occupation and work organisation

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Work 40 (2011) 425435 425DOI 10.3233/WOR-2011-1254IOS Press

Occupation, work organisation conditions and

the development of chronic psychological

distress

Alain Marchanda,b, and Marie-Eve BlancbaSchool of Industrial Relations, University of Montreal, Montreal, Quebec, CanadabInstitute of Public Health, University of Montreal, Montreal, Quebec, Canada

Received 12 January 2010

Accepted 4 April 2010

Abstract. Objective: The contribution of occupation and work organisation conditions to the development of chronic psycholog-

ical distress in the Canadian workforce was examined.

Participants: Longitudinal data came from the first five cycles (Cycle 1 = 19941995, Cycle 5 = 20022003) of Statistics

Canadas National Population Health Survey. A sample of 5,500 workers nested in 1,300 neighbourhoods and aged 15 to 55 years.

Methods: Data had a hierarchical structure and were analysed using multilevel logistic regression models.

Results: The results showed 46.4% of workers reported one episode of psychological distress, 23.5% more than one, and

10.6% three or more. Psychological distress decreased over time and varied significantly between individuals and neighbour-

hoods. Occupation was not significant, but psychological demands, job insecurity, and social support in the workplace wereimportant determinants. The results showed strong contributions of individual and outside work factors (family, social support,

neighbourhood).

Conclusions: Research in occupational mental health must expand theoretical and empirical frameworks in order to capture actual

workplace dynamics and the effects on workers mental health. Interventions designed to reduce mental health problems should

carefully evaluate not only the work environment itself, but also non-work factors and other individual characteristics.

Keywords: Psychological, distress/chronicity/longitudinal, study/occupation/work, organisation, conditions

1. Introduction

Over the years, a host of studies have been devotedto mental health problems in the workforce that mani-

fest as psychological distress, depression, and burnout.

In 2008, the World Health Organization identified de-

pression as the third leading cause of disability [1]

and many workers can develop chronic mental health

problems. However, the study of the development of

Address for correspondence: Alain Marchand, School of In-dustrial Relations, University of Montreal, P.O. Box 6128, StationCentre-ville, Montreal (Que), H3C 3J7, Canada. Tel.: +1 514 3436111, ext. 1288; Fax: +1 514 343 5764; E-mail: [email protected].

chronic mental problems has been largely neglected inthe scientific litterature, it has been estimated 19% of

Canadian workers reported more than one episode ofpsychological distress over a six-year period [2]. The

morbidity associated with mental health problems rep-

resents a significant burden for both businesses and thewhole of society, given the costs associated with men-

tal illness (absenteeism, lower productivity, indemni-ty payments, and health care). In Canada, for exam-

ple, related expenses were estimated at $51 billion in2003 [3].

We analysed the contribution of occupationand work

organisation conditions to the development of chron-ic psychological distress. According to many stud-

ies, type of occupation and work organisation condi-

1051-9815/11/$27.50 2011 IOS Press and the authors. All rights reserved


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426 A. Marchand and M. Blanc / The development of chronic psychological distress

tions are important factors for explaining the gene-

sis of mental health problems among individuals. Al-though studies have not specifically addressedthe prob-

lem of chronic psychological distress, the literature has

identified occupations at greater risk for mental health

problems, like white- and blue-collar workers, semi-

professionals, and supervisors [410]. Higher employ-

ment grades were also associated with distress [1113].

Mental health problems appeared widespread across

the occupational structure and it was estimated that oc-

cupational type accounted for 1 to 3% of the variance

in psychological distress [2,6].

Reviews of studies on work organisation conditions

have identified factors related to skill utilisation, de-

cision authority, psychological and physical demands,

social support in the workplace, and gratifications from

work [14,15]. The Job Demand-Control Model [16]

hypothesises decision latitude (high levels of skill util-

isation and decision authority) moderates psychologi-

cal demands, while the Demand-Control-SupportMod-

el [17] postulates low social support in the workplace

leads to an increase in the effect of the interaction be-

tween decision latitude and psychological demands.

