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Ergonomics
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Gender analysis of musculoskeletal disorders and

emotional exhaustion: interactive effects from
physical and psychosocial work exposures and
engagement in domestic work
a a b
Christina Ahlgren , Eva-Britt Malmgren Olsson & Christine Brulin
a
Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University,
SE-90187, Umeå, Sweden
b
Department of Nursing, Umeå University, SE-90187, Umeå, Sweden
Published online: 17 Jan 2012.

To cite this article: Christina Ahlgren , Eva-Britt Malmgren Olsson & Christine Brulin (2012): Gender analysis of
musculoskeletal disorders and emotional exhaustion: interactive effects from physical and psychosocial work exposures and
engagement in domestic work, Ergonomics, 55:2, 212-228

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 Ergonomics
Vol. 55, No. 2, February 2012, 212–228

Gender analysis of musculoskeletal disorders and emotional exhaustion: interactive effects from
physical and psychosocial work exposures and engagement in domestic work
Christina Ahlgrena*, Eva-Britt Malmgren Olssona and Christine Brulinb
a
Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, SE-90187 Umeå, Sweden; bDepartment
of Nursing, Umeå University, SE-90187 Umeå, Sweden
(Received 3 August 2010; final version received 26 November 2011)

The objective of this study was to assess the relationships between physical and psychosocial work exposures,
engagement in domestic work and work-home imbalance in relation to symptoms of musculoskeletal disorders and
emotional exhaustion in white- and blue-collar men and women. Three thousand employees from 21 companies
were asked to answer a questionnaire on family structure, household and child care tasks, work exposure,
work-home imbalance and symptoms of neck/shoulder disorders, low back disorders and emotional exhaustion.
Downloaded by [University of Delaware] at 23:56 31 May 2013

Women reported more musculoskeletal disorders and engagement in domestic work. Adverse at-work exposures
were highest in blue-collar women. High engagement in domestic work was not separately associated with
symptoms but paid work exposure factors were associated. High engagement in domestic work interacted with
adverse work exposure and increased risk estimates for low back disorders and emotional exhaustion.
Reported work-home imbalance was associated with neck/shoulder disorders in women and with emotional
exhaustion in both women and men.

Practitioner Summary. The current article adds to earlier research by showing that high engagement in
domestic work is not separately associated with increased symptoms, but interacts with psychosocial work exposure
variables to produce emotional exhaustion in both women and men and low back disorders in women.
Keywords: physical work load; psychosocial factors; domestic workload; work-home imbalance; musculoskeletal
disorders; emotional exhaustion; gender

1. Introduction neck (Wijnhoven et al. 2007, Leboeuf-Yde et al.

Women have higher prevalences of neck and low back
disorders and perceived fatigue than men (Lindström
2005, Fejer et al. 2006, Leijon et al. 2007, Wijnhoven
et al. 2007, Messing et al. 2009). This gender difference
is consistently reported in public health surveys
(Lindström 2005, Wijnhoven et al. 2007, Messing
et al. 2009), occupational health studies (Lundberg
et al. 1994) and studies on care-seeking behaviour
(Leijon et al. 2007). For example, the 12-month
prevalence of neck pain was 18.4% in women and
10.9% in men in a Canadian public health survey
(Messing et al. 2009). In a Swedish working popula-
tion, prevalence figures for neck/shoulder arm pain
were 25% in women and 15.4% in men (Leijon and
Mulder 2009), for low back pain 16.4% in women
and 12% in men (Leijon and Mulder 2009), and for
emotional exhaustion 21.8% in women and 15.6% in
men (Magnusson et al. 2008). Higher prevalences of
musculoskeletal pain among women were found for
most body parts, but they were most prominent in the
2009, Messing et al. 2009).
Among explanations advanced for gender
differences in musculoskeletal pain are different
exposures to risk factors at work, differences in pain
reporting (Riley et al. 1998) and a higher total
workload among women due to higher engagement in
household chores and child care. Studies on gender
differences in work exposure are complicated by
gender segregation in the labour market, with women
and men holding different jobs, and being assigned
different work tasks within the same job title. For
example, in the fish processing industry where more
women than men were diagnosed with neck/shoulder
disorders (Nordander et al. 1999), exposure
measurements showed gender differences in exposure
profiles. Constrained work postures, repetitive arm
movements and less varied work tasks were more
prevalent among women, and heavy lifting among
men. According to an extensive literature review by
Palmer and Smedley (2007), repetitive arm movements

