Int Arch Occup Environ Health (2005) 78: 198204 DOI 10.

1007/s00420-004-0581-7

O R I GI N A L A R T IC L E

Jian Li Wenjie Yang Yawen Cheng Johannes Siegrist Sung-Il Cho

Effortreward imbalance at work and job dissatisfaction in Chinese healthcare workers: a validation study

Received: 11 February 2004 / Accepted: 5 October 2004 / Published online: 15 March 2005 Springer-Verlag 2005

Abstract Objective: The aim of this study was to test the reliability and validity of the Chinese version of the 23item eortreward imbalance (ERI) questionnaire and to analyze its association with job dissatisfaction in a sample of Chinese healthcare workers. Methods: A selfreported survey was conducted, in university hospitals of China, among 192 male and 608 female healthcare workers. Results: Appropriate internal consistencies of the three scales: eort, reward, and overcommitment, were obtained. Exploratory factor analysis replicated the theoretically assumed structure of the ERI construct in men and women. Evidence of criterion validity was obtained from cross-correlations of the scales and from their correlations with gender, education and job dissatisfaction. Finally, all three scales were associated with an elevated odds ratio of job dissatisfaction, and the eect was strongest for the ERI ratio as predicted by theory. Conclusion: Based on the results of this study the Chinese version of the ERI questionnaire is considered a reliable and valid instrument for measuring psychosocial
J. Li S.-I. Cho (&) Department of Epidemiology, School of Public Health, Seoul National University, 28, Yeongun-dong, Chongno-ku, Seoul, 110-799, Republic of Korea E-mail: scho@snu.ac.kr Tel.: +82-2-7408868 Fax: +82-2-7477082 W. Yang Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, China Y. Cheng Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan J. Siegrist Department of Medical Sociology, University of Duesseldorf, Duesseldorf, Germany J. Li School of Public Health, Kunming Medical College, Kunming, China

stress at work. It is applicable to Chinese working populations and, in particular, to the healthcare sector. Keywords Eortreward imbalance Work stress Validity Job dissatisfaction Healthcare workers

Introduction
Owing to an increasing impact of psychosocial stress at work on health and economic loss (Dunham 2001; Landsbergis 2003), research in this area has witnessed rapid progress in recent time (Cooper 1998; Dunham 2001; Perrewe and Ganster 2002). Two theoretical approaches were studied with particular intensity and were shown to predict elevated disease risks in exposed populations rather consistently: the demandcontrolsupport model (Karasek and Theorell 1990; Karasek et al. 1998) and the eortreward imbalance (ERI) model (Siegrist 1996; Siegrist et al. 2004). The former model emphasizes the joint eects of high job demands and low decision latitude, which result in job strain, where low social support at work further increases the risk of job strain. The latter model focuses on the non-reciprocity of social exchange (i.e., high cost/low gain conditions in the work contract), which denes a state of emotional distress. In addition to situational characteristics of jobrelated eort and reward, the model includes a personal characteristic, a distinct pattern of coping with job demands, termed overcommitment, which aggravates stressful experience at work. The conditions identied in the two models are assumed to elicit recurrent states of excessive activation of the autonomic nervous system that, in the long run, contribute to the development of stress-related diseases. Both models were tested in a variety of working populations in prospective and cross-sectional epidemiological investigations. Their explanatory power was demonstrated for cardiovascular morbidity and mortality (Kivimaki et al. 2002; Kuper et al. 2002; Kuper

