Subjective health complaints: is coping more

Work & Stress

ISSN: 0267-8373 (Print) 1464-5335 (Online) Journal homepage: http://www.tandfonline.com/loi/twst20

Subjective health complaints: Is coping more important than control? Hege R. Eriksen & Holger Ursin To cite this article: Hege R. Eriksen & Holger Ursin (1999) Subjective health complaints: Is coping more important than control?, Work & Stress, 13:3, 238-252, DOI: 10.1080/026783799296048 To link to this article: http://dx.doi.org/10.1080/026783799296048

Published online: 26 Nov 2010.

Submit your article to this journal

Article views: 174

View related articles

Citing articles: 29 View citing articles

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=twst20 Download by: [Universitetsbiblioteket i Bergen]

Date: 04 December 2015, At: 02:48

w o r k & s t r e s s , 1999, v o l . 13, n o . 3 238± 252

Subjective health complaints : is coping more important than control ? HEGE R. ERIKSEN* and HOLGER URSIN Downloaded by [Universitetsbiblioteket i Bergen] at 02:48 04 December 2015

Department of Biological and Medical Psychology, University of Bergen, Aarstadveien 21, N-5009, Norway Keywords : Stress ; Coping ; Subjective health complaints ; Musculoskeletal pain ; Health symptoms ; Demand} control model. The in¯ uence of psychological demands in a work situation on subjective health complaints has been investigated. A demand } coping model has been developed and compared with the traditional demand } control model. The new model is based on the notion that all stressors (loads) are ® ltered by coping (positive response outcome expectancies) and defence mechanisms (stimulus distortion) before they gain access to the response system. A total of 1060 employees (401 men and 659 women) working in the Norwegian postal service ® lled out questionnaires on psychological demands, control, coping (Utrecht Coping List), job stress, and subjective health complaints (Subjective Health Complaint Inventory). Subjective health complaints were found to depend more on combinations of demands and coping than on demands and control. Individuals with high demands } low coping had most health problems, and those with low demands } high coping had the lowest level. Individuals with high demands } high coping had high reports of job stress, but not high levels of health problems. Individual coping mechanisms were more important for subjective health than were organizational factors.

1. Introduction The aim of this paper was to study whether the main psychological mechanisms used to manage stress in working life, coping and control, have any signi® cant in¯ uence on health. The study of health in occupational medicine has been moving in new directions. There is greater emphasis on psychosocial work-related stress factors than on the traditional physical sources of disease. There is also more emphasis on `non-speci® c symptoms’ (Spurgeon, Gompertz, and Harrington, 1996), or subjectively reported health problems (Eriksen, Svendsrù d, Ursin, and Ursin, 1998), than on traditional disease. Subjective health complaints are important for theoretical as well as practical reasons. It may be argued that absence of such complaints oVers an operationalizat ion of the WHO positive health concept (World Health Organization, 1991). However, more important is the very high prevalence of these complaints, especially in women (Eriksen et al., 1998). Such complaints are frequent causes of absenteeism and sickness certi® cation, in particular musculoskeletal pain (Tellnes, Svendsen, Bruusgaard, and Bjerkedal, 1989). Subjective health complaints also seem to have predictive value for the prognosis in many somatic conditions, even for survival when other known health risk factors are accounted for (for a review see Idler, and Benyamini, 1997). Subjective health complaints have been related to physical as well as psychosocial work stress factors. Back pain, for example, has been related to physical work load (see Burdorf, and Sorock, 1997 for a review), and neck and shoulder pain have been related to repetitive work practices (Veiersted, and Westgaard, 1993). However, physical work load does not * Author for correspondence. e-mail : hege.eriksen!

psych.uib.no.

Work & Stress ISSN 0267-8373 print } ISSN 1464-5335 online ’ 1999 Taylor & Francis Ltd http: } } www.tandf.co.uk } journals} tf } 02678373.html

Downloaded by [Universitetsbiblioteket i Bergen] at 02:48 04 December 2015

Demands, coping and control

239

explain all the complaints. It is now generally accepted that `the social organizational characteristics of work, and not just physical hazards, lead to illness and injury ’ (Karasek, 1997, p. 1± 134, 6). In addition, psychological emotional loads seem to be the most frequently reported stress stimuli, and the reason for most stress responses (Levine, & Ursin, 1991). In the analyses of potential psychosocial factors as modi® ers or direct causes of ill health, there are essentially two traditions. One tradition emphasizes the formal or òbjective ’ work conditions, and the other focuses on the stress management potential of each employee. The demand } control model is one of the most in¯ uential òbjective ’ models (Karasek, and Theorell, 1990).It is the combination of psychological demands, task control and skill use at work that predicts stress-related ill health and behavioural correlates of work. Jobs with high demands, low control, and low social support carry the highest risk of illness and disease. Low psychological demands and high levels of control carry the lowest risk. Jobs with high psychological demands and high control, and low psychological demands and low control, carry an average risk (Karasek, 1997). The model predicts disease, especially related to cardiovascular disease (Karasek, and Theorell, 1990; Schnall, Landsbergis, and Baker, 1994), and it is particularly the control dimension that is the most robust predictor (Theorell, and Karasek, 1996). Application of this model to musculoskeletal problems suggests a relationship, but fails to provide conclusive evidence to support the model (Bongers, de Winter, Kompier, and Hildebrandt, 1993). The newer tradition emphasizes individual stress management, coping abilities, and subjective feelings of being in control or being able to cope (Theorell, and Karasek, 1996). In this paper the authors have developed a demand } coping model, where the `control ’ axis has been replaced by a `coping ’ axis. The essential element of this model is that `coping ’ refers to the expectancy of being able to cope, not to any particular strategy or formal aspect of the work situation. Another characteristic of this model is that it builds on a pathophysiologi cal model and animal research demonstrating why these dimensions may have health consequences (Levine, and Ursin, 1991). It seems to be a consensus that the physical demands and psychological characteristics that produce a stress response have nothing in common. All stimuli are appraised (Folkman, and Lazarus, 1991) or ® ltered (Levine, and Ursin, 1991) before they gain access to the response system. The main `® lters’ are related to response outcome expectancy and stimulus expectancy (Bolles, 1972; Ursin, 1988). It is the individual’s experience of the demands and the expectancies of the outcome, which determine whether the demands will cause stress responses, which, again, may cause illness and disease in man and animals (Levine, and Ursin, 1991). Within this cognitive tradition, and in this paper, coping is de® ned as positive response outcome expectancies (Ursin, 1988). This means that the individual expects that he or she will be able to handle the situation with a positive result. In these situations, there is a low level of subjective health complaints (OlV, Brosschot, and Godaert, 1993; Eriksen, OlV, and Ursin, 1997), and low levels of psychophysiolog ical, psychoendocrine, and psychoimmune changes (Ursin, 1998). In situations where the individual can not develop this positive outcome expectancy sustained activation may occur, producing physiological, endocrine, and immune changes. Two terms are used to cover these expectancies. Helplessness is when there is established an expectancy that there is no relationship between the available responses and the environment (Overmier, and Seligman, 1967; Ursin, 1988; Levine, and Ursin, 1991). The individual expects that no matter what he or she does, he or she has no in¯ uence on the result. Hopelessness means that the individual has established a negative response outcome expectancy : all available responses bring a negative outcome (Ursin, 1988; Levine, and


