Chapter 7.
Working Conditions, the Work Environment
and Health
Örjan Hemström1
1 The National Institute for Working Life, SE-112 79 Stockholm, Sweden. Tel: + 46 8 730 93 96. E-mail: orjan.hemstrom@niwl.se
Scand J Public Health 2001; Suppl 58: 167± 184
Key words: Work and public health, working life, work environment, work-related disease, occupational ill-health.
E More than 70% of gainfully-employed people in
Sweden are by and large very satis® ed with their work
even though developments in working life are often
described as negative. At the same time the number
who feel averse to going to work has increased.
E The majority of physical and chemical/physical
work-environment exposure did not change during
the 1990s. The use of computers increased, however,
and passive smoking decreased.
E Blue-collar workers are still the most exposed to
physical loads. For women, the proportion with
heavy lifting increased in the ® rst half of the 1990s,
both for skilled blue-collar workers and for lower-
and middle-level white-collar workers. After 1995,
however, the proportion needing to lift heavy
weights in their jobs decreased for almost all groups.
E Otherwise, there appears not to have been any
levelling between classes as regards ergonomics
(uncomfortable work postures, etc).
E Concerning monotonous jobs and physically tiring
jobs there have been no real changes. Work involv-
ing high demands and little in¯ uence (tense work)
increased somewhat between 1995 and 1997.
E Fatal occupational accidents have declined during
the past thirty years.
E Absence on sick-leave for at least 30 days declined
before 1997 but has since increased, for women to
a higher level than in 1992. This is probably chie¯ y
because the proportion of older people among the
gainfully-employed has increased.
E Actual time worked increased from 1995 to 1999 for
women by an average of one hour a week. For
60± 64-year-olds of both sexes, however, it increased
by 2.5 hours a week.
E The new working life demonstrates an increased ele-
ment of just-in-time employment. Flexi-time and
freer contracts of employment are becoming more
common. Distance work is not becoming more
common.
Ñ Taylor & Francis 2001. ISSN 0301-7311
E The general level of vocational quali® cations is
slowly rising.
E Computer work is increasing. Sixty-three per cent
of women and 68% of men use computers in their
work.
E Work-pace and time pressure continue to grow.
Stressed work increased continuously during the
1990s, particularly among women. Almost 70% of
the gainfully employed had such jobs in 1997/98.
The proportion who work overtime increased
somewhat.
E The health lead enjoyed by the gainfully employed
is shortening. Self-assessed health deteriorated more
among those in work than among those out of work,
particularly after 1993.
E Worry, anxiety and fatigue have increased appre-
ciably since the end of the 1980s among both those
in work and those who are openly unemployed.
Worry and anxiety increased most, however, among
the unemployed.
E For municipal and county-council employees both
work environment and well-being developed in a
markedly negative direction during the 1990s. This
applied specially to teachers and health care and
nursing staV.
The Work Environment Can
AVect Health and Survival
This chapter treats both positive and negative aspects
of working conditions, the work environment and
health. Changes in the work environment during recent
years and their possible connections with changes in
public health are discussed. Many of the results given
are from the anthology Arbetsliv och haÈlsa 2000
( Working Life and Health 2000) (1). The statistical
material is chie¯ y Work Environment Surveys ( 2) from
Scand J Public Health 29 (Suppl 58)
168 O. HemstroÈ m
The National Board of Occupational Safety and Health
and Statistics Sweden (SCB), and the latter’s Surveys
of Living Conditions.
Factors in the work environment can contribute to
systematic diVerences in health between employees in
diVerent occupational classes (3± 5) or between men
and women (6). Occupational role is important for the
development of one’ s identity and one’ s self-esteem.
Exposure to diVerent work tasks is protracted in
terms of years, often repetitive and often very speci® c.
High occupational specialisation leads to large work-
environment diVerences between occupations.
The structure of occupation is changing
The structure of occupation is changing slowly in ways
that will be of signi® cance for what work environment
factors are common or uncommon at any given time.
A 100-year perspective shows how certain occupational
tasks have been eliminated through rationalisation
based on new technology. This applies chie¯ y to bur-
densome jobs in agriculture and forestry. At the same
time the working day and the working week have
gradually become shorter, vacation weeks have been
introduced, pensionable age has been lowered, etc.
These changes indicate that leisure time has increased
in relation to gainful employment. For women the
changes have been diVerent, when they have done a
great deal of unpaid work in the home. But this, too,
has been made easier through technical innovations
(7). In 1990/91, gainful employment represented about
25% of men’ s and 16.5% of women’ s total weekly time
among 20± 64 year-olds (8). During the past twenty
years it is probable that working time has hardly
shortened, if we except periods of raised unemployment
in the early 1990s. In a longer perspective, however,
women have paid employment to a greater extent.
Occupational structure sometimes also changes over
a shorter time. Between 1995 and 1999 the proportion
of women in health care and nursing decreased by 2.6
percentage units. For men, agriculture, forestry and
® shery, and manufacturing and construction, together
decreased to a corresponding extent ( Table 7:1). These
may be seen as relatively large changes over such a
short time. The only sector that has increased appre-
ciably is ® nancial activity and company services.
Men and women have very diVerent types of occupa-
tion. This gender-segregation is of long historical con-
tinuity (7) and may in itself increase the risk of ill-health
among men and women working in gender minorities
(6). In 1999 work in primary industry, manufacturing
and construction was over three times more common
for men (41%) than for women (13%). Health care and
nursing is dominated even more by women. Jobs here
Scand J Public Health 29 (Suppl 58)
are more than seven times more common among gain-
fully-employed women (35%) than among men (5%),
while work within education or research is more than
twice as common among women as among men.
Personnel strengths in care and nursing declined
during the ® rst part of the 1990s both in number and
as a proportion of the gainfully employed (11). The
probable consequence is that unpaid health care and
nursing, mostly performed by women (12), increased
by the same amount as tax- and fee-® nanced care
declined during the whole of the 1990s. More than one-
third of gainfully employed women were working in
health care and nursing in 1999. Their total workload
and that of other gainfully employed women may thus
have increased by the volume of care that has been
dismantled/rationalised out of existence.
Gainful Employment Cuts
Both Ways
In recent years the media have reported on increased
stress in working life. In the previous National Public
Health Report, descriptions of the changes in work-
ing life during the ® rst half of the 1990s predom-
inated. The proportion of gainfully employed people
of working age decreased, worry about losing jobs
increased, many of the gainfully employed had got
more to do and were ® nding it more diYcult to relax
during their free time. Negative stress in working life
was on the increase ( 13). A larger element of organis-
ational change presumably also has negative eVects on
the work environment and the health of the gainfully
employed (14). What genuine consequences have these
changes had on work environment and health state? Is
``occupational stress’ ’ negative or positive? Research
on working life and health ® nds it hard to establish
the connections, since the gainfully employed appear
to enjoy better health than those who have no work
and thus avoid the stress and loads of working life.
The economic conditions for people without jobs have,
however, worsened in relative terms since the start of
the 1990s owing to cut-backs in the welfare systems.
Particularly young people, immigrants and single par-
ents were severely aZicted during the 1990s by unem-
ployment and economic poverty (15). For those
without a paid job (16) economic stress may be more
negative than the demands and loads to which the
gainfully employed are subjected. As a contrast to
negative descriptions of developments in the working
environment during the 1990s, a surprisingly large
majority of the gainfully employed in Sweden are on
the whole very content with their jobs. The largest
proportion of the very dissatis® ed is among fairly
 Working Conditions, the Work Environment and Health 169

