Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data.

BACKGROUND: Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression. METHOD: We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol. RESULTS: We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32). CONCLUSIONS: Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

Predictors of continued playing or singing--from childhood and adolescence to adult years.

AIM: Many individuals play an instrument or sing during childhood, but they often stop later in life. This study surveyed adults representative of the Swedish population about musical activities during childhood. METHODS: We asked 3820 adults (65% women) aged from 27 to 54 from the Swedish Twin Registry, who took extra music lessons to those provided at school, to fill in a web-based questionnaire. Factors analysed were the age they started studying music, the instrument they played, kind of teaching, institution and educational content, number of lessons and perceived characteristics of the lessons, the music environment during their childhood years and their preferred music genre. All variables were dichotomised. RESULTS: Factors strongly associated with continued playing or singing were male sex, young starting age, cultural family background, self-selected instrument, attending music classes and more than once a week, church-related or private education, pop, rock or classical music, playing by ear and improvisation. CONCLUSION: Several significant predictors determined whether a child continued to sing or play an instrument as an adult and many could be externally influenced, such as starting at a young age, taking music classes more than once a week, improvisation and the type of music they played.

Job strain and the risk of severe asthma exacerbations: a meta-analysis of individual-participant data from 100 000 European men and women.

BACKGROUND: Many patients and healthcare professionals believe that work-related psychosocial stress, such as job strain, can make asthma worse, but this is not corroborated by empirical evidence. We investigated the associations between job strain and the incidence of severe asthma exacerbations in working-age European men and women. METHODS: We analysed individual-level data, collected between 1985 and 2010, from 102 175 working-age men and women in 11 prospective European studies. Job strain (a combination of high demands and low control at work) was self-reported at baseline. Incident severe asthma exacerbations were ascertained from national hospitalization and death registries. Associations between job strain and asthma exacerbations were modelled using Cox regression and the study-specific findings combined using random-effects meta-analyses. RESULTS: During a median follow-up of 10 years, 1 109 individuals experienced a severe asthma exacerbation (430 with asthma as the primary diagnostic code). In the age- and sex-adjusted analyses, job strain was associated with an increased risk of severe asthma exacerbations defined using the primary diagnostic code (hazard ratio, HR: 1.27, 95% confidence interval, CI: 1.00, 1.61). This association attenuated towards the null after adjustment for potential confounders (HR: 1.22, 95% CI: 0.96, 1.55). No association was observed in the analyses with asthma defined using any diagnostic code (HR: 1.01, 95% CI: 0.86, 1.19). CONCLUSIONS: Our findings suggest that job strain is probably not an important risk factor for severe asthma exacerbations leading to hospitalization or death.

Work health determinants in employees without sickness absence.

BACKGROUND: Working ability is known to be related to good physical condition, clear work tasks, positive feedback and other occupational, organizational and psychosocial factors. In Sweden, high levels of sickness absence are due to stress-related disorders and musculoskeletal pain. AIMS: To identify work health characteristics in a working population with a large variety of professional skills and occupational tasks. METHODS: Employers' data on occupation, sickness absence, age and gender in a working population of 11 occupational groups and questionnaire responses regarding work-organization, environment, work stress, pain, health, and socio-demographic factors were collected. Employees with no history of sick-leave were compared with those with a history of sick-leave (1-182 days, mean 25 days). RESULTS: Of 2641 employees, 1961 participated. Those with no history of sick-leave reported less work-related pain, work-related stress, sleep disturbances, worry about their health, 'sick-presenteeism', monotonous work, bent and twisted working positions and exposure to disturbing noise than those with a history of sick-leave (P < 0.001). They also reported better health, support from superiors, having influence on their working hours and evening and week-end working, longer working hours per week (P < 0.001) and more regular physical training (P < 0.01). Socio-demographic factors were less important than gender, and differences in responses between occupational groups were also found. CONCLUSIONS: Workers without a history of sick-leave experienced less stress, sleep disturbances, worry about their own health and less neck, shoulder and back pain and more support from their superiors and influence on their working hours.