240

H. R. Eriksen and H. Ursin

Ursin, 1991). Here the individual expects that no matter what he or she does to handle the situation, there will be a negative result, and it is his or her fault as well. In animal research similar situations may produce gastric ulcerations (Murison, and Overmier, 1990), cardiovascular pathology (Knardahl, 1983) and changes in brain metabolism (Coover, Ursin, and Murison, 1983). Unfortunately, there is no consensus or consistent use of the terms stress and coping in the literature. Coping often refers to the strategies or style used (Ways of coping ’, Lazarus, and Folkman, 1991). The generalized response outcome expectancy is diYcult to operationalize. In this paper the authors will use one particular factor from standard questionnaires for this dimension. Stress is also used inconsistently, sometimes referring to the stimulus, sometimes to the experience, and sometimes for the response (Levine, and Ursin, 1991). We have used standard job stress questionnaires for this variable, with the inherent ambiguity in the stress term. Previous literature on the psychological mechanisms involved in the relationship between work and health deal mostly with cardiovascular disease (Siegrist, 1996; Theorell, and Karasek, 1996); or sickness absence (North, Syme, Feeney, Shipley, and Marmot, 1996). How important is the individual feeling of coping for subjective health complaints in an ordinary working population ? We have attempted to compare two models, one emphasizing the more òbjective ’ control mechanisms available to the individual, and one emphasizing the more `subjective ’ type of response outcome expectancies.

2. Method 2.1. Participants and procedure A total of 1060 employees (mean age 5 37.4 years ; 95%CI 5 36.8± 38.2),consisting of 401 men (mean age 5 35.7 years ; 95%CI 5 34.6± 36.8) and 659 women (mean age 5 38.5 years ; 95%CI 5 37.7± 39.3) working in the Norwegian postal service participated in the study. Of these 521 were working with manual labour } transport, 168 in administrative positions, 276 in front desk } clerical positions, and 67 in management. The response rate was 68%. The data presented represent part of a screening process of employees participating in a randomized controlled intervention study, `Health in working life ’ (Mikkelsen, Saksvik, Eriksen, and Ursin, 1998b). The screening was conducted in 1996 and 1997. All participants volunteered for the study, and were informed about their rights according to Norwegian laws and the Helsinki declaration.

2.2. Instruments All data were measured by Norwegian versions of questionnaires, and included a broad range of factors, including age, gender, number of regular and extra hours of work, shiftwork, and education, in addition to the items in the speci® c questionnaires described below. If there were less than 50% of missing values within sub scales, mean values of the other items within that scale for that individual were computed, otherwise the score on that scale was treated as missing. 2.2.1. Psychological demands : Psychological demands were measured by ® ve questions with the short Swedish version (Theorell, Perski, Akerstedt, Sigala, Ahlberg-Hulte! n, Svensson, and Eneroth, 1988) of the psychological demands dimension from the demand } control model (Karasek, and Theorell, 1990). The questions were scored on a four-point scale, yielding a sum score for psychological demands (a 5 .70). High demands


241

are related to working fast and hard, excessive work, insuYcient time to work, or con¯ icting demands. High score represents high demands.