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and Marmot 2003; Peter et al. 2002; for review of earlier studies: Schnall et al. 2000), mild-to-moderate psychiatric symptoms (Stansfeld et al. 1999; Tsutsumi et al. 2001b), psychosomatic symptoms and self-reported health, among others (Ostry et al. 2003; Pikhart et al. 2001; Stansfeld et al. 1998; van Vegchel et al. 2001). However, most of those studies were conducted in Western countries, while only a few investigations are available from Asian societies such as Japan and Taiwan. This holds particularly true for the ERI model (Kawakami and Haratani 1999; Tseng and Cheng 2002; Tsutsumi et al. 2001a). In a situation where work stress has become a rapidly growing concern in China, there is an urgent need for its reliable and valid measurement. Most importantly, given a dramatic shift from a stateplanning-oriented economy to a market-driven economy, working life is increasingly characterized by high exibility and mobility, by xed contracts and increased job instability for a growing number of Chinese men and women (Christiani et al. 2002). As several of these conditions are assessed by the ERI model it is well justied to apply the measurement of this model to a Chinese working population. This paper has two aims. First, it sets out to investigate psychometric properties of the Chinese version of the ERI questionnaire by analyzing the factorial structure of its scales and the internal consistency. Secondly, it tests associations of the scales of the ERI questionnaire with a measure of job dissatisfaction in the study population: a sample of Chinese healthcare workers. Healthcare work is characterized by rather high levels of work stress internationally (Weinberg and Creed 2000), and it is of interest to know to what degree this holds true for China as well (Callaghan et al. 2000). In several studies, job dissatisfaction was associated with an elevated risk of leaving healthcare jobs, a fact that calls for increased preventive eorts (Bakker et al. 2000).

consisted of 800 subjects (73% of the initial population, n=1,093, or 84% of all respondents, n=947). This study protocol was approved by the research ethics committee of Seoul National University and was performed in accordance with the Declaration of Helsinki. Questionnaire The 23-item ERI questionnaire consists of three scales and is applied without any changes in this study. The three scales are termed extrinsic eort (6 items), reward (11 items, including money, esteem, job security and promotion prospects), and overcommitment (6 items). Responses to the items of extrinsic eort and reward are scored on a 5-point scale where a value of 1 indicates no respective stressful experience, and a value of 5 indicates very high stressful experience. The items of the scale overcommitment are scored on a 4-point scale (1 = full disagreement, 4 = full agreement with statement). Consequently, with such a scoring, the range for the scale eort is 6 to 30, for the scale reward 11 to 55, and for the scale overcommitment 6 to 24. Moreover, according to a predened algorithm, a ratio between the two scales eort and reward is calculated to quantify the degree of mismatch between high cost and low gain (Siegrist et al. 2004). Generally, two Chinese character systems are used in Chinese-speaking populations, while the pronunciations are the same. The traditional characters are used in Taiwan and the simplied characters are used in mainland China. Since one of us (Y. Cheng) has developed the traditional Chinese version of the ERI questionnaire for Taiwanese workers with satisfactory back-translation (Tseng and Cheng 2002), our simplied Chinese version was produced by a slight modication of Chengs version. That was to convert the Chinese characters from traditional to simplied and modify some expressions to meet mainland style. To this end, the original English and German versions of the questionnaire were used. Based on this information, the simplied Chinese version was processed and was backtranslated into English to check its agreement with the original. Job dissatisfaction was assessed by a 5-item scale from the Job Content Questionnaire (Cronbachs a coecient =0.61), with a range from 0 (complete satisfaction) to 1 (complete dissatisfaction) (Karasek et al. 1998). In addition, information on education, marital status, economic status, lifestyle and work history was collected. Statistical analysis Analysis of covariance (ANCOVA, adjusted for age) was used to compare the means of ERI scales by gender and occupation. The Cronbachs a coecients were examined to assess the internal consistency of the scales.

Methods
Subjects In this study, three university hospitals in Zhengzhou, China, were surveyed; one was a general hospital, another was a lung and heart care hospital, and another was a mother and child healthcare center. A questionnaire was sent to all 1,093 workers in the in-patient wards of the three hospitals and was returned by 947 workers. The response rates were 86% (651/755), 85% (92/108), and 89% (204/230), respectively. Owing to the small number of male nurses (8) and non-healthcare workers (11), they were excluded from the present analysis. Moreover, some subjects with missing values of gender (23), age (28), job title (31) and missing values of two or more ERI items (46) were also excluded. The excluded subjects did not dier signicantly from the remaining participants in socio-demographic and workrelated characteristics. The nal sample size of this study

