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The Measurement of Effort-Reward Imbalance at Work

Article  in  Social Science & Medicine · April 2004

DOI: 10.1016/S0277-9536(03)00351-4 · Source: PubMed

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 ARTICLE IN PRESS

Social Science & Medicine 58 (2004) 1483–1499

The measurement of effort–reward imbalance at work:

European comparisons
Johannes Siegrista,*, Dagmar Starkea, Tarani Chandolab, Isabelle Godinc,
Michael Marmotb, Isabelle Niedhammerd, Richard Petere
a
Department of Medical Sociology, University of Duesseldorf, PO Box 10 10 07, D-40001 Duesseldorf, Germany
b
Department of Epidemiology and Public Health, University College of London, London, UK
c
D!epartment d’ Epid!emiologie et Promotion de la Sant!e, Universit!e Libre de Bruxelles, Brussels, Belgium
d
#
INSERM U88, Hopital National de St. Maurice, France
e
Department of Epidemiology, University of Ulm, Germany

Abstract

Using comparative data from five countries, this study investigates the psychometric properties of the effort–reward
imbalance (ERI) at work model. In this model, chronic work-related stress is identified as non-reciprocity or imbalance
between high efforts spent and low rewards received. Health-adverse effects of this imbalance were documented in
several prospective and cross-sectional investigations. The internal consistency, discriminant validity and factorial
structure of ‘effort’, ‘reward’, and ‘overcommitment’ scales are evaluated, using confirmatory factor analysis.
Moreover, content (or external) validity is explored with respect to a measure of self-reported health.
Data for the analysis is derived from epidemiologic studies conducted in five European countries: the Somstress
Study (Belgium; n ¼ 3796), the GAZEL-Cohort Study (France; n ¼ 10; 174), the WOLF-Norrland Study (Sweden;
n ¼ 960), the Whitehall II Study (UK; n ¼ 3697) and the Public Transport Employees Study (Germany; n ¼ 316).
Internal consistency of the scales was satisfactory in all samples, and the factorial structure of the scales was consistently
confirmed (all goodness of fit measures were >0.92). Moreover, in 12 of 14 analyses, significantly elevated odds ratios
of poor health were observed in employees scoring high on the ERI scales.
In conclusion, a psychometrically well-justified measure of work-related stress (ERI) grounded in sociological theory
is available for comparative socioepidemiologic investigations. In the light of the importance of work for adult health
such investigations are crucial in advanced societies within and beyond Europe.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Effort–reward imbalance; Self-rated health; Work stress questionnaire; Europe

Introduction adult socioeconomic status. Beyond economic livelihood

In advanced societies, work continues to play an
important role for health and well-being in adult life.
Having a job is often a prerequisite for a continuous
income, and, more thoroughly than any other social
circumstances, employment characteristics determine
*Corresponding author. Department of Medical Sociology,
Heinrich Heine Universitat, Universitastrasse 1, Duesseldorf
40225, Germany. Fax: +49-81-12390.
E-mail address: siegrist@uni-duesseldorf.de (J. Siegrist).
a person’s occupation is important for socialization. It
provides opportunities for personal growth and devel-
opment, including the favorable experience of self in a
core social role, and allows participation in social
networks beyond primary groups.
The nature of work has undergone profound changes
during recent decades. Today, fewer jobs are defined by
physical demands and more by mental and emotional
demands. While jobs in mass production are decreasing,
employment in the service sector continues to rise.
Computer-based information processing is becoming a

