Workplace bullying and risk of suicide and suicide attempts: A register-based prospective cohort study of 98 330 participants in Denmark.

OBJECTIVES: The aim of this study was to analyze whether individuals reporting exposure to workplace bullying had a higher risk of suicidal behavior, including both suicide attempt and death by suicide, than those not reporting such exposure. METHODS: Using a prospective cohort study design, we linked data from nine Danish questionnaire-based surveys (2004-2014) to national registers up to 31 December 2016. Exposure to workplace bullying was measured by a single item. Suicide attempts were identified in hospital registers and death by suicide in the Cause of Death Register. Among participants with no previous suicide attempts, we estimated hazard ratios (HR) and 95% confidence intervals (CI), adjusting for sex, age, marital status, socioeconomic status, and history of psychiatric morbidity. RESULTS: The sample consisted of 98 330 participants (713 798 person-years), 63.6% were women, and the mean age was 44.5 years. Of these participants, 10 259 (10.4%) reported workplace bullying. During a mean follow-up of 7.3 years, we observed 184 cases of suicidal behavior, including 145 suicide attempts, 35 deaths by suicide and 4 cases that died by suicide after surviving a suicide attempt. The fully-adjusted HR for the association between workplace bullying and suicidal behavior was 1.65 (95% CI 1.06-2.58). The HR for suicide attempts and death by suicide were 1.65 (1.09-2.50) and 2.08 (0.82-5.27), respectively. Analyses stratified by sex showed a statistically significant association between workplace bullying and suicidal behavior among men but not women. CONCLUSIONS: The results suggest that exposure to workplace bullying is associated with an elevated risk of suicidal behavior among men.

Does leadership support buffer the effect of workplace bullying on the risk of disability pensioning? An analysis of register-based outcomes using pooled survey data from 24,538 employees.

PURPOSE: To investigate whether self-reported exposure to workplace bullying predicts the risk of disability pensioning among employees in two occupational groups-(1) employees working with clients or customers and (2) office workers and manual workers-and whether leadership support and occupational group moderates that association. METHODS: Survey data from 24,538 employees (112,889 person years) were fitted to a national register containing information on disability-pension payments. Using multi-adjusted Cox-regression analysis, observations were followed in the register to assess the risk of disability pensioning. The average follow-up time was 4.6 years (standard deviation [SD] = 1.5). RESULTS: Self-reported exposure to workplace bullying predicted an increased risk of disability pensioning (hazard ratio [HR] = 1.46; 95% confidence interval [CI]: 1.15-1.86). This association was moderated by leadership support: the association between workplace bullying and disability pensioning was significantly different for respondents who reported low leadership support (HR = 1.97; 95% CI: 1.38-2.80) compared to respondents who reported medium (HR = 1.03; 95% CI: 0.60-1.76) or high leadership support (HR = 1.08; 95% CI: 0.60-1.95). Further analyses showed similar associations between workplace bullying and the risk of disability pensioning among the two occupational groups. CONCLUSIONS: Self-reported workplace bullying increases the risk of disability pensioning, and this association is buffered by leadership support. Workplace bullying should be considered an important workplace stressor. This study indicates that workplaces may enhance worker retention by actively promoting measures to eliminate the occurrence of workplace bullying and to enhance leadership support.

The Third Version of the Copenhagen Psychosocial Questionnaire.

INTRODUCTION: A new third version of the Copenhagen Psychosocial Questionnaire (COPSOQ III) has been developed in response to trends in working life, theoretical concepts, and international experience. A key component of the COPSOQ III is a defined set of mandatory core items to be included in national short, middle, and long versions of the questionnaire. The aim of the present article is to present and test the reliability of the new international middle version of the COPSOQ III. METHODS: The questionnaire was tested among 23,361 employees during 2016-2017 in Canada, Spain, France, Germany, Sweden, and Turkey. A total of 26 dimensions (measured through scales or single items) of the middle version and two from the long version were tested. Psychometric properties of the dimensions were assessed regarding reliability (Cronbach α), ceiling and floor effects (fractions with extreme answers), and distinctiveness (correlations with other dimensions). RESULTS: Most international middle dimensions had satisfactory reliability in most countries, though some ceiling and floor effects were present. Dimensions with missing values were rare. Most dimensions had low to medium intercorrelations. CONCLUSIONS: The COPSOQ III offers reliable and distinct measures of a wide range of psychosocial dimensions of modern working life in different countries; although a few measures could be improved. Future testing should focus on validation of the COPSOQ items and dimensions using both qualitative and quantitative approaches. Such investigations would enhance the basis for recommendations using the COPSOQ III.