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Exploratory factor analysis was performed to test the ERI model, using maximum likelihood extraction and varimax rotation. Pearsons correlation coecients among age, education, ERI scales, and job dissatisfaction were calculated for men and women. Furthermore, multivariate logistic regression was performed to assess the criterion validity of ERI with regard to job dissatisfaction. The upper tertile scores of eort and overcommitment and the lower tertile scores of reward were dened as high-risk conditions, whereas a dichotomized eortreward ratio with a cut-point >1.0 was dened as a high-risk condition for imbalance (Peter et al. 1998; Siegrist et al. 2004). Job dissatisfaction was dened as a dichotomized variable with a cut-point at mean score. All analyses were conducted by the program SAS 8.

criterion of Kaisers eigenvalue >1 and the scree plot analysis, a four-factorial solution was applied. In both men and women, the factor patterns were quite similar and the hypothesized factorial structure is well identied. The second factor indicated eort clearly, and the third factor was associated with overcommitment with the exception of the item overwhelmed by pressure, which loaded on the second factor, whereas reward items loaded on the rst and the fourth factors Table 3.

Table 1 Characteristics of the study subjects (n=800)

Results
Socio-demographic information Table 1 gives information on the sample composition (means and percentages of socio-demographic and occupational characteristics). Of the 800 subjects in this study, 76.0% were women, and 62.4% were married. Mean age of men and women was 33.5 and 29.5 years, respectively. Duration of education was approximately 2.2 years longer for men than for women. Of the men, 35.6% and 63.4%, respectively, smoked and drank alcohol, while few women did so. Mean duration of healthcare work was 10.6 years in men and 9.1 years in women. Men experienced longer overtime work than women (9.9 h vs 3.5 h per week). Accordingly, men, on average, had higher positions and higher salaries than women. A majority of male physicians served in the departments of internal medicine and surgery, whereas the sample of female physicians and nurses was more evenly distributed across the departments. The prevalence of job dissatisfaction among men and women was well comparable (47.4% vs 49.2%). Scores of ERI scales and internal consistency reliability Means and standard deviations for each ERI scale are given in Table 2. After adjusting for age, we found that signicant gender dierences are obvious for all scales, where men, on average, suer from a higher degree of work stress. It should be mentioned that internal consistency of all scales is satisfactory, with a Cronbachs a of 0.78 for eort, 0.81 for reward, and 0.74 for overcommitment. No substantial dierences were found for men and women (details not shown). Factorial validity All 23 items of the three scales were included in an exploratory factor analysis. In accordance with the

Variables

Men (n=192) Mean SD 9.17 2.20 9.13 17.63 9.20 Percentage 68.06 30.37 1.57 40.33 29.28 30.39 53.16 46.84 64.40 35.60 36.65 63.35 100.00 41.71 30.48 27.81 32.28 67.72 51.32 36.65 2.09 2.09 7.85 52.60 47.40

Women (n=608) Mean 29.46 14.33 9.12 42.89 3.54 Number 369 220 11 260 245 90 427 177 590 10 530 48 216 392 359 171 37 180 425 235 134 34 131 74 309 299 SD 7.96 1.91 7.65 15.07 6.24 Percentage 61.50 36.67 1.83 43.70 41.18 15.12 70.70 29.30 98.33 1.67 91.70 8.30 35.53 64.47 63.32 30.16 6.52 29.75 70.25 38.65 22.04 5.59 21.55 12.17 50.82 49.18

Age (years) Education (years) Length of work (years) Time at work (h/week) Overtime work (h/week)

33.48 16.54 10.57 49.78 9.94

Number Marital status Married 130 Unmarried 58 Other 3 Salary (US dollars/month) <100 73 100150 53 >150 55 Exercise No 101 Yes 89 Smoking No 123 Yes 68 Alcohol drinking No 70 Yes 121 Occupation Physician 192 Nurse Position rank Low 78 Middle 57 High 52 Shift work No 61 Yes 128 Department Internal medicine 98 Surgery 70 Emergency 4 and ICU Gynecology and 4 obstetrics Pediatrics 15 Job dissatisfaction No 101 Yes 91

