Stress and Health

Stress and Health 21: 113–128 (2005)

Published online 3 March 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/smi.1045

Effort–reward imbalance at
work: the effects of work stress
on anger and cardiovascular
disease symptoms in a
community sample
Luke A. Smith,1,*,† Angela Roman,1 Maureen F. Dollard,1 Anthony H. Winefield1 and
Johannes Siegrist2
1
Work and Stress Research Group, University of South Australia, Australia
2
University of Duesseldorf, Germany

Summary
Two studies of the Effort–Reward Imbalance (ERI) model of work stress with different end points
were undertaken in community samples from the Adelaide (Australia) metropolitan area. Study
1 examined the relationship between ERI at work and state anger. Study 2 extended the first
and examined the relationship between ERI, anger and cardiovascular disease (CVD) symptoms.
Hierarchical multiple regression confirmed a significant relationship between ERI and state anger
in Study 1 even after controlling for extraneous variables. Study 2 showed that ERI increases
CVD symptoms via the mediating variable of anger (an indirect effect). Furthermore, Study 2
revealed that people of lower income were more likely to experience higher anger. The results of
both studies have far ranging consequences for the emotional and physical health of individuals
who are experiencing an imbalance between their efforts and perceived rewards at work and those
with lower incomes may be more vulnerable. The wider public health implications of the rela-
tionship between work stress, and emotional and physical well being in the community are dis-
cussed. Copyright © 2005 John Wiley & Sons, Ltd.

Key Words
effort–reward imbalance (ERI) model; work stress; state anger; trait anger; cardiovascular disease
(CVD)

Work stress—effort–reward imbalance occupational demands shifting from the physical

The nature of work has undergone immense
changes in the last few decades with the focus of
* Correspondence to: Luke Smith, 73 Maple Avenue,
Rostrevor 5073, SA, Australia. Tel: (08) 8365 4575;
(08) 8372 2178; Mobile: 0408 085 016.
†
E-mail: luke@alzheimerssa.asn.au
Copyright © 2005 John Wiley & Sons, Ltd.
to the psychological and emotional domain. One
of the most significant and alarming develop-
ments is an increase in psychosocial risk factors
or work related stress (de Jonge, Bosma, Peter, &
Siegrist, 2000; van Vegchel, de Jonge, Meijer, &
Hamers, 2001). One theory of work stress and
well-being is the ‘Effort–Reward Imbalance’
(ERI) model. In the ERI model, a person’s occu-
pation is regarded as a vehicle for the fulfilment
Received 30 April 2004
Revised 6 December 2004
Accepted 15 December 2004
 L. Smith et al.
of vital emotional and motivational needs. The
model was developed in order to account for the
increasing rates of cardiovascular disease (CVD)
and related health problems of workers in many
countries. The model developed by medical
sociologist Johannes Siegrist assumes that adverse
health effects can be produced by a lack of reci-
procity between efforts and rewards at work
(Siegrist, 1996).
More specifically, the model proposes that
effort at work is part of a socially organized
exchange process. In the workplace perceived
effort spent is viewed in terms of psychological
and physical demands. The effort of employees is
maintained by occupational rewards, which are
provided by society. Societal rewards are distrib-
uted to an employee via three transmitter systems.
These systems include money, esteem and career
opportunities/job security.
Siegrist (1996) argues that ERI has negative
mental and physical outcomes for an individual.
He suggests that an imbalance of effort and
reward in employment, specifically high effort
associated with low reward, can be stressful to
the individual as such an imbalance violates a
basic norm of social exchange, i.e. reciprocity.
A study conducted by Calnan, Wainwright, and
Almond (2000) found that key components of the
ERI model were significant predictors of work
stress and job satisfaction in employees of general
medical practices. Other examples of a stressful
imbalance include having a demanding and
unstable job or achieving great accomplishments
in the absence of possible promotional pathways
(de Jonge et al., 2000; Peter, Geibler, & Siegrist,
1998). A lack of reciprocity between efforts and
rewards may cause a state of emotional distress
that can lead to strain reactions like poor health
and psychopathological problems (van Vegchel et
al., 2001).
Research demonstrates that stress affects
people in different ways. The ERI model accounts
for this by emphasizing the importance of certain
individual attributes. The demands or workload
of a job is described as ‘extrinsic effort’ (Bosma
et al., 1998; Cooper, 1998; Peter et al., 1998).
The coping characteristics of a person are
described as ‘intrinsic effort’ and are based on a
need for control. Intrinsic effort influences the
motivation of an employee in demanding situa-
tions. It is developed over a long-term period in
individuals and may therefore mediate the effects
of stress. People with high intrinsic effort who
inflate their efforts in order to gain esteem and
114 Copyright © 2005 John Wiley & Sons, Ltd.
approval are said to have ‘overcommitment’.
This personal pattern of coping, which is similar
to the Type A Behaviour Pattern, is characterized
by excessive striving driven by a strong desire for
approval and esteem (de Jonge et al., 2000;
Tsutsumi, Ishitake, Peter, Siegrist, & Matoba,
2001). People who are high in overcommitment
will find an imbalance between their efforts and
rewards particularly stressful and are consequently
at a high risk of developing health problems
(Cooper, 1998; Kuper, Singh-Manoux, Siegrist, &
Marmot, 2002; van Vegchel et al., 2001).
High rates of ERI have been found in occupa-
tions that deal with person-based interactions.
In other words, ERI has been found to be more
prevalent in service occupations and professions
(Bakker, Killmer, Siegrist, & Schaufeli, 2000;
Kutash & Schlesinger, 1980). Kuper et al. (2002)
state that people of a lower socio-economic status
(SES) are also at a greater risk of suffering from
negative health consequences resulting from a
stressful work environment. This is attributed to
the fact that low SES people may not have the
material resources, social support and skills that
enable them to overcome stress related problems.
Despite the stress and unfulfilling conditions
produced by ERI, workers under such conditions
do not always modify their work behaviour to
combat the imbalance, as one might expect.
Rather, under certain conditions, individuals suf-
fering from a mismatch between effort expended
at work and rewards received continue their
working behaviour, thus maintaining the high
cost/low gain conditions. This could be due to a
lack of alternative options in the work domain,
such that the prospect of being laid off, demoted
or unemployed is seen as worse than the cost of
high effort with insufficient rewards (Peter &
Siegrist, 1997; Siegrist, 1996, 1998).
ERI—emotional health/anger
One of the most important and neglected areas
of organizational psychology is an understanding
of the causes, characteristics, and consequences
of emotions in the workplace (Brief & Weiss,
2002; Fitness, 2000). Components of the ERI
model of work stress have been linked with emo-
tional strain/distress and psychological outcomes
such as depression, anxiety, psychiatric disorder
and emotional burnout (Bakker et al., 2000;
Bennett, Lowe, Matthews, Dourali, & Tattersal,
2001; Stansfeld, Fuhrer, Shipley, & Marmot,
Stress and Health 21: 113–128 (2005)

