Public Health 181 (2020) 24e33

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Public Health
journal homepage: www.elsevier.com/locate/puhe

Review Paper

Job strain and mortality ratio: a systematic review and meta-analysis

of cohort studies
S. Amiri a, *, S. Behnezhad b
a
Behavioral Sciences Research Center, Lifestyle Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
b
Kharazmi University, Tehran, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Research has explored the relationship between job strain and adverse effects on physical
Received 21 August 2019 and psychological health. Accordingly, the effects of job strain on mortality risk were pooled based on
Received in revised form longitudinal studies.
12 October 2019
Study design: Systematic review and meta-analysis.
Accepted 30 October 2019
Methods: Both researchers searched for published articles in scientific databases until May 2019. Then,
the articles were screened based on the inclusion and exclusion criteria. The results were combined, and
analyses of subgroups and reviewing the bias of the publication were performed as well.
Keywords:
Job strain
Results: Seventeen longitudinal studies included in the meta-analysis were from three continents:
Mortality Europe, Asia, and America. The risk ratio (RR) of mortality based on job strain was equal to 1.20, with a
Systematic review confidence interval (CI) of 1.04e1.37 (P ¼ 0.00.10). In men, the RR is 1.21, and the CI is 1.02e1.44
Meta-analysis (P ¼ 0.032), and in women, the RR is 0.97 and CI is 0.84e1.12 (P ¼ 0.686). Evaluation of publication bias
indicated nothing significant.
Discussion: Based on the findings, it was found that job strain was a risk factor for mortality, and this
finding was more appropriate for men. Hence, reducing job strain can be a deterrent against the dangers
that threaten health.
© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction
Job stress is one of the main factors for adverse health outcomes
in industrialized countries.1,2 Accordingly, job strain, which is a
combination of high demand and low control at work, is one of the
most common definitions of psychosocial stress.3 According to
Karasek's model, a combination of high job demands and low job
control causes job strain.4 According to the job strain model, a
combination of the two aforementioned factors creates four job
statuses including high job strain, low job strain, active job, and
passive job.4,5 This model has been expanded with the addition of a
social factor.6,7
Job strain has been widely studied in relation to health. For
example, studies show the relationship between job strain and
cardiovascular disease,8e10 clinical depression,11 and the risk of
stroke.12,13 In addition, other studies also suggest a relationship
* Corresponding author.
E-mail addresses: rsr.amiri.s@bmsu.ac.ir, Amirysohrab@yahoo.com (S. Amiri).
between job strain and other dimensions of health including hy-
pertension,14 alcohol intake,15 tobacco smoking,16 and type 2 dia-
betes.17 Studies in the USA show that job stress is related to health
dimensions including body mass index in women,18 suicidal idea-
tion,19 and hypertension.20
Mortality or disease caused by occupational factors imposes
many economic burden on the community.21 There are many
psychological factors associated with an increased risk of
mortality.22 For example, studies have shown that lower posi-
tive effect,23 loneliness and social isolation,24 psychological
distress,25 depression,26 and anxiety27 were some psychological
risk factors for mortality. Studies have shown that there is an
association between stresses in general and job strain in
particular with the risk of dangerous diseases such as cardio-
vascular disease8 and stroke12,13 and these diseases can ulti-
mately lead to death.
However, to a degree, individual studies have been carried out
on the risk of mortality due to job strain. But the findings from
the studies have not yet been able to give an overview of the
overall risk ratio (RR). A large number of studies have focused on
the risk of job strain and mortality due to heart disease.22 As

https://doi.org/10.1016/j.puhe.2019.10.030
0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
 S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33 25

Identification

Records idenfied through Addional records idenfied

database searching through other sources
(n =2525) (n = 0)

Records aer duplicates removed

(n =2408)
Screening

Records excluded
Records screened (n = 2347)
(n =2408 )
Excluded based on
abstracts

Full-text arcles assessed

for eligibility
Eligibility

(n =61)

Full-text arcles excluded, with

Studies included in reasons
qualitave synthesis (n = 12)
(n = 29) 1 Same database.
11review studies.
Included

Studies included in
quantave synthesis
(meta-analysis)
(n = 17 )

Fig. 1. Selection flow diagram69.

