health and Community Medicine, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden
Correspondence: Lotta Dellve, Department of Public Health and Community Medicine, The Sahlgrenska Academy at Göteborg University, Box 414, SE-405 30 Göteborg, Sweden, tel: +46(0)31 786 31 58, fax: +46(0)31 40 97 28, e-mail: lotta.dellve{at}amm.gu.se
Received August 7, 2006, accepted January 8, 2007
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Abstract |
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Background: Despite the acknowledged role of leadership in the psychosocial work environment, few studies focus on how leadership qualities and strategies may act as key processes of importance to positive effects of workplace health promotion (WHP). The aim of this study was to increase knowledge about how leadership qualities and strategies in WHP projects influence employees’ long-term work attendance. Method: The 1- and 2-year effect of leadership on the prevalence of long-term work attendance among municipal human service workers (n = 3 275) was analysed using 3-year register-based data on sick leave, questionnaires and a qualitative categorization of each unit. Result: Increased leadership qualities, especially where leaders used rewards, recognition and respect, were associated with higher prevalence of work attendance at follow-up [PR 1.42 (1.20–1.69)]. Leaders’ strategies and views on work-related health had a significant impact on increased work attendance in projects that had goals clearly focusing on changeable factors [1.36 (1.11–1.67)], in multi-focused projects [1.60 (1.24–2.04)] and in projects aimed to increase employees’ awareness of their health. Workplace health promotion strategies with a single focus on strengthening individual, professional or organizational resources were negatively associated with work attendance. A higher proportion of employee work attendance was also seen in units whose leaders viewed the organization or the society (rather than individual workers) as responsible for the high rate of sick leave. Conclusion: Leadership, WHP strategies and leaders’ attitudes towards employee work-related health have importance for implementation processes, as well as affecting employee work attendance. In this study, multi-focused WHP interventions had the largest effect on work attendance.
Keywords: health promotion, management, psychosocial factors, sick leave, work ability
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Background |
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Although the role of leadership in the psychosocial work environment is well acknowledged, only few studies focus on how leaders can decrease work-related disorders and sick leave among subordinates.1 The key role that leaders play in the success of health-related workplace change processes is most often described rhetorically and theoretically. There is little empirical, systematic knowledge about how leadership qualities and strategies may act as key processes of importance to workplace health promotion (WHP) interventions.
Leadership and the psychosocial work environment
Leadership qualities are an important explanatory psychosocial factor for short and long spells of sick leavem,2 for sustainable work-related health among employees3–5 and for improved health among the leaders’ subordinates.6 How leadership is practised, e.g. in dealing with conflicts and providing support, as well as with regard to availability, has been connected to work-related health among employees in human service organizations (HSOs).7,3,4 Leadership styles, i.e. transformational styles, have been positively related to subordinates’ wellbeing.5,8 The influence that leaders have on work conditions can be both direct (e.g. through decisions to reduce work-related strain) and indirect (when conditions improve for better management of work-related strain). Healthy working conditions as well as employees’ confidence and pride in their work have been qualitatively related to supportive, confirmative and solution-oriented leadership attitudes as well as to trust and a confirmative climate at work.5 Furthermore, support from leaders is central to implementing and performing psychosocial workplace interventions.9 However, there is still a lack of knowledge about how leadership qualities and strategies have an impact on improving work-related health.
Leadership, workplace health promotion and work attendance
Negative trends in the psychosocial work environment10 and the amount of sick leave taken11 have urged the need for a shift in perspective towards focus on buffering factors that help achieve acceptable work attendance among employees.