1999; Tsutsumi, Kayaba, Theorell, & Siegrist,
2001).
A popular debate in the literature is the role of
negative affectivity in the work stress process.
The ‘reverse causation’ theory argues that people
with high negative affectivity such as anger, are
cynical towards their work environment because
they tend to focus on the negative aspects of their
world. However, other researchers believe that
the work environment itself can increase the
negative affectivity or trait emotions of indi-
viduals. Consequently, controlling for negative
affectivity could produce an underestimation of
the influence of work stressors on strain (Dollard
& Winefield, 1998). In the current study both of
these hypotheses were investigated.
Research shows that anger is a frequently expe-
rienced emotion. A community survey by Siegel
(1986) showed that over 75 per cent of those
sampled had been angry within 1 week. Some
researchers suggest that most people will experi-
ence annoyance and potential anger at least 10
times a day (Bensimon, 1997). The workplace has
been identified as one of the most frustrating envi-
ronments that people are faced with and as a
result, it is likely many people experience anger
at work, regardless of whether or not this feeling
is expressed (Allcorn, 1994; Bensimon, 1997;
Fitness, 2000). It is estimated that approximately
one quarter of all employees in the U.S.A. feel
chronically angry at work (Johnson & Indvik,
2001). The causes of anger in the workplace
range from immediate influences such as per-
ceived treatment at work to wider factors such as
the changing structure of the nature of work
(Bensimon, 1997; Diamond, 1982; Fitness, 2000;
Neuman & Baron, 1998).
Chen and Spector (1992) conducted a study
that examined the relationship between aggres-
sion, withdrawal, theft, and substance abuse. A
sample of 400 employees from various occupa-
tions was measured on five work stressors: role
ambiguity, role conflict, interpersonal conflict,
situational constraints, and workload. The state
anger scale, taken from the State-Trait Personal-
ity Inventory (STPI) (Spielberger et al., 1979), and
three items related to feelings of stress were
applied. The researchers found that job stress was
correlated with state anger, and that anger was
related to aggressive behaviour. The authors sug-
gested that work stressors may create feelings of
frustration in employees that can lead to feelings
of anger and acts of aggression. Research has
shown employee morale and productivity are
Copyright © 2005 John Wiley & Sons, Ltd.
Effort-reward imbalance at work
affected by employees who express their anger
through poor work performance, threats, harass-
ment, acts of sabotage against their employers,
and physical attacks (Allcorn, 1994).
Anger is often referred to in the literature as a
strong negative emotional state that has many
functions, which include energizing behaviour,
the expression of negative affect towards others,
defending against ego threat and a vehicle for
active coping. The main consequence of anger
is the disruption of behaviour through agitation
and cognitive interference (Allcorn, 1994;
Diamond; 1982; Douglas & Martinko, 2001).
The emotional state of anger can vary from mild
annoyance to extreme rage (Diamond, 1982;
Fehr & Russell, 1994). The literature on anger
generally discusses two types of anger. ‘State
anger’ is defined as an immediate emotional-
physiological response to a particular event.
Whereas state anger refers to an immediate
response, trait anger involves a predisposition to
experience state anger over time and events. Trait
anger reflects a tendency to be more easily
angered, respond with a higher intensity of anger
when provoked and to cope less well with anger
eliciting events. It is often seen as a stable per-
sonality trait (Deffenbacher et al., 1996; Douglas
& Martinko, 2001).
ERI—physical health
The most common physical health outcome that
has been linked to ERI concerns the cardiovascu-
lar system (Caltabiano & Sarafino, 2002;
Kivimaki et al., 2002; Kuper et al., 2002). Mea-
sures of CVD, including coronary heart disease
(CHD), coronary artery disease (CAD) and
studies focussing on symptoms of these diseases
are common in the stress-health literature. Two
separate studies by Bosma et al. (1998) and Kuper
et al. (2002) analysed samples from the Whitehall
II study. Both studies found that a high ratio of
efforts to rewards was a significant risk factor for
CHD. The indicators of CHD in this study were
angina pectoris and doctor-diagnosed ischemia.
Even though several mechanisms have been doc-
umented in experimental studies, a unified psy-
chophysiological basis linking work stress with
CVD is still lacking (Heslop, Davey-Smith,
Metcalfe, Macleod, & Hart, 2002; Stansfeld &
Marmot, 2002).
The causal link or mechanism between ERI
and specific health outcomes has been commonly
Stress and Health 21: 113–128 (2005) 115
 L. Smith et al.
hypothesized in two main theories. The first is
that ERI has a direct biological effect on the
development of CVD and this is supported by
epidemiological evidence. A review of cross-
sectional studies shows that ERI leads to sym-
pathetic nervous system (SNS) arousal, which is
associated with high blood pressure, increased
risk of myocardial infarction, increased choles-
terol and higher heart rate (Cohen, Kessler, &
Underwood-Gordon, 1995; Peter, Siegrist,
Hallqvist, Reuterwall, & Theorell, 2002; Vrijkotte,
Doornen, & de Geus, 1999). The second theory
suggests an indirect mechanism for the effect of
ERI on CVD symptoms. Stress resulting from ERI
can lead to the uptake of smoking, substance
abuse, bad dietary habits and restrict compliance
to medical regimes (Kuper et al., 2002; Siegman
& Dembrowski, 1989).
The third theory is that emotion, in particular
anger, plays an important role in the development
of CVD (Deffenbacher et al., 1996; Kop, 1999;
Mona, Fitzmaurice, Kubzansky, Rimm, &
Kawachi, 2003; VanderVoort & Ragland, 1996;
Wenneberg & Schneider, 1997). Diamond (1982)
undertook a critical analysis of the literature con-
cerning the role of anger in hypertension and
CHD. He concluded that anger and hostility
appeared to play an important role in the devel-
opment of hypertension, although the mechanism
for the relationship was not identified. On the
whole, the research review provided support for
the proposal that ‘emotion’ is relevant to under-
standing the psychophysiological mechanisms
associated with CVD. More recently Gallacher,
Yarnell, Sweetnam, Elwood, and Stansfeld (1999)
argue that numerous studies have shown that
anger is related to CVD. They conclude that there
is an increased risk of CVD from 1.5 to 2.6 for
high levels of anger compared to low levels of
anger.
Wenneberg and Schneider (1997) utilized
state/trait and anger expression scales to in-
vestigate potential risks for CHD. They found
collagen-induced platelet aggregation was posi-
tively correlated with both trait and state anger.
Platelet aggregation is regarded as a precipitant
of acute coronary events and a risk factor for
CHD. Similar to ERI, anger can directly cause an
increase of CVD symptoms through physiologi-
cal arousal such as heart rate, or indirectly via
psychosocial factors such as diet (Cohen et al.,
1995; Hemingway, 1995; Marmot & Wilkinson,
1999).
116 Copyright © 2005 John Wiley & Sons, Ltd.
Study 1: State anger and ERI at work
Previous research has demonstrated that state
anger is an emotion that is experienced in the
workplace with increasing frequency. Although a
number of possible links between anger and ERI
have been discussed in the literature (Diamond,
1982) no reported research has examined the
relationship empirically. Factors such as demo-
graphic variables, personal disposition variables,
and life satisfaction were also of interest in the
present study as they were assumed to affect the
relationship between the variables of interest and
state anger. This model is summarized in Figure
1.
Study 1 aimed to determine whether a rela-
tionship existed between reported ERI and
reported state anger in a community sample of
adults in paid employment in Adelaide, South
Australia and tested the following hypothesis:
Hypothesis 1: ERI would be positively
related to state anger, and this relationship
would be evident after controlling for life
satisfaction, trait anger, overcommitment
and the demographic variables; age, sex, job
industry, length of service, and job category.
Method
Participants. Data were collected from 102
participants from three metropolitan community
areas of Adelaide, South Australia (response rate
of 81 per cent). The participants were selected
from three different areas of SES.
Procedure. Byrne and Reinhart (1989) suggest
that studies of CVD should not be restricted to
Demographics
Personal Disposition State Anger
Life Satisfaction
Effort-Reward
Imbalance
Figure 1. ERI to state anger model.
Stress and Health 21: 113–128 (2005)