2.2.2. Control : Control (decision latitude) was measured by six questions with the short Swedish version (Theorell et al., 1988) of the decision latitude dimension from the demand } control model (Karasek, and Theorell, 1990) (a 5 .80). Four items refer to skill discretion (a 5 .74), and two items to decision authority (a 5 .81), scored on a four-point scale. The questions are related to creativity, skills, task variety, learning new things, and amount of repetitive work. High score represents high control. 2.2.3. Job stress : This was measured by 19 questions from the Cooper job stress questionnaire (Cooper, 1981), scored on a six-point scale, yielding four sub scales on the amount of perceived job stress (Endresen, Ellertsen, Endresen, Hjelmen, Matre and Ursin, 1991). High scores represent high levels of perceived stress. Communication (8 items, a 5 .88) is related to lack of communication and in¯ uence, con¯ icts with management, co-workers, and diVerent groups of employees. Leadership (4 items, a 5 .66) is related to the employees’ relationship to management and subordinates, feeling of being undervalued, and amount of pay. Workload (3 items, 5 .75), as sources of perceived stress is related to workload, time pressure and deadlines, and work-related demands in¯ uencing private life. Finally a factor, `Relocation’ (4 items, a 5 .61) is a mixed factor related to perceived stress caused by promotion prospects, relocation, managing people, and taking work home. 2.2.4. Coping : This was measured by the Instrumental Mastery Oriented Coping factor from the CODE (Eriksen et al., 1997), which is based on the Utrecht Coping List (UCL ; Schreurs, Tellegen, Van De Willige, and Brosschot, 1988; Schreurs, Van De Willige, Brosschot, and Grau, 1993) and a reduced Defense Mechanisms Inventory (DMI ; Gleser, and Ihilevich, 1969). The UCL consists of 47 statements about how one would cope with problems, scored on a four-point scale, yielding seven diVerent sub scales on active problem solving, palliative responses, avoidance and passive expectancy, seeking social support, depressive reaction pattern, expressing emotions, and comforting cognitions. Two coping factors are scored, based on previous factor analysis of the CODE (Eriksen et al., 1997). Only data from the Instrumental Mastery Oriented Coping factor (a 5 .80) is reported in this paper (OlV et al., 1993; Eriksen et al., 1997). Instrumental mastery oriented coping (active problem solving, avoidance and passive expectancy, and depressive reaction pattern) re¯ ects an instrumental, active, goal-oriented coping style with strategies such as direct intervention, considering diVerent solutions to the problem, and considering the problem to be a challenge. Individuals with high scores are not overwhelmed by the problem, or resigned to the situation, and do not avoid diYcult situations, but are optimistic about the outcome. This factor has been chosen as the main operationalizat ion of the `response outcome expectancy ’ ® lter, where coping is de® ned as positive outcome expectancy. The negative pole of this factor relates to no or negative response outcome expectancies (helplessness, hopelessness). 2.2.5. Subjective health complaints : Subjective health complaints were measured by 29 items on subjective somatic and psychological complaints experienced during the last 30 days, using the Subjective Health Complaint Inventory (SHC, Eriksen, Ihlebñ k, and Ursin, 1999) also known as Ursin’s Health Inventory (Ursin, Endresen, and Ursin, 1988). Severities were scored on a four-point scale, normally yielding ® ve sub scales on allergy (a 5 .51), ¯ u (a 5 .67), musculoskeletal pain (headache, neck pain, upper back pain, low

242



back pain, arm pain, shoulder pain, migraine, and leg pain) (a 5 .77), `pseudoneurology ’ (American Psychiatric Association, 1994) (palpitation, heat ¯ ushes, sleep problems, tiredness, dizziness, anxiety, and depression) (a 5 .70), and gastrointestina l problems (heartburn, epigastric discomfort, ulcer} non-ulcer dyspepsia, stomach pain, gas discomfort, diarrhoea, and constipation) (a 5 .66). Only severities on the last three sub scales were used in the data analyses due to low frequencies on allergy, and the instability on ¯ u. A score above 3 on the sub scales was regarded as a high score.

2.3. Analyses SPSS 7.5.1 for Windows was used for the statistical analyses. Multiple regression analysis with musculoskeletal pain, pseudoneurology, and gastrointestina l problems as dependent variables were used to identify the most important associations in the material. In order to control for age, this variable was entered ® rst, then the stepwise procedure was used. When testing prede® ned models (demand } control and demand } coping), the enter method was used. Logistic regression was used to calculate odds ratios of having high scores on musculoskeletal pain, pseudoneurology, and gastrointestina l complaints. Median scores on psychological demands and control were used to assign participants to four groups (demand } control model) : low strain jobs (low demands-high control), active jobs (high demands-high control), passive jobs (low demands-low control), high strain jobs (high demands-low control). Median scores on psychological demands and instrumental mastery oriented coping were used to assign participants to four groups in the demand } coping model, using the same terminology : low strain individuals (low demands-high coping), active individuals (high demands-high coping), passive individuals (low demands-low coping), and high strain individuals (high demands-low coping). Low strain jobs } individuals were assigned an odds ratio of 1 of having high scores on subjective health complaints to express the risk in the other groups. The diVerences in degree of complaints and job stress between the four demand } control and demand } coping groups, were examined by MANOVA analysis (Wilks’ k ), and analysis of between-subjects eVects. On the analysis of degree of complaints, musculoskeletal complaints, gastrointestina l problems and pseudoneurology were entered as dependent variables. On the analysis of degree of job stress, communication, leadership, relocation, and work load were entered as dependent variables. Post hoc tests were done using least signi® cant diVerence (LSD), and p value set to .05. DiVerences in degrees of freedom are due to missing data.

3. Results There was a high prevalence of subjective health complaints. Musculoskeletal pain was highest, reported by 71% (n 5 283) of the men and 85% (n 5 562) of the women. `Pseudoneurology ’ was reported by 61% (n 5 246) of the men and 73% (n 5 479) of the women. Gastrointestina l problems were reported by 46% (n5 184) of the men and 51% (n 5 338) of the women (see table 1 for mean scores).

3.1. Multiple regression The Karasek demand } control model, with psychological demands, intellectual discretion, and authority over decisions, showed very modest values : 4% for men and 2% for women for musculoskeletal pain ; 4% and 5%, respectively, for men and women for pseudoneurological complaints ; and for gastrointestina l complaints 1% for men and 2% for


243

Table 1. Mean and 95% CI of the mean on psychological demands, control, coping, subjective health problems, and job stress for men (n 5 401) and women (n 5 659).


Mean (95% CI of the mean)

Psychological demands Control (decision latitude) Intellectual discretion Authority over decisions Coping Instrumental mastery oriented coping Subjective health complaints Musculoskeletal pain Pseudoneurology Gastrointestinal problems Job stress Communication Leadership Relocation Work load

Men

Women

13.69 (13.44± 13.94) 15.09 (14.70± 15.47) 10.09 (9.82± 10.36) 4.99 (4.82± 5.16)

14.01 (13.83± 14.20) 14.36 (14.09± 14.63) 9.94 (9.75± 10.13) 4.44 (4.31± 4.57)

2.98 (2.94± 3.01)

2.93 (2.91± 2.95)

3.41 (3.02± 3.81) 2.21 (1.95± 2.47) 1.32 (1.12± 1.52)

5.33 (4.98± 5.68) 2.85 (2.62± 3.07) 1.73 (1.54± 1.91)

1.41 (1.30± 1.23 (1.13± 0.91 (0.82± 2.08 (1.97±

1.34 (1.25± 0.98 (0.91± 0.99 (0.91± 2.20 (2.10±

1.51) 1.33) 1.00) 2.20)

