Methods To Assess Workplace Stress and Psychosocial Factors

CHAPTER 55
Co py rig hte dM ate ria l

Barbara Curbow, Ph.D.*, David J. Laflamme,* M.P.H., C.H.E.S. Jacqueline Agnew, Ph.D.
School of Hygiene and Public Health, Johns Hopkins University Baltimore, Maryland There is increasing evidence that a high percentage of workers are exposed to occupational stressors on the job and that these stressors can contribute to a wide range of negative health outcomes including cardiovascular disease, musculoskeletal disorders, psychological disorders, injury, suicide, cancer, ulcers, and impaired immune function.1 In the environmental literature, stress has been associated with the perception and the reporting of symptoms related to indoor air quality (IAQ). Most frequently, this association is discussed within the context of sick building syndrome (SBS). In general, sick building syndrome can be thought of as one of a spectrum of workplace disorders that are characterized by a variety of nonspecific somatic and psychological symptoms (p. 220).2 Other commonly cited aspects of SBS are the worsening of symptoms during hours spent in the building and improvement on leaving the building and, often, an inability to find specific physical environmental causes. The problem of workplace stress often arises in building investigations, and in fact, the occurrence of SBS may heighten awareness of stressors and stress. This chapter is designed to provide information for two audiences: IAQ researchers and IAQ problem solvers. Researchers may focus more on the application and development of the theories and methodological issues that we discuss. Problem solvers may be more interested in the relevance of these theoretical and research issues for implementation of solutions. In the first section of this chapter, we will define the concept of stress and present the major occupational stress conceptual approaches. This will be followed by a discussion of some possible models of the IAQstress link. In the next section, we will present an overview of the literature on the IAQstress link, and we will discuss the variables that have been most frequently investigated. In the third section, we will discuss measures of occupational stress as they represent the major conceptual approaches. In the final section, we offer suggestions concerning implementation of these theories in the workplace.
* Department
METHODS TO ASSESS WORKPLACE STRESS AND PSYCHOSOCIAL FACTORS
Department of Health Policy and Management, Faculty of Social and Behavioral Sciences. of Environmental Health Sciences, Division of Occupational Health.
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55.2
ASSESSING IAQ
55.1 STRESS AT WORK

What Is Stress? Although the terms job stress and occupational stress are frequently used common parlance, in the research literature they must be distinguished from two related concepts: stressors and strain. Job stressors are the work-related environmental conditions or exposures that can potentially affect the psychological, social, and physiological health of an individual.3 Stressors can be measured subjectively (i.e., a workers perceptions of the environment) or objectively (i.e., actual characteristics of the environment). Strain refers to the negative outcomes (psychological, social, physical, and behavioral) associated with exposure to stressors.3 Stress is an intervening variable between stressors and strain. Using a definition by Lazarus,4 stress is the sense that environmental events tax or exceed the persons resources. The relationships among stressors, stress, and strain are depicted in Figure 55.1. Also included in the figure is another class of variablesmodifiers. As will be discussed below, several of the dominant occupational stress models assume that the stressor stress and the stress strain relationships can be altered by the presence or absence of modifying variables, which are generally classified as external to the person (e.g., social support) or internal to the person (e.g., coping strategies, self-esteem). For example, a common hypothesis in the literature is that people who are exposed to stressors but who have high social support will not experience effects as negative as will people who have low social support.

Conceptual Approaches in Occupational Stress We begin a discussion of measurement issues with an overview of the dominant conceptual approaches in the occupational stress literature because the selection of an approach should guide the variables that are examined in a study of the stressindoor air quality link. Vagg and Spielberger5 recently described the four major conceptual approaches that have informed the general occupational stress literature: personenvironment fit (PE fit),6 the demandcontrol model,7 the effortreward imbalance model,8 and the transactional model of stress.4 Although these models represent different views on the roles of the environment and the individual in the etiology of strain, shared aspects can be found among them. PersonEnvironment Fit. According to Hurrell et al.,3 the modern era of research on job stress began in the early 1960s at the University of Michigan. French and Kahn9 (cited in3) began a program of research on particular aspects of the work environment that might be detrimental to the individual. These aspects included role ambiguity, workload, role conflict, having responsibility for other persons, and relationships among members of the group. This early research led to the formulation of the PE fit model of job stress, which emphasizes the goodness of fit between the characteristics of the person and the properties of the environment.10 Although Vagg and Spielberger5 characterized PE fit as the most influential and most widely accepted of the job stress models, they also noted that it has been heavily criticized on both theoretical and methodological grounds. However, there is empirical support for it in the literature. For example, Conway et al.10 demonstrated that a misfit between perceived and desired levels of control was associated with poorer psychological adjustment. Demand-Control Model. The demand-control model of stress is concerned with the interactive effects of levels of job pressures (demands) and decision latitude (control).11 Different outcomes are associated with varying levels of demands and control.11 High demands and
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55.3
Stimulus
(stressor)
Intervening Variable
(perceived stress)
Response
(strain)

