Does occupational gender segregation influence the association of effort-reward imbalance with myocardial infarction in the SHEEP study?

  • Richard Peter
  • Anne Hammarström
  • Johan Hallqvist
  • Johannes Siegrist
  • Töres Theorell
  • SHEEP Study Group


The objective of this study was to investigate whether occupational gender segregation moderates the association between job stress in terms of effort-reward imbalance and the risk of myocardial infarction. This analysis was conducted in 1,381 cases and 1,697 referents of the Swedish SHEEP case control study aged 45-70 years. Information on myocardial infarction and biological coronary risk factors (e.g. hypertension, blood lipids) was achieved from clinical screenings. Information on socio-demographic variables, effort-reward imbalance, behavioral coronary risk factors (e.g., smoking), and additional coronary risk factors (e.g., diabetes, family history of coronary heart disease) was derived from well-tested standardized questionnaires. After adjustment for confounders the strongest association between overcommitment (the intrinsic component of effort-reward imbalance) and risk of belonging to the myocardial infarction group was found among women in male-dominated jobs (odds ratio [OR] = 2.71, 95% CI = 1.13-6.52) as compared to the remaining group (OR = 1.52, 95% CI = 1.01-2.31). Moreover, a significant interaction between pronounced overcommitment and male domination in relation to myocardial infarction was observed among women (OR = 2.44, 95% CI = 1.05-5.67). In men, an association between the ratio of effort and reward (the extrinsic component of the model) and risk of myocardial infarction was found for the majority, that is the group not working in women-dominated jobs (OR = 1.39, 95% CI = 1.04-1.86). Despite methodological limitations, this study gives preliminary evidence of a moderating effect of occupational gender segregation on the association of effort-reward imbalance (i.e., the intrinsic model component overcommitment) with acute myocardial infarction risk among women, but not among men.

Key words

occupational gender segregation work stress effort-reward imbalance myocardial infarction 