Job strain in relation to body mass index: pooled analysis of 160 000 adults from 13 cohort studies.

BACKGROUND: Evidence of an association between job strain and obesity is inconsistent, mostly limited to small-scale studies, and does not distinguish between categories of underweight or obesity subclasses. OBJECTIVES: To examine the association between job strain and body mass index (BMI) in a large adult population. METHODS: We performed a pooled cross-sectional analysis based on individual-level data from 13 European studies resulting in a total of 161 746 participants (49% men, mean age, 43.7 years). Longitudinal analysis with a median follow-up of 4 years was possible for four cohort studies (n = 42 222). RESULTS: A total of 86 429 participants were of normal weight (BMI 18.5-24.9 kg m(-2) ), 2149 were underweight (BMI < 18.5 kg m(-2) ), 56 572 overweight (BMI 25.0-29.9 kg m(-2) ) and 13 523 class I (BMI 30-34.9 kg m(-2) ) and 3073 classes II/III (BMI ≥ 35 kg m(-2) ) obese. In addition, 27 010 (17%) participants reported job strain. In cross-sectional analyses, we found increased odds of job strain amongst underweight [odds ratio 1.12, 95% confidence interval (CI) 1.00-1.25], obese class I (odds ratio 1.07, 95% CI 1.02-1.12) and obese classes II/III participants (odds ratio 1.14, 95% CI 1.01-1.28) as compared with participants of normal weight. In longitudinal analysis, both weight gain and weight loss were related to the onset of job strain during follow-up. CONCLUSIONS: In an analysis of European data, we found both weight gain and weight loss to be associated with the onset of job strain, consistent with a 'U'-shaped cross-sectional association between job strain and BMI. These associations were relatively modest; therefore, it is unlikely that intervention to reduce job strain would be effective in combating obesity at a population level.

A prospective cohort study of deficient maternal nurturing attitudes predicting adulthood work stress independent of adulthood hostility and depressive symptoms.

Stressful childhood environments arising from deficient nurturing attitudes are hypothesized to contribute to later stress vulnerability. We examined whether deficient nurturing attitudes predict adulthood work stress. Participants were 443 women and 380 men from the prospective Cardiovascular Risk in Young Finns Study. Work stress was assessed as job strain and effort-reward imbalance in 2001 when the participants were from 24 to 39 years old. Deficient maternal nurturance (intolerance and low emotional warmth) was assessed based on mothers' reports when the participants were at the age of 3-18 years and again at the age of 6-21 years. Linear regressions showed that deficient emotional warmth in childhood predicted lower adulthood job control and higher job strain. These associations were not explained by age, gender, socioeconomic circumstances, maternal mental problems or participant hostility, and depressive symptoms. Deficient nurturing attitudes in childhood might affect sensitivity to work stress and selection into stressful work conditions in adulthood. More attention should be paid to pre-employment factors in work stress research.

Managerial leadership and ischaemic heart disease among employees: the Swedish WOLF study.