Modifying Variables
FIGURE 55.1 Perceived stress as an intervening variable.
low control are associated with high levels of psychological strain; high demands and high control are associated with good stress, which can lead to high job motivation; and low demands and low control are associated with low job motivation. The demand-control model does not rule out a role for individual difference variables.7,11 Karasek et al.11 write: A dynamic version of the model integrates the job strain and active behavior hypothesis with personality characteristics measuring accumulated strain and self-esteem development7 with the goal of predicting strain development and learning over time (p. 323). Although support has been found for the model by many researchers, others have found that there is incomplete support for it. For example, Fletcher and Jones12 found small but independent effects (i.e., no interaction) for demands and control in predicting psychological strain and job and life satisfaction, but relationships with blood pressure were in the opposite direction. Bosma, Peter, Siegrist, and Marmot13 found support for the predictive ability of control but not demands for explaining new cases of coronary heart disease.
EffortReward Imbalance Model. This newer model states that stress occurs when there is a lack of reciprocity between the effort that a worker puts into a job and the potential rewards she or he receives for completing it (p. 295).5 Under conditions of high effort in response to external work pressures but low potential for reward (e.g., promotion), there is high work stress, which leads to health-related problems. Bosma et al.13 recently tested the effortreward imbalance model against the demandcontrol model in predicting the risk of coronary heart disease and found that the full effortreward imbalance model was associated with increased risk, but only the control component of the demandcontrol model was associated with increased risk. The concept of work rewards (or resources) has been investigated by other researchers in job stressnotably by Barnett and colleagues.14
Transactional Model. Lazarus4 conceptualization of the stress process differs from the previous three. In his model, potential stressors from the environment are subjected to a twostage appraisal process: The person first appraises whether the event is a challenge or a threat and if it is the latter, he or she then appraises the level of coping resources available to deal with the event. Key to this model is the notion of resources or what a person draws on in order to cope (p. 158).15 Stress can occur when the person does not have the necessary resourceswhether they are internal to the person (e.g., an optimistic disposition) or external to the person (e.g., social support)16to adequately respond to the external threat. Shared Features. All four of these models point to the importance of environmental stressors in the chain of events leading to a strain response. Two of the models (PE fit and transactional) focus on the role of individual characteristics in modifying the stress response (e.g., coping resources) and two (demandcontrol and effortreward imbalance) focus on additional aspects of work (e.g., job control or job rewards) as modifiers of the stress response. The concept of job
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55.4
ASSESSING IAQ

The NIOSH Model. The NIOSH Job Stress Model18 (Figure 55.2) integrates features of several of the dominant job stress models: It incorporates the measurement of stressors and job control and investigates their relationships with strain indicators and, ultimately, health outcomes. Additionally, it holds that the relationship between stressors strain can be modified by internal resources and external factors. The only component not found in the NIOSH model is the concept of perceived stressas used as an intervening variable. In fact, all of the approaches mentioned, except for the transactional model, do not explicitly measure the individuals overall sense of being taxed or overburdened by stressors. However, the NIOSH model represents an integrated model that can be used to conceptualize the aspects of the work environment and the person that may be critical to measure. Models of the Indoor Air QualityStress Relationship After selecting a conceptual approach to guide measurement of stressors, stress, and strain, it is necessary to focus on how the concept of indoor air quality fits within it. Three illustrative models of the stressindoor air quality link are presented in Fig. 55.3; all of these modIndividual Factors
Personality Stage of career
control is compatible with all of the models. As noted earlier, Conway et al.,10 using the PE fit model, found that a misfit between perceived and desired control was associated with poorer psychological adjustment. Control is a central aspect of the demandcontrol model and, in fact, some researchers have found the main effect for control to be the most highly predictive component of the model.13 Having control at work can be conceptualized as a rewarding aspect of work (effortreward imbalance), and perceived control has often been conceptualized as a personal resource that assists in adapting to stressors, for example, reference 17. Finally, two of the models explicitly acknowledge the importance of positive aspects of work (effortreward imbalance and transactional) and the notion is compatible with the PE fit model (e.g., misfit between perceived and desired rewards).
Job Stressors
Acute Reactions
Psychological, affect, job dissatisfaction
Job/task demands Work load Control Organizational Role demands Management Career security Interpersonal Physical Conditions
Illness
Physiological heart rate blood pressure
Hypertension CHD Alcoholism Mental illness
Behavioral sleep substance use
Financial status Family
Social support Coping
Nonwork
Buffers
FIGURE 55.2
NIOSH model of job stress and health. (From Hurrell.18)
55.5
els could be elaborated to include other factors. These models are all conceptually plausible, but they have very different implications for measurement, study design, problem solving, and workeremployer relationships. Model A. In model A, exposure to workplace stressors leads to an increased perception of IAQ symptoms, irrespective of the actual exposure to contaminants. This model is compatible with explanations for the stressIAQ link such as mass psychogenic illness,19 mass hysteria,20 and epidemic psychogenic illness.21 Typical of the explanation of the stressIAQ link is the following reasoning: High levels of occupational stress, especially when they are coupled with poor workermanagement relationships, lead to an increase in stress-related symptoms (e.g., fatigue). When the stress-related symptoms are linked with some physical environmental cue (e.g., odor) or some social environmental cue from coworkers (e.g., fainting), the stress-related symptoms may be misattributed to IAQ by workers. This, in turn, leads to an increase in the perception and reporting of symptoms. This explanation is often used post hoc by researchers when no detectable physical environmental cause can be found for the symptom reporting. It assumes that the problem originates in the psychosocial climate of the workplace, for example, in a poor organizational climate. If this model were to be tested, it would need, at a minimum, measures of the environmental stressors and perceptions/reporting of symptoms. It could, for example, be investigated within the demandcontrol or effortreward imbalance conceptual frameworks such that these two aspects of the environment could be assessed for their associations with symptoms. Model B. In model B, exposure to IAQ problems is considered a stressor within the workplace. Much as exposures to cold or noise at work are thought of as physical stressors that may increase perceived stress and lead to both physiological and psychosocial effects, IAQ problems could follow this same pattern. It is important to note that such a model would assume that the problem lies in the physical environment of the workplace and that IAQ problems would be perceived as stressors by most, if not all, of the exposed workforce. Investigators taking this stance would need, at a minimum, careful measures of the physical environment and a measure of perceived stress. Model C. In model C, the perception of IAQ symptoms is caused by some combination of actual exposure to IAQ problems, other workplace stressors, and individual factors. This model might lead to hypotheses such as the following: People who are exposed to poor IAQ and who
A

Exposure to work stressors Perception of IAQ symptoms B Exposure to IAQ problems Increased perceived stress C Exposure + Stressors + Individual factors Perception of IAQ symptoms
FIGURE 55.3 Possible models of the IAQstressor link.
55.6
ASSESSING IAQ