Work ability, work attendance and sick leave are affected by the complex interplay between individual, organizational and societal factors and their influence on health.12–14 Terms used in the literature and theories of work attendance have varied according to the writers’ intentions and focus.13 Work attendance has been studied and variously conceptualized as (i) a result of individual, social, organizational and societal influence;15,16 (ii) a measure of productivity;17 and (iii) an indicator of work ability.18,19 High work attendance has been related to organizational and psychosocial work conditions such as non-full-time work,18 high income, work commitment, job satisfaction13 and physically non-strenuous work tasks and stability.19
The ideas on health and work ability, and their relation to WHP, can be summarized as follows: (i) health and work ability are the product of individual responsibility and health-related behaviour; and (ii) health is a product of many aspects, many of which are outside individuals’ control.20 How leadership form strategies for WHP is poorly investigated, as is the empirical effect of leaders’ strategies. Therefore, in a first step we used a qualitative approach to describe central processes and contextual conditions forming leaders’ strategies to increase work attendance. The WHP projects comprised both individual-targeted lifestyle efforts and broader work organizational and work environment efforts. The results show that leaders’ conceptions of opportunities to influence employee health were qualitatively related to the kind of WHP projects and leaders’ strategies that were implemented, as well as to participatory processes in performing WHP projects. Their WHP platform was described as to the extent it was oriented towards employee participation. Leaders’ WHP strategies, i.e. strategies for approaching the problem, were related to the leaders’ views of the most appropriate focus for intervention (individuals, the organization or society) and to their conception of who was responsible for the negative trends in sick leave (the individuals, the organization or society). The leaders described various strategies for handling and developing resources. These were related to whether they viewed the workers as an economic obstacle in the budget process or whether they viewed the workers and the budget as economic resources.21
In the present article we studied the effect of leaders’ strategies on employees’ work attendance. The aim was to increase knowledge about how leadership qualities and strategies in WHP projects affect employees’ long-term work attendance.
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Method |
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Design
A prospective approach was used to investigate the impact of leadership qualities and WHP strategies on the prevalence of long-term work attendance. Qualitative analysis was followed by quantitative analyses. In the first step, we performed qualitative analysis of in-depth interviews with all WHP leaders (n = 23).21 In order to stratify analyses according to leadership strategies, each unit was categorized according to the qualitative categories of WHP strategies, the WHP platform and attitudes related to influencing employees’ health. This article presents the quantitative estimations of effects on long-term work attendance.
Setting and study group
The setting was a Swedish city (the municipality of Göteborg which is divided into21 geographical areas with its own District Committee, directly subordinate to the City Council), where general policies on human service issues, legislation, and rights related to social security and employment regulations were standard, but where organizational factors may vary between the districts. The highly developed social security system of Sweden covers all citizens; sickness absence of more than 1 day is paid by the employer, while certified sick leave of more than 2 weeks is paid by the social security system. The study period 2002–05 was politically stable and with only minor changes in employment and staff turnover rates.
The local authority gave financial support to WHP projects at municipal HSOs. Human service organization leaders applied for their projects and funding was granted for 21 WHP projects (covering 34 work units from 14 districts) of totally 40 applications. Stratified purposeful sampling was performed to cover a variation in type of work-place health promotion activities and socioeconomic districts.
At baseline the study group comprised 3275 human service workers (table 1) aged 20–65 years and employed at 34 work units in preschools, schools and leisure activity centres, as well as in care of the elderly, social work and care of the disabled. Most of the workers were female (87%) and older than 45 years (61%). One-third were employed full-time. Employees working within elderly care and in schools represented one-third each of the study population.
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Long-term work attendance
The outcome, prevalence of long-term work attendance, was defined as employees who had taken no, or at the most, 7 days of sick leave during 1 year.13 Individual data on days of sick leave were obtained from the employers’ registers during the 3-year study period. We excluded absence for other reasons such as vacation, taking care of own sick children and pregnancy- or maternity-related absence.
Leadership qualities
Leadership qualities and leadership-related psychosocial workplace conditions were measured using the questionnaire ‘Swedish Costumer Satisfaction Index’ (SCSI),22 distributed yearly by Statistics Sweden. Employees answered the questionnaire individually, and the answers were then grouped by work unit. An index was constructed of general leadership qualities with regard to the following five items: My supervisor (1) delegates responsibility in a wise manner; (2) delegates work tasks in a wise manner; (3) is sensible about work climate and activities; (4) has the ability to handle rising conflicts in a good manner and (5) has the ability to lead the group towards common goals. Rewards and recognition were analysed as an index of three items: My (1) supervisor; (2) colleagues and (3) clients appreciate(s) my task performance. Cronbach's 
for the index was satisfactory. Single items indicating goal clarity (The goals for my work are realistic; I know what is expected of me and with regard to my work performance), respect (I am respected at my workplace) and trust/stability (I trust my supervisor; I have trust in the top management; I feel confident in facing organizational changes; There's a good atmosphere among my colleagues and We can have an open and free discussion at my workplace) were selected as indicators of leadership-related psychosocial workplace conditions and investigated in relation to work attendance. All items had a 10-point response scale (1 = I totally disagree and 10 = I totally agree).
