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Asia Pac J Public Health. Author manuscript; available in PMC 2016 March 31.
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Published in final edited form as:

Asia Pac J Public Health. 2016 January ; 28(1 Suppl): 41S–52S. doi:10.1177/1010539515598834.

Perceived Job Stress and Presence of Hypertension Among

Administrative Officers in Sri Lanka
Anuji Upekshika Gamage, MBBS, MSc (Community Medicine), MD (Community Medicine)1
and Rohini De Alwis Seneviratne, MBBS (Hons), MD(Colombo), DipMedEd(Dundee),
MMEd(Dundee), FCCP(SL)2
1Ministry of Health, Colombo, Sri Lanka
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2General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka

Abstract
A cross-sectional survey was carried out among 275 and 760 randomly selected senior officers
(SOs) and managerial assistants (MAs) aged between 30 and 60 years. Sum of scores of efforts,
rewards, and overcommitment and effort–reward ratio assessed job stress. Blood pressure was
measured and classified using JNC-7 guidelines. The response rates of SOs and MAs were 98.9%
and 97.2%, respectively. The prevalence of job stress based on high effort–rewards imbalance
among SOs and MAs was 74.6% and 80.5%, respectively. The prevalence of overcommitment
among SOs and MAs was 35.3% and 29%, respectively. Statistically significant differences (P = .
05) were observed between the prevalence of effort–reward imbalance and overcommitment
among SOs and MAs. Multivariate analysis indicated effort–reward imbalance (odds ratio [OR] =
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2.8; 95% confidence interval [CI] = 1.1–7.4), high efforts (OR = 2.5; 95% CI = 1.2–5.3), and
overcommitment (OR = 2.5; 95% CI = 1.1–5.6) were significantly associated with hypertension
among SOs. Similarly, effort–reward imbalance and high efforts increased the risk of hypertension
by 2-fold (OR = 2.2; 95% CI = 1.1–4.2) and 3-fold (OR = 3.02; 95% CI = 1.9–4.8), respectively,
among the MAs. A significant number of administrators are afflicted by job stress, and job stress
was significantly associated with hypertension.

Keywords
ERI questionnaire; job stress; hypertension; effort–reward imbalance; administrators
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Introduction
Work life has undergone major structural and technological changes since the beginning of
the 1990s. Alongside the advances, workplaces with physically taxing and hazardous

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Corresponding Author: Anuji Upekshika Gamage, No. 6, Ruskin Place, Hazelwood Park, South Australia 5066, Australia.
anujigamage@gmail.com.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The contents of this report are solely the responsibility of the authors, and do not necessarily represent the official views of the
National Institutes of Health.
 Gamage and De Alwis Seneviratne Page 2

working conditions have reduced in number; however, the psychosocial conditions that
affect the central nervous system have increased.1,2 Studies have repeatedly proven the
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inverse relationship between unfavorable psychosocial work environments and employee

health and well-being.3–6 Many other studies have reported that job stress is related to the
incidence and prevalence of cardiovascular disease.5–8 It is postulated that one of the
underlying mechanisms through which job stress increases cardiovascular disease is
mediated through high blood pressure.7 Job stress has been proven to be associated with
high blood pressure. Several analytical studies have proven significant positive associations
of job stress and hypertension.7,9,10

Numerous conceptualizations of job stress models have been developed to date.11 However,
2 theoretical models have gained prominence to predict health risks in the exposed
populations: the demand control model12 and the effort–reward -imbalance (ERI) model.13
The latter model focuses on nonreciprocity of social exchange, which contributes to stress,
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and defines 3 psychosocial dimensions at work—effort, reward, and overcommitment—and

