Elsevier

Psychoneuroendocrinology

Volume 30, Issue 10, November 2005, Pages 1033-1038
Psychoneuroendocrinology

Social reciprocity and health: New scientific evidence and policy implications

https://doi.org/10.1016/j.psyneuen.2005.03.017Get rights and content

Summary

The work contract is based on the norm of social reciprocity where appropriate rewards are provided for efforts and achievements at work. The effort-reward imbalance model of work stress maintains that contractual non-reciprocity in terms of high efforts spent and low rewards received is frequent if people have no alternative choice in the labour market, if they are exposed to heavy competition or if they are intrinsically motivated to engage in excessive work-related commitment. According to the model, long-term exposure to effort–reward imbalance increases the risk of stress-related disorders. An overview of results from prospective epidemiological investigations testing the model is given. Overall, people who experience failed reciprocity at work are twice as likely to suffer from incident cardiovascular disease, depression or alcohol dependence compared to those who are not exposed. Associations are stronger for men than for women. Policy implications of findings for improved worksite health promotion are discussed.

Introduction

It is almost a hundred years since psychosomatic medicine evolved as a scientific programme. Over the century different paradigms shaped psychosomatic research, among them, most obviously, psychoanalysis, behaviourism, stress research, medical sociology and epidemiology. Today, molecular biology and genetics offer tempting new transdisciplinary research perspectives. Despite this diversity there is also a continuity of fundamental inquiry into psychosomatic topics. The mind–body problem and the potential discrepancy between people's self perceived ill health and biomedically assessed diagnosis are two such topics. It is probably accurate to state that Holger Ursin has made original contributions to both problems. First, in the frame of ecologically valid experimental stress research, he and his colleagues showed that environmental challenges adversely affect bodily systems only if they produce sustained autonomic arousal. Sustained autonomic arousal is contingent on the absence of coping in terms of positive outcome expectancy (Ursin and Eriksen, 2004). More recently, Ursin focussed on the socio-behavioural consequences of self-rated ill health and perceived pain-in particular back pain-in the absence of objectively diagnosed lesions. These patient-based decisions in terms of sick leave and early retirement have far reaching economic and psychosocial implications (Eriksen and Ursin, 2002).

Psychobiology and behavioural medicine have contributed—and continue to contribute—a lot to the growth of psychosomatic medicine. A more modest role in this regard is played by health-related social sciences, in particular medical sociology and social epidemiology. Yet, in this contribution an example is given on how a sociological hypothesis can cross-fertilize psychosomatic and behavioural medicine by linking the structure of social opportunities with well-being and biological functioning via distinct types of stressful everyday experiences.

These links between the structure of social opportunities and health are mediated in large part by the quality of self-experience that is available from core social roles in adult life, such as the marital and parental role, the work role, or relevant civic roles. Having access to, and acting successfully in these social roles is important for individual need fulfilment.

In addition to meeting goals such as securing income, comfort, social stability and support these roles offer opportunities of positive self-experience, in particular self-efficacy and self-esteem. Positive experience of self is contingent on opportunities of belonging, acting or contributing, and of receiving favourable feedback. Take for instance the work role where opportunities of learning new skills, of mastering difficult tasks, or of meeting demands with a sense of responsibility and commitment may produce favourable effects on self-efficacy. Self-efficacy has been defined as the belief a person has in his or her ability to accomplish tasks, based on a favourable evaluation of one's competence and of expected outcomes (Bandura, 1985). Similarly, the work role can act as a source of recurrent positive experience of self-esteem. This is the case when achievements that meet or even exceed expectations are reciprocated by equitable rewards or when collaboration occurs in an atmosphere of mutual respect and trust. Though it is not exclusive, the work role offers particularly strong and important incentives of positive self-experience.

Conversely, lack of positive self-experience at work can be detrimental to health and well-being. We tested this hypothesis in extensive studies in the frame of a newly developed theoretical model, effort-reward imbalance at work (Siegrist, 1996). This model builds on the notion of social reciprocity, a fundamental principle of interpersonal behaviour and an ‘evolutionary old’ grammar of social exchange. Social reciprocity is characterized by mutual cooperative investments based on the norm of return expectancy where efforts are assumed to be equalized by respective rewards (Gouldner, 1960). Failed reciprocity resulting from a violation of this norm elicits strong negative emotions and sustained stress responses because it operates against this fundamental principle.