*Corresponding author. Email: christina.ahlgren@physiother.umu.se

ISSN 0014-0139 print/ISSN 1366-5847 online

Ó 2012 Taylor & Francis
http://dx.doi.org/10.1080/00140139.2011.646319
http://www.tandfonline.com
 Ergonomics
in combination with neck flexion are a risk factor for
neck pain. Other studies show that when women and
men have similar exposure to repetitive work tasks,
women report higher rates of neck/shoulder disorders
(Arvidsson et al. 2006, Nordander et al. 2009). In the
study by Arvidsson et al (2006), women rated their
psychosocial work environment as less good than did
men in the same job. Whether women and men face
different risk factors in relation to low back pain is
unclear because most studies of back pain do not
stratify for gender. Also, many studies show similar
risks of low back pain by gender (Punnett and Herbert
2000).
Hooftman et al. (2004) attempted to adjust for
labour market differences in a literature review that
calculated the gender ratio in risk estimates. They
found that awkward arm postures were a larger risk
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factor for neck/shoulder pain in women than in men
and that lifting weights carried a higher risk for back
pain in men than in women. However, since exposures
were not precisely estimated, it is not clear that men
and women were exposed at the same level to these
factors; men could have lifted heavier weights and arm
postures of women might have been more awkward.
Lower evidence grades for relations between neck/
shoulder and low back disorder and psychosocial work
factors than for physical exposure are found in a
review by Palmer and Smedley (2007). A review of
longitudinal studies concludes that high work demands
and low control at work cause neck/shoulder disorders
although the relation is weak and unspecific (Bongers
et al. 2006). No conclusive evidence of gender dif-
ferences in relation to psychosocial exposure variables
such as demand/control, or social support and risk for
musculoskeletal pain was found by Hooftman et al.
(2004). Emotional exhaustion is a subscale of the
Maslach Burnout Inventory (Maslach et al. 1996) and
has been used separately to measure negative con-
sequences of adverse psychosocial working conditions.
High work demands and low decision authority are
found to be similar risk factors for emotional exhaus-
tion in men and women (Magnusson et al. 2008).
Social support is similarly associated with emotional
exhaustion in both men and women, although low
support from superiors was more important for men,
and support from fellow workers was more important
for women (Magnusson et al. 2008).
Studies are inconclusive on whether the known
higher exposure of women to a double workload, i.e.
they are both employed and responsible for household
work and child care, explains their poorer health. A
number of studies, in Sweden and other countries,
found that women had a higher total workload when
work outside and in the family setting were considered
together (Gjerdingen et al. 2000, Emslie et al. 2004,
213
Väänänen et al. 2004, Kranz et al. 2005, Berntsson
et al. 2006). Although these studies were performed
in different countries with different employment rates
for women, the results are consistent: Women have a
total workload exceeding that of men by five to nine
hours per week (Lundberg et al. 1994, Väänänen et al.
2004, Gjerdingen et al. 2000, Emslie et al. 2004).
Over the long term, a consistently higher workload
may be expected to have negative health effects
through increased physical and psychological strain as
well as fewer recovery periods. However, the
associations between a high total workload and
measures of ill health are inconclusive. Household
responsibilities and job strain are both independent
risk factors for increased symptoms (most frequently
reported as musculoskeletal disorders and tiredness) in
women; interactions between these variables increase
the risk (Krantz and Östergren 2001). Using the
presence of children in the family as a proxy for
increased total workload has shown an association
between this measure and health problems among both
women and men. A longitudinal study found increased
fatigue when both men and women who were
employed full-time became parents (Nordenmark
2004a). With public health data, Floderus et al. (2008,
2009) found that full-time working mothers had more
symptoms and worse self-rated health compared to
women without children who were in full-time work.
The association is strengthened by a greater number of
children (Floderus et al. 2008, 2009). A greater number
of children was also associated with increased low back
pain in both women and men (Silman et al. 1995).
These findings support the role stress theory, which
suggests that overload due to simultaneous demands
from several sources can lead to health problems
because of increased physical workload and/or
increased stress from conflicting demands (Lundberg
et al. 1994, Nordenmark 2004a). However, other
studies support a contradictory theory – the multiple
role theory, which states that engagement in many
arenas is beneficial for health since negative
experiences in one area can be outweighed by positive
experiences in another, and that multiple roles
promote health through increased social support, self-
esteem and a better financial situation (Sorensen and
Verbrugge 1987, Marshall and Barnett 1993,
Nordenmark 2004b). Support for this theory is found
in different settings. In studies on white-collar
employees, a high total workload is not associated with
higher scores on a symptom scale (Berntsson et al.
2006, Mellner et al. 2006). Full-time working women
do not seek care for neck/shoulder or low back
symptoms at a higher rate than part-time working
women (Josephson et al. 2003). Holding several social
roles and increasing the number of social roles are both
 214 C. Ahlgren et al.
associated with decreased symptoms of ill health
among Swedish men and women in a longitudinal
study (Nordenmark 2004b). The fact that both theories
of increased and diminished effects of a double
workload find support in empirical studies indicates a
complex association between health and strain from a
double work-load. Some studies find that only an
extremely high total workload constitutes a health risk.
For example, only women with a total paid workload
of more than 60 h per week, or more than 40 h per
week of household work, show an increased risk of
seeking care for low back pain (Josephson et al. 2003).
White-collar employees who work more than 80 h per
week experience stress in paid work but have no
increase in symptoms of ill health (Berntsson et al.
2006).
Long work hours or work in several arenas (both
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housework, child care and employed work) might not
induce health problems, but conflicting demands from
work and family have negative health effects (Emslie
et al. 2004, Väänänen et al. 2004). Both men and
women who face work-home conflicts report health
problems as defined by psychological symptoms
(Emslie et al. 2004, Väänänen et al. 2004), physical
symptoms and self-reported health (Emslie et al. 2004).
The perception of work-family conflict may differ for
women and men. Some studies show that women
experience negative work-to-family spill over as more
detrimental to health than do men, yet negative family-
to-work spill over is experienced similarly by women
and men (Väänänen et al. 2004, Mennino et al. 2005).
Cultural demands who calls for women to take on
household work and child care in order to be a good
mother and wife despite holding an employment might
lead to exhaustion due to lack of recovery (Tierney
et al. 1990). Lundberg and Frankenhaeuser (1999)
showed, in a study on managerial workers, increased
levels of stress hormones in women at the end of the
work day, while men’s stress hormones continued to
decrease. The authors interpreted the result as if
women started a ‘new work shift’ at home.
The objective of our study was to assess the
interaction between physical and psychosocial work
exposure and the domestic workload, as well as work-
home imbalance, with symptoms of musculoskeletal
disorders and emotional exhaustion in white- and blue-
collar men and women.
2. Materials and methods
Data were collected in Sweden during 2008 as part of a
study on gender equality in health. The study was
cross-sectional and administered to employees in
companies that were characterised as more or less
gender equal. Nine thousand companies in the Swedish
private labour market were ranked according to a
gender equality score. The gender equality score was
constructed from the distribution of the following
register data for women and men in the company: ratio
of employed men to women; salaries for women and
men; number of days off work for temporary child care
and ratio of women to men in leadership positions
within the company (Sörlin et al. 2011). The gender
equality score was used as a proxy for gender
equality attitudes in the organisation, which for
example could mean that men were encouraged to take
parental leave and that women and men in the same
job were equally paid. Statistics Sweden then chose 21
companies, 9 in computer science and 12 in the food
industry, as a representative sample of companies with
high and low demands for education among employees
and high and low scores on gender equality The
companies varied in size from small companies with a
couple of employees to large companies with more
than 200 employees. Small and large companies were
equally represented in the two industrial sectors.
Thereafter, Statistics Sweden distributed a
comprehensive questionnaire to 3000 employees in the
21 selected companies.
The questionnaire included questions on
demographics, employment hours, family structure,
household work tasks, physical and psychosocial work
exposures, work-home imbalance, perceived gender
equality, health-related factors and lifestyle factors.
This article presents analyses concerning employment
hours, physical and psychosocial work exposure,
household and child care work tasks, work-home
imbalance, and neck/shoulder pain, low back pain and
emotional exhaustion.
2.1. Work-related questions
Questions related to paid work included occupational
title, employment status (permanent, temporary, self-
employed), working hours (full-time, long part-time,
short part-time), physical work exposure and
psychosocial work exposure. Occupational titles were
classified into categories according to a manual issued
by Statistics Sweden (1983). Thereafter, occupational
categories were classified into blue- and white-collar
workers using the Swedish socioeconomic classification
(SEI) of occupational categories (Statistics Sweden
1983). Twenty-four employees could not be classified
due to lack of occupational title. In Sweden, full-time
work is defined as working 38–40 h per week.
Responses on employment hours were categorised as
full-time work (90–100% of full time), long part-time
work (50–89% of full-time) and short part-time work
(less than 50% of full-time). A work week variable was
constructed by assigning a full-time work score of
 Ergonomics
3 and long part-time work score 2 and short part-time
work score 1.
A constrained and physical heavy work variable was
constructed from three questions: hours doing con-
strained work, hours in bent and twisted postures, and
frequency of lifting/carrying objects. Constrained work
was measured with the question, ‘How much of an
ordinary workday is your work so constrained that you
cannot leave your work station for a short while?’ and
scored on a six-point scale from nothing at all to almost
all the time. Bent and twisted postures were measured
by: ‘How often do you bend and twist your body the
same way several times an hour?’ scored on a five-point
scale from never to every day. ‘How often do you lift or
carry objects weighing more than 10 kilos at work?’ was
scored on a 4-point scale from never to more than 50
times a day. In the analyses, each question was dichoto-
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mised into a high and low exposure group. High
exposure was defined as having constrained work half
or more of the working day, bending and twisting the
body several times an hour more than two to three times
a week, or lifting 10 kg more than 10 times a day. High
exposure in two of the three questions was considered as
a high constrained physical workload and other
response categories as light physical workloads.
The demand/control questionnaire (Karasek and
Theorell 1990) was used to measure psychosocial
exposure at work. This validated Swedish version has
five questions that deal with psychological demands
and six questions that deal with decision latitude or
work control. Responses were summed into demand
and control indices, with high values representing high
demands and high control respectively. Each index was
dichotomised into a high and low exposure group
based on the upper quartile. Social support at work
was measured with questions from Karasek and
Theorell (1990). Six questions were rated on a 4-point
scale from ‘agree totally’ to ‘do not agree at all’.
Responses were summed into a social support index
and dichotomised into a high and low social support
group based on the upper quartile.
2.2. Family-related questions
Family-related questions were: living with a partner or
single; number of children; children’s ages; and time
engaged in household and child care tasks relative to
spouse/partner engagement. A household work index
was formed using two criteria. The first set of
indicators measured which partner in the relationship
spent more time doing the following household chores:
(1) cleaning the house, (2) cooking and washing dishes,
(3) regular shopping, (4) doing the laundry and (5)
planning and organising housework. Each question
was answered as ‘I spend the most time’, ‘we share
215
equally’, or ‘my partner spends the most time’ and was
scored as 3, 2, or 1, respectively. Respondents who
lived alone were assigned a score of 2 (the same as
sharing equally) and single parents were assigned a
score of 3 for the tasks. Scores for the five questions
were summed and divided by five, giving an average
score of 1 to 3. Cronbach’s alpha for the average score
was 0.75. In order to adjust the household workload to
family size, the average was upgraded for the number
of children below 18 years of age. Eighteen years of age
was chosen, as most young people live with their
parents until leaving upper secondary school, and
household work tasks as cooking, regular shopping or
doing the laundry were not expected to be reduced in
families with teenagers. In order to not overestimate
household work at the expense of employed work, we
estimated that two children did not imply double
amount of household work compared to one child.
Therefore, the average of work tasks was multiplied by
1.25 for one child, 1.5 for two children, 1.75 for three
children and 2 for four or more children. The
household work index ranged from 1 to 6. A higher
value indicates a higher workload. Time spent in child
care tasks compared to the partner was used to
construct a child care index in the same way as the
household workload index. The rated tasks included:
(1) drop off and pick up children at the child care
centre; (2) participate in child care or school meetings
or take the children to the dentist or doctor and (3)
take the children to and from leisure activities. The
tasks were rated from 1 to 3 according to which
member of the couple used the most time for the
activities. Taking children to day care was only
reported by respondents with pre-school children, few
respondents with children older than 12 years reported
tasks as taking children to and from leisure activities.
Participating in school meetings or taking children to
doctor and dentist was primarily reported by couples
with children below 12 years. To not disregard families
with older children doing such tasks 18 year as the
child’s age was chosen. Respondents with no children
or children older than 18 years were given a score of 0.
Thus, the child care index ranged from 0 to 3 and
higher values indicate a higher workload. Cronbach’s
alpha for the index was 0.84.
2.3. Work-home imbalance
Two questions from the General Nordic Questionnaire
for Psychological and Social Factors at Work (QPS)
(Wännström et al. 2009) were used to measure perceived
work-home imbalance. The two questions were ‘Do
demands from your home and family affect your work
negatively?’ and ‘Do demands from your work affect
your home and family negatively?’ The responses were
 216 C. Ahlgren et al.

