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Occup Environ Med: first published as 10.1136/oemed-2019-106015 on 29 October 2019. Downloaded from
http://oem.bmj.com/
on October 31, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Original rEsEarch
Perceived and content-related emotional demands at
work and risk of long-term sickness absence in the
Danish workforce: a cohort study of 26 410
Danish employees
Elisabeth Framke ,
1,2
Jeppe Karl sørensen,
1
Mads nordentoft,
1
nina Føns Johnson,
1
anne helene garde ,
1,2
Jacob Pedersen ,
1
ida E h Madsen ,
1
reiner rugulies
1,2,3
►
additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
oemed-2019-106015).
ABSTRACT
Objectives
This study aimed to examine whether high
emotional demands at work predict long-term sickness
absence (lTsa) in the Danish workforce and whether
associations differ by perceived and content-related
1
national research centre
emotional demands.
for the Working Environment,
Methods
We included 26 410 individuals from the
copenhagen, Denmark
2
Work Environment and health in Denmark study, a
Department of Public health,
nationwide sample of the Danish workforce. Emotional
University of copenhagen,
copenhagen, Denmark
demands at work were measured with two items: one
3
Department of Psychology,
assessing perceived emotional demands (asking how
University of copenhagen,
often respondents were emotionally affected by work)
copenhagen, Denmark
and one assessing content-related emotional demands
(frequency of contact with individuals in difficult
Correspondence to
situations). lTsa was register based and defined as
Dr Elisabeth Framke, national
research centre for the Working
spells of ≥6 weeks. respondents with lTsa during 2
Environment, copenhagen,
years before baseline were excluded. Follow-up was 52
Denmark; [email protected]
weeks. Using cox regression, we estimated risk of lTsa
per one-unit increase in emotional demands rated on a
received 7 June 2019
revised 26 september 2019
five-point scale.
accepted 4 October 2019
Results
During 22 466 person-years, we identified
1002 lTsa cases. Both perceived (hr 1.20, 95% ci
1.12 to 1.28) and content-related emotional demands
(hr 1.07, 95% ci 1.01 to 1.13) predicted risk of lTsa
after adjustment for confounders. Further adjustment for
baseline depressive symptoms substantially attenuated
associations for perceived (hr 1.08, 95% ci 1.01 to
1.16) but not content-related emotional demands
(hr 1.05, 95% ci 1.00 to 1.11). individuals working
in occupations with above-average values of both
exposures had an increased risk of lTsa (hr 1.32, 95%
ci 1.14 to 1.52) compared with individuals in all other
job groups.
Conclusions
Perceived and content-related emotional
demands at work predicted lTsa, also after adjustment
for baseline depressive symptoms, supporting the
© author(s) (or their
interpretation that high emotional demands may be
employer(s)) 2019. re-use
permitted under cc BY-nc. no
hazardous to employee’s health.
commercial re-use. see rights
and permissions. Published
by BMJ.
Key messages
What is already known about this subject?
►
Whether high emotional demands at work are
hazardous to employee’s health is debated.
►
Some studies found that emotional demands
predicted long-term sickness absence (LTSA)
and depression. Other studies raised concerns
that these associations might have been
affected by bias related to the measurement of
emotional demands.
What are the new findings?
►
Both perceived and content-related emotional
demands at work predicted a higher risk of
LTSA.
►
Adjusting for the baseline psychological state
of the individual attenuated the estimate for
perceived emotional demands more than
for content-related emotional demands, but
estimates for both types of demands remained
statistically significant.
How might this impact on policy or clinical
practice in the foreseeable future?
►
The results support the interpretation that high
emotional demands contributes to a higher risk
of LTSA.
►
Workplaces may consider reducing emotional
demands at work as a mean for ensuring or
improving employee’s health.
►
Further research on work-related resources that
may buffer the effect of emotional demands
at work would provide insights on prevention
possibilities.
to clients’ sorrows and worries, and handling
aggressive customers and clients.
1–5
Whether a high level of emotional demands at
work is hazardous to employee’s health is debated.
