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Co py rig hte dM ate ria l
Barbara Curbow, Ph.D.*, † David J. Laflamme,* M.P.H., C.H.E.S. Jacqueline Agnew, Ph.D.†
School of Hygiene and Public Health, Johns Hopkins University Baltimore, Maryland There is increasing evidence that a high percentage of workers are exposed to occupational stressors on the job and that these stressors can contribute to a wide range of negative health outcomes including cardiovascular disease, musculoskeletal disorders, psychological disorders, injury, suicide, cancer, ulcers, and impaired immune function.1 In the environmental literature, stress has been associated with the perception and the reporting of symptoms related to indoor air quality (IAQ). Most frequently, this association is discussed within the context of sick building syndrome (SBS). In general, sick building syndrome “can be thought of as one of a spectrum of workplace disorders that are characterized by a variety of nonspecific somatic and psychological symptoms” (p. 220).2 Other commonly cited aspects of SBS are the worsening of symptoms during hours spent in the building and improvement on leaving the building and, often, an inability to find specific physical environmental causes. The problem of workplace stress often arises in building investigations, and in fact, the occurrence of SBS may heighten awareness of stressors and stress. This chapter is designed to provide information for two audiences: IAQ researchers and IAQ problem solvers. Researchers may focus more on the application and development of the theories and methodological issues that we discuss. Problem solvers may be more interested in the relevance of these theoretical and research issues for implementation of solutions. In the first section of this chapter, we will define the concept of stress and present the major occupational stress conceptual approaches. This will be followed by a discussion of some possible models of the IAQ–stress link. In the next section, we will present an overview of the literature on the IAQ–stress link, and we will discuss the variables that have been most frequently investigated. In the third section, we will discuss measures of occupational stress as they represent the major conceptual approaches. In the final section, we offer suggestions concerning implementation of these theories in the workplace.
* †Department


Department of Health Policy and Management, Faculty of Social and Behavioral Sciences. of Environmental Health Sciences, Division of Occupational Health.

55.1 Copyright © 2001 by The McGraw-Hill Companies

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What Is Stress? Although the terms job stress and occupational stress are frequently used common parlance, in the research literature they must be distinguished from two related concepts: stressors and strain. Job stressors are the work-related environmental conditions or exposures that can potentially affect the psychological, social, and physiological health of an individual.3 Stressors can be measured subjectively (i.e., a worker’s perceptions of the environment) or objectively (i.e., actual characteristics of the environment). Strain refers to the negative outcomes (psychological, social, physical, and behavioral) associated with exposure to stressors.3 Stress is an intervening variable between stressors and strain. Using a definition by Lazarus,4 stress is the sense that environmental events tax or exceed the person’s resources. The relationships among stressors, stress, and strain are depicted in Figure 55.1. Also included in the figure is another class of variables—modifiers. As will be discussed below, several of the dominant occupational stress models assume that the stressor → stress and the stress → strain relationships can be altered by the presence or absence of modifying variables, which are generally classified as external to the person (e.g., social support) or internal to the person (e.g., coping strategies, self-esteem). For example, a common hypothesis in the literature is that people who are exposed to stressors but who have high social support will not experience effects as negative as will people who have low social support.

Co py rig hte dM ate ria l
Conceptual Approaches in Occupational Stress We begin a discussion of measurement issues with an overview of the dominant conceptual approaches in the occupational stress literature because the selection of an approach should guide the variables that are examined in a study of the stress–indoor air quality link. Vagg and Spielberger5 recently described the four major conceptual approaches that have informed the general occupational stress literature: person–environment fit (P–E fit),6 the demand–control model,7 the effort–reward imbalance model,8 and the transactional model of stress.4 Although these models represent different views on the roles of the environment and the individual in the etiology of strain, shared aspects can be found among them. Person–Environment Fit. According to Hurrell et al.,3 the modern era of research on job stress began in the early 1960s at the University of Michigan. French and Kahn9 (cited in3) began a program of research on particular aspects of the work environment that might be detrimental to the individual. These aspects included role ambiguity, workload, role conflict, having responsibility for other persons, and relationships among members of the group. This early research led to the formulation of the P–E fit model of job stress, which emphasizes the goodness of fit between the “characteristics of the person and the properties of the environment.”10 Although Vagg and Spielberger5 characterized P–E fit as the “most influential” and “most widely accepted” of the job stress models, they also noted that it has been heavily criticized on both theoretical and methodological grounds. However, there is empirical support for it in the literature. For example, Conway et al.10 demonstrated that a misfit between perceived and desired levels of control was associated with poorer psychological adjustment. Demand-Control Model. The demand-control model of stress is concerned with the interactive effects of levels of job pressures (demands) and decision latitude (control).11 Different outcomes are associated with varying levels of demands and control.11 High demands and
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Fletcher and Jones12 found small but independent effects (i. The concept of job Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. For example. This newer model states that “stress occurs when there is a lack of reciprocity between the effort that a worker puts into a job and the potential rewards she or he receives for completing it” (p.” which can lead to high job motivation.g. there is high work stress.METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS 55.. coping resources) and two (demand–control and effort–reward imbalance) focus on additional aspects of work (e. but only the control component of the demand–control model was associated with increased risk. low control are associated with high levels of psychological strain. Siegrist. but relationships with blood pressure were in the opposite direction.. Effort–Reward Imbalance Model.15 Stress can occur when the person does not have the necessary resources—whether they are internal to the person (e. Shared Features..e.. job control or job rewards) as modifiers of the stress response. All four of these models point to the importance of environmental stressors in the chain of events leading to a strain response. Although support has been found for the model by many researchers. Key to this model is the notion of resources or what a person “draws on in order to cope” (p. Lazarus’4 conceptualization of the stress process differs from the previous three. 323). which leads to health-related problems. In his model. and low demands and low control are associated with low job motivation.7.g.3 Stimulus (stressor) Intervening Variable (perceived stress) Response (strain) Co py rig hte dM ate ria l Modifying Variables FIGURE .5 Under conditions of high effort in response to external work pressures but low potential for reward (e. Bosma. high demands and high control are associated with “good stress. potential stressors from the environment are subjected to a twostage appraisal process: The person first appraises whether the event is a challenge or a threat and if it is the latter. The concept of work rewards (or resources) has been investigated by other researchers in job stress—notably by Barnett and colleagues. social support)16—to adequately respond to the external threat. 158).13 recently tested the effort–reward imbalance model against the demand–control model in predicting the risk of coronary heart disease and found that the full effort–reward imbalance model was associated with increased risk.g...11 Karasek et al.g. he or she then appraises the level of coping resources available to deal with the event. promotion).14 Transactional Model.1 Perceived stress as an intervening variable. Bosma et al. no interaction) for demands and control in predicting psychological strain and job and life satisfaction. an optimistic disposition) or external to the person (e. Peter. and Marmot13 found support for the predictive ability of control but not demands for explaining new cases of coronary heart disease. 295). The demand-control model does not rule out a role for individual difference variables. Two of the models (P–E fit and transactional) focus on the role of individual characteristics in modifying the stress response (e. others have found that there is incomplete support for it.11 write: “A dynamic version of the model integrates the job strain and active behavior hypothesis with personality characteristics measuring accumulated strain and self-esteem development7 with the goal of predicting strain development and learning over time” (p.g.