Table 7:1. The structure of economic sectors in Sweden in 1999 for men and for women. Percentage of gainfully-employed and
change 1995± 99

Men Women

Change Change
Sector 1999 1995± 1999 1999 1995± 1999

Agriculture, forestry, ® shery, manufacturing, extraction of minerals, energy 41 Õ 2.4 13 Õ 0.5

production; construction
Trade and communications 23 0.6 15 Õ 0.6
Finance, business services 14 2 11 1.5
Education and research 6 0.1 12 0.9
Care and nursing 5 Õ 0.1 35 Õ 2.6
Personal and cultural services, waste disposal 7 0.1 9 0.8
Public administration etc 5 Õ 0.2 5 0.4
Total 100 100

Source: Labour Force Surveys (9,10).

young men, but even here they represent only just
under 15% ( Table 7.2).
That gainful employment can protect one against ill-
health is scarcely a new notion. Regarding women’ s
increased gainful employment, discussions as to
whether paid work is a health factor or a risk factor
have been lively. Most studies have found that gainfully
employed women have lower mortality than those who
work in the home (17). Some authorities, however,
consider that it is better to study other indicators of
health, chie¯ y mental well-being: women with two jobs
experience a particular form of stress from the com-
bination of unpaid work in the home and paid emp-
loyment (18, 19). Double work probably involves
increased diVerences in health between men and women
irrespective of whether they have the same working
environment in their paid employment. One con-
sequence may be that women become more vulnerable
through working overtime or through increasing their
time in paid work, since this can increase their total
work load. Many women also have low salaries and in
many respects ``worse’ ’ jobs than men. Unpaid work
in the home may for this reason also protect people
against ill-health since it may involve relative improve-
ment of the work environment for some women with
particularly unrewarding and exhausting jobs (20). On
the other hand, there is a weakening of social support
and the working-community spirit experienced by most
of the gainfully employed. This is often oVered as an
explanation for why unpaid workers in the home have
worse health than wage-earners ( 21). Only small pro-
portions of employees in diVerent socioeconomic
groups lack support and encouragement from work-
mates ( Table 7:3). On the other hand half of male and
40% of female self-employed people ( largely without
employees of their own) lack this positive factor in
their daily work. Larger proportions of women (87%)
than men (79%) consider that they get support and
encouragement from workmates and colleagues. This
is least common among older men (72%).
In sum, a large majority of the gainfully employed
are very satis® ed with their work despite the present
negative descriptions of how working life is develop-
ing. Most get support and encouragement from their
Table 7:3. Proportion of gainfully-employed people (%) who
cannot get support or encouragement from workmates or
colleagues, 1999

Women Men
Table 7.2. Proportion of gainfully-employed people (%) who
are on the whole very satis® ed, or very unsatis® ed, respectively,
Unskilled blue-collar 12 18
with their work, 1999
Skilled blue-collar 7 15
Lower white-collar 14 19
Very satis® ed Very dissatis® ed
Middle white-collar 11 18
Upper white-collar 17 19
Men Women Men Women
Self-employed 40 51
16± 29-year-olds 69 69 15 12 16± 29-year-olds 10 11
30± 49-year-olds 70 72 10 9 30± 49-year-olds 13 20
50± 64-year-olds 76 75 6 6 50± 64-year-olds 15 28
Total 71 72 10 9 All 13 21

Source: (2). Source: (2).

Scand J Public Health 29 (Suppl 58)

170 O. HemstroÈ m
colleagues, the exception being certain self-employed
people. The social importance of gainful employment
as a promoter of health indicates that public health is
probably favoured by as many as possible being gain-
fully employed.
The quali® cation level is rising
The proportion of gainfully employed people declined
strongly because of unemployment during the ® rst half
of the 1990s and then remained at what for Swedish
conditions was a historically low level. The lowest level
appears to have been reached in 1997 (22). This all-
time low applies to men: women’ s development is
diVerent. Only just over half of women aged 20± 64
were gainfully employed as late as in 1970 ( 23). Their
employment rate subsequently increased continuously
± a trend which, however, was broken at the beginning
of the 1990s.
Between 1995 and 1999 gainful employment
increased somewhat among men particularly 20±
34-year-olds and 55± 59-year-olds ( Figure 7:1). For
women there were no overall changes but employment
increased among the 16± 19 and 55± 59-year-olds by 2.3
percentage units and 2.8 percentage units, respectively.
Among foreign citizens, gainful employment increased
by almost eight percentage units, but nevertheless in
1999 only just over half of these were gainfully
employed. The diVerence between men and women in
proportions of employed people increased somewhat
at the end of the 1990s (from a 2.6-percentage-unit
diVerence in 1995 to a 3.9 diVerence in 1999). One
cause was the staV reductions in the predominantly
female public sector after 1995, while predominantly
male private activities recovered somewhat. A ``new’’
group experienced great diYculties in obtaining work
when the competition for jobs increased during the
1990s, namely single parents with children (chie¯ y
women). Their unemployment tripled from just over
10% in 1990 to about 31% in 1997 (15).
Another long-term trend that continued during the
1990s is that the average level of quali® cations slowly
rose. The proportion of occupational categories with-
out training requirements is declining, as is the pro-
portion of lower white-collar workers, while the
proportions with white-collar occupations at middle
level and above is increasing. The relative increase has
taken place in those groups that have traditionally had
better health than others and women’ s proportion, par-
ticularly, has increased in these white-collar occupa-
tions (4). A quarter of the gainfully employed are still,
however, unskilled blue-collar workers, and this pro-
portion has not decreased since 1995 (22). A question
that has been discussed is whether work environment
Scand J Public Health 29 (Suppl 58)
factors that characterise many blue-collar occupations,
e.g. physically demanding work, are decreasing at the
same time as the average level of quali® cation is
increasing; or whether the white-collar groups are
taking over some of these physically demanding tasks
from unemployed previously blue-collar workers (15).
Yet we should expect that the rise in quali® cation level
will have a positive eVect on public health.
While the proportion in gainful employment is
increasing and the level of quali® cation is rising there
are tendencies towards negative development of gainful
employment. The proportion of the employed who feel
some aversion to going to work increased disquietingly
between 1995 and 1999, from 13% to 18% among men
and from 14% to 18% among women (2).
Occupational Ill-health
Large health diVerences between groups
of gainfully-employed people and others
Among the gainfully employed and those who are not
there are appreciable diVerences between socioecon-
omic groups in how general health states are assessed
( Table 7:4). For one thing, long-term unemployed
women felt that their health was better than skilled
female commodity?? workers’ . The former reported less
good health three times more often and the latter four
times more often than white-collar workers at middle
level. Female lower white-collar workers or those with
other blue-collar occupations, had less good health to
at least twice the extent that white-collar workers at
middle level did. Among men the variations in health
between the groups were smaller than among women.
Certain occupations thus appear to be linked with
greater risks of ill health. This is particularly evident
for blue-collar women in production jobs with a pre-
dominance of men and for men and women at the
lowest white-collar level.
Only those on early retirement have abundant ill-
health, women 25 times as much and men 11 times as
much as white-collar workers at middle or upper level.
It is impossible to say with any certainty how large a
proportion of those on disability pension developed
impaired health owing to shortcomings in their work
environment, harassment etc. We know that disorders
of the locomotive organs plus mental illness and symp-
toms together caused 78% of women’ s early retirement
and 57% of men’ s in 1999. Earlier unfavourable work
environments, chie¯ y in blue-collar occupations, prob-
ably caused the majority of locomotive disorders. For
the mental symptoms the contribution of the work
 Working Conditions, the Work Environment and Health 171