1.42) 1.05) 1.07) 2.30)

women. However, for the demand } coping model, the explained variance was higher for pseudoneurological complaints, 11% for men and 18% for women, by psychological demands and instrumental mastery oriented coping. For musculoskeletal pain the values were slightly higher than for the demand } control model (5% for men, and 4% for women), for gastrointestina l problems the levels were about the same low level (1% and 3%, respectively). 3.2. Demand } control and demand} coping models Odds ratios based on demand } control showed with few exceptions that employees in high strain jobs were at a higher risk of reporting musculoskeletal pain, pseudoneurology, and gastrointestina l problems, compared to employees in low strain jobs (reference category) (table 2). There were only minor diVerences between the age-adjusted models and the fully adjusted models (table 2). Similar, but stronger diVerences were found between demand } coping groups. High strain individuals were at much higher risk of reporting musculoskeletal pain, pseudoneurology, and gastrointestina l problems compared to low strain individuals (reference category) (table 2). Also here, only minor diVerences between the age-adjusted and the fully adjusted model were found, except for musculoskeletal pain in men. 3.2.1. Demand} control model analysis : There were signi® cant overall group diVerences between the four demand } control groups on degree of subjective health complaints (Wilks’ k (9, 2300) 5 .96, p ! .001). Analysis of between-subjects eVects showed signi® cant diVerences between the groups on musculoskeletal pain (F(3,947) 5 9.30, p ! .001), pseudoneurology (F(3, 947) 5 10.40,p ! .001), and gastrointestina l problems (F(3, 947) 5 2.78, p ! .05). (1) Musculoskeletal pain. Employees in high strain jobs showed signi® cantly higher scores compared to the other groups. Employees in low strain jobs showed signi® cantly lower scores compared to the other groups. Employees in active jobs did not diVer

1.0 2.37 (1.24± 4.52) 1.51 (0.81± 2.81) 4.29 (2.16± 8.52)

1.0 1.07 (0.65± 1.75) 1.49 (0.96± 2.29) 2.97 (1.81± 4.89)

161 132 206 151

1.0 1.24 (0.73± 2.09) 1.20 (0.78± 1.87) 1.98 (1.22± 3.20)

137 118 233 166

127 81 119 68

1.0 2.32 (1.19± 4.51) 1.29 (0.69± 2.44) 3.78 (1.86± 7.68)

113 82 137 68

Musculoskeletal OR (95% CI)

1.0 2.62 (1.29± 5.34) 4.76 (2.53± 8.94) 10.30 (5.36± 19.79)

1.0 0.71 (0.29± 1.77) 2.57 (1.29± 5.10) 3.62 (1.70± 7.71)

1.0 2.00 (1.08± 3.71) 1.64 (0.95± 2.82) 3.44 (1.97± 6.01)

1.0 0.64 (0.27± 1.55) 1.47 (0.74± 2.93) 2.48 (1.15± 5.33)

Pseudoneurology OR (95% CI)

1.0 1.85 (0.95± 3.63) 1.35 (0.72± 2.53) 2.34 (1.25± 4.41)

1.0 0.64 (0.19± 2.18) 1.39 (0.55± 3.52) 3.52 (1.41± 8.80)

1.0 2.80 (1.45± 5.51) 1.23 (0.65± 2.32) 1.53 (0.79± 3.00)

1.0 0.91 (0.27± 3.00) 1.45 (0.54± 3.87) 3.31 (1.21± 9.07)

Gastrointestinal OR (95% CI)

*Reference category. **Adjusted for age, education, regular and extra work hours, and shift work.

Demand } coping Men Low strain* Active Passive High strain Women Low strain* Active Passive High strain

Demand } control Men Low strain* Active Passive High strain Women Low strain* Active Passive High strain

n

Adjusted for age

1.0 1.04 (0.58± 1.87) 1.46 (0.88± 2.44) 2.43 (1.37± 4.31)

1.0 2.95 (1.39± 6.28) 1.63 (0.81± 3.29) 2.83 (1.30± 6.16)

1.0 1.37 (0.74± 2.53) 1.14 (0.66± 1.97) 1.48 (0.83± 2.67)

1.0 1.76 (0.82± 3.76) 0.94 (0.43± 2.07) 2.78 (1.18± 6.56)

Musculoskeletal OR (95% CI)

1.0 2.44 (1.05± 5.67) 4.89 (2.31± 10.34) 9.69 (4.48± 20.98)

1.0 0.95 (0.34± 2.67) 2.63 (1.19± 5.79) 3.97 (1.68± 9.39)

1.0 2.25 (1.07± 4.76) 2.10 (1.06± 4.15) 3.85 (1.90± 7.77)

1.0 0.97 (0.36± 2.62) 1.23 (0.50± 3.03) 2.25 (0.85± 5.92)

Pseudoneurology OR (95% CI)

Fully adjusted**

1.0 1.97 (0.92± 4.22) 1.49 (0.72± 3.08) 2.67 (1.29± 5.53)

1.0 0.48 (0.11± 2.01) 1.06 (0.36± 3.15) 2.93 (1.05± 8.19)

1.0 3.08 (1.44± 6.59) 1.36 (0.64± 2.91) 1.73 (0.79± 3.79)

1.0 1.12 (0.30± 4.21) 1.20 (0.33± 4.31) 2.22 (0.64± 7.77)

Gastrointestina l OR (95% CI)

Table 2. Odds ratios and 95% CI for demand } control and demand } coping and high reports of musculoskeletal pain, pseudoneurology, and gastrointestina l problems.