some researchers have found the main effect for control to be the most highly predictive component of the model. for example. do not explicitly measure the individual’s overall sense of being taxed or overburdened by stressors. reference . it is necessary to focus on how the concept of indoor air quality fits within it. Additionally. However.g. job dissatisfaction Job/task demands • Work load • Control Organizational • Role demands • Management • Career security • Interpersonal Physical Conditions Illness Physiological heart rate blood pressure Hypertension CHD Alcoholism Mental illness Behavioral sleep substance use Financial status Family Social support Coping Nonwork Buffers FIGURE 55. health outcomes. all of the approaches mentioned. affect. Job Stressors Acute Reactions Psychological.2) integrates features of several of the dominant job stress models: It incorporates the measurement of stressors and job control and investigates their relationships with strain indicators and. all of these modIndividual Factors Personality Stage of career control is compatible with all of the models. The only component not found in the NIOSH model is the concept of perceived stress—as used as an intervening variable. ultimately. 55.knovel. (From Hurrell.10 using the P–E fit model. it holds that the relationship between stressors → strain can be modified by internal resources and external factors.18) Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www.. The NIOSH Job Stress Model18 (Figure 55. Three illustrative models of the stress–indoor air quality link are presented in Fig. misfit between perceived and desired rewards). As noted earlier. Conway et al. two of the models explicitly acknowledge the importance of positive aspects of work (effort–reward imbalance and transactional) and the notion is compatible with the P–E fit model (e. found that a misfit between perceived and desired control was associated with poorer psychological adjustment. stress.55. the NIOSH model represents an integrated model that can be used to conceptualize the aspects of the work environment and the person that may be critical to measure..4 ASSESSING IAQ Co py rig hte dM ate ria l The NIOSH Model. except for the transactional model.2 NIOSH model of job stress and health. Models of the Indoor Air Quality–Stress Relationship After selecting a conceptual approach to guide measurement of stressors. in fact.13 Having control at work can be conceptualized as a rewarding aspect of work (effort–reward imbalance). Finally. and strain.3. In fact. Control is a central aspect of the demand–control model and. and perceived control has often been conceptualized as a personal resource that assists in adapting to stressors.

g. other workplace stressors. especially when they are coupled with poor worker–management relationships.. When the stress-related symptoms are linked with some physical environmental cue (e. It is important to note that such a model would assume that the problem lies in the physical environment of the workplace and that IAQ problems would be perceived as stressors by most. This.3 Possible models of the IAQstressor link. leads to an increase in the perception and reporting of symptoms. In model B.g. be investigated within the demand–control or effort–reward imbalance conceptual frameworks such that these two aspects of the environment could be assessed for their associations with symptoms. for example.5 els could be elaborated to include other factors. This explanation is often used post hoc by researchers when no detectable physical environmental cause can be found for the symptom reporting. problem solving. study design. of the exposed . Model A. It assumes that the problem originates in the psychosocial climate of the workplace. Model B. exposure to workplace stressors leads to an increased perception of IAQ symptoms. at a minimum.g. irrespective of the actual exposure to contaminants. In model A.”21 Typical of the explanation of the stress–IAQ link is the following reasoning: High levels of occupational stress.”19 “mass hysteria. exposure to IAQ problems is considered a stressor within the workplace. and worker–employer relationships. for example.knovel. it would need. in turn. but they have very different implications for measurement. odor) or some social environmental cue from coworkers (e. and individual factors. the perception of IAQ symptoms is caused by some combination of actual exposure to IAQ problems. These models are all conceptually plausible. Model C. This model is compatible with explanations for the stress–IAQ link such as “mass psychogenic illness. careful measures of the physical environment and a measure of perceived stress.. at a minimum. IAQ problems could follow this same pattern. lead to an increase in stress-related symptoms (e. in a poor organizational climate.METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS 55. fainting). In model C. Much as exposures to cold or noise at work are thought of as physical stressors that may increase perceived stress and lead to both physiological and psychosocial effects.”20 and “epidemic psychogenic illness. This model might lead to hypotheses such as the following: People who are exposed to poor IAQ and who A Co py rig hte dM ate ria l Exposure to work stressors Perception of IAQ symptoms B Exposure to IAQ problems Increased perceived stress C Exposure + Stressors + Individual factors Perception of IAQ symptoms FIGURE 55. Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. It could. measures of the environmental stressors and perceptions/reporting of symptoms. if not all. fatigue).. If this model were to be tested. Investigators taking this stance would need. the stress-related symptoms may be misattributed to IAQ by workers.