samples of middle-aged, middle-class males in
professional or managerial occupations. There-
fore, suburbs for distribution of questionnaires
were randomly selected from a list of Local Gov-
ernment Area (LGA) values in metropolitan
Adelaide (Real Estate Institute of South Australia,
2002), ensuring that each of the three suburbs
were high, medium and low SES (based on prop-
erty value). This was achieved to maximize the
range of types of occupations and SES levels. Five
streets were randomly selected and approached in
each suburb via a doorknock, which occurred
during the evening (6:00–8:00 p.m.) on week-
nights for 4 weeks. Upon approaching a house,
the researcher introduced herself, explained the
nature of the study, and requested that the indi-
vidual complete the questionnaire. Upon agree-
ment to participate, individuals were presented
with a letter outlining the nature of the study,
participation requirements, and further contacts
regarding queries. Recruits were asked to com-
plete the questionnaire and seal it in the envelope
provided for collection by the researcher the next
day.
Measures—ERI. ERI was measured with the
23-item ERI scale (Siegrist, 1996). Extrinsic effort
(alpha = 0.75) was measured by six items.
Reward (alpha = 0.85) was measured by 11 items,
which was further broken down into status,
esteem and security rewards. Participants were
asked to indicate whether they agreed or dis-
agreed with statements, such as ‘I have constant
time pressure due to a heavy work load’ for
extrinsic effort and ‘I receive the respect I deserve
from my colleagues’ for reward. Participants
who agreed with these statements were further
required to indicate the level of distress they felt
as a result of the circumstances addressed in the
item. Responses were scored on a five-point scale;
0 points allocated to a response of disagree and
5 allocated to a response of ‘I am very distressed’.
Overcommitment (alpha = 0.75) was measured
by six items, such as ‘I get easily overwhelmed by
time pressures at work’. Participants were asked
to respond to the Likert-type format by indicat-
ing their level of agreement with each statement
on a four-point scale, ranging from strongly dis-
agree to strongly agree.
Anger. Both the trait and state anger scales
were taken from the STPI (Spielberger et al.,
1979). The trait anger scales consisted of 10 items
regarding the disposition of the individual. The
Copyright © 2005 John Wiley & Sons, Ltd.
Effort-reward imbalance at work
trait anger scale (alpha = 0.86) instructed par-
ticipants to respond to statements such as ‘I am
quick tempered’ with the general frequency with
which the statements were true on a four-point
scale. The state anger scale (alpha = 0.85) con-
tained 10 items relating to how the participant
was feeling at the time of completing the ques-
tionnaire, and thus contained items such as ‘I am
furious’. The response format was a Likert scale
ranging from almost never (1) to almost always
(4) for the trait anger scale, and not at all (1), to
very much so (4) for the state anger scale.
Life satisfaction. The satisfaction with life
scale (Diener, Emmons, Larsen, & Griffin, 1985)
followed a Likert-scale format. It consisted of five
statements such as ‘In most ways my life is close
to ideal’ (item 1), and subjects were required to
indicate their level of agreement with each state-
ment. The response structure contained seven
responses, including strongly disagree (scored as
1), disagree, slightly disagree, neither agree nor
disagree, slightly agree, agree, and strongly agree
(scored as 7). Addition of the scores on each item
revealed a single life satisfaction score of between
5 and 35 for each participant. Reliability analy-
sis revealed an alpha coefficient of 0.86 for this
scale.
Job satisfaction. Job satisfaction was measured
by a single item taken from the Job Satisfaction
Scale (Warr, Cook, & Wall, 1979). The item
consisted of the question ‘Taking everything into
consideration how do you feel about your job?’
Participants were required to indicate how satis-
fied they were with their job on a seven point
scale, ranging from extremely dissatisfied (scored
as 1), to extremely satisfied (scored as 7).
Research has shown that a single item measure is
an accurate representation of overall job satisfac-
tion (Wanous, Reichers, & Hudy, 1997).
Demographic information. The questionnaire
asked for information regarding age and sex.
Furthermore, participants were asked to indicate
job sector (public or private sector), the number
of years they had been employed at that job,
and which of five categories described their job
best (manager/administrator, professional/semi-
professional, tradesperson, clerical/sales/service,
labourer). Categories were obtained from the
nine categories of the Australian Bureau of
Statistics (1997) and modified to create the five
categories in the present study.
Stress and Health 21: 113–128 (2005) 117
 L. Smith et al.