scored from 1 to 5, (1 being ‘very seldom or never’ and 5
being ‘very often/always’), summed and averaged to a
score from 1 to 5. In the analyses, the score was
dichotomised at the upper quartile.
2.4. Health-related questions
The Nordic questionnaire (Kuorinka et al. 1987) was
chosen to capture the prevalence of musculoskeletal
disorders. Disorders in the neck, shoulders, upper back
and lower back during the last three months and
whether the disorders led to absence from work were
rated. Answers of ‘no’ were given a score of 1, ‘yes’ was
scored as 2 and a disorder leading to absence from
work was scored as 3. The demarcation between the
neck and the shoulders when reporting common work-
related disorders as shoulder myalgia and tension neck
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odds ratios were also adjusted for the work-related
confounding variables company’s gender equality
score, employment hours and blue- or white-collar
worker. Interaction between work exposure variables
and domestic work load was studied using additive
interaction according to Rothman and Greenland
(1998). Interaction variables for work exposure and
domestic work were constructed by combining
engagement in domestic work load with each of the
work exposure variables demand, control, support and
physically heavy work. Interaction variables were
constructed as dummy variables with four exposure
strata. Stratum one with no/low exposure at work and
low engagement in domestic work load (reference
category), Stratum two low exposure at work and high
engagement in domestic work load, Stratum three
high work exposure and low engagement in domestic