relationships with coworkers) modifiers.. although IAQ is often suspected. difficulty in concentrating. the term SBS is used to describe a variety of symptoms reported by workers in a common building. and sensitivity to odors. workplace. allergies) and external (e.25 Many studies have focused on IAQ as a cause for SBS and frequently have shown that complaints are not fully explained by contaminant levels.29 Although a few studies have used case-control designs. SBS symptoms reported by workers include eye. For an in-depth discussion of SBS refer to Chapter 66 in this handbook. nose. and transactional conceptual frameworks. No specific cause or illness can be identified. allergies) or psychological (e. research into this area has shown that nonbuilding-related factors contribute to SBS.. Nearly 100 additional review and discussion articles were also retrieved and examined. it was comprehensive and representative in scope. and the have high levels of workplace stressors and/or who have either a biological (e. This model would be compatible with the P–E fit. usually an office building.. Table 55. the psychosocial environment. relevant internal (e.22 The bibliographies for several of the major articles were cross-examined for commonly cited articles. or throat irritations.1.55.2 THE IAQ-STRESS LINK: REVIEW OF THE LITERATURE Overview The literature reviewed here was compiled principally through online searches of the National Library of Medicine’s PubMed database and the American Psychological Association’s PsycINFO database. and affected workers commonly show no clinical signs of illness. the psychosocial work environment. These were used in various combinations. in this chapter we will present a review of SBS studies that have included measures of occupational stressors and psychosocial factors. indoor air pollution.28 The prevalence of workers with at least one SBS symptom has been reported to be as high as 70 percent.26 For this reason. dizziness.27. and these were obtained. depression.g. Several review/discussion articles and empirical articles containing no psychosocial variables are also cited. sick building syndrome.6 ASSESSING IAQ Co py rig hte dM ate ria l 55. Several more articles came from the Indoor Air 99 Conference Proceedings CDROM. high trait anxiety) vulnerability would perceive and report a higher level of symptoms. researchers would need measures of the physical work environment. The World Health Organization defines it as “specific symptoms with unspecified aetiology which are experienced by a proportion of people working or living in a particular building and disappear after leaving it. anxiety. More than one study examining SBS complaints found that they were not associated with IAQ. Using this model. Although the search was not exhaustive. headache. fatigue. and indoor air quality. mass psychogenic illness. dry cough.g. psychological stress. the majority Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. psychosocial. however they are not included in Table 55. This model would assume that the problem might lie in a combination of the physical environment. . and symptom perceptions and reporting. Some of the key words used in the search were stress.”23 Sick building syndrome symptoms are most evident during the work shift and diminish or disappear upon leaving the building. As noted earlier.knovel.1 contains the 17 empirical articles containing psychosocial variables that are cited in this section.. dry or itchy skin. Although the name implies that building factors are the cause of the symptoms. A total of 29 articles containing original empirical data on psychosocial variables relating to sick building syndrome or indoor air quality were retrieved and examined.g. NIOSH.24 These symptoms are often vague and difficult to measure.g. nausea.

psychological job demands. Neurobehavioral Symptom Checklist. in the absence of significant levels of IAQ pollutants. attitude toward tobacco smoke exposure. supervisor support. Can’t attribute SBS to psychological factors alone. and Perceived Stress Scale Job satisfaction scale adapted from Job Satisfaction Scale4 Cross-sectional Questionnaire: MMPI. decision latitude. job satisfaction and social support from the family. 55. Perceived Stress Scale. environmental exposures. Control. Symptom Checklist-90-Revised. and VDT use significantly associated with total number of SBS symptoms. decision latitude. or NSC. job category.1 IAQ-Stress Studies Study Influences on sick building syndrome symptoms in three buildings34 N/number of buildings* 624/3 py rig hte dM ate ria Country Instrument Design Measurements South Africa Profile of Mood States Cross-sectional Questionnaire: psychological state. smoking history. Canada A component of Karasek Job Content Questionnaire and a component of the NIOSH General Job Stress questionnaire Case-control Findings Psychological symptoms predictive of SBS symptoms. job satisfaction. Also skill discretion. job stress. Also odors.knovel. decision authority. physical environmental variables. reports of SBS. job satisfaction. in-house neurobehavioral symptom checklist. Symptom Checklist-90Revised. musculoskeletal pains. and decision authority when substituted in logistic model for skills creation. family support. These personal and occupational factors account for 10% of variation in the number of SBS symptoms reported. The role of psychosocial factors in the report of building-related symptoms in sick building syndrome33 111/3 Effects of personal and occupational factors on sick building syndrome reports in air-conditioned offices26 3155/18 Gender.TABLE 55. Smoking associated w/symptoms. skills . job insecurity. interpersonal relationships at work. SBSϩ and SBSϪ groups did not differ significantly in PSS. physical exertion. humidity and temp. Investigation of factors affecting mass psychogenic illness in employees in a fish-packing plant57 269/1 Mass psychogenic illness symptoms associated strongly w/skills creation. coworker support. VDT use. MMPI. United States Cross-sectional Questionnaire developed from first author’s previous work. SBS symptoms. SC-90-R. Perception of sociocultural stressors (work and outside work). job stress. skills creation. Job stress not statistically significantly associated w/SBS. Job stress. United States MMPI.7 Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. Smoking policy used to separate into experimental groups.