assumes that effort at work is spent as a part of the work contract, and rewards are provided
in terms of money, esteem, and career opportunities including job security.2 In addition to
these 2 work-related dimensions, overcommitment at work acts as a personal risk factor and
is defined as a set of attitudes, behaviors, and emotions that reflects excessive commitment
combined with strong need for approval and esteem.14 Thus, this model considers both the
extrinsic factors, efforts and rewards, and the intrinsic characteristic, overcommitment.
According to the ERI model, chronic job stress is caused by an imbalance between high
efforts spent and low rewards received and is aggravated by overcommitment.13 Both cross-
sectional and longitudinal studies have proven that the ERI model has a more predictive
ability of job stress compared with the demand control model.15,16
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The Ministry of Public Administration and Home Affairs, which is situated in Colombo
district, is the Centre of Civil Administration and facilitates and coordinates services related
to public administration, district administration, divisional administration, village
administration, civil registration, and employees’ welfare. It deals with a number of areas
such as public policy making on organizational excellence, human resource management,
institutional development, electronic government, and good governance targeting social and
economic development along with the national priorities of the government. Senior officers
and managerial assistants attached to government public administrative offices are
authorized officers to conducted administrative tasks in the country. They are entrusted with
coordination and conduct of the aforementioned administrative tasks. The immense weight
of responsibility in carrying out administrative work, handling people, and seeking solutions
exposes them to a psychologically demanding work environment, leading to occupational
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stress, which in turn can adversely affect their health. Senior officers and managerial
assistants are 2 different study populations although they work under the same roof. These 2
populations have different job roles and responsibilities, exposing them to different
determinants of ill health, especially hypertension. Although administrative officers are
burdened with high workload, no study has specifically examined the association of
occupational status and work-related factors such as job stress and health effects. Although
risk factors like age, unhealthy diet, alcohol consumption, and smoking are well-known
determinants, these factors explain only a part of the risk of development of hypertension.9

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 Gamage and De Alwis Seneviratne Page 3

Colombo district was chosen for the present study for several reasons. Recent urbanization
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and rapid social, demographic, and economic transition have affected employees’ physical
and psychosocial health in many ways. This problem is most significant in Colombo district,
which consists of a diverse socioeconomic composition and which has the highest
population density of all Sri Lankan districts. An adequate sample size of the 2 populations,
especially the senior officers, could be recruited from Colombo district, as a majority of
offices that operates under the Ministry of Public Administration and Home Affairs are
situated here.

Although job stress serves as a risk factor for psychological and physical ill-health, Sri
Lanka has a paucity of evidence on the prevalence of job stress and its impact on
cardiovascular diseases such as hypertension. The recent emerging trends of prevention
initiatives and government investment in programs to control noncommunicable diseases in
Sri Lanka necessitate policy decisions and effective interventions such as health-promoting
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work settings. This needs evidence and policy-relevant recommendations. Hence, this study
was carried out to determine the prevalence of job stress and explore the relationship
between perceived job stress and presence of hypertension among senior officers and
managerial assistants of government administration offices in a district of Sri Lanka.

Methods
Participants
A descriptive cross-sectional study was conducted among senior officers and managerial
assistants attached to public administration offices in the Colombo District. In this district,
there are 23 such offices. The total number of senior officers (SOs) and managerial assistants
(MAs) attached to the institutions were 358 and 1231, respectively. The study population
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comprising full-time, permanent SOs and MAs between the ages of 30 to 60 years and
employed for at least a period of 1 year or more in a similar government institution in a
similar cadre post were selected for the study. Officers on maternity or other long leave and
officers on prolonged (more than 1 month) steroid therapy confirmed by documented
evidence were excluded from the study.

Sample size calculation to detect prevalence of hypertension was done assuming the
prevalence of hypertension among adults was 20%,17 95% confidence interval, and a
precision of 0.05 using the formula to detect a population proportion. Ten percent was added
to account for nonresponse. Sample size calculation was done separately for SOs and MAs,
since they were regarded as 2 study populations. Thus, the final calculated sample size for
SOs and MAs was 275 and 760, respectively. A stratified simple random sampling technique
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was used to select the SOs and MAs. Stratification was done according to 23 institutions
they are attached to, and the number needed to select from each institution was decided
according to probability proportionate to the size (PPS). The required number of SOs and
MAs from each institution was selected randomly based on the number allocated to each
institution according to PPS. The latest updated version of the payroll was used as the
sampling frame for the purpose of sampling, and the completeness was checked with an
institutional name list prior to use. A unique ID number was given to all the eligible officers.