syndrome is difficult. Therefore, the symptom loca- work load and Stratum four high work exposure and
tions were treated together. Scores from the neck and high engagement in domestic work load. The
shoulder were averaged to a neck-shoulder index distribution of the study population in the different
ranging from 1 to 3, with higher values indicating a exposure strata is shown in Table 1. Thereafter,
greater disorder. Cronbach’s alpha for the index was interaction was tested using a synergy index (SI) as
0.77. The index was dichotomised at the upper quartile proposed by Rothman and Greenland (1998). A
for logistic regression analyses. Scores from 75th synergy index (SI) 4 1 was considered as interaction,
percentile and above were defined as severe disorders while a synergy index (SI) 5 1 was considered as no
and scores below this were defined as no or mild interaction. SI was determined using the algorithm;
disorders. Scores on low back disorders (LBP) were
dichotomised, and scores of three were defined as
RRðABÞ  1
having a severe disorder, while lower scores were SI ¼
defined as no or mild disorder. RRðAb  1Þ þ RRðaB  1Þ
Emotional exhaustion was measured with the
emotional exhaustion subscale of the Maslach Burnout RR ¼ risk ratio
Inventory (Maslach et al. 1996). The scale consists of Ab ¼ exposed to one of the factors
five questions rated on a 6-point scale from every day
to a few times per year or less. Responses were summed Table 1. Number of men and women in different
and averaged for an emotional exhaustion index from exposure strata used in analysed of interaction
1 to 6, with a higher value indicating more exhaustion. between psychosocial and physical exposure variables
and domestic workload.
Cronbach’s alpha for the index was 0.86. For logistic
regression analyses, the index was dichotomised at the Stratum 1 2 3 4
75th percentile.
Work demand and domestic workload
Men 482 125 180 51
Women 235 106 109 35
2.5. Statistical analyses
Work control and domestic workload
The statistical analyses were performed using SPSS/PC Men 524 142 138 34
software package (PASW 18.0.1). Basic analyses were Women 184 94 155 45
stratified by gender and occupational status (blue- and Work support and domestic workload
white-collar worker). Between-group analyses were Men 377 99 286 77
performed using Pearson chi-square tests (categorical Women 181 85 166 54
variables) and independent two sample t-tests (con- Heavy physical work and domestic workload
tinuous variables). Associations between each health Men 493 139 167 36
Women 218 111 131 31
outcome variable and work exposure and domestic
work load were analysed using univariate logistic Notes: Stratum 1 Low work exposure þ low engagement in
regressions stratified by gender. In a second step, the domestic work. Stratum 2 Low work exposure þ high engagement
in domestic work. Stratum 3 High work exposure þ low
odds ratios were adjusted for personal confounding engagement in domestic work. Stratum 4 High work
variables such as age and smoking and in a third step exposure þ high engagement in domestic work.
 Ergonomics 217