These variables were controlled while studying symptom reporting differences by study situation and physical environment. Health symptoms and the work environment in four nonproblem United States office buildings28 646/4 No strong relationships between symptoms and air contaminants. perception of the physical environment.1 IAQ-Stress Studies (Continued ) Study Performance. mood. outside of work. . work satisfaction. work content. study situation and sensitivity45 N/number of buildings* 90/— py rig hte dM ate ria Country Instrument Design Measurements United States Semantic Differential Measures of Emotional State questionnaire Experimental Odor. and the NIOSH Job Stress Instrument Cross-sectional Sweden Psychosocial rating scales included in article Retrospective Work stress. 11 buildings Degree of psychosocial dissatisfaction and SBS associated. NIOSH-NCHS building and Library of Congress building study questionnaires. Degree of psychosocial dissatisfaction and SBS associated.TABLE 55. Psychosocial stress. as well as other nonpsychosocial variables. Indoor air quality and personal factors related to the sick building syndrome36 Volatile organic compounds. influence over job tasks. task performance and mood effects associated with malodor. respirable dust. job satisfaction. stress at work.knovel. hard or fast work. believed odor effects. 129/6 55. health symptoms. perceptions of environment. demands control and social support. decision latitude. conflicting supervisory instructions. workload. conflict in supervisory instructions. job stress) less strongly associated w/symptoms. Strongest symptom association with perceived physical workspace condition. Questionnaire: SBS symptoms. work satisfaction. climate of cooperation during the last 6 months. working hard or fast. Psychosocial factors (job satisfaction. and personal factors related to prevalence and incidence of sick building syndrome in primary schools37 . as well as other nonpsychosocial variables. psychosocial index. climate of cooperation at work. mood. 528/2 A combination of stress from psychosocial factors and physical factors is associated with symptoms and satisfaction w/IAQ. Multifactorial origin. (Not specifically an SBS study) Sweden Case-control .8 Copyright © 2001 by The McGraw-Hill Companies Retrieved from: . United States Adapted from a variety of instruments including EPA Indoor Environmental Quality Survey. task performance. and health during exposure to intermittent odors58 Covariations among attitude to the indoor air quality. Multifactorial origin. psychosocial index Findings Believed health. Sweden Psychosocial rating scales included in article Longitudinal Work stress.

work stress.TABLE 55. A case-referent study of personal. quantity of work inhibits job satisfaction. work functions. Epidemiology of sick building syndrome and its associated risk factors in Singapore30 2856/56 Influence of personal characteristics. and psychosocial factors on the sick building syndrome60 2829/19 The sick building syndrome (SBS) in office workers. temperature. noise. youth. psychosocial factors (influence on organization of the daily work. little influence and high work pace. A casereferent study of personal. IAQ did not predict SBS symptoms. High levels of work-related stress. job category. and degree of personal influence). Questionnaire: psychosocial work index. predicted SBS symptoms. Facial skin symptoms. buildingand VDT-related risk indicators35 339/— Psychosocial conditions related to an increased prevalence of reported SBS symptoms. Sweden Questionnaire described and validated in previous article by same author and referenced in this one Case-referent (matched casecontrol) Sweden Questionnaire described and validated in previous article by same author and referenced in this one Case-referent (matched case-control) Psychosocial work index. SBS symptoms. Complaints not predictive of IAQ. age. sex. Workload index strongest. work speed. Singapore Cross-sectional Questionnaire: stress. too much noise. Singapore Cross-sectional Questionnaire: . airflow. health history. varied work.9 Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. temperature. work place position. history of allergy or other medical conditions. Only dissatisfaction with superior or with quantity of work had significant effect on symptoms if all included. personal factors (including work satisfaction. Dose-response. health complaints typical of SBS were stress related. sex. satisfaction w/superior. work load/support index. noise. Building factors strongly associated. psychosocial. 55. poor lighting. 163/— Psychosocial conditions a risk factor for facial skin symptoms in VDT users. Findings Psychosocial work climate has influence on SBS symptom prevalence. work load index. . All psychosocial factors strongly associated w/symptoms when added separately. Sweden Cross-sectional Questionnaire: SBS symptoms. Denmark Cross-sectional Questionnaire: building factors. psychosocial. Influence of indoor air quality and personal factors on the sick building syndrome (SBS) in Swedish geriatric hospitals59 Sick building syndrome: An emerging Stress-Related Disorder27 2160/6 In buildings w/no recognized environmental problems. and building-related risk indicators38 Facial skin symptoms in visual display terminal (VDT) workers.knovel. eye irritation associated with psychosocial work climate.1 IAQ-Stress Studies (Continued ) Study N/number of buildings* 287/8 py rig hte dM ate ria Country Instrument Design Measurements Sweden MM040B (Department of Occupational Health in Orebro. job-related factors. lighting. female.

Netherlands Cross-sectional Electronic questionnaire: satisfaction with welfare (tasks. No relation between indoor climate and other aspects of quality of working life61 80/4 People in this setting (university chemistry departmen did not misattribute their dissatisfaction to the wrong source. fire hazards.10 Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www.) Findings Gender differences in SBS symptoms found to be . relationships. toilets.1 IAQ-Stress Studies (Continued ) Study Why do women report ‘sick building symptoms’ more often than men?40 N/number of buildings* 4943/— py rig hte dM ate ria Country Instrument Design Measurements Sweden Physchosocial workload index described in previoous article by same author and referenced in this one Cross-sectional Gender. equipment. cleaning. SBS symptoms. and perceptions of psychosocial work conditions (psychosocial work index— same as above). personal factors. perceptions of physical conditions. rather than a reporting behavior difference. light. 55.TABLE 55. etc. furniture. *N ϭ number of subjects/workers. noise. working hours. physical health problems. exposure factors at home and work. and conditions at work) and safety and health (indoor climate.knovel.