55.2 THE IAQ-STRESS LINK: REVIEW OF THE LITERATURE
Overview The literature reviewed here was compiled principally through online searches of the National Library of Medicines PubMed database and the American Psychological Associations PsycINFO database. Some of the key words used in the search were stress, psychological stress, workplace, sick building syndrome, psychosocial, mass psychogenic illness, indoor air pollution, and indoor air quality. These were used in various combinations. Several more articles came from the Indoor Air 99 Conference Proceedings CDROM.22 The bibliographies for several of the major articles were cross-examined for commonly cited articles, and these were obtained. Although the search was not exhaustive, it was comprehensive and representative in scope. A total of 29 articles containing original empirical data on psychosocial variables relating to sick building syndrome or indoor air quality were retrieved and examined. Nearly 100 additional review and discussion articles were also retrieved and examined. Table 55.1 contains the 17 empirical articles containing psychosocial variables that are cited in this section. Several review/discussion articles and empirical articles containing no psychosocial variables are also cited; however they are not included in Table 55.1. As noted earlier, the term SBS is used to describe a variety of symptoms reported by workers in a common building, usually an office building. The World Health Organization defines it as specific symptoms with unspecified aetiology which are experienced by a proportion of people working or living in a particular building and disappear after leaving it.23 Sick building syndrome symptoms are most evident during the work shift and diminish or disappear upon leaving the building. No specific cause or illness can be identified, although IAQ is often suspected. Although the name implies that building factors are the cause of the symptoms, research into this area has shown that nonbuilding-related factors contribute to SBS. SBS symptoms reported by workers include eye, nose, or throat irritations, headache, nausea, dry cough, dry or itchy skin, dizziness, difficulty in concentrating, fatigue, and sensitivity to odors.24 These symptoms are often vague and difficult to measure, and affected workers commonly show no clinical signs of illness.25 Many studies have focused on IAQ as a cause for SBS and frequently have shown that complaints are not fully explained by contaminant levels.26 For this reason, in this chapter we will present a review of SBS studies that have included measures of occupational stressors and psychosocial factors. For an in-depth discussion of SBS refer to Chapter 66 in this handbook. More than one study examining SBS complaints found that they were not associated with IAQ.27,28 The prevalence of workers with at least one SBS symptom has been reported to be as high as 70 percent.29 Although a few studies have used case-control designs, the majority
have high levels of workplace stressors and/or who have either a biological (e.g., allergies) or psychological (e.g., high trait anxiety) vulnerability would perceive and report a higher level of symptoms. This model would assume that the problem might lie in a combination of the physical environment, the psychosocial environment, and the individual. Using this model, researchers would need measures of the physical work environment, the psychosocial work environment, relevant internal (e.g., anxiety, depression, allergies) and external (e.g., relationships with coworkers) modifiers, and symptom perceptions and reporting. This model would be compatible with the PE fit, NIOSH, and transactional conceptual frameworks.
TABLE 55.1 IAQ-Stress Studies

Study Influences on sick building syndrome symptoms in three buildings34 N/number of buildings* 624/3
py rig hte dM ate ria

Country Instrument Design Measurements South Africa Profile of Mood States Cross-sectional Questionnaire: psychological state, job stress, interpersonal relationships at work, SBS symptoms, musculoskeletal pains, environmental exposures. United States MMPI, Symptom Checklist-90Revised, in-house neurobehavioral symptom checklist, and Perceived Stress Scale Job satisfaction scale adapted from Job Satisfaction Scale4 Cross-sectional Questionnaire: MMPI, Symptom Checklist-90-Revised, Neurobehavioral Symptom Checklist, Perceived Stress Scale. United States Cross-sectional Questionnaire developed from first authors previous work. Job stress, job satisfaction, physical environmental variables, smoking history, attitude toward tobacco smoke exposure, job category, VDT use, reports of SBS. Smoking policy used to separate into experimental groups. Perception of sociocultural stressors (work and outside work), skills discretion, skills creation, decision authority, decision latitude, physical exertion, psychological job demands, job insecurity, coworker support, supervisor support, family support, job satisfaction and social support from the family. Canada A component of Karasek Job Content Questionnaire and a component of the NIOSH General Job Stress questionnaire Case-control
Findings
Psychological symptoms predictive of SBS symptoms. Also odors, humidity and temp. Job stress not statistically significantly associated w/SBS. Cant attribute SBS to psychological factors alone. Smoking associated w/symptoms. Control, SBS and SBS groups did not differ significantly in PSS, MMPI, SC-90-R, or NSC.
The role of psychosocial factors in the report of building-related symptoms in sick building syndrome33
111/3
Effects of personal and occupational factors on sick building syndrome reports in air-conditioned offices26
3155/18
Gender, job stress, job satisfaction, and VDT use significantly associated with total number of SBS symptoms, in the absence of significant levels of IAQ pollutants. These personal and occupational factors account for 10% of variation in the number of SBS symptoms reported.
Investigation of factors affecting mass psychogenic illness in employees in a fish-packing plant57
269/1
Mass psychogenic illness symptoms associated strongly w/skills creation. Also skill discretion, decision latitude, and decision authority when substituted in logistic model for skills creation.
55.7
TABLE 55.1 IAQ-Stress Studies (Continued )

Study Performance, mood, and health during exposure to intermittent odors58 Covariations among attitude to the indoor air quality, perception of the physical environment, study situation and sensitivity45 N/number of buildings* 90/