Whereas some studies found that emotional
demands are associated with a higher risk of sick-
ness absence, depressive symptoms and psycholog-
ical distress,
6–16
other studies raised concerns that
the measurement of emotional demands may have
biassed associations.
2 17
1
To cite:
Framke E,
sørensen JK,
nordentoft M,
et al.
Occup Environ Med
Epub
ahead of print: [please include
Day Month Year]. doi:10.1136/
oemed-2019-106015
INTRODUCTION
Emotional demands at work concern aspects of
work that require sustained emotional effort of
employees.
1
Examples of emotionally demanding
work tasks are dealing with sick or dying patients,
taking care of clients’ emotional needs, responding
Framke E,
et al. Occup Environ Med
2019;0:1–6. doi:10.1136/oemed-2019-106015
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Previously, emotional demands have primarily been measured
as perceived emotional demands, for example, with items like
‘how often do you feel emotionally affected by work?’. This type
of item may measure both characteristics of the work environ-
ment (ie, that work is emotionally demanding) and factors related
to the emotional processing of the individual (ie, a psychological
state of the individual). Thus, measuring emotional demands as
perceived emotional demands mixes the exposure to emotional
demands with the psychological state of the individual, and it
remains unclear if subsequent outcomes are due to the exposure,
the psychological state of the individual or both.
To address possible bias concerning the measurement of
emotional demands, Vammen
et al
recently compared how
perceived and content-related emotional demands were associ-
ated with risk of clinical depression.
2
Unlike perceived emotional
demands, items on content-related emotional demands do not to
mix the environmental exposure and the individual’s psycholog-
ical state but focus on the content of the job task, such as dealing
with others’ grieves and worries. The study found that perceived
emotional demands but not content-related emotional demands
predicted risk of clinical depression, strengthening concerns
about bias in studies examining perceived emotional demands.
The study by Vammen
et al
was limited, although, by including
only public sector employees, a relatively small study population
of about 3000 participants and low statistical power with only
62 cases of depression at follow-up.
In this article, we investigate the association between different
conceptualisations of emotional demands and risk of long-term
sickness absence (LTSA) in a nationwide sample of the Danish
workforce with more than 25 000 employees. We chose LTSA
as the outcome because LTSA is a valid indicator of ill-health,
predicting both disability and mortality.
18–20
In addition to measuring perceived and content-related
emotional demands by self-report, we also measured these two
types of emotional demands by job title, by aggregating self-
reported emotional demands to the job group level. Measuring
occupational exposures on the job group level instead of the
individual level reduces reporting bias, although it might simul-
taneously increase risk of non-differential misclassification.
21
We examined the prospective association between perceived
and content-related emotional demands, measured on the indi-
vidual level and the job group level, and risk of LTSA during a
1-year follow-up. We further examined if adjustment for partici-
pants’ psychological state at baseline affected the strengths of the
associations.
Occup Environ Med: first published as 10.1136/oemed-2019-106015 on 29 October 2019. Downloaded from
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on October 31, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Figure 1
Flow chart towards the final study sample. lTsa, long-term
sickness absence; MDi, Major Depression inventory.
(49.4%). We excluded 2020 respondents who were not working,
3540 with a history of LTSA or due to censoring (early retire-
ment, statutory retirement pension and emigration) during 2
years before baseline, and finally, 1574 with missing information
on exposures (n=689) or potential confounders (register-based
covariates: n=318; depressive symptoms: n=567), yielding a
sample of 26 410 participants. This sample was used for all anal-
yses in this study.
Measurement of emotional demands
We measured emotional demands at work with two items: one item
on perceived emotional demands and one item on content-related
emotional demands. Perceived emotional demands were measured
with the question: ‘How
often are you emotionally affected by your
work?’.
Content-related emotional demands was measured with
the question: ‘How
often at work are you in contact with individ-
uals in difficult situations (individuals who for example, are affected
by serious disease, accident, grief, crisis, or social problems)?’.
Both
items were rated on a five-point scale (1:
Never; 2: Seldom; 3:
Sometimes; 4: Often; 5: Always).