Downloaded by [Universitetsbiblioteket i Bergen] at 02:48 04 December 2015 244 H. R. Eriksen and H. Ursin



245

from employees in passive jobs (see ® gure 1 and table 3 for mean values and 95% CI). (2) Pseudoneurology . As for musculoskeletal pain, employees in high strain jobs showed signi® cantly higher scores compared to the other groups. Employees in low strain jobs scored signi® cantly less compared to the other groups. There were no diVerences between active and passive jobs (® gure 1 and table 3). (3) Gastrointestina l problems . There were few signi® cant diVerences between the groups on gastrointestina l problems, but the pattern was similar to musculoskeletal pain and pseudoneurology (® gure 1 and table 3). Employees in high strain jobs had higher scores than employees in low strain jobs. (4) Job stress. There were signi® cant overall diVerences between the demand } control groups on reports of job stress (Wilks’ k (12, 2686)5 .77, p ! .001), with signi® cant diVerences on communication (F(3, 1018) 5 42.8, p ! .001), leadership (F (3, 1018) 5 21.1, p ! .001), relocation (F(3, 1018) 5 10.4, p ! .001), and workload (F(3, 1018)5 84.3, p ! .001) as sources of job stress. Employees in high strain and active jobs scored signi® cantly higher on communication, leadership, relocation, and workload compared to the other groups. Passive, and low strain jobs did not diVer signi® cantly (table 3). 3.2.2. Demand} coping model analysis : There were signi® cant overall group diVerences between the demand } coping groups on degree of subjective health complaints (Wilks ’ k (9, 2288) 5 .89, p ! .001). Analysis of between-subjects eVects showed signi® cant diVerences between the groups on musculoskeletal pain (F(3,942) 5 18.67, p ! .001), pseudoneurology (F(3, 942) 5 34.55, p ! .001), and gastrointestina l problems (F (3, 947) 5 5.93, p ! .05). (1) Musculoskeletal pain. High strain individuals showed signi® cantly higher scores compared to the other three groups. Low strain individuals scored signi® cantly lower than the other groups. Active individuals did not diVer signi® cantly from passive individuals (® gure 1 and table 3). (2) Pseudoneurology . High strain individuals showed signi® cantly higher scores compared to the other three groups. Low strain individuals scored signi® cantly lower than the other groups. Active individuals scored signi® cantly lower compared to passive individuals (® gure 1 and table 3). (3) Gastrointestina l problems . There were few signi® cant diVerences between the groups on gastrointestina l problems, but the pattern was similar to musculoskeletal pain and pseudoneurology (® gure 1 and table 3). However, high strain individuals showed signi® cantly higher scores compared to the other three groups. (4) Job stress. There were signi® cant overall diVerences between the demand } coping groups on reports of job stress (Wilks k (12, 2670) 5 .76, p ! .001), with signi® cant diVerences on communication (F(3, 1012)5 48.2, p ! .001) leadership (F(3, 1012) 5 29.5, p ! .001), relocation (F(3, 1012) 5 15.8, p ! .001), and workload (F(3, 1012)5 90.3, p ! .001) as sources of job stress. All the groups diVered signi® cantly from each other on communication. High strain individuals scored signi® cantly higher on communication compared to the other groups, followed by active, passive, and low strain individuals (table 3). High strain individuals had signi® cantly higher scores on leadership compared to the other groups. Signi® cantly lower scores were reported by low strain individuals. Active and passive individuals did not diVer signi® cantly from each other (table 3).



246

Figure 1. Relations between subjective health and the two models : demands } control and demands } coping.

Relocation was the job stress scale with fewest diVerences between the groups. High strain and active individuals had highest scores on relocation. High strain individuals scored signi® cantly higher compared to passive and low strain individuals. Low strain individuals had signi® cantly lower score compared to all the other groups. Active individuals did not diVer signi® cantly from passive and high strain individuals (table 3).


247

Table 3. Mean and 95% con® dence interval of the mean on subjective health complaints and job stress problems for men (n 5 401) and for women (n 5 659), divided into the demand } control, and demand } coping groups.


Mean (95% CI of the mean) Musculoskeletal pain Demand } control Low strain Active Passive High strain Demand } coping Low strain Active Passive High strain Pseudoneurology Demand } control Low strain Active Passive High strain Demand } coping Low strain Active Passive High strain Gastrointestina l problems Demand } control Low strain Active Passive High strain Demand } coping Low strain Active Passive High strain Communication Demand } control Low strain Active Passive High strain Demand } coping Low strain Active Passive High strain Leadership Demand } control Low strain Active Passive High strain

Men

Women

2.80 (2.07± 4.17 (3.10± 2.79 (2.26± 4.67 (3.64±

3.52) 5.24) 3.31) 5.70)

4.53 (3.77± 5.17 (4.33± 5.36 (4.79± 6.09 (5.37±

5.29) 6.01) 5.92) 6.81)

2.16 (1.66± 3.85 (2.83± 3.46 (2.75± 5.06 (3.99±

2.66) 4.86) 4.17) 6.14)

4.21 (3.59± 4.58 (3.84± 5.62 (4.99± 6.62 (5.85±

4.84) 5.32) 6.25) 7.38)

1.68 (1.19± 1.92 (1.48± 2.40 (1.91± 2.98 (2.34±

2.17) 2.36) 2.88) 3.63)

2.10 (1.69± 3.29 (2.71± 2.57 (2.24± 3.48 (2.97±

2.52) 3.87) 2.90) 3.99)

1.45 (1.08± 1.77 (1.37± 2.80 (2.22± 3.20 (2.53±

1.82) 2.18) 3.38) 3.86)

1.70 (1.37± 2.34 (1.94± 2.89 (2.53± 4.29 (3.71±

2.03) 2.74) 3.25) 4.88)

1.21 (0.87± 0.91 (0.58± 1.34 (0.96± 1.93 (1.38±

1.55) 1.24) 1.72) 2.48)

1.35 (1.00± 2.30 (1.76± 1.63 (1.33± 1.78 (1.39±

1.70) 2.84) 1.92) 2.16)

1.18 (0.81± 1.05 (0.73± 1.42 (1.05± 1.80 (1.21±

1.55) 1.37) 1.79) 2.38)

1.32 (0.98± 1.81 (1.34± 1.68 (1.37± 2.15 (1.73±

1.66) 2.29) 1.98) 2.57)

1.10 (0.93± 1.69 (1.44± 1.09 (0.93± 2.20 (1.93±

1.27) 1.94) 1.24) 2.47)

1.08 (0.92± 1.65 (1.47± 1.03 (0.91± 1.72 (1.55±

1.25) 1.84) 1.16) 1.89)

1.03 (0.88± 1.77 (1.51± 1.16 (0.98± 2.09 (1.82±

1.18) 2.03) 1.33) 2.36)

0.86 (0.73± 1.53 (1.36± 1.22 (1.07± 1.83 (1.65±

0.99) 1.71) 1.36) 2.01)

0.93 (0.76± 1.48 (1.24± 1.03 (0.89± 1.80 (1.55±

1.10) 1.72) 1.18) 2.04)

0.72 (0.58± 1.09 (0.92± 0.88 (0.76± 1.26 (1.09±

0.86) 1.26) 0.99) 1.42)

[continued overleaf

248

H. R. Eriksen and H. Ursin Table 3.

(cont.)