Per cent
14

12

10

-2

-4
16± 19 20± 24 25± 34 35± 44 45± 54 55± 59 60± 64 16± 64
Age

Men Women Foreign nationals

Fig. 7:1. Changes in proportions of employed persons from 1995 to 19991 among men, women and foreign citizens in diVerent age groups.
Source: (9, 10).
1
In 1999 the proportion of employed people between 16 and 64 years was 74.8% for men, 70.9% for women and 52.5% for foreign nationals.

Table 7:4. Relative diVerences in self-assessed general health which the Swedish initials are ISA. There is a large
``worse than good’’ for men and women aged 20± 64 years number of unrecorded cases here and current practice
in some socioeconomic groups. Middle- and upper-level
white-collar workers form comparison group (value= 1),
may change rapidly. The proportion of approved
age-standardised applications sank from 80% at the end of the 1980s to
about 40% in the middle of the 1990s. In addition, the
Men Women law was changed in 1993 ( 24).
The readiness to notify is aVected by changes in the
Odds ratios Odds ratios
regulations, and hence statistics for work-related dis-
Unquali® ed service workers 1.8 2.3 eases are not reliable as a measure of the health of the
Quali® ed manufacturing workers 1.8 4.2 gainfully employed. What they do show is that the
Lower white-collar 2.2 2 incidence of noti® ed work-related disease hardly
Middle & upper white-collar 1 1 changed after 1993 (3± 4 per 1,000 gainfully employed )
Disability pensioners 11 25
while it was signi® cantly higher between 1985 and 1993
Unpaid work in the home 3.5 3.1
Long-term unemployed people 2.7 3.1 (7± 17 per 1,000 gainfully employed ).
Yet there have been some interesting changes in the
Source: (4). reasons for work-related disease during the past few
years. Requirements for what can be accepted as a
environment is probably considerably smaller. For work-related disease have become more stringent, yet
both sexes alcohol and drug abuse play a part and this the number of noti® ed cases of ostracism and harass-
may have started before they entered the labour ment has grown from about 300 (1996) to 500 (1998)
market. for women and from about 75 to 175 for men (25).
The largest increases are in predominantly female
occupations such as care, nursing and the school.
Victimisation by one’ s superiors or in connection with
Statistics on work-related disease
reorganisations is given as the most common cause,
Our knowledge on the exact causal chain of many but harassment by clients also occurs. Of the work-
diseases is lacking, and it may be hard to decide related diseases caused by stress, mental strains or har-
whether a disorder is directly work-related. Occu- assment only about 8% are noti® ed while about 48%
pational diseases are de® ned in such a way that the of occupational accidents leading to contact with a
work environment is of decisive importance for their physician doctor are noti® ed (24). This indicates that
origin. Occupational diseases must be reported to the the number of unrecorded cases may be large, particu-
Information System for Occupational Injuries, for larly within occupations where women predominate.

Scand J Public Health 29 (Suppl 58)

172 O. HemstroÈ m
Accidents at work
Workplace accidents2 with fatal outcomes declined
between 1970 and 1999 except for 1985 to 1990 (26).
Almost only men die in accidents at work, most com-
monly in the age group 55 to 64 years. Particularly
susceptible are agricultural workers, forestry workers,
woodcutters, ® shermen, panel beaters, machine oper-
ators, constructional machinery drivers and recycling
plant employees. The excess risks in these occupations
are high over time. On the other hand, the risk groups
have become somewhat smaller since at least four of
them belong to economic sectors which are shrinking
( Table 7:1).
The number of people reporting occupational acci-
dents leading to at least 30 days’ sick-leave did not
show the same positive trend during the 1990s as the
number of fatal accidents did. A period of decline for
both sexes (1986± 1995) was followed in 1996 by a
weak but disquieting rise in these accidents (26). More
pressure at work, more elderly employees, an improved
labour market and increased levels of compensation
for sick-listing are being discussed as possible reasons
for the increase in the past few years in occupational
accidents with long sick absence.
Disorders of the locomotive organs
Disorders of the locomotive organs are an important
cause of prolonged pain and impairments. For this and
for social-economic reasons, it is of great interest to be
able to prevent them. Lower-back, neck, shoulder,
arm/hand, hip and knee pain is common in this group
of disorders. For some complaints speci® c risk factors
have been found in the work environment. For
example, the use of hand power tools (exposure to
vibration) is connected with injuries to nerves and
blood vessels and may lead to impaired feeling and the
carpal tunnel syndrome. Whole-body vibration, high
exposure to twisted work postures and heavy lifts are
particularly related to disorders of the lumbar back.
Hip arthrosis is common among agricultural workers
but it has not been established which particular work
items increase the risk of this (24, 27).
Disorders of the locomotive organs are the dominat-
ing reason for disability pension among both sexes. In
1999 they underlay 31% of men’ s and 45% of women’ s
newly granted disability pensions (28). Groups with
much heavy lifting and other ergonomic loads in their
occupations, blue-collar workers of both sexes and self-
employed males ( Table 7:5) receive disability pensions
more than middle and upper white-collar workers do
2
Workplace accidents are also dealt with under Occupational
accidents in chapter 3.
Scand J Public Health 29 (Suppl 58)
(4). That more male lower white-collar workers do this
almost certainly has other causes than physical load.
Such drawbacks, however, are not the only causes
of locomotive disorders. Psychosocial factors such as
low job satisfaction are also associated with these
disorders (27).
Computer use is also considered able to lead to
locomotive complaints. From 1992 to 1998 the pro-
portion of noti® ed load disorders in which work
with computer equipment was speci® ed as the cause
increased from 6% to 12% for women and from just
under 1% to 4% for men (29). Trouble from the
lumbar back, neck/upper back, shoulders/arms and
wrists/hands is more common among oYce workers
who spend at least three-quarters of their working time
in front of a computer than among those who only
spend one-quarter of their time in this way. The fre-
quency of this trouble is greatest among those with
monotonous entry work. About half the women doing
entry work have problems with the neck, back, shoul-
ders, arms and/or hands at least one day per week.
Among male oYce workers with entry work the pro-
portion is a few percent lower. The proportion with
such trouble did not change substantially, however, in
groups diVerently exposed during the years this was
studied (1989± 1997). The general trend towards more
use of computers is increasing the importance of pre-
venting such complaints, e.g. correctly organised work
places. Women are more in the risk zone than men,
partly because oYce work is commoner among women
and partly because women more often have e.g. mono-
tonous entry work. The psychosocial work climate also
appears signi® cant. Both male and female computer
users with poor social support or with work tasks
combining poor control with high mental demands
include particularly high proportions with locomotive
problems (29).
Skin diseases
Skin diseases constitute a relatively large proportion
of work-related diseases but the number noti® ed to
work-injury statistics has more than halved, from
2,000± 3,000 cases per year in the 1980s to way below
1,000 (30). About 90% of the skin diseases caused by
environmental factors at work are hand eczema.3
Women, chie¯ y aged 19± 49 are particularly vulnerable.
Hand eczema often involves long periods of sick-leave
and worsened quality of life in the form of sleep dis-
turbance and altered social relations. In occupations
where wet work, cleansing agents and particularly aller-
genic substances such as natural rubber, hand eczema
is common. The proportion reporting skin diseases at
3
See also chapter 3 on allergies.
 Working Conditions, the Work Environment and Health 173