We calculated a mean score of the two items (Cronbach’s
Alpha=0.56), resulting in a score from 1 to 5, and we also
used the two items as single measures. Further, we analysed the
two single items as categorical variables. For this analysis, we
collapsed the response categories ‘Never’ and ‘Seldom’ because
of the low number of respondents in the category ‘Never’.
METHODS
Study design and participants
We analysed the prospective association between emotional
demands at work with risk of LTSA by linking information on
emotional demands, assessed with survey data from the Work
Environment and Health in Denmark Study (WEHD), to register
information on LTSA and covariates retrieved from nationwide
registers. Time of follow-up was 52 weeks.
WEHD is a biennial survey of the work environment and health
in Denmark from 2012 to 2020. WEHD is based on a nationwide
sample of Danish employees aged 18 to 64 years. For this study,
we combined data from the 2014 and 2016 waves as these two
waves included identical items for measuring emotional demands,
whereas the wording in the 2012 wave was slightly different.
Figure 1
shows the flow chart towards the final study sample.
In total, 67 844 individuals were invited in the 2014 and 2016
waves of WEHD. Of these, 33 544 responded to the questionnaire
2
Measurement of LTSA
We identified LTSA in the Danish Register for Evaluation of
Marginalisation (DREAM)
22
that includes weekly information
on all social transfer payments in Denmark since 1991. Since
2012, sickness absence spells of 31 consecutive days or more
are registered in DREAM. Sickness absence spells that lasts for
30 days or less are payed for and managed by the employer.
Framke E,
et al. Occup Environ Med
2019;0:1–6. doi:10.1136/oemed-2019-106015
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Sickness absence spells≥31 days are partly reimbursed by the
municipalities that manage the course of these longer sickness
absence spells. Accordingly, we defined LTSA as ≥31 consecu-
tive days, corresponding to ≥6 weeks in the DREAM register.
For each participant, we measured the first episode of LTSA after
the date of questionnaire completion and followed each indi-
vidual for up to 52 weeks.
Table 1
Baseline characteristics of the study population
N
Age
Sex
Women
Men
Education
Primary and lower secondary education
Upper and post secondary education
First stage tertiary education
Second stage tertiary education
Cohabitation
Yes
No
Children living at home
No children
At least one child aged 0–7 years
At least one child aged 8–17 years (no
children younger than 8 years)
MDI
Perceived emotional demands at work
Never/seldom
Sometimes
Often
Always
Content-related emotional demands at work
Never/seldom
Sometimes
Often
Always
MDI, Major Depression Inventory.
9947
7368
5386
3709
37.7
27.9
20.4
14.0
9525
10 567
5171
1147
36.1
40.0
19.6
4.3
3.0
1.2
14 694
5174
6542
55.6
19.6
24.8
8.1
2.8
7.4
1.0
20 524
5886
77.7
22.3
13 921
12 489
3751
11 244
7859
3556
52.7
47.3
14.2
42.6
29.8
13.5
%
Mean
45.3
SD
11.4
Occup Environ Med: first published as 10.1136/oemed-2019-106015 on 29 October 2019. Downloaded from
http://oem.bmj.com/
on October 31, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Measurement of covariates
As potential confounders we included age, sex, education,
cohabitation, children living at home. We further adjusted for
depressive symptoms at baseline as a measure of individuals’
psychological state when responding to the questionnaire. All
covariates have been associated with both emotional demands
and LTSA in previous Danish studies,
7 23 24
and were there-
fore considered potential confounders. Information on these
potential confounders was retrieved from Danish population-
based registers,
25–28
except for depressive symptoms that were
measured in WEHD.