Leadership workplace health promotion strategies
Qualities in leadership WHP strategies were dichotomously categorized (0/1 or, where not appropriate, as missing) for each work unit based on the results of an earlier qualitative study. Leaders’ WHP goals was categorized as: strengthening physical, professional or organizational resources or increasing awareness of own (i.e. the employees’) health. If two or more goals were targeted, the work unit was categorized as a multi-focused WHP. Leaders’ focus of WHP was categorized as being either on the individuals or on the organization. The leaders’ created platform for WHP projects was categorized as derived from work groups expressing needs and ideas (versus being derived from leaders’ own ideas), targeting clearly changeable goals (versus targeting unrealistic goals within the framework of available resources and decision authority) and in terms of broad employee participation in development of the WHP projects (versus the WHP project being performed mainly by the supervisor). The leaders’ attitudes towards responsibility for employees’ health were categorized as Individual lifestyle creates high sick leave rates; Work conditions create high sick leave rates; or Societal conditions create high sick leave rates. Also, the leaders’ expressed view of both the employees and the budget as organizational resources (as opposed to the view of employees as an obstacle to the budget) was also categorized. The categorizations were performed by the qualitative interviewer (KS) 1 year before the statistical analysis was performed by the other authors (LD, RV).
Statistical analysis
Prevalence ratios (PRs) with 90% confidence intervals (90% CIs) were calculated to estimate statistical relations. In the stratified analysis at work unit level we used 90% CIs because of low power and assumed low precision. At first we linked individual-level register-based data on work attendance to work unit questionnaire-based data on leadership qualities and psychosocial workplace conditions. Next we performed stratified analyses of pre-categorized leadership qualities and long-term work attendance (both at individual and work-unit level). A statistical analysis of variance (ANOVA) was used to estimate relations for the continuous variable, i.e. work unit prevalence of work attendance. Statistical calculations were performed using SAS, version 9.1, and JMP, version 5.0 (SAS Institute, Cary, NC, USA).
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Results |
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Work attendance among human service workers
Of the 3 275 participating human service workers one-third took no sick leave at all, while 58% took up to 7 days of sick leave during a year (table 1). The highest prevalence of work attendance was found among workers in the care of the disabled and among male workers. The lowest prevalence was found among workers in the care of the elderly.
Leadership qualities and work attendance
Increased leadership qualities were related to higher prevalence of work attendance at follow-up (table 2). Increased leadership-related psychosocial qualities were related more to no days of sick leave per year than to a maximum of 7 days of sick leave per year. Especially increased rewards and recognition and increased respect were most strongly related to increased work attendance (no sick leave per year). Furthermore, a positive relation was seen between increased work attendance and working in units where there was increased respect and trust (in both the supervisor and top management), a positive work climate and open discussion.
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Leadership strategies and work attendance
Leaders’ platforms had importance for increased work attendance. First, with regard to the leaders’ platform for WHP projects it was important how the goals of change were defined. In projects whose goals clearly focused on changeable factors, there was an increase in individual and work unit work attendance (tables 3 and 4). Secondly, solely participant-oriented platforms had lower rates of work attendance at follow-up than did combined participant/leader-oriented platforms or solely leader-oriented platforms.
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Work attendance at individual and work unit level increased in multi-focused projects and in projects that aimed to increase employees’ awareness of their health and wellbeing. At the long-term follow-up, there was a stronger relation between multi-focused interventions and a high prevalence of work attendance [PR 1.60 (90% CI 1.24–2.04)]. Workplace health promotion strategies focusing on individuals were positively associated with individual work attendance (table 3) and negatively related to work unit work attendance. A higher proportion of work attendance was also seen in those units where the leader viewed the organization or the society (as opposed to individual workers) as responsible for the high rate of sick leave.
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Discussion |
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In this study, leadership qualities, leader WHP strategies and leaders’ attitudes towards employee work-related health in WHP projects had a significant impact on employees’ long-term work attendance. The main results show that leaders with multi-focused intervention strategies had the strongest long-term effect on employee work attendance. Increased leadership qualities, especially where leaders used rewards, recognition and respect, also had a stronger effect on work attendance. Strategies comprising a single focus (focusing on strengthening individual, professional or organizational resources) showed the lowest prevalence of work attendance at follow-up. In the following, the results will be discussed in relation to previous results and implications for practice.
