American J Industrial Med - 2024 - Schulte - An Urgent Call

DOI: 10.1002/ajim.
23583
COMMENTARY
An urgent call to address work‐related psychosocial hazards

and improve worker well‐being
Paul A. Schulte PhD1 | Steven L. Sauter PhD1 | Sudha P. Pandalai MD2 |

Hope M. Tiesman PhD3 | Lewis C. Chosewood MD4 | Thomas R. Cunningham PhD2 |
Steven J. Wurzelbacher PhD5 | Rene Pana‐Cryan PhD6 |
Naomi G. Swanson PhD | Chia‐Chia Chang MPH | Jeannie A. S. Nigam MS2
2 4
|
6 7 6
Dori B. Reissman MD | Tapas K. Ray PhD | John Howard MD
1
Advanced Technologies and Laboratories
International Inc., Gaithersburg, Abstract
Maryland, USA
Work‐related psychosocial hazards are on the verge of surpassing many other
2
Division of Science Integration, National
Institute for Occupational Safety and Health,
occupational hazards in their contribution to ill‐health, injury, disability, direct and
Centers for Disease Control and Prevention, indirect costs, and impact on business and national productivity. The risks associated
Cincinnati, Ohio, USA
with exposure to psychosocial hazards at work are compounded by the increasing
3
Division of Safety Research, National
Institute for Occupational Safety and Health, background prevalence of mental health disorders in the working‐age population.
Centers for Disease Control and Prevention, The extensive and cumulative impacts of these exposures represent an alarming
Morgantown, West Virginia, USA
4
public health problem that merits immediate, increased attention. In this paper, we
Office of the Director, National Institute for
Occupational Safety and Health, Centers for review the linkage between work‐related psychosocial hazards and adverse effects,
Disease Control and Prevention, Atlanta, their economic burden, and interventions to prevent and control these hazards. We
GA, USA
5
identify six crucial societal actions: (1) increase awareness of this critical issue
Division of Field Studies and Engineering,
National Institute for Occupational Safety and through a comprehensive public campaign; (2) increase etiologic, intervention, and
Health, Centers for Disease Control and
implementation research; (3) initiate or augment surveillance efforts; (4) increase
Prevention, Cincinnati, OH, USA
6 translation of research findings into guidance for employers and workers; (5)
Occupational Safety and Health, Centers for increase the number and diversity of professionals skilled in preventing and
Disease Control and Prevention, Washington,
addressing psychosocial hazards; and (6) develop a national regulatory or consensus
DC, USA
7
standard to prevent and control work‐related psychosocial hazards.
Occupational Safety and Health, Centers for
Disease Control and Prevention, Cincinnati, KEYWORDS
OH, USA
economics, mental health, occupational safety and health, psychological effects, work
organization
Correspondence
Sudha P. Pandalai, MD, 1090 Tusculum Ave.,
MS C‐15, Cincinnati, OH 45226, USA.
Email: Spandalai@cdc.gov
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
Published 2024. This article is a U.S. Government work and is in the public domain in the USA. American Journal of Industrial Medicine published by Wiley
Periodicals LLC.
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500 | COMMENTARY
1 | INTRODUCTION work stressors.”81 The relationship between work and mental health is
also bidirectional, where mental and physical health can influence work
Exposure to work‐related psychosocial hazards is projected to become a performance.82 The complexity of psychosocial hazards and mental
major occupational health and safety threat, with significant implications health associations present significant challenges for understanding
for workers, businesses, and the national economy.1–9 This threat may these relationships and addressing such hazards to mitigate the burden
affect many of the 169.6 million US workers by 2030 and result in and stigma of mental health outcomes in working populations.
adverse mental and physical health, leading to increased morbidity, Concerns over work‐related psychosocial hazards are compounded
mortality, and disability.10,11 In turn, these effects could have major by the increasing prevalence of mental health disorders in the
impacts on national, business, and worker economic circumstances.12 population.12 Seventy‐six percent of workers reported at least one
Given the growing evidence of the connections between work and symptom of a mental health condition, which increased by 17% in just 2
health outcomes, there is a pressing need to prevent work‐related years.83 Figure 1 conceptualizes a nested set of domains beginning with
psychosocial hazards and the adverse cognitive, emotional, behavioral, the US general population, proceeding to the US workforce, and
physiological, and economic effects associated with them.6,12–14 This progressing to those workers with work‐related psychosocial exposures.
paper is a commentary that describes the critical national problem of The smallest domain includes workers with adverse health effects from
exposure to psychosocial hazards and resultant adverse effects. The work‐related exposures. The intersection of the prevalence of mental
paper provides a narrative and nongraded summary of the scientific disorders across the nested population domains highlights that some
literature and identifies six societal actions that can help address the portion of adverse worker health effects are mental health in nature and
problem of work‐related psychosocial hazards. that some baseline of mental health conditions in a worker that might be
Work‐related psychosocial hazards are aspects of the design and observed in the general population could be relevant for health effects
management of work and its social‐organizational context that have associated with exposure to psychosocial hazards.
the potential to cause physical and psychological harm (Table 1).79 In the USA, for many reasons, the time is right to address
Beyond their effects on health, psychosocial hazards can impair psychosocial hazards more aggressively. First, the prevalence and
workers' ability to participate effectively in the work environment impact of psychosocial hazards in today's workplaces appear to be
and with other people in and outside of work.80 Table 2 presents a escalating.13,49,84 Second, the changing nature of work due to non‐
summary of the behavioral, mental, and physical health effects standard work arrangements and resultant precariousness of work
reported as being associated with work‐related psychosocial hazards. underpins the increase of adverse health effects.85‐87 Third, the
Exposure to work‐related psychosocial hazards is widespread, and, COVID‐19 pandemic increased awareness that work is a social
in Mental health at work: a review of interventions in organizations, Silvaggi determinant of health and that work‐related hazards can have a major
and Miraglia note that “the workplace can negatively affect work- impact on mental health.88‐92 Fourth, the scientific and public health
ers' mental health by intensifying an existing situation or contributing to communities are calling for an expanded focus for occupational
the development of mental health conditions via exposure to excessive safety and health (OSH) to address psychosocial hazards and
TABLE 1 Psychosocial aspects of work and related hazards.
Psychosocial aspects of work Associated psychosocial hazards
Job content Lack of variety or short work cycles; fragmented or meaningless work; under‐use of skills; high uncertainty;
continuous exposure to difficult clients, patients, pupils, etc.
Workload and work pace Work overload or too little work, machine pacing, high levels of time pressure, continually subject to tight
deadlines
Work schedule Shift work, night shifts, inflexible work schedules, unpredictable hours, long or unsociable hours
Control Low participation in decision‐making; lack of control over workload, pacing, shift working, etc.
Environment and equipment Inadequate equipment availability, suitability, or maintenance; poor environmental conditions such as lack of
space, poor lighting, excessive noise
Organizational culture and function Poor communication; low levels of support for problem solving and personal development; poor managerial
support; lack of definition of, or agreement on, organizational objectives
Interpersonal relationships at work Social or physical isolation, poor relationships with superiors, interpersonal conflict, lack of social support,
harassment, bullying, poor leadership style, third‐party violence
Role in organization Role ambiguity, role conflict, responsibility for people
Career development Career stagnation and uncertainty, under‐promotion or over‐promotion, poor pay, job insecurity, low social
value of work
Home‐work interface Conflicting demands of work and home, low support at home, problems relating to both partners being in the
labor force (dual career)
Source: Adapted from Mellor et al. (2011)169, Leka and Jain (2014),168 and Cox et al. (2005)21.
COMMENTARY | 501
T A B L E 2 Selected scientific literature describing the association between occupation, psychosocial hazards, and adverse behavioral, mental
health, and physical effects.
Effects Representative references
Absenteeism Dobson et al., 202015; Sitarević et al., 202316
Accidents EU–OSHA, 200717; Gomez‐Ortiz et al., 201818
Alcohol and drug use Richter et al., 202119; Virtanen et al., 201520
Anxiety Cox et al., 200521; Niedhammer et al., 202111; Harvey et al., 201722
Behavioral disorders Chamoux et al., 201823; Harvey et al., 201722
Burnout Maslach and Leiter, 201624; Schaufeli et al., 200925; Ahola et al., 200726; Kivimäki et al., 201227; O'Connor
et al., 201828
Cardiovascular disease Niedhammer et al., 202111; Pega et al., 202129; Kivimäki et al., 200630; Belkic et al., 200431; Kuper et al.,
200232; Schnall et al., 199833
Cigarette smoking Conway et al., 198134; van den Berge et al., 202135
Cognitive impairment Grzywacz et al., 201636; Elovainio et al., 200937; Peterson et al., 200838
Depression Niedhammer et al., 202111; Theorell et al., 201539; Leka, 2010; Cox et al., 200521; Mikkelson et al., 202140;
WHO, 202241; Rugulies et al., 202342; Madsen et al., 201743; Rugulies et al., 201744
Fatigue Åkerstedt et al., 200445; Tang et al., 201646; Jalilian et al., 201947
Health‐related quality of Ray et al., 202148; Bhattacharya and Ray, 202149; Ray et al., 201450
life (HRQL)
High blood pressure Schnall et al., 199833; Rosenthal and Alter, 201251
Migraine headache Wilkins and Beaudet, 199852; Urhammer et al., 202053; Magnavita, 202254
Mood disorders Lovelock, 20196; Netterstrøm et al., 200855; Woo and Postolache, 200856
Negative emotional reactions Jordan et al., 200257; West et al., 201658
Obesity Ostry et al., 200659; Kivimäki et al., 200360; van den Berge et al., 202135
Poor self‐reported health Stadin et al., 201961; Niedhammer et al., 202262
Posttraumatic stress disorder Spence Laschinger and Nosko, 201563; Nielsen et al., 201564; Rudkjoebing et al., 202065
Sickness Absence Kivimäki et al., 200360; Duchaine et al. 202066; Goorts et al., 202067
Sleep disturbance Rugulies et al., 200968; Peterson et al., 200838; Åkerstedt, 199569; Rudkjoebing et al., 202065
Stress reaction Nieuwenhuijsen et al., 201070; WHO 200371; van der Molen et al., 202072
Subjective well‐being decrease Ray, 202173; de Jonge et al., 200074
Suicide and suicidal ideation Niedhammer et al., 202111; Woo and Postolache, 200856; Milner et al., 201875; Aronsson et al., 201776
Work/family imbalance Hämmig et al., 201177; Jerg‐Bretzke et al., 202078
well‐being.3,9,80,83,93‐96 Fifth, the National Institute for Occupational 2 | BASIS F OR A CTION

