Ever since 1976, when his doctoral thesis at the Massachusetts Institute of Technology introduced his demand-control theory, Robert Karasek, PhD, has been a trailblazer in demonstrating how work stress results in compromised health. He is currently with the Danish National Institute of Occupational Health and Safety, on sabbatical from the Department of Work Environment at the University of Massachusetts, Lowell. (5,6,7)

Q: Did you encounter skepticism when you introduced the demand-control model?

A: Of course there were skeptics. Many American scientists were associating job stress with Type A behavior at that time. Other stress researchers were using a single dimensional model that said that workloads and environmental demands led to high stress.

Q: Your approach is more complex?

A: The model has two dimensions. One relates to the demands of the work, particularly the mental and psychological demands. The other measures the control the individual has over the demands in that situation.

There are two hypotheses. The first has to do with what most people would call bad stress. When the demands are high and the individual has little control over them, the negative consequences of strain or stress develop.There is increased risk of physical illness and diverse negative emotional states.

The second hypothesis deals with what some call good stress: as long as the job demands are not too overwhelmingly high and there are high levels of individual job control, there usually are feelings of satisfaction, motivation, and possibilities of learning new things - that is, challenging work - even new coping strategies that could prevent illness.

Later, social support was added to the model as a third independent dimension. So our current job content questionnaire measures psychological and physical demands of the job, the individual's decisional latitude, the level of job insecurity, and social support.

Q: How widely has the model been used?

A: Japan and six European countries now are using it for a study of job stress, heart disease, and absenteeism, with 40,000 subjects in each case. Nothing on this scale has ever been done in the United States. Indeed; there has been no national survey of job characteristics and well-being for over 20 years in the U.S. This is done every several years in some European countries.

Q: What other studies have there been abroad and in the U.S.?

A: Since 1981, there have been over 70 studies. There have been 36 heart studies in the U.S., Canada, and Scandinavia, and 25 of them found significant association with heart disease. That's substantial empirical support.

Q: What about other illnesses and disorders?

A: Many studies have shown significant ties to absenteeism, mental disorders, and immune system disorders. Also musculoskeletal problems, such as repetitive strain injuries, which usually don't have only physical causes. Psychosocial factors also play a large role.

Q: Can the model measure job stress of everyone, from factory workers to physicians?

A: Yes, it is applicable to all occupations. The assembly line worker is one of the most compelling images of the 20th century - an individual with low decision latitude and a high-intensity job. It evokes that Charlie Chaplin image of a frantic speed-up. That image propelled in part the development of our model.

The model also measures demand-control dimensions in high status jobs like those of physicians. Many of them now are experiencing transformations that undermine their job control and use of personal judgment that are critically important to their satisfaction in their work and to both their patients' health and their own.

Q: What's the solution?

A: Certainly, there are individually-based solutions which provide short-term stress relief, but we need to begin thinking about long-term, social solutions. We are seeing huge amounts of mental strain, heart disease, immune system disorders, musculoskeletal disorders, absenteeism, and other problems. They involve enormous human suffering and huge costs to modern society. These are political-scale issues, and they should be part of our political discussion of how our society and the economy should work. But they are not, certainly not in the United States, although this discussion is now beginning in northern Europe and Japan.

Q: Should the workplace change its behavior?

A: There are ways to improve workers' control over their situations, their pace of work, their tools, and the methods they use in the workplace. For one thing, it's important to have open communication. This requires an organizational culture that fosters trust, and of course trust doesn't come from slogans - it comes from demonstrated behaviors at the company.

Incentives of various kinds could be given to companies to set up programs for work groups to discuss their sources of stress in the workplace and how to take them into account. The "health circles" in some German workplaces do this very effectively. We should try them here. Some people say we can't listen to Europe, but I think we are hopelessly penalizing ourselves when we say this. We are perfectly willing to adopt management strategies that increase job stress from any country in the world, but when it comes time to protect ourselves from job stress we say, "No, that can't work here."

Employees also need to feel that the company can be influenced by social and political processes in which they are stakeholders, not just by decisions of financial powers who may decide to close down the factory tomorrow.

Q: You mentioned social support on the job. How would that work?