Education was measured as the highest achieved education
and categorised into four groups using the International Stan-
dard Classification of Education (ISCED)
29
: primary and lower
secondary (ISCED level 0–2); upper and post secondary (ISCED
level 3–4); first stage tertiary (ISCED level 5); and second stage
tertiary education (ISCED level 6). Cohabitation was measured
as married/cohabiting yes versus no. Children living at home
were categorised into three groups: no children; at least one
child aged 0–7 years; at least one child aged 8–17 years (and
no children younger than 8 years). Depressive symptoms were
measured with the Major Depression Inventory (MDI)
30
in the
2014 and 2016 waves of WEHD. The MDI consists of 10 items
assessing the level of depressive symptoms during the last 2
weeks. Each item was measured on a scale ranging from 0 (the
symptom has not been present at all) to 5 (the symptom has been
present all of the time). The items were summed to an MDI score
(0–50), with higher scores indicating higher levels of depressive
symptoms and included in the analyses as a continuous measure.
Statistical analysis
We analysed the association between emotional demands and
subsequent LTSA by calculating HR and 95% CI using Cox
proportional hazards regression models. We followed each indi-
vidual for up to 52 weeks from the date of completing the ques-
tionnaire until first episode of LTSA or censoring due to early
retirement, disability retirement, statutory retirement pension,
maternity leave, emigration, death or end of study, whichever
came first. Information on reasons of censoring was retrieved
from DREAM.
22
First, we analysed the emotional demands mean score as a
predictor for LTSA. Second, we analysed the separate scores for
perceived and content-related emotional demands. Third, we
analysed perceived and content-related emotional demands as
categorical predictor variables.
We calculated unadjusted estimates and estimates adjusted for
age, sex, education, cohabitation and children living at home
(model 1), and further adjusted for baseline depressive symptoms
(model 2).
Finally, we aggregated perceived and content-related emotional
demands to the job group level by calculating the mean scores
for each of the two items by job group defined by the three-digit
level of DISCO-08, the Danish version of the International Stan-
dard Classification of Occupations’ (ISCO)-08 system. Next,
we assigned these mean scores to all individuals of the same job
group. We plotted the job group mean scores of perceived and
Framke E,
et al. Occup Environ Med
2019;0:1–6. doi:10.1136/oemed-2019-106015
content-related emotional demands against each other to visually
display where each job group was located with regard to perceived
and content-related emotional demands. Using the scatter plot, we
identified job groups scoring above the mean on both perceived
and content-related emotional demands and calculated the risk of
LTSA among individuals in these job groups compared with indi-
viduals in all other job groups in the study population.
All analyses were conducted using SAS statistical software V
.9.4.
RESULTS
Characteristics of the study population
Table 1
shows baseline characteristics of the study population.
About half of the study population was women (52.7%) and
the mean age was 45.3 years (SD=11.4). Most participants had
upper and post secondary education as their highest completed
education (42.6%), were cohabiting (77.7%) and had no chil-
dren living at home (55.6%). The mean MDI score was 8.1
(SD=7.4). About a quarter responded ‘often’ or ‘always’ to the
item on perceived emotional demands (23.9%), and about a
third of the study population responded ‘often’ or ‘always’ to
the item on content-related emotional demands (34.4%).
Individual-level emotional demands at work and subsequent
risk of LTSA
During 22 466 person-years, we identified 1002 cases of LTSA
(45 per 1000 person-years). Among participants experiencing an
LTSA event during follow-up, the mean time from baseline to
event was 24 weeks.
3
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Table 2
Associations of emotional demands at work at baseline with risk of long-term sickness absence during 52 weeks of follow-up
n
Emotional demands score
One-unit increase
Perceived emotional demands at work
One-unit increase
Never/seldom
Sometimes
Often
Always
Content-related emotional demands at work
One-unit increase
Never/seldom
Sometimes
Often
Always
26 410
9947
7368
5386
3709
1002
325
273
218
186
45
38
43
48
60
1.14
1.00
1.14
1.25
1.56
0.97 to 1.34
1.06 to 1.49
1.30 to 1.87
1.08 to 1.19
1.07
1.00
1.03
1.07
1.28
0.87 to 1.21
0.89 to 1.27
1.07 to 1.55
1.01 to 1.13
1.05
1.00
1.02
1.02
1.22
0.87 to 1.20
0.86 to 1.22
1.01 to 1.47
1.00 to 1.11
26 410
9525
10 567
5171
1147
1002
282
394
262
64
45
34
44
60
67
1.25
1.00
1.27
1.74
1.93
1.09 to 1.48
1.47 to 2.06
1.47 to 2.53
1.17 to 1.33
1.20
1.00
1.15
1.55
1.70
0.98 to 1.35
1.30 to 1.84
1.30 to 2.24
1.12 to 1.28
1.08
1.00
1.06
1.24
1.25
0.91 to 1.25
1.04 to 1.48
0.94 to 1.65
1.01 to 1.16
26 410
1002
45
1.27
1.19 to 1.36
1.18
1.10 to 1.27
1.10
1.02 to 1.18
Cases
Cases per
1000 PY
Unadjusted
HR
95% CI
Model 1
HR
95% CI
Model 2
HR
95% CI
Occup Environ Med: first published as 10.1136/oemed-2019-106015 on 29 October 2019. Downloaded from
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Model 1: Age, sex, education, cohabitation and children living at home.