aB ¼ exposed to the other factor
AB ¼ exposed to both factors
Odds ratios were used as estimates of relative risk.
Associations between each interaction variable
and the respective health outcome (neck/shoulder
disorder, low back pain and emotional exhaustion)
was calculated. The same step-wise inclusion of
confounding variables was used in analysis of interac-
tion variables as for separate exposure variables. Crude
and adjusted odds ratios are shown. Multivariate
logistic regression modelling was performed separately
for each health outcome variable. Firstly, all explana-
tory variables with a significant association were
included together with confounding variables. Sec-
ondly, interaction variables with estimates indicating
interaction in univariate analyses replaced separate
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respondents were older than 65 years of age. They
were excluded because 65 years is the usual retirement
age in Sweden. Women, older and more educated
respondents were slightly over-represented among
respondents compared to the non-respondents. For 24
respondents occupational title was missing so they
could not be classified as white- or blue-collar workers.
3. Results
Responses from 1373 employees constituted the basis
for the analysis: 813 white-collar workers (551 men and
262 women) and 560 blue-collar workers (307 men
and 253 women). White-collar workers included 76%
of employees in the computer science sector and 24%
employees in the food production sector, while
blue-collar workers included 98.5% employees in the

exposure variables in the model. Logistic regression
analyses are presented with odds ratios (OR) and 95%
confidence intervals (CI)
The study was approved by the Research Ethics
Committee at Umeå University.
2.6. Response rate and drop outs
In total, 1407 employees responded to the question-
naire with a response rate of 49.2%. Ten of the
food production sector. The mean age was 42.3 (10.7)
years with no significant difference between blue- and
white-collar workers or between men and women. As
expected, white-collar employees had higher education
with about 70% of both men and women holding a
university degree. This compares to less than 10% of
blue-collar men and women with university degrees.
Twenty-six per cent of blue-collar men and 33% of
blue-collar women reported compulsory school as their
highest education (Table 2).

Table 2. Distribution of demographics characteristics and work-related variables among white- and blue-collar
men and women.

White-collar workers Blue-collar workers

Variable Men (n ¼ 551) Women (n ¼ 262) Men (n ¼ 307) Women (n ¼ 253)
Mean age (M, SD) 42.5 (9.5) 40.7 (8.9) 41.3 (11.8) 44.3(12)
Education (%)
Compulsory school 5.2 1.9 25.7g 33.3g
Secondary school 26.1 24.3 65.5g 59.8
University 68.9g 73.7g 8.9 7.8
Family situation (%)
Living with partner 81.4 85.4 72.1 75.3
Children 74.7 77.8 67.2 79.2
Children 18 years 54.7g 61.8*g 47.2 40.9
Children 12 years 42.6g 50.4*g 32.3 24.0
Children 7 years 29.7g 37.6*g 22.4* 11.8
Employment status (%)
Permanent 97.7 95.8 88.5 87.7
Temporary 1.2 3.1 9.6g 21.9g
Self-employed 1.8 1.1 1.0 0.8
Working hours (%)
Full-time 96.2* 76.2 88.9* 72.7
Long part-time 3.5 22.8* 8.8 22.9*
Short part-time 0.4 0.8 2.3g 4.4g

Notes: *Statistically significant difference between men and women in the white- or blue-collar work group respectively. gStatistically
significant difference between women in blue- and white collar work or men in blue- and white collar work. Chi-square test was used
in the analyses and the significance level set to p 5 0.05.
 218 C. Ahlgren et al.

3.1. Family structure and work load from house hold
chores and child care
The majority of both white- and blue-collar workers
were living in partnerships and had children. Eighty-
two per cent of respondents with children had one to
two children and only 11 respondents had more than
three children. White-collar women had children below
12 years of age significantly more often than white-
collar men or blue-collar men or women, while blue-
collar women more often had children older than 18
years (Table 2).
Distribution of the household work index showed
that women were more engaged in household chores
than their partners, both in families with and without
children (Table 3). The most equally shared household
tasks were shopping and planning or organising the
household. The most unequal tasks were doing the
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men. Full-time working hours were higher among men
than women and highest among white-collar men.
Family situation had little influence on men’s working
hours. Twenty-two per cent of women in both white-
and blue-collar work worked long part-time hours
(Table 2). Women with children below 12 years of age
worked part-time more often than men or women with
older children. Blue-collar workers reported higher
rates of adverse working conditions, both physical and
psychosocial, than did white-collar workers, but the
latter reported a higher rate of intense VDU work.
The highest rates of adverse working conditions were
found among blue-collar women, with significantly
higher exposure to all variables (Table 3).
3.3. Work-home imbalance

laundry and cleaning the house, and women spent
more time than their partner on both. White-collar
women reported spending more time than their partner
on child care compared to both white-collar men and
blue-collar women and men (Table 3). The child care
task most often shared equally between spouses was
taking the children to leisure activities.
3.2. Work situation and work load
3.2.1. Paid work
Permanent employment with full-time work was the
most common employment status for both women and
White-collar men and women experienced slightly
but not significantly higher work-home imbalance than
blue-collar workers. For both men and women, the
work-home imbalance increased when there were
children in the family (Table 3).
3.4. Musculoskeletal disorders and emotional
exhaustion
The prevalence of neck/shoulder and low back
disorders as well as emotional exhaustion during the
three preceding months was high, and even higher
among blue-collar than white-collar workers (Table 4).
Among both white- and blue-collar workers, women

Table 3. Exposure to risk factors at work, household work index in different family configurations, and child care index
by age of child in white- and blue-collar men and women.