In this study, long-term work attendance increased in multi-focused projects, supporting earlier studies also suggesting that multi-focused WHP interventions have a positive effect.23 Workplace health promotion strategies undertaken to solely strengthen individual, professional or organizational resources in this study were not related to increased work attendance. At work unit level, targeting the organization, but not individuals, had a positive effect on work attendance. Also, sick leave during 15–59 days per year decreased where leaders targeted individual employees [PR 0.72 (90% CI 0.56–0.89)] or the organization [0.69 [0.54–0.88)], as well as in multi-targeted interventions [0.76 (0.66–0.87)].29
Workplace health promotion projects with goals clearly focusing on changeable factors increased long-term work attendance. Also, increased goal clarity among WHP leaders was related to increased work attendance. The results support the hypothesis of cybernetic regulation processes of target levels and workload affecting employee health in HSOs, where decision authority with regard to resources and budget is dependent on political prioritizing.24 Individual demands among HSO workers can be described as organizational and individual disagreement at goal level.24 Incongruency between such agreements on goal achievement, i.e. poor goal clarity, can be an important mechanism explaining work-related stress or beneficial mastery among human service workers.25 Feedback on task performance can give clarity with regard to role and goals, and positively influence work satisfaction and commitment.25 Goal clarity from top management organizations has been related to higher work attendance among home care workers.13 Likewise, poor goal clarity has been related to long-term sick leave (>21 days) among white-collar workers.26
Increased leadership qualities were related to higher prevalence of work attendance at follow-up, especially where leaders made increased use of rewards and recognition, and respect. This supports Siegrist's (1996) model of balanced effort and reward to prevent stress among employees, with imbalance leading to stress reactions, low job satisfaction, absence from work and cardiovascular diseases.27 Reward and reasonably balanced demands seem especially important for HSO workers with emotionally demanding tasks, e.g. in client relations in the care of children, and the disabled and elderly. Also, an increased positive work climate and open discussion at the workplace were related to increased work attendance. Earlier studies have shown the negative impact of poor work climate on wellbeing,28 work disability3 and sick leave.26 In the same population, a relation was seen to exist between long-term sick leave and leadership qualities. Strengthened leadership, with increased trust in the supervisor and increased goal clarity, was found to be a protective factor against long-term sick leave [PR 0.90 (90% CI 0.83–0.98)].29 Forming pride in their work and confidence among employees through good leadership and a trustful and confirmative climate may be a key process in healthy working conditions.5
Leaders’ attitudes towards and views on work-related health were seen to be important for achieving increased work attendance. A higher proportion of employee work attendance was also seen in units where leaders viewed the organization or society (rather than individual workers) as responsible for the high rate of sick leave. Consequently, in the absence of stigmatization processes there was increased work ability. (The opposite could be expected if individuals were being held solely responsible, since being regarded as a ‘problem’ may not necessarily create increased work ability among subordinates.) Likewise, increased trust in leaders and top management was related to higher work attendance.
In this and other empirical studies, participatory processes have shown mixed results for work-related health.30 The positive effects of participatory processes are almost taken for granted. However, there may be difficulties in performing real participation in work unit developmental processes since such participation puts demands on both leadership and followership.31 Also, the power-related processes may have an impact in various directions.32
Methodological discussion
There is no general consensus on what defines good work attendance in the literature. The measures of work attendance in the present paper (no, and a maximum of 7 days’ sick leave per year) were chosen on the basis of results from one recent methodological study from the same country. In that study, the number of days of sick leave per year were analysed in relation to psychosocial work conditions in order to contribute to the definition of acceptable work attendance. A maximum of 7 days of sick leave per year was related to positive work factors. When the number of days of sick leave exceeded 14 days per year there was a more clear relation to negative work-related factors.13 However, these cut of points needs to be further studied in relation to social insurance systems and branches.
This study and earlier studies highlight the importance of studying the whole process during intervention studies in working life.33–35 Strategies are formed and changes take place not only through rational choices but through conceptions, attitudes, values and political interests. This implies that working life interventions cannot normally be expected to have direct health outcomes. Instead, direct intervention effects are mediated in several steps, and during this process moderation is likely to occur. Saksvik et al. (2002) argue in favour of combining qualitative and quantitative methodology in intervention research to achieve deeper knowledge about key moderating conditions.36 If only end outcomes are studied, relevant effects, e.g. of leadership strategies, may be missed. In a sense, feasibility and process studies aim to develop our understanding of what may happen during interventions. A basic question concerns the processes that unfold during an intervention in a particular context and that may influence the outcome of the intervention. Can it be implemented according to intention? This should preferably be investigated before any large-scale intervention programme is launched. The longer the intervention, the more complex and difficult it will be to predict these processes. And process aspects that are complex and difficult to predict are hard to measure and control for in data analysis when specific intervention effects are searched for/required. However, the controlled study design offers the most generalizable effect estimations of causal relations if dependent and independent factors are known and if it is possible to perform. Randomization of studied units would also decrease the possibility of selection effects by very engaged and committed leaders was not possible in this study, nor was it necessary at this level of knowledge development. Instead, repeated measures were performed. And, the selection of WHP-projects followed qualitative criteria, i.e. strategic purposeful selection to cover variations in type of interventions and broad representations of represented district (informational representative sampling).