Longitudinal associations of burnout with heart rate variability in patients following acute coronary syndrome: A one-year follow-up study.

OBJECTIVE: To investigate longitudinal associations of burnout with heart rate variability (HRV) in patients after their first events of acute coronary syndrome (ACS). METHODS: In total, two hundred eight patients participated in this one-year follow-up study. On the day before discharge, their personal burnout level was assessed by the Copenhagen Burnout Inventory. HRV signals were collected at four time points: the day before discharge, one month, six month and one year after discharge. HRV was measured by 24-hour ambulatory electrocardiography and analyzed in time and frequency domains. Generalized estimating equations were applied to analyze the associations of burnout at baseline with longitudinal tracking of HRV during follow-up in format of natural logarithmic transformation. RESULTS: After adjusting for relevant confounding factors, high burnout at baseline was significantly associated with low standard deviation of NN intervals (SDNN), a time domain measure of HRV (p < 0.05). Also, baseline burnout was inversely associated with five frequency domain measures, i.e., high frequency power (HF), low frequency power (LF), very low frequency power (VLF), and ultra low frequency power (ULF), and total power (TP) (all p < 0.05). CONCLUSION: Personal burnout is longitudinally associated with decreased HRV during one-year period among patients after first ACS.

It is not just about occupation, but also about where you work.

OBJECTIVES: Dentistry is characterized by a meaningful but also stressful psychosocial working environment. Job satisfaction varies among staff working under different organizational forms. The aim of this study was to identify (i) to what extent crucial psychosocial work environment characteristics differ among occupations in general public dental clinics in Sweden, and (ii) how much of the variation within each occupation is attributable to the organizational level. METHODS: All staff (N=1782) employed in four public dental organizations received an email with personal log-in to an electronic questionnaire based on the Copenhagen Psychosocial Questionnaire. After two reminders, a response rate of 75% was obtained. Responses from 880 nonmanagerial dentists, dental hygienists and dental nurses working in general practices were included in our analyses. RESULTS: First, we compared the three dental occupations. We found that job demands, task resources (eg influence, possibilities for development and role clarity), strain symptoms and attitudes to work differed among occupations, dentists having the least favourable situation. Next, we compared the four organizations for each occupational group, separately. For dentists, a significant and relevant amount of variance (P<.05 and ICC >.05) was explained by the organizational level for 15 of 26 subscales, least pronounced for task resources. By contrast, for dental nurses and hygienists, the corresponding number was 2 subscales of 26. The psychosocial working environment of people working at the organization with the highest levels of strain indicators and the least positive work-related attitudes differed systematically from the organization with the most favourable profile, in particular regarding job demands and leadership aspects. CONCLUSION: In conclusion, the psychosocial working environment depended to a large degree on occupation and, for dentists in particular, also on their organizational affiliation. The findings suggest a potential for designing interventions at organizational level for improvements of the psychosocial working environment for dentists.

Ranking of psychosocial and traditional risk factors by importance for coronary heart disease: the Copenhagen City Heart Study.

AIMS: To rank psychosocial and traditional risk factors by importance for coronary heart disease. METHODS AND RESULTS: The Copenhagen City Heart Study is a prospective cardiovascular population study randomly selected in 1976. The third examination was carried out from 1991 to 1994, and 8882 men and women free of cardiovascular diseases were included in this study. Events were assessed until April 2013. Forward selection, population attributable fraction, and gradient boosting machine were used for determining ranks. The importance of vital exhaustion for risk prediction was investigated by C-statistics and net reclassification improvement. During the follow-up, 1731 non-fatal and fatal coronary events were registered. In men, the highest ranking risk factors for coronary heart disease were vital exhaustion [high vs. low; hazard ratio (HR) 2.36; 95% confidence interval (CI), 1.70-3.26; P < 0.001] and systolic blood pressure (≥160 mmHg or blood pressure medication vs. <120 mmHg; HR 2.07; 95% CI, 1.48-2.88; P < 0.001). In women, smoking was of highest importance (≥15 g tobacco/day vs. never smoker; HR 1.74; 95% CI, 1.43-2.11; P < 0.001), followed by vital exhaustion (high vs. low; HR 2.07; 95% CI, 1.61-2.68; P < 0.001). Vital exhaustion ranked first in women and fourth in men by population attributable fraction of 27.7% (95% CI, 18.6-36.7%; P < 0.001) and 21.1% (95% CI, 13.0-29.2%; P < 0.001), respectively. Finally, vital exhaustion significantly improved risk prediction. CONCLUSION: Vital exhaustion was one of the most important risk factors for coronary heart disease, our findings emphasize the importance of including psychosocial factors in risk prediction scores.

