The European Journal of Public Health Advance Access published online on August 8, 2007
The European Journal of Public Health, doi:10.1093/eurpub/ckm077
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Work stress and mental health in a changing society
Maria S Kopp1, Adrienne Stauder1, György Purebl1, Imre Janszky2 and Árpád Skrabski3
1 Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
2 Department of Public Health Sciences, Karolinska Institutet, Norrbacka, 6
3 Vilmos Apor Catholic College, Vác
Correspondence: Prof. Maria S. Kopp, MD, PhD. Semmelweis University, Institute of Behavioural Sciences, H-1089 Budapest, Nagyvárad t 4, Hungary, tel: 36-1-210-2953, fax: 36-1-210-2955, e-mail: kopmar{at}net.sote.hu
Received January 21, 2007, accepted June 20, 2007
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Abstract |
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Background: The aim of this representative study in the Hungarian population was to analyse the association between work-related factors and self-reported mental and physical health after controlling for negative affect and hostility as personality traits. Methods: The effects of job related factors on Beck Depression Score, WHO well-being score and self-rated health (SRH) were analysed in a representative sample of 3153 male and 2710 female economically active Hungarians. Results: In both genders negative affect was the most important correlate of depression, well-being and SRH, whereas hostility was closely associated only with depression. Job insecurity, low control and low social support at work, weekend work hours, job-related life events and dissatisfaction with work and with boss were independent mental health risk factors, but there were important gender differences. Job related factors seem to be equally important predictors of mental health as social support from family. Conclusion: The results of this large national representative study indicate that independent of negative affect and hostility, a cluster of stressful work-related psychosocial conditions accounts for a substantial part of variation in self-reported mental and physical health of the economically active population in Hungary.
Keywords: depression, gender, negative affect, self-rated health, well-being, work stress
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Introduction |
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According to the World Health Report, 2001, mental and stress related disorders are important determinants of early death in Europe.1 These factors are especially important in the transforming societies of Central-Eastern-Europe (CEE). The morbidity and mortality crisis in the middle aged population accompanying the economic transformation of CEE countries represents an extraordinary burden. Previous research showed that depression, feelings of hopelessness and loss of control are serious risk factors for premature morbidity and mortality in the region.2–7 In the middle aged population, work and working conditions are central in determining well-being and promoting mental health.8–13 Hungary has witnessed a major change in the labour market since 1970. This change is characterized by an increased mobility and a high degree of job instability and associated loss of control.6 Given the relatively low wage levels in the majority of the employed people, dual earning careers and holding a second or even a third job are frequent phenomena. These developments are more frequent among groups with lower socio-economic status, as indicated by lower educational degree or lower income, because they often have fewer alternatives. According to our previous study, weekend working hours and other work related conditions might be regarded significant risk factors for premature cardiovascular mortality in the Hungarian population.14
Earlier studies confirmed the impact of psychosocial working conditions on mental distress and well-being.15,16 According to Stansfeld9 and Ferguson et al.17 negative affectivity accounts for some of the variance in the association between work stress and mental health but do not explain the association between work characteristics and depressive symptoms. The French GAZEL study confirmed these findings, where the adverse psychosocial working conditions were significant predictors of depressive symptoms independent of personality traits.18
Our hypothesis was that both work related environmental factors and personality variables such as negative affect and hostility have independent influence on self-reported mental and physical health in the economically active Hungarian population.
To test our hypothesis, we analysed the determinants of the relationships between work related protective and risk factors and self-reported mental and physical health, including personality factors such as negative affect and hostility. We also analysed gender differences considering the high morbidity and premature mortality rates of the middle aged Hungarian men.2–7 According to our earlier findings there were marked gender differences in work related correlates of premature cardiovascular mortality rates in Hungary.14 As a substantial proportion of women takes part in the labour market in Hungary, it is of interest to analyse to what extent working conditions are associated with male and female mental health compared to social support from family.