201 Table 2 Means and SDs for ERI questionnaire scales by gender and occupation Scale Male physicians (n=192) Mean Extrinsic eort Reward Eortreward ratio Overcommitment
a

Female physicians (n=216) Mean 14.91 48.28 0.59 15.63 SD 4.63 6.44 0.25 2.97

Female nurses (n=392) Mean 15.61 45.37 0.66 15.88 SD 4.71 7.35 0.30 2.86

Pa

Total (n=800)

SD 5.05 7.63 0.48 3.05

Mean <0.0001 <0.0001 <0.0001 <0.0001 15.63 46.28 0.66 15.95

SD 4.80 7.28 0.34 2.95

16.45 45.92 0.72 16.48

Dierence between male physicians, female physicians, and female nurses (ANCOVA, adjusted for age)

Table 3 Exploratory factor analysis: factor pattern of ERI 23 items using maximum likelihood extraction and varimax rotation (n=800). Only items with factor loading >0.40 are shown Scale Men (n=192) F1 Extrinsic eort Time pressure Interruptions Responsibility Pressure to work overtime Physical demands Increasing demands Respect from superiors Respect from colleagues Adequate support Unfair treatment Job promotion prospects Undesirable change Job security Adequate position Adequate respect and prestige Adequate work prospects Adequate salary/income Overwhelmed by pressure Think about work Relax and switch o work Sacrice too much for job Work still on mind Trouble sleeping at night F2 0.74 0.45 0.56 0.66 0.46 0.53 0.60 0.41 0.64 0.65 0.50 0.42 0.40 0.66 0.68 0.54 0.48 0.50 0.60 0.90 0.50 9.0 0.76 0.67 0.46 0.57 0.61 0.60 0.67 0.68 0.49 0.68 0.52 0.68 0.55 8.2 F3 F4 Women (n=608) F1 F2 0.66 0.48 0.50 0.54 0.50 0.67 0.50 0.79 0.49 F3 F4

Reward

Overcommitment

Variance explained (%)

16.7

12.6

6.1

12.0

11.8

6.0

Criterion validity To explore criterion validity of this measure of workrelated stress, we produced a correlation matrix with the three ERI scales and with age, education and job dissatisfaction, separately for men and women. As indicated in Table 4, extrinsic eort has a signicantly negative correlation with reward and a positive correlation with overcommitment, whereas reward negatively correlates with overcommitment. All ERI scales are signicantly related to job dissatisfaction in the expected direction. In addition, some gender dierence are observed where eort and overcommitment are associated with education in men, but not in women, and where reward is associated with education in women, but not in men. Using multivariate logistic regression after adjusting for gender, age, marital status, education, smoking,

alcohol drinking, exercise, salary, occupation, department, position rank, overwork, and shift work, we found that high eort for men, low reward, and high overcommitment for women, were all independently related to job dissatisfaction. Finally, the core stress theoretical construct of the ERI model, the ERI ratio, was associated with an over ve-times higher odds ratio of job dissatisfaction, thus clearly exceeding the eects of the single components of the model Table 5.

Discussion
This study found satisfactory psychometric properties of the Chinese version of a theory-based questionnaire measuring work stress in terms of ERI. Importantly, an imbalance between high eort and low reward in Chinese healthcare workers was associated with an over

202 Table 4 Correlations among age, education, ERI scales, and job dissatisfaction Variables Gender Variables indicated by number 1 1. Age (years) 2. Education (years) 3. Extrinsic eort 4. Reward 5. Overcommitment 6. Job dissatisfaction Men Women Total Men Women Total Men Women Total Men Women Total Men Women Total Men Women Total 1.00 0.10 0.39*** 0.36*** 0.12 0.07 0.10** 0.03 0.16*** 0.12** 0.13 0.11** 0.13*** 0.12 0.12** 0.13*** 1.00 0.30*** 0.07 0.16*** 0.02 0.23*** 0.13*** 0.18* 0.02 0.10** 0.03 0.06 0.04 1.00 0.51*** 0.38*** 0.42*** 0.51*** 0.56*** 0.55*** 0.27*** 0.24*** 0.24*** 1.00 0.18* 0.32*** 0.29*** 0.44*** 0.40*** 0.41*** 1.00 0.18* 0.20** 0.19*** 1.00 2 3 4 5 6