Country Instrument Design Measurements United States Semantic Differential Measures of Emotional State questionnaire Experimental Odor, task performance, health symptoms, mood, believed odor effects. (Not specifically an SBS study) Sweden Case-control , Psychosocial stress, workload, work content, demands control and social support. These variables were controlled while studying symptom reporting differences by study situation and physical environment. Questionnaire: SBS symptoms, stress at work, outside of work, perceptions of environment, job satisfaction, decision latitude, hard or fast work, conflicting supervisory instructions. United States Adapted from a variety of instruments including EPA Indoor Environmental Quality Survey, NIOSH-NCHS building and Library of Congress building study questionnaires, and the NIOSH Job Stress Instrument Cross-sectional Sweden Psychosocial rating scales included in article Retrospective Work stress, work satisfaction, climate of cooperation during the last 6 months, psychosocial index. Sweden Psychosocial rating scales included in article Longitudinal Work stress, work satisfaction, climate of cooperation at work, psychosocial index
Findings
Believed health, task performance and mood effects associated with malodor.
528/2
A combination of stress from psychosocial factors and physical factors is associated with symptoms and satisfaction w/IAQ.
Health symptoms and the work environment in four nonproblem United States office buildings28
646/4
No strong relationships between symptoms and air contaminants. Strongest symptom association with perceived physical workspace condition. Psychosocial factors (job satisfaction, influence over job tasks, working hard or fast, conflict in supervisory instructions, job stress) less strongly associated w/symptoms.
Indoor air quality and personal factors related to the sick building syndrome36 Volatile organic compounds, respirable dust, and personal factors related to prevalence and incidence of sick building syndrome in primary schools37 .
11 buildings
Degree of psychosocial dissatisfaction and SBS associated, as well as other nonpsychosocial variables. Multifactorial origin. Degree of psychosocial dissatisfaction and SBS associated, as well as other nonpsychosocial variables. Multifactorial origin. .
129/6
55.8

Study N/number of buildings* 287/8

Country Instrument Design Measurements Sweden MM040B (Department of Occupational Health in Orebro, Sweden Cross-sectional Questionnaire: SBS symptoms, personal factors (including work satisfaction, work stress, and degree of personal influence), noise, temperature, airflow. Singapore Cross-sectional Questionnaire: stress, SBS symptoms. Singapore Cross-sectional Questionnaire: stress, noise, lighting, health history, sex, age, temperature. Denmark Cross-sectional Questionnaire: building factors, job category, sex, work functions, psychosocial factors (influence on organization of the daily work, varied work, satisfaction w/superior, work speed, quantity of work inhibits job satisfaction, little influence and high work pace. Questionnaire: psychosocial work index, work load index, work place position. Sweden Questionnaire described and validated in previous article by same author and referenced in this one Case-referent (matched casecontrol) Sweden Questionnaire described and validated in previous article by same author and referenced in this one Case-referent (matched case-control) Psychosocial work index, work load/support index.
Findings Psychosocial work climate has influence on SBS symptom prevalence. Facial skin symptoms, eye irritation associated with psychosocial work climate.
. Influence of indoor air quality and personal factors on the sick building syndrome (SBS) in Swedish geriatric hospitals59 Sick building syndrome: An emerging Stress-Related Disorder27
2160/6
In buildings w/no recognized environmental problems, health complaints typical of SBS were stress related. Dose-response. Complaints not predictive of IAQ. IAQ did not predict SBS symptoms. High levels of work-related stress, too much noise, history of allergy or other medical conditions, poor lighting, youth, female, predicted SBS symptoms. Building factors strongly associated. All psychosocial factors strongly associated w/symptoms when added separately. Only dissatisfaction with superior or with quantity of work had significant effect on symptoms if all included.
Epidemiology of sick building syndrome and its associated risk factors in Singapore30
2856/56
Influence of personal characteristics, job-related factors, and psychosocial factors on the sick building syndrome60
2829/19
The sick building syndrome (SBS) in office workers. A case-referent study of personal, psychosocial, and building-related risk indicators38 Facial skin symptoms in visual display terminal (VDT) workers. A casereferent study of personal, psychosocial, buildingand VDT-related risk indicators35
339/
Psychosocial conditions related to an increased prevalence of reported SBS symptoms. Workload index strongest.
163/
Psychosocial conditions a risk factor for facial skin symptoms in VDT users.
55.9

Study Why do women report sick building symptoms more often than men?40 N/number of buildings* 4943/

Country Instrument Design Measurements Sweden Physchosocial workload index described in previoous article by same author and referenced in this one Cross-sectional Gender, SBS symptoms, working hours, personal factors, exposure factors at home and work, perceptions of physical conditions, and perceptions of psychosocial work conditions (psychosocial work index same as above). Netherlands Cross-sectional Electronic questionnaire: satisfaction with welfare (tasks, relationships, and conditions at work) and safety and health (indoor climate, light, furniture, equipment, physical health problems, noise, cleaning, fire hazards, toilets, etc.)
Findings
Gender differences in SBS symptoms found to be real, rather than a reporting behavior difference.
No relation between indoor climate and other aspects of quality of working life61
80/4
People in this setting (university chemistry departmen did not misattribute their dissatisfaction to the wrong source.
*N number of subjects/workers.
55.10
55.11

