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What Can Balance the Effort? Associations

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What Can Balance the Effort?
Associations between Effort-Reward Imbalance,
Overcommitment, and Affective Disorders in German Teachers
DIRK LEHR, ANDREAS HILLERT, STEFAN KELLER
Affective disorders in schoolteachers are a frequent
reason for absenteeism and early retirement. The objec-
tive of this study was to clarify the relationship between
effort-reward imbalance at work, overcommitment, and
affective disorders. In addition, we examined the differ-
ential impact of different types of reward (salary, job
security/promotion, and esteem). In a matched case-
control study of 244 teachers, 122 teachers in inpatient
treatment for affective disorders were compared to 122
healthy controls. Logistic regression analyses revealed
strong associations between effort-reward imbalance
and affective disorders. Overcommitment was not an
independent risk factor for depression. The lack of
esteem by supervisors or colleagues was a more impor-
tant risk factor for depression than low salary or job
security. Results suggest that perceived esteem is essen-
tial in understanding the nature of stress. Interventions
for preventing depression in the workplace should
address supervisors and colleagues skills in adequately
appreciating their supervisees and co-workers. Key
words: effort-reward imbalance; work stress; mental dis-
orders; teachers; esteem; Germany
I N T J O C C U P E N V I R O N H E A LT H 2 0 0 9 ; 1 5 : 3 7 4 3 8 4
T
he Global Burden of Disease Study initiated by
the World Health Organization found that affec-
tive disorders, in particular depression, strongly
impact Disability Adjusted Life Years (DALY), especially
in highly developed countries.1 For high-income coun-
tries, unipolar depressive disorders are assumed to
become the most important cause for DALYs in 2030.2
Langlieb and DePaulo stated that substantial research
exists on several causes of depression, including gender,
specific brain disorders, and genetic factors, but
research on the impact of the work environment is lim-
ited. 3 Given the fact that professional work plays a major
role in an individuals life, it is important to investigate
the impact of work-related stress on affective disorders.4,5
Received from: Department of Medical Psychology, Faculty of
Human Medicine at Philipps University Marburg, Germany (DL);
Roseneck Center of Behavioral Medicine, Prien am Chiemsee, Ger-
many (AH); University of Hawaii, USA (SK). Send correspondence
to: Dirk Lehr, PhD, Department of Medical Psychology, Faculty of
Human Medicine at Philipps University Marburg, Karl von Frisch
Strasse 4, 35032 Marburg/Lahn, Germany; tel: +49 (0)6421/28-
64872; email: <dirk.lehr@staff.uni-marburg.de>.
Disclosures: The authors declare no conflicts of interest.
374
Many investigators found an unfavorable state of
mental health in teachers.6,7 Studies consistently
report that 1035% of teachers suffer from mental
health issues.8-10 Teachers retiring because of ill health
due to mental disorders is an important health issue in
several countries. For example, according to the
German Federal Ministry of the Interior, every third
teacher takes an early retirement.11 Also, in other
countries mental and behavioral disorders are consis-
tently one of the main reasons for retirement.1214
Weber et al. found evidence that affective disorders
are the dominant type of mental health disorder lead-
ing to early retirement.14 Despite numerous studies on
stress and burnout in teachers, the question of which
factors increase the risk for affective disorders in
teachers remains largely unanswered.
Reviewing the state of research on teachers health,
Guglielmi and Tatrow8 complain about the conceptual
vacuum that generally characterizes those empirical
investigations.8 On the other hand, there exist theo-
ries that may contribute to understanding the situation.
One potential theoretical framework to address this
problem is the effort-reward imbalance (ERI) model.15,16
The ERI model includes two principal components:
ERI as a structural component and overcommitment
(OC) as a personal component. The first component
focuses on the balance between the effort required by
the demands of the job and the reward obtained for
this effort. Three types of rewards exist: financial com-
pensation, safety of the workplace or chance of profes-
sional development, and, finally, immaterial rewards
such as approval, esteem, and praise. An imbalance
between the perceived costs and the perceived ben-
efits of the labor invested can give rise to a negative
emotional state that can increase the risk for mental or
physical symptoms.
Tsutsumi and Kawakami stated that there is little
occupation-specific evidence on the importance of the
various types of reward.17 They assumed the three types
of reward could impact health differently depending
on the occupational group. Van Vegchel et al. demon-
strated that the distinction between specific rewards
was a fruitful extension of the ERI model.18 In Dutch
health care workers, they found that an imbalance
between esteem and effort increased fatigue and psy-
chosomatic symptoms. They argued that other rewards,
such as job security and salary, were of minor impor-
tance because these needs already appeared to be satis-
fied in the workers they surveyed. According to a
report of the Organization for Economic Cooperation
and Development (OECD), German teachers also have
high job security and sufficient income.19 For teachers,
esteem also appears to be an important reward. For
example, according to the Eurydice Report, teachers in
European countries generally report a lack of social
recognition and appreciation. 20 Conversely, the expec-
tation of social recognition from their students was an
important incentive for teachers and influenced their
choice of profession.10 The desire to have a safe work-
place or a good salary was of minor importance.
Systematic reviews of a large number of studies
found evidence that a multitude of stress-related psy-
chosomatic complaints are associated with an effort-
reward imbalance.5,17,21 Associations between self-
reported depressive symptoms and ERI were found in a
study of population samples from three Central and
Eastern European countries.22 In the prospective
Whitehall II cohort study among English civil servants,
Stansfeld et al. demonstrated that ERI predicted self-
reported mild psychiatric disorders.23
Presently, however, there are few studies based on
the ERI model in the domain of teachers health.
Unterbrink et al.9 found an ERI in 20% of surveyed
teachers, but they did not report effects of ERI on
health. In the Netherlands, a perceived lack of reci-
procity between teachers and their students and col-
leagues was related with psychosomatic complaints and
burnout symptoms.24,25
The second component of the ERI model involves a
workers level of commitment. According to Siegrist,
OC is a personal characteristic that can be defined as a
cognitive-motivational pattern of coping with work-
related demands.16,26 It is characterized by spending
excessive effort at work and is indicated by an inability
to withdraw from work. OC should be especially impor-
tant in professions that are characterized by a high
degree of control over work activities, which is likely
the case in teaching. For example, German teachers
are obligated to conduct their classes at a fixed time
schedule, but are free in choosing time and place for
their preparations. This flexibility is estimated to
account for 3050% of the total work time and provides
opportunity for creative and self-controlled work.27
According to Karasek and Theorell, teaching is an
active job, characterized by high job demands com-
bined with high skill discretion and decision author-
ity.28 In contrast, in those jobs that offer a fixed struc-
ture and leave little opportunity for self-directed work,
OC appears to be a less important factor in determin-
ing overall health. In the context of mental health
among blue-collar workers, ERI and OC independently
predicted higher degrees of depression in public trans-
portation workers.29 Tsutsumi et al. corroborated these
findings in workers in a small Japanese plant.30
VOL 15/NO 4, OCT/DEC 2009 www.ijoeh.com
To summarize, there is evidence that there is an asso-
ciation between ERI and self-reported depressive symp-
toms in different countries and across some profes-
sions. When OC was included in the studies, this
variable also proved to be related to depressive symp-
toms. Based on the review of existing literature in the
context of the ERI model applied to the situation of
teachers, we have identified some shortcomings that
need to be addressed:
1. We do not know whether the reported findings in
civil servants or blue-collar workers can be general-
ized to academic professions like teaching.
2. Previous studies about affective disorders did not
include ill employees. Research on the ERI model
has been used in case-control studies only in the
investigation of cardiovascular diseases.31,32 Case
control studies allow for consideration of the
healthy worker effect.33 Accordingly, it is possible
to investigate associations between adverse health
and working conditions not only among the sur-
vivors of stressful working conditions, but also
among those whose health has been severely
impacted by such conditions.
3. There is insufficient information about whether the
reported relationships between ERI, OC, and
depression can be replicated by studies that utilize
clinical diagnoses according to the International
Classification of Disease (ICD-10),34 rather than self-
reported symptoms of depression.
4. Little is known about the differential impact of vari-
ous kinds of rewards on ERI. In his scale, Siegrist
summed up the magnitude of different rewards to a
total score which implied that all three reward cate-
gories were of equal importance.16 Van Vegchel et al.
pointed out that this assumption is doubtful.18 De
Jonge and Dormann argue that this assumption
causes very different job characteristics to be
lumped together.35 They suggest that different
rewards impact affective outcomes differently and
that outcomes are dependent on the importance of
the expected reward for the individual. There are to
date no studies that specifically evaluate the differ-
ential importance of different types of reward or the
importance of OC for clinically significant depres-
sion in teachers.
5. Other studies have been criticized repeatedly for the
arbitrary use of cut-off points that are not empiri-
cally validated.21,36 An evaluation study revealed
some disadvantages in established approaches to
define cut-off points proposed in ERI literature,
especially with regard to sensitivity.37
STUDY AIM AND HYPOTHESES
The aim of the present study was to explore the rela-
tionship of affective disorders, the ERI model, differ-
What Can Balance the Effort? 375
TABLE 1 Demographic Profile, Job Characteristics, and ERI Scores of Controls and Cases.
Healthy Sample (n = 122) Clinical Sample (n = 122)
Depression Score (CES-D)* 4.70 (3.62) 22.63 (13.04)