Table 7:5. Relative diVerences in the prevalence of pain, exhaustion/tiredness and worry among groups of gainfully-employed
people. Comparison groups= 1. The in¯ uence of the factors age, country of birth, being a single parent, socioeconomic group
and other factors in the table has been eliminated

Pain Tiredness/exhaustion Worry

Men Women Men Women Men Women

Temporary employment/permanent employment 0.65* 0.98 0.72 0.89 0.52* 0.82

Public employment/private employment 0.66 1.34 0.96 1.27 1.29 1.44
Municipal employment/private employment 1.42* 1.12 1.42* 1.19 1.53* 1.33*
Exposed to work environment/unexposed
High mental demands+ low control 1.74* 1.70* 2.41* 2.24* 2.86* 2.96*
Ergonomic loads 2.15* 2.28* 2.26* 2.41* 1.37* 1.64*
Dust 1.90* 2.09* 1.33 2.36* 1.47* 1.15
Chemicals 1.61* 1.33 1.80* 0.96 1.63* 1.48
Heavy lifts 1.59* 1.53* 2.08* 1.75* 1.24 1.48*
Threat of lay-oV/no threat of dismissal 1.38* 1.14 1.96* 1.45*
Subsidiary occupation/no subsidiary occupation 1.04 1.33* 1.86* 1.56*

* p<0.05.
Source: Work Environment Survey 1997 (36).

work is highest among dental employees (chie¯ y dental
nurses). Contact with plastic substances in tooth ® lling
material and natural latex rubber in protective gloves
is the chief cause. Second in the statistics come workers
in chemical processing and rubber and plastics manu-
facture (31). Hairdressers, nurses, machine ® tters,
cooks, cold buVet staV, cleaners and kitchen staV are
groups with a much elevated risk of hand eczema (32).
Around 45% of all gainfully employed women work in
the care and service sectors, with elements of handling
where the risk of skin trouble is great. That these
occupations moreover are very labour-intensive makes
it particularly important to prevent skin diseases (30).
Cardiovascular diseases
Many cardiovascular diseases, particularly myocardial
infarction, are strongly related to high age and are rare
below 35 years. Myocardial infarctions have decreased
appreciably in a number of countries and in Sweden
particularly among middle-aged men (around 45± 64
years) since 1980. The work environment can contrib-
ute to a portion of cardiovascular cases. Around 15%
of myocardial infarctions in people of working age
may be work-related. Factors in the work environment
that have links with myocardial infarction are tense
work (high mental demands and small decision latit-
ude) imbalance between level of eVort and reward com-
ponents (if the level of eVort at work is not rewarded ),
sedentary work, exposure to noise, carbon monoxide,
passive smoking, carbon disulphide, lead, cobalt and
arsenic (33). In a Swedish study, shift work was related
to myocardial infarction, particularly in the age group
45± 55 years (34).
An issue that has been studied surprisingly little is
whether long working hours and overtime work is
connected with cardiovascular disease. A Japanese
study revealed a signi® cant U-shaped connection
between working time and myocardial infarction for
men (35). Those who worked at least 11 hours a day
ran a 2.4-times-higher risk than men with an average
length of working day. Those who worked few hours,
however, ran an even higher risk of myocardial infarc-
tion (3.1 times higher).
It is hard to say how this should be interpreted. It
seems at ® rst hand that a reasonable amount of gainful
employment prevents rather than causes myocardial
infarction. If an increasing proportion of gainfully
employed people work much overtime in the future
this can lead to a negative development with more
myocardial infarctions as a consequence.
In 1999 38% of men and 29% of women in Sweden
stated that they worked overtime at least one day a
week, an increase since 1997 by 5 percentage units
among women and by two among men (2). For women
the rise represents a further increase since 1995, when
22% reported overtime work.
The role of cardiovascular diseases as the cause of early
retirement, however, did not change between 1992± 94 and
1995± 98 for either sex. They caused about 6% of early
retirement pensions among women and almost 15%
among men during both periods (28). The latest ® gures
indicate a further decline in cardiovascular diseases for
both sexes. Only 5% and 13% respectively of newly-granted
disability pensions were for any such disease in 1999,
according to the National Social Insurance Board.

Scand J Public Health 29 (Suppl 58)