Stimulus (Stressors) Numerous stressors have been investigated in relation to sick building syndrome. These fall into two basic categories based on measurement characteristics: physical and psychosocial stressors. Often the physical stressors are measured objectively, and the psychosocial stressors are measured subjectively, although this is not always the case. Physical Stressors Physical stressors that have been measured in SBS studies include environmental tobacco smoke, vibration, lighting, noise, temperature, and a variety of other measures. Results from a study of 2856 office workers in 56 buildings30 included noise, temperature, and poor lighting among the stressors that predicted SBS symptoms. Higher temperatures have been found by others to be connected with higher levels of symptoms.31 Noise complaints have originated from ceiling-mounted unit ventilators.32 When noise stems from ventilation units, there is the danger that levels of contaminants will increase because of occupants shutting down the noisy unit and interrupting the flow of proper ventilation. Tobacco smoke is an environmental factor that has been found to be associated with SBS symptoms,33 in addition to being responsible for increased rates of lung cancer. Odors, humidity, and temperature in three buildings studied by Bachmann and Myers34 were related to an increase in SBS symptoms. The Office Illness Project in northern Sweden35 linked work responsibilities, such as video display terminal (VDT) use, with facial skin symptoms. Perceived physical workspace condition has also been shown to have a strong association with symptom reporting.28 Psychosocial Stressors Organizational factors such as work climate have not been as well examined in relation to SBS but nonetheless may have an effect on symptoms. Two Swedish studies36,37 found that a negative climate of cooperation at work was positively associated with SBS symptoms. Ooi and Goh27 found similar results. In a matched case-control study of SBS in office workers,38 the psychosocial workload index was related to an increased prevalence of symptoms. The authors of this study created an index for psychosocial work from three questions asking about interesting and stimulating work, too much work to do, and opportunity to influence the working conditions. These concepts coincide nicely with the demandcontrol model described earlier. Bachmann and Myers34 based their measurement of job stress on questions asking the extent subjects had enough time for their work, had spare time, chose their work, chose how and when to work, used their skills at work, and found their work interesting, rewarding or satisfying. The authors cite Karaseks work6 as the basis for these questions. Job stress was not statistically significantly associated with SBS symptom reporting. Interestingly, interpersonal work relationships were also investigated in this study. However, details were not provided on how this factor was measured. Interpersonal work relationships were not found to be associated with SBS symptoms.
have used cross-sectional questionnaires and causal relationships are consequently difficult to assess (see Table 55.1). It is important to keep in mind that many of the variables discussed in this section are surrogates for actual measures of the causes of SBS, many of which are poorly understood or simply unknown. Sick building syndrome is perhaps best explained using a multifactorial approach such as that depicted by the model in Figure 55.1. The variables described below are categorized by the headings in this model.
55.12
ASSESSING IAQ

Modifying Variables Modifying variables act to moderate or mediate the effects of stressors on the person. They may be protective or they may increase susceptibility and are generally classified as internal or external to the person. Internal. Regarding the effects of age, Ooi and colleagues30 found that younger employees reported more SBS symptoms than did older employees. The researchers hypothesize that this effect could be a result of environmental adaptation and a self-selection process among older employees who had worked in the building longer. A history of allergy, not surprisingly, has been shown to be predictive of SBS symptoms.30 This is an example of why it is so difficult to determine the causes of SBSsymptoms of SBS often match symptoms of other conditions such as allergic reactions. Because it is known that females generally report health symptoms more than men do,39 it is not unexpected to learn that this finding carries over into SBS symptom reporting.34 It is not clear why females report symptoms at higher rates. Some researchers posit that women are simply more attuned than men to physical symptoms.27 Stenberg and Wall40 reported females and males work under unequal physical and psychosocial conditions. Their findings suggest that the gender differences in SBS symptoms are not the result of reporting behaviors. Mood states have also been shown to account for differences in symptom reporting between men and women.41 One study of SBS in three buildings34 used questions derived from the Profile of Moods States Questionnaire to measure psychological symptoms such as anxiety, irritability, anger, depression, claustrophobia, tiredness, forgetfulness, and difficulty sleeping or concentrating, finding that these predicted several SBS symptoms. The authors noted, however, it is arguable whether psychological symptoms are a cause or an effect of SBS. Personality has been postulated as potentially playing a role in SBS.42 Personality may act as a modifier between stressful workplace characteristics and SBS outcomes, mediating the effects on each individual. Crawford and Bolas,43 in their review of SBS studies investigating personality, concluded, the handful of studies in the area are inconclusive. It has been measured using instruments such as the Minnesota Multiphasic Personality Inventory, the Eysenck Personality Inventory, or Ravens Standard Progressive Matrices,44 but these are general multifactorial inventories of personality, and they may not be specific enough to be of much use. Measures that are more specific should be included in future research to better define the possible relationship between personality and SBS symptoms. Intervening Variable (Perceived Stress) Job stress has consistently been shown by several studies27,30,34,45 to be predictive of SBS symptoms. Ooi and Goh27 had subjects rate the climate of cooperation at work on a 10-point scale ranging from 0 (not stressful) to 10 (extremely stressful). Work-related physical and mental stress were similarly evaluated. A definition of stress was not provided to the respondents. Odds ratios calculated for these three measures showed consistent incremental changes that the authors concluded were suggestive of a positive doseresponse relationship
In a study of four nonproblem U.S. office buildings,28 a scale for job stress was based on the demandcontrol model, incorporating scores for perception of influence over work and having to work hard. Job satisfaction and conflicting supervisory instructions were also investigated. All of these factors were found to be statistically significantly associated with SBS symptoms, although the relationships were not very strong. The questionnaire was adapted from a variety of instruments used by other researchers, includingthe NIOSH Job Stress Instrument.
55.13

Summary of Literature Review Overall, the literature supports the theory that SBS symptoms are not always related to IAQ problems. Job stress, job satisfaction, job demands, and job control play significant roles in SBS. Gender has clearly been identified as a confounding variable in SBS studies, and researchers and other SBS investigators must remember to stratify by gender when performing analyses. The instruments used in the studies to date have been quite varied. Many investigators refine their instruments from study to study or adapt the instruments used by others, making it difficult to compare between studies. An attempt to develop summary statistics for the variables in the studies listed in Table 55.1 proved nearly impossible due to the inconsistencies in the measurement methodologies used in each study. There is an explicit need to increase the use of validated measurement instruments such as the ones described in the next section. Doing so will not only improve the validity and reliability of the measures in SBS studies but also will allow for cross-comparisons and pave the road for future meta-analyses.
between stress and SBS symptoms. The possibility of interaction between the perception of stress and several covariates (thermal discomfort, medical condition, noise, lighting, age) was investigated; however, no significant effect modification was found. In another study investigating the effects of personal and occupational factors on SBS reports,26 job stress and job satisfaction were measured using several questions answered on a 5-point rating scale (strongly agree, mostly agree, uncertain, mostly disagree, strongly disagree). Six questions making up the job satisfaction scale were adapted from a previously constructed job satisfaction scale.4 The five items making up the job stress scale were adapted from several sources. Factor analyses were performed on both scales, yielding Cronbachs values of .90 for job satisfaction and .70 for job stress. Both job stress and job satisfaction were significantly related to the total number of SBS symptoms, in the absence of significant levels of IAQ pollutants. Still, the occupational and personal factors investigated in this study only accounted for 10 percent of the variation in the number of SBS symptoms reported.
55.3 INSTRUMENTS AND MEASUREMENT ISSUES