temperature. humidity. used their skills at work. and a variety of other measures. Interpersonal work relationships were not found to be associated with SBS symptoms. many of which are poorly understood or simply unknown.33 in addition to being responsible for increased rates of lung cancer. .1). Perceived physical workspace condition has also been shown to have a strong association with symptom reporting.28 Psychosocial Stressors Organizational factors such as work climate have not been as well examined in relation to SBS but nonetheless may have an effect on symptoms. there is the danger that levels of contaminants will increase because of occupants shutting down the noisy unit and interrupting the flow of proper ventilation. rewarding or satisfying. temperature. Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. In a matched case-control study of SBS in office workers.METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS 55.knovel. and found their work interesting. Physical Stressors Physical stressors that have been measured in SBS studies include environmental tobacco smoke. Higher temperatures have been found by others to be connected with higher levels of symptoms.11 Co py rig hte dM ate ria l Stimulus (Stressors) Numerous stressors have been investigated in relation to sick building syndrome. Results from a study of 2856 office workers in 56 buildings30 included noise. chose their work. The Office Illness Project in northern Sweden35 linked work responsibilities. These fall into two basic categories based on measurement characteristics: physical and psychosocial stressors.” These concepts coincide nicely with the demand–control model described earlier. Often the physical stressors are measured objectively. Sick building syndrome is perhaps best explained using a multifactorial approach such as that depicted by the model in Figure have used cross-sectional questionnaires and causal relationships are consequently difficult to assess (see Table 55.” “too much work to do.31 Noise complaints have originated from ceiling-mounted unit ventilators. Tobacco smoke is an environmental factor that has been found to be associated with SBS symptoms. such as video display terminal (VDT) use. lighting. chose how and when to work. Ooi and Goh27 found similar results. interpersonal work relationships were also investigated in this study. and poor lighting among the stressors that predicted SBS symptoms.37 found that a negative climate of cooperation at work was positively associated with SBS symptoms. details were not provided on how this factor was measured. and temperature in three buildings studied by Bachmann and Myers34 were related to an increase in SBS symptoms. with facial skin symptoms. vibration. Job stress was not statistically significantly associated with SBS symptom reporting. The variables described below are categorized by the headings in this model. Bachmann and Myers34 based their measurement of job stress on questions asking the “extent subjects had enough time for their work.” and “opportunity to influence the working conditions.32 When noise stems from ventilation units. Interestingly. It is important to keep in mind that many of the variables discussed in this section are surrogates for actual measures of the causes of SBS.38 the psychosocial workload index was related to an increased prevalence of symptoms.1. and the psychosocial stressors are measured subjectively. The authors of this study created an index for psychosocial work from three questions asking about “interesting and stimulating work. although this is not always the case. However. Odors.” The authors cite Karasek’s work6 as the basis for these questions. had spare time. Two Swedish studies36. noise.

mediating the effects on each individual.” Their findings suggest that the gender differences in SBS symptoms are not the result of reporting behaviors. Regarding the effects of age. tiredness. Ooi and colleagues30 found that younger employees reported more SBS symptoms than did older employees.30.27 Stenberg and Wall40 reported “females and males work under unequal physical and psychosocial conditions. finding that these predicted several SBS symptoms. claustrophobia. A history of allergy.34 It is not clear why females report symptoms at higher rates. however. not surprisingly.30 This is an example of why it is so difficult to determine the causes of SBS—symptoms of SBS often match symptoms of other conditions such as allergic reactions.44 but these are general multifactorial inventories of personality. Crawford and Bolas.knovel. All of these factors were found to be statistically significantly associated with SBS symptoms. Ooi and Goh27 had subjects rate the climate of cooperation at work on a 10-point scale ranging from 0 (not stressful) to 10 (extremely stressful). concluded. Because it is known that females generally report health symptoms more than men do.41 One study of SBS in three buildings34 used questions derived from the Profile of Moods States Questionnaire to measure psychological symptoms such as In a study of four nonproblem U.34.” Personality has been postulated as potentially playing a role in SBS. They may be protective or they may increase susceptibility and are generally classified as internal or external to the person. Measures that are more specific should be included in future research to better define the possible relationship between personality and SBS symptoms.55.28 a scale for job stress was based on the demand–control model. Odds ratios calculated for these three measures showed consistent incremental changes that the authors concluded were suggestive of a positive dose–response relationship Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. including…the NIOSH Job Stress Instrument. irritability. Job satisfaction and conflicting supervisory instructions were also investigated. “it is arguable whether psychological symptoms are a cause or an effect of SBS. forgetfulness. Intervening Variable (Perceived Stress) Job stress has consistently been shown by several studies27. has been shown to be predictive of SBS symptoms. The researchers hypothesize that this effect could be a result of environmental adaptation and a self-selection process among older employees who had worked in the building longer. the Eysenck Personality Inventory. and they may not be specific enough to be of much use. although the relationships were not very strong. incorporating scores for perception of influence over work and having to work hard.42 Personality may act as a modifier between stressful workplace characteristics and SBS outcomes.12 ASSESSING IAQ Co py rig hte dM ate ria l Modifying Variables Modifying variables act to moderate or mediate the effects of stressors on the person. anger. “the handful of studies in the area are inconclusive.45 to be predictive of SBS symptoms.” .43 in their review of SBS studies investigating personality. Some researchers posit that women are simply more attuned than men to physical symptoms. or Raven’s Standard Progressive Matrices.S. depression. Mood states have also been shown to account for differences in symptom reporting between men and women. Internal. The authors noted. Work-related physical and mental stress were similarly evaluated.” It has been measured using instruments such as the Minnesota Multiphasic Personality Inventory.39 it is not unexpected to learn that this finding carries over into SBS symptom reporting. A definition of stress was not provided to the respondents. office buildings. “The questionnaire was adapted from a variety of instruments used by other researchers. and difficulty sleeping or concentrating.