OBJECTIVE: To investigate the association between managerial leadership and ischaemic heart disease (IHD) among employees. METHODS: Data on 3122 Swedish male employees were drawn from a prospective cohort study (WOLF). Baseline screening was carried out in 1992-1995. Managerial leadership behaviours (consideration for individual employees, provision of clarity in goals and role expectations, supplying information and feedback, ability to carry out changes at work successfully, and promotion of employee participation and control) were rated by subordinates. Records of employee hospital admissions with a diagnosis of acute myocardial infarction or unstable angina and deaths from IHD or cardiac arrest to the end of 2003 were used to ascertain IHD. Cox proportional-hazards analyses were used to calculate hazard ratios for incident IHD per 1 standard deviation increase in standardised leadership score. RESULTS: 74 incident IHD events occurred during the mean follow-up period of 9.7 years. Higher leadership score was associated with lower IHD risk. The inverse association was stronger the longer the participant had worked in the same workplace (age-adjusted hazard ratio 0.76 (95% CI 0.61 to 0.96) for employment for 1 year, 0.77 (0.61 to 0.97) for 2 years, 0.69 (0.54 to 0.88) for 3 years, and 0.61 (0.47 to 0.80) for 4 years); this association was robust to adjustments for education, social class, income, supervisory status, perceived physical load at work, smoking, physical exercise, BMI, blood pressure, lipids, fibrinogen and diabetes. The dose-response association between perceived leadership behaviours and IHD was also evident in subsidiary analyses with only acute myocardial infarction and cardiac death as the outcome. CONCLUSION: If the observed associations were causal then workplace interventions should focus on concrete managerial behaviours in order to prevent IHD in employees.

Associations between systemic pro-inflammatory markers, cognitive function and cognitive complaints in a population-based sample of working adults.

BACKGROUND: The knowledge is limited regarding the relation between systemic inflammatory biomarkers and subjective and objective cognitive functioning in population-based samples of healthy adults across the adult age-span. Thus, the aim of this study was to study a selection of four pro-inflammatory biomarkers (IL-6, MCP-1, TNF-α, CRP) in relation to executive cognitive functioning, episodic memory and subjective cognitive complaints (SCC) in a population-based sample of 215 working adults (age 25-67). RESULTS: Higher levels of MCP-1 were associated with poorer executive cognitive functioning, even after adjustments for demographical factors, health status/conditions, SCC and depressive symptoms. IL-6 and CRP were associated with poorer executive cognitive functioning, but these associations covaried with age especially and were not present after adjustment for demographical factors. MCP-1 was associated with poorer episodic memory, but this association also covaried with age especially and was not present after adjustment for demographical factors, and CRP was associated with episodic memory only among participants without reported health conditions. Higher MCP-1 levels were also associated with more SCC and this association covaried with depressive symptoms, while higher levels of TNF-α were associated with less SCC. CONCLUSION: Low grade inflammatory processes in terms of higher systemic levels of pro-inflammatory biomarkers (MCP-1, IL-6 & CRP) were associated with poorer executive functioning in this sample of working adults, and MCP-1 was so after extensive adjustments. Support for associations between these biomarkers and episodic memory and SCC were more limited. Future research should address the causality of associations between low grade inflammatory processes and cognitive functioning.

Quality of life and maintenance of improvements after early multimodal rehabilitation: a 5-year follow-up.

PURPOSE: There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up. METHOD: The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status. RESULTS: Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation. CONCLUSIONS: These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.

Are intrinsic motivational factors of work associated with functional incapacity similarly regardless of the country?

BACKGROUND: Many psychosocial models of wellbeing at work emphasise the role of intrinsic motivational factors such as job autonomy, job complexity, and innovativeness. However, little is known about whether the employees of multinational enterprises differ from country to country with regard to intrinsic motivational factors, and whether these factors are associated with wellbeing similarly in the different countries. The purpose of this study was to examine the level of intrinsic motivational factors and their impact on functional incapacity in different countries in a multinational corporation. METHODS: In 2000, data were collected from a globally operating corporation with a questionnaire survey. The participants were 13 795 employees (response rate 59%; 56% under age 45; 80% men; 61% blue collar employees), who worked in similar industrial occupations in five countries (Canada, China, Finland, France, and Sweden). RESULTS: The Chinese employees reported higher autonomy and lower complexity at work than the employees from the other countries. After adjustment for age, sex, socioeconomic status, and physical work environment, job autonomy, and job complexity at work were associated with functional incapacity in most countries, whereas in China the impact was significantly stronger. In Finland and in China employees with low innovativeness at work were more prone to functional incapacity than corresponding employees in other countries. CONCLUSIONS: The level of intrinsic motivational factors varied between the Chinese employees and those in other countries. In line with theoretical notions, the relation between intrinsic motivational factors of work and functional incapacity followed a similar pattern in the different countries. However, these country specific results show that a culture specific approach to employee wellbeing should also be applied.