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Methods |
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Sample
The sampling method was described in detail elsewhere.19 The Hungarostudy 2002 is a national cross-sectional survey representative of the Hungarian population above the age of 18 according to sex, age and the 150 sub-regions in the country. In 2002, 12 643 persons were interviewed in their homes. The sample represented 0.16% of the population above age 18. The refusal rate was 17.7%. For each refusal, another person was selected from the same community with similar demographic characteristics of age and sex.19–20 5863 economically active people between the age 18–65 were included into the present study, 3153 men and 2710 women. There were 1292 public employees, 3587 employees, 812 self-employees and 172 on-call workers in the examined sample.
Measures
Mental health measures
The mental health measures of the study were described in detail elsewhere.19
Shortened Beck Depression Score
Depressive symptoms and severity of depression were measured by the 9-item shortened version of the Beck Depression Inventory (BDI). This is a reliable measure for screening the severity of depressive symptoms in community surveys.6,20–22 The Hungarian version of this scale was earlier validated in the general population and on clinical samples and it can be transformed reliably into the original BDI score.22
WHO Well-being scale19,20,23
This 5-item measure of well-being had a Cronbach 
of 0.84 in this study. (0 = lowest score, 15 = maximal score).19,20 Validation of the short (5-item) version of the WHO Well-Being Scale was completed on the basis of a Hungarian representative health survey (Hungarostudy2002).20,24
Self-rated health (SRH)
SRH was measured with the question: ‘How do you rate your health in general?’ There were five responses: very good; good; fair; poor; and very poor.19 We also asked about relative SRH, ‘How do you rate your health compared to others in your age group?’ There were five responses: much better, better, the same, worse and much worse).
Negative affect21,25
Negative affect is an 8-item sub-scale of the type D personality questionnaire. It was measured by the Hungarian version of type D personality questionnaire. It had a Cronbach of 0.84. (0 = lowest score, 24 = maximal score)20 According to the type D (‘distressed’) personality concept, individuals characterized by negative affectivity (NA) personality dimension tend to experience more distress in life because of the characteristic way in which they deal with emotional stress.20,25
Hostility
To measure hostility a shortened version of the Cook–Medley Hostility Scale was used.5,6 This 5- item measure of shortened version of the Cook–Medley Hostility Scale had a Cronbach of 0.63 (0 = lowest score, 15 = maximal score) on the basis of a Hungarian representative health survey (Hungarostudy 2002).26
Work related protective and risk factors14
Control at work was assessed by Likert scaled answers (0 to 3) to the item ‘How much can you influence what happens in your working group?’.6
Items on job security (‘I am happy with my level of job security’), dissatisfaction with work (‘I am unhappy with my work situation") and dissatisfaction with the boss (‘I am dissatisfied with my boss(es)’) were assessed by Likert scaled answers 0 to 2.27
‘Job related troubles in the last 5 years’ were recorded as part of the Life Events questionnaire.27 It was assessed by Likert scaled answers (0 to 2).
Social support at work was measured by answers (0–3) to the item ‘How much help do you receive from co-workers in difficult life situations?’.6,14
The number of working hours per week days and on weekend days (paid and unpaid work as well) was recorded.
Personal income was assessed with the help of a separate card showing eight categories (from 50 thousand HUFs or less = 1 to 500 thousand HUF or more = 8 per month).
Further psychosocial variables
Perceived social support from family
Perceived social support from partner (spouse or cohabiting partner), parents and relatives was assessed by separate answers to the items ‘How much help do you receive from partner (spouse or cohabiting partner), parents and relatives in difficult life situations?’, respectively. Each type of support was scored from 0 to 3, indicating the degree of perceived support ranging from ‘none’ to a ‘great deal’.6,14
Demographic control variables
Education was measured by the number of years in education. Age of the persons was included.
Statistical methods
SPSS (1999) Base 9 was used for multivariate analyses. Multiple stepwise linear regression analyses with standardized beta weights were performed in the present study. We also examined gender differences in the relations between work characteristics and the mental health outcomes. We included gender into the models (together with age) for each work characteristics–mental health outcome relationship and tested the interaction term between gender and work characteristics.