  1. Abell, L. L., Levy, B. B., Brodie, B. B., & Kendall, F. E. (1952). A simplified method for the estimation of total cholesterol in serum and demonstration of its specifity. Journal of Biological Chemistry, 195, 357–366.Google Scholar
  2. Alexanderson, K., Leijon, M., Åkerlind, I., Rydh, H., & Bjurulf, P. (1994). Epidemiology of sickness absence in a Swedish county in 1985, 1986 and 1987. A three year longitudinal study with focus on gender, age and occupation. Scandinavian Journal of Social Medicine, 22(1), 27–34.PubMedGoogle Scholar
  3. Arber, S., & Gilbert, N. (Eds.). (1991). Women and working lives: Divisions and change. London: Macmillan.Google Scholar
  4. Barnett, R., Brennan, R., & Marshall, N. (1994). Gender and the relationship between parent role, quality and psychological distress. Journal of Family Issues, 15, 229–252.CrossRefGoogle Scholar
  5. Bernin, P., & Theorell, T. (2001). Demand-control-support among female and male managers in eight Swedish companies. Stress and Health, 17, 231–243.CrossRefGoogle Scholar
  6. Bosma, H., Peter, R., Siegrist, J., & Marmot, M. (1998). Two alternative job stress models and the risk of coronary heart disease. American Journal of Public Health, 88, 68–74.PubMedCrossRefGoogle Scholar
  7. Connell, R. W. (1987). Gender and power. Sydney: Allen & Unwin.Google Scholar
  8. Efron, B. (1975). The efficiency of logistic regression compared to normal discriminant analysis. Journal of the American Statistical Association, 70, 892–898.CrossRefGoogle Scholar
  9. Emslie, C., Hunt, K., & Macintyre, S. (1999). Problematizing gender, work, and health: The relationship between gender, occupational grade, working conditions, and minor morbidity in full-time bank employees. Social Science & Medicine, 48, 33–48.CrossRefGoogle Scholar
  10. Evans, J. (2004). Men nurses: A historical and feminist perspective. Journal of Advanced Nursing, 47(3), 321–328.PubMedCrossRefGoogle Scholar
  11. Evans, O. & Steptoe, A. (2002). The contribution of gender-role orientation, work factors and home stressors to psychological well-being and sickness absence in male- and female-dominated occupational groups. Social Science & Medicine, 54, 481–492.CrossRefGoogle Scholar
  12. Frankenhaeuser, M., Lundberg, U., & Chesney, M. (1991). Women, work and health. Stress and opportunities. New York: Plenum Press.Google Scholar
  13. Gallo, L. C., Troxel, W. M., Kuller, L. H., Sutton-Tyrrell, K., Edmundowicz, D., & Matthews, K. A. (2003). Marital status, marital quality, and atherosclerotic burden in postmenopausal women. Psychosomatic Medicine, 65(6), 952–962.PubMedCrossRefGoogle Scholar
  14. Glynn, L. M., Christenfeld, N., & Gerin, W. (1999). Gender, social support, and cardiovascular responses to stress. Psychosomatic Medicine, 61(2), 234–242.PubMedGoogle Scholar
  15. Hall, E. M. (1989). Gender, work control and stress: A theoretical discussion and an empirical test. International Journal of Health Services, 19, 725–745.PubMedCrossRefGoogle Scholar
  16. Hall, E. (1992). Double exposure: The combined impact of the home and work environments on psychosomatic strain in Swedish women and men. International Journal of Health Services. 22(2), 239–260.PubMedCrossRefGoogle Scholar
  17. Hallman, T. (2003). Gender perspective on psychosocial risk factors. Conditions governing women’s lives in relation to stress and coronary health disease. Unpublished thesis, Karolinska Institute, Dept of Clinical Neuroscience, Section for Personal Prevention, Stockholm, Sweden.Google Scholar
  18. Härenstam, A., Aronsson, G., & Hammarström, A. (2001). Gender and health from a future perspective. In P. Östlin, M. Danielsson, F. Diderichsen, A. Härenstam, & G. Lindberg (Eds.), Gender Inequalities in Health: A Swedish perspective (pp. 269–304). Cambridge, MA: Harvard Center for Population and Development Studies, Harvard University Press.Google Scholar
  19. Hensing, G., & Alexanderson, K. (2004). The association between sex segregation, working conditions, and sickness absence among employed women. Occupational and Environmental Medicine, 61(2), e7.PubMedCrossRefGoogle Scholar
  20. Hosmer, D. W., & Lemeshaw, S. (1989). Applied logistic regression. New York: Wiley.Google Scholar
  21. Hunt, K., & Emslie, C. (1998). Men’s work, women’s work? Occupational sex roles and health. In K. Orth-Gomer, M. Chesney, & N. K. Wenger (Eds.), Women, stress, and heart disease (pp. 37–107). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.Google Scholar
  22. Johnson, J. V., Stewart, W., Hall, E. M., Fredlund, P., Theorell, T. (1996). Long-term psychosocial work environment and cardiovascular mortality among Swedish men. American Journal of Public Health, 86, 324–331.PubMedCrossRefGoogle Scholar