0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0277-9536(03)00351-4
 ARTICLE IN PRESS
1484 J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
part of a growing number of job profiles. In a large
survey of European workers (Paoli & Merlli!e, 2001) 60
percent work at very high speeds, 40 percent are
confined to monotonous work, 49 percent indicate
permanent and direct contact with clients, and 25
percent are working on shift rotation.
These changes in the nature of work have coincided
with changes in the labor market. Women and older
people comprise a growing proportion of the work
force. Part-time working and flexible work arrangements
have also increased. Perhaps most importantly for
health, job instability, forced mobility and unemploy-
ment are becoming more prevalent, resulting in an
increase in job career discontinuity, forced early retire-
ment and job loss. Surveys report that 30 percent of
workers are currently in insecure jobs (Ferrie, Marmot,
Griffiths, & Ziglio, 1999), and a significant proportion of
middle-aged men and women are no longer participating
in the labor market due to early, often involuntary
retirement (Brugiavini, 2001).
Social inequalities in the quality of work and in access
to the labor market have been reported in numerous
studies, such that it can be concluded that the benefits
and costs of working life are unequally distributed
across society. This conclusion also holds true for the
health burden of working life. A social gradient of
health according to occupational standing has been
documented for all-cause mortality (Fox & Adelstein,
1978; Kitagawa & Hauser, 1973; Marmot, Shipley, &
Rose, 1984), coronary heart disease morbidity and
mortality (Marmot, Adelstein, Robinson, & Rose,
1978; Marmot, Bosma, Hemingway, & Stansfeld,
1997), psychiatric disorders, especially depression (Mar-
mot, Shipley, Brunner, & Hemingway, 2001; Stansfeld,
Fuhrer, Shipley, & Marmot, 1999) and chronic bron-
chitis (Marmot et al., 2001). These social inequalities in
health deserve particular attention considering that after
the first years of childhood, midlife is the time when
social differences in mortality are most pronounced
(Goldblatt, 1990; Marmot et al., 1998). Therefore, the
role of work in explaining health inequalities in midlife
provides a core research task. More specifically, an
adverse psychosocial work environment is likely to
contribute to the unequal health burden in a significant
way (Marmot, Theorell, & Siegrist, 2002; Schrijvers, van
de Mheen, Stronks, & Mackenbach, 1998). Despite
considerable progress in this field there is still a lack of
agreement among scientists on how to define and
measure an adverse psychosocial work environment.
The aim of this article is to advance this debate by
focusing on one measurement approach termed effort–
reward imbalance at work. The theoretical model
underlying this measure is briefly outlined, and the
scales measuring the components of this model are
described. In the main part, psychometric properties of
these measures are analyzed by drawing upon several
epidemiologic investigations, thus enabling comparisons
across different working populations in Europe.
The theoretical model
Health adverse and health promoting psychosocial
work environments are defined by the interaction
between a person’s cognitions, emotions, and behaviors
and his or her social environment. Traditional biome-
dical approaches cannot directly measure this interac-
tion. While crude measures may focus on particular
characteristics of the work place, the stressful character
of a psychosocial factor is more appropriately assessed
by using self-report data obtained from questionnaires
and interviews. But, given the complexity and variability
of work-related psychosocial factors, these measure-
ments need to be based on a theoretical model.
Theoretical models of work stress selectively reduce
the complexity and variation of interactions between the
work environment and the working person by focusing
on those general components that may explain its direct
or indirect effects on health. Several such models have
been developed and tested (for review, e.g., see Cooper,
1998; Dunham, 2001), with two models receiving
particular attention in recent years: the demand-control
model (Karasek, 1979; Karasek & Theorell, 1990) and
the model of effort–reward imbalance (Siegrist,
1996a, b). The former model has been tested in a large
number of investigations (for review see Marmot et al.,
2002; Schnall, Belkic, Landsbergis, & Baker, 2000).
Although a few studies show negative findings, an
impressive body of evidence documents the explanatory
power of the model or its single components.
The latter model has been developed and tested more
recently, with a rapid increase of evidence documenting
its role in explaining adverse health (for review see
Schnall et al., 2000; Marmot et al., 2002; Siegrist, 2002).
While these two models complement each other (see
Discussion) the focus of this contribution is on the
effort–reward imbalance model, and more specifically
on the psychometric properties of its measurement. This
model assumes that effort at work is spent as part of a
contract based on the norm of social reciprocity where
rewards are provided in terms of money, esteem, and
career opportunities including job security. Further-
more, the model assumes that work contracts often fail
to be fully specified and to provide a symmetric
exchange where complete equivalence exists between
requested efforts and given rewards. In particular, this is
the case when there is little choice on the part of
employees, such as a lack of alternatives in the labour
market (e.g. low level of skill) or restricted mobility.
Moreover, employees themselves may accept such
contracts for strategic reasons (e.g. to improve their
chances for career promotion at a later stage). Non-
symmetric contracts are expected to be frequent in a
 ARTICLE IN PRESS
J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
global economy that is characterized by job insecurity,
forced occupational mobility, short-term contracts and
increased wage competition.
According to the model, the experience of a lack of
reciprocity in terms of high ‘costs’ and low ‘gains’ elicits
negative emotions in exposed people. Feelings of not
being appreciated in an adequate way or of being treated
unfairly and disappointments resulting from inappropri-
ate rewards are paralleled by sustained strain reactions
in the autonomic nervous system. This is due to the fact
that the recurrent experience of reward deficiency in a
core social role impairs successful self-regulation (Sieg-
rist, 2000). Thus, in the long run, the imbalance between
high effort and low reward at work increases illness
susceptibility as a result of continued strain reactions.
So far, structural conditions of ‘high cost/low gain’
conditions at work have been specified by the model. A
final assumption concerns individual differences in the
experience of effort–reward imbalance. People charac-
terized by a motivational pattern of excessive work-
related commitment and a high need for approval
(‘overcommitment’) are at increased risk of strain from
non-symmetric exchange. For instance, they may expose
themselves more often to high demands at work, or they
exaggerate their efforts beyond what is formally needed.
As a result, their susceptibility to the frustration of
reward expectancies is increased. There is some evidence
of intrapersonal stability over time of this motivational
pattern (Siegrist, 1996b). Therefore, it can be considered
a psychological risk factor in its own, even in the
absence of structural conditions of imbalance at work.
However, the proposed model posits that strongest
effects on health and well-being are expected to occur if
structural and personal conditions act in concert. Hence,
on this theoretical ground, overcommitment is hypothe-
sized to modify (i.e. increase) the effect on health
produced by effort–reward imbalance at work.
In summary, the proposed theoretical model is based
on the sociological hypothesis that formalized social
exchange, as mediated through core social roles (the
work role), is rooted in contracts of reciprocity of cost
and gain. It defines structural conditions of non-
symmetric contracts that result in strain from an
imbalance between high effort and low reward. In
addition, it addresses individual differences in the
experience of this imbalance (overcommitment) by
assuming an effect modification of overcommitment on
the association of effort–reward imbalance with health.
It is important to stress that this model does not
represent a black-box approach towards studying work
stress that is restricted to the structural level of analysis
(such as e.g. the demand-control model (Karasek &
Theorell, 1990)), but integrates structural and personal
components. However, these two components are
distinguished both at the conceptual and methodological
level. It is assumed that a combination of both sources
1485
of information according to predefined procedures (see
below) provides a more accurate estimate of the adverse
health effects resulting from non-reciprocity compared
to a restriction of information to one of these sources.
Methods
Study samples
This report is based on data obtained from working
men and women in five different European countries:
Belgium, France, Germany, Sweden and UK. Coordi-
nated data collection and analysis was the result of the
authors’ collaboration in the frame of a scientific
programme on social variations in health expectancy
in Europe, supported by the European Science Founda-
tion. In most instances the measures analyzed in this
contribution were administered as part of data collection
in already established longitudinal observational inves-
tigations.
The Somstress Study (Belgium)
The Belgian data came from the baseline data
collection of the Somstress Study and was conducted
in four companies across Belgium in the years 1999 and
2000 (Godin & Kittel, 2003). The sample is made of
3796 employees (2056 men, 1740 women) aged 18–66
years (mean age 4078,7). Companies were selected
according to their structural environment and job
stability. Among the four worksites, one can be
considered stable, two are in an in-between situation—
with one company in a more unstable environment than
the other one—and one is categorized as unstable. The
aim of the Somstress Study is to analyze the health
effects of these contextual economic conditions and, in
the process, to explore the role of an adverse psycho-
social work environment. The overall participation rate
of employees from the four companies was approxi-
mately 40 percent, with participants being representative
of the total registered work force of the enterprises
in terms of sociodemographic and socioeconomic
characteristics.
The GAZEL-Cohort Study (France)
The GAZEL-Cohort was established in 1989 and
included 20,624 subjects aged 35–50 years working at the
French National Electric and Gas Company Electricit!e
de France-Gaz de France (for detailed baseline sample
description see Goldberg et al., 2001). Since 1989 this
cohort has been followed by yearly self-administered
questionnaires and by data collection from personnel
and medical departments of the company. In the 1998
survey the French version of the effort–reward imbal-
ance questionnaire was applied (Niedhammer & Siegrist,
1998; Niedhammer, Siegrist, Landre, Goldberg, &
 ARTICLE IN PRESS
1486 J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
Leclerc, 2000). The response rate to the 1998 ques-
tionnaire was 73 percent. Retired people (n ¼ 4259) and
other non-working subjects (n ¼ 206) were excluded,
thus leaving a sample of 10,174 subjects (7251 men and
2923 women).
The WOLF-Norrland Study (Sweden)
Men and women beyond age 33 from several
companies representing different sectors in the Northern
region of Sweden (Norrland) were invited to participate
in an observational study on associations between
working conditions and cardiovascular risk factors,
with a focus on hypertension, high levels of blood lipids
and hemostatic factors. The study protocol was almost
identical to that of a previous, much larger investigation
conducted in the greater Stockholm area (Peter et al.,
1998). The WOLF-Norrland Study included the original
Swedish version of the effort–reward imbalance ques-
tionnaire at baseline screening in a sample of 960
participants (738 men and 222 women). Compared to
the total group this sample was somewhat older and
consisted of a larger proportion of men.
The Whitehall II Study (UK)
The Whitehall II Study of 10,308 male and female
civil servants was set up in 1985 to investigate and
understand the causes of social inequalities in health
(Marmot et al., 1991). A major aim of the study has
been to investigate occupational and other social
influences on a range of diseases, most notably coronary
heart disease. At baseline all participants attended
medical examinations and completed questionnaires
covering a wide range of information including: health
status, work stress, social support, health behaviors,
stressful life events and mental health. Several follow-up
assessments were conducted. At phase five, 7270
participants were included, 5000 of whom were still in
employment and eligible to fill in the effort–reward
imbalance questionnaire. The response rate was 74
percent (n ¼ 3697). This group was representative of
the total Whitehall II phase five sample with the
exception of a slight underrepresentation of women
and lower-educated civil servants.
The Public Transport Employees Study (Germany)
A group of female and male employees of a large
public transport company in a major city in Germany
was invited to participate in a cross-sectional study. The
occupations consisted of bus and subway drivers, repair
personnel and administrative staff (Joksimovic, Starke,
Knesebeck, & Siegrist, 2002). Data collection was
conducted during two working days only and selection
criteria for participation were age (35–60 years), dura-
tion of membership in the company (>2 years) and
fluency in German language. A total of 316 employees
participated (268 men, 48 women). Proportions of the