Table I. Means (M), standard deviations (SD), ranges, and reliability

coefficients for continuous variables.
Variable N M SD Range Alpha
Age 102 38.57 11.83 18–64
Years at job 101 6.59 8.26 0–42
ERI 97 0.52 0.29 0.2–2.34
Overcommitment 101 13.44 3.11 6–22 0.75
Trait anger 97 16.58 4.46 10–32 0.86
State anger 100 11.22 2.59 10–26 0.85
Life satisfaction 101 23.26 6.67 8–35 0.86
Job satisfaction 101 4.98 1.22 1–7

Results Table II. Frequencies and percentages for categorical

variables.
Demographics of participants. The study con- Variable N Percentage
sisted of participants ranging in ages from 18 to
64 (mean, M = 39 years; standard deviation SD Gender
= 12 years). The sample was relatively even in Male 52 51.0
terms of sex (Males = 52, Females = 50). Descrip- Female 50 49.0
Job sector
tive statistics of the sample are summarized in
Private 63 61.8
Tables I and II. Public 37 36.2
Missing 2 2.0
Correlations between variables. Table III Job category
demonstrates the correlations between variables Manager/administrator 18 17.6
of interest employed in the study. Correlations Professional/semi-professional 51 50.0
coefficients were defined as small when r = 0.20, Tradesperson 10 9.8
as medium when r = 0.30, and as large when Clerical/sales/service 17 16.7
Labourer 6 5.9
r = 0.50 (Cohen, 1992).

Correlations with state anger. As anticipated,

ERI correlated positively with state anger,
showing a medium size correlation, r (93) = 0.41,
p < 0.01. Trait anger was also found to correlate
with state anger, however this relationship
was small, r (95) = 0.26, p < 0.01. A small
negative relationship was demonstrated between
state anger and life satisfaction, r (97) = -0.25,
p < 0.05.
Hierarchical regression analyses. A hierarchi-
cal multiple regression analysis was conducted to
determine whether a relationship existed between
ERI and state anger (hypothesis 1), after con-
trolling for possible confounding variables. The
results of the regression analysis are presented in
Table IV.
As Table IV shows, the only independent vari-
ables that were significant predictors of state
anger after controlling for other variables, were
ERI and trait anger.
Discussion
The results supported the hypothesis that ERI is
associated with state anger. Of all the variables,
ERI shows the largest positive correlation with
state anger. Furthermore, results of a hierarchical
regression analysis demonstrated that after con-
trolling for factors, such as demographics, over-
commitment, trait anger, and life satisfaction, ERI
made an independent contribution to levels of
state anger. This finding suggests that individuals
who suffer from an imbalance of effort and
reward at work, such that they contribute greater
efforts to their work than they receive in reward,
have the propensity to feel angrier than those who
are not experiencing ERI. Further, levels of anger
in the community may have their origins in stress-
ful conditions at work.

118 Copyright © 2005 John Wiley & Sons, Ltd. Stress and Health 21: 113–128 (2005)
 Table III. Intercorrelations of variables.
1 2 3 4 5 6 7 8 9 10 11 12 13

1. Age —

Copyright © 2005 John Wiley & Sons, Ltd.

2. Sex -0.11 —
3. Job sector -0.24* -0.09 —
4. Length of service 0.51** -0.28** -0.12 —
5. Manager/administrator† 0.20* 0.01 0.09 0.14 —
6. Professional/semi-professional† 0.20* -0.12 -0.15 0.15 -0.46** —
7. Tradesperson† -0.29** -0.19 0.12 -0.11 -0.15 -0.33** —
8. Clerical/sales/service† -0.14 0.30** -0.01 -0.22* -0.21* -0.45** -0.15 —
9. Labourer† -0.17 0.01 0.02 -0.08 -0.12 -0.25* -0.08 -0.11 —
10. Overcommitment 0.15 -0.07 0.03 0.06 0.15 0.09 -0.09 -0.24* 0.05 —
11. Trait anger -0.30** -0.02 0.08 -0.13 -0.04 -0.25* 0.24* 0.07 0.18 0.01 —
12. Life satisfaction 0.00 0.06 0.04 0.07 0.05 0.08 -0.13 0.09 -0.23* -0.08 -0.25* —
13. ERI -0.02 -0.17 0.16 0.08 -0.03 -0.05 0.03 -0.09 0.25* 0.27** 0.09 -0.42** —
14. State anger -0.13 -0.09 0.11 0.07 0.01 -0.14 -0.00 0.07 0.17 0.17 0.26** -0.25* 0.41**

** p < 0.01, * p < 0.05. Sex: 1 = male, 2 = female; job sector: 1 = public, 2 = private.
†
Variables dummy coded from job category.