Relationships of organizational social capital with the presence of "gossip and slander," "quarrels and conflicts," sick leave, and poor work ability in nursing homes.

PURPOSE: This study aimed to explore the associations of organizational social capital (OSC) with the presence of "gossip and slander," the presence of "conflicts and quarrels," sick leave prevalence, and prevalence of poor work ability in frontline working personnel of nursing homes. METHODS: A total of 239 subjects (81 % participation), working in 11 different nursing homes, took part in a cross-sectional questionnaire study. Following end points were considered, they are as follows: prevalence of "gossip and slander," "conflicts and quarrels," sick leave, and poor work ability. Associations with OSC were explored at individual level (binomial log-linear regression analysis) and on group level (Kendall's tau correlation coefficients). RESULTS: Significant associations were found between OSC and "gossip and slander," sick leave, and poor work ability, both in the individual- and group-level analyses. The associations showed a higher significance level in the group-level analyses, with the strongest association found between mean OSC of the workplace and the prevalence of poor work ability at the workplace (τ = -0.722; p = 0.002). CONCLUSIONS: This study demonstrated significant associations of OSC with three end points that are relevant within the framework of well-being at work in nursing homes. The results are suggestive that OSC should be treated as a characteristic of the entire workplace, rather than as an individually experienced characteristic. The strikingly strong association between OSC and prevalence of poor work ability is suggestive for an important role of OSC within the context of maintaining work ability.

Do managers experience more stress than employees? Results from the Intervention Project on Absence and Well-being (IPAW) study among Danish managers and their employees.

OBJECTIVE: To examine whether managers' perceived stress and work strain is higher than perceived stress and work strain among employees. METHODS AND PARTICIPANTS: The study is based on questionnaire responses from 2052 respondents (128 managers and 1924 employees) at 48 worksites. Bi-variate and multivariate analyses were used to explain possible differences in stress levels and related mediators. RESULTS: Managers experienced higher demands, higher level of conflicts, and lower degree of social support from peers. They tended to experience significantly lower emotional stress, whereas this trend was insignificant with regards to behavioural, somatic and cognitive stress. The difference was partly explained by higher scores in the psychosocial work environment factors; job satisfaction, perceived management quality from their managers, influence, degrees of freedom at work, possibilities for development and meaning of work. For behavioural stress, 41% of the difference was explained by the preventive factors, 20% for somatic stress, 39% for emotional stress and 56% for cognitive stress. CONCLUSIONS: This study indicates that the preventive psychosocial factors explain parts of the managers' lower stress level. These results contradict the lay perception of managers being under higher pressure and experiencing more stress than employees. Interventions aiming at reducing employee stress levels, especially regarding behavioural and cognitive stress, could benefit from focussing on psychosocial work environment exposures such as skill discretion, meaning of work, psychological demands, information flow and management quality.

Impact of burnout and psychosocial work characteristics on future long-term sickness absence. Prospective results of the Danish PUMA Study among human service workers.

OBJECTIVES: The objective of this study was to examine if burnout and psychosocial factors predicted long-term sickness absence (>2 weeks) at work unit level. METHODS: Data were collected prospectively at 82-work units in human services (PUMA cohort, PUMA: Danish acronym for Burnout, Motivation and Job satisfaction) followed up during the proceeding 18 months regarding onset of long-term sickness absence. Questionnaire data regarding burnout and psychosocial factors were aggregated at work unit level. We used Poisson regression models with psychosocial factors and burnout as predictors of long-term sickness absence for more than 18 months based on data from a national absence register. RESULTS: Long-term sickness absence was predicted by psychosocial factors and by burnout at work unit level. CONCLUSION: To reduce sickness absence, organizations within human services should improve the psychosocial work environment, and equally important, the organizations should be attentive to employees with symptoms of burnout.

Is the demand-control model still a usefull tool to assess work-related psychosocial risk for ischemic heart disease? Results from 14 year follow up in the Copenhagen City Heart study.