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Computer-generated random numbers were used to identify the study participants. The
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identified officers were met face to face and invited to participate in the study.

Ethical clearance was obtained from the Ethical Review Board of Faculty of Medicine,
University of Colombo (EC-11-178-17.11.2011). Permission and consent were obtained
from the Ministry of Public Administration and Home Affairs and all heads of institutions
before commencement of the study. Written informed consent was obtained from all
respondents after informing the following in the information sheet: the purpose, the
objectives, and benefits to the occupational group by conducting this study.

A self-administered questionnaire (SAQ) was used to gather information, which consisted of

3 broad components: sociodemographic characteristics; work-related information, which
included validated Sinhala Effort Reward Imbalance Questionnaire; and lifestyle-related
correlates of hypertension. In addition to the SAQ, a data collection form was used to record
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blood pressure (BP), anthropometric measurements, fasting blood sugar values, and to
record information on the past medical history and drug history of the participants.

To assess test–retest reliability, 10% of the questionnaires were readministered to randomly

selected study participants 2 weeks after the initial data collection.

Measures
Blood Pressure—The BP measurements were done based on the American Heart
Association BP measurement recommendations,18 which reduced the intraobserver error of
BP measurements. All BP measurements were carried out by the principal investigator.
Participants were allowed to sit for 5 minutes before measuring BP. The participants were
asked to refrain from smoking or ingesting caffeine during the 30 minutes preceding the BP
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measurement. A cuff with a bladder that is 12–13 cm × 35 cm in size with a larger bladder
for fat arms was used. The bladder within the cuff will encircle at least 80% of the arm. The
cuff was placed at the heart level of the patient. The disappearance of Phase V Korotkoff
sounds was used to measure the diastolic BP. Two BP readings were obtained separated by 1
minute. The average of these 2 values was taken.

When the first 2 readings differed by more than 5 mm Hg, an additional reading was taken
and averaged. Classification of hypertension was done based on the classification of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC-7).19 A person was considered to be a hypertensive if he/she was an
already diagnosed case of hypertension and/or on treatment or with a current systolic BP of
≥140 mm Hg or diastolic BP ≥90 mm Hg (JNC-7 criteria).
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Job Stress—The ERI questionnaire, which was in English (see the appendix), was
translated into Sinhala and validated in a similar population prior to its use. The ERI
questionnaire was a self-administered questionnaire and contained 23 items, each graded on
a 5-point scale, in 3 domains that concerned the psychosocial aspects of work, namely,
efforts, rewards, and overcommitment. The items efforts and rewards included 5 responses
marked on a Likert-type scale and were answered in 2 steps. In the first step, the respondents
were asked whether the item content described a typical experience in the workplace. If they

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agreed, they were asked about the level of distress. The overcommitment items were scored
on a 4-point Likert-type scale ranging from strongly agree to strongly disagree.20 The
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responses to each item of efforts and reward were scored in 5-point scales. Accordingly, the
possible range of scores for “effort” and “reward” was from 6 to 30 and from 11 to 55,
respectively. A ratio between the “effort” and “reward” scales can be computed as below,
and as the main purpose of statistical analyses is to test associations of ERI at work with
health, the following procedures are currently recommended.21

Effort–reward ratio—This measurement provides an approximate of the mismatch

between the efforts and the rewards. It is assumed that the imbalance between effort and
reward is the cause for adverse health outcomes. A single score is calculated from the effort
and reward scale sums for each respondent by using the formula e/(rc), where e is the sum of
the effort items, r is the sum of the reward items, and c is the correction factor fixed at 0.454
if the numerator (efforts) contains 5 items or fixed at 0.545 if the numerator (efforts)
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contains 6 items. Therefore, a score equal to 1 indicates an even balance between the
elements of effort and reward for that individual. Scores greater than 1 indicate an
unfavorable ratio of effort to reward (high effort/low reward), and scores less than 1 indicate
a favorable ratio of effort to reward (low effort/high reward).2