*P<0.05, **P<0.01, ***P<0.001

Table 5 Adjusted odd ratios of job dissatisfaction by eortreward imbalance, adjusted for age, marital status, education, exercise, smoking, alcohol drinking, salary, department, position rank, overwork, shift work (additional adjustment for occupation in women); 95% condence intervals are shown in parentheses Parameter Extrinsic eort Reward Eortreward ratio Overcommitment *P<0.05, **P<0.01, ***P<0.001 Degree Low High High Low 1 >1 Low High Men (n=192) 1.00 2.90 1.00 1.63 1.00 5.27 1.00 1.13 (1.18, 7.13)* (0.75, 3.56) (1.53, 18.20)** (0.48, 2.63) Women (n=608) 1.00 1.37 1.00 2.98 1.00 5.35 1.00 2.41 (0.86, 2.20) (1.96, 4.54)*** (2.42, 11.81)*** (1.56, 3.72)***

ve-times higher risk of job dissatisfaction. Measuring an adverse psychosocial work environment in a reliable and valid way in specic populations, such as Chinese healthcare workers, is an essential prerequisite for developing targeted preventive measures against this newly emerging occupational disease risk. Preliminary evidence has indicated that this questionnaire can be applied to other occupational groups in mainland China (industrial and transport workers; Xu et al. 2004) and in Taiwan (employees in the microelectronics industry; Tseng and Cheng 2002). Concerns about intercultural comparability of a measurement approach developed in Western societies are certainly justied (Yu 1997), but the ndings, overall, show satisfactory consistency with the ones obtained from psychometric studies in dierent socio-cultural settings (Hanson et al. 2000; Li et al. 2003; Siegrist et al. 2004; Tsutsumi et al. 2001a). More specically, the internal consistency of the scales was well comparable to values obtained from Western studies. Concerning mean scores, eort was rated higher in men than in women in this study, and respective ratings were higher than the ones obtained

from female industrial and transport workers in China (Xu et al. 2004) and from male industrial workers in Taiwan (Tseng and Cheng 2002) and in Korea (Li et al. 2003). Mean scores of reward, summarizing esteem, salary, promotion prospects and job security, were lower in Chinese healthcare workers than in skilled industrial workers, but higher than in semi-skilled or unskilled workers. It is of particular interest to note that all three healthcare groups, male physicians, female physicians, and nurses, exhibit unusually high mean scores of overcommitment. High intrinsic eort in a relatively unrewarding but demanding working context may aggravate negative emotions and stressful experience (Bakker et al. 2000; van Vegchel et al. 2001). The results of exploratory factor analysis demonstrate that the factor solution in both male and female healthcare workers reects the theoretically postulated structure quite well. There is one interesting exception. The item overwhelmed by pressure loads on the eort scale rather than the overcommitment scale, indicating a more externally oriented attribution of work stress. As similar ndings are reported from other Asian studies (Li