A: First, good collaboration among co-workers and a feeling of trust with curbs on harassment of different types. Secondly, a value system that goes beyond marketplace values. For example, in the health care system, doctors and nurses who are trained to take good care of patients, not just to cut costs. This is the value system that dominated, of course, before privatization of health care.

Q: Would productivity have to suffer?

A: I would say that improved health is consistent with improving productivity, but only of a certain kind - productivity associated with increased human capabilities, increased skill, increasing effective collaboration. These are indeed the productivity areas of the future. Witness, the Internet; innovative product development; networked production; education; and health care in its true forms. Thus, there are large-scale social solutions to stress problems which could work.

Interview #2:

'Curing "Sick" Work Sites'

Mark Cullen, MD, is director of the Occupational and Environmental Medicine Program at Yale University's School of Medicine. He is currently laying the scientific groundwork that his team will use to create healthier work environments in the plants of a major multinational metal producing corporation.

Q: How can you design a work environment that is low in job stress?

A: None of us yet knows exactly what makes a work environment ideal, safe, and healthful, but many of us are trying to put a name to it, so we can begin to explore it. What's clear is that the focus should be at the level of the organization, because you're trying to understand something that's bigger than any one individual.

Q: Is it that unprecedented? Do you have examples to build on?

A: It's a lot like a related area of research that has had more attention - neighborhoods that are supportive or detrimental to health. You usually start off by taking a sample of people in the neighborhood, asking them about how supportive and trusting their neighbors are. "Would your neighbor help you out in a fix?" "Would you trust your neighbor to call you if your kid wasn't in school one day?" And you go on from there.

Q: So in the workplace you start by measuring trust and social support?

A: That could be one starting point, but there are others. For example "surrogate" approaches, such as looking at job appraisals rather than the environment itself. This comes from the idea that employees will be rated favorably by their supervisors in work environments where people have a high level of perceived control over their jobs and an appropriate level of work demand. In work environments that are very autocratic, you are likely to see many unfavorable ratings.

Of course, we also look into the environment itself to see what may be either a protective factor or an accelerator of bad stress. We have some strong presentiments about what it is about a work environment that might be good for your health, but from a scientific point of view, it's all still quite untested.

Q: When might the testing start?

A: I can't tell you in detail, but one of my biggest "patients" is a large multinational with many locations in this country and around the world that all perform exactly the same kind of work. When you visit the workplaces they seem pretty similar, and the product looks very similar, yet the cost of insuring the workers, just among the North American plants, is quite different from location to location because the health of the employees is different from one site to another.

The workers are all roughly the same age, the same social class, doing the same kinds of work. Their jobs all would appear to be the same on paper. They're all reasonably well paid, and they all have universal access to health care with wonderful benefits. So why does it cost $3,000 a year to insure somebody in one location and $8,000 in another?

Q: Can you tell what makes the difference?

A: We think it has something to do with the whole relationship that exists between employees and their work environment. We think some of the environments are life support structures for the people lucky enough to be working in them. They have absolutely low rates of serious chronic diseases. Conversely, I think there are some facilities where the risk of disease appears to be no better than in the population as a whole, and perhaps even worse.

Q: What can you do about the facilities falling behind?

A: I think our challenge is to figure out what it is we can change. We can't triple the workers' income or quickly modify all their good or bad habits or change their diets. But we can educate them and make the work environment different, and that's part of the thrust of this whole research line.

The idea is not new. What's new is the way we are going to do it. First we'll try to do the science. If the science works, we'll try to do the interventions to make things better.

Of course, I'm very interested in how people internalize their environmental experience. I'm very interested in the hormonal levels and other physiological correlates of work stress. But frankly, from a preventive health point of view, I'm more interested in what we can do to make these environments less stressful and allow people to have better control over those environments.

Women: Taking the Stress Home

Women are more likely than men to bring job stress home, studies have shown. Science is starting to figure out why.

Karen Messing, PhD, an ergonomist and geneticist at the University of Quebec in Montreal, and her colleagues have conducted extensive studies of the problems of women working in cookie factories, as x-ray technicians, on hospital cleaning staffs, as elementary school teachers, as telephone operators, and in chicken-processing plants.(3,10,11) These studies show that women's jobs often involve a large number of what may look like insignificant difficulties but that add up to a high level of job stress, higher than that associated with men's jobs.