174 O. HemstroÈ m
Diseases of the air passages
Vocational exposure appears to be an important causal
factor in the occurrence of adult asthma despite great
variation among studies (30). Particular risk occupa-
tions are, e.g. bakers (exposure to ¯ our dust), chemical-
processing-plant operators (various plastic chemicals),
plastics workers, car painters/spray painters (isocyan-
ates), animal minders (urine and hair from animals),
operating theatre staV (natural rubber). In some of
these occupations, work-related nose complaints are
common, particularly among animal minders, bakers,
veterinary surgeons and foodstuV workers. Dusty work
may facilitate the occurrence of chronic mucous cough.
Exposure to cadmium, stone dust or the enzyme
papain, which is used for tenderising meat, may
increase the risk of the severe form of chronic bron-
chitis (COPD). Smoking, however, is the most common
cause of this disease and passive smoking in the work
environment therefore seems to be an important risk
factor.
Exposure to asbestos appreciably increases the risk
of silicosis, asbestosis, pulmonary cancer (mesotheli-
oma) and lung cancer ( 24, 30). It takes a long time for
these diseases to develop, so that even if such exposure
has basically ceased nowadays, many new cases occur
owing to earlier exposure to asbestos.
Brain damage
Brain damage caused by e.g. organic solvents in the
work environment has decreased from about 70 cases
in 1990 to fewer than 10 in 1998 (24). While part of
the decline is probably because of reduced willingness
to notify, other sources show a similar positive trend.
Painters have been particularly exposed to organic
solvents, and a changeover to more water-based paints
probably contributed to the positive development of
work-related brain damage during the 1990s.
Self-assessed ill-health
Analyses of the Work Environment Surveys from 1991
to 1997 indicate that ergonomic loads, high mental
demands and low control over one’ s own work, as well
as exposure to dust, chemicals and heavy lifts, in¯ uence
both men’ s and women’ s states of health negatively
(36) ( Table 7:5). Being a municipal employee is con-
nected with all types of ill-health for men (only with
worry for women). Temporary work, as against this,
is related rather to better health than permanent
employment is. For both sexes the threat of lay-oV or
having some subsidiary occupation involves worry.
Scand J Public Health 29 (Suppl 58)
Sick-leave
Sick-leave for at least 30 days changed rapidly during
the 1990s. Between 1992 and 1997 the number of people
on sick-leave at any one time decreased for both sexes.
From 1997 it rose again, for women to a higher level
in 1999 than in 1992. It may be assumed that sick-
leave is aVected by both the work environment and
health and by labour market factors such as economic
¯ uctuations and changes in rules and levels of com-
pensation ( Figure 7:2). The proportion of older people
among the gainfully employed is also signi® cant for
sick-leave since disease depends heavily upon age (28).
In times of low unemployment sick-leave tends to
be high, possibly because many have jobs and hence
there are many persons liable to fall sick. High unem-
ployment, means instead that many of those who are
liable to fall-sick have become unemployed and this
may, in addition, increase discipline among the gain-
fully employed, reducing the tendency to report sick.
Apart from long-term illness, other factors may explain
the increase in long-term sick-leave. One is that the
rules for disability pension have been changed. Labour
market considerations are no longer a reason for early
retirement. Limiting the ¯ ow from long-term sick-
leave, which often precedes disability pension, to disab-
ility pension leads to an increase in long-term sick-
leave. The fact that the gainfully employed population
is ageing is, however, the most important cause of
changes in long-term sick-leave, particularly for
women. Long-term sick-leave (90 days or more) has
for at least the last 20 years been caused chie¯ y by
disorders of the locomotive organs (38% among
women and 40% among men in 1998) (28).
Regardless of economic conditions, changes in the
rules and the proportion of older people among the
gainfully employed, socioeconomic group is a factor
that may aVect health and later sick-leave. Groups with
an elevated risk of premature death, self-assessed ill-
health and disability pension, i.e. blue-collar workers,
Sick days per insured
35
Men
30
Women
25
20
15
10
5
0
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
Fig. 7:2. Sickness cash bene® t days per insured person 1995± 1999.
Source: National Insurance Board.
 Working Conditions, the Work Environment and Health
lower white-collar workers and self-employed men,
are also on long-term sick-leave more often (4).
Association of the work environment with certain types
of long-term ill-health (particularly of the locomotive
organs) probably contributes to these systematic
diVerences for diVerent health measures, including
sick-leave and disability pension.
Lost working years, mortality
The risks of dying prematurely and of disability pen-
sion diVer greatly in diVerent occupations (37). What
emerges particularly is the health risks connected with
having ``heavy tiring work tasks in typical blue-collar
occupations’ ’ (37). Such work is also often monoton-
ous, with unsuitable working postures, not only heavy.
This is most evident for women. For men, there are
also a number of service occupations, e.g. hotel and
restaurant work, among the occupations with many
lost working years. The sustainable jobs appear to be
typical white-collar ones, even though white-collar
workers experience more mental strain and higher
mental demands, and though signi® cantly more of
them than of blue-collar workers experience worry (4,
36). Largely the same occupational groups had many
lost working years in the 1990s as in the 1980s (37).
Changes in the Work
Environment During the
1990s
Small changes in physical demands and
ergonomic loads
There are very large diVerences in physical load
between diVerent occupations. Blue-collar occupations
are most subjected to these, upper white-collar least.
Heavy lifts are about 46 times more common among
skilled blue-collar workers (32.6%) than in a white-
collar occupation at upper level (0.7%). Ergonomic
disadvantages are about ® ve times commoner in the
former group. Gender diVerences exist chie¯ y regard-
ing heavy lifts, which are commoner among men, but
such diVerences are very small compared with the class
diVerences.
Work tasks such as manual work, exerting oneself
so that one breathes more rapidly, heavy lifts, working
in twisted body postures, working bent forward with-
out support for hands and arms or working with hands
raised, have in common that they can contribute to
locomotive disorders. This type of work task changed
175
surprisingly little during the 1990s (2). The Surveys
of Living Conditions show a very small decrease
(36%± 34%) in physically demanding jobs between
1993± 94 and 1997± 98 (15).
For some of the gainfully employed, however, certain
physical work loads have increased. From 1991 to 1997
the proportion with heavy lifts in their work declined
in many groups ( Table 7:6), while from 1997 to 1999
there was no change either for men (20%) or for women
(14%) (1). Between 1991 and 1995, however, the pro-
portion with heavy lifts increased among women, both
municipal employees and skilled workers, and low- and
middle-level white-collar workers. That the proportion
with heavy lifts increased among the former may pos-
sibly be because some white-collar workers took over
work tasks from former blue-collar workers. In medical
care such expansion of work has been fairly common
(19). Nursing orderlies and assistant nurses have
become rarer but their heavy work tasks have not.
Other ergonomically burdensome work tasks such
as forward-bent work without arm or hand support,
or work in twisted body postures, did not change gener-
ally during the period 1991± 1997 ( Table 7:6). On the
other hand they decreased for the self-employed by
more than four percentage units but increased particu-
larly for lower white-collar workers and for skilled
blue-collar workers. The increase for those born
abroad, except for the OECD, may appear large but
should be interpreted with caution since they are fairly
few in this sample.
Large gender diVerences in chemical and
physical exposure
There appear to have been no appreciable general
changes during the 1990s regarding the prevalence of
noise, vibration from hand power tools, heat causing
the body to sweat, cold, oil or cutting ¯ uids, cleaning
agents and/or disinfectants, water, human secretions
or air pollution ( 2). The proportion exposed to passive
smoking decreased, however, continually during the
whole decade. Regarding most chemical/physical ex-
posure, there are appreciable gender diVerences (see
Figure 7:3). It is about nine times commoner for
women to be exposed to human secretions (saliva,
blood, urine, faeces or vomit) in their work than for
men. On the other hand, men are exposed to vibrations
from hand power tools approximately seven times more
frequently than women. This is because men and
women to a large extent have diVerent occupations.
Computer work increasing in all groups
Computer work and work at the screen has continually
increased for a fairly long time. The increase appears
Scand J Public Health 29 (Suppl 58)
176 O. HemstroÈ m

Table 7:6. Relative diVerences in the prevalence of pain. exhaustion/fatigue and worry among groups of gainfully-employed
people. Comparison groups= 1. The eVect of factors age. country of birth. single parent. socioeconomic group and other factors
in the table has been eliminated

