Emotional demands at work and risk of long-term sickness Continuation........

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Emotional demands at work and risk of long-term sickness Continuation........

.......influence and high physical demands at work do not appear to exacerbate the association between high emotional demands and risk of long-term sickness absence. The measures of influence and of possibilities for development in our study are similar to the concepts of decision authority and skill discretion, respectively, in the demand–control model.11 Decision authority and skill discretion are usually combined into the variable of job control in the demand-control model. Our results showed that the interactions of emotional demands with influence and possibilities for development, respectively, yielded different results, suggesting that it could be fruitful in the demand-control model to analyze decision authority and skill discretion not only in combination but also separately. The strengths of this study include the use of a large nationwide cohort of 1 521352 employed individuals and the register-based outcome and covariates measurement. 

    The job-exposure matrix-based approach enabled us to measure emotional demands, influence, possibilities for development, role conflicts, and physical demands at work for all employees in the study population. Furthermore, the job exposure matrix-based approach reduced the risk of reporting bias as the exposure was not measured at the individual level but was estimated by the occupational groups of the participants. This study has several limitations. First, the job exposure matrix-based approach means that we did not analyze directly the association between emotional demands, the effect modifiers, and the risk of long-term sickness absence, but analyzed the association between working in occupations that on average had a certain level of exposure (with regard to emotional demands and the effect modifiers) and risk of long-term sickness absence. 

    This analysis method might lead to exposure misclassification, as some employees might have had low individual-level emotional demands while working in occupations with high average emotional demands and vice versa, which would most likely lead to underestimating the observed associations.30 Second, the Danish registers on sickness absence do not include information on diagnoses, which meant that we could only measure all-cause long-term sickness absence and not cause-specific long-term sickness absence. For example, it might be that the risk of long-term sickness absence in relation to emotional demands is higher for long-term sickness absence due to common mental disorders than for long-term sickness absence due to musculoskeletal disorders. Third, the time of follow-up was long, with a mean of 7·8 years, and the level of emotional demands might have changed during this time for some participants, which could have led to imprecise exposure measurement, as individuals could have changed job groups and underestimation of the association. 

    However, a sensitivity analysis with a 1-year follow-up produced estimates similar to the main analysis estimates. Fourth, we did not incorporate possible period effects in emotional demands, to reflect changes in the labor market or in society. Effects were, however, constant over time, with proportional hazards throughout the complete follow-up period. Fifth, the analyses did not account statistically for clustering of data, as no such standard approach is available when estimating confidence limits for RERI. Sixth, the cohort included all employed individuals residing in Denmark who were aged 30–59 years in 2000. The results, therefore, apply to this age group and to employees in Denmark. As sickness absence systems differ between countries, generalizations to other countries should be made with caution. Seventh, our analyses were limited to incident long-term sickness absence among individuals who had no history of long-term sickness absence in the last 3 years before the start of follow-up, and the results might not apply to people who have recurrent long-term sickness absence. In conclusion, in this large, job exposure matrix-based cohort study in Denmark, employees in occupations with high emotional demands had a higher risk of long-term sickness absence than those in occupations with low emotional demands over 7·8 years of follow-up. 

    Additive interaction analyses indicated that the association between high emotional demands and risk of long-term sickness absence was exacerbated in a synergistic way by the presence of low possibilities for development and high role conflicts at work. In three sensitivity analyses, the synergism remained robust for low possibilities for development in two analyses and for role conflicts in one analysis. Contrary to our hypothesis, low influence and high physical demands at work did not exacerbate the association between high emotional demands and long-term sickness absence. Our findings raise the hypothesis that in emotionally demanding occupations, increasing possibilities for development at work and preventing or reducing high work-related role conflicts might reduce long-term sickness absence. Our results suggest that this hypothesis does not apply to low influence or high physical demands at work. Further interventional research, including randomized controlled trials, is needed on these effect modifiers and other psychosocial factors at work that might modify the high risk of long-term sickness absence in relation to high emotional demands, to evaluate the effectiveness of such interventions in real-life settings. Contributors EF, JKS, IEHM, and RR designed and planned the study. EF and JKS accessed and verified the data and did the statistical analyses. EF wrote the first draft of the report. 

    All authors contributed to the interpretation of data and revised the report. EF, JKS, IEHM, and RR jointly decided to submit the report and all other authors approved the decision. All authors had full access to all the data in the study, approved the final version of the report, and agree to be accountable for all aspects of the work.

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