While the contribution of the components (demand,

control, social support) in these two models to work-

ers mental health are well supported in longitudinal

studies [18,19], the majority of empirical studies havefailed to support the interactions between demands and

control, and between demand-control and social sup-

port [5,1829]. Siegrists Effort-Reward Imbalance

Model [30] posits the discrepancy between workplace

demands and rewards leads to distress, and there is

some evidence to support this hypothesis [27,2938].

The multilevel theoretical model of mental health de-

terminants in the workforce is an integrated model

postulating the role of stress promoted by constraints-

resources embedded in macrosocial structures (occu-

pational structure), structures of daily life (workplace,

family, social networks outside the workplace, neigh-

bourhood) and agentpersonality(demographics, physi-

cal health status, psychological traits, life habits, stress-

ful childhood events). This is the more recent model

and has received some support [2,15]. Since the impact

is not limited to work factors, the multilevel model of

mental health determinants in the workforce incorpo-

rates and recognises the role of marital, parental, and

family economic status; marital and parental strains;

social support outside the workplace,gender, age, phys-

ical health, self-esteem, locus of control and sense of

cohesion; and physical activities, smoking, and life

events occurring before the age of 18 years. All of

these elements have been shown to be associated with

mental health [14,15].Despite numerous studies on workers mentalhealth,

the development of chronic psychological distress in

the workforce and the extent to which occupation and

work organisation conditions are related to this phe-

nomenon have been neglected. Furthermore, the field

of occupational mental health has encountered consid-

erable difficulty integrating, both theoretically and em-

pirically, the various elements that make up the so-

cial environment (work, family, social networks, lo-

cal community-neighbourhood) of workers to explain

the contribution of occupation and work organization

conditions to psychological distress [15,18]. Research

designs have not included a broad range of workplace

conditions to which individuals are subjected, as just

as they have not been to take into account both occupa-

tions and work organizationconditions. Most of the re-

search reviewed for the present study looked at specific

occupations, limiting generalization from these results.

To better understand how work is related to the devel-

opment of chronic psychological distress, the research

used a large Canadian prospective cohort study to in-

vestigate the role of occupation and work organisation

conditions on repeated episodes of psychological dis-

tress, using the multilevel theoretical model of mental

health determinants in the workforce.

2. Methods

2.1. Data

Eight years of longitudinal data were derived from

the five cycles of Statistics Canadas National Popula-

tion Health Survey (NPHS; Cycle 1: 1994-1995; Cycle

2: 19961997; Cycle 3: 19981999; Cycle 4: 2000

2001; Cycle 5: 20022003). The initial cohort includ-

ed 17,276 subjects selected based on a two-stage sam-

pling design. The first stage was a sample of indepen-

dent clusters selected from homogeneous strata of the

Canadian territory. In the second stage, a sample of

households was selected within each cluster, and one

member was sampled from each household. Telephone

and face-to-face interviews yielded high response rates

for each cycle (80.6%93.6%), for an overall attrition

rate of 27.4%. For this study, all respondents aged

15 to 55 years and working during Cycle 1 were se-

lected (n = 7,338). After cases with missing valueswere deleted, the NPHS cohort analysed in this study

comprised 5,500 workers nested in 1,300 neighbour-


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A. Marchand and M. Blanc / The development of chronic psychological distress 427

hoods, with an average of 5.6 workers per neighbour-

hood (unbalanced design). In urban areas, neighbour-hoods were defined according to Statistics Canada cen-sus tracts (CT). CTs are small geographic units hav-ing homogeneous socio-economic characteristics. CTs

are found within census metropolitan areas and censusagglomerations with urban core populations of 50,000.In rural areas, census subdivisions (CSD) were used.The CSD is the general term applied to small townsand municipalities. In the analysis, data were weighted

according to selection probabilities, non-responseratesfor each cycle, and distribution by gender, age, andprovince in the 1996 Canadian Census.