different occupational groups in the sample were
comparable to the company’s work force as a whole.
Women were underrepresented in the sample. Mean age
of participants was 44.8 years (77.6) among men and
43.7 (76.4) among women.
Measures
As the aim of the present study was to assess the
reliability and validity of the effort–reward imbalance
(ERI) questionnaire in different study samples from
different countries, internal consistency of the scales
(Cronbach’s a) and factorial validity (confirmatory
factor analysis) were analyzed. Moreover, content (or
external) validity of the questionnaire was assessed in
four of the five data sets (excluding WOLF-Norrland) as
an identical measure of health, and that of self-rated
health was available. This measure was based on
answers to a single Likert-scaled item: ‘How do you
rate your general health status?’ ranging from ‘bad’ to
‘very good’ (5-point scale in all studies except GAZEL
where an 8-point scale was used). This question was
shown to predict subsequent deterioration in health
status in a number of prospective investigations (Idler &
Benyamini, 1997).
The effort–reward imbalance (ERI) questionnaire
The measurement of the model of effort–reward
imbalance at work is restricted to self-report data for
three reasons. First, because it combines descriptive and
evaluative information on perceived demands (effort)
and rewards. Secondly, it requires information on
personal coping characteristics (overcommitment).
Thirdly, information on distant working conditions
cannot be collected by other techniques (e.g. job
security, promotion prospects, adequacy of salary in
view of training). Thus, assessment of effort–reward
imbalance at work relies on indicators that are measured
by psychometric scales containing Likert-scaled items.
Essentially, three psychometric scales are measured
(effort, ‘reward’, overcommitment), and the scale
‘reward ‘ is assumed to act as a latent factor underlying
three theoretically postulated subscales of occupational
rewards. The combination of information from these
scales according to a pre-defined algorithm provides an
opportunity of measuring the theoretical construct.
Effort
Effort is measured either by five or six items that refer
to demanding aspects of the work environment (three
items measuring quantitative load, one item measuring
qualitative load, one item measuring increase in total
load over time). One item measuring physical load is
sometimes included as described below. In previous
studies, the five-item version excluding physical load has
 ARTICLE IN PRESS
J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
been found to be psychometrically appropriate in
samples characterized predominantly by white collar
jobs whereas the six-item version was appropriate in
blue collar samples and occupational groups with
manual workers. While this observation may support
the validity of the measure, it is recommended to include
the item on physical load into the scale in those
occupational groups only where prevalence of physical
workload is part of the typical task profile. Accordingly,
as the majority of jobs included in this analysis are
white-collar rather than blue-collar jobs, the following
analyses are based on the five-item version (see
Appendix). Items are answered in two steps. First,
subjects agree or disagree whether or not the item
content describes a typical experience of their work
situation. Subsequently, subjects who agree are asked to
evaluate to what extent they usually feel distressed by
this typical experience. The rating procedure is defined
as follows: (1) does not apply; (2) does apply, but subject
does not consider herself or himself distressed; (3) does
apply and subject considers herself or himself somewhat
distressed; (4) does apply and subject considers her or
himself distressed; (5) does apply and subject considers
herself and himself very distressed. A sum score of these
ratings is constructed as the uni-dimensionality of the
scale has been documented in several studies (Hanson,
Schaufeli, Vrijkotte, Plomp, & Godaert, 2000; Nied-
hammer et al., 2000; Tsutsumi, Ishitake, Peter, Siegrist,
& Matoba, 2001; see also Results section). Thus, a total
sum score based on the five items measuring effort varies
between 5 and 25. The higher the score, the more
perceived demands are experienced as stressful.
Reward
Reward is measured by 11 items. Theoretically, we
expect three factors to result from factor analysis: (a)
financial reward, (b) esteem reward, (c) reward related to
promotion prospects (career) and job security. In
empirical terms, it is almost impossible to disentangle
financial from career-related aspects. Therefore, we
postulate a three-factorial structure of the construct of
occupational reward with a first factor defined by
financial and career-related aspects, a second factor
defined by esteem rewards, and a third factor defined by
the gratification of job security (see Appendix). The
three dimensions are assumed to load on one latent
factor (reward). This assumption has been tested and
confirmed in several second-order factor analyses,
including data sets from this study. Although this test
is not subject of the current confirmatory factor analyses
where the model fit of a three-factorial construct is
analyzed with regard to its consistency across different
occupational groups and across the different language
versions of the measures, the following information may
strengthen our approach. For instance, in the Somstress
Study, a measure of goodness of fit (GFI) (see Statistical
1487
analysis), was clearly improved (0.951) in a second-order
factor analysis testing the three reward subscales if
compared to a uni-dimensional factor analysis (0.915).
Similar results were obtained from a respective analysis
of data from the Public Transport Employees Study
(GFI=0.962 vs. 0.871).
The answering and scoring procedures are those for
the effort items. A score of 11 indicates the perception of
the lowest rewards whereas a score of 55 reflects a very
high level of reward (reverse coding).
Effort–reward ratio
Given that a rather complex set of subjectively
experienced work-related circumstances is being mea-
sured by a limited number of items, we attempt to
analyze this information as exhaustively as possible.
Thus, in a first approach, the two sum scores can be used
for estimation of their separate effects on outcome
criteria, such as health indicators. For instance, in
occupational groups characterized by underload rather
than overload (e.g. doormen), low reward per se may be
associated with an elevated risk.
However, in keeping with the theoretical assumption
stated above, it is postulated that the imbalance between
effort and reward is what matters most. Imbalance may
be constructed and analyzed by using a pre-defined
algorithm based on information obtained from the
effort and reward scales (Peter et al., 1998; for discussion
see Siegrist, 2002). A ratio is computed for every
respondent according to the formula: e=ðrxc) where ‘e’
is the sum score of the effort scale, ‘r’ is the sum score of
the reward scale and ‘c’ defines a correction factor for
different numbers of items in the nominator and
denominator. The correction factor is 0.454545 if the
nominator contains five items (5/11). As a result, a value
close to zero indicates a favorable condition (relatively
low effort, relatively high reward), whereas values
beyond 1.0 indicate a high amount of effort spent that
is not met by the rewards received or expected in turn.
The construction of this ratio serves as an approx-
imate estimate of the costs and gains experienced in
everyday working life that are not repeatedly subject to
explicit reasoning on trade-off by working people
themselves. Thus, the ratio may capture part of the
strain reactions that would be missed if the measurement
of imbalance were based exclusively on subjective
evaluation (that is, asking the respondent if reciprocity
exists). In stress physiological terms, according to the
theory of affective information processing (Le Doux,
1996), this assumption is crucial as only part of the flow
of information resulting from the psychosocial environ-
ment is subject to conscious computational processing.
Strain reactions and negative emotions elicited by the
experience of non-reciprocal exchange at work may
bypass conscious awareness, as is the case for a
substantial part of affective processing in general.
 ARTICLE IN PRESS
1488 J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
As an independent predictor of health outcomes this
ratio is either transformed into a binary variable (values
p1.0 vs. >1.0) or transformed logarithmically into a
continuous measure. Logarithmic transformation of the
continuous scale is performed in order to place 1.0 as the
center point for the scale. The use of a continuous
measure has the advantage of providing more informa-
tion and generating more robust statistical effects
compared to the binary measure (Niedhammer, Teck,
Starke, & Siegrist, 2003; Pikhart et al., 2001). Based on
continuous information, quartiles or tertiles of the ratio
can be defined, and dose–response relationships between
effort–reward ratio and health can be explored (see
Discussion). However, if several data sets are analyzed
in a comparative way, as is the case in this study,
transformation of the ratio into a binary variable (>1.0
vs. p1.0) may be useful.
Overcommitment
Originally, the cognitive-motivational pattern of
coping with demands characterized by an excessive
work-related overcommitment and a high need for
approval has been measured by a psychometric scale
containing 29 items (‘need for control’; Siegrist, 1996a).
The 29 items measure four relevant aspects of this
coping pattern: need for approval (6 items), competi-
tiveness and latent hostility (6 items), impatience and
disproportionate irritability (8 items), and inability to
withdraw from work obligations (9 items). The four
respective subscales were repeatedly found to load on
one latent factor in second-order factor analysis. A high
score, as defined by the upper tertile of the total factor
score of these 29 items, was shown to predict adverse
health in several prospective and cross-sectional studies
(Siegrist, 2002).
Despite the predictive validity of the total score the
factorial structure of the four subscales was not
successfully replicated in several studies (Hanson et al.,
2000; Niedhammer et al., 2000), and the full psycho-
metric scale was considered too long for epidemiologic
research. A shorter version of the overcommitment scale
was developed focusing on the core notion of spending
excessive effort at work as evidenced by the respondent’s
inability to withdraw from work obligations and to
develop a more distant attitude towards job require-
ments. This subscale (inability to withdraw from work
obligations) resulted in predicted health outcomes of
similar strength as those by the longer scale. Moreover,
it showed the highest internal consistency in previous
analyses and had an acceptable scalability (Hanson et al.,
2000; Siegrist et al., 2001). Exploratory and confirma-
tory factor analyses were conducted using data from
different study samples to develop a statistically more
appropriate short scale.
Based on varimax-rotated exploratory main compo-
nent analysis of data from four study samples it was
found that six items documented consistently high
loadings on one latent factor. Five of these items
belonged to the subscale ‘inability to withdraw from
work obligations’, and one item to the subscale
‘impatience and disproportionate irritability’. These
two subscales were also highly correlated with coeffi-
cients ranging from r ¼ 0:74 to 0:88:
These six items were subjected to confirmatory factor
analysis to evaluate goodness of fit, and results yielded
acceptable reliabilities (Siegrist et al., 2001). Gender
differences and differences in health outcomes were then
analyzed comparing the original and the newly devel-
oped short scale with excellent properties observed for
the short scale (Joksimovic et al., 2002; Siegrist et al.,
2001). Based on this evidence, the short version of the
scale overcommitment (six items, see Appendix) is
recommended for measuring the personal component
of the model. Given the uni-dimensionality of this scale
the six four-point Likert scaled items are computed to a
total score varying from 6 to 24. The higher the score,
the more likely a subject is to experience overcommit-
ment at work.
The 23 items of the effort–reward imbalance ques-
tionnaire were translated from German to French,
English and Swedish, and the adequacy of translation
was checked by respective experts. In addition, an
independent back-translation was performed, according
to established standards of cross-cultural research, and
the version was adapted as necessary. In case of the
Whitehall II Study, a few items were not included (see
footnotes in Tables 2 and 3).
Statistical analysis
Psychometric information on the scales includes
mean, standard deviation, and scale reliability (Cronba-
ch’s a). Information on discriminant validity is given for
gender, age and education. Confirmatory factor analysis
was performed to test the dimensional structure of the
theoretical model (using the statistical package AMOS
4). Goodness of fit was assessed by the GFI and the
AGFI index as well as Chi-square and root-mean square
residual (RMR). GFI and AGFI indicate the amount of
variance and covariance explained by the model (Back-
haus, Erichson, Plinke, & Weiber, 2000; Byrne, 2001).
Values X0.90 are considered satisfactory. RMR is the
square root of the mean of the squared discrepancies
between the implied and the observed covariance
matrices (Kelloway, 1998). A value p0.05 is considered
satisfactory.
The maximum likelihood method was applied to
estimate parameters (Hayduk, 1987).
In addition to these test-statistical models, we applied
logistic regression analysis to test associations of the
components of the model with a binary outcome, self-
rated health (Hosmer & Lemeshow, 1989). Prevalence
 ARTICLE IN PRESS
J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499 1489