Safety and Health (NIOSH) has established a foundational approach, Total
Worker Health®, focusing on the design and organization of work and In this paper, we call for action based on three questions: (1) How
nonwork factors that affect the well‐being of workers.97 This approach is strong is the link between exposure to work‐related psychosocial
a holistic perspective that focuses on how work affects overall health and hazards and adverse effects on workers? (2) How large is the
well‐being, including physical, psychological, social, and economic health and economic burden of these hazards and effects? (3)
98,99
aspects. Sixth, there are efforts to achieve parity between mental What can employers do to address work‐related psychosocial
and physical health in workers' compensation insurance coverage so that hazards? To answer these questions, we draw upon national and
the former is no longer treated as a “second‐tier” health condition.100 international research, authoritative policies and frameworks,
Finally, many countries and international organizations have developed and NIOSH guidance on reducing work‐related psychosocial
policies on psychosocial hazards,1,6,9,17,101‐103 though the USA has not. hazards.1,6,11,80,89,104,105 In the following sections, we present
For further information on mental health and well‐being in the workplace, our findings and conclude with a call to action which outlines six
see Supporting Information S1: SI 1. actions that may reduce psychosocial hazards at work and improve
502 | COMMENTARY
FIGURE 1 Conceptual map of the US burden of adverse effects from work‐related psychosocial hazards.
worker mental health and well‐being. We begin by discussing how One of the work‐related hazards with a significant body of
work affects well‐being. research is job strain. Job strain results from exposure to job stressors
such as the combination of work with high demands and low control.
Meta‐analyses have found job strain to be associated with a 23%
3 | THE LINK B ETWEEN WORK‐ R E L A T E D increase in CHD28 and a 30% increase in the risk of stroke.106
P S Y C H O S O C I A L H A Z A R D S AN D A D V E R S E Another systematic review of papers published between 1985 and
H E A L TH E FF E C T S 2014 found workers who reported job stressors, including job strain,
had an increased incidence of ischemic heart disease.107 In a meta‐
Harvey et al. (2017) conducted a systematic meta‐review of the analysis of European cohort studies Kivimäki and colleagues (2012)
literature on work and mental health conditions (depression, anxiety, found, after adjustment for sex and age, a hazard ratio of 1.23 (95%
22
and stress‐related conditions). The review found a moderate level CI: 1.10, 1.37) for CHD among those reporting job strain.27
of evidence for associations with health effects for work organization Workplace violence (WPV) is another psychosocial hazard that
variables, including high job demand, low job control, low workplace has been shown to negatively impact workers' physical and mental
social support, effort‐reward‐imbalance, low organizational proce- health. A recent systematic review of 24 studies found associations
dural justice, low organizational relational justice, organizational between WPV and poor mental health and psychological distress.65
change, job insecurity, temporary employment status, atypical work- The effects of WPV have been relatively well‐studied, particularly
ing hours, bullying, and role stress.22 In a more recent meta‐analysis, among healthcare providers. WPV is associated with adverse mental
Niedhammer et al. (2021) also found significant associations between health, depression, anxiety, posttraumatic stress disorder (PTSD),
job strain, effort‐reward imbalance, job insecurity, and long working burnout, sleep problems, increased use of antidepressants, and
hours with coronary heart disease (CHD), stroke, and depression.11 decreased job satisfaction and quality of life.65
COMMENTARY | 503
Psychosocial hazards are also associated with chronic and T A B L E 3 Estimated prevalence of work‐related psychosocial
traumatic injuries. A 2021 article identified 24 systematic reviews hazards in the United States in 2018 based on the Quality of Work
and 5 longitudinal studies and found evidence of generally consistent Life supplement to the General Social Survey.
findings for an association of job demands, job strain, effort/reward‐ Prevalence in