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et al. 2003; Tseng and Cheng 2002), respective cultural connotations deserve more attention. Theoretically, the reward scale consists of three components: the nancial and career-related aspects, the esteem rewards, and the gratication of job security (Siegrist 1996; Siegrist et al. 2004). In this present study, the reward items loaded on two factors, which was also found in other Asian studies (Tseng and Cheng 2002; Tsutsumi et al. 2001a; Xu et al. 2004). This could be approved in the postulated assumption of the ERI model, in return. Moreover, we performed a conrmatory factor analysis additionally, to test the dimensional structure of the theoretical model (data not shown). The goodness of t index (GFI) for each ERI scale was over 0.90, in agreement with the European studies (Siegrist et al. 2004). This information indicates the satisfactory data t with the ERI model as the statistical justication. Gender dierences in work stress could be observed in our study. Men scored higher in eort and overcommitment but lower in reward than women. This pattern was reversed in other studies, particularly for reward (Tseng and Cheng 2002; Siegrist et al. 2004). A closer look at the correlation matrix (Table 4) reveals that women with higher education, contrary to men, did not exhibit higher eort or higher overcommitment but did receive higher reward. This fact may reect a continued impact of traditional gender roles on attitudes and motivations where pressure towards professional success is felt much more directly by upwardly mobile men than by women. As a consequence, men expose themselves more often to demanding situations and react by high intrinsic eort. Women are exposed to a lower workload as they are expected to accept more family-related obligations (Lee et al. 2002; Nelson and Burke 2002). Furthermore, during the past ve decades, Chinese womens working conditions and health status have been improved greatly, especially the empowerment of women in the communist society. The comparably equal payment and accessible opportunity at work make well-educated women perceive a higher reward from work than men (Christiani et al. 2002; Yu and Sarri 1997). Obviously, this interpretation calls for an indepth exploration of gender roles in work stress research (Nelson and Burke 2002). In terms of criterion validity, this study found consistent associations of all scales of the model with a validated measure of job dissatisfaction, both in men and women. As predicted by theory, eects were strongest for the combined measure (eortreward ratio), and they remained almost unchanged after adjusting for a large number of confounding variables. As job dissatisfaction predicts the intention to change or leave the job (Cherniss 1992), these ndings are of interest to those who are responsible for hospital management and for the planning of healthcare personnel. Several limitations of the study need to be discussed. First, given the cross-sectional design and the absence of any objective measure of the criterion variable, the validity of reported results is restricted. In particular, it

has been argued that reporting bias (e.g., due to a negative attributional style) invalidates reported associations (McLeod et al. 2001). This criticism cannot be ruled out by the present study, but is met by evidence from prospective investigations, based on ERI measures, that include data on incident physical disease, such as coronary heart disease, and that furthermore control for attributional style (e.g., Kuper et al. 2002; Kuper and Marmot 2003; Schnall et al. 2000). There exists at least one study in mainland China on criterion validity of ERI measures, using an objective health indicator. In their investigation on work stress, family stress, and health, Xu et al. (2004) have shown a signicant interaction eect of ERI at work and of family stress on systolic blood pressure. A second limitation points to our sample, which is restricted to healthcare workers in university hospitals. Accordingly, urban and higher socio-economic groups are probably over-represented with regard to the composition of Chinese healthcare workforce. Nevertheless, no systematic recruitment bias was observed, and the sample size was appropriate for application of the statistical analyses that are needed for psychometric tests. Finally, the results of this report do not represent all analytical options oered by the ERI model. Additional analyses could be performed to test an interaction term between the eortreward ratio and overcommitment (Bakker et al. 2000), to explore the eects of single components of the reward construct (van Vegchel et al. 2001), or to analyze continuous data of the eortreward ratio (Pikhart et al. 2001). Moreover, separate and combined eects of the ERI model and the demand controlsupport model need to be tested in future studies, as has been successfully done in several studies (Kivimaki et al. 2002; Ostry et al. 2003; Pikhart et al. 2001; Siegrist et al. 2004; Tsutsumi et al. 2001b). In conclusion, despite these limitations, this study found evidence to support the use of measuring psychosocial stress at work in terms of the ERI model in a reliable and valid way in Chinese healthcare workers. In addition, job dissatisfaction was strongly associated with perceived work stress. These ndings may support efforts towards reducing stress at work in healthcare professions and beyond.
Acknowledgments The authors gratefully acknowledge Miss Lili Ding for her professional translation from German to Chinese, and Dr. Laiyong Tan and Dr. Zhijiang Zangs back-translation to English during the development of the questionnaire. Last but not least, the authors thank the two referees for their helpful suggestions.

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