Gender (% female)** 69.7 65.6

Age*,** 45.13 (8.14) 51.75 (6.90)
Job status (% fulltime)** 59.0 61.7
Martial status (% with partner)** 69.7 64.2
Years of job experience*,** 19.04 (9.30) 25.86 (8.65)
Number of children*,** 1.41 (0.99) 1.39 (1.69)
Students per class*,** 24.16 (4.00) 24.84 (5.45)

Effort* 12.92 (3.76) 20.45 (4.77)

Reward* 49.93 (5.01) 39.94 (8.74)
Salary* 17.31 (3.08) 15.68 (3.70)
Job security* 9.07 (1.33) 7.41 (1.78)
Esteem* 23.56 (2.50) 16.85 (5.66)
ERI ratio*,a 0.49 (0.17) 1.03 (0.47)
ESPI ratio*,b 0.53 (0.24) 0.96 (0.45)
EJI ratio*,c 0.50 (0.21) 1.02 (0.53)
EEI ratio*,d 0.47 (0.18) 1.26 (0.89)
Overcommitment* 14.70 (3.38) 18.11 (3.52)
*Mean (SD); **Variables were considered in the matching procedure.
For comparison, the CES-D score for the German population is 10.72 (8.03), including healthy and an unspecified number of
depressed people.
a
Effort-reward imbalace ratio based on global reward scores.
b
Effort-salary/promotion imbalance.
c
Effort-job security imbalance.
d
Effort-esteem imbalance.