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Conclusions |
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TopAbstractBackgroundMethodResultsDiscussionConclusionsAcknowledgementsReferences |
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Leadership qualities and leaders’ WHP strategies and attitudes towards employee work-related health have importance for implementation processes as well as for employee work attendance. Multi-focused WHP interventions had the largest long-term effect on work attendance. Multi-focused WHP interventions had the largest long-term effect on work attendance
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Acknowledgements |
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This research project was performed in cooperation with the City of Göteborg which financed the WHP projects. We are grateful to the skilful WHP project leaders, and especially to process leader Helen Torstensson at the City Office. We are also grateful to the Swedish Governmental Agency for Innovation Systems and the Swedish Social and Working Life Foundation for financial support of the scientific evaluation and research study.
Key points
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References |
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1 Nyberg A, Bernin P, Theorell T. The impact of leadership on the health of subordinates (2005) Stockholm: National Institute for Working Life.
2 Nielsen M, Rugulies R, Christensen K, Smith-Hansen L, Kristensen T. Psychosocial work environment predictors of short and long spells of registered sickness absence during a 2-year follow up. J Occup Environ Med (2006) 48:591–8.[CrossRef][Web of Science][Medline]
3 Dellve L, Lagerström M, Hagberg M. Work system risk factors for permanent work disability among home care workers: a case-control study. Int Arch Occup Environ Health (2003) 76:216–24.[Web of Science][Medline]
4 Eriksen W, Bruusgard D, Knardahl S. Work factors as predictors of sickness absence: a three month prospective study of nurses' aides. Occup Environ Health (2003) 60:271–8.
5 Nilsson K, Hertting A, Pettersson I-L, Theorell T. Pride and confidence at work: potential predictors of occupational health in a hospital setting. BMC Public Health (2005) 5:92.[CrossRef][Medline]
6 Theorell T, Emdad R, Arnetz B, Weingarten A-M. Employee Effects of an Educational program for managers at an Insurance Company. Psychosom Med (2001) 63:724–33.
7 Brulin C, Gerdle B, Granlund B, Höög J, Knutsson A, Sundelin G. Physical and psychosocial work related risk factors associated with musculosceletal symptoms among home care personnel. Scand J Caring Sci (1998) 12:104–10.[CrossRef][Web of Science][Medline]
8 Sosik J, Godshalk V. Leadership styles, mentoring functions received, and job-related stress: a conceptual model and preliminary study. J Org Behav (2000) 21:365–90.[CrossRef]
9 Kompier M, Cooper C, Geurts S. A multiple case study approach to work stress prevention. Eur J Work Org Psychol (2000) 9:371–400.[CrossRef]
10 Kristensen T, Hannerz H, Høgh A, Borg V. The Copenhagen Psychosocial Questionnaire—a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health (2005) 31:438–49.[Web of Science][Medline]
11 Alexanderson K, Norlund K. Sickness absence - causes, consequences, and physician's sickness certification practice. A systematic literature review by the Swedish Council on Technology Assessment in Health Care. Scand J Public Health (2004) 32(Suppl 63):12–258.
12 Alexandersson K. Sickness absence: a review of performed studies with focused on levels of exposures and theories utilized. Scand J Soc Med (1998) 26:241–9.[Web of Science][Medline]
13 Dellve L, Eriksson J, Vilhelmsson R. Assessment of long-term work attendance within human service organisations. In: WORK (2006) In press.
14 Tuomi K, Illmarinen J, Seitsamo J, Huuhtanen P, Martikainen R, Nygård C-H, et al. Summary of the Finnish research project (1981–1992) to promote the health and work ability of ageing workers. Scand J Work Environ Health (1997) 23(Suppl 1):66–71.