no significant effect modification was found.13 Co py rig hte dM ate ria l Summary of Literature Review Overall. Use of Theory. uncertain. as seen in the previous section.1 shows that the targeted domains. Factor analyses were performed on both scales. and job control play significant roles in SBS. the occupational and personal factors investigated in this study only accounted for 10 percent of the variation in the number of SBS symptoms reported. or biological exposures. mostly agree. several studies of indoor air effects have included psychosocial measures. have varied . Doing so will not only improve the validity and reliability of the measures in SBS studies but also will allow for cross-comparisons and pave the road for future meta-analyses. The possibility of interaction between the perception of stress and several covariates (thermal discomfort. few have explicitly related the selection of variables to a conceptual theory. between stress and SBS symptoms. Job stress. or confounding effects on the health outcomes of interest.26 job stress and job satisfaction were measured using several questions answered on a 5-point rating scale (strongly agree. job satisfaction. A theory-based approach to the investigation of indoor air quality questions provides a framework that guides both the selection of appropriate variables and the examination of their statistical relationships. Table 55. Additionally. Still. studies Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. In another study investigating the effects of personal and occupational factors on SBS reports. medical condition. This enables characterization of the modifying effects of psychosocial variables in relation to environmental measures of chemical. yielding Cronbach’s values of .3 INSTRUMENTS AND MEASUREMENT ISSUES Problems Found in Existing Studies Although. The instruments used in the studies to date have been quite varied. job demands. strongly disagree). 55. Gender has clearly been identified as a confounding variable in SBS studies. Additionally. Many investigators refine their instruments from study to study or adapt the instruments used by others. in the absence of significant levels of IAQ pollutants. physical. Most studies designed with a psychosocial component have not addressed a comprehensive set of relevant domains.knovel.90 for job satisfaction and .70 for job stress. however. noise.METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS 55. An attempt to develop summary statistics for the variables in the studies listed in Table 55. the literature supports the theory that SBS symptoms are not always related to IAQ problems. making it difficult to compare between studies. modifying. and researchers and other SBS investigators must remember to stratify by gender when performing analyses. It also allows for inclusion of variables previously reported to be associated with health outcomes.1 proved nearly impossible due to the inconsistencies in the measurement methodologies used in each study. Six questions making up the job satisfaction scale were adapted from a previously constructed job satisfaction scale. There is an explicit need to increase the use of validated measurement instruments such as the ones described in the next section. lighting.2 allows for the comprehensive inclusion of relevant domains that may have main.4 The five items making up the job stress scale were adapted from several sources. age) was investigated. mostly disagree. A model such as that presented in Figure 55. as well as their respective measures. Both job stress and job satisfaction were significantly related to the total number of SBS symptoms.

In addition to content validity. The development of occupation-specific measures is a complex and iterative process. Generic Instruments. it is desirable to limit random measurement error by ensuring that the instrument is characterized by two forms of reliability. Examples are the scales typically used to measure workrelated control.36. based on job stress models. demands. Thus. Better ascertainment and documentation of measurement characteristics would strengthen studies of the indoor environment–stress link. in the analyses. would constitute a contribution not only to the study at hand but also to future investigations. a number of investigators have employed measurement techniques for psychosocial concepts without reporting their respective psychometric properties. or conceptual clarity. Most studies that have considered the relationship between jobrelated stressors and health outcomes have depended on the use of generic measures to describe levels of job stressors. This has been addressed by Baker.. internal consistency and stability over time.55. . A recent issue of the Journal of Occupational Health Psychology was devoted to overviews of these instruments3.knovel. have been developed by our team and used with worker populations such as childcare. For example. Job Content Questionnaire11). and construct validity. Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. For example. another desirable property. the relative importance of single domains within the index will not be apparent. To support sound inferences. occupation-specific stress measures. This process. telecommunications. Several standardized instruments are available for which validity and reliability have been established. psychosocial domains should be represented by measures that meet acceptable levels of validity and reliability.5 and to in-depth reviews of specific instruments. but it can better help explain the variance observed in stress-related health outcomes and thus better guide the design of effective preventive interventions. Item intercorrelations and test-retest analyses provide the means for assessing these characteristics. Finally. Although these tools can be used to demonstrate general effects of work factors on stress. Thus. measures should have established face validity. designed according to a theoretical model avoid redundancy among variables unless it is an aim of the study to develop or validate new measurement instruments. and social support (i.14 ASSESSING IAQ Co py rig hte dM ate ria l Psychometric Properties.38 This approach neglects the richness of the data set and masks the influence of specific components of the index on any observed associations. the use of composite indexes does not inform decisions regarding preventive interventions. combining responses for separate measures. a limitation is their inability to identify specific work-related stressors. which indicates the ability of a measure to address its respective domain of the conceptual theory. Predictive validity.47 who pointed to the need to identify specific stressors in developing realistic prevention strategies for reducing stress. which can take considerable effort. Some investigations have collected data on several psychosocial variables but have subsequently included only one composite index. and military workers.46 but this relationship is obscured when the values for level of social support are embedded within a summed composite index. Major Comprehensive Instruments There has been a proliferation of broad-based comprehensive job stress measures over the past two decades. indicating comparability of responses with other measures of the same constructs.e. represents the degree to which the measure is known to correlate with expected criteria such as anticipated health outcomes. social support has been shown to be an important modifier of workplace stressors.

locus of control. workload.15 Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. feedback Ma ter i Domains Internal modifiers External modifiers Internal motivation Coping and social support Type A behavior. job risk Job pressure. and physical strain Sources of pressure in work environment Role demands. organizational structure 4 Occupational Stress Inventory64 5 Occupational Stress Indicator65 P–E fit P–E fit D–C Transactional yri gh ted Occupational role stress. psychosocial. organizational support Job satisfaction. autonomy. task identity.knovel. control. workload. feedback. task significance. psychological and physical demands. task demands Decision latitude. vocational. illnesses 55. task identity.TABLE 55. friendships Interpersonal . cognitive demands Organizational stress. orientation toward personal growth. somatic complaints. time pressure. job satisfaction. autonomy. quality of work Job satisfaction and security D–C P–E fit Depression.2 Measures of Occupational Stress and Examples of the Domains They Represent Instrument/reference 1 Job Diagnostic Survey22 Approach5 P–E fit D–C E–R Work-related stressors Skill variety. job satisfaction. physical and mental health 6 Stress Diagnostic Survey66 7 Job Content Questionnaire67 8 Generic Job Stress Questionnaire68 9 Work Stress Inventory69 10 Job Stress Survey 70 Pressure-strain. coworker interaction. coping strategies Social support Self-esteem Social support Effects Job satisfaction 2 Job Characteristics Index62 3 Work Environment Scale63 P–E fit Skill variety. exposure to physical hazards Examples: role conflict and ambiguity.