Effect of sum of score of single components on health—The sums of scores of

each scale, namely, efforts, rewards, and overcommitment, could be used to analyze
associations with health. Individuals with scores in the upper tertile are considered to have
an excessive asymmetry between efforts and rewards at work, which may increase the
likelihood of psychological stress.2

Other Variables—Height was measured using a microtoise steel tape and recorded to the
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nearest 0.5 cm. The subjects looked straight ahead with their head, back, and feet touching
the vertical support.

Weight was measured without shoes on an electronic digital weighing scale to the nearest
100 g, and the scale was calibrated after each field session against a standard weights set.
The body mass index (BMI) is calculated by weight in kilograms divided by the square of
the height. The classification and cutoff points used were based on the anthropometry of
adult Asians. A BMI of ≤18.49 kg/m2 was regarded as underweight, 18.50 kg/m2 to 23.00
kg/m2 as desirable, 23.01 kg/m2 to 27.50 kg/m2 as overweight, and ≥27.51 kg/m2 as
obese.22

A flexible, nonelastic measuring tape was used to measure the waist and hip circumference.
The recordings were made to the nearest 0.2 cm. The cutoff points for waist and waist–hip
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ratio given by the World Health Organization expert consultation for the classification of
South Asians on obesity23 was used to classify the study participants.

All participants were investigated for diabetes mellitus by measuring fasting plasma glucose
level using a venous blood sample. Two milliliters of venous blood was collected from each
individual. The blood samples were obtained after an overnight fast of at least 8 hours.

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 Gamage and De Alwis Seneviratne Page 6

Dysglycemia was defined as either fasting blood sugar of >110 mg/dL and current use
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(within past 4 weeks) of insulin or oral hypoglycemic drugs.

The SAQ and data collection form were anonymous in order to maximize reliability with
regard to information obtained. The ERI questionnaire was adopted and validated to be used
in the Sri Lankan context (the 3 subscales, namely, efforts, rewards, and overcommitment,
had Cronbach’s α coefficients of .80, .84, and .60, respectively). The designing of the tools
was based on the STEP-wise approach to Surveillance (STEPS) of the NCD risk factor
questionnaire24 and International Physical Activity Questionnaire (IPAQ).25 The SAQ was
pretested among 15 randomly selected SOs and MAs from a district adjacent to Colombo.
Administration of the SAQ was followed by a cognitive debriefing, and further revisions
were made based on the suggestions, with special attention to the final wording of questions
to ensure clarity and flow. The data collection was conducted during the period of May to
December 2012.
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Procedure
The main purpose of statistical analysis is to test associations of ERI at work with health.
The detailed analysis of the ERI questionnaire that is currently recommended is given above.

Statistical analysis was conducted employing the software package SPSS (version 16).
Using JNC-7 guidelines, the employees were identified as having hypertension or not. The
prevalence of job stress and hypertension among SOs and MAs was calculated with the
respective confidence intervals.

The χ2 test was performed to assess the relationship between job stress and hypertension as
well as relationship of other correlates with hypertension. The correlates that were
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significantly associated with hypertension were used in logistic regression models for
multivariate analysis. During multivariate analysis, the dependent variable was hypertension
status of the participants as decided according to the JNC-7 guidelines for the classification
of hypertension. Those who were having hypertension were coded as “1,” and those without
hypertension were coded as “0.” All variables were entered into the logistic regression
model as dichotomous variables. Risk level for each dichotomous variable was identified,
level 1 indicating “high risk” and level 0 indicating “low risk.” “Low risk” category of each
variable was identified by the lower proportion of hypertension seen in that category. The
odds ratios (ORs) with confidence intervals (CIs) were calculated to quantify the strength of
association between hypertension and correlates. The significant level was considered as P
≤ .05. The risk was expressed as OR and its 95% CI.
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Results
Of the 275 SOs invited for the study, 272 responded. Therefore, the response rate of SOs
was 98.9%. Of the 760 MAs invited, 739 responded; hence, the response rate for MAs was
97.2%. Selected sociodemographic and occupational characteristics of SOs and MAs are
given in Table 1.