OBJECTIVES: To test the usefulness of the Demand-Control Model as predictor for ischemic heart disease (IHD). MATERIALS AND METHODS: One thousand one hundred forty six actively employed men and women from the general population of Copenhagen participated at baseline in 1993-1994. They filled in questionnaires on the Demand-Control Model, job title, work place, civil status, family income, leisure time activity, smoking, medication, social support, social relations, conflicts, job responsibility, satisfaction, and insecurity and went through a medical examination, including measurements of coronary risk factors. All deaths and hospital admissions due to IHD, including first myocardial infarction (MI) in the cohort were traced in the Danish registries of deaths and hospital admissions to June 2007. RESULTS: 104 cases of first time hospitalisation or death due to IHD including 49 cases of MI occurred during 14 years follow up. Odds ratio (OR) compared to the relaxed group was 1.1 (0.1-3.1) among women and 1.6 (0.4-4.9) among men after confounder adjustment. Neither demands nor control were significantly associated with IHD. Among men 50 years of age or more, the risk for IHD was, however, elevated in the job strain group and the active group (OR = 3.5 and 3.2 respectively). Job insecurity was, however, strongly associated with IHD in men (OR = 2.7 (1.1-5.6)) after all adjustments. The risk was increased for MI too (OR = 2.7 (1.2-6.1)). Among women, the only significant association with IHD was for job dissatisfaction (OR = 3.0 (1.2-7.6)). CONCLUSION: In this population and in a period and society characterized by relative wealth and increasing employment rates, the Demand-control Model did not predict IHD. However, the feeling of job insecurity predicted both IHD and MI among men and job dissatisfaction predicted IHD among women.

Cortisol, estrogens and risk of ischaemic heart disease, cancer and all-cause mortality in postmenopausal women: a prospective cohort study.

BACKGROUND: Chronic stress may affect morbidity and mortality through neuroendocrine changes, and the ratio of cortisol to sex steroid hormones has been suggested as a biomarker of stress. We aim to address a relation between the ratio of cortisol to estrogens (C/E) and risk of ischaemic heart disease (IHD), hormone-dependent cancers and all-cause mortality among postmenopausal women. METHODS: Estradiol and cortisol were measured in a subset of 838 women randomly drawn from the second wave of the Copenhagen City Heart Study (n = 5297 examined in 1981-83) as well as among all women who developed hormone-dependent cancers after baseline. The participants were followed in nationwide registers until 2007, with < 0.1% loss to follow-up. RESULTS: The C/E ratio was not associated with self-reported stress, and there were no clear associations with IHD (highest vs lowest quartile: HR = 1.23; 95% confidence interval 0.83-1.81), hormone-dependent cancers (0.69; 0.45-1.08) or all-cause mortality (1.10; 0.86-1.41). CONCLUSIONS: The C/E ratio was not associated with morbidity and mortality in women, and we cannot replicate the robust findings of a relation between the cortisol to testosterone ratio and IHD previously reported in men. Whether the C/E ratio is a reasonable biomarker of stress is debatable.

The development of the psychosocial work environment in Denmark from 1997 to 2005.

OBJECTIVE: The aim of the study was to elucidate the development of the psychosocial work environment in Denmark from 1997-2005. METHODS: The analyses were based on two national questionnaire surveys (N1=1062; N2=3517) of randomly selected employees who completed the Copenhagen Psychosocial Questionnaire. The psychosocial work environment was described by 19 scales and 6 single items. RESULTS: Quality of leadership and social support from supervisors were the only dimensions that saw improvements. The negative developments were: higher work pace, less influence (job control), less possibilities for development (skill discretion), lower level of meaning of work, more role conflicts, decreased role clarity, reduced sense of community, less social support from colleagues, increased conflicts at work, more threats of violence and more slander and gossip. CONCLUSIONS: The psychosocial work environment in Denmark has deteriorated during the period 1997-2005. This deterioration was seen not just among certain groups of employees but in all subgroups, incorporating gender, age and socioeconomic status. The negative development of a country's psychosocial work environment is worrying; as such, there is a strong need to change this negative trend.

Work-related psychosocial factors and the development of ischemic heart disease: a systematic review.

The literature on the relationship between work-related psychosocial factors and the development of ischemic heart disease (IHD) was systematically reviewed: 33 articles presented 51 analyses of studies involving male participants, 18 analyses involving female participants, and 8 analyses with both genders. Twenty of the studies originated in the Nordic countries, and the major dimensions of the Demand-Control Model were the focus of 23 articles. A balanced evaluation of the studies indicates moderate evidence that high psychologic demands, lack of social support, and iso-strain are risk factors for IHD among men. Studies performed during recent years have not shown evidence for lack of control as a risk factor for IHD. Several studies have shown that job strain is a risk factor, but in the more recent ones, these associations can be fully explained by the association between demands and disease risk. Insufficient evidence was found for a relationship between IHD and effort-reward imbalance, injustice, job insecurity, or long working hours. Studies involving women are too few to draw any conclusion concerning women, work stress, and IHD.