Mean (95% CI of the mean) Demand } coping Low strain Active Passive High strain Relocation Demand } control Low strain Active Passive High strain Demand } coping Low strain Active Passive High strain Work load Demand } control Low strain Active Passive High strain Demand } coping Low strain Active Passive High strain

Men

Women

0.86 (0.72± 1.46 (1.23± 1.11 (0.94± 1.80 (1.54±

0.99) 1.69) 1.29) 2.07)

0.59 (0.47± 1.04 (0.88± 1.01 (0.88± 1.32 (1.15±

0.70) 1.21) 1.14) 1.48)

0.79 (0.62± 1.17 (0.95± 0.68 (0.55± 1.24 (1.01±

0.96) 1.39) 0.81) 1.47)

0.80 (0.65± 1.11 (0.93± 0.92 (0.78± 1.16 (0.99±

0.96) 1.29) 1.06) 1.32)

0.69 (0.55± 1.16 (0.95± 0.79 (0.63± 1.23 (0.98±

0.83) 1.37) 0.94) 1.47)

0.66 (0.52± 1.01 (0.85± 1.06 (0.91± 1.25 (1.07±

0.79) 1.17) 1.21) 1.43)

1.59 (1.40± 2.49 (2.25± 1.73 (1.56± 3.12 (2.87±

1.78) 2.73) 1.90) 3.37)

1.68 (1.50± 2.82 (2.58± 1.76 (1.62± 2.79 (2.60±

1.87) 3.06) 1.90) 2.97)

1.55 (1.39± 2.62 (2.37± 1.77 (1.58± 2.97 (2.70±

1.72) 2.86) 1.97) 3.23)

1.51 (1.35± 2.65 (2.43± 1.91 (1.75± 2.93 (2.74±

1.67) 2.87) 2.06) 3.12)

All groups diVered signi® cantly from each other on workload. High strain individuals had highest scores on workload followed by active, passive and low strain individuals. 4. Discussion `Coping ’, de® ned in this paper as an expectancy of positive outcomes, had more impact on all subjective health complaints than `control ’ (decision latitude, Karasek, and Theorell, 1990). The main features of the operationalizat ion of coping are being optimistic about outcomes, having low scores on helplessness and hopelessness, considering problems as challenges, never being overwhelmed or resigned, and approaching diYcult situations. Coping, therefore, is associated with an instrumental, goal oriented coping style, but it is not a strategy in this de® nition, it is an expectancy. The individual will use whatever strategy he or she believes is the best for solving the problem with a positive result. Control (decision latitude, Karasek, and Theorell, 1990), was operationalized according to Theorell et al. (1988) as creativity, skills, task variety, learning new things, and low score on repetitive work. In both models the health eVects depend on the combination with the psychological demands. In the classical demand } control model of Karasek, and Theorell (1990), high demands may cause illness and disease if the individual does not have control in the work situation. The present ® ndings are that this relationship is stronger for `coping ’ than for `control ’ for subjective health complaints, particularly for muscle pain and `pseudoneurological ’ complaints. The combination of high demands and low coping was the worst combination. High



249

strain individuals (high demands, low coping) reported more health complaints and job stress compared to the other groups. Active individuals (high demands, high coping) had quite high reports of job stress, but not very high health complaints. This is assumed to be due to a dampening of stress responses by their coping `® lter ’. Low strain individuals (low demands, high coping) had low reports of job stress, and low reports of subjective health complaints. Finally, passive individuals (low demands, low coping) had quite high reports of subjective health complaints, but not as high as the high strain individuals. It is assumed that the main agent for the health eVects is the coping expectancy. However, active and passive individuals may diVer also in their lifestyle, for instance in physical exercise, and in enthusiasm and motivation for a positive and healthy lifestyle. Similar relationships were found for the reports of perceived job stress. High strain individuals, followed by active individuals, reported most job stress compared to the other groups, except on relocation, where high strain individuals did not diVer from active individuals. Low strain individuals had the lowest reports on all job stress scales. High strain individuals experienced high psychological demands but lacked the ability to cope eYciently with the demands. This may result in high degrees of experienced job stress, sustained activation and negative health consequences. According to our psychosomatic theory put forward in this paper high demands give rise to catabolic rather than anabolic eVects (Ursin, 1980; Arnetz, 1984). On the other hand, the relative good health condition of the active individuals, considering their high level of demands, and high reports of job stress, suggests that they may have an anabolic type of activation assumed to be associated with èustress’ (Selye, 1974) and health (Ursin, 1980; Arnetz, 1984). The main diVerence between the demand } control and the demand } coping models seems to be the emphasis on the òbjective ’ organization of the work in the demand } control model, and the emphasis on `subjective ’ outcome expectancy in the demand } coping model. Both models use the same measure for psychological demands. In recent developments and discussions of the control dimension in the demand } control model, the relation between objective control and the subjective reports of being in control is discussed (North et al., 1966; Theorell, Tsutsumi, Hallquist, Reuterwall, Hogstedt, Fredlund, Emlund, Johnson, and the SHEEP study group 1998). In these reports, there is a reasonable agreement between the subjective and objective reports of being in control, and a subjective feeling of being in control is closer to our coping concept. There is, therefore, a possible convergence between the models when subjective evaluations of the situation are considered. Karasek, and Theorell (1990) suggested that `coping ’ might result from growth and learning in a high demand-high control situation (Karasek, and Theorell, 1990), again emphasizing the importance of job rather than individual characteristics. We suggest that individual coping mechanisms and other personal factors are present before one enters a job. These mechanisms in¯ uence the selection of and for the job, but may be reinforced by the work design, and the relationship between eVort and rewards (Siegrist, 1996). The present data were collected during a diYcult period for the employees, which may have in¯ uenced the data. The majority of the employees were characterized by high demands and low control in their work, compared to other population groups (Theorell, Miche! lsen, Nordemar, and Stockholm MUSIC 1 Study Group, 1991). The Norwegian postal service underwent profound organizational changes during the investigation period, with cut-backs, closing of post oYces, etc. This might have in¯ uenced status control (Siegrist, 1996), with threats to continuity of occupational roles. The reports of communication, leadership, and relocation as sources of job stress were higher than what have been found in other studies (Endresen et al., 1991). The moderate, but signi® cant