imbalance, and increased risk for workplace musculoskeletal dis- percentage
Psychosocial hazard Specific job characteristics (%)
orders, though the authors concluded there was insufficient evidence
linking psychosocial hazards with an increased risk for traumatic Job content Stressful work 29
108
injuries. However, other longitudinal studies have reported Does not allow to apply skills 7
significant associations between psychosocial hazards and increased Do not learn new things 7
risk for injury, especially among certain sub‐populations, such as
Face conflicting demands 23
older workers.109,110
The workplace psychosocial environment can influence worker Requires repeated heavy lifting 51
well‐being along multiple pathways. Most commonly cited are Workload and
psychophysiological effects of stress, which result from a chronic work pace
Not enough time to get 16
imbalance between work demands and ability to cope with those job done
demands111,112; from efforts to conserve resources113; and from Not enough people to get 25
imbalance of effort and rewards.114 Other cited research involves the job done
relationship between allostatic load—the physiological measure of Requires to work very fast 69
cumulative stress on the body leading to cardiovascular diseases—
Job demand interferes 43
and other health conditions.115 Sorensen et al. (2016) illustrated in a
family life
conceptual model that work‐related psychosocial factors may also
Work schedule
influence health and safety behaviors and engagement in workplace
health programs, and in turn, influence health and safety outcomes as Inability to take time off when 26
116 needed
well as enterprise outcomes (such as absences and turnover).
While the case that work‐related psychosocial hazards are causal Doing irregular or rotating 13
shifts
factors for adverse health effects is strongly supported in the
literature,11,117–119 there remains some concern over causality. Control
Critics argue that many of the studies are cross‐sectional and only Do not take part in decision‐ 24
describe associations. Also, conclusions are limited because of the making
use of self‐reported data. Although more recently, prospective Environment and
studies have been conducted on outcomes such as cardiovascular equipment
Lack of smoothness in the 21
disease and depression, self‐reporting is still an issue.40,120 However, running of workplace
causal inference always involves some level of judgment based on
Poor safety and health 5
integrating diverse types of evidence.121 When this is done, the
conditions
collective body of literature on work‐related psychosocial factors
Role in organization
suggests that controlling psychosocial hazards will prevent or reduce
adverse physiological and psychological outcomes such as those Does not have enough 5
information to do the job
shown in Table 2.11,17,87,91,122–124 We next examine the substantial
properly
burden and costs associated with work‐related psychosocial hazards.
Do not know what is expected 5
at work
4 | B U R D E N O F W O R K ‐R E L A T E D Career development
P S Y C H O S O C I A L H A Z A R D S AN D A D V E R S E Job insecurity 10
P H Y S I C A L A N D ME NT A L HE A L T H EF F E C T S Earnings not fair compared to 37
other workplaces
4.1 | Exposure to work‐related psychosocial Little chances of promotion 40
hazards
Interpersonal
relationships
Most workers have the potential to be exposed to some degree of No trust in management 17
at work
work‐related psychosocial hazards due to meeting expectations and Supervisor not helpful enough 12
deadlines, working or interacting with others, balancing work with life Not treated with respect 6
responsibilities, and coping with difficult work processes.6,9,117 Table 3
(Continues)
displays the estimated national prevalence of psychological hazards in
504 | COMMENTARY
TABLE 3 (Continued) 4.3 | Economic burden of work‐related

Prevalence in
psychosocial hazards
percentage
Psychosocial hazard Specific job characteristics (%) Goh et al. (2016) assessed direct US medical costs of exposure to 10
Discriminated for work‐related psychosocial hazards at $187 billion (in 2014 dollars).130
These stressors included unemployment, lack of health insurance,
Age 8
exposure to shift work, long working hours, job insecurity, work‐
Sex 6
family conflict, low job control, high job demand, low social support at
Race 6 work, and low organizational justice.130 The total cost, including
Harassed at work indirect and intangible costs from these exposures, was not assessed,
but if it had, it would likely be much higher.131 Exposure to work‐
Sex 3
related psychosocial hazards also results in the decline of non‐
Other 7
pecuniary economic outcomes such as workplace productivity and
Note: Obtained from General Social Survey (GSS), 2018—NIOSH Quality workers' health‐related quality of life. As one example, a study found
of Work Life (QWL) supplement. The sample data (N = 1413) is weighted
that workers exposed to precarious working conditions on average
to represent the US working population. The weights (WTSALL) are
provided by the GSS to account for the probability of selection, lose 0.4 healthy days and have 1.2 days of limited activity within a
subsampling and number of adults in the household. This helps to address 30‐day period.49 Further information on the economic burden of
the subsampling of certain demographic and geographical groups. To psychosocial hazards may be found in Supporting Information
know more, consult the GSS Codebook (https://gssdataexplorer.norc.org/
S1: SI 4.
gssweighting).
4.4 | Assessing the effects of psychosocial hazards