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Results |
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Mean depression score (male: 4.77 + 0.12, female: 5.70 + 0.14, t = 4.97, P = 0.000) and negative affect (male: 4.56 + 0.09, female: 5.76 + 0.10, t = 9.04, P = 0.000) were higher among active women, while WHO well-being (male: 8.64 + 06, female: 8.23 + 0.07, t = 4.59, P = 0.000), self rated health (male: 3.65 + 0.01, female: 3.59 + 0.01, t = 3.20, P = 0.001) and hostility (male: 3.84 + 0.05, female: 3.50 + 0.05, t = 21.6, P = 0.000) were higher among men. Among the work related factors perceived control in work (1.73 + 0.02, female: 1.57 + 0.02, t = 5.58, P = 0.000), income (2.03 + 0.02, female: 1.69 + 0.02, T = 12.43, P = 0.000), work related troubles as life events (male: 0.31 + 0.01, female: 0.27 + 0.01, T = 2.27, P = 0.023), and dissatisfaction with boss (male: 0.55 + 0.01, female: 0.51 + 0.01,T = 2.54, P = 0.011) were significantly higher among men, while weekend working hours (male: 6.48 + 0.08, female: 7.21 + 0.07, t = 6.92, P = 0.000) were higher among women. Education of women was significantly higher. Perceived social support from parents and from relatives was significantly higher among women, while perceived social support from partner was higher among men. There was no significant difference according to gender in age, perceived job security, dissatisfaction with work, week day working hours and perceived social support from co-workers.
Table 1 shows the correlation coefficients among depression, well-being, SRH, relative SRH and negative affect, hostility, work related variables, social support from family and education for the male and female sample separately. Negative affect was the most important correlate of BDI, well-being and SRH but hostility correlates more closely with depression than with the other two self-reported health measures. SRH was more closely connected with income and education than with the subjective work related factors; but well-being seems to be more strongly influenced by job security, job control and job related life events than by income. Job related life events, job insecurity and low income were in close connection with depression. Most of the family support variables showed similar connections with BDI, well-being and SRH, as the work related variables; only the perceived support from parents was more important as regards SRH. Age was in closer correlation with depression than with negative affect. SRH decreased and depression increased highly significantly with age.
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In multiple linear models, negative affect was most closely connected with mental health measures in each case; however, the work related factors remained significant as well. In the multiple regression analysis, in both genders, negative affect, hostility and age were most strongly associated with depression, while level of education and income were in weaker inverse correlation with BDI score. (table 2) Among men job insecurity and dissatisfaction with work, while among women dissatisfaction with boss had independent connections with BDI. Job related troubles as life events were significantly connected with BDI in both genders. The above variables explained 39.7% of the total variance of the depression score among men, and 40.3% of total variance among women, while work related factors accounted for 19% of the variance among men and for 5% among women. In comparison to work related factors education explained 6% of male and female variance of BDI scores.
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As far as the WHO well-being score is concerned, negative affect was again most closely connected with it, but education was not among the significant explanatory variables. Hostility showed weaker connection with well-being than with depression among women and no independent connection with well-being among men. (table 3) Control at work, job security and income were important positive correlates of well-being in both genders. Job related life events were negatively correlated with well-being in men as well as in women. Dissatisfaction with work, dissatisfaction with boss and social support from co-workers were significant variables only in men. These variables explained the 17.0% of total variance of well-being for men, and explained 19.5% of the variation among women (table 3).
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Subjective health, i.e. self-rated health shows a partially different picture. Age, education and income explained a considerable part of SRH, both among men and women, but negative affect was also significantly associated with SRH (table 4). In both genders, the most important work related factor was troubles at work in the past 5 years as life event. Weekend working hours were negatively connected with SRH in both genders. Social support from co-workers was in significant connection with male SRH and satisfaction with boss with female SRH. The above variables explained 18.1% among female and 20.1% among male self rated health.