2.2. Measures

2.2.1. Psychological distress

Psychological distress was measured with the K6questionnaire[39] based on the Composite Internation-

al Diagnostic Interview [40], which yielded diagnosesaccording to criteria from the DSM-III-R and the 10thedition of the International Classification of Diseases(ICD-10). Respondents were to indicate, on a 5-pointLikert scale (never/all the time), the frequency of sixsymptoms over the preceding month: feel so sad that

nothing could cheer youup; nervous; restless orfidgety;hopeless; worthless; everything was an effort. Thepsychological distress score was distributed between

0 and 24 (Cronbachs alpha = 0.77). The scale wasfurther dichotomised to identify the presence/absenceof psychological distress. Based on prior internationalstudies [4145], the cut-off point ( 5) was set to cor-respond to the last quintile of the distribution of psy-

chological distress in the general Canadian populationin 1994-1995 [2]. Overall, taking repeated measure-ments of psychological distress in this study allowed

us to analyse more precisely how individual patternsof psychological distress changed over time, therebycapturing the development of a chronic state.

2.2.2. Occupation

Occupations were categorised according to the four-digit codes of Statistics Canadas 1991 Standard Oc-cupational Classification (SOC-1991) [46]. Overall,

471 occupations were first merged into the 16 cate-gories of the Pineo, Porter and McRobert classificationof occupation [47]. To take care of the large number ofcategories and previous research showing greater riskfor mental health problems in specific occupations, the16 categories were further mergedinto six large groups:

senior managers, managers, supervisors, professionals,white-collar workers, and blue-collar workers.

2.2.3. Workplace

Skill utilisation, decision authority, physical andpsychological demands, social support at work and

job insecurity were derived from Statistics Canada

brief version of the Karasek Job Content Question-

naire (JCQ) [48], which was based on a five-point Lik-

ert scale (completely disagree/completely agree). Skill

utilisation included three items (your job requires that

you learn new things, your job requires a high level of

skills, your job requires that you do thingsover and over

[reversed coding]), and decision authority two items

(your job allows you freedom to decide how you do

your job, you have a lot to say about what happens in

your job). Physical demands included one item (your

job requires a lot of physical effort) and psychologi-

cal demands were based on two indicators (your job

is very hectic, you are free from conflicting demands

that others make (reversed coding). Job insecurity in-

cluded one item (your job security is good) and social

support included three items (you are exposed to hos-

tility or conflict from people you work with (reversed

coding); your supervisor is helpful in getting the job

done, the people you work with are helpful in getting

the job done). Repeated measurements of these scales

gave acceptable reliabilities, ranging from 0.68 to 0.86,

and indicated that concept meanings were not changing

over time [49]. Further, reliabilities of the mean of skillutilization, decision authority, physical and psycholog-

ical demands across the 471 occupations of SOC-1991

were 0.88, 0.77, 0.88 and 0.56 respectively, which are

quite similar to reliabilities of the complete version of

the JCQ [50]. As for the other variables, hours worked

were evaluated by summing the number of hours devot-

ed to the main job and to other jobs (where applicable).

Irregular work schedules was a dichotomous variable

where 0 = normal shift and 1 = rotating, split, on call,other.

2.2.4. Family and social network

Marital status distinguished between people living

together as a couple (coded 1) and those with other

marital situations (coded 0). Parental status was mea-

sured by the presence of children who lived with the

respondent, grouped into three age categories: 5 years

old and under, 611 years old, 1224years old. House-

hold income was determined using a five-point ordinal

scale (low/high) from Statistics Canada, which mea-

sured the level of income in relation to household size.