Problems Found in Existing Studies
Although, as seen in the previous section, several studies of indoor air effects have included psychosocial measures, few have explicitly related the selection of variables to a conceptual theory. Most studies designed with a psychosocial component have not addressed a comprehensive set of relevant domains. Additionally, Table 55.1 shows that the targeted domains, as well as their respective measures, have varied greatly.
Use of Theory. A theory-based approach to the investigation of indoor air quality questions provides a framework that guides both the selection of appropriate variables and the examination of their statistical relationships. A model such as that presented in Figure 55.2 allows for the comprehensive inclusion of relevant domains that may have main, modifying, or confounding effects on the health outcomes of interest. This enables characterization of the modifying effects of psychosocial variables in relation to environmental measures of chemical, physical, or biological exposures. It also allows for inclusion of variables previously reported to be associated with health outcomes. Additionally, studies
55.14
ASSESSING IAQ

Psychometric Properties. To support sound inferences, psychosocial domains should be represented by measures that meet acceptable levels of validity and reliability. In addition to content validity, which indicates the ability of a measure to address its respective domain of the conceptual theory, measures should have established face validity, or conceptual clarity, and construct validity, indicating comparability of responses with other measures of the same constructs. Predictive validity, another desirable property, represents the degree to which the measure is known to correlate with expected criteria such as anticipated health outcomes. Finally, it is desirable to limit random measurement error by ensuring that the instrument is characterized by two forms of reliability, internal consistency and stability over time. Item intercorrelations and test-retest analyses provide the means for assessing these characteristics. Several standardized instruments are available for which validity and reliability have been established. However, a number of investigators have employed measurement techniques for psychosocial concepts without reporting their respective psychometric properties. Better ascertainment and documentation of measurement characteristics would strengthen studies of the indoor environmentstress link. This process, which can take considerable effort, would constitute a contribution not only to the study at hand but also to future investigations. Generic Instruments. Most studies that have considered the relationship between jobrelated stressors and health outcomes have depended on the use of generic measures to describe levels of job stressors. Examples are the scales typically used to measure workrelated control, demands, and social support (i.e., Job Content Questionnaire11). Although these tools can be used to demonstrate general effects of work factors on stress, a limitation is their inability to identify specific work-related stressors. This has been addressed by Baker,47 who pointed to the need to identify specific stressors in developing realistic prevention strategies for reducing stress. For example, occupation-specific stress measures, based on job stress models, have been developed by our team and used with worker populations such as childcare, telecommunications, and military workers. The development of occupation-specific measures is a complex and iterative process, but it can better help explain the variance observed in stress-related health outcomes and thus better guide the design of effective preventive interventions. Major Comprehensive Instruments There has been a proliferation of broad-based comprehensive job stress measures over the past two decades. A recent issue of the Journal of Occupational Health Psychology was devoted to overviews of these instruments3,5 and to in-depth reviews of specific instruments.
designed according to a theoretical model avoid redundancy among variables unless it is an aim of the study to develop or validate new measurement instruments. Some investigations have collected data on several psychosocial variables but have subsequently included only one composite index, combining responses for separate measures, in the analyses.36,38 This approach neglects the richness of the data set and masks the influence of specific components of the index on any observed associations. Thus, the relative importance of single domains within the index will not be apparent. For example, social support has been shown to be an important modifier of workplace stressors,46 but this relationship is obscured when the values for level of social support are embedded within a summed composite index. Thus, the use of composite indexes does not inform decisions regarding preventive interventions.
TABLE 55.2 Measures of Occupational Stress and Examples of the Domains They Represent
Instrument/reference 1 Job Diagnostic Survey22
Approach5 PE fit DC ER
Work-related stressors Skill variety, task significance, task identity, autonomy, feedback
Ma ter i
Domains Internal modifiers External modifiers Internal motivation Coping and social support Type A behavior, locus of control, coping strategies Social support Self-esteem Social support
Effects Job satisfaction
2 Job Characteristics Index62 3 Work Environment Scale63 PE fit
Skill variety, autonomy, feedback, coworker interaction, task identity, friendships Interpersonal relationships, orientation toward personal growth, organizational structure
4 Occupational Stress Inventory64 5 Occupational Stress Indicator65
PE fit
PE fit DC Transactional
yri gh ted
Occupational role stress; vocational, psychosocial, and physical strain Sources of pressure in work environment Role demands, workload, time pressure, task demands Decision latitude, psychological and physical demands, exposure to physical hazards Examples: role conflict and ambiguity, workload, control, cognitive demands Organizational stress, job risk Job pressure, organizational support
Job satisfaction, physical and mental health
6 Stress Diagnostic Survey66 7 Job Content Questionnaire67 8 Generic Job Stress Questionnaire68 9 Work Stress Inventory69 10 Job Stress Survey
70
Pressure-strain, job satisfaction, quality of work Job satisfaction and security
DC
PE fit
Depression, somatic complaints, job satisfaction, illnesses
55.15
p p Examples of the Domains y p ( Represent ) TABLE 55.2 Measures of Occupational Stress and They (Continued ) Domains
Instrument/reference 11 Pressure Management Indicator71
Approach5 Transactional
Work-related stressors Skill i relationships k i ifiat work; k id i Workload; recognition; organization climate; personal responsibility; managerial role; daily hassles; homework balance
Ma ter i
Internal modifiers External modifiers Drive; patienceimpatience; problem focus; lifework balance; use of social support; control; personal influence
Effects Satisfaction with job, organization; perceived job security; commitment to organization; state of mind; energy level; confidence level; resilience; physical symptoms
12 Interpersonal Conflict at Work72 Organizational Constraints Quantitative Workload Inventory Physical Symptoms Inventory
yri gh ted
Conflict with others at work Constraints on work Amount of work and work pace
Somatic symptoms
55.16
55.17