2018. Close to 30% of workers responded that they, either always or in workers' compensation claims
often, found their work stressful. Almost 70% agreed that they had to
work very fast, and 43% perceived that demand at their job interferes Workers' compensation (WC) systems provide limited but useful
with their family life. Approximately a quarter of workers believed they information on the adverse effects of psychosocial hazards, but
do not have any decision‐making power at work, and a similar considerations around compensability related to mental health
percentage reported an inability to take time off work when needed. conditions vary from state to state. Mental health conditions may
Another psychosocial hazard not included in the table is WPV. WPV appear in WC systems in three main ways.132 One is physical–mental,
appears to be increasing. Between 2015 and 2019, nonfatal WPV where a physical injury/illness leads to or exacerbates a mental health
events among workers increased by 25%.125 WPV can result in condition. Another is mental–physical, where a mental stimulus
physical, psychological, and financial costs to workers and their (psychological stressor) leads to or exacerbates a physical condition.
employers. See Supporting Information S1: SI 2 for further information A third is mental–mental, where a mental stimulus exacerbates a
on exposure to work‐related psychosocial hazards. mental health condition.
The physical–mental type comprises most mental health WC
claims132 since all states allow these types of claims. However, the
4.2 | Prevalence of adverse mental health effects proportion of physical–mental WC cases is difficult to pinpoint, since
these cases can only be identified through detailed claims review for
Depressive and anxiety disorders are among the leading causes of mental health diagnoses, treatments, and medications. Based on
disability burden worldwide. Prevalence estimates and resulting 2015–2017 private sector WC data from California, mental stress
disability are higher than most chronic diseases.126 More than 47% and mental disorder claims (where the primary coded nature of injury
of Americans are expected to be diagnosed with a mental health was mental‐related) represented 1.3% of all claims.95 By contrast,
127
disorder at some point in their lifetime. Therefore, it is likely that based on 2014–2016 private sector WC data from Tennessee, mental
most workplace managers, employers, and workers will engage with a stress and mental disorder claims represented only 0.09% of all
coworker with a mental health condition at work. Overall, 2.7% of claims.133 Although the frequency of mental–physical or
working adults experienced some form of serious psychological mental–mental WC claims is low, it is increasing in US states.95,132
distress.128 Daly, using data from the National Health Interview This may be due to an increase in state WC laws to cover these
Survey, concluded there has been an upward trend in reported claims.132,134 COVID‐19 has also increased the number of first
psychological distress among working people in the United States, responders, healthcare providers, and others reporting mental‐
129
increasing 40% over the period 1999–2018. See Supporting related claims, and there may be an increased awareness of mental
Information S1: SI 3 for background information on mental health health conditions among employers and workers.132,134 The cost for
disorders. claims is discussed in Supporting Information S1: SI 5.
COMMENTARY | 505
5 | WHAT CA N EMPLOYERS DO TO There are multiple approaches employers can take to mitigate work‐
ADDRESS WORK ‐R ELATE D P SYCHOSOCIAL related psychosocial hazards. These approaches can target the individual
HAZARDS? (e.g., health promotion and stress management programs) or the
organization (e.g., work redesign) and can be delivered at primary,
5.1 | The hierarchy of controls and work‐related secondary, or tertiary prevention levels (Table 4).136 The general approach
psychosocial hazards should start with applying primary prevention approaches at the broadest
levels. In the case of psychosocial hazards, this means interventions that
In OSH, the hierarchy of controls has been used to prioritize effective alter the work environment, rather than individually focused psychosocial
and sustainable control solutions.98 The hierarchy of controls has supports.1,138 Organizational‐level solutions approaches are likely to be
been adapted to reflect TWH principles and can serve as a framework more efficient, have a broader impact, and be more sustainable. In
98
for addressing work‐related psychosocial hazards. NIOSH recom- addition, primary prevention efforts benefit all workers, including those
mends applying the five levels of the hierarchy in the following order: unable to access individual services. For these reasons, organizational
interventions are the key recommended approach for improving
1. eliminate negative working conditions and barriers to safety, psychosocial working conditions in various countries.97,124,139
health, and well‐being; Next, we describe the evidence for both organizational and
2. substitute safer and healthier workplace policies, work processes, individually focused interventions that address work‐related psycho-
and practices; social hazards. It is suggested that comprehensive approaches, which
3. redesign the work environment to enhance working conditions include both organizational and individual‐level interventions, may be
and improve safety, health, and well‐being; the most impactful and sustainable.97,124,140
4. educate all employees and provide resources for improved
knowledge; and
5. encourage or reinforce adoption of safe and healthy practices. 5.2 | Effectiveness of organizational interventions
Workplace health and well‐being interventions can also be Aust et al. (2023) conducted a meta‐review of 957 studies and found
conceptualized as another hierarchy: primary (prevention and strong quality evidence for the effectiveness of organizational level
mitigation of risk), secondary (treatment or early intervention interventions focusing on “changes in working time arrangements”
following exposure), and tertiary (limiting further harms and rehabili- and moderate evidence for “influence on work tasks or work
tation to resume work).135,136 organization,” “healthcare approach changes,” and “improvements
TABLE 4 Model for categorizing workplace stress management preventive interventions.a,b
Level Primary preventiona Secondary preventiona Tertiary preventiona Outcome measuresc
Organizational Improving work content, Improving communication Vocational rehabilitation, Productivity, turnover,
fitness programs,b and decision‐making, outplacement absenteeism, financial claims
career development conflict management,
fitness programsb
Individual and Time management, Peer support groups, Posttraumatic stress Job stressors such as demands,
organizational improving interpersonal coaching, career assistance programs, control, support, role
interface skills, work/home planning group psychotherapy ambiguity, relationships,
balance change, burnout
Individual Pre‐placement medical Cognitive behavioral Rehabilitation after sick leave, Mood states, psychosomatic
examination, didactic techniques, relaxation disability management, complaints, subjective
stress management case management, experienced stress,
individual psychotherapy physiological parameters, sleep
disturbances, health behaviors
Source: Adapted from De Jonge and Dollard (2002)137 and Dinos et al. (2017).136
a
Primary prevention involves interventions to prevent causal factors of stress‐related symptoms at work. Secondary prevention involves interventions to
reduce the severity or duration of stress‐related symptoms. Tertiary prevention involves interventions to provide rehabilitation and maximize functioning
among those with chronic stress‐related or health conditions impacting work.136
b
Fitness programs could be a primary prevention strategy if they promote or maintain health to protect workers while doing their jobs. They could,
however, also be a secondary prevention strategy, for example, after illness or injury. Also fitness programs could be characterized as health promotion
programs. Having policies to support health promotion (e.g., providing opportunities to participate during work hours) would be an organizational‐level
intervention, while the program components themselves (e.g., employees using onsite exercise facilities; attending seminars) are more individual‐level
intervention approaches.
c
These are level‐specific outcomes. It would be possible to measure intervention outcomes across levels. The outcomes shown in the table are just the
most prominent examples of outcomes associated with different intervention levels/approaches.
506 | COMMENTARY
of the psychosocial work environment.”141 They also found strong approaches, as well as both primary and secondary approaches.152 In
quality evidence for interventions about “burnout (chronic or long‐ this systematic review, there was a promising number of interven-
lasting exhaustion related to work)” and moderate quality evidence tions designed to incorporate both primary and secondary prevention
for “various health and well‐being outcomes.” The meta‐review methods, with 32% of interventions employing hybrid designs.
concluded that while organization‐level interventions are still
relatively rare, there is growing evidence that they, especially when
combined with individual‐level interventions, can be effective in 6 | S O C I E T A L A C T I O N S TO AD D R E S S
promoting positive, healthy work.142,143 For further information on WORK‐ RELATED PSYCHOSOCIA L HA ZARDS
the effectiveness of organizational interventions, see Supporting
Information S1: SI 6. As illustrated in this paper, exposure to work‐related psychosocial
hazards and associated mental health outcomes on workers, employ-
ers, and society is growing and creating an urgent need for action. Six
5.3 | Effectiveness of individual interventions actions are recommended: (1) increase awareness of this critical issue
through a comprehensive public campaign; (2) increase etiologic,
Many recent approaches that address work‐related psychosocial hazards intervention, and implementation research; (3) initiate or augment
engage workers in various health promotion strategies. The rapid growth surveillance efforts (to better capture incidence, prevalence, and
of workplace health promotion (WHP) programs related to stress and costs of psychosocial hazards and their adverse effects); (4) increase
mental health conditions is indicative of this tendency to focus on translation of research findings into guidance for employers and
individual approaches to managing psychosocial hazards. A study of workers; (5) increase the number and diversity of professionals skilled
17,469 employed US adults from the 2015 National Health Interview in preventing and addressing psychosocial hazards; and (6) develop a