ential reward characteristics, and OC in German teach-
ers with and without clinical depression. The study inte-
grates diagnoses by professional psychotherapists and,
therefore, does not rely solely on self-report measure-
ments. We use Receiver-Operating Characteristic
(ROC) analyses to empirically determine meaningful
cut-off points for ERI as well as OC. Through a series of
regression models, we evaluate the contribution of ERI,
OC, and the three different rewards to the explained
variance of depression while controlling for relevant
confounders. Specifically, we expect that German
teachers in treatment for depression will show a less
favorable ERI and more OC than healthy controls, that
ERI and OC are associated with affective disorders, and
that for this occupational group the perceived lack of
esteem will be more important as a predictor for
depression than perceived inadequate financial com-
pensation or insufficient job security.
METHODS
Setting and Participants
The study sample consisted of 244 schoolteachers and
followed a case-control design.38 One-half of the sample
(N = 122) were sick-listed for affective disorders and inpa-
tients at the Roseneck Center of Behavioral Medicine,
Prien am Chiemsee, Germany. These individuals were
considered cases. According to the International Classifi-
cation of Mental and Behavioral Disorders (ICD-10), they
fulfilled criteria of disorders with depressive cardinal
symptoms: F32, F33, F34, F41.2, or F43.2043.22. Diag-
noses were made by professional psychotherapists.
Healthy controls were selected from a larger sample
according to various criteria. Firstly, they had to be capa-
ble of working and not sick-listed at the time of investi-
gation. Secondly, they had to be free of depression. The
potential controls completed the German version39 of
the Centre for Epidemiologic Studies-Depression Scale
(CES-D).40 Those with scores of 15 or higher were
rejected. The cut-off value assigned individuals to a
diagnosis of depression with a sensitivity of 95%.41
Each individual with clinical depression was paired
with a healthy control individual, matching for demo-
graphic variables (sex, age, martial status, number of
children) and job characteristics (full-time vs. part-
time, years of job experience, class size).
As expected, the healthy control group had depres-
sion scores below the German population (including
healthy and an unspecified number of depressed
people)39 and far below the group with clinical depres-
sion (Table 1). The matching procedure was successful
with regard to five variables (sex, martial status,
number of children, full-time vs. part-time, class size).
However, cases were slightly older (M = 51.75 years, SD
= 8.14 vs. M = 45.13 years, SD = 6.90) and, consequently,
had more years on the job (M = 25.86 years, SD = 8.65
vs. M = 19.04 years, SD = 9.30). Most participants were
female (67.6%), married or lived with a partner
(66.9%), and had an average of 1.40 children (SD =
1.38). Sixty percent worked full time. The size of the
teachers class averaged 24.50 students (SD = 4.77).

376 Lehr et al. www.ijoeh.com INT J OCCUP ENVIRON HEALTH

Measurements
The components of the ERI model were measured with
a standardized questionnaire.16,42 The measurement of
exposure information is crucial in case-control stud-
ies.38 To minimize negative recall bias, the diseased
group was investigated at the end of their inpatient
treatment, assuming that the affective state of patients
would have improved at this time. Therefore, ratings on
the job situation should less biased by the actual mood.
Effort/Job Demands. The effort scale contains six items
with an internal consistency of Cronbachs
= .78. It
measures both qualitative and quantitative aspects of
work demands, such as time pressure, extensive respon-
sibility, frequent interruptions, or increasing workload.
Occupational rewards. We used the global rewards scale,
which is composed of three sub-scales on the corre-
sponding dimensions of rewards. The three dimen-
sions of rewards have been confirmed repeatedly by
second-order and confirmatory factor analyses.26
Global reward. The scale consisted of 11 items
addresing the perceived adequacy of (a) salary, (b)
job security or promotion prospects, and (c) esteem
expressed by superiors and colleagues (Cronbachs