15 Aronsson G, Gustafsson K. Sickness presenteeism: prevalence, attendance-pressure factors, and an outline of a model for research. J Occup Environ Med (2005) 47:958–66.[CrossRef][Web of Science][Medline]
16 Kivimaki M, Head J, Ferrie JE, Hemingway H, Shipley MJ, Vahtera J, et al. Working while ill as a risk factor for serious coronary events: the Whitehall II study. Am J Public Health (2005) 95:98–102.
17 Burton WN, Chen CY, Conti DJ, Schultz AB, Pransky G, Edington DW. The association of health risks with on-the-job productivity. J Occup Environ Med (2005) 47:769–7.[Web of Science][Medline]
18 Dellve L, Karlberg C, Allebeck P, Herloff B, Hagberg M. Macro-organisational factors, the incidence of work disability and work ability among the total work force of home care workers in Sweden. Scand J Public Health (2006) 34:17–25.
19 Lindberg P, Vingård E, Josephson M, Alfredsson L. Retaining the ability to work - associated factors at work. Eur J Public Health (2005) 14.
20 Shain M, Kramer D. Health promotion in the work-place: framing the concept, reviewing the evidence. Occup Environ Med (2004) 61:643–8.
21 Skagert K, Dellve L, Håkansson K. Resurser och hälsa: Ledares föreställningar om möjligheter och vägar att påverka anställdas hälsa och minska sjukskrivning (Resources and health: Leader's strategies to increase employees’ health and work attendance). (2003) Göteborg: Sahlgrenska Hospital and Academy, Dept Occup Environm Med. Report No 101.
22 Fornell C. A national customer satisfaction barometer: the Swedish experience. J Marketing (1992) 56:6–21.[CrossRef]
23 Pelletier K. A review and analysis of the clinical - and cost-effectiveness studies of comprehensive health promotion and disease management programs in the worksite:1998–2000. Update. Am J Health Promot (2001) 16:107–16.[CrossRef][Web of Science][Medline]
24 Pousette A. Feedback and Stress in Human Service Organizations, in Department of Psychology (dissertation). (2001) Göteborg: GöteborgUniversity.
25 Jacobsson C, Pousette A, Thylefors I. Managing stress and feelings of mastery among Swedish comprehensive school teachers. Scand J Educ Res (2001) 45:37–53.[CrossRef]
26 Väänänen A, Kalimo R, Toppinen-Tanner S, Mutanen P, Peiró J, Kivimäki M, et al. Role clarity, fairness, and organzational climate as predictors of sickness absence. A prospective study in the private sector. Scand J Public Health (2004) 32:426–34.[CrossRef][Web of Science][Medline]
27 Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occupa Health Psychol (1996) 1:27–71.[CrossRef]
28 Kivimäki M, Elovainio M, Vahtera J. Workplace bullying and sickness absence in hospital staff. Occup Environ Med (2000) 57:656–60.
29 Dellve L, Skagert K, Vilhelmsson R, Eriksson J, Eklöf M. Hälsofrämjande arbetsmiljöprojekt inom social service. (Workplace health promotion projects in human service organisations). (2006) Göteborg: Sahlgrenska Hospital and Academy, Dept Occup Environm Med. Report No 111.
30 Dellve L, Skagert K, Eklöf M. Delaktighet och struktur i systematiskt arbetsmiljöarbete (Participation and structure in systematic health and safety management). (2004) Göteborg: Sahlgrenska Hospital and Academy, Dept Occup Environm Med. Report No 107.
31 Degeling P, Carr A. Leadership for the systematization of helth care: the unaddressed issue in health care reform. J Health Org Manag (2004) 18:399–414.[CrossRef]
32 Braynion P. Power and leadership. J Health Org Manag (2004) 18:447–63.[CrossRef]
33 Wickström G. Intervention studies in the health care sector (2000) Stockholm: National Institute for Working Life.
34 Goldenhar L, LaMontagne A, Katz T, Heaney C, Landsbergis P. The Intervention Research Process in Occupational Safety and Health: An Overview From the National Occupational Research Agenda Intervention Effectiveness Research Team. J Occup Environ Med (2001) 43:616–22.[Web of Science][Medline]
35 Griffiths A. Organizational interventions. Facing the limits of the natural science paradigm. Scand J Work Environ Health (1999) 25:589–96.[Web of Science][Medline]
36 Saksvik P, Nytrö K, Dahl-Jörgensen D, Mikkelsen A. A process evaluation of individual and organizational occupational stress and health interventions. Work & Stress (2002) 16:37–57.[CrossRef][Web of Science]
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