Survey found that 46.6% reported at least one WHP practice was national regulatory or consensus standard to prevent and control
available at their workplace, and among those, 57.8% participated.144 A work‐related psychosocial hazards.
common feature of WHP is engagement in physical activity, and reviews
indicate these interventions show promising results in reduced absentee-
ism and presenteeism.145 Individual interventions may also be easier to 6.1 | Increase awareness of this critical issue
implement than organizational interventions.136 through a comprehensive public campaign
While there is a significant body of literature to support the
effectiveness of individual approaches to managing psychosocial The extent, severity, and burden of psychosocial hazards on workers,
hazards, some qualifications to this observation should be noted.146 while known and addressed by some employers, is not acknowledged
First, a review of stress management interventions found little research or acted upon by others.82 For prevention and control of work‐
comparing the effectiveness of stress management interventions at the related psychosocial hazards to be prioritized, awareness needs to be
individual and organizational levels.146,147 Further reviews of individual‐ improved. Preventing them must become part of the organizational
level interventions have also noted that effects can be short‐lived or culture, similar to the way businesses acknowledge traumatic injuries
148,149
that data on long‐term effects are absent altogether. or chemical hazards. To influence the culture, a broad‐based
campaign led by a coalition of business, labor, insurers, government
agencies, and professional associations should be developed. The
5.4 | What is the most effective approach? campaign should popularize the burden of work‐related psychosocial
hazards, the means to address them, and models of successful efforts.
There is growing evidence to support a comprehensive approach in One recent step toward increasing awareness is the report by the
which integrated systems are developed that address all three Surgeon General on workplace mental health and well‐being.2
elements of prevention (primary, secondary, and tertiary) for work‐
related psychosocial hazards (Table 4).6,123,124,150 That is, the more
comprehensive an intervention may be, the greater the potential for 6.2 | Increase etiologic, intervention, and
impact.151 implementation research
Also, a recent meta‐analysis confirms that workplace resources
applied at the individual, group, leaders, and organization levels are While there is a rich body of research on work‐related psychosocial
123,150
each related to employee well‐being and performance. Other hazards and their adverse health effects, there are still knowledge
scholars have suggested that “approaches to workplace well‐being gaps on their etiology, interventions, and implementation.11,43,153
interventions that selectively cross‐fertilize and adapt elements of There is a rather consistent body of research that certain psycho-
health promotion interventions offer promise for realizing a broader social working conditions (job strain, effort‐reward imbalance, job
change agenda and for building inherently healthy workplaces.”135 insecurity, and long work hours) are strongly linked with adverse
Another recent systematic review has identified the most effective health effects. There is still a need, however, for a greater under-
approaches, including both organizationally‐ and individually‐focused standing of causality.154 The evaluation by Madsen and Rugulies
COMMENTARY | 507
(2021) shows modest pooled relative risks less than 2.0, so residual scientific literature to draw upon.82,123,124,140 “The lack of knowledge
confounding (a problem for observational studies with low relative may be due to a number of factors including that psychosocial
154
risks) could be an issue. Moreover, most studies include self‐ hazards are not tangible or easily observable and workplace
reported data and could therefore be affected by differential bias.154 psychological safety is a relatively new concept for some employ-
Further work, using job exposure matrices, will help mitigate ers.”82 Anger et al. (2015, 2019) found that there was a lack of
limitations of self‐reports of job demand and job control. dissemination and implementation of effective interventions.152,159
More intervention studies on the control of psychosocial hazards There is a need to translate and distill scientific information and make
are also needed. Evaluation of workplace interventions that improve it available to employers and workers. Concerted actions are needed
mental health is complex and requires sophisticated evaluation to get effective information to employers and increase the likelihood
designs”154 “Future research should use mixed methods to evaluate that they will use it.160
organizational interventions by addressing how different mechanisms
in specific contexts produce specific outcomes.”153 Research is also
needed on how risk assessments can be utilized to study psychosocial 6.5 | Increase the number and diversity of
142
hazards. While risk matrix approaches have been applied to other professionals skilled in preventing and addressing
work‐related hazards (e.g., nanoparticles, physical hazards), there is a psychosocial hazards
need to evaluate risk matrix approaches' utility and cost‐
effectiveness for exposure to psychosocial hazards.142 There is a lack of mental health literacy nationally and a shortage
of professionals who are knowledgeable about work‐related
psychosocial hazards. There are calls for training psychologists
6.3 | Initiate or augment surveillance efforts and occupational health professionals so that there are more
professionals in occupational health psychology (OHP), but the
The need for national surveillance of work‐related psychosocial response in terms of training new investigators and practitioners
hazards was recommended in a review of surveillance systems for has not been sufficient.161 There is a need for more emphasis by
155
psychosocial risks in 20 countries. The USA currently has limited government agencies, universities, professional associations, em-
surveillance of psychosocial hazards. Research and intervention ployers, and unions to increase the investment in training
priorities are driven by the extent to which the exposures and occupational health psychologists. There is also a need to bridge
effects can be surveilled and addressed nationally. There is also a OHP and occupational safety and health to support a more central
need for improved monitoring at the organizational level to drive role for OHP in the OSH field.161 Additionally, it is useful to
prevention and control programs for psychosocial hazards. expand the knowledge base of OSH. For example, the Australian
At the organizational level, important surveillance efforts are the Institute of Health and Safety has developed a core OSH body of
assessment of the workers' and employers' attitudes toward organiza- knowledge on psychosocial hazards for generalist OSH practition-
tional practices.140 There are existing tools such as the 2021 NIOSH ers.117 Also, the role of Employee Assistance Programs (EAP)
Worker Well‐Being Questionnaire, the Harvard “Thriving” question- needs to be expanded and modernized to make them more
naire, the NIOSH Quality of Worklife questionnaire, and others that can impactful, including having EAPs provide both individually focused
assess workers' concerns.156,157 Additionally, questions about work‐ services and organizational‐level interventions.162
related psychosocial hazards have been added to periodic occupational
supplements to the National Health Interview Survey to assess
population‐based prevalence (https://www.cdc.gov/niosh/topics/nhis/ 6.6 | Develop a national regulatory or consensus
default.html). The RAND Corporation has also sponsored an American standard to prevent and control work‐related
Working Conditions Survey (https://www.rand.org/pubs/research_ psychosocial hazards
briefs/RB9973-1.html). Data on work‐related psychosocial hazards
may also be found, to a limited extent, in the CDC Behavioral Risk The OSH Act of 1970 and the Federal Coal Mine Safety and
158
Factor Surveillance System. However, for more complete assessment Health Act of 1969 address the OSH of US workers. These standards
of the prevalence and incidence of work‐related psychosocial hazards were promulgated by the Mine Safety and Health Administration and
and their adverse effects, national surveillance systems should be the Occupational Safety and Health Administration (OSHA) generally
augmented. with input from NIOSH and others through criteria documents,
research, and testimony. Psychosocial hazards and effects are
mentioned in the OSH Act as “psychological factors” but with limited
6.4 | Increase translation of research findings into specifications or emphasis.163
guidance for employers and workers In developing a standard for work‐related psychosocial
hazards, it is useful to consider whether addressing these hazards
Many employers lack knowledge of their responsibility for, and how would be best served by following the past approach for standards
to control, work‐related psychosocial hazards, despite an adequate (e.g., a “specification” approach) or whether something different,
508 | COMMENTARY
TABLE 5 Examples of existing standards to address work‐related psychosocial hazards.
Place, date
Name of standard promulgated Description
Guidance on the management of psychosocial risks in United Kingdom, 2011 Voluntary – provides guidance and good practice on assessing and
the workplace (Leka et al., 2011)105 managing psychosocial risks at work.
National standard for Canada for psychosocial health Canada, 2013 Voluntary – focused on promoting workers' psychological health
and safety in the workplace (Can/CSA, 2013)102 and preventing psychological harm due to work‐related
factors.
Stress Check Program (Kawakami & Tsutsumi, Japan 2015 Mandatory national policy for monitoring and screening
2016)165 psychological stress in the workplace.
ISO 45003: Occupational health and safety at work – International, 2021 Voluntary consensus standard; Guidance on the management of
guidelines for managing psychosocial risks (ISO, psychosocial risks and promoting well‐being at work.
2021)103
Managing psychosocial hazards at work: code of Australia, 2022 Mandatory – code is intended to provide some practical guidance
practice (Work Health and Safety Commission, on how to comply with general language in the legal, standard
2022)166 imposed by law.
Note: See Cobb (2022)1, Jain et al. (2021),167 and Lovelock (2019)6 for a broader assessment of international regulations and guidance.
such as a “performance” approach should be considered.164 The A UT H O R C O N T R I B U TI O NS