250


associations between perceived job stress and subjective health complaints were gender and complaint speci® c. However, there are also signi® cant gender diVerences in the prevalence of subjective health complaints (Eriksen et al., 1998). The general relationships between health and demand } coping seem to be the same for men and women in the present data. We believe that the data and models discussed in this paper may be generalized to other work situations. The apparent multicausal nature of subjective health complaints agrees with basic psychobiologica l assumptions on the relationship between psychological and physical aspects of well-being (Ursin, 1997). It may seem irrelevant whether the emphasis in prevention and treatment of job-related health problems should be the individual or the organization. The main goal is the same. The work situation and the organization of work should favour organizational learning (Mikkelsen, Saksvik, and Ursin, 1998a; Mikkelsen et al., 1998b) and optimize the possibilities to develop positive response outcome expectancies (our de® nition of coping).

Acknowledgements The authors would like to thank Robert Murison for his careful reading of the manuscript and useful comments, and Linda Sandal and Nina Konglevoll for technical assistance. The project was funded with grants from the Norwegian Research Council.

References Am e r i c a n Ps y c h i a t r i c As s o c i a t i o n (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM -IV ) (4th ed.). Washington, DC : American Psychiatric Association. Ar n e t z , B. B. (1984).The potential role of psychosocial stress on levels of hemoglobin A1c (HbA1c) and fasting plasma glucose in elderly people. Journal of Gerontology , 39, 424± 429. Bo l l e s , R. C. (1972). Reinforcement, expectancy and learning. Psychological Review , 79, 394± 409. Bo n g e r s , P. M., d e Wi n t e r , C. R., Ko m p i e r , M. A., & Hi l d e b r a n d t , V. H. (1993). Psychosocial factors at work and musculoskeletal disease. Scandinavian Journal of Work , Environment and Health , 19, 297± 312. Bu r d o r f , A., & So r o c k , G. (1997).Positive and negative evidence of risk factors for back disorders. Scandinavian Journal of Work , Environment and Health , 23, 243± 256. Co o p e r , C. L. (1981). The Stress Check. New York : Prentice-Hall. Co o v e r , G. D., Ur s i n , H., & Mu r i s o n , R. (1983). Sustained activation and psychiatric illness. In H. Ursin, & R.Murison (vol. Eds.), Advances in the Biosciences : Vol . 42. Biological and Psychological Basis of Psychosomatic Disease (pp. 249± 258). Oxford : Pergamon Press. En d r e s e n , I. M., El l e r t s e n , B., En d r e s e n , C., Hj e l m e n , A. M., Ma t r e , R., & Ur s i n , H. (1991). Stress at work and psychological and immunological parameters in a group of Norwegian female bank employees. Work and Stress , 5, 217± 227. Er i k s e n , H. R., Ih l e b á k , C., & Ur s i n , H. (1999). A scoring system for subjective health complaints (SHC). Scandinavian Journal of Public Health , 1, 63± 72. Er i k s e n , H. R., Ol f f , M., & Ur s i n , H. (1997).The CODE : A revised battery for coping and defense and its relations to subjective health. Scandinavian Journal of Psychology , 38, 175± 182. Er i k s e n , H. R., Sv e n d s r é d , R., Ur s i n , G., & Ur s i n , H. (1998). Prevalence of subjective health complaints in the Nordic European countries in 1993. European Journal of Public Health , 8, 294± 298. Fo l k m a n , S., & La z a r u s , R. S. (1991). Coping and emotion. In A. Monat, & R. S. Lazarus (Eds.), Stress and Coping (3rd ed.) (pp. 207± 227). New York : Columbia University Press. Gl e s e r , G. C., & Ih i l e v i c h , D. (1969). An objective instrument for measuring defense mechanisms. Journal of Consulting and Clinical Psychology , 33, 51± 60. Id l e r , E. L., & Be n y a m i n i , Y. (1997). Self-rated health and mortality : A review of twenty-seven community studies. Journal of Health and Social Behavior , 38, 21± 37.