= .84).
Salary/Promotion. The salary scale had 4 items (Cron-
bachs
= .77) and requested an evaluation of effort
and achievement as well as a rating of the adequacy
of the salary and promotion prospects.
Job security. The job security scale was comprised of
just 2 items, each of which related to job security and
future prospects of the work situation. The items are
poorly interrelated (r = .03). Variance is strongly
constricted, as 94% denied having poor job security.
Esteem. The esteem scale was measured with 5 items
(Cronbachs
= .87) and addressed the support and
respect provided by colleagues and superiors. Sara-
son et al. emphasized the close relationship between
esteem, worth, and support, writing that, The essence
of a supportive relationship is the communication of
acceptance and the feeling that one is worthwhile,
capable, and a valued member of a group43
Effort-reward imbalance. Siegrist16 suggested an algo-
rithm to assess the imbalance between effort and
reward by computing an effort/reward ratio for the
global reward scale. The imbalance score is the ratio
between the total score of the effort scale (e) and the
total score of the respective reward scale (r). It is cal-
culated by ERI = e/(r  c). The factor c controls for dif-
ferent numbers of items in the nominator and denom-
inator (c = number of items in the nominator/number
of items in the denominator). Generally, the ERI ratio
is calculated based on the Global reward scale. To inves-
tigate the impact of the various rewards, we also calcu-
VOL 15/NO 4, OCT/DEC 2009 www.ijoeh.com
lated three specific imbalances based on the Salary/Pro-
motion, Job security, or Esteem scores, respectively. These
specific imbalances were termed: Effort-salary/promo-
tion imbalance (ESPI), Effort-job security imbalance
(EJI), Effort-esteem imbalance (EEI).
Overcommitment. The scale is comprised of 6 items
(Cronbachs
= .80). OC is operationalized as a worker
spending too much time and effort in work-related
matters, and feeling unable to withdraw from work or
to stop thinking about the job after they have left work
for the day.
Statistical Methods. Logistic regression analyses were con-
ducted to investigate associations between affective dis-
orders and potential risk factors. As reviews on the ERI
model had revealed, most studies used cut-off scores for
ERI and OC measures.5,17 Especially for reasons of com-
parability with other studies, we used cut-off scores in
the first series of analyses. In order to prove the stability
of results, and because of the known disadvantages of
dichotomization, we performed a second set of regres-
sion analyses including potential risk factors as continu-
ous variables.44 For direct comparison, all risk factors
were entered into a single regression model.
To ensure validity, we based our analyses on cut-offs
that were empirically evaluated in ROC analyses. Based
on the assumption that sensitivity and specificity are of
equal importance, we assumed the optimal cut-off
values to be the maximum of the Youden Index (sensi-
tivity + specificity 1).45 It was suggested that a cut-off
value of > 0.715 for the ERI ratio and of > 16 for OC was
most appropriate.37 We also conducted ROC analyses
to determine optimal cut-off points for specific imbal-
ances (ESPI, EJI, EEI) according to the maximum of
the Youden Index .
RESULTS
Receiver-Operating-Characteristic Analyses
Since the correct prediction of healthy individuals
should be as important as the prediction of diseased
individuals, the maximum of the Youden Index served
as cut-off point. Sensitivity and specificity of the cut-offs
suggested by Lehr et al.37 can be seen in Table 2. Cut-
off points for specific imbalances were found to be
close to the cut-off for the global ERI ratio.
Correlation Analyses
Table 3 shows a Pearson intercorrelation matrix of the
variables used in regression analysis. The data demon-
strate that affective disorders are related to all the com-
ponents of the ERI model. The substantial correlation
of the components with age indicates that this variable
is a confounder and, therefore, will have to be con-
trolled for in the subsequent analyses.
What Can Balance the Effort? 377
TABLE 2 Sensitivity, Specificity, and Youden-Index at Optimal Cut-off Point
Cut-off Sensitivity 95%CI Specificity 95%CI Youden Index 95%CI
ERI ratioa > 0.715 75.4 66.882.8 91.0 84.495.4 66.4 56.876.0
ESPI ratiob > 0.65 77.1 68.684.2 77.1 68.684.2 54.1 43.664.7
EJI ratioc > 0.71 72.1 63.379.9 86.1 78.691.7 58.2 47.968.5
EEI ratiod > 0.60 85.3 77.791.0 84.4 76.890.4 69.7 60.778.7
OCe > 16.0 70.5 61.678.4 68.6 59.876.9 39.3 27.850.8
a
Effort-reward imbalace ratio based on global reward scores.
b
Effort-salary / promotion Imbalance
c
Effort-job security imbalance.
d
Effort-esteem imbalance.
e
Overcommittment.

Regression Analyses for Different Kinds of
Effort-Reward Imbalances
To further investigate the relationship between the
components of the model and the affective state of the
individuals, we performed multivariate binary logistical
regression analyses. We utilized a regression model
with two dichotomous (ERI high vs. low, OC high vs. low)
predictors, two confounders (age, gender), and affec-
tive disorders as criteria.
Different tests46 suggested a good overall fit of the
regression model (Homer and Lemeshow 2 = 10.38, df
= 8.0, p = 0.239; Cox and Snell R2 = 0.45; Nagelkerke R2
= 0.60; classification accuracy = 82.6%). The results
showed that only the ERI ratio was able to predict
depressive disorders (odds ratio [OR], 21.84; 95% con-
fidence interval [95%CI], 9.2950.82), whereas the
contribution of OC was insignificant (OR, 1.95; 95%CI,
0.904.23).
Table 4 contains the ORs and the corresponding
relative risks (RR) for different regression models.
Despite the known advantages of ORs, Davies et al.47
commented on the difficulty in interpreting them ade-
quately, sometimes leading to misinterpretations of
ORs in terms of the RRs.48 To facilitate interpretation,
we used Zhang and Yus method of approximation for
the conversion of ORs into RRs. However, it should be
noted that RRs, unlike ORs, are sample dependent.
Review of the RRs indicates that individuals with ERI
were four times more likely to suffer from affective disor-
ders than individuals with no imbalance. The strength of
the association can also be described by the number of
persons who have to be exposed to the imbalance situa-
tion to produce one additional harmful event (number
needed to harm, NNH).49 In terms of NNH, if two teach-
ers are exposed to ERI, one individual will suffer from an
affective disorder (NNH, 1.6; 95%CI 1.42.0).
The multivariate analysis reveals that OC does not
affect the risk for affective disorders. The first and the
second regression models in Table 4 underscore that,
after introduction of the ERI ratio, the RR for affective
disorders remained almost constant even when OC was
added to the model.
Next, we analyzed the relevance of the three reward
components separately: salary, job security, and esteem.
Logistic regression analyses were conducted separately
for each specific ERI ratio. The results revealed a three-
fold increase of the risk when there was an imbalance
between effort and salary or between effort and job
security. Consistent with our expectation, there was a