This principle of social reciprocity lies at the core of the employment contract which defines distinct obligations or tasks to be performed in exchange with equitable rewards. The model of effort-reward imbalance is based on the assumption that efforts spent at work are not reciprocated by equitable rewards under specific conditions. These rewards include money, esteem and career opportunities, including job security. The model of effort-reward imbalance claims that lack of reciprocity between the costs and gains (i.e. high cost-low gain conditions) elicits negative emotions with special propensity to sustained autonomic and neuroendocrine activation.

In structural terms, this imbalance results from the fact that the social exchange between employee and employer is based on an incomplete contract. An incomplete contract does not specify the full range of detailed obligations and benefits (Fehr and Gächter, 2000). In incomplete contracts, assumptions of trust in mutual commitment are made. However, under the following conditions incomplete contracts are likely to result in high cost-low gain conditions. First, the risk of non-reciprocity in exchange is particularly high if employees have no alternative choice in the labour market. This is the case, for instance, if their skills are poor or if they subscribe to short-term contracts. Less frequently non-reciprocity at work is experienced by workers as a negative life event, as contract violation or failed contract.

Secondly, employees themselves may contribute to effort–reward imbalance at work either intentionally or unintentionally. For instance, they may accept job arrangements that are considered unfair for a certain time for a strategic reason, as they tend to improve their chances or career promotion and related rewards at a later stage. This pattern is often observed in early stages of professional careers, among others. Failed success after long lasting investment is particularly harmful to a person's well-being and health.

Third, there are psychological reasons of a continued mismatch between efforts and rewards at work. People characterized by a motivational pattern of excessive work-related overcommitment and a high need for approval may suffer from inappropriate perceptions of demands and their own coping resources more often than their less involved colleagues (Siegrist, 1996, Siegrist, 2002). Perceptual distortion prevents them from accurately assessing cost–gain relations. As a consequence, they underestimate the demands, and overestimate their own coping resources while not being aware of their own contribution to non-reciprocal exchange.

In summary, the proposed theoretical model is based on the sociological hypothesis that structured social exchange, as mediated through core social roles (the work role), is rooted in contracts of reciprocity of cost and gain. Conditions of failed social reciprocity are in part structural (or extrinsic) and in part personal (or intrinsic). Structural conditions of recurrent experience of high effort and low reward at work include lack of alternative choice in the labour market, lack of mobility, low level of skills and confinement to a short-term contract. Personal conditions include strategic choices of the workers (although these often may be induced by social pressure) and characteristics of individual coping with the demands and rewards at work (overcommitment).

Three hypotheses are tested: 1. People characterized by an imbalance between (high) effort and (low) reward (failed reciprocity) are at elevated risk of stress-related diseases (over and above the risk associated with each one of the components). 2. People scoring high on ‘overcommitment’ are at elevated risk of stress-related diseases. 3. Relatively highest risk of stress-related diseases is expected in people who are characterized by the co-manifestation of conditions (1, 2).

In the following section a test of these hypotheses is presented although not in a systematic way as most of the evidence relates to the first hypothesis. Details on the measurement of effort-reward imbalance at work can be found elsewhere (Siegrist et al., 2004). However, it should be mentioned that ‘effort’ and ‘reward’ are measured by two uni-dimensional scales containing 6 and 11 Likert-scaled items respectively. Imbalance is assessed by applying a standardized algorithm (ratio effort/reward). ‘Overcommitment’ is equally measured by a Likert-scale containing 6 items in its short version. Reliability, factorial structure and different types of validity (convergent, discriminant, criterion validity) of these scales were analysed, including comparison of self-report data with contextual information (where available) (Siegrist, 1996, Siegrist et al., 2004).

Section snippets

Scientific evidence

Several sources of information on associations between psychosocial stress at work and health are available, such as data from cross-sectional and case-control studies, from prospective epidemiological observational investigations, from studies using ambulatory monitoring techniques or experimental designs and from intervention trials. The prospective epidemiological observational study is considered a gold standard approach in this field because of its temporal sequence (exposure assessment

Policy implications and conclusions

In view of the fact that coronary heart disease, depression, and Type II-diabetes are likely to become leading causes of premature death and of life years defined by disability worldwide, and in view of the fact that alcohol dependence is one of the most important addiction-related public health problem the policy implications of the findings presented in Section 2 deserve special attention. Measures to improve the balance between effort and reward and, hence, to improve reciprocity and

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