variations in businesses and the subjective nature of some Paul A. Schulte conceived the paper, authored various sections,
psychosocial hazards and adverse effects may not readily lend organized and edited it. Steven L. Sauter participated in developing
themselves to the type of standards developed for chemical and overall concept and provided extensive input to all sections and general
physical hazards. Rather, a more general, performance‐focused conception. Sudha P. Pandalai participated in developing overall
process for work‐related psychosocial hazards may be more concept, provided overall assessments and editing, and authored
appropriate. section on burden. Hope M. Tiesman participated in developing the
Another issue is whether a standard should be legally binding or overall concept, contributed to the section on burden, edited and
voluntary (Table 5).168,169 The European Union has various work‐ revised the paper. Lewis C. Chosewood participated in developing
related, psychosocial standards and laws, some of which have been overall concept and provided significant editorial input. Thomas R.
168,169
implemented for more than 10 years. A voluntary workplace Cunningham participated in developing overall concept and authored
psychosocial standard has been in place in Canada since 2013.102 In interventions section. Steven J. Wurzelbacher participated in developing
2021, the International Organization for Standardization also overall concept and authored workers’ compensation section. Rene
published a voluntary global standard, which is being utilized by Pana‐Cryan participated in developing overall concept and provided
103
various organizations. The American National Standards Insti- economic and editorial input. Naomi G. Swanson: participated in
tute has adopted the ISO standard as a Nationally Adopted developing overall concept and provided editorial input. Chia‐Chia
International Standard.103 The USA could benefit by being consistent Chang participated in developing overall concept and provided editorial
with the global effort to address work‐related psychosocial hazards input. Dori B. Reissman participated in developing overall concept and
by developing a US‐initiated standard.1 provided editorial input. Tapas K. Ray participated in developing overall
concept, authored sections on economic burden, and provided editorial
input. John Howard participated in developing overall concept and
7 | C ONC LUS I ON S provided significant editorial input.
There is compelling evidence that workers are increasingly being ACKNOWLEDGME NT S