Relationship of nurse burnout with personality characteristics and coping behaviors.

Burnout of nurses at university hospitals was analyzed in relation to their personality characteristics and coping behaviors. A self-administered questionnaire regarding burnout (the Copenhagen Burnout Inventory), work-related stressors (the Nursing Job Stressor Scale), personality characteristics (Short-Form Eysenck Personality Questionnaire-Revised), and coping behaviors (the short Japanese version of Brief COPE) was used. We obtained answers from 778 nurses (response rate: 94.9%), and analyzed 707 female registered nurses. Multiple regression analysis showed that neuroticism was more closely related to personal, work-related, and client-related burnout than extroversion. Covariate structure analysis revealed that among the nurses with high neuroticism and low extroversion, client-related burnout was found to be correlated with stressors in relation to conflict with patients and with positive coping behaviors. Among the nurses with low neuroticism and high extroversion, client-related burnout correlated with the coping behavior of behavioral disengagement and conflict with patients. In both groups, an increase in quantitative workload was associated with a higher score for stressors arising from conflict with patients, leading to client-related burnout. These results suggest that acquisition of skills to cultivate appropriate coping behaviors might be useful for reducing client-related burnout in relation to nurses' personality characteristics. These findings need to be further endorsed by intervention studies.

Perceived stress and cause-specific mortality among men and women: results from a prospective cohort study.

The authors assessed the effect of psychological stress on total and cause-specific mortality among men and women. In 1981-1983, the 12,128 Danish participants in the Copenhagen City Heart Study were asked two questions on stress intensity and frequency and were followed in a nationwide registry until 2004, with <0.1% loss to follow-up. Sex differences were found in the relations between stress and mortality (p = 0.02). After adjustments, men with high stress versus low stress had higher all-cause mortality (hazard ratio (HR) = 1.32, 95% confidence interval (CI): 1.15, 1.52). This finding was most pronounced for deaths due to respiratory diseases (high vs. low stress: HR = 1.79, 95% CI: 1.10, 2.91), external causes (HR = 3.07, 95% CI: 1.65, 5.71), and suicide (HR = 5.91, 95% CI: 2.47, 14.16). High stress was related to a 2.59 (95% CI: 1.20, 5.61) higher risk of ischemic heart disease mortality for younger, but not older, men. In general, the effects of stress were most pronounced among younger and healthier men. No associations were found between stress and mortality among women, except among younger women with high stress, who experienced lower cancer mortality (HR = 0.51, 95% CI: 0.28, 0.92). Future preventive strategies may be targeted toward stress as a risk factor for premature death among middle-aged, presumably healthy men.

What characterizes persons with high levels of perceived stress in Denmark? A national representative study.

AIMS: Stress is a growing public health problem, but there are only a few studies with national representative samples on the occurrence of stress. The aim of this study was to assess the level of stress, measured by the Perceived Stress Scale, in Denmark, and to identify and characterize the group with high levels of stress by factors measured at both the individual and neighbourhood levels in a national representative sample of the Danish population. METHODS: The 10,022 participants in the National Health Interview Survey 2005 were asked about perceived stress and individual factors in a cross-sectional design. Information on neighbourhood factors was derived from a national registry. Data were analysed by means of logistic regression models. RESULTS: Low education, heavy smoking, physical inactivity, lack of social network and poor working conditions were associated with perceived stress. For women, living in a neighbourhood with low average education, and for men, living in a neighbourhood with a high rate of crime and a low degree of ethnic diversity, were associated with higher perceived stress. Perceived stress was also related to indicators of morbidity. CONCLUSIONS: The group with high perceived stress is characterized by individual and neighbourhood factors with negative impacts on quality of life and risk of illness. This knowledge can guide future stress prevention efforts. Additionally, the results suggest a negative social component where perceived stress, unhealthy lifestyle and low social status are accumulated, and perceived stress might be used as a measure to identify groups characterized by accumulation of risk factors.

Are work-related stressors associated with diagnosis of more advanced stages of incident breast cancers?