Acoustics and psychosocial environment in intensive coronary care.

BACKGROUND: Stress, strain, and fatigue at the workplace have previously not been studied in relation to acoustic conditions. AIMS: To examine the influence of different acoustic conditions on the work environment and the staff in a coronary critical care unit (CCU). METHOD: Psychosocial work environment data from start and end of each individual shift were obtained from three shifts (morning, afternoon, and night) for a one-week baseline period and for two four-week periods during which either sound reflecting or sound absorbing tiles were installed. RESULTS: Reverberation times and speech intelligibility improved during the study period when the ceiling tiles were changed from sound reflecting tiles to sound absorbing ones of identical appearance. Improved acoustics positively affected the work environment; the afternoon shift staff experienced significantly lower work demands and reported less pressure and strain. CONCLUSIONS: Important gains in the psychosocial work environment of healthcare can be achieved by improving room acoustics. The study points to the importance of further research on possible effects of acoustics in healthcare on staff turnover, quality of patient care, and medical errors.

Psychosocial and physiological factors in relation to blood pressure at rest--a study of Swedish men in their upper twenties.

The interrelationships between psychosocial factors, several physiological variables and blood pressure (BP) were investigated in 88 young men (aged 26-32 years) in whom high, intermediate or low BP had been recorded at the age of 18 years. In the original high BP group, venous plasma noradrenaline was normal but adrenaline levels elevated. At the follow-up adrenaline correlated with systolic blood pressure (SBP), and this was also so after controlling for overweight and serum gamma-glutamyltranspeptidase [gamma-GT, a marker for alcohol consumption, which showed an independent association with diastolic blood pressure (DBP)]. Low assertiveness (low scores of verbal and indirect aggression) correlated with high BPs, even after controlling for other psychosocial variables. Several associations between psychosocial job variables and physiological variables were found. Among self-reported job variables, excessive 'demands' and 'bossing others' (but not 'decision latitude' or 'psychosocial conflict') were associated with high SBP. Habitual smoking of cigarettes was not associated with BP at rest, but influenced several associations between psychosocial and physiological variables. Men with high BP at rest and low plasma renin activity (PRA) reported more psychosocial problems at work and lower assertiveness than other groups.

Job characteristics and the incidence of myocardial infarction.

In Sweden, there are large differences in the incidence of myocardial infarction (MI) among occupational groups. These differences may to some extent be due to work environment factors, including psychosocial job strain. The aim of the present study was to estimate the relative risk (RR) of MI for Swedish men and women in high strain occupations as compared to those in low strain occupations. The association between job strain and MI was studied by case-control methods. The study base comprised the population of four Swedish counties from 1976-1981 and of Stockholm county from 1976-1984. Incident cases of MI were identified through hospital discharges together with deaths. Information about occupation was obtained from the 1970 and the 1975 censuses and individuals were characterized with regard to job strain on the basis of their job title. In all, 9295 cases and 26 101 controls with unchanged type of occupation from 1970 to 1975 were included in the analyses. Men and women aged < 65 in high strain occupations showed an RR of 1.1-1.4, and men age < 55 an RR of 1.2-1.6 compared to those in low strain occupations. Similar results were obtained in analyses of male white and blue collar workers respectively. If the association between job strain and MI is causal this could be of great importance in explaining differences in MI incidence among occupational groups in Sweden.

Incidence of myocardial infarction among male Finnish immigrants in relation to length of stay in Sweden.