TABLE 3 Pearson Intercorrelations of the Variables included in Regression Analyses (n = 244)

1 2 3 4 5 6 7 8 9 10 11 12
1. Affective disordera
2. Gender .04
3. Age .42** .19**
4. Effort .67** .06 .32**
5. Global reward .60** .01 .32** .66**
6. Salary .24** .00 .16* .37** .73**
7. Job security .48** .01 .28** .57** .64** .35**
8. Esteem .63** .02 .27** .62** .87** .42** .44**
9. Overcomitment .45** .20** .16* .59** .42** .25** .29** .41**
10. ERI ratiob .70** .04 .34** .96** .83** .52** .63** .76** .57**
11. ESPI ratioc .59** .06 .31** .88** .82** .70** .55** .65** .54** .95**
12. EJI ratiod .66** .03 .34** .93** .72** .40** .82** .61** .53** .93** .85**
13. EEI ratioe .72** .03 .34** .94** .81** .42** .57** .82** .56** .98** .88** .89**
*Correlation is significant at the p < .05 level, two tailed. **Correlation is significant at the p < .01 level, two tailed.
a
Affective disorder = 1, no disorder = 0; female = 0, male = 1.
b
Effort-reward imbalace ratio based on global reward scores.
c
Effort-salary/promotion imbalance.
d
Effort-job security imbalance.
e
Effort-esteem imbalance.

378 Lehr et al. www.ijoeh.com INT J OCCUP ENVIRON HEALTH

TABLE 4 Odds Ratios and the Corresponding Relative Risks of Affective Disorders by OC and ERI Using Global
Reward, Salary, Job Security, or Esteem as Reward Indicators
Variable OR 95%CI p-value RR 95%CI
Full model with global reward scores
ERI high vs. lowa 21.84 9.3950.82 < .001 4.02 3.374.38
OC high vs. lowb 1.95 0.904.23 .090 1.52 0.932.15
ERI with global reward scores
ERI high vs. lowa 28.73 12.9263.90 < .001 4.16 3.654.44
ESPI with salary/promotion as reward
ESPI high vs. lowc 9.02 4.7916.99 < .001 3.17 2.563.63
EJI with job security as reward
EJI high vs. lowd 12.73 6.4725.04 < .001 3.29 2.763.63
EEI with esteem as reward
EEI high vs. lowe 29.13 13.7661.66 < .001 6.04 5.036.67
Note: Odds ratios adjusted for gender and age.
a
ERI high = Effort-reward imbalace ratio based on global reward scores > 0.751.
b
OC high = Overcommitment > 16.
c
ESPI high = Effort-salary/promotion imbalance ratio > 0.65.
d
EJI = Effort-job security imbalance ratio > 0.71.
e
EEI = Effort-esteem imbalance ratio > 0.60.

higher risk (six fold) when the individuals reported an
imbalance between effort and esteem.
Regression Analyses Including All Components
of the Model
Finally, we conducted logistic regression analyses with
effort, OC, salary, job security, and esteem as continu-
ous variables and controlled for gender and age to
determine which of these five variables were most rele-
vant. Therefore it was possible to consider the inter-
correlations between all model components, especially
with regard to the different rewards. First, all variables
were entered into the model. Second, in order to spec-
ify a more parsimonious model, a stepwise forward
logistic regression was conducted.
Table 5 shows regression coefficients, Wald statistics,
and p-values for each variable. Because continuous vari-
ables have a higher statistical power than dichotomous
variables, the different measures of the overall fit of the
regression for the full model improved (2 Log-Likeli-
hood [2LL] = 150.98; Homer and Lemeshow 2 = 5.12,
df = 8, p = .75; Cox and Snell R2 = .54; Nagelkerke R2 =
.71; classification accuracy = 85.7%). The maximum
likelihood-ratio statistic was used for the stepwise logis-
tic regression analysis. While the full model contained
five model components, the stepwise model resulted in
two predictors. The parsimonious model is character-
ized by the following indices: 2LL = 158.41; Homer
and Lemeshow 2 = 6.59, df = 8, p = .58; Cox and Snell
R2 = .52; Nagelkerke R2 = .69; classification accuracy =
84.8%. Besides effort and esteem, no other variable con-
tributed to improving the regression model (Table 5).
To investigate whether there was a significant loss of
information, the parsimonious model was compared
against the full model by testing the difference of the -
2 Log-Likelihood values using chi square statistics.50 No
significant difference was found (2 = 158.41 150.98 =
7.43; df = 3; p = .059). Based on the stepwise regression
model, over 80% of both healthy controls and diseased
individuals could be correctly classified (Table 6). The
prediction of healthy individuals was slightly better

TABLE 5 Logistic Regression Models for Predicting Clinical Depression

Model Predictor B Std.Error Wald df p-value 2LL
Full model Constant 3.364 2.895 1.350 1 .245 150.98
Gender .248 .464 0.286 1 .593
Age .096 .030 10.307 1 .001
Effort .230 .062 13.736 1 < .001
Salary/Promotion .156 .074 4.378 1 .036
Esteem .328 .069 22.909 1 < .001
Job security .246 .146 2.818 1 .093
Overcomitment .080 .074 1.167 1 .280

Stepwise model Constant 3.021 2.058 2.155 1 .142 158.41

Gender .193 .438 0.195 1 .658
Age .094 .028 10.906 1 .001
Effort .276 .052 28.586 1 < .001
Esteem .289 .061 22.417 1 < .001
Note: The full model included all extrinsic and intrinsic components of the ERI model as continuous predictors and two confounders.