  23. Jünsson, D., Rosengren, A., Dotevall, A., Lappas, G., & Wilhelmsen, L. (1999). Job control, job demands, and social support at work in relation to cardiovascular risk factors in MONICA 1995, Göteborg. Journal of Cardiovascular Risk, 6, 379–85.Google Scholar
  24. Kim, J. O., & Muller, C. W. (1978). Factor analysis. Statistical Methods and Practical Issues. London: Sage.Google Scholar
  25. Kivimäki, M., Leino-Arjas, P., Luukkonen, R., Riihimäki, H., Vahtera, J., & Kirjonen, J. (2002). Work stress and risk of cardiovascular mortality: Prospective cohort study of industrial employees. British Medical Journal, 325, 857–860.PubMedCrossRefGoogle Scholar
  26. Kleinbaum, D. G., Kupper, L. L., & Morgenstern, H. (1982). Epidemiologic research—Principles and quantitative methods. New York: Van Norstrand Reinhold.Google Scholar
  27. Klumb, P. L., & Lampert, T. (2004). Women, work, and well-being 1950–2000: A review and methodological critique. Social Science & Medicine, 58(6), 1007–1024.CrossRefGoogle Scholar
  28. Leijon, M., Hensing, G., & Alexanderson, K. (2004). Sickness absence due to musculoskeletal diagnoses: Association with occupational gender segregation. Scandinavian Journal of Public Health, 32(2), 94–101.PubMedCrossRefGoogle Scholar
  29. Lundberg, U. (2002). Gender, multiple role, and physiological reactions. In S. Wamala & J. Lynch (Eds), Gender and social inequalities in health. A public health isssue (pp. 123–157). Lund, Sweden: Studentlitteratur.Google Scholar
  30. Matschinger, H., Siegrist, J., Siegrist, K., & Dittman, K. (1986). Type A as a coping career: Towards a conceptual and methodological redefinition. In T. H. Schmidt, T. M. Dembroski, and G. Blümchen (Eds.), Biological and psychological factors in cardiovascular disease (pp. 104~). Berlin: Springer.Google Scholar
  31. Matthews, S., Hertzman, C., Ostry, C., & Power, C. (1998). Gender, work roles, and psychosocial work characteristics as determinants of health. Social Science & Medicine, 46, 1417–24.CrossRefGoogle Scholar
  32. Orth-Gomer, K., & Chesney, M. A. (1997). Social stress/strain and heart disease in women. In G. J. Desmond & N. K. Wenger (Eds.), Women and heart disease (pp. 407–420). London: Martin Dunitz Ltd.Google Scholar
  33. Orth-Gomer, K., Wamala, S. P., Horsten, M., Schenck-Gustafsson, K., Schneiderman, N., & Mittleman, M. A. (2000). Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. Journal of the American Medical Association, 284(23), 3008–3014.PubMedCrossRefGoogle Scholar
  34. Östlin, P. (2002). Gender inequalities in health: The signifance of work. In S. Wamala & J. Lynch (Eds), Gender and social inequalities in health. A public health isssue (pp. 43–65). Lund, Sweden: Studentlitteratur.Google Scholar
  35. Östlin, P., Alfredsson, L., Hammar, N., & Reuterwall, C. (1998). Myocardial infarction in male and female dominated occupations. Occupational and Environmental Medicine, 55, 642–644.PubMedCrossRefGoogle Scholar
  36. Peter, R. (1991). Berufliche Belastungen, Belastungsbewältigung und koronares Risiko bei Industriearbeitern [Work stress, coping behavior, and coronary risk among blue-collar workers]. Hamburg Münster, Germany: Lit.Google Scholar
  37. Peter, R., Alfredsson, L., Hammar, N., Siegrist, J., Theorell, T., & Westerholm, P. (1998). High effort, low reward and cardiovascular risk factors in employed Swedish men and women— Baseline results from the WOLF-Study. Journal of Epidemiology and Community Health, 52, 540–547.PubMedGoogle Scholar
  38. Peter, R., Alfredsson, L., Knutsson, A., Siegrist, J., & Westerholm, P. (1999). Is a stressful psychosocial work environment mediating the effects of shiftwork on cardiovascular risk factors in men? Scandinavian Journal of Work Environment and Health, 25, 376–381.Google Scholar
  39. Peter, R., & Siegrist, J. (1999). Chronic psychosocial stress at work and cardiovascular disease: The role of effort-reward imbalance. International Journal of Law and Psychiatry, 22, 441–449.PubMedCrossRefGoogle Scholar
  40. Peter, R., Siegrist, J., Hallqvist, J., Reuterwall, C., & Theorell, T. (2002) Psychosocial work environment and myocardial infarction: Improving risk estimation by combining two complementary job stress models in the SHEEP Study. Journal of Epidemiology and Community Health, 56, 294–300.PubMedCrossRefGoogle Scholar
  41. Pugh, H., & Moser, K. (1990). Measuring women’s mortality differences. In H. Roberts (Ed.), Women’s health counts (pp. 93–112). London: Routledge.Google Scholar