In Finland, the incidence of coronary heart disease is reported to be about twice as high as in the neighbouring country of Sweden. The aim of this study was to find out what happens to this excess risk among Finnish immigrants to Sweden. A geographically defined population in Stockholm County was followed up in the in-patient care registry and the cause-of-death registry in order to find cases for a case-control study. All episodes of myocardial infarction (ICD numbers 410.00 and 410.99) that had occurred in men born between 1911 and 1935 during the period 1974-76 were recorded. An age-matched control group was randomly selected from the population. By means of the civil registration system it was possible to identify country of birth and length of stay in Sweden. Of the 356 cases, 32 (9%) had been born in Finland compared with 55 (6%) of the 887 controls. The overall relative risk for the Finnish immigrants compared with native Swedes was 1.7. For the group of Finnish immigrants who had been in Sweden for 20 years or more the relative risk was 1.3. It was concluded that since the relative risk decreases during the stay in Sweden the environmental factors dominate the explanation of the difference in the relative risk of developing myocardial infarction between Finland and Sweden.

'Workload' and risk of myocardial infarction--a prospective psychosocial analysis.

The study group consisted of 5187 building construction workers aged 41-61 in Greater Stockholm who had all responded to a psychosocial questionnaire and had been in full-time work without long-lasting illness episodes in the year before the study. A factor analysis of about 60 psychosocial variables was performed, and on this basis three indices were formed. The study group was followed for two years in official registers yielding information on morbidity and mortality. The 'workload' index was demonstrated to be significantly associated with subsequent risk of myocardial infarction.

The relationship of disturbing life-changes and emotions to the early development of myocardial infarction and other serious illnesses.

Nine thousand and ninety seven male members of the construction building workers trade union in Stockholm, aged between 41 and 61 years, were asked to complete a postal questionnaire between September and November 1972. The questionnaire was comprised of several psychosocial questions including life-change items for the preceding year. All subjects were followed up for a 12 to 15-month period with regard to death from all causes and hospitalization for myocardial infarction (MI). The urban section of the sample was also followed up for other serious illnesses. The main results were as follows: (a) The life-change measurement technique did not predict near-future MI; (b) A pre-formed discord index predominantly composed of self-rated type A behaviour and dissatisfaction variables predicted a significant number of near-future MIs; (c) One individual life-change, increased responsibility at work, predicted significantly about 10 per cent of near-future MIs; (d) Elevated life-change measures for the last year indicated increased risk of near-future neurosis onset; (e) Several questions about irritability and dissatisfaction, for example hostility in queuesor with slow persons and dissatisfaction with home life, predicted several kinds of illnesses; (f) Other variables, for example, having grown up as a late child in a large family, perception of financial state, mode of living, marital status and tobacco smoking, were important in illness prediction.

Type of occupation and near-future hospitalization for myocardial infarction and some other diagnoses.

Using three different registers a cohort study was undertaken to describe the relationship between type of occupation and hospitalization. A total of 958 096 subjects aged 20-64 years were followed-up for one year regarding inpatient care. Several significant associations between type of occupation and incidence of hospitalization for different diagnoses were observed. Male subjects employed in occupations where a high proportion reported a combination of hectic work and few possibilities to learn new things were more frequently hospitalized for myocardial infarction than other working men. The relative 'hospitalization' ratio for men 20-54 years of age in these strenuous occupations was estimated as 1.6 with a 95% confidence interval of 1.3-1.9. For women, the relative 'hospitalization' ratio in the ages 20-64 in occupations where a high proportion reported a combination of hectic and monotonous work was estimated as 1.6 with a 95% confidence interval of 1.1-2.3. Both these associations were statistically significant even after controlling for 12 possible confounding factors.

Time trends in survival from myocardial infarction in Stockholm County 1976-1984.