odds ratios and 95 percent confidence intervals derived
from the logistic regression models are provided.
Results
The five study populations vary considerably with
regard to their occupational and sociodemographic
composition. While the French GAZEL cohort, the
Swedish WOLF cohort and the Belgian Somstress
cohort are composed of different occupational groups,
including blue-collars and white-collars, the British
Whitehall cohort of civil servants and the German
public transport employees represent professionally
more homogeneous groups. In terms of age and gender
these samples also differ quite remarkably, as can be
seen from Table 1. In each study, the proportion of men
is higher than the proportion of women, most notably in
the case of public transport workers and least so in the
case of the Belgian sample. Mean age of employees in
the GAZEL and the Whitehall Study is higher compared
to mean age in the remaining three studies. Variations
according to level of education are also present. When
interpreting respective figures one should bear in mind
the limited comparability of educational levels across
different countries and age cohorts. As can be seen, the
proportion of employees with less than college education
is lowest in the Swedish and the British samples, and
highest in the French and the German samples.
Educational differences according to gender are most
pronounced in the Whitehall population and least
pronounced in the Somstress sample.
These variations in types of occupation, education, age
and gender provide opportunities to evaluate the work
stress measure in different populations. Moreover, some
aspects of discriminant validity of the scales with respect
to major sociodemographic variables can be tested. To
this end, means and standard deviations of the
effort, reward and overcommitment scales according to
gender, age and educational degree are displayed (see
Table 2).
The effort scale is composed of five items with a score
ranging from 5 to 25. Mean scores are highest in the
Belgian and the Swedish groups. In three countries, the
score was higher in men than in women whereas a
reverse tendency was found in the Whitehall group.
Scores decreased with age in the two elderly cohorts
(GAZEL, Whitehall), but not consistently among the
remaining groups. Mean effort is significantly higher
among better-educated groups in four samples, and a
similar non-significant tendency is observed in the
smaller German sample. Overall, the internal consis-
tency of the scale is satisfactory.
The reward scale consists of 11 items (score ranging
from 11 to 55). Reward scores are lower in the
Belgian sample compared to the other groups;
however, approximately half of the Belgian study
population was threatened by job instability, whereas
in the four remaining populations job stability was
relatively high. Reward scores do not differ according
to gender in a consistent way, but there is a tendency
of higher scores among older employees and especially
in men (significant associations in four of five sub-
groups). A positive association of reward with educa-
tional degree is observed in the GAZEL and Somstress
samples. In the Whitehall sample this association
is not present. However, when replacing education by
employment grade (a more accurate indicator of
socioeconomic position that was not available in a
comparative way for the remaining studies) a
clear-cut gradient is observed with higher reward
scores among higher employment grades. The internal
consistency of the reward scale is satisfactory in all
samples.