Heavy lifts Ergonomic loads

Change Change
1997 1991± 97 1997 1991± 97

Self employed 21 Õ 5.6 23 Õ 4.5

Upper white-collar 1 Õ 0.4 6 Õ 1.1
Middle white-collar 7 + 1.9 12 + 1.6
Lower white-collar 7 + 0.8 14 + 3.3
Skilled blue-collar 33 + 2.4 33 Õ 0.7
Unskilled blue-collar 28 Õ 1.0 36 + 1.9
Men 20 Õ 2.8 20 Õ 0.9
Women 14 + 1.1 23 + 0.3
Native-born 17 Õ 0.71 21 Õ 0.31
Born abroad, within OECD 18 + 0.31 25 Õ 1.01
Born abroad, outside OECD 21 Õ 1.51 36 + 2.91
16± 30 yrs. 21 Õ 1.6 25 Õ 0.1
31± 54 yrs. 16 + 0.3 21 + 0.5
55± 64 yrs. 14 Õ 3.3 20 Õ 1.9
Private employment 18 Õ 2.7 22 Õ 0.7
Public employment 4 Õ 4.7 10 Õ 3.1
Municipal employment 18 + 2.2 23 + 0.1
Permanently employed 16 Õ 0.4 21 Õ 0.2
Temporarily employed 19 Õ 0.8 27 + 1.2
All 17 Õ 1.0 22 Õ 0.2
1
The change refers to the years 1993± 97.
Source: Work Environment Survey 1997 (36).

very general and can be noted in all socioeconomic

Exposure groups, age groups and among both sexes (2). In
almost all groups the proportion exposed to computer
Noise work and to work at the screen was larger in 1999 than
the previous years. In 1999, 63% of women and 68%
Vibration
of men used computerised equipment in their work.
Heat causing
Sweating
The proportion of users is greatest in the age groups
Cold
30 to 49 years (2).
Oil or cutting
fluides
Cleansing/dis-
infection agents
Actual working time has increased
Water
among women and older people
Human In public debate the message is often being spread that
secretions a shrinking band of gainfully employed people are
Air pollution getting more and more to do in their jobs. The labour
Passive smoking force surveys contain particulars of the numbers of
weekly hours actually worked per gainfully employed
0 5 10 15 20 25 30 35 person. The AKU statistics show no changes for men
Per cent between 1995 and 1999. They worked just over 40
Men Women
hours per week. Women worked on average approxi-
mately one hour more in 1999 (33.7) than in 1995
Fig. 7:3. Proportion of gainfully-employed men and women (%) (32.8). The average working time for men in the age
reporting exposure to certain chemical and physical factors at least
one quarter of the time 1999. group 20 to 24 years increased however by 2.6 hours.
Source: (2). For 60± 64-year-olds of both sexes, average working

Scand J Public Health 29 (Suppl 58)

 Working Conditions, the Work Environment and Health
time increased by 2.5 hours (9, 10). The latter changes
may be of signi® cance for public health since older
people are normally more susceptible to illness than
younger and almost certainly less equipped for
increased gainful employment.
Employment contract terms less ® xed
In Sweden inde® nite-term hiring has traditionally pre-
dominated. During the 1990s an increase was noted
in other forms of employment such as just-in-time
employment, project employment and substitute
employment (22). Fixed-time employment increased
from just over 7% to 12% for men and from 14% to
19% for women between 1991 and 1999 (2). Such
forms of employment have become commoner in all
age groups but are still considerably more so among
younger people. At the end of the 1990s almost 40%
of women under 30 had some form of temporary
employment (38). The rate of increase, however,
appears to have been highest among older people, and
a levelling-oV took place between public, private and
municipal employees (36). Fixed-time employment was
about twice as common among those born outside
Sweden as among native-born people in 1997/98 (15).
Here, then, a clear change in general conditions can be
observed, possibly of signi® cance for work environ-
ment and health. Insecure contracts of employment
may have many undesirable consequences such as the
fear of saying what one thinks (39). Of seven diVerent
employment groups, the just-in-time-employed are
worst oV regarding possibilities of training and in¯ u-
ence over their work (22). Conditions for certain
people with freer employment, chie¯ y the project-
employed, do not, however, diVer much from those
with more permanent employment. They even have
somewhat better conditions than part-time workers
with ® xed conditions of employment.
New forms of company organisation
In the ``new working life’’ one sees an increased element
of just-in-time employment, slimmed-down and more
¯ exible organisations. Large-scale operation is being
replaced by concepts such as slimming, downsizing
and outsourcing ( 22), that is, lean organisations, high
specialisation of core activities and increased sub-
contracting of other activities. These organisational
changes have not been limited to the private sector.
In particular they have entered medical care. Some
employees have ¯ exible working hours, and distance
work may be on the increase (40). Should this con-
tinue, the borderlines between leisure time and working
time may become more diVuse. It appears to be largely
177
white-collar workers who have these ``looser’ ’ jobs
(19).
It has been observed that an increased element of
such new working arrangements may aVect both the
work environment and the proportion of gainfully
employed people who fall outside work-environment
and working-hour legislation (14, 40). Women with
these jobs risk impaired physical well-being through
overstrain if they also bear the main responsibility for
work in the home ( 19). ``Freer’ ’ jobs are by no means
a new phenomenon. For agricultural workers and
people with small businesses, the borderlines between
work and leisure have long been diVuse. The propor-
tion of gainfully employed people on ¯ exitime
increased between 1997 and 1999 by three percentage
units for both sexes, to 54% for women and 63% for
men. The proportion at home at least one day a week
is still low at 8% for both sexes, however, and appears
not to have increased between 1997 and 1999 ( 2).
``Looser’ ’ jobs still remain fairly uncommon and
appear largely limited to high-income earners without
children (19).
The proportion with monotonous work (about 16%
of the gainfully employed ) together with those with
physically burdensome jobs (approximately 40% of the
gainfully employed ) changed insigni® cantly between
1989/90 and 1997/98 (15).
Mental demands and in¯ uence over
one’ s work
A poor psychosocial work environment may consist of
tense work or of a combination of high mental
demands and little in¯ uence on or control over one’ s
own work (36). Such jobs increased somewhat from
just over 17% in 1995 to 19% in 1997. The change
appears general and to have aVected most groups about
the same ( less than two percentage unit increases)
except for public employees who saw a rise by just over
four percentage units (from 10% to 14%).
Is it the demand dimension or the control dimension
± or both ± that have changed? Some aspects of control,
e.g. being able to determine one’ s work pace for at
least half of working time, changed for the worse in
all socioeconomic groups after 1995 for both sexes ( 2).
Considerably more women than men cannot do this:
61% compared with 45% in 1999. However it seems
likely that the mental demands have changed most,
perhaps particularly work tempo and time pressure.
Work tempo and time pressure continue
to increase
Stressed work continued to increase during the 1990s
and in 1997/98 almost 70% of the gainfully employed
Scand J Public Health 29 (Suppl 58)
178 O. HemstroÈ m
Per cent
60
50
40
30
20
10
Men
0 0
1989 1991 1993 1995 1997
Unqualified blue-collar
Middle-level white-collar
Fig. 7:4. Proportions of gainfully-employed men and women, by socioeconomic group, reporting that they feel so stressed for at least half
their time that they cannot think of anything but their work, and have no time to talk 1989± 1999.
Source: (2).
had such jobs (15). The increase in stressed work pos-
sibly indicates a generally increasing time pressure and
stress in working life, as is often claimed ( 13, 41).
On average, the proportion who worked overtime
increased somewhat between 1997 and 1999: from 23%
to 28% among women and from 36% to 38% among
men. In 1999 33% of women and 39% of men worked
during their lunch break at least one day a week,
worked overtime or took work home. This implies a
small increase for women but not for men since 1997
(2). This is particularly common (54%± 80%) among
diVerent types of teacher, management staV/managers
and certain occupations in health and medical care.
Some of these groups, particularly teachers and medical
care staV, also reportedly have a high rate of sickness
at work as well as sick-leave (42).
The proportion who state that that they have so
much to do for at least half their working time that
they have no time talk or think of anything but work
has increased generally since 1989, but not for all
groups ( Figure 7:4). Among male upper white-collar
workers the proportion sank from 46% in 1989 to 37%
in 1999. Among men the diVerences between socioecon-
omic groups are tending to narrow. This stress indic-
ator appears common among male self-employed
people (40% or more). Women generally report more
stress than men in most socioeconomic groups with
the exception of the self-employed. Among female,
middle-level white-collar workers the increase was very
sharp between 1991 and 1997. More than half of female
Scand J Public Health 29 (Suppl 58)
Per cent
60
50
40
30
20
10
Women
1999 1989 1991 1993 1995 1997 1999
Qualified blue-collar Lower white-collar
Upper white-collar Self-employed
white-collar workers at middle level and above were so
stressed that they thought of nothing but work and
had no time to talk. For all the gainfully employed,
the proportion with such stress declined by 2 percent-
age units among men and by 1 among women between
1997 and 1999. The level of this stress indicator appears
to have peaked in 1997.
Violence and threats of violence
common in certain occupations
In certain employee groups violence or threat of viol-
ence is common. As many at two thirds (annual aver-
age) of female attendants and others are reported to
have experienced this during 1997/99 as are over half
of male security staV and care and nursing staV ( 2).
Violence or threat of violence varies greatly among
diVerent socioeconomic groups ( Table 7:7). It was
more common among women than among men and
particularly common among female skilled blue-collar
workers (30%). Violence and threats of violence can
lead to both personal injury and mental ill-health such
as worry, tensions and stress (26). The volume of such
threats has not changed since 1995.
Less worry about redundancy
The threat of being laid-oV appears to involve mental
complaints such as worry (35). Such threats have
 Working Conditions, the Work Environment and Health 179