In Stockholm county, a rapid decline in mortality from acute myocardial infarction (AMI) was observed among middle-aged men in the early 1980s. In the present study survival among AMI patients from 1976 to 1984 was investigated in order to explore whether improvements in survival may have contributed to this decline. AMI patients aged 30-74 years (n = 16,108) were identified through a hospital discharge register. Deaths within one year of hospital admission were ascertained by means of linkage to the national cause of death register. Survival 1 year after hospital admission increased in both genders during the period 1981-1984, but among women there was no uniform trend over the whole study period. The estimated age-adjusted relative risk of death within one year after hospital admission for patients with a first infarction admitted to hospital in 1983-1984 as compared to in 1981-1982 was 0.88 for men and 0.79 for women. The causes of the observed increase in survival could not be determined from this study, but changes in medical intervention as well as diagnostic improvements may have been important. Improved survival may have contributed to about 30% of the decline in mortality from AMI among middle-aged men in Stockholm county during the early 1980s.

Effect of change in the psychosocial work environment on sickness absence: a seven year follow up of initially healthy employees.

STUDY OBJECTIVE: To investigate the impact of changes in psychosocial work environment on subsequent sickness absence. DESIGN: Analysis of questionnaire and sickness absence data collected in three time periods: 1990-1991, before the recession; 1993, worst slump during the recession; and 1993-1997, a period after changes. SETTING: Raisio, a town in south western Finland, during and after a period of economic decline. PARTICIPANTS: 530 municipal employees (138 men, 392 women) working during 1990-1997 who had no medically certified sick leaves in 1991. Mean length of follow up was 6.7 years. MAIN RESULTS: After adjustment for the pre-recession levels, the changes in the job characteristics of the workers during the recession predicted their subsequent sick leaves. Lowered job control caused a 1.30 (95% CI = 1.19, 1.41) times higher risk of sick leave than an increase in job control. The corresponding figures in relation to decreased social support and increased job demands were 1.30 (95% CI = 1.20, 1.41) and 1.10 (95% CI = 1.03, 1.17), respectively. In some cases there was an interaction with socioeconomic status, changes in the job characteristics being stronger predictors of sick leaves for employees with a high income than for the others. The highest risks of sick leave (ranging from 1.40 to 1.90) were associated with combined effects related to poor levels of and negative changes in job control, job demands and social support. CONCLUSION: Negative changes in psychosocial work environment have adverse effects on the health of employees. Those working in an unfavourable psychosocial environment before changes are at greatest risk.

Psychosocial work environment and myocardial infarction: improving risk estimation by combining two complementary job stress models in the SHEEP Study.

OBJECTIVES: Associations between two alternative formulations of job stress derived from the effort-reward imbalance and the job strain model and first non-fatal acute myocardial infarction were studied. Whereas the job strain model concentrates on situational (extrinsic) characteristics the effort-reward imbalance model analyses distinct person (intrinsic) characteristics in addition to situational ones. In view of these conceptual differences the hypothesis was tested that combining information from the two models improves the risk estimation of acute myocardial infarction. METHODS: 951 male and female myocardial infarction cases and 1147 referents aged 45-64 years of The Stockholm Heart Epidemiology (SHEEP) case-control study underwent a clinical examination. Information on job stress and health adverse behaviours was derived from standardised questionnaires. RESULTS: Multivariate analysis showed moderately increased odds ratios for either model. Yet, with respect to the effort-reward imbalance model gender specific effects were found: in men the extrinsic component contributed to risk estimation, whereas this was the case with the intrinsic component in women. Controlling each job stress model for the other in order to test the independent effect of either approach did not show systematically increased odds ratios. An improved estimation of acute myocardial infarction risk resulted from combining information from the two models by defining groups characterised by simultaneous exposure to effort-reward imbalance and job strain (men: odds ratio 2.02 (95% confidence intervals (CI) 1.34 to 3.07); women odds ratio 2.19 (95% CI 1.11 to 4.28)). CONCLUSIONS: Findings show an improved risk estimation of acute myocardial infarction by combining information from the two job stress models under study. Moreover, gender specific effects of the two components of the effort-reward imbalance model were observed.