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Furthermore, we tested gender differences in the relations between work characteristics and the mental health outcomes. Relationship between dissatisfaction with the boss and depression was significantly more pronounced among women when compared to men, the age adjusted standardized beta coefficient for the interaction term was 0.049, P = 0.02. Women had a stronger positive correlation between depression and weekend work hours then men, the age adjusted standardized ß-coefficient for the interaction term was 0.147, P = 0.002. We also found a statistically significant gender difference in the relation between perceived social support and mental health outcomes. Women had a stronger negative correlation between perceived help from parents and spouse, and depression. The standardized ß-values for the interaction were, –0.134, P = 0.009 and –0.136, P = 0.014, respectively. Women also had a stronger positive correlation between perceived help from parents and the WHO well-being scale, ß = 0.110, P = 0.032. The rest of the possible interactions did not reach the level of statistical significance.
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Discussion |
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Based on a large national representative survey our study found consistent associations between work stress and self-rated mental and physical health. We analysed the relationships between work related protective and risk factors and self-reported mental and physical health including personality factors such as negative affect and hostility. The study was performed in Hungary, a country undergoing rapid political and economical changes, where these changes led to unfavourable tendencies in rates of middle aged morbidity and mortality 2,3,6,7,14
The recording of positive mental health indicators such as well-being and perceived health together with depressive symptoms enabled us to detect the associations of positive and negative mental health parallel.
As expected, we found a close association between depressive symptoms, negative affect and hostility. Interestingly, hostility was less closely associated with the well-being measure both among men and women. In the case of self-rated health, negative affect was not so important predictor as in the case of depression and well-being, but in both genders negative affect was the second explaining variable after age. In spite of this close association, negative affect and hostility could be clearly differentiated from depression, well-being, and self-rated health.
After adjusting for negative affect and hostility as potential confounding variables the association between work related measures and depressive symptoms, well-being and self-rated health remained significant, depressive symptoms showing the closest connection with work related factors in both genders, more so among men. From work related factors, job insecurity, low control, troubles at work as life events, dissatisfaction with work and with boss, and low social support at work were all significant independent mental health risk factors in both genders, but there were important gender differences.
Concerning well-being, job security and control at work were the most important determinants in both genders. Male well-being was challenged by negative factors such as job related life events, dissatisfaction with the work situation and with boss, while social support from co-workers was positively associated with male well-being.
In the multiple regression model, personal income was less closely connected to well-being than the other subjective job related measures; interestingly, more so among men than among women. This result underlines the importance of working conditions for well-being compared to the objective personal income. According to our results job related factors are equally important predictors of mental health as the well documented social support from family.
Concerning the development of depressive symptoms, we cannot determine simple causal relationships as there is a strong inter-relationship between mental health and social functioning. However, as we controlled our data for negative affect and hostility, we can assume that work related problems are significant risk factors in development of depressive symptoms independently from negative appraisal. Naturally, in such cases there is a circular causality, which shows that people with depressive symptoms have higher risk of work related problems, while people in a state of well-being profit more from work related protective factors. From the point of view of mental health promotion, it is of great importance to prevent the vicious circle of mental health deterioration and insecure working environment.
The concept of work related stress may be important component explaining the health deterioration of Central-Eastern European societies following their transition to a market economy.14,28 One factor might be that work related stress is closely linked to mental health. In the present study, we found that job insecurity, low control in work, low social support from co-workers, dissatisfaction with work and problems with work as life events are strongly associated with the severity of depressive symptoms, well-being and self-rated health in a population based study. In a theoretical model, negative affect (a trait variable) may act as a predisposing factor for negative mental health state in environmental stress situations (e.g. job insecurity, low control, etc.), and coping strategies could be assumed as the (modifiable) mediators between stress and mental health. That is, that those individuals, who react with negative emotions to environmental stress have a higher risk for negative psychological state (e.g. depressive symptoms, etc), but coping strategies strongly influence the outcome. Nevertheless, coping strategies also have their psychosocial background factors such as education, income or social support. Further, longitudinal research is needed for the clarification of the circular inter-relationships of environmental stress, mediating variables (e.g. negative affect, hostility, coping), psychosocial background factors and physical and psychological well-being.