White-collar workers Blue-collar workers

Variable Men (n ¼ 551) Women (n ¼ 262) Men (n ¼ 307) Women (n ¼ 253)
Work exposure (%)
High demands
Low control 7.4 10.5 43.2g 72.7*g
Low support 39.1 34.5 49.2g 55.5*g
Physically heavy work 5.9 5.4 55.1g 65.4*g
Intense VDU-work 85.5g 92.6g 7.3 10.6
Work-home imbalance (%) 29.9 24.4 21.1 22.4
Children 12 years (%), (n ¼ 526) 37.4g 32.8g 28.4 19.7
High total workload (%) 23.3g 37.5*g 16.2 20.0*
Household work index (M, SD)
Partner, no children (n ¼ 341) 1.8 (0.3) 2.2 (0.3)* 1.9 (0.3) 2.2 (0.4)*
Partner and children (n ¼ 903) 2.1 (0.7) 3.4 (0.9)* 1.9 (0.8) 2.9 (0.9)*
Single and children (n ¼ 162) 3.9 (0.7)* 3.3 (0.8) 3.7 (0.9) 3.6 (0.7)
Child care index (M, SD)
Children 12 years (n ¼ 526) 1.9 (1.1) 2.3 (1.3)*g 1.7 (1.1) 1.4 (1.4)
Children 18 years (n ¼ 698) 1.7 (1.1) 2.1 (1.3)*g 1.4 (1.1) 1.4 (1.3)
Domestic work index (M, SD), (n ¼ 1370) 3.1 (1.5)g 4.4 (2.1)*g 2.8 (1.5) 3.4 (1.7)*

Notes: *Statistically significant difference between men and women in the in the white- or blue-collar work group respectively.
g
Statistically significant difference between women in blue- and white collar work or men in blue- and white collar work. Chi-square test was
used in analyses of percentage distributions and independent samples t-test for indices. The significance level was set to p 5 0.05.
 Ergonomics 219

Table 4. Prevalence of neck/shoulder disorders, low back disorders, and emotional exhaustion among white- and
blue-collar men and women with and without home living children.

White-collar workers Blue-collar workers

Variable Men (n ¼ 551) Women (n ¼ 262) Men (n ¼ 307) Women (n ¼ 253)
Neck/shoulder disorders (%) 25.1 51.7* 35.9g 63.3*g
No or grown up children 20.2 55.6* 35.8g 60.5*
Children 518 years 24 54.6* 34.1g 64.0*
Low back disorders (%) 38.7 42.1 54.1g 63.3*g
No or grown up children 44.0 51.9* 54.5g 65.3*g
Children 518 years 39.3 42.0 59.2g 63.0*g
Emotional exhaustion (%) 19.6 23.3 32.6g 45.6*g
No or grown up children 14.2 23.1* 29.3g 43.0*g
Children 518 years 19.6 24.1 37.2g 49.5*g

Notes: *Statistically significant difference between men and women in the white- or blue-collar work group respectively (Chi-square
test and p 5 0.05). gStatistically significant difference between women in blue- and white collar work or men in blue- and white collar
work. Chi-square test was used in the analyses and the significance level set to p 5 0.05.
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had a higher prevalence of neck/shoulder disorders and
blue-collar women had the highest prevalence of low
back disorders and emotional exhaustion (Table 4).
No difference in neck/shoulder disorders was found
between employees with and without children irrespec-
tive of the children’s ages. Employees without children
living at home had higher prevalence’s of low back
disorders than employees with children below 18 years,
while the opposite was found for prevalence’s of
emotional exhaustion (Table 4). There was no differ-
ence between full and part-time working men or
women in prevalence of neck/shoulder or low back
disorder. White-collar women in full-time work had
significantly higher scores on emotional exhaustion
compared to part-time working white-collar women
(p ¼ 0.04, independent t-test) (data not shown).
3.5. Associations between health outcome variables
and interaction between work exposure and domestic
work load and work-home imbalance
3.5.1. Neck/shoulder disorders
Univariate analyses showed no increased risk for neck/
shoulder disorders in employees with high engagement
in domestic work or employees in companies cate-
gorised as less gender equal (Table 5). Significant
associations with neck/shoulder disorders were found
for smoking [OR 1.9 (1.2–3.1)], full-time work [OR 1.7
(1.1–2.6)] and being a blue-collar worker [OR1.7 (1.2–
2.3)] in men and being a blue-collar worker [OR 1.6
(1.1–2.3)] in women (Table 5). All work exposure
variables were significantly associated with neck/
shoulder disorders also after adjusting for personal
and work-related confounding variables. In men the
adjusted association with high work demands reached
[OR 1.7 (1.2–2.8)], low work control [OR 1.7 (1.0–2.4)],
low work support [OR 1.4 (1.0–1.9)] and constrained
physical heavy work [OR 2.0 (1.4–2.8)]. In women
high work demands did not reach significance, but the
adjusted odds ratio for low work control was [OR 1.7
(1.2–2.5)], low work support [OR 1.7 (1.2–2.5)] and
constrained physical heavy work [OR 1.7 (1.0–2.5)]
(Table 5). Work-home imbalance was significantly
associated with neck/shoulder disorders in women with
[OR 1.6 (1.1–2.5)] (Table 5). No significant interactions
were found between engagement in domestic work and
physical or psychosocial work exposure variables. In
the multivariate models, all variables significantly
associated in univariate analyses together with
personal and work-related confounding variables were
included. Only high work demands remained
significantly associated with neck/shoulder disorders
in men with [OR 1.5 (1.1–2.2)] and in women only
work-home imbalance with [OR 1.6 (1.1–2.5)]
remained significant (Table 5).
3.5.2. Low back disorders
Univariate analyses showed no increased risk for low
back disorders in employees with high engagement in
domestic work or employees in companies categorised
as less gender equal (Table 6). Work exposure variables
significantly associated with low back disorders in
univariate analyses adjusted for personal and work-
related confounding variables in men was low work
support with [OR 1.3 (1.0–1.7)] and in women low
work control [OR 2.3 (1.4–3.8)], low work support
[OR 2.1 (1.3–3.4)] and constrained physical heavy
work [OR 2.1 (1.3–3.4)] (Table 6). Interaction between
high engagement in domestic work and exposure to
low work control and low work support was found in
women. Odds ratios for an association between low
back disorders and low work control increased from
 220 C. Ahlgren et al.