Table 7:7. Proportions of gainfully-employedpeople (%) who proportion of students and unemployed people grew
during the previous 12 months had been subjected to violence sharply in this group. A change like this should have
or threats of violence. 1999
decreased the health diVerences between the gainfully
Women Men employed and others, and there is some support for
this in data from the Surveys of Living Conditions for
Unskilled blue-collar 20 13 the period 1986/87 to 1996/97. Self-assessed ill-health
Skilled blue-collar 30 6 declined more among those without gainful employ-
Lower white-collar 9 12
Middle-level white-collar 18 13 ment than among those in work, monotonous or not
Upper white-collar 13 8 monotonous, particularly after 1993 ( Figure 7:5).
Self employed 7 8
16± 29-year-olds 16 9
30± 49-year-olds 18 10 Work environment not the only
50± 64-year-olds 13 8
explanation of poorer mental health
All 17 9
DiVerences between the mental health of the gainfully
Source: (2). employed and the unemployed may also be explained
both by the idea that work entails better health and
decreased during the past few years, with the improve- the idea that the unemployed had worse health even
ment of the labour market situation. The proportion before they became unemployed (43). Following in the
who worry about redundancy sank between 1997 and wake of unemployment, however, were increased thre-
1999 from 15% to 11% for women and from just over ats of dismissal and increased elements of insecure
13% to 11% for men (2). appointment that presumably also aVected the mental
well-being of the gainfully employed. Women’ s mental
health in particular appears to have been negatively
in¯ uenced by worry about unemployment (44). Worry,
Can Changes in the Working anxiety and fatigue all increased appreciably between
1988/89 and 1996/97 among the gainfully employed
Environment Be Linked to and the openly unemployed ( Table 7:8) (43). Worry
Changes in Public Health? and anxiety increased, however, most among the unem-
ployed, perhaps indicating that e.g. worry about the
labour market aVects the prevalence of worry/anxiety
Narrowing health lead among the and fatigue in all groups. There may be increased gen-
eral insecurity among both the unemployed and those
gainfully employed in work.
Gainful employment has both positive and negative Regarding the contribution of the work environment
eVects upon the health of the population, but it is hard to changes in mental ill-health, the results are some-
to determine how great its signi® cance is. Apart from what puzzling. Psychosocial burdens such as a hectic
the positive eVects of work in the form of self-esteem, atmosphere and pressure of time (stress) increased for
social support etc. and the negative eVects of possible the gainfully employed during the whole of the 1990s.
injurious environments, the prevalence of health in any Had the increased time pressure in working life been
given group is aVected by who is included in it. Healthy important for mental well-being one could expect
people are selected ® rst for gainful employment while more deterioration of well-being among the gainfully
people with impaired health more often end up with- employed (43). The result calls for some re¯ ection. For
out work. both sexes, reduced opportunities of combining private
To obtain a paid job a certain degree of health is life and gainful employment, plus worsened job secur-
required, certain personal characteristics ± e.g. the right ity, appear to generate mental ill-health (44). Yet these
quali® cations, training or certi® cates in competition for factors can hardly have caused mental ill-health to
available jobs -and some initiative. These character- develop similarly among both the gainfully employed
istics are not the result of gainful employment. and the unemployed. Rather, they support the assump-
Correspondingly, a relatively large proportion of soci- tion that general changes such as an economic turn-
ally handicapped people gather among those without down, unstable labour market or changed working
gainful employment. The composition of the group organisations underlie mental ill health. The general
without gainful employment is of great signi® cance ± trend may also be illustrated by the fact that gain-
ill-health is most widespread if this group consists only fully employed men and women reported fatigue and
of the disability pensioners. During the 1990s the listlessness more often after 1993 ( Figure 7:6).

Scand J Public Health 29 (Suppl 58)

180 O. HemstroÈ m

Per cent Per cent

60 60

50 50

40 40

30 30

20 20

10 10
Men Women
0 0
1986/87 1988/89 1990/91 1992/93 1994/95 1996/97 1986/87 1988/89 1990/91 1992/93 1994/95 1996/97

Unoccupied Unoccupied
Monotonous work Monotonous work
Not monotonous work Not monotonous work

Fig. 7:5. Proportion of 20± 64-year-olds (%) who judged their health as ``less good’’ among men and women who lacked occupation, had
monotonous work or who did not have monotonous work. Age-standardised.
Source: Survey of Living Conditions, Statistics Sweden.

Per cent Per cent

50 50

40 40

30 30

20 20

10 10

Men Women

0 0
1989 1991 1993 1995 1997 1999 1989 1991 1993 1995 1997 1999

Unqualified blue-collar Qualified blue-collar Lower white-collar

Middle-level white-collar Upper white-collar Self-employed

Fig. 7:6. Proportions of gainfully-employed men and women, by socioeconomic group, reporting tiredness and listlessness every week
1989± 1999.
Source: (2).