Selection of an Instrument. When selecting an instrument, there are conceptual, methodological, and practical issues to consider. As noted in Table 55.2, most of the instruments have identifiable conceptual approaches that they represent. The primary conceptual issues are to select an instrument that represents the framework to be employed and that covers the constructs that are of interest. Methodological issues include consideration of the psychometric properties of the instruments (validity, reliability), whether normative data are available that pertain to worker characteristics of interest (e.g., by gender, race, type of job), the method of administration (survey, interview, observation), the reading level of the instrument (is it too high or low for the audience?), and the ease of scoring, analyzing, and interpreting the findings. Practical issues include cost of the instrument, amount of time to administer it, and whether additional expertise is needed in the team to be able to use the results. Perceived Stress. Notably missing in Table 55.2 is a dimension representing perceived stress. This lack is because most instrument packages measure perceived stressors but not perceived stress (i.e., the feeling of being overwhelmed or unable to garner sufficient resources). A detailed discussion of the measurement of perceived stress has been provided by Monroe and Kelley.48 They conclude that only one instrument is an empirically established indexthat falls into the category of general appraisal instruments (p. 138)the Perceived Stress Scale.49 The original version of this instrument included 14 items such as, In the last month, how often have you felt that you were unable to control important things in your life? and In the last month, how often have you felt that you were on top of things? Shorter versions of the instrument have also been developed.50
Depicted in Table 55.2 are descriptions of 12 multicomponent instruments that are used most frequently in the literature. Further descriptions are found in the special issue of JOHP, in the literature, and on the instrument Websites. As can be seen in Table 55.2, all of the instruments cover multiple types of work-related stressors. Coverage of other domains is less consistent. Many researchers fill in the gaps in the coverage of domains by using additional, targeted instruments (e.g., for depression, anxiety).
55.4 IMPLEMENTATION ISSUES
Ideally, the IAQstress link would be prevented through management of the physical environment and/or the psychosocial environment. Realistically, most IAQ specialists, unless they are conducting longitudinal research, will be brought into an ongoing situation. It is likely, if the problems have gone on for some time or if there is a poor organizational climate, that emotions and opinions of workers and management may be polarized. Within such a setting, it becomes more difficult to find a resolution that will satisfy all groups, and interpersonal communication becomes as important as scientific findings. Below, we outline some implementation issues that we believe are critical to consider; several of these issues have been presented in more detail elsewhere.51
Address Concerns in a Timely Manner
Although it may be tempting to take a wait and see attitude when responding to IAQ problems, this is problematic for at least three reasons. First, and foremost, workers health may be at risk and time may exacerbate health problems. Second, the most important characteristic of an IAQ team is credibility. In the persuasive communications field, source credibility is viewed as essential to most communications settings.52 Credibility is intertwined with
55.18
ASSESSING IAQ

Involve Workers from the Beginning Worker representatives should be involved in the process to the greatest extent possible. There are several reasons for this. First, and most importantly, the imposition of a solution on a worker group is likely to be viewed negatively and as another violation of trust in the employeeemployer relationship. When workers are barred from the process, it can lead to the circulation of rumors and half-truths, which can further undermine confidence in the IAQ team. Second, exclusion of workers sets up an insider versus outsider dynamic that prohibits positive interpersonal communications. Third, by not including workers, IAQ specialists are losing a vital source of information. Workers are specialists in providing information about how they see the IAQ problem (e.g., is it a matter of high or low concern?), the perceived causes for the problem (e.g., ventilation system versus carpeting), the influence of the problem on the social environment (e.g., is it causing rifts among groups of workers?), and communications needs of workers (what do they want to know, and who do they want to tell them?). Some IAQ specialists may believe that if they conduct a session with workers to tell them what is happening and why, they have fulfilled their inclusion obligations. We disagree with this approach, which has been faulted in the risk communication literature.53 There are multiple roles for workers in the inspection of the IAQstress link. First, a small but representative set of workers who have the trust and respect of their colleagues should be part of the core decision-making team. They can provide valuable insights into the dynamics of the workplace and how different approaches may be perceived by their coworkers. Second, larger groups of workers may be used in key informant interviews, focus groups, or surveysall valuable tools to gather information on the issues listed above. Use an Interdisciplinary Team Although not all IAQ cases will warrant an in-depth response, there are times when the use of an interdisciplinary team may be critical. Cases that involve large groups of workers, highly publicized or politically sensitive issues, or vulnerable populations are candidates for an extensive examination of the IAQstress link. At a minimum, an interdisciplinary team should involve specialists in the areas of IAQ, occupational health, occupational stress measurement, and risk communication. Each of these disciplines can contribute to multifaceted examination and reporting of the issues. Carefully Think Through the Conceptual Approach That Is Used We have outlined four distinct and one hybrid conceptualizations of occupational stress in this chapter. The conceptual approach that is used will determine the variables to be measured, the study design, the assumed IAQstress model, and the conclusions that can be drawn. The IAQ team members should think about the entire scope of the workfrom how
two related characteristics: knowledgeability and trustworthiness. Even the best of scientists (i.e., those high in knowledgeability) can be compromised by poor trustworthiness. A prompt response is essential to maintaining the trust of workers, as are other actions that will be described below. Third, it is difficult, if not impossible, to dismiss accounts of mass psychogenic illness (MPI) in the literature on IAQ. A prompt response is more likely to interrupt any potential sequencing of MPI events such as using cues from coworkers to attribute vague symptoms to IAQ problems.
55.19