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Prevalence of Job stress

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The prevalence of job stress (JS) based on effort–rewards imbalance among SOs and MAs
was 74.6% (95% CI = 69.4% to 79.8%) and 80.5% (95% CI = 77.6% to 83.4%),
respectively. The prevalence of overcommitment among SOs and MAs was 35.3% (95% CI
= 29.8% to 41.2%) and 29% (95% CI = 25.7% to 32.3%), respectively. Statistically
significant difference was observed between the prevalence of effort–reward ratio (z = 2.03;
P = .05) and overcommitment (z = 1.9; P = .05) among SOs and MAs (Table 2).

Prevalence of Hypertension
The crude prevalence of hypertension based on classification of the JNC-7 criteria among
30- to 60-year-old SOs and MAs attached to government public administration offices was
32.4 per hundred population (95% CI = 26.8–37.9) and 29.4 per hundred population (95%
CI = 26.2–32.7), respectively. The age- and sex-adjusted prevalence of hypertension among
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30- to 60-year-old SOs and MAs attached to the aforementioned offices was 32.9 per
hundred population with a 95% CI of 27.4 to 38.6, and 33.01 per hundred population with a
95% CI of 29.6 to 36.4, respectively. The observed differences between the 2 percentages
among SOs and MAs were not statistically significant (P > .05).

Stress and Hypertension

When considering job stress assessed using the ERI ratio, which measured the imbalance, it
was significantly higher (P < .05) among SOs diagnosed as having hypertension, 78.4% (n =
69). Considering the MAs, 84.1% (n = 138) diagnosed as having hypertension reported as
having effort–reward imbalance and was a statistically significant (P < .05) correlate of
hypertension (Table 3).
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High perceived efforts was significantly associated (P = .05) with hypertension among SOs
and MAs. Among the SOs who were diagnosed to have hypertension, nearly half (47.7%; n
= 42) had perceived higher efforts at work, while among MAs, 51.2% (n = 111) with
hypertension had high perceived efforts.

In multivariate analysis, job stress measured by high effort–reward imbalance, high efforts,
and overcommitment were significant occupation-related correlates among SOs. Having
high ERI ratio increased the risk of hypertension by 3-fold (OR = 2.8; 95% CI = 1.1–7.4).
The presence of high perceived efforts (OR = 2.5; 95% CI = 1.2–5.3) and overcommitment
(OR = 2.5; 95% CI = 1.1–5.6) were other significant correlates of hypertension. Effort–
rewards imbalance (OR = 2.2; 95% CI = 1.1–4.2) and perceived high efforts (OR = 3.02;
95% CI = 1.9–4.8) increased the risk of hypertension among MAs (Table 3).
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Discussion
To our knowledge, no other study has analyzed the 2 components of the ERI model, effort–
reward imbalance and overcommitment, in relation to hypertension in South Asia. Data were
obtained from standardized, psychometrically validated questionnaire and were collected
under standardized conditions. The Sri Lankan administrators are essentially white-collar

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workers; thus, the question of physical extrinsic effort was excluded during validation of the
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ERI questionnaire in the Sri Lankan context.

The prevalence based on effort–reward imbalance among SOs and MAs was high, and
possible explanations would be while they are exerting high efforts the rewards in terms of
salary, promotions, and appreciation would be low. Since they are all public sector
employees, job security would not pose a threat. The ERI ratio was higher among SOs as
expected, this finding is consistent with studies done elsewhere.26,27 The variability in the
ERI ratios and scores among these 2 job categories could be due to career perspectives,
expectations, and personal challenges.