In the last decades, community based follow-up studies demonstrated a significant association between work related stress and cardiovascular mortality and morbidity.13,29–31 Depression is also an independent cardiovascular risk factor. After controlling the results according to smoking and other known risk factors for cardiovascular disorders, the apparently healthy individuals who had elevated depression ratings were more likely both to develop and die of coronary heart disease; this means that not only depressive disorders, but also increased depressive symptomatology is an independent risk factor, especially among men.32,33
Although socioeconomic factors, especially education are closely connected with severity of depressive symptoms and poor SRH, work related factors seem to be more important in respect of mental well-being, especially among men. Although personal income significantly correlated with mental health parameters, it seems to be less important than other protective factors such as job security, control in work, social support at work and satisfaction with work in respect of depression and well-being. There is a balance between psychological and material rewards and efforts, which might determine the work related satisfaction; income is only one factor in this model.12,14
Weekend working hours were negatively connected with SRH in both genders, which show that overwork, especially the lack of weekend recreation is an important risk factor of poor perceived health. The weekday working hours were positively connected with SRH. This connection might show that healthier people work more on weekdays compared to the less healthy people. In contrast to week days working hours, weekend work might be an important risk factor among the active population, which influences negatively the SRH and health perspectives of the population.14
The main limitation of our study was that the analyses were cross-sectional, therefore, we cannot describe causal connections, only cross-sectional associations. Depressive symptoms may have preceded negative appraisals of the environment (i.e. reverse causation), or alternatively, a third underlying cause may have explained both dissatisfaction as well as the onset of depression. Although we corrected the data according to personality trait of negative affect and according to hostility in individuals, this circular causality might play an important role. Interestingly, men were more dissatisfied with their working environment despite their lower level of negative affect and depression. Only hostility was significantly higher among men. For example, dissatisfaction with boss was higher among men, but it was less significantly connected with depression and self-rated health among men than among women.
Another limitation of the study was that we used only a few key indicators to determine work related stress based on our earlier positive research results in this field and on the work stress questionnaire of Rahe and Tolles.27,6,7,14 This study design included neither the original job content questionnaire34,35 nor the original effort-reward imbalance questionnaire.12 In such a large population based study it is difficult to include detailed questionnaires. As we had no objective measurements of the psychosocial work environment, we could not establish whether objective conditions or negative perceptions had caused the perceived high stress at work. As mental health is also a subjective construct, the subjective evaluation of the working situation might be of central importance.
Despite these limitations the results of this large national representative study indicate that independently of negative affect and hostility, a cluster of stressful work-related psychosocial conditions accounts for a substantial part of variation in the mental health of the economically active male and female population in Hungary. Despite the possibility of circular causality, there is a need for occupational mental health services at work places which might prevent job stress related mental and physical health deterioration in the active population.
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This study was supported by the National Research Fund (OTKA) projects No T-32974 (2000), OTKA TS-40889 (2002) and TS-049785 (2004), Scientific School Grants and NKFP 1/002/2001 and NKFP 1b/020/2004. I.J. was supported by the FAS post doc grant 2006-1146, Sweden. The authors would like to thank to the other members of the ‘Hungarostudy 2002’ team (Csilla Raduch, János Réthelyi, Csilla Csoboth, Éva Susánszky, Zsuzsa Szántó, György Gyukits, János L
ke, Andrea Ódor, Katalin Hajdu, András Székely, László Sz
cs, Sándor Rózsa), to the network of district nurses for the home interviews, for Professor András Klinger for the sampling procedure, and for the National Population Register for the selection of the sample.
Key points
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References |
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