mentioned previously, extensive meta-analysis studies have Methods

examined the relationship between job strain and different di-
mensions of health. But so far, no systematic and meta-analysis
study of the relationship between job stress and mortality risk
has been performed. In addition, sex differences in relation to the
subject of the present study are important. This study was con-
ducted with the aim of estimating the mortality risk based on job
strain and also analyzing several subgroups, in particular
assessing gender effects on the association between job strain
and mortality. Therefore, three main objectives were pursued in
the present study. First, the issue that high job strain leads to an
increased risk of mortality was examined. Second, it was inves-
tigated whether there are sex differences in the association be-
tween high job strain and risk of mortality. Third, the association
between high job strain and risk of mortality was evaluated
based on the continents.
To perform the present study, we relied on the PRISMA28
protocol. Given that the present study is a systematic review,
several important databases were studied in the field of current
research. These databases included PubMed, Scopus, Embase,
ResearchGate, and Google Scholar, which were searched using
keywords. Searching in these databases was limited to articles
published before May 2019.
Eligibility criteria
Some criteria were considered for selecting the studies: (1)
Longitudinal design studies were our concern; (2) exposure vari-
able was defined as job strain; (3) outcome variable was defined as
mortality ratio; (4) studies were eligible if they reported one of the
Table 1

26
Studies included in the meta-analysis.

Author and Country Study design Age Sex Sample Job strain Mortality (due to) Quality assessment Results Adjustment for other
publication size covariates
Selection Confounders Performance Withdrawals/
year
bias dropouts

Alterman USA Prospective (25 38e56 years Men 1683 Karasek's model Death certificates Low Low Low Low Relative risk 1.03 (CI: Age, systolic blood
1994 years) (coronary heart 0.75e1.41) pressure, serum
disease) cholesterol
concentration, number
of cigarettes smoked
per day, intake of
ethanol, family history
of cardiovascular
disease, years of
education, occupational
class
Bonsdorff Finland Prospective (28 44e58 years Both, % 5731 Karasek's model Finnish National Low Low Low Low Hazard ratio Age, occupational
2012 years) at baseline women Population Register High strain group, smoking, alcohol
unknown Men: 1.14 (CI: 0.96 intake and physical
e1.35) activity, cardiovascular

S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33

Women: 0.89 (CI: 0.72 disease, metabolic
e1.09) disorders, and cancer
Eaker 2004 USA Prospective (10 18e77 years Both, 3,039 Karasek's model Unknown Low Low Low Low Relative risk Age, systolic blood
years) 43.7% High strain pressure, the ratio of
women Men: 1.17 (CI: 0.66 total cholesterol to high
a
e2.07) density lipoprotein
Women: 1.31 (CI: 0.41 cholesterol, BMI,
e4.17)a cigarette smoking, and
diabetes
Falk 1992 Sweden Prospective (6 Unknown Men 621 Karasek's model Cause of Death High High Low Low Relative risk: 1.60 (CI: Social class,
years) Register 1.00e2.50) cardiovascular risk
factors, ations in
follow-up time
Johnson Sweden Prospective (9 Unknown Men 7219 Was constructed Official Swedish Low High Moderate Low Risk ratio: 1.92 (CI: 1.15 Age
1989 years) from two items personal e3.21)
identification
number
(cardiovascular
disease)
€ki
Kivima Finland Prospective >18 years Both, 812 Work demand Statistics Finland High Low Low Moderate Hazard ratio Age, sex, occupational
2002 (mean: 25.6 32.9% and job control national mortality High strain group, smoking and
years) women scales register 2.22 (CI: 1.04e4.73) physical activity,
(cardiovascular) systolic blood pressure,
cholesterol
concentration, and BMI
€ki
Kivima Finland, Prospective Unknown Both, % 102,663 Job Content National death Low Moderate Low Low Hazard ratio Study, age, smoking
2018 France, (13.9 years) women Questionnaire registries Men: 1.68 (CI: 1.19 status, physical activity,
Sweden, unknown and Demand- e2.35) alcohol consumption,
and the Control Women: 1.11 (CI: 0.68 BMI, and socio-
UK Questionnaire e1.84) economic status
Lee 2002 USA Prospective (4 46e71 years Women 35,038 Karasek's model Kin or postal Low High Low Low Relative risk Age
years) authorities, national High strain
death index 1.09 (CI: 0.40e2.92)
Nilsen 2016 Sweden Prospective (13 18e75 Both, % 1393 Karasek's model Swedish Cause of Moderate High Low Low Hazard ratio Age, sex, and physical
years) women Death Register High strain work environment
unknown Total: 1.41 (CI: 1.03
e1.94)
Men: 1.29 (CI: 0.81
e2.03)
 Women: 1.56 (CI: 1.00
e2.45)
Padyab Sweden Prospective 40e60 Both, 74,988 Karasek demand/ Nationwide health Low High Low Low Hazard ratio Age
2014 (mean ¼ 11.3 in years at 51.1% control model registers High strain
men; baseline women (cardiovascular) Men: 0.87 (CI: 0.61
mean ¼ 11.8 in e1.24)
women) Women: 0.66 (CI: 0.34
e1.33)
Slopen USA Prospective (10 57 ± 5 years Women 22,086 Karasek's Job National Death Low Low Low Low Hazard ratio Age; race; study drug
2012 years) Content Index High strain randomization,
Questionnaire (cardiovascular) 1.02 (CI: 0.37e2.81) education,; health
professional education;
income, depressive/
anxious symptoms,
smoking, alcohol
intake, BMI; history of
hypertension, diabetes
mellitus, and
hypercholesterolemia;
physical activity,
parental history of