Notes: Crude estimates and estimates adjusted for age, smoking, company’s gender equality, employment hours, blue collar work and number of children below 18 years in the family are given as
0.8 (0.5–1.4)
1.3 (0.9–1.9)
1.0 (0.5–1.7)

(0.8–1.9)
(0.9–2.4)
(0.9–2.1)
(0.7–2.2)
(1.0–2.4)
Table 5. Logistic regression analyses showing univariate associations and the most fitted multivariate model between neck/shoulder disorders and exposure to engagement

1.0(0.9–1.0)
1.1 (0.6–2.1)

(0.8-1.1)
[OR 1.6 (0.9–3.8)] in Stratum 2 to [OR 2.7 (1.5–4.7)]

Women
Multivariate model
in Stratum 3 and [OR 3.4 (1.4–8.3)] in Stratum 4 and
for an association with low support at work from

0.9
1.2
1.4
1.4
1.3
1.5
[OR 1.6 (0.7–3.4)] in Stratum 2 to [OR 1.9 (1.2–3.1)] in
Stratum 3 to [OR 3.2 (1.5–6.9)] in Stratum 4 (Table 6).

(0.7–2.1)
(0.5–1.4)
(0.9–2.3)
(0.8–1.9)

(1.1–2.2)
(0.8–1.9)
(0.9–1.2)
(0.9–2.2)
(0.9–1.7)
(0.8-1.9)
(0.9–10) Work-home imbalance did not increase the risk for low
Men

back disorders in either women or men. In the

multivariate model stratified by gender and adjusted
1.0
1.2
0.9
1.4
1.2

1.0
1.5
1.3
1.1
1.4
1.2

odds ratios (OR) and 95% confidence intervals. Different combinations between work exposures and engagement in domestic work are given as interaction strata.
by personal and work-related confounding variables,
0.8 (0.6–1.2)a 0.9 (0.6–1.3)b the separate variables for work control and work

1.5 (1.0–2.2)a 1.4 (0.9–2.1)b

1.8 (1.3–2.6)a 1.7 (1.2–2.5)b
1.8 (1.2–2.5)a 1.7 (1.2–2.5)b
1.8 (1.2–2.6)a 1.7 (1.0–2.5)b
0.9 (0.8-1.1)a 0.9 (0.8-1.1)b support were replaced with interaction variables. In the
model for men being a blue-collar worker was the only
Women adjusted

variable that remained significantly associated with

low back disorders. In the multivariate model for
1.6 (1.1–2.5)b women constrained physical heavy work remained
0.7 (0.8–2.1)a
1.1(0.8–1.6)a
1.6 (1.1–2.4)a

significant and in the interaction variable combining

work control with engagement in domestic work the
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risk for low back disorders increased from [OR 2.6

(1.3–5.2)] in Stratum 2 to [OR 3.2 (1.9–5.2)] in Stratum
3 to [OR 5.3 (2.5–11.5)] in Stratum 4. The interaction
Women crude
(1.0–1.0)
(0.8–2.3)
(0.4–1.0)
(0.8–1.6)
(1.1–2.3)
(0.5–1.1)

(1.2–2.5)
(1.3–2.6)
(1.2–2.6)
(1.0–2.4)
(0.7-1.3)

variable combining work support and engagement in

(1–2.2)

domestic work showed an inverse direction in the

Univariate model
in domestic work and exposure to psychosocial and physical work factors and work home imbalance.

multivariate analysis compared to the univariate

1.0
1.4
0.6
1.2
1.6
0.8
1.0
1.5
1.8
1.8
1.8
1.6

analysis. Low support at work together with high

engagement in domestic work (Stratum 4) was not in
the model, low support at work and low engagement in
(0.9–2.2)b

(1.2–2.4)b
(1.0–2.4)b
(1.0–1.9)b
(1.4–2.8)b
(0.9-1.1)b

domestic work (Stratum 3) remained significant with

[OR 1.7 (1.1–2.8)] and high support at work and high
Men adjusted

engagement in domestic work significantly reduced

(0.7–1.5)a 1.4
(0.9–1.1)a 1.0
(1.2–2.8)a 1.7
(1.2–2.5)a 1.7
(1.1–1.9)a 1.4
(1.5–2.9)a 2.0

the odds ratio to [OR 0.5 (0.3–9.9)] compared to the

(0.9–1.7)b
(0.6–1.4)a
(1.0–2.5)a
(1.1–2.1)a

reference category high support and low engagement

in domestic work. This indicates a shared variance
between the variables work control and work support
0.9
1.6
1.5
1.0
0.9
1.7
1.7
1.4
2.0
1.2

in associations with low back disorders.

(1.0–1.0)
(1.2–3.1)
(0.5–1.3)
(1.1–2.6)
(1.2–2.3)
(0.7–1.4)
(0.8–1.3)
(1.2–2.3)
(1.4–2.7)
(1.1–2.0)
(1.6–3.1)
(0.8–1.6)
Men crude

3.5.3. Emotional exhaustion

Univariate analyses showed no increased risk for
1.0
1.9
0.9
1.7
1.7
1.0
0.9
1.7
1.9
1.5
2.2
1.2

emotional exhaustion in employees with high

engagement in domestic work or employees in
Occupational status (white collar/blue collar)

companies categorised as less gender equal (Table 7).