In our study, the prevalence of hypertension among employees having effort–reward

imbalance was above 75% for both categories of workers. Overcommitted employees too
had a higher prevalence of hypertension. People with high overcommitment too will
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exaggerate efforts for their need for approval and rewards, and a discrepancy between efforts
and rewards would aggravate stress.7

Job stress as measure by ERI was a significant correlate of hypertension among SOs and
MAs. Hence, a combination of higher efforts and lower rewards increased the risk of
hypertension among administrators.

The Whitehall II study, a cohort study conducted among British civil servants, reports
significant effect of effort–rewards imbalance on all coronary heart disease incidence7 and
adds evidence to the current report. The results of our study confirm previous findings in a
similar cross-sectional design that ERI is associated with hypertension. Siegrist13 reports
that high efforts–rewards imbalance significantly (P < .05) increased the risk of hypertension
among middle managers (OR = 6.8; 95% CI = 1.7–26.6), and Peter et al,28 in a study
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conducted among Swedish men and women, report high efforts–rewards ratio increased the
risk of hypertension equally among men (OR = 1.69; 95% CI = 1.13–2.53) and women (OR
= 1.57; 95% CI = 0.9–2.7). High perceived effort was a significant correlate of hypertension
among the administrators, and this supports the findings of the Whitehall II study, which was
a follow-up study.7

In spite of the likelihood that job stress is a risk factor for hypertension,7,28 the strength of
association from different studies cannot be directly compared as the methods of assessing
job stress and the population studied differed from one study to another.29

The strengths of our study are the following: to our knowledge this is the first study to test
effort–rewards imbalance as a correlate of hypertension in South Asia. In the current study,
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many confounding factors and effect modifiers were controlled for during analysis. Poor
psychosocial conditions usually measured by socioeconomic status (SES) are related with
poor psychosocial characteristics and unhealthy behaviors. In the current study, we adjusted
for grade of work and family income, both of which predict the SES, which would weaken
the argument that association of stress and health outcomes is merely a result of confounding
by SES.7

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There are some limitations that should be considered when interpreting the findings of this
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study. This study was conducted in the government administration offices in the Colombo
district and the results may not be applicable to all administrative employees in the country.
However, since all the government administrative offices in the district of Colombo were
included in the study, the findings of this study are applicable to all SOs and MAs of
administrative offices in the said district. The present study identified correlates of
hypertension through a cross-sectional comparative study design. This precluded the
assessment of the temporal relationship between hypertension and associated factors;
therefore, no causal inference can be drawn. Therefore, further research using a longitudinal
design should be undertaken to identify the effect of job stress on hypertension.

Other life stressors such as family life stressors, financial burden, and health burden were not
assessed in the current study. Due to the lack of data on other life stressors, it was not
possible to examine the potential confounding effects of the above and thus would affect the
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causal interpretation of results. Hence, a future study could conduct a comprehensive

evaluation of stress with multiple domains and its effect on health.

This study was also limited to those currently working, which could have contributed to a
healthy worker effect.30 According to the study design, all subjects on prolong leave were
excluded from analyses. It is possible that some subjects were on prolonged leave due to
work-related ill-health. In future studies, it could be useful to measure the latest work
conditions for early retired or those on prolonged sick leave.

Conclusion and Recommendation

This study indicates that the prevalence of job stress among SOs and MAs attached to
government administrative offices is relatively high and a serious problem. More than three
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quarters of the population suffered from efforts–rewards imbalance and suggests there is a
significant level of imbalance between efforts the employees exert and the rewards received
in return among administrators. This calls for urgent prevention and control measures for job
stress among all employees in the aforementioned offices. The management should seek for
and be aware of excessive efforts and render necessary support at work as balance should be
gained between the effort expended and rewards received. In addition, the management
should be trained to encourage workers and appreciate and support them at work, as it is best
that rewards be improved rather efforts decreases.7