S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33

myocardial infarction
before the age of 60
years; marital status,
current work status,
menopausal status
Laszlo 2010 Sweden Prospective (8.5 45e70 years Both, % 676 Swedish National Cause of High Low Low Low Hazard ratio Age, sex, education,
years) women Demand-Control Death Register High strain occupational class,
unknown Questionnaire 1.65 (CI: 0.91e2.98) managerial status,
overtime work, shift
work, household work
and the interaction
term between
household work, age
Zhu 2004 Denmark Prospective Unknown Women 41,769 By two questions Unknown Low Low Moderate Low Hazard ratio Maternal age, gravidity,
(unknown) High strain history of spontaneous
0.97 (CI: 0.69e1.36) abortion, smoking, pre-
pregnancy BMI,
occupation, working
posture, working hours
per week, heavy lifting,
perceived physically
strenuous work,
support from
coworkers
Tsutsumi Japan Prospective (9 18e65 years Both, 12490 WHO-MONICA Agency of General Low Low Low Low Relative risk Age, educational
2006 years) 60.7% Psychosocial Affairs and the High strain attainment, occupation,
women Study Ministry of Health Men: 0.79 (CI: 0.47 smoking, alcohol
Questionnaire e1.31) intake, physical activity,
Women: 0.72 (CI: 0.32 BMI, total cholesterol,
e1.64) hypertension, diabetes,
the community
Brunner Finland Prospective Unknown Both, 812 Work demand National mortality High High Low Moderate Hazard ratio Age, sex, father's
2004 (mean ¼ 25.6 32.9% and job control register High strain occupational group,
years) women scales (cardiovascular) 2.15 (CI: 1.10e4.40) height, education,
occupational group,
income
Amick 2002 USA 7746 Low Moderate Low Moderate Multivariate analysis
(continued on next page)

27
 28 S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33

following indicators: RR, odds ratio, hazard ratio, or confidence

obesity, and depressed

Age, sex, survey, living
alone, low educational
interval (CI).

alcohol consumption,
Adjustment for other

level, smoking, high

Data extraction
covariates

Extracting the results from the articles was carried out by the

mood
researchers independently, and then, the disputed items were
resolved through the discussion. The following data were extracted
Odds ratio 1.23 (CI: 0.85

from the articles: authors and publication year, country, age, sex,
0.82 (CI: 0.36e1.84)

sample size, job strain measure, mortality data, results, and

adjusted variables.
Hazard Ratio
High strain

Quality assessment
Results

e1.79)

To evaluate the quality of the studies, Effective Public Health

Practice Project Criteria29 was used, in which four dimensions of
Selection Confounders Performance Withdrawals/

qualitative assessment were used.