Table 1
Sociodemographic characteristics of the study samples
GAZEL Whitehall II WOLF-Norrland Public transport workers Somstress

Men Women Men Women Men Women Men Women Men Women

N % N % N % N % N % N % N % N % N % N %

Age (years) 7251 2923 2783 914 738 222 267 48 2055 1739
o40 — — — — — — — — 62 8.4 17 7.7 80 29.9 15 31.3 630 30.8 977 56.3
40–44 — — 273 9.3 — — — — 102 13.8 26 11.7 60 22.4 10 20.8 453 22.1 360 20.7
45–49 1304 17.9 1351 46.2 869 31.2 299 32.7 124 16.8 46 20.7 51 19.0 13 27.1 580 28.3 248 14.3
50–54 5147 70.9 1056 36.1 1097 39.4 334 36.5 115 15.6 39 17.6 36 13.4 10 20.8 316 15.4 114 6.5
>54 800 11.0 243 8.3 817 29.4 281 30.7 335 45.4 94 42.3 40 14.9 — — 66 3.2 35 2.0

Education 7251 2923 2687 847 738 222 267 48 2055 1739
oCollege 4788 66.0 2117 72.4 714 26.6 366 43.2 272 36.9 66 29.7 238 89.1 37 78.7 1262 62.9 745 43.2
College 485 6.7 365 12.5 818 30.4 185 21.8 291 39.4 90 40.5 8 3.0 5 10.6 490 24.4 747 43.3
University 1976 27.2 441 15.1 1155 43.0 296 34.9 175 23.7 66 29.7 21 7.9 5 10.6 253 12.6 231 13.4
 1490
Table 2
Internal consistency and discriminant validity of the three scales of the model (differences calculated with t-tests for two independent samples, Kolmogorov–Smirnov–Test (Z),
ANOVA or Kruskal Wallis respectively)

Effort
GAZEL Whitehall IIa WOLF-Norrland Public transport workers Somstressb

J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499

Men Women tðpÞ Men Women ZðpÞ Men Women tðpÞ Men Women ZðpÞ Men Women tðpÞ
ðN ¼ 6447) ðN ¼ 2454Þ ðN ¼ 2783Þ ðN ¼ 914Þ ðN ¼ 738Þ ðN ¼ 222Þ ðN ¼ 256Þ ðN ¼ 46Þ ðN ¼ 2045Þ ðN ¼ 1724Þ

Sum score7SD 11.5774.28 11.3474.27 0.025 8.2472.80 8.5473.12 0.043 13.3174.87 12.3174.97 0.009 12.6573.93 11.7073.89 0.720 14.4272.52 14.1972.78 0.007

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Cronbach’s a 0.75 0.75 0.73 0.76 0.71 0.78 0.68 0.61 0.64 0.72

Age
o40 — — — — 13.58 10.59 13.17 12.29 14.51 14.12
40–44 — 11.23 — — 13.75 11.77 13.12 11.44 14.32 14.49
45–49 11.70 11.57 8.84 8.79 14.01 12.61 12.68 10.92 14.49 14.05
50–54 11.65 11.28 8.34 9.05 13.63 12.67 12.55 12.10 14.25 14.29
>54 10.82 10.32 7.63 7.75 12.75 12.49 10.85 — 14.69 13.81
0.000 0.002 0.000 0.000 0.075 0.590 0.008 0.846 0.396 0.182

Education
oCollege 11.46 11.10 7.86 7.96 12.22 10.86 12.66 11.22 14.11 13.58
College 11.59 11.68 8.17 8.56 13.19 12.44 11.13 12.50 14.72 14.61
University 11.82 12.13 8.53 9.30 15.19 13.59 13.10 15.00 15.39 14.84
0.014 0.000 0.000 0.000 0.000 0.006 0.394 0.120 0.000 0.000

Reward
GAZEL Whitehall IIc WOLF-Norrland Public transport workers Somstressb

Men Women tðpÞ Men Women ZðpÞ Men Women tðpÞ Men Women ZðpÞ Men Women tðpÞ
ðN ¼ 6447Þ ðN ¼ 2454Þ ðN ¼ 2783Þ ðN ¼ 914Þ ðN ¼ 738Þ ðN ¼ 222Þ ðN ¼ 248Þ ðN ¼ 42Þ ðN ¼ 2012Þ ðN ¼ 1671Þ

Sum score7SD 46.7177.86 46.6578.24 0.025 34.4875.60 33.9176.09 0.048 46.4077.7 45.1977.1 0.029 41.5278.93 42.7979.01 0.894 28.8674.82 29.1774.88 0.057
Cronbach’s a 0.86 0.88 0.83 0.84 0.79 0.70 0.86 0.87 0.78 0.77

Age
o40 — — — — 46.16 46.41 38.85 40.00 29.58 29.24
40–44 — 46.97 — — 47.23 45.65 40.50 39.20 28.87 29.28
45–49 46.22 46.66 33.77 33.71 46.29 45.09 40.67 46.92 28.41 28.93
 50–54 46.59 46.53 34.13 33.23 45.31 45.08 44.03 45.25 28.11 28.48
>54 48.22 46.72 35.72 34.95 46.61 44.93 47.56 — 29.83 29.74
0.000 0.905 0.000 0.002 0.44 0.94 0.000 0.115 0.000 0.474

Education
o College 46.25 46.76 34.46 34.59 46.64 47.15 41.95 44.15 28.44 28.78
College 46.49 45.57 34.36 34.08 46.09 44.56 34.13 36.75 29.14 29.23
University 47.85 47.01 34.55 33.36 46.55 44.08 40.00 38.75 30.52 30.15
0.000 0.038 0.841 0.032 0.67 0.024 0.087 0.309 0.000 0.010

Overcommitment

J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499

GAZEL Whitehall IId WOLF-Norrland Public transport workers Somstress

Men Women tðpÞ Men Women ZðpÞ Men Women tðpÞ Men Women ZðpÞ Men Women tðpÞ
ðN ¼ 6289Þ ðN ¼ 2404Þ ðN ¼ 2783Þ ðN ¼ 914Þ ðN ¼ 738Þ ðN ¼ 222Þ ðN ¼ 265Þ ðN ¼ 48Þ ðN ¼ 2056Þ ðN ¼ 1740Þ

Sum score7SD 2.5170.61 2.5770.63 0.000 2.0270.76 2.0670.78 0.810 1.7970.61 1.8570.61 0.24 2.047.63 2.107.61 0.819 2.5770.60 2.5370.59 0.031

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Cronbach’s a 0.79 0.79 0.81 0.82 0.80 0.80 0.74 0.64 0.81 0.80

Age
o40 — — — — 1.83 1.88 1.90 2.20 2.47 2.47
40–44 — 2.52 — — 1.83 1.89 2.07 2.02 2.54 2.56
45–49 2.48 2.58 2.09 2.16 1.95 1.93 2.22 1.95 2.64 2.63
50–54 2.51 2.58 2.04 2.08 1.80 1.81 2.22 2.22 2.69 2.67
>54 2.54 2.48 1.93 1.89 1.90 1.80 1.91 — 2.68 2.76
0.086 0.16 0.000 0.000 0.004 0.83 0.008 0.675 0.000 0.000

Education
oCollege 2.48 2.56 1.93 1.88 1.67 1.85 2.03 2.05 2.59 2.54
College 2.51 2.56 2.02 2.08 1.72 1.74 2.19 2.17 2.55 2.51
University 2.59 2.60 2.11 2.27 2.07 1.99 2.12 2.27 2.51 2.55
0.000 0.482 0.000 0.000 0.000 0.045 0.683 0.828 0.079 0.531

p-values underlined.
a
Whitehall II: Effort excludes question ERI 6.
b
Somstress: Items were measured by a 4-point Likert scale.
c
Whitehall II: Reward excludes questions ERI 14, ERI 17.
d
Whitehall II: Overcommitment excludes question OC 1

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1492 J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499