Stress and Health 21: 113–128 (2005)

Effort-reward imbalance at work

119
 L. Smith et al.

Table IV. Hierarchical regression analysis predicting state anger.

Source DR2 df B (each step) B (full model) t
Step 1
Demographics 0.099 8,82
Age -0.189 -0.186 -1.421
Sex -0.114 -0.058 -0.552
Job sector 0.081 0.006 0.061
Years in job 0.212 0.181 1.514
Manager 0.059 0.046 0.430
Tradesperson -0.035 -0.084 -0.749
Clerical 0.144 0.186 1.692
Labourer 0.172 0.027 0.250
Step 2
Personal disposition 0.085* 2,80
Overcommitment 0.222* 0.134 1.260
Trait anger 0.210 0.182 1.743*
Step 3
Life satisfaction 0.049* 1,79 -0.242* -0.131 -1.148
Step 4
ERI 0.055* 1,78 0.283* 0.283* 2.466*
Full model: R2 = 0.288, Adjusted R2 = 0.179, F(12,78) = 2.63
* p < 0.05, t values derived from final model.

Demographics
CVD
Age Anger In Symptoms
Sex Trait Angina
Average Yearly Salary Intermittent-
Clerical/sales/service Anger
Claudication
Anger Out Myocardial-
Infarction
Effort Reward Blood Pressure
Referral
Imbalance

Figure 2. Stress/trait model.

Study 2: Trait anger, ERI at work and CVD
Previous research has shown that ERI is related
to negative emotional outcomes, such as anger
as well as physical outcomes, such as CVD and
musculoskeletal problems. Furthermore, the way
individuals express anger has also been found to
influence their chance of showing CVD symptoms
with most research highlighting the role of anger
suppression (anger in). Study 2 was based on the
model in Study 1 with a few alterations. The vari-
able of state anger was replaced by trait anger,
given that trait anger (how you have been feeling
generally) may be a more relevant assessment of
emotional reaction to the chronic stressor of ERI
(personal communication by Professor Charles
Spielberger to Luke Smith, April 14, 2003). In
Study 2 two models were tested. In the first
model, ERI was assumed to influence trait anger
(Dollard & Winefield, 1998). Consequently, trait
anger was assumed to influence an individual’s
chance of having CVD symptoms either directly
or through the anger expression variables of
anger in or anger out. Clerical/sales/service was
included in the model because it has been found
to be the occupational group with the highest
prevalence of ERI (Kutash & Schlesinger, 1980).
It was decided not to incorporate overcommit-
ment as a variable in the model because of its lack
of a significant relationship with anger in Study
1. The model is summarized in Figure 2.
An alternative theory is that trait anger influ-
ences an individual’s perception of ERI at work.
This theory of ‘reverse causation’ was also