Two researchers who studied trends for physically
and mentally tiring work during the 1990s found that
teachers and county council employees had undergone
a particularly unfavourable development in recent
years (45). They observed that people who work with
people generally report tiredness more than do people
in other types of occupation, but also that computer
specialists showed a positive development regarding
tiring work. Another study also showed that municipal
employment (here including county council employees)

Scand J Public Health 29 (Suppl 58)

 Working Conditions, the Work Environment and Health
was related to many types of ill-health, e.g. pain and
worry (36).
Worsened working conditions in health
care, nursing and schools
Health among municipal and county council employees
developed particularly negatively during the 1990s. An
increasing number of reorganisations, often in com-
bination with savings and cut-backs in staV, probably
contributed to certain forms of ill-health. Teachers and
care and nursing staV probably experienced the greatest
changes since they changed employers. Teachers went
from public to municipal employers. Care and nursing
staV changed partly to semi-private work. Some moved
from county council to primary/municipality appoint-
ments. A number of analyses and statistics also indicate
that these groups showed the worst development in
both work environment and well-being during the late
1990s. It should be possible to consider reward factors
at work (promotion opportunities, wage raises etc.) as
healthy, protective factors. Yet in this respect as well,
teachers and health and medical care staV appear to
have had worse conditions than others. The combina-
tion of eVort and reward components at work seems
connected with ill-health (46). Nursing and education
include professions with an imbalance between eVort
and reward. Teachers and certain care and nursing staV
are among those who most frequently work overtime
or in the lunch break, or who take work home. They
also belong to the occupational groups where people
most often work despite illness and their incomes are
among the lowest (42). Negative changes in care, nurs-
ing and the school have been underlined in an action
plan for measures aimed at the work environment (14).
Reorganisations and large cut-backs have probably
brought with them greatly increasing workloads for
the workers, more for women since they predominate
in these areas. Note also that this is primarily a sector
issue (municipalities and county councils) rather than
one of gender. Men in these sectors reported particu-
larly much ill-health ( Table 7:5).
Table 7:8. Self-reported worry or anxiety and fatigue (%) among openly-unemployed and gainfully-employed people. and the
change between the periods
Worry/anxiety
1988± 89 1996± 97
Gainfully employed 8 12
Openly unemployed 19 26
Source: Survey of Living Conditions 1988± 89 and 1996± 97 (43).
181
Technological changes may be
signi® cant
As has emerged above it is clear that reorganisations
and cut-backs have been common and have had more
negative consequences for municipal and county coun-
cil employees than for others. However, reorganisation
can scarcely explain the fact that the increase in mental
ill-health is at least equally large among e.g. the un-
employed (42). The previous section showed that
exposure to physical and chemical/physical working
environments had hardly changed. The same applied
to the volume of monotonous work and mentally bur-
densome work. A conceivable alternative explanation
of the increased stress and time pressure may be the
increased use of computers.
Regarding working life and the conditions for paid
work, public discussion often reveals a lack of perspect-
ive which frequently leads to today’s problems being
perceived as new and unique (41). This may also be
the case with certain diVuse health complaints (e.g.
fatigue and ``burn out’ ’), which may be caused by
combinations of many factors, physical as well as psy-
chosocial disadvantages, which may seem new but
which often have historical predecessors (47, 48).
The introduction of new technology may increase
the incidence of diVuse health complaints. Tech-
nological changes have also been ascribed decisive
importance in the new working life (22). The increased
use of computers, particularly VDU work, has brought
changes in work environments which may also be
assumed to have consequences for health. A larger
element of ® xed, monotonous work and lack of vari-
ation and natural breaks are contributory factors. The
most tiring computer work is monotonous entry work,
which is considerably more common among women
than among men. Developments in information tech-
nology may have contributed to increased mental load
and stress in working life (29).
Some researchers consider that both physical and
psychosocial work environment factors may cause
ill-health, but it is unusual that they have analysed
Fatigue
Change in Change in
percentage units 1988± 89 1996± 97 percentage units
+4 31 38 +7
+6 32 39 +7
Scand J Public Health 29 (Suppl 58)
182 O. HemstroÈ m
combinations of physical and psychosocial components
(27). Computers are examples of a work environment
component with both physical and psychosocial
aspects (29). Ergonomic and psychosocial conditions
associated with the workstation may have contributed
to neck and upper-back complaints ( Figure 7:7)
increasing in a manner similar to fatigue and listlessness
(Figure 7:6). The increase is more noticeable for
women in both cases. Fatigue and listlessness did not
start to increase until after 1993 while complaints from
the neck/upper back increased during the whole of
the 1990s.
A new working life ± but traditional
work risks persist
Some people consider that we partly got a new working
life (22) at the end of the 1990s. We have gained
modern working and living conditions (19) and a larger
component of ¯ exible organisations (14). It is unclear
how much old organisations have changed and what
new working conditions may, in their turn, in¯ uence
the health of the gainfully employed. Freer contracts
of employment, for example, do not appear to be
related to ill-health (36) and distance work is unusual
and is not increasing.
Increased computer work is a concrete example of
modern changes in working life that may have aVected
Per cent
50
40
30
20
10
Men
0 0
1989 1991 1993 1995 1997 1999
Unqualified blue-collar
Middle-level white-collar
Fig. 7:7. Proportions of gainfully-employed men and women (%) by socioeconomic group, reporting pain in the upper back or neck every
week 1998± 99.
Source: (2).
Scand J Public Health 29 (Suppl 58)
the ergonomic and the psychosocial working environ-
ment, possibly also with a certain signi® cance for public
health, perhaps in combination with increased time
pressure and overtime work. These changes may have
resulted in increased prevalence of mental overloading
(e.g. tiredness) and symptoms from the locomotive
organs (e.g. neck complaints). One factor that should
also be considered from the public health viewpoint is
that the gainfully employed population are ageing. At
the end of the 1990s the proportion in gainful employ-
ment increased among 55± 59-year-olds ( Figure 7:1),
and actual working time increased most for the
60± 64-year-olds. Exposure time to diVerent types of
work environment also increased most for the oldest
members of the work-force, the group which is prob-
ably most liable to develop health problems. Changes
in the age composition of the gainfully employed are
also of great signi® cance for e.g. changes in sick-leave
(28).
Diseases of the locomotive system still predominate
as the cause of early retirement pensions, even though
mental ill-health is increasing somewhat in signi® cance
(28). Modern working conditions perhaps have
stronger links with indicators of mental ill-health than
of physical. Victimisation and ostracism as a cause of
work-related disease, for example, have increased
appreciably during the past few years. A lasting impres-
sion of changes of the 1990s is that hardly anything
Per cent
50
40
30
20
10
Women
1989 1991 1993 1995 1997 1999
Qualified blue-collar Lower white-collar
Upper white-collar Self-employed
 Working Conditions, the Work Environment and Health
has happened regarding physical work environment
factors even though the quali® cation level has increased
somewhat among the gainfully employed. Most tradi-
tional work tasks appear to be still with us, and ``load
injuries’ ’ owing to heavy lifts, unsuitable work pos-
tures, vibration, and monotonous work are still per-
haps the most serious work-related health problem in
Sweden (49). This suggests that elimination of physical,
ergonomic and monotonous work tasks would prob-
ably prevent most serious cases of sickness that can
lead to pain, long sick-leave and shorter lives.
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