Overcommitment, measured by six items, has scores
ranging from 6 to 24. Overall, a U-shaped distribution is
observed with increasing age with men and women aged
45–54 generally having the highest scores. Employees
with higher educational levels tend to exhibit higher
scores of overcommitment, but again, this association is
not significant for all subgroups. The internal consis-
tency of the scale is appropriate in all samples, with the
exception of the small sample of female transport
workers in Germany.
Despite the heterogeneity of the samples in terms of
occupation, education, age and gender composition,
there are some rather consistent tendencies. The mean
levels of effort and reward are higher in better-educated
groups. Lower effort is associated with increasing age in
the two study populations with a high proportion of
elderly subjects, and higher reward is associated with
increasing age, in particular among men. Finally, the
reward scale seems to reflect contextual conditions, such
as increased job instability, as evidenced by low scores in
the Belgian sample where job instability is higher than in
the remaining groups.
Table 3 summarizes the results of confirmatory factor
analyses for the effort, reward and overcommitment
scales. Respective analyses are performed separately for
the three scales within each sample, based on three
statistical models specified according to the theoretical
assumptions (see Introduction and Methods; see Ap-
pendix). This information is crucial as the statistical
justification of using the single scales and the composite
measure of the effort–reward ratio for explaining health
relies on the goodness of fit of the measurement model
with the data. With regard to the effort scale, the model
fit based on the assumption of one latent factor with five
variables loading on this factor was appropriate in all
five samples. Mean residual variances and covariances

Table 3
Criteria of goodness of fit of the three components of the model (confirmatory factor analysis)

Effort
GAZEL Whitehall II WOLF-Norrland Public transport company Somstress
ðN ¼ 8901Þ ðN ¼ 3697Þ ðN ¼ 960Þ ðN ¼ 283Þ ðN ¼ 3685Þ

Chi2 ðpÞ 373.44 (0.000) 21.39 (0.000) 22.94 (0.000) 6.72 (0.242) 93.19 (0.000)
Chi2/df 74.69 10.57 4.59 1.35 18.64
GFI 0.984 0.997 0.991 0.991 0.990
AGFI 0.953 0.986 0.972 0.972 0.971
RMR 0.039 0.012 0.035 0.036 0.018
Loading (e.) 0.54–0.79 0.30–0.67 0.51–0.84 0.51–0.69 0.42–0.57
a 0.79 0.74 0.71 0.72 0.68

Reward
GAZEL Whitehall II WOLF-Norrland Public transport companya Somstress
ðN ¼ 8901Þ ðN ¼ 3697Þ ðN ¼ 960Þ ðN ¼ 283Þ N ¼ 3534

Chi2 ðpÞ 1966.02 (0.000) 280.24 (0.000) 222.25 (0.000) 47.60 (0.191) 996.96 (0.000)
Chi2/df 47.95 16.49 5.56 1.19 24.32
GFI 0.957 0.981 0.959 0.971 0.951
AGFI 0.931 0.959 0.933 0.952 0.921
RMR 0.052 0.032 0.063 0.049 0.030
Loading (e.) 0.24–0.87 0.35–0.74 0.37–0.83 36–0.87 0.33–0.83
a 0.85 0.83 0.80 0.86 0.79

Overcommitment
GAZEL Whitehall II WOLF-Norrland Public transport company Somstress
ðN ¼ 8695Þ ðN ¼ 3697Þ ðN ¼ 894Þ ðN ¼ 283Þ ðN ¼ 3699Þ

Chi2 ðpÞ 618.51 (0.000) 33.33 (0.000) 56.63 (0.000) 19.37 (0.02) 28.43 (0.000)
Chi2/df 68.723 6.670 6.292 2.15 5.69
GFI 0.976 0.996 0.979 0.980 0.997
AGFI 0.944 0.989 0.951 0.953 0.991
RMR 0.0288 0.015 0.025 0.032 0.009
Loading (e.) 0.44–0.84 0.27–0.78 0.48–0.84 0.31–0.84 0.55–0.86
a 0.79 0.81 0.79 0.73 0.82
a
In the Public Transport Study a correlation between two measurement errors on items belonging to the same factor (ERI7 and
ERI8) was accepted in order to improve the model fit.
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Table 4
Self-rated health and the core components of the ERI model (results form logistic regression analyses)

GAZEL Whitehall II Public transport workers Somstress

Men Women Men Women Total Men Women

ðN ¼ 5343Þ ðN ¼ 1815Þ ðN ¼ 2668Þ ðN ¼ 843Þ ðN ¼ 283Þ ðN ¼ 2056Þ ðN ¼ 1740Þ

OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Effort–reward ratio
p1 1 1 1 1 1 1 1
>1 2.6 2.0–3.3 2.8 2.0–4.1 3.5 2.3–5.3 5.2 3.0–9.3 3.1 1.4–6.5 3.2 1.8–5.7 1.6 0.8–3.0

Overcommitment
Low 1 1 1 1 1 1 1
High 1.5 1.3–1.8 1.8 1.5–2.3 2.2 1.7–2.8 1.7 1.1–2.5 1.5 0.9–2.5 3.5 2.2–5.6 2.6 1.4–4.9