VOL 15/NO 4, OCT/DEC 2009 www.ijoeh.com What Can Balance the Effort? 379
TABLE 6 Classification Table
Predicted
___________________ Percentage
Controls Cases Correct
Observed Controls 107 15 87.7%
Cases 22 100 82.0%
Total 84.8%
(87.7%) than the prediction of participants suffering
from depression (82.0%).
To summarize, there was a strong association be-
tween ERIs and mental disorders. Teachers with ERIs
demonstrated a three to six times higher risk of pre-
senting affective disorders, depending on the type of
reward. Of the rewards, esteem was the most impor-
tant. This result was found in two different series of
regression analyses. OC appeared to be associated with
affective disorders only when it was analyzed separately.
OC did not influence the likelihood of suffering from
affective disorders when the other components of the
ERI model were taken into consideration.
DISCUSSION
The objective of this study was to investigate the associa-
tion between ERI, OC, and mental disorders in school-
teachers. Consistent with our expectations, a high risk
for suffering from affective disorders was found for
teachers experiencing an imbalance between efforts and
rewards, even if age and gender were controlled for as
confounders. Applying a more conservative approach, a
strong effect still remains when only the lower part of the
confidence interval is taken into account.5
When we take a broader perspective and include
other professions in our discussion, we find very consis-
tently that ERI impacts on depressive mood in studies on
civil servants,23 public transport workers,29 and workers
in automobile factories.30 These findings can be repro-
duced regardless of the study design and the methods of
data acquisition. Consequently, the present study adds to
the already existing evidence about the validity of the
ERI model for the explanation of affective disorders and
confirms the generalizability of these relationships.
Overcommitment
Overcommitment was assumed to be a personal char-
acteristic that could influence health in a profession
like teaching which has a comparatively high degree of
autonomy and self-directed work strategies. The results
show that OC is related to disturbed mood when we
restrict ourselves to a bivariate analysis, but contrary to
the results of other authors, like Larisch et al.29 and
Tsutsumi et al.,30 we did not find an important contri-
bution of OC to the explanation of depression in the
multivariate regression analyses.
One possible interpretation of this finding is that
there are prevailing effects of situational factors over
380 Lehr et al.
personal factors in the sense that teachers health is
predominantly effected by an external situation. Some
empirical evidence supports this assumption and sug-
gests taking the type of school into account.51 For
example, Rose and Seibt found that approximately
10% of the variance of health indicators could be
explained by differences between schools. 52
A methodological explanation would be to suggest
that there is an inadequate fit of the levels of general-
ization employed in the operationalization of the con-
structs. Affective disorders, contrary to the symptoms
of sleep disorders or headaches, refer to a general
health condition. The same is true for the ERI con-
struct, which according to De Jonge and Dormann
requires a global rating of the professional situation.35
OC is different. An inspection of the items suggests a
greater specificity. Half of the items refer to the inabil-
ity to unwind from work and to sleep and other prob-
lems that may result (e.g. If I put off something that
needs to be done today, Ill have trouble sleeping at
night or Work is usually still on my mind when I go to
bed). Consequently, the focus is on a specific health
problem, primarily work-related sleeping disturbances.
Discrepancies between the levels of specificity of the
three test instruments could produce biases by facilitat-
ing the detection of a relationship between variables at
an equal level of specificity and impeding detection of
such a relationship between variables at different levels.
Finally, Siegrist suggests that the OC items measure
coping characteristics, but there are concerns regard-
ing this assumption.16 Semmer et al. point out that
expressions like have trouble, relax, get over-
whelmed are more prone to indicating the outcome of
coping strategies than the coping strategies them-
selves.53 De Jonge and Dormann argue that the corre-
sponding scales do not specifically reflect the supposed
concepts. 35 In fact, a closer inspection of the items
reveals that sleep disturbances are the predominant
issue in the scale. This is also evident in the studies of
Kudielka et al.54 and Preckel et al.,36 who found signifi-
cant associations between the OC scale and sleep dis-
turbance. Potentially, there is a conceptual overlap
between OC as a risk factor and quality of sleep as a cri-
terion, which constitutes a frequent problem in
research about the health of teachers.8,55 This leads to
the assumption that the OC scale in its current form
may have limited construct validity, which complicates
the interpretation of findings about the impact of OC
on health. Future studies will need to address such
methodological issues as the level of measurement
specificity and the construct validity.
Effort-Reward Imbalance Theory
Our expectations regarding the impact of ERIs were
confirmed. The risk for affective disorders is closely
related to the discrepancies between effort and reward.
www.ijoeh.com INT J OCCUP ENVIRON HEALTH
Esteem. Because different regression models identified
the importance of external esteem, these results are
assumed to be stable and meaningful. The reward that
impacted risk the most is the esteem provided in the
professional social environment. This is in accordance
with the results obtained by Van Vegchel et al.18 Subse-
quent analyses did not reveal any additional effects of
other rewards such as salary and job security. This
means that perceived esteem is sufficient for balancing
the perceived effort in the teachers included in this
study. Conceptualizing oneself as a good, valuable, and
capable person, having a positive self-image, and being
approved by others are basic needs.56 Both the respect
an individual receives from others and his or her posi-