"Women's higher job stress at home may be a combination of less job control and more at-home responsibilities - which means women are thinking more about their life at home while they're on the job and more conscious of their jobs when they're at home," she says. "Building those bridges is the number one problem reported by working women who have children, and it's getting close to the top for men, too."

It's not just that women have more responsibility for child care and housekeeping. Messing says women's jobs are also more likely to be rigidly structured, so many of them can't take the time to make a doctor's appointment or find a sitter when child care arrangements falter.

Society doesn't judge women entirely on what they do at work, whereas men's traditional sense of self is based on conducting their work life well and being a good provider. Thus, women generally don't feel "the terrible pressure that men feel to ensure economic survival with their jobs," Messing says. "I don't think there are many women who commit suicide because they've been fired or who go around shooting everybody up."

Stressful Numbers:

More than four in 10 American workers (44 percent) are either "very" or "extremely" concerned about stress from work demands, and 88 percent of them say the amount of stress they feel on the job is an important factor, according to a national poll of 1,000 workers.

Ability to balance work and family is the number one priority cited by those surveyed - more important than job security, quality of working environment, and relationships with co-workers and supervisors.

Eighty-seven percent of the workers reported they are concerned with getting enough sleep, with 60 percent saying they are very or extremely concerned about it.

The survey, conducted from February 5 to 27, 1999, by economists at Rutgers University's John J. Heldrich Center for Workforce Development, also found:

• 46% of U.S. workers spend more than 40 hours a week at work, and 18% work more than 50 hours a week.
• 45% say they have to work overtime with little or no notice.
• 49% say on-site child care is important, but only 12% of employers offer the benefit.
• 80% say they would enroll in training or education if offered by their employer.

For more survey data: http://www.heldrich.rutgers.edu/news.html

The Research:

1. Bosma H, Marmot MG, et al. (February 22, 1997). "Low Job Control and Risk of Coronary Heart Disease in Whitehall II Study." British Medical Journal, 314(7080): 558-65.
2. Bosma H, Siegrist J, Marmot MG. (1998). "Two Alternative Job Stress Models and the Risk of Coronary Heart Disease." American Journal of Public Health, 88(1): 68-74.
3. Dumais L and Messing K. (1993). "Make Me a Cake as Fast as You Can." Work, Employment and Society, 7(3): 363-382.
4. Ferrie JE, Marmot MG, et al. (January 1998). "An Uncertain Future: the Health Effects of Threats to Employment Security in White-collar Men and Women." American Journal of Public Health, 88(7) 1030-6.
5. Karasek RA, et al. (October 1998). "The Job Content Questionnaire: an Instrument for Internationally Comparative Assessments of Psychosocial Job Characteristics." Journal of Occupational Health Psychology, 3(4):322-355.
6. Karasek RA and Theorell T. (1992). "Healthy Work: Stress, Productivity and the Reconstruction of Working Life." Ingram Price.
7. Karasek RA. (1999, in press). "The New Work Organization, Conducive Production, and Work Quality Policy." in M Marmot (ed.) Labor Market Changes and Job Insecurity: A Challenge for Social Welfare and Health Promotion, pp. 78-105, World Health Organization, Copenhagen.
8. Lundberg U and Frankenhaeuser M. (April 1999). "Stress and Workload of Men and Women in High-Ranking Positions." Journal of Occupational Health Psychology, 4(2): 142-151.
9. Marmot, MG. (1998). "Improvement of Social Environment to Improve Health." Lancet, 331: 57-60.
10. Messing K, et al, (March 1998). "Sex as a Variable Can Be a Surrogate for Some Working Conditions." Journal of Occupational Environmental Medicine, 40: 250-260.
11. Messing K, et al. (January 1997). "The 120-second Minute: Using Analysis of Work Activity to Prevent Psychological Distress Among Elementary School Teachers." Journal of Occupational Health Psychology, 2(1): 45-62.

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The Center for the Advancement of Health is a health policy institute founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation. It works to incorporate into standard health care those proven strategies that recognize and respond to how profoundly our attitudes, emotions, behaviors, social relations and economic status impact the onset of some diseases, the progression of many and the management of nearly all. Facts of Life is funded in part by the Fetzer Institute.

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