There was a significantly high prevalence of hypertension among the subjects with high job
stress. Furthermore, the study identified job stress as an independent and a strong
contributory factor for hypertension mediating through efforts and rewards imbalance and
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high efforts at the workplace. Clinicians should be made aware of the association of job
stress and increased risk of hypertension when assessing a patient with hypertension,
especially uncontrolled hypertension, so that appropriate preventive measures could be
recommended. It would be beneficial to conduct research to identify prevalence and
determinants of job stress and its association with other cardiovascular diseases. This should
include a broad range of employees and worksites to ensure the generalizability of the
research findings.

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Based on the current evidence, it can be recommended to implement effective preventive

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strategies and interventions for prevention of job stress, especially by establishing health-
promotion policies at the workplace.

Acknowledgments
We thank Professor Johannes Siegrist at University of Düsseldorf for granting permission to adopt and validate the
Effort–Reward Imbalance Questionnaire to the Sri Lankan context. The authors gratefully acknowledge the time
and effort given by all the institutions and participants to make this study a success.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of
this article: This research was supported by in part by the Noncommunicable Disease Unit, Ministry of Health Sri
Lanka, and the ASCEND Program which is funded by the Fogarty International Center at the United States’
National Institutes of Health (NIH), under Award Number D43TW008332 (ASCEND Research Network).
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Appendix
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The Original 23-Item Effort–Rewards Imbalance (ERI) Mode

Effort
ERI 1 I have constant time pressure due to a heavy work load.
ERI 2 I have many interruptions and disturbances while performing my job.
ERI 3 I have a lot of responsibility in my job.
ERI 4 I am often pressured to work overtime.
ERI 5 My job is physically demanding.
ERI 6 Over the past few years, my job has become more and more demanding.
Reward
ERI 7 I receive the respect I deserve from my superiors.
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ERI 8 I receive the respect I deserve from my colleagues.

ERI 9 I experience adequate support in difficult situations.
ERI 10 I am treated unfairly at work.
ERI 11 My job promotion prospects are poor.
ERI 12 I have experienced or I expect to experience an undesirable change in my work situation.
ERI 13 My employment security is poor.
ERI 14 My current occupational position adequately reflects my education and training.
ERI 15 Considering all my efforts and achievements, I receive the respect and prestige I deserve at work.
ERI 16 Considering all my efforts and achievements, my job promotion prospects are adequate.
ERI 17 Considering all my efforts and achievements, my salary/income is adequate.
Overcommitment
OC 1 I get easily overwhelmed by time pressures at work.
OC 2 As soon as I get up in the morning I start thinking about work problems.
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OC 3 When I get home, I can easily relax and “switch off” work.
OC 4 People close to me say I sacrifice too much for my job.
OC 5 Work rarely lets me go, it is still on my mind when I go to bed.
OC 6 If I postpone something that I was supposed to do today I’ll have trouble sleeping at night.
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Table 1

Sociodemographic/Economic and Occupational Characteristics of the Senior Officers (n = 272) and

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Managerial Assistants (n = 739).

Senior Officers Managerial Assistants

Variable n % n %
Age (years)
30–39 108 39.7 320 43.3
40–49 73 26.8 228 30.8
50–60 91 33.5 191 25.9
Gender
Female 156 57.4 578 77.3
Male 116 42.6 168 22.7
Level of education
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G.C.E. Ordinary Level passed 0 0 17 2.3

G.C.E. Advanced Level passed 9 3.3 100 13.5
Technical/diploma/vocational training 128 47.1 397 53.7
University degree 24 8.8 64 8.7
Postgraduate degree 111 40.8 161 21.8
Average monthly salary (Rs)
10 000–29 000 135 49.6 712 96.3
30 000–49 000 107 39.4 27 3.7
≥50 000 30 11.0 0 0
Family income (Rs)
≤20 000 4 1.5 32 4.3
21 000–59 000 160 58.8 612 82.8
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60 000–99 000 80 29.4 72 9.8