(RMR) were well below the threshold of 0.05, and the
model explains more than 95 percent of observed
variance and covariance (GFI, AGFI). Additional
information reveals that the latent construct explains a
substantial part of the observed variance of the single
variables, as evidenced by respective factor loadings.
The model of the reward scale is more complex as
three latent factors are specified: esteem, salary and
career, and job insecurity (see Methods section and
Appendix). Table 3 indicates that the residual variances
and covariances are again satisfactory though slightly
elevated for the five study samples, and the proportion
of explained variances and covariances is therefore
slightly lower, ranging from 92.1 to 95.9 percent (after
adjustment for degrees of freedom). Factor loadings (l)
and Cronbach’s a are well comparable to those of the
remaining scales. In all analyses, moderate or high
correlations between the three factors esteem, salary and
career, and job insecurity were observed, thus support-
ing the notion of an underlying ‘reward’ factor.
For the overcommitment scale findings are similar to
the effort scale in which one latent factor is assumed
with all variables loading on this factor. In all samples
mean residual variances and covariances were very low,
ranging from 0.009 to 0.032, and, after adjusting for the
number of degrees of freedom (AGFI), the model
explains between 94.4 and 99.1 percent of observed
variances and covariances. Moreover, factor loadings (l)
and Cronbach’s a are again high. Thus, this information
provides a solid test statistical basis of the short version
of the overcommitment scale (see Appendix).
In summarizing the results of the factorial structure,
the constructs underlying the theoretical effort–reward
imbalance model have been replicated in five indepen-
dent samples of working men and women in different
European countries. Neither the fit of the models nor the
regression coefficients changed when analyses were
performed separately for men and women. Therefore,
the model holds equally true for men and women.
Last, we present separate information on the content
validity of the model’s core components (i.e. the effort–
reward ratio (>1.0 vs. p1.0)) and overcommitment (i.e.
upper tertile of scores vs. remaining group), using self-
reported health as an indicator. As a measure of self-
rated health was not available from the WOLF-Norr-
land Study, the following analyses are restricted to the
remaining four samples. Table 4 displays the results of
logistic regression analyses using a dichotomous out-
come criterion (poor vs. remaining categories of self-
rated health). Analyses are performed separately for
men and women in the three investigations with large
samples, and combined in the case of German transport
employees due to small sample size. Results indicate
significantly elevated odds ratios of poor self-rated
health in the groups characterized by high effort and
low reward in all four samples (varying between 2.4 and
5.2) with the one exception of women in the Somstress
Study. Similarly, scoring high on overcommitment is
associated with significantly elevated risk of poor self-
rated health in all analyses except the public transport
employees. Elevated odds ratios vary between 1.5 and
3.5, indicating that effects are somewhat less pro-
nounced than with the effort–reward ratio. Controlling
for age did not significantly modify the observed effects.
Discussion
The results of this comparative epidemiologic inves-
tigation in five European countries reveal good psycho-
metric properties of the scales measuring effort–reward
imbalance at work.
For the five samples, internal consistency and
discriminant validity were assessed and their factorial
structure was analyzed by using parallel confirmatory
factor analyses. In addition, one aspect of content
validity was examined with self-rated health as the
outcome. In almost all subgroups, significantly elevated
 ARTICLE IN PRESS
1494 J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
odds ratios of poor health are observed among employ-
ees who have an imbalance between effort and reward
and those who are characterized by a high level of
overcommitment.
This is the first report assessing the reliability and
validity of the short form (23 items) of the effort–reward
imbalance questionnaire in a comparative analysis based
on samples of employed men and women from five
different European countries. In addition to testing
psychometric properties of the scales, this comparative
analysis is of theoretical relevance as it adds two aspects
to the current understanding of psychosocial stress at
work. First, it underlines the importance of reciprocated
exchange in a core social role (work) for maintaining
good health as high cost and low gain states increase the
risk of illness. Secondly, it illustrates the advantage of
disentangling the extrinsic from the intrinsic compo-
nents of the complex person–work environment inter-
action at the conceptual and operational level. More
specifically, the model’s extrinsic component (effort–
reward ratio) has been complemented by introducing a
personal style of coping with work demands (over-
commitment). Combining these components improves
the model’s predictive power.
Before discussing methodological aspects of this
study, the relation of the current model to alternative
or complementary formulations of work stress needs to
be addressed.
The demand-control model of work stress is the most
influential and most widely tested approach towards
assessing psychosocial stress at work (Karasek &
Theorell, 1990). There are several similarities between
the demand-control and the effort–reward imbalance
model. They both represent general models of work
stress with a selective analytical focus. Both are
measured by a standardized self-administered question-
naire and data are analyzed according to predefined
procedures. However, the demand-control model is
open to alternative or supplementary measures (e.g.
imputation of job characteristics scores (Amick et al.,
2002; Schnall et al., 2000)). There is also a strong
conceptual and methodological overlap between the two
scales of demand and effort.
Yet, clear conceptual and methodological differences
exist. First, the demand-control model has been
introduced and measured as a concept that is restricted
to the structural aspects of the psychosocial work
environment, whereas the effort–reward imbalance
model includes both structural and personal character-
istics. Secondly, components of the effort–reward
imbalance model (salaries, career opportunities/job
security) are linked to more distant macro-economic
labor market conditions, while the demand-control
model’s major focus is on work place characteristics.
Finally, the two different stress theoretical orientations
(control vs. reward) have different implications for
policy: whereas the control paradigm points to the
structure of power, division of labor and democracy at
work, the reward paradigm addresses the issue of
distributive justice and fairness. The two models offer
opportunities for combining information on work strain
and health as conditions of low control and low reward
at work often cumulate within specific occupational
groups. Preliminary evidence from a large-scale study
indicates that combined effects of the two models on
cardiovascular health are considerably stronger than
their separate effects (Peter, Siegrist, Hallqvist, Reuter-
wall, Theorell & the SHEEP Study Group, 2002).
Moreover, in the Whitehall II Study (Bosma, Peter,
Siegrist, & Marmot, 1998) it was found that the
demand-control model (the control dimension only)
and the effort–reward imbalance model predict the
incident coronary heart disease with equal strength
when using appropriate statistical controls. There is now
a growing number of studies available that contain
information on both models and, thus, explore their
separate and combined effects on health (see Siegrist,
2002).
Several other general concepts of work stress have
been proposed and tested, most notably the person
environment fit model (Edwards, Caplan, & van
Harrison, 1998) and models based on equity theory in
social psychology (Walster, Walster, & Berscheid, 1978).
While the person environment fit model has brought
conceptual and methodological innovations into the
field of occupational stress, it remains difficult to assess
its ability to predicting adverse health effects. Because
the model is complex, it is difficult to deduce and test
predictions in an unequivocal way and, thus, compare it
with the other two models.
At first glance, core notions of equity theory and of
the effort–reward imbalance model seem quite similar.
Yet, a closer look reveals clear differences. First, equity
theory predicts a curvilinear relationship between equity
and strain: perceiving oneself as deprived as well as
perceiving oneself as advantaged evokes negative emo-
tions. Accordingly, receiving too much is considered as
detrimental as receiving too little. This proposition
clearly differs from the effort–reward imbalance model
where inappropriately low gain only matters for adverse
outcomes. This conclusion is in accordance with the
predictions of prospect theory (Kahneman & Tversky,
1979) and of the conservation of resources theory
(Hobfall, 1998). In addition, it is confirmed by evidence
derived from neuroscience research (Gehring & Wil-
loughby, 2002). Secondly, while equity theory proposes
two levels of comparison (equity in interpersonal and
intrapersonal terms) without specifying their separate or
combined effects on strain the current model analyses
equity of reward exclusively as a function of invested
effort. This restriction is in accordance with propositions
derived from sociological exchange theory (Gouldner,
 ARTICLE IN PRESS
J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
1960; for additional discussion of equity theory in this
framework see Siegrist, 2002).
Several methodological aspects of this study need to
be discussed. First, the validity of self-assessed measures
of work stress is a controversial topic. Although in
conceptual terms there is a need to include the working
person’s experience into any comprehensive assessment
of work stress, such measures are often subject to
reporting bias and may be influenced by specific
personality characteristics, moods and contexts (Kahne-
man, Diener, & Schwarz, 1999; Schnall et al., 2000;
Semmer, Zapf, & Greif, 1996; Spector, Zapf, Chen, &
Frese, 2000). To minimize these sources of error, several
strategies were followed in some, but not all studies
measuring effort–reward imbalance at work: contextual
validation; adjustment for a specific response style
(negative affectivity); repeated measurement and differ-
ent techniques of data collection (computer-assisted
interview vs. self-administered questionnaire). Contex-
tual validation was performed in studies on blue collar
workers and middle managers where objective indicators
(job instability, blocked mobility, inequality in wages)
were analyzed in relation to information obtained from
the questionnaire (Siegrist, 1996b). In a recent Japanese
study, sensitivity to change over time of the scales was
documented in a company that was faced with a
significant economic crisis (Tsutsumi, Nagami, Mori-
moto, & Matoba, 2002). Two studies that included the
overcommitment scale in intervention trials aiming at a
reduction of work-related stress and overcommitment
also indicated that the scales were sensitive to change
over time (Aust, Peter, & Siegrist, 1997; Puls, Inhester, &
Wienhold, 2002).
Several investigations adjusting for negative affectiv-
ity demonstrated the persistent significance of the
model’s scales on health indicators (Bosma et al., 1998;
Hanson et al., 2000; Joksimovic et al., 2002; Stansfeld,
Fuhrer, & Shipley, 1999). Repeated measures were
obtained from the longitudinal blue collar study
(Siegrist, 1996b). To date, the consistency of informa-
tion obtained from repeated measurement has been
satisfactory. Similarly, comparison of computer-assisted
interview data with data received from self-administered
questionnaires did not reveal remarkable differences
with the exception of less missing values with computer-
assisted data. An additional argument supporting the
validity of the measures is provided by the numerous
investigations that use medically diagnosed diseases,
biomedical risk factors and continuously recorded
physiological parameters (ambulatory blood pressure,
heart rate, heart rate variability) as outcome measures
(Kivim.aki et al., 2002; Kuper, Singh-Manoux, Siegrist,
& Marmot, 2002; for review of earlier findings see
Siegrist, 2002).
The cross-sectional design of this study points to a
substantial limitation, and that of reverse causation and
1495
common method variance. While these problems cannot
be resolved in the study, the focus of this contribution is
on psychometric properties of the scales in a compara-
tive perspective. Because other prospective and cross-
sectional studies have documented associations of the
effort–reward imbalance model with self-rated health
(Niedhammer et al., 2003; Pikhart et al., 2001), reverse
causation is unlikely to invalidate the findings.
It should also be mentioned that the samples included
in this comparative study are heterogeneous in terms of
professions. While this heterogeneity has been intended
in order to test the application of the measures in a
broad spectrum of employed populations, it remains
nevertheless unclear to what extent the reported
psychometric properties hold true for other professional
groups. Comparable factor analyses of the scales were
conducted in samples of specific professional groups
such as physicians (Calnan, Wainwright, & Almond,
2000), nurses (Bakker, Killmer, Siegrist, & Schaufeli,
2000), dental technicians (Tsutsumi et al., 2001) and
software specialists (Hanson et al., 2000). Moreover,
these and other studies indicate that the scales can be
applied to sociocultural populations that differ from
those in western and northern European countries, such
as countries in Central and Eastern Europe (Pikhart
et al., 2001), China (Xu, Cao, Lee, & Critchley, 2000),
Japan (Tsutsumi et al., 2001, 2002), the United States
(Rugulies & Krause, 2000) and Canada (Kerr, Ibrahim,
Peter, & Sullivan, 2000).
A further limitation of this study relates to the
statistical analyses that were applied to test the model’s
assumptions. As imbalance between effort and reward is
assumed to be of crucial importance, a ratio of the effort
and reward scales is constructed. In several studies
effects of the ratio on health were tested taking into
account main effects and interaction terms of the two
scales. Evidence so far indicates that effects based on
continuous information on the ratio are more powerful
than effects based on other formulations (Kuper et al.,
2002; Niedhammer et al., 2003; Pikhart, 2002). There-
fore, using the ratio as a continuous log-scaled variable
is proposed as a most convenient statistical approach in
future studies unless more sophisticated methods have
been developed. One interesting refinement concerns
the test of separate effects on health produced by the
three reward components in relation to effort. Estimat-
ing the relative contribution of reward components is of
particular interest for intervention studies (Vegchel,
Jonge, Bakker, & Schaufeli, 2002).
Likewise, improved statistical modeling may also
apply to the combined analysis of the two components
(ratio, overcommitment) of the model. In this study,
separate effects were only analyzed. Other investigations
have applied a linear structural equation modeling
(Siegrist, 1996b) or analyzed effect modification (over-
commitment modifies the effect of the ratio on health;
 ARTICLE IN PRESS
1496 J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499