120 Copyright © 2005 John Wiley & Sons, Ltd. Stress and Health 21: 113–128 (2005)

explored in the study through a second model
that swapped the places of trait anger and ERI in
the Stress/Trait Model. This model was called the
Reverse Causation Model (Cohen et al., 1995;
Dollard & Winefield, 1998).
Study 2 aimed to determine if a relationship
exists between ERI, trait anger and CVD symp-
toms in a community sample of adults in paid
employment in Adelaide, South Australia.
The study aimed to test the following
hypotheses in the Stress/Trait Model:
(1) Trait anger would be positively asso-
ciated with CVD symptoms.
(2) Trait anger would mediate the rela-
tionship between ERI and CVD
symptoms.
(3) Anger in (anger suppression) and
anger out (overt expression) would
mediate the relationship between trait
anger and CVD symptoms.
The study aimed to test the following
hypotheses in the Reverse Causation Model:
(4) ERI would be positively associated
with CVD symptoms.
(5) ERI would mediate the relationship
between trait anger CVD symptoms
in the Reverse Causation Model.
(6) Anger in (anger suppression) and
anger out (overt expression) would
mediate the relationship between ERI
and CVD symptoms.
Method
Participants. Data were collected from 118
participants from three socio-economic metro-
politan areas of Adelaide, South Australia
(response rate 73 per cent). The participants were
selected from three different areas of SES.
Procedure. The procedure used in this study
was similar to the procedure used in Study 1,
except that the targeted suburbs for question-
naire distribution were randomly selected from
Adelaide Metropolitan areas from the latest
Australian Bureaus of Statistics census of popu-
lation and housing (Cretteden, 2001). Three
suburbs were taken from each of a high-income,
medium-income and low-income household.
Measures—ERI. This was measured by a mod-
ified version of Siegrist’s (1996) original ERI 23-
Copyright © 2005 John Wiley & Sons, Ltd.
Effort-reward imbalance at work
item scale, which was used in Study 1. In the
current study participants were not asked to agree
or disagree with the statement and then indicate
their level of distress but instead to indicate on a
four-point scale the extent to which they agree or
disagree with the statement. Replacing the ‘dis-
tressed’ component of the scale with a four-point
agree/disagree scale was hypothesized to reduce
the affective evaluative aspect of the scale and
problems associated with common method vari-
ance and conceptual overlap with affective out-
comes (Dollard & de Jonge, 2003). Furthermore,
in Study 1 participants encountered many prob-
lems with the ERI scale including confusion with
the use of the rating scale.
Responses on the modified scale were scored on
a four-point scale ranging from ‘strongly disagree’
(1) to ‘strongly agree’ (4). Extrinsic effort (alpha
= 0.74) was measured by six items and reward
(alpha = 0.80) was measured by 11 items.
Trait anger. The same measure was used as in
Study 1 (alpha = 0.83).
Anger expression. The anger expression vari-
ables of anger in (suppression), anger out (overt
expression) and anger control were assessed
using Spielberger’s anger expression (AX) scale
(Spielberger et al., 1986). All 24 items were pre-
sented under a general headline of ‘When angry
or furious I . . .’ and participants were asked to
respond to how often they generally reacted or
behaved in the manner described in the state-
ments. Anger in (alpha = 0.79) was measured by
six items involving statements such as ‘I control
my anger’. The scale was scored with 1 point for
‘almost never’ through to 4 points for ‘almost
always’.
Anger out or anger expression was measured
by six items from the AX scale (alpha = 0.76).
Each item contained a statement such as ‘I argue
with others’ and a response format identical to
the one used in the anger in scale.
CVD symptoms. According to Siegrist (per-
sonal communication, March 11, 2003) the
London School of Hygiene Questionnaire on
Chest Pain is still the most valid self-report
measure for CVD symptoms. This questionnaire
measured the CVD symptoms of angina, possible
myocardial infarction and intermittent claudica-
tion (Rose, McCartney, & Ried, 1977). Angina
(Part A) and intermittent claudication (Part C)
were measured using self-report checklists involv-
Stress and Health 21: 113–128 (2005) 121
 L. Smith et al.
ing questions with a ‘yes or no’ to questions such
as ‘have you ever had pain or discomfort in your
chest?’ Other questions related to certain charac-
teristics of a symptom, i.e. the response of 10
minutes or less to ‘how much time does it take
until the pain goes away?’ Part B measured pos-
sible myocardial infarction or possible ‘heart
attack’ and instructed participants who had expe-
rienced chest pain to mark its position with an X.
Throughout the questionnaire small alterations
were made to the original questions and some
questions removed in order to improve the relia-
bility of the questionnaire.
Many researchers argue that the use of a
questionnaire as an indicator of CVD can be
problematic (Bosma et al., 1998: Ramsay,
McDermott, & Bray, 2001). Therefore in order
to improve and increase the data on CVD symp-
toms in the current study, two additional ques-
tions were added in Part D after the sections from
the London School of Hygiene Questionnaire.
Question A concerned blood pressure and asked
‘In the past two years have you had your blood
pressure taken by a health professional or used
a self-administered machine?’ Participants who
indicated that they had high blood pressure,
which is a known symptom and risk factor for
CVD, were assigned a score of 1. Question B
asked, ‘In the past two years have you consulted
a health professional with regard to chest pain,
heart attack, or any other cardiovascular related
health problems?’ This addition is similar to
those made in other studies that have utilized
the London School of Hygiene Questionnaire
on Chest Pain (Bullpitt et al., 1990; Yarnell,
Sweetnam, Baker, & Bainton, 1988). Participants
who answered ‘yes’ to this question were allo-
cated a score of 1. The ‘CVD symptoms’ variable
was computed by adding the number of CVD
symptoms that any one participant had out of a
score of five. For example, a person with possible
Table V. Means (M), Standard deviations (SD), ranges, and reliability
coefficients for continuous variables.
Variable N M
Age 118 38.64
Months at job 117 110.00
Salary 113 $50,333
ERI 104 1.01
Trait anger 113 17.73
Anger in 116 16.03
Anger out 118 13.65
122 Copyright © 2005 John Wiley & Sons, Ltd.
myocardial infarction, high blood pressure and a
referral to a doctor would be given a score of 3
out of 5 for CVD symptoms.
Demographic information. The questionnaire
asked participants for the same demographic
information as in Study 1. Average yearly salary
was included as a SES indicator because of its link
with work stress vulnerability and negative health
consequences (Kuper et al., 2002).
Results
Demographics of participants. The study con-
sisted of participants ranging in ages 19 to 72 (M
= 39 years, SD = 13 years). The sample involved
69 males (58.5 per cent) and 49 females (41.5 per
cent). The descriptive statistics for the study are
summarized in Tables V and VI.
Statistical analysis. Alterations were made to
the data to meet the basic assumptions of the sta-
tistical analyses. To improve the power of average
yearly salary and ERI, missing data were con-
verted into the mean of their original variables. A
Mahalanobis Analysis revealed that two cases
violated the critical limit for multivariate outliers
and were consequently excluded from the path
analyses.
Path analyses. Path analysis is a form of
Structural Equation Modelling and enables the
examination of direct and indirect associations
between one or more independent variables and
one or more dependent variables. A direct asso-
ciation concerns the path coefficient between two
variables, while an indirect association connects
one variable with another variable through the
significant paths of other variables. It differs from
other linear equation models in that mediated
SD Range Alpha
13.30 19–72
124.62 1–516
$29,214 $5,200–$150,000
0.32 0.46–2.75
4.84 10–34 0.83
4.06 8–28 0.79
3.53 8–24 0.76
Stress and Health 21: 113–128 (2005)
 Effort-reward imbalance at work

pathways can be examined, however the direction theory, regarding causality within the path model.
of these relationships cannot be established. A path diagram may involve two kinds of vari-
Instead, the one-headed arrows between variables ables: exogenous and endogenous. Exogenous
represent predetermined hypotheses taken from variables on the left hand side of the diagram
have no incoming arrows and the model does not
try to explain them. Endogenous variables do
Table VI. Frequencies and percentages for categorical have incoming arrows and can be either inter-
variables. vening or dependent variables. Arrows pointing
Variable N Percentage directly to an endogenous variable without a vari-
able preceding it is indicating the variance of the
Sex residual (unexplained variance). Path coefficients
Male 69 58.5 (standardized regression coefficients taken from a
Female 49 41.5
Job sector
multiple regression) are used to show the direct
Private 75 63.6 effect of an independent variable on a dependent
Public 42 35.6 variable in path model. When the model has two
Missing 1 0.8 or more causal variables, path coefficients are
Job category standardized partial regression coefficients, with
Manager/administrator 29 24.5 previous variables controlled for with the use of
Professional/semi-Professional 56 47.5 standardized data (Klem, 1995).
Tradesperson 8 6.8
Clerical/sales/service 21 17.8
Labourer 4 3.4
Correlations. The correlations for all of the
Angina variables used in the path analyses are shown in
Angina 8 6.8 Table VII. The only variable that was significantly
No Angina 110 93.2 correlated with CVD symptoms was trait anger
Possible myocardial infarction r(109) = 0.23, p < 0.05. Furthermore, ERI was
Possible myocardial infarction 23 19.5 associated only with trait anger r(109) = 0.22,
No myocardial infarction 95 80.5 p < 0.05.
Intermittent claudication
Possible intermittent claudication 21 17.8
No intermittent claudication 97 82.2
Fit of models. To determine the fit for the
Blood pressure Stress/Trait Model presented in Figure 2, the
Not measured 25 21.6 implied correlations (sum of direct effects, indirect
Low 13 11.5 effects, spurious effects and the unanalysed effects)
Normal 65 55.4 were calculated for all pairs of variables. By com-
High 13 11.5 paring the implied correlations with the observed
Referral to doctor correlations, it is possible to determine how well
No 100 84.7 the model reproduced the original correlations.
Yes 16 13.6
Missing 2 1.7
The average of the absolute differences
between the observed and implied correlations is

Table VII. Correlations for all variables in the path analyses.