Moderate
dropouts

Meta-analysis

To analyze the results, several steps have been taken. First, all
the results extracted from the studies were made logarithmic;
Low
bias

then, the random-effects method was used to combine the re-

sults of the studies and obtain the total effect size. Finally, several
subgroup analyses were performed based on sex, continent, and
Quality assessment

dimensions of qualitative assessment of the studies. In addition,

Low

heterogeneity and bias of publication were reviewed using the

following methods: the Cochrane chi-squared (Q test) and I2
statistic for heterogeneity30,31 and funnel plots, Begg's test,
Low

Egger's test, and the trim-and-fill method32e34 for publication

bias. Stata-14 was for all of analysis.
Mortality (due to)

reasons for non-

Results
Reports of the

departments
Local health
response

Study selection

After searching, 2525 articles were retrieved from these data-

bases. Based on the PRISMA flowchart in Fig. 1, 2404 articles
Questionnaire

remained after deleting the repetitive articles. A total of 2347 ar-

strain model
Karasek job-

Job Content
Sample Job strain

ticles were reviewed based on their abstract and were deleted

owing to the irrelevancy of the subject of research. A total of 61
articles were evaluated for eligibility. In the prefinal phase, 29 ar-
ticles were introduced in the qualitative synthesis. At that stage, 12
6817

review articles and one article that shared the database with
size

another article were dropped. After the aforementioned steps,

unknown

seventeen articles7,22,35e49 were reviewed, the specifications of

women

women
43.62 ± 14.30 Both, %

37.4%
25e74 years Both,

which are given in Table 1. The meta-analysis included studies from

Sex

the three continents Europe, Asia, and Americas, and more studies
were available from Sweden and the USA.

Quality assessment
years
Age

BMI, body mass index; CI, confidence interval.

Based on the qualitative assessment carried out according to the

Prospective (10

Prospective (11

criteria, the following results were obtained. This qualitative

Study design

assessment took place in four dimensions. The results about ‘se-

Results calculated by authors.

lection bias’ showed that twelve articles, four articles, and one
years)

years)

article had low, moderate, and high bias, respectively. In

‘confounder bias,’ nine, two, and six articles had low, moderate, and
Germany

high bias, respectively. In ‘performance bias,’ fifteen and two

Author and Country

studies had low and moderate bias, respectively. In ‘withdrawal/

Table 1 (continued )

dropout bias,’ thirteen and four studies had low and moderate bias,
publication

respectively.
Baumert
2014

The RR of mortality based on job strain in Fig. 2 shows that this

year

ratio is equal to 1.20 with a CI of 1.04e1.37 and P ¼ 0.0.10. The

a

population for this analysis contained 325,583 participations.

 S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33 29

Fig. 2. Forest plot of job strain and mortality. CI, confidence interval; RR, risk ratio.