Jonge, Bosma, Peter, & Siegrist, 2000; Kuper et al., participating civil service departments and their
2002). Additional statistical analyses should explore welfare, personnel, and establishment officers; the
whether ‘effort’, ‘reward’ (and its subscales) and ‘over- Occupational Health and Safety Agency; the Council
commitment’ are really separate constructs by conduct- of Civil Service Unions; all participating civil servants in
ing an overall confirmatory factor analysis on all items the study; and all members of the Whitehall II Study
simultaneously. In fact, such an approach has been Team.
successfully tested with different data sets, including the
Somstress Study data (see also Hanson et al., 2000). In
the Somstress data, the overall model fit (GFI) was Appendix
0.923, and the RMSEA measure was 0.065. The
standardized regression weights of the latent construct Effort
on ‘effort’ were 0.62, on ‘overcommitment’ 0.86, and on ERI1 I have constant time pressure due to a heavy
‘reward’ –0.45. This information indicates that, indeed, work load.
the theoretically assumed structure of the proposed ERI2 I have many interruptions and disturbances in
theoretical model fits the data. my job.
In conclusion, a psychometrically well-justified ERI3 I have a lot of responsibility in my job.
measure of work-related stress (ERI) grounded in ERI4 I am often pressured to work overtime.
sociological theory is available for comparative socio- ERI6 Over the past few years, my job has become
epidemiologic investigations. In the light of the im- more and more demanding.
portance of work for adult health such investigations are
critical in advanced societies within and beyond Europe. Reward
Component esteem
ERI7 I receive the respect I deserve from my
Acknowledgements superiors.
ERI8 I receive the respect I deserve from my
The collaborative research presented in this paper was colleagues.
supported by the European Science Foundation’s ERI9 I experience adequate support in difficult
Scientific Programme on ‘Social Variations in Health situations.
Expectancy in Europe’. Authors thank Craig Pollack ERI10 I am treated unfairly at work.
and Andreas Roedel for their help in finalizing the ERI15 Considering all my efforts and achievements, I
paper. Further acknowledgement concerns the single receive the respect and prestige I deserve at
studies. SOMSTRESS: This study was supported by the work.
Federal Office for Scientific, Technical and Cultural
Affairs (SSTC) in Belgium. GAZEL and WOLF-Norr- Component job promotion
land: The authors would like to thank the Medical ERI11 My job promotion prospects are poor.
Committee of EDF-GDF, all the workers of the ERI14 My current occupational position adequately
GAZEL cohort, and the members of the GAZEL study reflects my education and training.
team, especially Marcel Goldberg and Annette Leclerc, ERI16 Considering all my efforts and achievements,
who made the GAZEL study possible. The same holds my work prospects are adequate.
true for the workers of the WOLF cohort, the WOLF ERI17 Considering all my efforts and achievements,
study group, especially Lars Alfredsson, Anders Knuts- my salary/income is adequate.
.
son, Tores Theorell and Peter Westerholm. Public
Transport Study: Authors thank all study participants Component job security
and the collaborators Ljiljana Joksimovic and Olaf von ERI12 I have experienced or I expect to experience an
dem Knesebeck. The study was supported by the undesirable change in my work situation.
German Ministry of Research and Technology (C1 ERI13 My job security is poor.
Public Health). Whitehall II: The Whitehall II Study has
been supported by grants from the Medical Research Overcommitment
Council; British Heart Foundation; Health and Safety OC1 I get easily overwhelmed by time pressures at
Executive; Department of Health; National Heart Lung work.
and Blood Institute (HL36310), US, NIH: National OC2 As soon as I get up in the morning I start
Institute on Aging (AG13196), US, NIH: Agency for thinking about work problems.
Health Care Policy Research (HS 06516); and the John OC3 When I get home, I can easily relax and ‘switch
D and Catherine T MacArthur Foundation Research off’ work.
Networks on Successful Midlife Development and OC4 People close to me say I sacrifice too much for
Socioeconomic Status and Health. We also thank all my job.
 ARTICLE IN PRESS
J. Siegrist et al. / Social Science & Medicine 58 (2004) 1483–1499
OC5 Work rarely lets me go, it is still on my mind
when I go to bed.
OC6 If I postpone something that I was supposed to
do today I’ll have trouble sleeping at night.
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