Use a Comprehensive Conceptual Approach from the Beginning. We advise IAQ teams to use a comprehensive approach from the beginning rather than to collect information in a fragmented and piecemeal fashion. For example, the NIOSH approach would allow for the collection of variables that could test an overall model. Use Psychometrically Sound and Relevant Instruments Psychometrically sound instruments are those that have high levels of validity and reliability and that have been developed using standard, accepted methods (compare with reference 54). Relevant instruments are those that (1) measure components of the conceptual approach used and (2) are appropriate for the population. Much has been written concerning the selection of psychometrically sound instruments in the occupational stress field, but the issue of relevance may be subtler. For example, when exploring the effects of personality as a moderator of stressors on SBS symptoms, some researchers have used extensive personality batteries such as the MMPI.33 The problem with this approach is threefold. First, researchers have not justified the use of such a broad-scale instrument with sound, theory-based assessments of how and why certain components are important. Second, the length of such instruments makes it difficult to adequately cover other important aspects of the conceptual approach due to respondent fatigue. Third, the items in such batteries may seem overly intrusive and lacking in face validity to respondents. This, in turn, could threaten the overall acceptance of the entire data collection instrument. A second example of relevance is based on gender. There is speculation in the field that some instruments or approaches may not be suitable to adequately describe the work that women do.55 Use a Strong Study Design Most of the studies that we have reviewed involve cross-sectional data. A common limitation has been the inability to determine the temporal relationships between exposure to stressors and symptom outcomes. This is especially important in the study of stress-related conditions because of the possibility that health problems may change the way workers perceive their environment, therefore introducing a bias toward positive findings. Even some case-control studies have faced the difficulty of ascertaining the timing of symptoms relative to the stressor experiences. Although longitudinal studies may be challenging, they may be useful in circumstances where organizational changes are introduced and symptom development, or resolution, can be tracked. Longitudinal designs will be particularly helpful in the evaluation of intervention strategies. Another feature of previous studies has been the use of internal control groups, often in studies of single buildings that have already been declared problem buildings. Although this design makes it possible to control for many factors that are unique to an organization, it can limit the external validity of the investigation. The ability to generalize findings will
the problem is framed to the possible solutionsbefore selecting a model. For example, if the demandcontrol model is selected, it would imply the following: (1) Workers perceptions of the physical and psychological demands put on them and the amount of control that they have over their work would be in the primary areas of inspection (although, newer versions of this approach also include social support; (compare with reference 46). (2) The model implies that workers with high demands and low control would exhibit the strongest reactions to IAQ problems. (3) Appropriate interventions would include altering the levels of demands or control or the balance between the two. Each conceptual approach has distinct implications.
55.20
ASSESSING IAQ
be enhanced by studying populations most representative of those who experience the stressors of interest. These and other issues that lend strength to investigations, such as adequate power, blinding to exposure or outcome status, control for major confounding variables, and avoidance of measurement error have been discussed by Mendell.56

Use Appropriate Data Collection Techniques Three primary categories of data collection may be used in stress studiesself-administered surveys, interviews, and observations. By far, the most widely used method is the selfadministered survey because it is less labor intensive and generally cheaper to conduct. No matter which method is used, several aspects of data collection need to be considered. First and foremost, worker confidentiality must be maintained. This is true for ethical reasons and to establish and maintain trust within the organization. Second, it is important to get as representative of a sample as is possible. If all of the worker group cannot be surveyed or observed, a random sample should be used. Once workers are selected to be in the targeted group, reasonable efforts to increase the response rate should be employed (multiple and varied contacts) to reduce the effects of selection bias. Use Sensitivity in Communicating Results As noted above, workers should be consulted on the communications issue. If they are kept apprised of the results as the study progresses, a crisis at the end of the study can be avoided. Workers should be assessed for their levels of knowledge on topics that are essential to fully understanding the results (e.g., probability). Efforts should be made to give workers the information tools that they need to understand and interpret the findingsthis is essential to allay concerns. In addition, input from workers on what topics they want information about and who they want to tell them should be gathered. It may be that members of the IAQ team have sufficient credibility that workers will accept hearing the findings from themor, they may prefer to have a neutral, outside person present the findings. Special Issues around Null Findings. Logically, we might expect that the dominant emotion following negative results would be relief. However, this is not always the case. If negative findings are presented in a situation where there is mistrust and suspicion, they may raise feelings of hostility and anger in workers. Even within a situation of positive relationships, negative findings may lead to feelings of frustration because workers have to search for another cause for their symptoms. The IAQ team needs to recognize that negative emotions can surface even when things seem positive and that these negative emotions should not be belittled or minimized. Persons who have high levels of symptoms or concerns may need individualized attention.
55.5 CONCLUSION
The use of a conceptual framework and psychometrically sound instruments will aid the researcher and problem solver alike, providing a basis for understanding and measuring workplace stress and psychosocial factors that may be contributing to IAQ problems. There is no doubt that workplace stress and psychosocial factors often play a role in IAQ problems. By addressing these issues in an investigation, IAQ specialists will benefit from a greater understanding of the contributing factors in each unique situation. This will allow for tai-
55.21
lored solutions to be effectively designed and implemented, often leading to quicker and more complete resolution of the problems. Building residents may be more likely to welcome sensitive communication of findings based on scientifically sound investigations following the guidelines outlined in this chapter.

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ASSESSING IAQ

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CHAPTER 55

Co py rig hte dM ate ria l