tive evaluation of the self foster self-esteem.57 Not being
appreciated by others appears to be a strong threat to
an individuals well-being.
The relationship between self-esteem and stress has
been conceptualized in various ways. Paul and Moser58
emphasize the relationship between self-esteem and
employment. For example, the loss of employment has
disastrous effects on self-esteem and, as a result, it also
has an impact on mental health. Others view self-
esteem as a resource to buffer stress. Jex and Elacqua
found a relationship between work stress and depres-
sion only in people with low levels of global self-esteem,
while individuals with high self-esteem were not
effected by an unfavorable environment.59 Finally,
workplace threats to self-esteem can be seen as a source
of stress.53 Folkman et al. assumed that in the context
of the transactional stress model, threats to self-esteem
are taken into consideration in the process of primary
appraisal.60 Similarly, the lack of esteem is thought to
be a cause of stress within the framework of the ERI
model. It is well known that experiencing attacks on
self-esteem, like workplace bullying, has strongly
adverse effects on health.61 A remarkable result of this
study is that the absence of expected positive conse-
quences, like esteem, also seems to have a strong
adverse impact on mental health.
The strong effect of esteem in our study may be
explained by the overlap of professional self-esteem
and global self-esteem of teachers seen in previous
investigations. Jex and Elacqua found a strong rela-
tionship between organization-based self-esteem and
global self-esteem.59 Semmer and Jacobshagen assume
a high relevance of professional identity for the devel-
opment of global self-esteem in workers with higher
levels of education, such as teachers.62 Moreover, the
selection of teaching as a profession appears highly
motivated by the expectation of personal and emo-
tional rewards.63,10 If this reward is lacking despite the
continuous effort, the outcome can be disastrous.
Another explanation could be based on teachers
implicit expectations for respect and support in inter-
actions with colleagues and supervisors. An implicit
understanding of what is and is not acceptable in a rela-
VOL 15/NO 4, OCT/DEC 2009 www.ijoeh.com
tionship can be defined as a psychological con-
tract.64,65 It is important to note that people may not
always be able to specify precisely what constitutes the
psychological contract with their organization, supervi-
sors, or colleagues. However, they are aware when their
sense of rightness and expectations had been vio-
lated.66 The violation of a psychological contract results
in feelings of injustice, which in turn can lead to
damage to self-esteem.64 In this sense, Schmitz et al.
have shown the adverse impact of unrealistic expecta-
tions towards team support among teachers. 67
In summary, teachers could become vulnerable to
adverse health affects in low esteem situations when
there is a strong overlap between professional and gen-
eral self-esteem and when their psychological contract
is based on high expectations regarding interaction
with others.
Salary/promotion. In our study, salary affected health
only as long as other rewards had not been included in
the calculations. An explanation may be the generally
good salary of teachers in Germany.19 In reference to
the income level, Van Vegchel et al. assumed that salary
only impacts health when it is below a certain thresh-
old, but that above that threshold additional income
would not lead to a better health outcome.18 In terms
of Maslows hierarchy of needs, after satisfaction of
material needs, higher level needs (like esteem) would
become more important.68 De Cremer, however, points
out that the level of income not only serves to satisfy
material needs, but also expresses public appreciation
and is therefore related to self-esteem.69 Furthermore,
if a supervisor offers opportunities for promotion this
could be appraised as appreciation for past perform-
ance and confidence in future work of the employee.
Job security. In our study, the effects of job security are sim-
ilar to those of salary. Almost all participants denied suf-
fering from poor job security. In Germany, job security
ranked among the top ten reasons for choosing a teach-
ing career.10 Most German teachers are civil servants and
have tenure.19 As elevated unemployment rates are a
highly salient issue in Germany, we would have expected
that teachers would assign a higher value to job security.
One possible explanation goes back to Herzbergs theory
of work motivation, which distinguishes between satisfiers
and dissatifiers in the workplace and holds that dissati-
fiers only cause unfavorable effects when they are threat-
ened or completely lacking.70 Job security and salary are
considered to be dissatifiers.
Effort. The ERI questionnaire focuses on job demands
such as time pressure, interruptions, increasing work
load, or overtime work. Initially, it would not seem
likely that esteem should be an adequate counterbal-
ance for these demands. Esteem can appear to be more
closely related to social stressors like rude colleagues or
What Can Balance the Effort? 381
disrespectful students, items not included in the ques-
tionnaire. However, Semmer et al. focused on the per-
ceived legitimacy of job demands. 53 His stress as an
offense to self approach provides a linkage between
demands and esteem. Teachers may perceive demands
caused by time pressure, interruptions, increasing work
load, or overtime work as natural or legitimate parts of
their job. Other teachers, who regard these stressors as
illegitimate, may experience such efforts as an offense
to their self-esteem. Hence, interruptions would go
along with negative cognitions such as They dont
appreciate my work, or increasing work load could be
associated with thoughts such as They think of me as a
sluggard. These interpretations can result in a
decrease in self-esteem. Therefore, a conceptual match
between effort and esteem seems to be plausible.
Limitations and Methodological Considerations
One limitation of the present study is the cross-sec-
tional design. The ERI model postulates that an ERI is
the cause of health restrictions and this assumption has