Fig. 3. Forest plot of job strain and risk of mortality based on sex. CI, confidence interval; RR, risk ratio.
30 S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33
Subgroup Analysis
The study of the relationship between job strain and mortality
based on sex in Fig. 3 shows that in men, the RR is 1.21 and CI is
1.02e1.44 (P ¼ 0.032); in women, the RR is 0.97 and CI is 0.84e1.12,
but it was not significant (P ¼ 0.686).
The results in Fig. 4 show that the risk of mortality based on job
strain in the Europe continent is as follows: RR ¼ 1.29 and
CI ¼ 1.07e1.56 (P ¼ 0.007); the population for this analysis included
243,501 participations. But no significant association was found
between job strain and mortality in the America continent, with an
RR of 1.12 and CI of 0.91e1.38 (P ¼ 0.280); 34,554 participations
formed the population of this analysis.
The results based on qualitative evaluation are presented in
Fig. 5. Accordingly, in studies with low bias in adjusted variables,
the relationship between job strain and mortality reduced, but this
was not significant (P ¼ 0.487) (see Fig. 6).
Publication bias
Based on the results of two bias tests, namely, Begg's test
(P ¼ 0.411) and Egger's test (P ¼ 0.130), there is no Publication bias,
but the trim-and-fill method34 imputed three missing studies. The
heterogeneity level was equal to 47.2%, which is a low degree of Fig
6 heterogeneity,50 and Cochrane chi-squared (Q test) was 30.33
(df ¼ 16) (P ¼ 0.016). In addition, heterogeneity in subgroup ana-
lyses was also examined. However, significant differences in the
levels of heterogeneity were not visible.
Fig. 4. Forest plot of job strain and mortality based on the continent. CI, confidence interval; RR, risk ratio.
Discussion
The purpose of this study was to determine the mortality risk
based on job strain. For this purpose, a systematic review and
meta-analysis were conducted. A total of seventeen cohort studies
from nine countries were included in the meta-analysis. The first
findings of the present study showed that the risk of mortality in
people with job strain is 20% higher than in the referral group.
Thus, job strain increases the risk of mortality. Several possible
explanations can be presented to show how and by what mech-
anism job strain increases the risk of death. In some studies
included in the meta-analysis, the cause of death was attributed to
cardiovascular diseases. In addition, review studies suggest that
job strain increases the risk of coronary heart disease.8,10,51,52 As
studies have shown, 28.1% of all deaths are attributed to cardio-
vascular diseases.53 The mechanism by which occupational stress
affects the risk of cardiovascular disease may be due to the direct
pathway through the nervous system or neuroendocrine system
or indirectly through changes in health-related behaviors or psy-
chosocial effects.54 In this regard, experimental studies have
shown the relationship between job strain and blood pressure55
and hypertension,56 which can ultimately lead to a risk of dis-
ease and death. Another mechanism that can be mentioned in this
regard is that occupational stress is associated with mental illness
and that mental illness can be a cause of death. For example, job
strain is associated with clinical depression and increases the risk
of clinical depression,11 and depression is associated with various
mortality factors.57e59 On the other hand, it should be taken into
 S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33
Fig. 5. Job strain and mortality based quality assessment. CI, confidence interval; RR, risk ratio.

31
32 S. Amiri, S. Behnezhad / Public Health 181 (2020) 24e33
Fig. 6. Funnel plot of job strain and mortality. RR, risk ratio; s.e., standard error.
account that job strain can lead to an unhealthy lifestyle and
various diseases, and these diseases increase the risk of mortality.
Accordingly, it was indicated that job strain is a precursor to an
unhealthy lifestyle.60 Job strain is related to smoking, physical
inactivity, and underweight,60 each of which can lead to diseases
and deaths. It is shown that smoking is also a risk factor for
mortality,61,62 and high physical activity can reduce the risk of all
types of deaths.63
Nine studies on women and 9 studies on men examined a
mortality risk based on job strain. The results of this study
showed that the risk of mortality in men with job strain is 21%
higher than in the referral group, but for women, this finding
was not significant. In explaining the sex differences, several
issues should be noted. The fact that men are more likely to be
at risk of mortality owing to job strain can be attributed to the
fact that men have lower life expectancy than women,64,65 and
it should be noted that this issue is beyond the job strain. On
the other hand, it has also been shown that men and women
respond differently to job demands,66 this will cause more job
pressure, and it consequently has a negative impact on their
health. Accordingly, studies have recommended that gender
differences should be considered in the relationship between
work and health.67
The results of the meta-analysis of five studies from America
and 12 studies from the continent of Europe showed that in Eu-
ropean studies, the risk of mortality is 29% higher among those
with job strain than among those of the referral group. In Americas,
this significant relationship was not found. In addition, the study of
the publication bias showed that the heterogeneity level is low,
which shows the strength of the present study.
This study has limitations. Except for a study from Japan,
other studies that included in the meta-analysis were from Eu-
ropean countries and the USA. Because these countries are
developed and industrialized, there are limitations in general-
izing the findings to other countries. Studies in the meta-
analysis have carried out different levels of control over the
variables; this can have effects on the unadjusted variables. The
method of measuring job strain can also play a role in hetero-
geneity of the studies, although the heterogeneity of studies was
low. Most of the studies used the Karasek model to measure job
strain, and this model is known to be valid for measuring job
strain.4,68 There were strong points in the present study. This is
the first study of its kind. In this case, several important sub-
group analyses were performed including sex, continent, and
quality assessment dimensions.
Author statements
Author contributions
The authors contributed to the formation of the subject, col-
lecting and extracting data, analyzing data, writing a draft, and
suggesting some changes. All authors have approved the final
version of the article before submission.
Ethical approval
None sought.
Funding
None to declare.
Competing interests
None to declare.
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