251

Ka r a s e k , R. (1997). Demand } control model : A social, emotional, and physiological approach to stress risk and active behaviour development. In S. L. Sauter, L. R.Murphy, J. J. Hurrell, & L. Levi (Eds.), Psychosocial and Organizational Factors . ILO Encyclopedia of Occupational Health and Safety (pp. 34.6± 34.14). Geneva : ILO. Ka r a s e k , R., & Th e o r e l l , T. (1990). Healthy Work : Stress , Productivity , and the Reconstruction of Working Life. New York : Basic Books. Kn a r d a h l , S. (1983).Psychological pathogenesis of arterial hypertension. In H. Ursin, & R.Murison (vol. Eds.), Advances in the Biosciences : Vol. 42. Biological and Psychological Basis of Psychosomatic Disease (pp. 223± 238). Oxford : Pergamon Press. La z a r u s , R. S., & Fo l k m a n , S. (1991). The concept of coping. In A. Monat, & R. S. Lazarus (Eds.), Stress and Coping (3rd ed.) (pp. 189± 206). New York : Columbia University Press. Le v i n e , S., & Ur s i n , H. (1991). What is stress ? In M. R. Brown, G. F. Koob, & C. Rivier (Eds.), Stress : Neurobiology and Neuroendocrinol ogy (pp. 1± 21). New York : Marcel Dekker. Mi k k e l s e n , A., Sa k s v i k , P. é ., & Ur s i n , H. (1998a). Job stress and organizational learning climate. International Journal of Stress Management , 5, 197± 209. Mi k k e l s e n , A., Sa k s v i k , P. é ., Er i k s e n , H. R., & Ur s i n , H. (1998b). The impact of learning opportunities and decision authority on occupational health. Work and Stress , 13, 20± 31. Mu r i s o n , R., & Ov e r m i e r , J. B. (1990).Proactive actions of psychological stress on gastric ulceration in ratsÐ real psychobiology. Annals of the New York Academy of Sciences , 597, 191± 200. No r t h , F. M., Sy m e , S. L., Fe e n e y , A., Sh i p l e y , M., & Ma r m o t , M. (1996). Psychosocial work environment and sickness absence among British civil servants : The Whitehall II study. American Journal of Public Health , 86, 332± 340. Ol f f , M., Br o s s c h o t , J. F., & Go d a e r t , G. (1993).Coping styles and health. Personality and Individual DiVerences , 15, 81± 90. Ov e r m i e r , J. B., & Se l i g m a n , M. E. (1967). EVects of inescapable shock upon subsequent escape and avoidance responding. Journal of Comparative and Physiological Psychology , 63, 28± 33. Sc h n a l l , P. L., La n d s b e r g i s , P. A., & Ba k e r , D. (1994).Job strain and cardiovascular disease. Annual Review of Public Health , 15, 381± 411. Sc h r e u r s , P. J. G., Te l l e g e n , B., Va n De Wi l l i g e , G., & Br o s s c h o t , J. F. (1988). De Utrechtse Coping Lijst : Handleiding . Lisse : Swets en Zeitlinger. Sc h r e u r s , P. J. G., Va n De Wi l l i g e , G., Br o s s c h o t , J. F., & Gr a u , G. (1993). De Utrechtse Copinglijst : UCL. Handleiding (2nd rev. edn.). Lisse : Swets en Zeitlinger. Se l y e , H. (1974). Stress without Distress . Philadelphia : J. B. Lippincott. Si e g r i s t , J. (1996).Adverse health eVects of high-eVort} low-reward conditions. Journal of Occupational Health Psychology , 1, 27± 41. Sp u r g e o n , A., Go m p e r t z , D., & Ha r r i n g t o n , J. M. (1996). Modi® ers of non-speci® c symptoms in occupational and environmental syndromes. Occupational and Environmental Medicine , 53, 361± 366. Te l l n e s , G., Sv e n d s e n , K. O., Br u u s g a a r d , D., & Bj e r k e d a l , T. (1989). Incidence of sickness certi® cation. Proposal for use as a health status indicator. Scandinavian Journal of Primary Health Care, 7, 111± 117. Th e o r e l l , T., & Ka r a s e k , R. A. (1996). Current issues relating to psychosocial job strain and cardiovascular disease research. Journal of Occupational Health Psychology , 1, 9± 26. Th e o r e l l , T., Mi c h e ! l s e n , H., No r d e m a r , R., & St o c k h o l m Mu s i c 1 St u d y Gr o u p (1991). Tre arbeidsmiljo$ index som anva$ nts i Stockholmsunderso$ kningen 1. In M. Hagberg, & C. Hogstedt (Eds.), Stockholmsunder soX kningen 1. Data frac n en tvaX rsnittsundersoX kning av ergonomisk og psykosocial exponering samt sjuklighet och funktion i roX relseorganen (pp. 150± 154). Stockholm : MUSIC Books. Th e o r e l l , T., Pe r s k i , A., Ak e r s t e d t , T., Si g a l a , F., Ah l b e r g -Hu l t e ! n , G., Sv e n s s o n , J., & En e r o t h , P. (1988). Changes in job strain in relation to changes in physiological state. Scandinavian Journal of Work , Environment and Health , 14, 189± 196. Th e o r e l l , T., Ts u t s u m i , A., Ha l l q u i s t , J., Re u t e r w a l l , C., Ho g s t e d t , C., Fr e d l u n d , P., Em l u n d , N., Jo h n s o n , J. V., & Th e Sh e e p St u d y Gr o u p (1998). Decision latitude, job strain and myocardial infarction : A study of working men in Stockholm. American Journal of Public Health , 88, 382± 388. Ur s i n , H. (1980). Personality, activation and somatic health. A new psychosomatic theory. In S. Levine, & H. Ursin (Eds.), Coping and Health (pp. 259± 279). New York : Plenum Press. Ur s i n , H. (1988). Expectancy and activation : an attempt to systematize stress theory. In D.


252


Hellhammer, I. Florin, & H. Weiner (Eds.), Neurobiological Approaches to Human Disease (pp. 313± 334). Toronto : Huber. Ur s i n , H. (1997). Sensitization, somatization, and subjective health complaints. International Journal of Behavioral Medicine , 4, 105± 116. Ur s i n , H. (1998). The psychology in psychoneuroendocrinology. Psychoneuroendo crinology , 23, 555± 570. Ur s i n , H., En d r e s e n , I. M., & Ur s i n , G. (1988). Psychological factors and self-reports of muscle pain. European Journal of Applied Physiology and Occupational Physiology , 57, 282± 290. Ve i e r s t e d , K. B., & We s t g a a r d , R. H. (1993). Development of trapezius myalgia among female workers performing light manual work. Scandinavian Journal of Work , Environment and Health , 19, 277± 283. Wo r l d He a l t h Or g a n i z a t i o n (1991).Health for All Targets . The Health Policy for Europe (European Health for All series No. 4) (Updated edn.). Copenhagen : World Health Organization, Regional OYce for Europe. Submitted June 1998. Revised version accepted February 1999.