Marital, parental, and economic status were measured

for all cycles of the NPHS. Couple-related strain was

based on an additive scale of three items (true/false)


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428 A. Marchand and M. Blanc / The development of chronic psychological distress

developed by Wheaton [51]. Child-related strain was

measured with an additive scale that included two items(true/false), also developed by Wheaton [51]. A reli-

ability of 0.86 was estimated from repeated measure-

ments of both couple-related strain and child-related

strain. Social support outside the workplace was mea-

sured using an additive scale with four items that dealt

with the presence of a confidant; of someone to count

on in a crisis situation; of someone to count on when

making personal decisions; and of someone who makes

one feel loved and cared for. Given its marked asym-

metry, the scale was divided into two categories: low

support (0 = 0, 1, 2, 3) and high support (1 = 4).

2.2.5. Personality of the agent

Gender was a dichotomous variable coded 0 for men

and 1 for women. Age was measured at the beginning

of Cycle 1. Physical health status tallied the number of

physical health problems affecting respondents using a

list of 22 health problems (e.g., heart disease, cancer,

arthritis). Self-esteem (alpha = 0.85) was measuredby six five-point items (disagreement/agreement) de-

veloped by Rosenberg [52]. The (internal) center of

control (alpha = 0.76) was derived from the scale de-veloped by Pearlin and Schooler [53], which included

seven five-point items (agreement/disagreement). The

sense of coherence (alpha = 0.83) was based on theAntonovsky scale [54], which included 13 seven-point

items (multiple choice). Tobacco use was calculated

based on the number of cigarettes smoked per week.

Physical activity was measured by the monthly fre-

quencywith which one or more physical activities were

practiced for more than 15 minutes. Stressful child-

hood events quantified how many of seven items de-

veloped by Wheaton occurred before age 18 (e.g., two

weeks or more spent in the hospital; parents divorcing;

alcohol or drug abuse by parents) [51].

Table 1 presents summary descriptive data for each

NPHS Cycle for the overall sample.

2.3. Analysis

The data set had a hierarchical structure in which re-

peated measurements (level 1, n = 14,399) were nest-ed in workers (level 2, n = 5,500), and workers werenested in their respective neighbourhoods (level 3, n =1,300). Because the dependent variable was binary,

we used repeated measures logistic multilevel regres-

sion models [55,56] to analyse the probability (risk)

of developing repeated episodes of psychological dis-

tress over the eight-year period. Estimation using these

models does not require individuals be observed in each

cycle of the survey. Assuming a random distributionof missing values, subjects not followed for all cycles

afford less information for estimating the variation be-

tween levels of the data structure. Therefore, psycho-

logical distress is evaluated for individuals at work at

each particular cycle of data. The general model used

was of the form:

Logit(ijk(t)) = (t) + p0Xpijk(t)

+r0Xrjk + 00k + 0

ijk(t) is the risk of a psychological distress episode

i (level 1) for worker j (level 2) in neighbourhood k

during the time interval t (t = 1..5). (t) represents

model intercepts for each value oft (t = t1). p0are

slopes for independent worker variables varying with

time (Xpij(t)), and r0 are slopes for constant-time in-

dependent worker variables (Xrjk ). 00k and 0j are

error terms for neighbourhoodand workers, respective-

ly. 00k and 0j are assumed to follow a normal dis-

tribution with variances 2 and 2 estimated from the

data. The model accounts for the non-independence of

the observations generated from repeated episodes of

psychological distress in workers as well as for the clus-

tering of observations at the neighbourhood level. The

complex sampling design is thus taken into account.

Parameters were estimated using the method of pre-

dictive quasi-likelihood (PQL) with a second-order

Taylor expansion provided by the MlwiN 2.02 soft-

ware [57]. Because data were weighted, robust sand-

wich estimators for standard errors were comput-

ed [56]. In all cases, the significance of individual re-

gression coefficients was evaluated using a bilateral Z

test, and the probability of rejection of the null hypoth-

esis was set at P < 0.05. For random parameters (2,

2) Wald tests were applied with halved p-values (P

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occupation and work organisation