The focus of this model is on reciprocity of exchange in occupational life where high-cost/low-gain conditions are considered particularly stressful. Variables measuring low reward, in terms of low status control (e.g., lack of promotion prospects, job insecurity) in association with high extrinsic (e.g., work pressure) or intrinsic (personal coping pattern, e.g., high need for control) effort independently predict new cardiovascular events in a prospective study on blue-collar men. Furthermore, these variables partly explain prevalence of cardiovascular risk factors (hypertension, atherogenic lipids) in 2 independent studies. Studying adverse health effects of high-effort/low-reward conditions seems well justified, especially in view of recent developments of the labor market. Remarkable progress has been achieved during the past 20 years in the study of associations between work and health in general, and between psychosocial hazards at work and adverse health outcomes in particular (e.g.,

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SummaryBackgroundPublished work assessing psychosocial stress (job strain) as a risk factor for coronary heart disease is inconsistent and subject to publication bias and reverse causation bias. We analysed the relation between job strain and coronary heart disease with a meta-analysis of published and unpublished studies.MethodsWe used individual records from 13 European cohort studies (1985–2006) of men and women without coronary heart disease who were employed at time of baseline assessment. We measured job strain with questions from validated job-content and demand-control questionnaires. We extracted data in two stages such that acquisition and harmonisation of job strain measure and covariables occurred before linkage to records for coronary heart disease. We defined incident coronary heart disease as the first non-fatal myocardial infarction or coronary death.Findings30 214 (15%) of 197 473 participants reported job strain. In 1·49 million person-years at risk (mean follow-up 7·5 years [SD 1·7]), we recorded 2358 events of incident coronary heart disease. After adjustment for sex and age, the hazard ratio for job strain versus no job strain was 1·23 (95% CI 1·10–1·37). This effect estimate was higher in published (1·43, 1·15–1·77) than unpublished (1·16, 1·02–1·32) studies. Hazard ratios were likewise raised in analyses addressing reverse causality by exclusion of events of coronary heart disease that occurred in the first 3 years (1·31, 1·15–1·48) and 5 years (1·30, 1·13–1·50) of follow-up. We noted an association between job strain and coronary heart disease for sex, age groups, socioeconomic strata, and region, and after adjustments for socioeconomic status, and lifestyle and conventional risk factors. The population attributable risk for job strain was 3·4%.InterpretationOur findings suggest that prevention of workplace stress might decrease disease incidence; however, this strategy would have a much smaller effect than would tackling of standard risk factors, such as smoking.FundingFinnish Work Environment Fund, the Academy of Finland, the Swedish Research Council for Working Life and Social Research, the German Social Accident Insurance, the Danish National Research Centre for the Working Environment, the BUPA Foundation, the Ministry of Social Affairs and Employment, the Medical Research Council, the Wellcome Trust, and the US National Institutes of Health.

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OBJECTIVES: This study examined the association between two alternative job stress models-the effort-reward imbalance model and the job strain model-and the risk of coronary heart disease among male and female British civil servants. METHODS: The logistic regression analyses were based on a prospective cohort study (Whitehall II study) comprising 6895 men and 3413 women aged 35 to 55 years. Baseline measures of both job stress models were related to new reports of coronary heart disease over a mean 5.3 years of follow-up. RESULTS: The imbalance between personal efforts (competitiveness, work-related overcommitment, and hostility) and rewards (poor promotion prospects and a blocked career') was associated with a 2.15-fold higher risk of new coronary heart disease. Job strain and high job demands were not related to coronary heart disease; however, low job control was strongly associated with new disease. The odds ratios for low job control were 2.38 and 1.56 for self-reported and externally assessed job control, respectively. Work characteristics were simultaneously adjusted and controlled for employment grade level, negative affectivity, and coronary risk factors. CONCLUSIONS: This is apparently the first report showing independent effects of components of two alternative job stress models-the effort-reward imbalance model and the job strain model (job control only)-on coronary heart disease.

This short version of the ERI questionnaire reveals satisfactory psychometric properties, and can be recommended for further use in research and practice.

Medical Research Council, Economic and Social Research Council, European Union New and Emerging Risks in Occupational Safety and Health research programme, Finnish Work Environment Fund, Swedish Research Council for Working Life and Social Research, German Social Accident Insurance, Danish National Research Centre for the Working Environment, Academy of Finland, Ministry of Social Affairs and Employment (Netherlands), US National Institutes of Health, British Heart Foundation.

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