≥100 000 28 10.3 23 3.1
Occupational characteristics
Duration of service in the current workplace (years)
≤5 178 65.4 457 61.8
6–10 64 23.5 214 29
11–20 19 7.1 40 5.4
≥21 11 4 28 3.8
Average work hours per week (hours)
40 60 22.1 255 34.5
41–50 159 58.5 417 56.4
≥51 53 19.4 67 9.1
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Commuting distance (km)

≤10 67 24.6 200 27.1
11–20 106 39 191 25.8
21–30 39 14.3 113 15.3
31–40 19 7 70 9.5

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Senior Officers Managerial Assistants

Variable n % n %
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≥41 41 15.1 165 22.3

Grade of work
Special grade 58 21.3 22 3
Grade I 89 32.7 189 25.6
Grade II 56 20.6 305 41.3
Grade III 69 25.4 223 30.1
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Table 2

Distribution of Employees by Presence of Job Stress.

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Status of Occupational Stress SOs (n = 272) MAs (n = 739) P Value

High effort–rewards ratio 203 (74.6%); 95% CI = 69.4–79.8 595 (80.5%); 95% CI = 77.6–83.4 z = 2.03; P = .05
Over commitment 96 (35.3%); 95% CI = 29.8–41.2 214 (29%); 95% CI = 25.7–32.3 z = 1.9; P = .05
High efforts 98 (36%); 95% CI = 30.3–41.7 304 (41.1%); 95% CI = 37.6–44.6 z = −1.5; P = .14
Low rewards 102 (37.5%); 95% CI = 31.8–43.2 216 (29%); 95% CI = 25.7–32.3 z = −0.6; P = .5

Abbreviations: SO, senior officer; MA, managerial assistant; CI, confidence interval.
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Table 3

Efforts–Reward Imbalance and Hypertension Among Senior Officers and Managerial Assistants.

Senior Officers Managerial Assistants

Variable Hypertensive, n (%) Unadjusted OR Adjusted ORa Hypertensive, n (%) Unadjusted OR Adjusted ORa

High ERI ratiob 69 (78.4) 1.4 (0.7–2.5) 2.8 (1.1–7.4) 138 (84.1) 1.4 (0.9–2.2) 2.2 (1.1–4.2)

Overcommitmentb 47 (53.4) 1.5 (0.9–2.4) 2.5 (1.1–5.6) 96 (44.2) 1.4 (1–2.1) —

High effortsb 42 (47.7) 2.1 (1.2–3.5) 2.5 (1.2–5.3) 111 (51.2) 2.6 (1.8–3.7) 3.0 (1.9–4.8)

51 (58.0) 1.3 (0.8–2.2) — 140 (64.5) 1.1 (0.7–1.3) —

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Low rewardsb

Abbreviations: OR, odds ratio; CI, confidence interval.

a
Odds ratios (95% CIs) for hypertension were estimated using multiple logistic regression analysis with control for the univariate analysis the following: age >40 years, male sex, Rs >50 000 per month
average monthly salary, high body mass index/waist hip ratio, dysglycemia, self-reported dyslipidemia, positive family history, current smoking, current alcohol consumption, physical inactivity, energy
dense diet, <5 servings per day fruit and vegetable consumption, >5 g per day salt consumption, lesser commuting distance (<20 km per day), higher grade of work (Special Grade and Grade I), high
occupational stress as measured by ERI ratio, high efforts, and overcommitment, and a health promotional work setting, with the low-strain group serving as the reference.
b
Classified according to the ERI model *e/(r/c); e is the sum score of the effort scale; r is the sum score of the reward scale; c is a correction factor. Correction factor is the ratio between the number of items
included in the effort scale and the number of items in the rewards scale. The correction factor is fixed at 0.454 if the numerator (efforts) contains 5 items. The correction factor is fixed at 0.545 if the
numerator (efforts) contains 6 items.20 See the appendix—not retained in the final model.

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