daily hassles. homework balance Ma ter i Internal modifiers External modifiers Drive.knovel. confidence level. control. patienceimpatience. state of mind. commitment to organization. perceived job security. physical symptoms 12 Interpersonal Conflict at Work72 Organizational Constraints Quantitative Workload Inventory Physical Symptoms Inventory yri gh ted Conflict with others at work Constraints on work Amount of work and work pace Somatic symptoms 55. personal responsibility. personal influence Effects Satisfaction with . use of social support. resilience.2 Measures of Occupational Stress and They (Continued ) Domains Instrument/reference 11 Pressure Management Indicator71 Approach5 Transactional Work-related stressors Skill i relationships k i ifiat work. organization.16 Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. managerial role. organization climate. energy level. recognition. k id i Workload.p p Examples of the Domains y p ( Represent ) TABLE 55. life–work balance. problem focus.

49 The original version of this instrument included 14 items such as. and interpersonal communication becomes as important as scientific findings. Within such a setting. Below. Practical issues include cost of the instrument.. that emotions and opinions of workers and management may be polarized. Many researchers fill in the gaps in the coverage of domains by using additional.. 55.knovel. As noted in Table 55. the most important characteristic of an IAQ team is credibility. and foremost. the reading level of the instrument (is it too high or low for the audience?). it becomes more difficult to find a resolution that will satisfy all groups. 138)—the Perceived Stress Scale. and interpreting the findings. A detailed discussion of the measurement of perceived stress has been provided by Monroe and Kelley. by gender.4 IMPLEMENTATION ISSUES Ideally. how often have you felt that you were unable to control important things in your life?” and “In the last month.2. most IAQ specialists. the IAQ–stress link would be prevented through management of the physical environment and/or the psychosocial environment. in the literature. whether normative data are available that pertain to worker characteristics of interest (e. unless they are conducting longitudinal research. amount of time to administer it.51 Address Concerns in a Timely Manner Although it may be tempting to take a “wait and see” attitude when responding to IAQ problems.52 Credibility is intertwined with Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. “In the last month. Notably missing in Table 55. Further descriptions are found in the special issue of JOHP. reliability). Methodological issues include consideration of the psychometric properties of the instruments (validity. there are . race.48 They conclude that only one instrument is “an empirically established index…that falls into the category of general appraisal instruments” (p. how often have you felt that you were on top of things?” Shorter versions of the instrument have also been developed.. When selecting an instrument. the method of administration (survey. This lack is because most instrument packages measure perceived stressors but not perceived stress (i. will be brought into an ongoing situation. Realistically. we outline some implementation issues that we believe are critical to consider.17 Co py rig hte dM ate ria l Selection of an Instrument. In the persuasive communications field.METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS 55. the feeling of being overwhelmed or unable to garner sufficient resources).g. and the ease of scoring. if the problems have gone on for some time or if there is a poor organizational climate. and whether additional expertise is needed in the team to be able to use the results. methodological. and practical issues to consider.2. this is problematic for at least three reasons. all of the instruments cover multiple types of work-related stressors.50 Depicted in Table 55. The primary conceptual issues are to select an instrument that represents the framework to be employed and that covers the constructs that are of interest. several of these issues have been presented in more detail elsewhere.2 is a dimension representing perceived stress. source credibility is viewed as essential to most communications settings. Perceived Stress. As can be seen in Table 55. interview. analyzing.2 are descriptions of 12 multicomponent instruments that are used most frequently in the literature. observation). type of job). for depression. targeted instruments (e. and on the instrument Websites. It is likely. workers’ health may be at risk and time may exacerbate health problems. Coverage of other domains is less consistent. anxiety). most of the instruments have identifiable conceptual approaches that they represent. Second. First.

larger groups of workers may be used in key informant interviews. Cases that involve large groups of workers. occupational stress measurement. they have fulfilled their inclusion obligations. Second. Third. Carefully Think Through the Conceptual Approach That Is Used We have outlined four distinct and one hybrid conceptualizations of occupational stress in this chapter. the influence of the problem on the social environment (e. . occupational health. Even the best of scientists (i. those high in knowledgeability) can be compromised by poor trustworthiness. Third.e. the study design.g. First. and communications needs of workers (what do they want to know. Workers are “specialists” in providing information about how they see the IAQ problem (e. At a minimum. They can provide valuable insights into the dynamics of the workplace and how different approaches may be perceived by their coworkers. A prompt response is essential to maintaining the trust of workers. if not impossible. focus groups. The IAQ team members should think about the entire scope of the work—from how Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. the perceived causes for the problem (e.. the assumed IAQ–stress model. which can further undermine confidence in the IAQ team. an interdisciplinary team should involve specialists in the areas of IAQ.knovel. is it a matter of high or low concern?). exclusion of workers sets up an “insider versus outsider” dynamic that prohibits positive interpersonal communications... The conceptual approach that is used will determine the variables to be measured. ventilation system versus carpeting).18 ASSESSING IAQ Co py rig hte dM ate ria l Involve Workers from the Beginning Worker representatives should be involved in the process to the greatest extent possible. Some IAQ specialists may believe that if they conduct a session with workers to tell them what is happening and why. IAQ specialists are losing a vital source of information. and the conclusions that can be drawn. and risk communication.g. which has been faulted in the risk communication literature. and who do they want to tell them?). Second.53 There are multiple roles for workers in the inspection of the IAQ–stress link. the imposition of a “solution” on a worker group is likely to be viewed negatively and as another violation of trust in the employee–employer relationship. There are several reasons for this.55.. We disagree with this approach. Each of these disciplines can contribute to multifaceted examination and reporting of the issues. there are times when the use of an interdisciplinary team may be critical. and most importantly. to dismiss accounts of mass psychogenic illness (MPI) in the literature on IAQ. is it causing rifts among groups of workers?). or vulnerable populations are candidates for an extensive examination of the IAQ–stress link. Use an Interdisciplinary Team Although not all IAQ cases will warrant an in-depth response. When workers are barred from the process. A prompt response is more likely to interrupt any potential sequencing of MPI events such as using cues from coworkers to attribute vague symptoms to IAQ problems. highly publicized or politically sensitive issues. as are other actions that will be described below. First. or surveys—all valuable tools to gather information on the issues listed above. it is difficult.g. a small but representative set of workers who have the trust and respect of their colleagues should be part of the core decision-making team. it can lead to the circulation of rumors and two related characteristics: knowledgeability and trustworthiness. by not including workers.