exposed to work‐related psychosocial hazards resulting in harmful The authors appreciate comments by Leslie B. Hammer, PhD, Ron
health and economic effects to them, their companies, their Goetzel, PhD, Jonathan L. Steinberg, PhD, and Ellen P. Cobb, JD, on
communities, and to nations. Action needs to be taken to reverse earlier versions of this manuscript. The authors are grateful for significant
83
this trend. In this paper, evidence for these hazards is reviewed, and editorial guidance and comments from Ms. Mary Beth Bohman (CDC/
six remedial actions that may ameliorate a growing and significant NIOSH). All errors are solely those of the authors. The authors thank
public health problem are presented. When done comprehensively, Jeffrey Jacobson, Antje Ruppert, and Emma McAvoy for technical
preventing and addressing work‐related psychosocial hazards will support. All work was conducted under the auspices of the National
help protect workers and promote work as a means to achieving Institute for Occupational Health and Safety (NIOSH). P. A. S. and S. L. S.
greater health and well‐being for all. work for Advanced Technologies and Laboratories International, Inc. and
COMMENTARY | 509
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Saf Sci. 2011;49(7):1040‐1046. doi:10.1016/j.ssci.2011.01.010
et al. An urgent call to address work‐related psychosocial
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S UP P O R T I N G I N F O R M A T I O N 2024;67:499‐514. doi:10.1002/ajim.23583
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An urgent call to address work‐related psychosocial hazards