1 2 3 4 5 6 7 8
1. Age
2. Sex -0.21*
3. Salary 0.26** -0.37**
4. Clerical/sales/service† -0.06 0.24** -0.34**
5. ERI 0.05 -0.02 -0.01 -0.16
6. Trait anger -0.30** 0.07 -0.29** 0.14 0.22*
7. Anger out -0.23* 0.02 -0.18 0.13 0.16 0.68**
8. Anger in -0.22* 0.09 -0.23* 0.13 0.13 0.47** 0.24**
9. CVD symptoms 0.08 0.01 -0.14 0.09 0.15 0.23* 0.13 0.14
* p < 0.05, ** p < 0.01. Sex: 1 = male, 2 = female.
†
Dummy coded from job category.

Copyright © 2005 John Wiley & Sons, Ltd. Stress and Health 21: 113–128 (2005) 123
 L. Smith et al.
the absolute residual. According to Klem (1995),
the absolute residual of 0.007 for the model indi-
cates a good fit between the original correlations
and those in the predicted model. Another model
that was based on the Reverse Causation theory
was tested and the absolute residual indicated a
good fit with the data.
The path model for ERI and CVD symptoms.
The Stress/Trait Model and the Reverse Causa-
tion Model were both tested using path analyses.
The Reverse Causation Model was not supported
by the data. However, the Stress/Trait Model
presented in Figure 2, showed significant as-
sociations between variables as predicted by the
theory. Therefore, it was concluded that the
Stress/Trait Model best represented the relation-
ship between ERI and CVD symptoms from the
data. The absolute residuals revealed that the dis-
tance between implied correlations and the orig-
inal correlations was the largest in age and sex.
Therefore, these variables were taken out of the
path model. The model is presented in Figure 3.
The effects of anger expression on CVD symp-
toms were assessed by the regression of CVD
symptoms on two predictor variables (anger in
and anger out). The results indicated that the two
predictors did not significantly account for the
variance in CVD symptoms R2 = 0.04, F(2, 109)
= 2.0, p > 0.05.
The effects of trait anger (predictor variable)
were then regressed on anger in, anger out and
CVD symptoms. The results indicated that trait
anger accounted for 19 per cent of the variance
in anger, 33.3 per cent of the variance in anger
out and 6 per cent of the variance in CVD
symptoms.
.90**
ERI
.19*
.44**
Ave Yearly –.21* Trait Anger
Salary
.58**
.06
Clerical/Sales/
.67**
Service
Figure 3. The path diagram for the stress/trait model. Note: *p < 0.05; **p < 0.01.
124 Copyright © 2005 John Wiley & Sons, Ltd.
The variables of ERI, salary and clerical/sales/
service significantly accounted for 10 per cent of
the variance in trait anger. All of the standardized
path coefficients between variables are presented
in Figure 3.
Discussion
It can be concluded that the Stress/Trait Model
proposed in Figure 2 represented the relationship
between ERI and CVD symptoms in this study
better than the Reverse Causation Model. The
path analysis for the model showed that trait
anger had a direct positive association with CVD
symptoms, supporting hypothesis 1. Further-
more, ERI had an indirect association with CVD
symptoms via trait anger. Therefore, the results
support the Stress/Trait theory that people who
have high trait anger as a result of a perceived
imbalance between their efforts and rewards at
work are more likely to show CVD symptoms.
However, the results did not support the hypoth-
esis that the anger expression variables of anger
in and anger out would mediate the relationship
between trait anger and CVD symptoms. Trait
anger alone mediated the relationship between
ERI and CVD symptoms, as predicted by hypoth-
esis 2. Salary also had a significant negative
association with trait anger and an indirect
association with CVD symptoms.
General discussion
The aim of Study 1 was to investigate the rela-
tionship between stress caused by ERI at work
Anger In .81*
.12
.23*
CVD
Symptoms
.13
Anger Out .97
Stress and Health 21: 113–128 (2005)