Model 2: Age, sex, education, cohabitation, children living at home and MDI.
PY, person-years.
Table 2
shows the unadjusted and adjusted estimates and 95%
CI of the prospective association between emotional demands at
work at baseline and risk of LTSA. In the unadjusted model, a
one-unit increase in the emotional demands score predicted risk
of LTSA with an HR of 1.27 (95% CI 1.19 to 1.36). The estimate
attenuated after adjustment for age, sex, education, cohabitation
and children living at home (HR 1.18, 95% CI 1.10 to 1.27, model
1) and further adjustment for depressive symptoms (HR 1.10, 95%
CI 1.02 to 1.18, model 2) but remained statistically significant.
When we analysed the scores for perceived and content-related
emotional demands separately, we found that both scores predicted
risk of LTSA after adjustment for age, sex, education, cohabitation
and children living at home, with perceived emotional demands
showing stronger associations (HR 1.20, 95% CI 1.12 to 1.28)
than content-related emotional demands (HR 1.07, 95% CI 1.01
to 1.13). After further adjustment for depressive symptoms, the
estimate for perceived emotional demands attenuated substantially
(HR 1.08, 95% CI 1.01 to 1.16), whereas the estimate for content-
related emotional demands changed only marginally (HR 1.05,
95% CI 1.00 to 1.11).
In supplementary analyses, we repeated models 1 and 2 for
the emotional demands score without excluding individuals with
LTSA during the 2 years before baseline from the study popu-
lation, but while adjusting for LTSA during the 2 years before
baseline in both models. Results were similar to the results of the
main analysis (results not shown).
Table 3
shows the results from the analysis of risk of LTSA
among individuals working in job groups that scored above the
mean on both perceived and content-related emotional demands
compared with individuals working in all other job groups. The
HR was 1.32 (95% CI 1.14 to 1.52) in the most adjusted model.
DISCUSSION
This study of a nationwide sample of 26 410 employees in
Denmark showed that emotional demands, measured with
a global score, a perceived emotional demands score and a
content-related emotional demands score, predicted a higher
risk of LTSA during a 1-year follow-up in the most-adjusted
model that included adjustment for the psychological state of
the individual at baseline. The adjustment for the psychological
state attenuated the estimate for perceived emotional demands
more than for content-related emotional demands.
Further analyses showed that individuals working in job
groups that scored above the mean on both perceived and
content-related emotional demands compared with individuals
Content-related and perceived emotional demands by job
group and risk of LTSA
Figure 2
shows a scatter plot of the mean scores of the two emotional
demands items by job group according to the three-digit level of
DISCO-08 occupational classification system. There was a posi-
tive correlation (r
2
=0.35) between perceived emotional demands
and content-related emotional demands. Job groups that scored
above the mean on both measures of emotional demands were, for
example, primary school and early childhood teachers (234), other
teaching professionals (235), medical doctors (221), nursing and
midwifery professionals (222), and personal care workers in health
services (532) (see online supplementary appendix 1 for the scores
for each job group).
4
Figure 2
Job group mean scores of perceived and content-related
emotional demands at work items by job group according to the three-digit
level of DiscO-08 occupational classification system.