(3) Appropriate interventions would include altering the levels of demands or control or the balance between the two. theory-based assessments of how and why certain components are important. researchers have not justified the use of such a broad-scale instrument with sound. could threaten the overall acceptance of the entire data collection instrument. Although longitudinal studies may be challenging. but the issue of relevance may be subtler. it can limit the external validity of the investigation. the items in such batteries may seem overly intrusive and lacking in face validity to respondents. they may be useful in circumstances where organizational changes are introduced and symptom development. Even some case-control studies have faced the difficulty of ascertaining the timing of symptoms relative to the stressor experiences. Relevant instruments are those that (1) measure components of the conceptual approach used and (2) are appropriate for the population. A second example of relevance is based on gender. when exploring the effects of personality as a moderator of stressors on SBS symptoms. if the demand–control model is selected. For example. This. The ability to generalize findings will Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. Use Psychometrically Sound and Relevant Instruments Psychometrically sound instruments are those that have high levels of validity and reliability and that have been developed using standard.METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS 55. For example. Second. We advise IAQ teams to use a comprehensive approach from the beginning rather than to collect information in a fragmented and piecemeal fashion. Longitudinal designs will be particularly helpful in the evaluation of intervention strategies. A common limitation has been the inability to determine the temporal relationships between exposure to stressors and symptom outcomes.19 Co py rig hte dM ate ria l Use a Comprehensive Conceptual Approach from the Beginning. often in studies of single buildings that have already been declared “problem buildings. Each conceptual approach has distinct implications. This is especially important in the study of stress-related conditions because of the possibility that health problems may change the way workers perceive their environment. it would imply the following: (1) Workers’ perceptions of the physical and psychological demands put on them and the amount of control that they have over their work would be in the primary areas of inspection (although.knovel. (compare with reference 46).com the problem is framed to the possible solutions—before selecting a model. Third. Much has been written concerning the selection of psychometrically sound instruments in the occupational stress field.33 The problem with this approach is threefold. Another feature of previous studies has been the use of internal control groups. the length of such instruments makes it difficult to adequately cover other important aspects of the conceptual approach due to respondent fatigue. (2) The model implies that workers with high demands and low control would exhibit the strongest reactions to IAQ problems.55 Use a Strong Study Design Most of the studies that we have reviewed involve cross-sectional data. some researchers have used extensive personality batteries such as the MMPI.” Although this design makes it possible to control for many factors that are unique to an organization. therefore introducing a bias toward positive findings. or resolution. There is speculation in the field that some instruments or approaches may not be suitable to adequately describe the work that women do. For example. in turn. newer versions of this approach also include social support. accepted methods (compare with reference 54). . the NIOSH approach would allow for the collection of variables that could test an overall model. First. can be tracked.

Efforts should be made to give workers the information tools that they need to understand and interpret the findings—this is essential to allay concerns. 55.knovel. Second. such as adequate power. this is not always the case. they may prefer to have a neutral. The IAQ team needs to recognize that negative emotions can surface even when things seem positive and that these negative emotions should not be belittled or minimized. It may be that members of the IAQ team have sufficient credibility that workers will accept hearing the findings from them—or.g. Once workers are selected to be in the targeted . No matter which method is used. probability). outside person present the findings. several aspects of data collection need to be considered. they may raise feelings of hostility and anger in workers. a random sample should be used. This will allow for tai- Copyright © 2001 by The McGraw-Hill Companies Retrieved from: www. the most widely used method is the selfadministered survey because it is less labor intensive and generally cheaper to conduct. reasonable efforts to increase the response rate should be employed (multiple and varied contacts) to reduce the effects of selection bias. Use Sensitivity in Communicating Results As noted above. it is important to get as representative of a sample as is possible.56 Co py rig hte dM ate ria l Use Appropriate Data Collection Techniques Three primary categories of data collection may be used in stress studies—self-administered surveys. IAQ specialists will benefit from a greater understanding of the contributing factors in each unique situation.. Logically. If they are kept apprised of the results as the study progresses. control for major confounding variables. workers should be consulted on the communications issue. negative findings may lead to feelings of frustration because workers have to search for another cause for their symptoms.20 ASSESSING IAQ be enhanced by studying populations most representative of those who experience the stressors of interest. Persons who have high levels of symptoms or concerns may need individualized attention. we might expect that the dominant emotion following negative results would be relief. These and other issues that lend strength to investigations. If all of the worker group cannot be surveyed or observed. and observations. By addressing these issues in an investigation. First and foremost. input from workers on what topics they want information about and who they want to tell them should be gathered. blinding to exposure or outcome status. This is true for ethical reasons and to establish and maintain trust within the organization. If negative findings are presented in a situation where there is mistrust and suspicion. interviews.55. worker confidentiality must be maintained. Workers should be assessed for their levels of knowledge on topics that are essential to fully understanding the results (e. In addition. Special Issues around Null Findings. providing a basis for understanding and measuring workplace stress and psychosocial factors that may be contributing to IAQ problems. There is no doubt that workplace stress and psychosocial factors often play a role in IAQ problems. By far. and avoidance of measurement error have been discussed by Mendell. Even within a situation of positive relationships.5 CONCLUSION The use of a conceptual framework and psychometrically sound instruments will aid the researcher and problem solver alike. However. a crisis at the end of the study can be avoided.

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