been supported empirically by longitudinal studies.23
Cross-sectional studies are able to detect associations
but cannot prove temporality. Temporality is one of
nine factors in determining cause-effect relationships
according to the Hill Causation Model.71 Nevertheless,
other criteria proposed by Hill, like strength of associa-
tion, consistency, plausibility, and coherence were met.
However, it may well be that individuals suffering
from depression tend to withdraw and avoid opportu-
nities to receive feedback by others that might
strengthen their self-esteem. Consequently, depression
may be the cause of an ERI and not vice versa. The rela-
tionship between threats to self-esteem and depression
could probably be best described as a vicious cycle. In
that sense the present study may only describe one half
of the cycle.
Furthermore, a conceptual overlap between predic-
tor and criterion must be considered.55 As low self-
esteem is one characteristic of depression, one could
argue that the risk factor (lack of esteem) and the out-
come variable (affective disorders) are overlapping.
This limitation could not be excluded completely and
may partially account for the rather strong effect. Nev-
ertheless, low self-esteem and lack of perceived exter-
nal esteem are clearly distinguishable concepts. The
first one refers to self-evaluation of the whole person
with regard to all domains of life, the latter focuses on
a specific part of working life. There is also a theoreti-
cal distinction, with external esteem being regarded as
one source of self-esteem.57 Including a direct measure
of self-esteem would have allowed us to investigate the
importance of a perceived absence of external esteem
on self-esteem.
A final limitation is our reliance on self-report data
in the measurement of the ERI variables. The results
382 Lehr et al.
reflect the perception of the individual. The Eurydice
Report claims that teachers subjectively underestimate
the esteem they receive compared to the more objec-
tive perceptions of external observers.20 In future stud-
ies, self-report data should be complemented by obser-
vations of supervisors or colleagues behavior that is
indicative of esteem.
One strength of the study is the inclusion of ill par-
ticipants in a controlled study design. This procedure
allows controlling for the healthy worker effect.33 Our
data, therefore, are not biased by a selection of sur-
vivors of adverse working conditions.
Second, the diagnosis of depression is based on an
assessment provided by professional psychotherapists
and does not solely rely on questionnaire data, which
assures the validity of the diagnosis. Guglielmi and
Tatrow determined that inclusion of self-report data in
both the predictor and the criterion lead to artificially
elevated relations due to common method variance.8
Third, we took the critique about arbitrary fixation
of the cut-off values into consideration. The presented
ROC analyses allowed the computation of cut-off
points with known diagnostic characteristics.
CONCLUSIONS
In our sample of teachers, the ERI model predicts a
dependence of depressive disorders on an imbalance
between effort and reward in the workplace. To our
knowledge, this is the first case-control study that found
evidence that the ERI model is valid for clinically sig-
nificant affective disorders. Those teachers who report
that their professional efforts outweigh the rewards dis-
play a greater risk of suffering from depression than
those who report a balance between the effort and
reward. Furthermore, some rewards were also found to
be more important than others. For an occupation like
teaching that has high job security, comparatively high
income, and high expectations with regard to social
recognition from their students, external esteem is of
major importance. Teachers working under high effort
conditions without receiving sufficient esteem in
return are six times more likely to be depressive than
their balanced counterparts. This leads to the conclu-
sion that external esteem can balance the effort.
Personal characteristics like OC do not further
increase the risk for depression, but this may be due to a
mismatch between predictor and criterion or shortcom-
ings with regard to the operationalization of the sup-
posed concept.
Overall, results suggest that external esteem might
be of major theoretical importance to understanding
the nature of stress. The role of external esteem and
self-esteem for occupational stress should be investi-
gated more intensively. This could be a fruitful direc-
tion for further research on the ERI model and theo-
retical advancement.
www.ijoeh.com INT J OCCUP ENVIRON HEALTH
 Our findings have several implications for prevent-
ing depression and for promoting health in the work-
place.72 When the objective is to prevent depressive
disorders, various strategies are recommended. Person-
centered interventions, like stress management train-
ings, should provide teachers with tools to reduce their
vulnerability in low external esteem situations. The
overlap between occupational and general self-esteem,
adequate expectations of approval by colleagues and
supervisors, or the ability to appreciate ones work
might be important topics.
With regard to job-centered health promotion, it
seems essential to control specific demands like time
pressure, increasing work load, overtime work, or tight
deadlines. The situation may be improved by the provi-
sion of additional resources by the administration.
Finally, there is also a need for a culture of esteem.
Politicians, supervisors, colleagues, and students need
to be aware that the mental health of teachers depends
largely on the esteem they experience in their profes-
sional environment. If they are interested in an
enhancement of the situation, they should seek cre-
ative ways to communicate esteem and make teachers
feel worthwhile, competent, and valued.43 Positive feed-
back, showing interest in a persons work, taking con-
cerns seriously, asking for advice, believing in the abili-
ties of others, explaining ones decisions, or giving
employees the responsibility to make their own deci-
sions73 might be effective ways to demonstrate esteem
in the workplace.
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