Framke E,
et al. Occup Environ Med
2019;0:1–6. doi:10.1136/oemed-2019-106015
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Table 3
Risk of long-term sickness absence among individuals working in job groups characterised by both high perceived and high content-
related emotional demands at work compared with individuals working in all other job groups
n
Job group level combined measure
All other combinations
High perceived and high content-related
18 340
8070
609
393
39
58
1.00
1.49
1.31 to 1.69
1.00
1.32
1.14 to 1.52
1.00
1.32
1.14 to 1.52
Cases
Cases per
1000 PY
Unadjusted
HR
95% CI
Model 1
HR
95% CI
Model 2
HR
95% CI
Occup Environ Med: first published as 10.1136/oemed-2019-106015 on 29 October 2019. Downloaded from
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on October 31, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Model 1: Age, sex, education, cohabitation and children living at home.
Model 2: Age, sex, education, cohabitation, children living at home and MDI.
MDI, Major Depression Inventory; PY, person-years.
working in all other job groups had a higher risk of LTSA and
that the estimate did not change after adjustment for the psycho-
logical state of the individual.
This study contributes with new insight into the potential
effects of high emotional demands for employees’ risk of LTSA
by using separate measures of perceived and content-related
emotional demands in a nationwide cohort, by adjusting for
the baseline psychological state of the individual and by aggre-
gating data to the job group level to circumvent reporting bias.
A previous study by Vammen
et al
2
concluded that perceived
emotional demands, but not the less reporting bias prone measure
content-related emotional demands, were a risk factor for clin-
ical depression. Therefore, the authors suggested that associa-
tions found in previous studies and in their own study may be
explained by the individuals’ perception and not by the actual
content of emotionally demanding work tasks. Consequently,
the findings by Vammen
et al
did not support a causal effect of
emotional demands at work and employee’s health. The present
study, however, suggests that both perceived and content-related
emotional demands are a risk factor for LTSA, a strong predictor
of morbidity and mortality. Further, our findings suggest that the
association between emotional demands and ill-health can only
partly, but not completely, be attributable to the psychological
state of the individual at the time when individuals are reporting
their emotional demands exposure. This interpretation is further
supported by the results from the analyses showing that job
group level averaged exposure to the combination of both types
of emotional demands predicted individual-level risk of LTSA.
Results from observational studies suggest that good leader-
ship did not substantially buffer the negative effects of emotional
demands at work on employee’s health,
31
that work-related goal
attainment moderated the negative effect of effort in emotion
work on employee well-being
32
and that experiencing one’s
work as emotionally enriching and meaningful reduced the
effect of emotional demands on exhaustion.
33
Strengths and limitations
The strengths of this study include the large cohort consisting of
26 410 individuals in a nationwide sample of the Danish work-
force in the age group 18–64 years and the use of outcome and
covariate measurements from Danish population-based registers.
As participants were followed-up in registers, attrition during
follow-up was minimal. A further strength is that we addressed
possible reporting bias by adjusting for baseline depressive symp-
toms as a proxy measure for participants’ psychological state and
by aggregating the individual-level exposures to the job group
level in additional analyses.
Some limitations need to be mentioned. First, we only had
two single item measures available for emotional demands.
By measuring our two exposure variables with only one item
each, we likely have measured limited aspects of perceived and
Framke E,
et al. Occup Environ Med
2019;0:1–6. doi:10.1136/oemed-2019-106015
content-related emotional demands. The content-related item
focused on frequency of contact with individuals in difficult
situations, where difficult situations were elaborated with exam-
ples like being in contact with individuals who, for example, are
affected by serious disease, accident, grief, crisis or social prob-
lems. These are rather serious situations and it is possible that we
did not capture less serious forms of content-related emotional
demands, such as having to care for emotional needs of others
(eg, nursing home residents), helping others solving conflicts (eg,
younger pupils in primary school) or handling rude customers
(eg, in supermarkets). Our study would have benefitted from
including more items to study different aspects of the concept
of content-related emotional demands. Second, while attrition
during follow-up was minimal due to register-based follow-up
with full coverage, the baseline response rate of about 50% raises
concerns about selective responding. Analyses of Danish national
work environment surveys have shown that response rates tend to
be lower among men, individuals of younger age and individuals
of lower education,
34 35
and we adjusted for these key sociodemo-
graphic variables in our analyses. Further, it is possible that risk of
sickness absence was different for baseline responders and non-
responders; however, we could not examine this, as we did not
have information on sickness absence rates of non-responders.