and state anger, while controlling for other pos-
sible confounding variables. In Study 2, trait
anger was not used as a control but as a predic-
tor variable with the additional aim of analysing
the relationship between ERI and CVD symp-
toms.
The results of Study 1 found that ERI was sig-
nificantly related to state anger after controlling
for confounding variables. In Study 2 ERI was
significantly associated with anger. The results
also revealed that ERI was not directly associated
with CVD symptoms, however a significant indi-
rect relationship was found between ERI and
CVD symptoms via trait anger. This implies that
trait anger is a potential mediator between ERI
and CVD symptoms. Furthermore, salary was
found to be associated with trait anger directly
and indirectly with CVD symptoms.
ERI and anger
Both Study 1 and Study 2 aimed to examine the
relationship between ERI and anger. Study 1
found a positive association between state anger
and ERI. This implies that people who experience
ERI at work were generally angrier during the
time of the data collection. However, Study 2
found a positive association between ERI and
trait anger. This result suggests that people who
experience an imbalance between their efforts
and rewards at work may develop an ingrained
tendency to experience higher levels of anger over
time. A link between the two studies is possible
considering that trait anger predisposes a person
to interpret events with higher anger and gener-
ally experience more state anger. Despite the lack
of research examining the specific relationship
between ERI and anger, the results of the current
study were consistent with the work of Chen and
Spector (1992), who also found a relationship
between work stressors and anger.
Implications for the model
An analysis of the ‘Stress/Trait Model’ found that
trait anger had a direct positive association with
CVD symptoms and that ERI had an indirect
association with CVD symptoms via trait anger.
These results imply that perceived high efforts to
low rewards at work may increase trait anger in
individuals through chronic stress, which in turn
increases their chances of experiencing CVD
Copyright © 2005 John Wiley & Sons, Ltd.
Effort-reward imbalance at work
symptoms. These conclusions are consistent with
the central concept of the ERI theory, which states
that a lack of reciprocity between efforts and
rewards at work may cause a state of emotional
distress that can lead to psychopathological prob-
lems (van Vegchel et al., 2001). Furthermore, this
finding supports the conclusion of Gallacher et al.
(1999) that numerous studies have reinforced
the belief that anger is related to heart disease.
However, the results did not support the hypoth-
esis that the anger expression variables of anger
in and anger out would mediate the relationship
between trait anger and CVD symptoms.
The SES indicator variable ‘average salary’ had
a significant negative association with trait anger
and an indirect association with CVD symptoms
in the model. The results indicated that a person
with a lower average yearly salary might have an
increased chance of experiencing high trait anger
and CVD symptoms. These results also support
other research linking low SES to CVD (Kuper
et al., 2002).
Practical implications
Study 2 highlights a possible process involving
trait anger, through which ERI may increase an
individual’s chance of experiencing CVD symp-
toms. The finding that ERI is related to CVD
symptoms is consistent with the findings of
numerous other studies (Bosma et al., 1998;
Kuper et al., 2002) and has implications at an
individual, community and organizational level.
CVD is recorded as one of the most common
causes of death in Western society. Hypotheti-
cally, reducing the prevalence of ERI at work may
improve the emotional and cardiovascular health
of many individuals. Reducing CVD symptoms
in employees may also have positive benefits for
organizations. Healthier employees have been
found to be more efficient at work, take fewer
sick days and give longer service to an organiza-
tion (Kasl, 1996; Peter & Siegrist, 1997).
Many studies have found that high levels of
anger can be harmful to the health of an individ-
ual and the function of an organization. A worker
who interprets events with increased anger and
generally experiences more anger will generally
not work at an optimum level and will show more
aggression to work mates, which is a common
organizational problem (Allcorn, 1994; Vander-
Voort & Ragland, 1996). Organizations need to
be aware that a lack of rewards provided to
Stress and Health 21: 113–128 (2005) 125
 L. Smith et al.
employees can cause negative emotional and phys-
ical health. Reducing ERI at work may involve
increasing rewards for employees not just through
salary or status, but through esteem and recogni-
tion and job security, or tackling demands directly.
On a final note, the discovery of an association
between average yearly salary, trait anger and
CVD symptoms deserves some discussion. The
link between low SES and CVD is well docu-
mented (Kuper et al., 2002) but not between low
SES and anger. People of lower SES (as measured
by salary) may be more vulnerable to the experi-
ence of higher anger because of their circum-
stances, which in turn could lead to CVD
symptoms.
Methodological limitations
The study had a number of limitations. Cross-
sectional designs were utilized for convenience
but are unable to determine causality. The rela-
tionships and order of variables presented in
the Stress/Trait Model are based on theory. The
model was judged a better fit of the relationship
between ERI and CVD symptoms than the
Reverse Causation theory from significant find-
ings in the results. For a concrete conclusion to
made concerning the order and causal influence
of variables in the relationship between ERI,
anger and CVD symptoms a longitudinal study
with numerous time waves would be preferable.
Another limitation is that unlike most other
studies researching ERI and CVD symptoms, the
current study used a self-report measure rather
than physiological measures of CVD symptoms.
Self-report measures of CVD symptoms are
generally inferior clinical judgement. Self-report
measures of CVD symptoms are at risk of
over-reporting or under-reporting prevalence
rates of symptoms. However, the aim of this
research was to examine associations between
variables and some caveats must be drawn
around interpreting evidence of prevalence rates
from the data. Unfortunately the current study
could only feasibly employ self-report measures
of CVD symptoms because of restrictions on
time, finance and resources. Although inferior to
objective measures of CVD, the London School
of Hygiene Questionnaire on Chest Pain is still
the most valid self-report measure of CVD symp-
toms (Bosma et al., 1998; Heyden et al., 1971;
Lundmen, Liljefors, Cederlöf & Friberg, 1971;
Ramsay et al., 2001; Rose, Blackburn, Gillum, &
126 Copyright © 2005 John Wiley & Sons, Ltd.
Prineas, 1982; Siegrist, personal communication,
March 11, 2003).
Finally the sample sizes were limited, which
may have influenced the power of both studies.
However, a high response rate of 81 per cent for
Study 1 and 73 per cent for Study 2, as well as
the sampling of a heterogeneous community popu-
lation enhanced the generalizability of the study.
Furthermore, both studies showed a very similar
job category pattern and public/private sector
ratio indicating that the population employment
demographics are consistent across studies, and
they were also representative of the Adelaide met-
ropolitan community.
Research directions
Although Study 1 and 2 contained possible limi-
tations, the results present an interesting picture of
the relationship between work stress, anger and
CVD symptoms. Future studies could build on
current findings to give an even greater picture of
the wide-ranging effects of ERI on public health.
Through improvements in sample size, more direct
measures of CVD symptoms and the utilization of
a longitudinal design, more reliable conclusions
relating to causality could be obtained.
Future directions for research could include dif-
ferent measures of physical and emotional health.
Other measures of physical symptoms may
involve musculoskeletal symptoms, sleep related
problems or immune related measures or blood
pressure. Finally, it would be a positive step to use
the information from this study and others to
redesign jobs to decrease ERI to offset the poten-
tially damaging consequences of anger to the indi-
vidual and to the organization. Interventions in
this area could enhance the emotional and physi-
cal health of workers and productivity of
organizations.
Acknowledgement
We would like to thank Professor Charles Spielberger
from the University of South Florida for his valuable
assistance.
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