Paul A. Schulte PhD1 | Steven L. Sauter PhD1 | Sudha P. Pandalai MD2 |

Am J Ind Med. 2024;67:499–514. wileyonlinelibrary.com/journal/ajim | 499

TABLE 1 Psychosocial aspects of work and related hazards.

Psychosocial aspects of work Associated psychosocial hazards

Role in organization Role ambiguity, role conflict, responsibility for people

Effects Representative references

Absenteeism Dobson et al., 202015; Sitarević et al., 202316

Accidents EU–OSHA, 200717; Gomez‐Ortiz et al., 201818

Behavioral disorders Chamoux et al., 201823; Harvey et al., 201722

Negative emotional reactions Jordan et al., 200257; West et al., 201658

Poor self‐reported health Stadin et al., 201961; Niedhammer et al., 202262

Subjective well‐being decrease Ray, 202173; de Jonge et al., 200074

Work/family imbalance Hämmig et al., 201177; Jerg‐Bretzke et al., 202078

well‐being.3,9,80,83,93‐96 Fifth, the National Institute for Occupational 2 | BASIS F OR A CTION

findings for an association of job demands, job strain, effort/reward‐ Prevalence in

TABLE 3 (Continued) 4.3 | Economic burden of work‐related

4.4 | Assessing the effects of psychosocial hazards

TABLE 4 Model for categorizing workplace stress management preventive interventions.a,b

Level Primary preventiona Secondary preventiona Tertiary preventiona Outcome measuresc

TABLE 5 Examples of existing standards to address work‐related psychosocial hazards.

such as a “performance” approach should be considered.164 The A UT H O R C O N T R I B U TI O NS

There is compelling evidence that workers are increasingly being ACKNOWLEDGME NT S

169. Mellor N, Mackay C, Packham C, et al. ‘Management Standards’ and

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