Third, it is possible that some unmeasured psychological char-
acteristics may have been related to selection into occupations
with high emotional demands and higher risk of sickness absence
and therefore may have biassed our results.
11
Excluding individ-
uals with LTSA during the 2 years before baseline and adjusting
for baseline depressive symptoms may partly, but not completely,
have accounted for this bias. Fourth, the administrative registers
in Denmark that we can use for research purposes do not include
information on the cause of LTSA. Therefore, we do not know
whether the 1002 LTSA episodes in this study were due to mental
disorders, somatic diseases or injuries. Fifth, although long-term
sickness absence is closely related to both morbidity and mortality
and, thus, can be regarded as an indicator of ill-health,
18–20
inci-
dent sickness absence is likely not exclusively determined by ill-
health, but probably also by other factors, such as sickness absence
legislations and practices, financial aspects or general attitudes
at workplaces towards sickness absence.
36
Future research may
investigate whether these factors might confound or moderate
the association between emotional demands at work and risk of
LTSA. Finally, a sixth limitation is related to generalisability. As
we conducted our study in a large sample of employed Danish
residents from a wide range of job groups, we consider our results
as generalisable to the Danish workforce. However, our results
may not be generalisable to workforces in other countries, as
national sickness absence legislations could influence the associa-
tions between working conditions and LTSA. Further studies on
emotional demands at work and LTSA in other countries, partic-
ularly other than Nordic countries, are encouraged.
5
 BEU, Alm.del - 2019-20 - Bilag 89: Orientering om første NFA-artikel fra projektet om sammenhæng mellem følelsesmæssige krav i arbejdet og langtidssygefravær, fra beskæftigelsesministeren
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Workplace
CONCLUSION
Perceived, content-related and job group aggregated levels
of emotional demands at work all predicted risk of LTSA.
Adjustment for the baseline psychological state of the indi-
vidual measured by depressive symptoms affected the estimate
for perceived emotional demands more than the estimate for
content-related emotional demands but associations remained
statistically significant in all analyses. This study therefore
supports the notion that high emotional demands at work are
a risk factor of LTSA. As LTSA is a valid indicator of ill-health,
we conclude that high emotional demands at work may be
hazardous to employee’s health.
Contributors
EF, JKs, iEhM and rr contributed to the conception of the study, and
all authors contributed to the interpretation of data. JKs and EF conducted the data
analysis. EF drafted the manuscript, and all authors critically revised it and approved
the final version.
Funding
This study was funded by the Danish Work Environment research Fund
(grant numbers 27-2017-03 and 10-2016-02).
Competing interests
none declared.
Patient consent for publication
not required.
Ethics approval
The national committee on health research Ethics. The study
was approved by The Danish Data Protection agency through the joint notification
of the national research centre for the Working Environment (no. 2015-57-
0074). all data are stored in a protected server environment hosted by statistics
Denmark.
Provenance and peer review
not commissioned; externally peer reviewed.
Data availability statement
Data may be obtained from a third party and are
not publicly available.
Open access
This is an open access article distributed in accordance with the
creative commons attribution non commercial (cc BY-nc 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. see: http://creativecommons.org/licenses/by-nc/4.0/.
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Elisabeth Framke
http://orcid.org/0000-0002-5702-3954
anne helene garde
http://orcid.org/0000-0002-1553-2291
Jacob Pedersen
http://orcid.org/0000-0003-4429-3485
ida E h Madsen
http://orcid.org/0000-0003-3635-3900
reiner rugulies
http://orcid.org/0000-0002-7752-131X
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