OBJECTIVE: To assess the relation between work-related stressors and breast cancer incidence and prognostic characteristics (estrogen receptor status, grade, lymph node status, size, stage) at the time of diagnosis. METHODS: The 18,932 women included in the Danish Nurse Cohort reported work-related stressors in 1993 and again in 1999 and were followed until the end of 2003 in national registries. Prognostic characteristics were obtained from a clinical database and fewer than 0.1% were lost to follow up. RESULTS: During follow-up, 455 women were diagnosed with breast cancer. Neither women with high work pressure (HR = 1.17; 95% CI: 0.79, 1.73) nor women with self-reported low influence on work organization (0.98; 0.69, 1.39) or long working hours (0.93; 0.54, 1.58) were at higher risk of breast cancer than women with no such stressors. Women with high work tempo had a slightly higher risk of breast cancer (1.25; 1.02, 1.54) than women with a suitable work tempo, but there was no dose-response effect. There were no clear differences in the prognostic characteristics of breast tumors diagnosed in women with and without work-related stressors. CONCLUSIONS: Work-related stressors do not affect breast cancer risk or the prognostic characteristics of incident breast cancers at the time of diagnosis. These results may be a comfort to working women and can hopefully prevent self-blaming among women who develop breast cancer.

Psychometric properties of the Chinese version of Copenhagen burnout inventory among employees in two companies in Taiwan.

This study examined the psychometric properties of two selected scales--'personal burnout' and 'work-related burnout'--from the Chinese version of the Copenhagen Burnout Inventory (C-CBI) in 384 employees from two companies in Taiwan. A self-administered questionnaire was used that included the two C-CBI scales, the scales of mental health, vitality and general health from the Short Form 36 (SF-36), perceived level of job stress, job satisfaction, working hours, as well as measures for psychological job demands, job control, work-related social support, and over-commitment to work. Both the C-CBI personal burnout scale and work-related burnout scale had high internal consistency and were correlated well with other health, job characteristics, and perception of work measures;furthermore, exploratory factor analysis extracted two empirical factors. However, the two C-CBI scales were highly correlated in the present population and appeared to measure overlapping concepts. Some comments and suggestions were raised for further improvement.

Analyzing sickness absence with statistical models for survival data.

OBJECTIVES: Sickness absence is the outcome in many epidemiologic studies and is often based on summary measures such as the number of sickness absences per year. In this study the use of modern statistical methods was examined by making better use of the available information. Since sickness absence data deal with events occurring over time, the use of statistical models for survival data has been reviewed, and the use of frailty models has been proposed for the analysis of such data. METHODS: Three methods for analyzing data on sickness absences were compared using a simulation study involving the following: (i) Poisson regression using a single outcome variable (number of sickness absences), (ii) analysis of time to first event using the Cox proportional hazards model, and (iii) frailty models, which are random effects proportional hazards models. Data from a study of the relation between the psychosocial work environment and sickness absence were used to illustrate the results. RESULTS: Standard methods were found to underestimate true effect sizes by approximately one-tenth [method i] and one-third [method ii] and to have lower statistical power than frailty models. CONCLUSIONS: An uncritical use of standard methods may underestimate the effect of work environment exposures or leave predictors of sickness absence undiscovered.

Self-rated health and semen quality among 3,457 young Danish men.

OBJECTIVE: To study the relationship between self-rated health (SRH) and semen quality. DESIGN: Cross-sectional study of men attending a compulsory physical examination to determine their fitness for military service from 1996 to 2005. SETTING: Young men were approached when they were summoned for a compulsory physical examination to determine their fitness for military service in two major Danish cities. PATIENT(S): A total of 3,457 Danish young men delivered a semen sample, had a physical examination performed, and responded to a questionnaire including a question about SRH. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Semen quality and testis size. RESULT(S): After control for confounders, men with good and poor SRH had, respectively, 0.5 mL (95% CI: -0.8, -0.1) and 0.8 mL (95% CI: -2.4, 0.8) smaller testes size compared to men with very good SRH, the trend was statistically significant. Men with good and poor SRH had, respectively, 12.2% (95% CI: -21.2%, -2.2%) and 26.9% (95% CI: -55.7%, 20.8%) lower total sperm count compared to men with very good SRH, the trend was statistically significant, and had +0.4% (-1.4%, 2.2%) and 1.4% (-3.5%, 0.7%) fewer morphologically normal sperms (trend statistically significant). Percentages of motile spermatozoa and semen volume were not significantly associated with SRH. CONCLUSION(S): We found significant associations between SRH and semen quality and testicular size. Given the cross-sectional study design, we cannot establish a causal relationship but argue that SRH may be associated with semen quality. Our findings need to be validated and confirmed with other study designs (preferably prospective) and in populations of different age structure and fertility status.