Original articleEffort–reward imbalance and relational injustice at work predict sickness absence: The Whitehall II study
Introduction
Sickness absence is an important occupational problem that has a marked impact on productivity and on costs of health insurance. In the United Kingdom, total days lost due to sickness absence are estimated to cost the economy over £13 billion and about 6.8 working days are lost per employee [1]. In the United States, the total days lost due to sickness absence are estimated to represent 3–7% of the regularly scheduled workdays [2], [3], signifying a loss of approximately 550 million workdays each year for the industry [4]. These figures are compatible with those in other western countries [5]. Sickness absence has also been shown to be a good indicator of overall health status. In particular, long spells of sickness absence (>7 days) are closely associated with ill health, medical conditions, and subsequent mortality [6], [7], [8]. Not surprisingly, efforts to identify modifiable determinants of sickness absence are increasing, and in this research, psychosocial factors at work have received growing attention. However, prospective empirical evidence for associations between psychosocial factors at work, as defined by conceptual models that identify its stressful components, and sickness absence is still scarce.
Two such models, the effort–reward imbalance model [9] and the model of organizational justice (and specifically its component of relational justice) [10], [11] are particularly promising in this context as they have been shown to predict reduced health as well as reduced commitment and motivation towards work.
The effort–reward imbalance model of work stress applies the notion of reciprocity between efforts and rewards to the workplace setting. According to this model, failed reciprocity in terms of high efforts and low rewards elicits strong negative emotions in combination with sustained autonomic activation and has adverse long-term consequences for health [12]. In addition, recurrent reward frustration reduces commitment and motivation of employees and increases withdrawal behavior [13]. Rewards may include money, career opportunities, including job security, and the experience of esteem and recognition for achievements. Effort–reward imbalance at work is frequent in employees with limited alternative choice in the labour market, in those exposed to heavy competition, and in overly committed people.
The organizational justice model concerns fairness of treatment at work and has also been linked to health and motivation [14], [15], [16], [17], [18]. An important aspect of justice, relational justice, involves the extent to which supervisors consider employees' viewpoints, are able to suppress personal biases, and take steps to deal with subordinates in a fair and truthful manner. Low justice in such managerial treatment is assumed to reduce employee motivation and cooperation and increase psychological distress and risk of stress-related morbidity.
This article compares the relative contribution of two work stress models, effort–reward imbalance and organizational (relational) justice, towards predicting sickness absence. Using a longitudinal study design, with data from the Whitehall II cohort of British civil servants, we explore these associations separately for short (≤7 days) and long (>7 days) spells of sickness absence, as long spells of sickness absence have been found to be stronger predictors of mortality and morbidity [7], [8] and the risk factors may also be different for short and long spells of absence [19]. Furthermore, because the health effects of working conditions may differ in the short and long term, we study immediate and longer term effects of these work stress models on short and long sickness absence spells, using absence data from two follow-up periods. Importantly, gender-specific analyses of these associations are provided.
Section snippets
Study participants
Nonindustrial civil servants aged 35–55 years working in the London offices of 20 civil service departments were invited to participate in the Whitehall II study [20]. Between 1985 and 1988, participants attended a screening examination and completed a self-report questionnaire (Phase 1). Altogether 10,308 civil servants (6895 men and 3413 women) were examined, giving an overall response rate of 73%. Ethical approval for the Whitehall II study was obtained from the University College London
Baseline characteristics
This article includes the 5860 men and 2540 women with measures of effort–reward imbalance and relational justice at baseline, sickness absence data in 1985–1989, and complete data on baseline covariates. Men and women in administrative grades were more likely to report high effort–reward imbalance than their counterparts in clerical/support grades (Table 1). The 1908 participants not included in the analyses tended to be slightly older, males, and from the lower employment grades. Relational
Discussion
The two measures of work stress, effort–reward imbalance and relational injustice, predicted subsequent rates of sickness absence in models adjusted for socioeconomic status and baseline health. Findings were of a similar order of magnitude for short spells and long spells of sickness absence in the first (immediate) period for both work stress measures. In general, results were also consistent in the immediate and later sickness absence periods. Associations were broadly similar for men and
Acknowledgments
The Whitehall II study has been supported by grants from the Medical Research Council; British Heart Foundation; Health and Safety Executive; Department of Health; National Heart Lung and Blood Institute (HL36310), National Institutes of Health (NIH): National Institute on Aging (AG13196), NIH; Agency for Health Care Policy Research (HS06516); and the John D. and Catherine T. MacArthur Foundation Research Networks on Successful Midlife Development and Socioeconomic Status and Health. M.K., also
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