  42. Pugliesi, K. (1995). Work and wellbeing: Gender differences in the psychological consequences of employment. Journal of Health and Social Behavior, 36, 57–71.PubMedCrossRefGoogle Scholar
  43. Reuterwall, C., Hallqvist, J., Ahlbom, A., De Faire, V., Diderichen, F., Hogstedt, C., et al. (1999). Higher relative but lower absolute risks of myocardial infarction in women than in men: Analysis of some major risk factors in the SHEEP Study. Journal of Internal Medicine, 246, 161–174.PubMedCrossRefGoogle Scholar
  44. Rosenfield, S. (1989). The effects of women’s employment: Personal control and sex differences in mental health. Journal of Health and Social Behavior, 30, 77–91.PubMedCrossRefGoogle Scholar
  45. Siegrist, J. (1996). Adverse health effects of high-effort/low-reward conditions. Journal of Occupational Health Psychology, 1, 27–41.PubMedCrossRefGoogle Scholar
  46. Siegrist, J., Peter, R., Junge, A., Cremer, P. & Seidel, D. (1990). Low status control, high effort at work and ischemic heart disease: Prospective evidence from blue-collar men. Social Science & Medicine, 31, 1127–34.CrossRefGoogle Scholar
  47. Siegrist, J., Starke, D., Chandola, T., Godin, I., Niedhammer, I., & Peter, R. (2004). The measurement of effort-reward imbalance at work: European comparisons. Social Science & Medicine, 58, 1483–1500.CrossRefGoogle Scholar
  48. Statistics Sweden (1989). Occupations in the Population and Housing Census 1985 according to the Nordic standard occupational classification and the Swedish socioeconomic classification. Stockholm: Author.Google Scholar
  49. Statistics Sweden. (2004). Women and men in Sweden. Facts and figures 2004. Stockholm: Sweden.Google Scholar
  50. Theorell, T., & Karasek, R. (1996). Current methodological issues relating to psychosocial job strain and cardiovascular disease research. Journal of Occupational Health Psychology, 1, 9–26.PubMedCrossRefGoogle Scholar
  51. Theorell, T., Michelson, H., & Nordemar, R. (1991). Tre arbetsmiljö- index soma anväts i Stockholmsundersökening 1 [Three work environment indices which are used in the Stockholm study 1]. In M. Hagberrg & C. Hogstedt (Eds.), Stockholmsundersökningen 1 (Stockholm study 1). Stockholm, Sweden: Music Books: pp. 150–154.Google Scholar
  52. Theorell, T., Tsutsumi, A., Hallqvist, J., & The SHEEP Study Group. (1998). Decision latitude, job strain, and myocardial infarction: A study of working men in Stockholm. American Journal of Public Health, 88, 382–88.PubMedCrossRefGoogle Scholar
  53. van Vegchel, N., de Jonge, J., Bakker, A. B., & Schaufeli, W. B. (2002). Testing global and specific indicators of rewards in the Effort-Reward Imbalance Model: Does it make any difference? European Journal of Work and Organizational Psychology, 11, 403–421.CrossRefGoogle Scholar
  54. Waldron, I., & Jacobs, A. (1989). Effects of multiple roles on women’s health—Evidence from a national longitudinal study. Women and Health, 15, 3–19.CrossRefGoogle Scholar
  55. Wamala, S. (1999). Socioeconomic status and cardiovascular vulnerability in women. Psychosocial, behavioral and biological mediators. Unpublished thesis, Karolinska Institute, Dept. of Public Health Sciences, Division of Preventive Medicine, Stockholm, Sweden.Google Scholar
  56. Wamala, S. P., Mittleman, M. A., Horsten, M., Schenck-Gustafsso, K., & Orth-Gomer, K. (2000). Job stress and the occupational gradient in coronary heart disease risk in women. The Stockholm Female Coronary Risk Study. Social Science & Medicine, 51, 481–489.CrossRefGoogle Scholar
  57. Warnick, G. T. (1983). Colirometric assessment of high density lipoprotein cholesterol. In G. R. Cooper (Ed.), Selected methods of clinical chemistry (pp. 91–99). Washington DC: American Association for clinical chemistry.Google Scholar
  58. Westberg, H. (1998) Where are women in today’s workplace? In Å. Kilbom, K. Messing, & C. Bildt Thorbjörnsson (Eds.), Women’s health and work (pp. 27–57). Solna, Sweden: National Institute for Working Life.Google Scholar

Copyright information

© International Society of Behavioral Medicine 2006

Authors and Affiliations

  • Richard Peter
    • 1
  • Anne Hammarström
    • 2
  • Johan Hallqvist
    • 3
  • Johannes Siegrist
    • 4
  • Töres Theorell
    • 5
  • SHEEP Study Group
  1. 1.Department of EpidemiologyUniversity of UlmUlmGermanyGermany
  2. 2.Department of Public Health and Clinical MedicineUmea UniversitySweden
  3. 3.Department of Public Health Sciences, Division of Social MedicineKarolinska InstituteStockholmSweden
  4. 4.Department of Medical SociologyUniversity of DuesseldorfGermany
  5. 5.National Institute for Psychosocial Factors and HealthStockholmSweden

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