Constrained physical heavy work (no/yes)
Work support (high support/low support)

All work exposure factors showed significant over-

Work control (high control/low control)
Employment hours (part-time/fulltime)

risks for emotional exhaustion, also after adjusting for

High engagement in domestic work

personal and work-related confounding variables. In

Company’s gender equality index

men high work demands reached [OR 6.1 (4.3–8.7)],

Number of children 518 years

low work control [OR 2.2 (1.5–3.3)], low work support

Work demands (low/high)

[OR 3.8 (2.7–5.4)] and constrained physical heavy

work [OR 3.9 (2.5–6.0)] (Table 7). The corresponding
Work-home imbalance

over-risks in women were high work demands [OR 5.1

Smoking (no/yes)

(3.3–7.8)], low work support [OR 3.7 (2.5–5.6)] and

constrained physical heavy work [OR 2.2 (1.4–3.7)].
Age (years)

Experienced work-home imbalance increased the risk

Variables

for emotional exhaustion in both men and women with

[OR 3.5 (2.5–5.0)] and [OR 5.1 (3.2–8.1)], respectively.
Engagement in domestic work showed interactions
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Table 6. Logistic regression analyses showing univariate associations and the most fitted multivariate model between low back disorders and exposure to engagement in
domestic work and exposure to psychosocial and physical work factors and work home imbalance.

Univariate model Multivariate model

Interaction Men Women
Variables strata Men crude adjusted crude Women adjusted Interaction Men Women
Age (years) 1.0 (0.98–1.0) 1.0 (0.9–1.0) 1.0 (0.9–1.0) 1.0 (0.9–1.0)
Smoking (no/yes) 1.9 (1.2–3.0) 1.2 (0.8–2.0) 1.6 (0.9–2.8) 1.2 (0.6–2.1)
Company’s gender equality index 0.9 (0.6–1.5) 1.0 (0.7–1.5)a 0.6 (0.4–0.9) 0.6 (0.4–0.9)a 1.1 (0.7–1.7) 0.9 (0.5–1.5)
Employment hours (part-time/fulltime) 1.4 (0.9–2.2) 1.4 (0.9–2.1)a 1.2(0.9–1.6) 1.2 (0.9–1.6)a 1.2 (0.8–2.0) 1.1 (0.8–1.5)
Occupational status (white collar/blue collar) 1.9 (1.4–2.5) 1.8 (1.3–2.4)a 2.7 (1.9–3.8) 2.6 (1.8–3.8)a 1.6 (1.1–2.3) 1.2 (0.7–2.2)
Number of children 518 years 1.0 (0.9–1.2) 1.1 (0.9–1.4)a 0.9 (0.8–1.1) 1.1 (0.8–1.5)a 1.0 (0.9–1.2) 0.8 (0.6–1.1)
High engagement in domestic work 1.0 (0.7–1.4) 0.9 (0.6–1.3)a 0.9 (0.7–1.3) 0.9 (0.6–1.3)a 1.0 (0.9–1.0) 1.0 (0.9–1.0)
1.1 (0.8–1.6)b 1.2 (0.8–1.8)b
Work demands (low/high) 1.4 (1.1–1.9) 1.4 (1.0–1.9)a 1.3 (0.9–1.9) 1.3 (0.9–1.9)a 1.6 (0.9–2.8) 1.2 (0.6–2.1)
1.3 (0.9–1.8)b 1.0 (0.7–1.5)b
Work control (high control/low control) 1.5 (1.1–2.1) 1.4 (1.0–1.9)a 3.0 (2.1–4.4) 2.9 (2.0–4.3)a 1.3 (0.8–1.9) 1.4 (0.9–2.4)
1.0 (0.7–1.5)b 2.3 (1.4–3.8)b
Ergonomics

High control þ low engagement in domestic work 2 1.0 (0.7–1.4) 1.0 (0.6–1.5)b 1.3 (0.8–2.0) 1.6 (0.9–3.8)b 1.0 (0.7–1.6) 2.6 (1.3–5.2)
Low control þ low engagement in domestic work 3 1.3 (0.9–1.9) 0.9 (0.6–1.5)b 3.5 (2.2–5.5) 2.7 (1.5–4.7)b 0.9 (0.6–1.4) 3.2 (1.9–5.2)
Low control þ high engagement in domestic work 4 2.0 (0.9–4.1) 1.4 (0.7–3.1)b 3.2 (1.7–6.1) 3.4 (1.4–8.3)b 1.1w 1.3 (0.6–3.1) 5.3 (2.5–11.2)
Work support (high support/ low support) 1.4 (1.1–1.9) 1.4 (1.0–1.8)a 2.3 (1.6–3.3) 2.3 (1.6–3.3)a 1.3 (0.9–1.2) 1.6 (1.1–2.4)
1.3 (1.0–1.7)b 2.0 (1.4–2.9)b
High support þ high engagement in domestic work 2 1.2 (0.8–1.8) 1.1 (0.7–1.9)b 0.9 (0.6–1.5) 1.6 (0.7–3.4)b 0.5 (0.3–0.9)
Low support þ low engagement in domestic work 3 1.5 (1.1–2.0) 1.4 (1.0–1.9)b 2.2 (1.4–3.5)b 1.9 (1.2–3.1)b 1.7 (1.1–2.8)
Low support þ high engagement in domestic work 4 1.3 (0.8–2.1) 1.2 (0.7–2.1)b 2.2 (1.2–3.8)b 3.2 (1.5–6.9)b 1.5 w
Constrained physical heavy work (no/yes) 1.9 (1.4–2.7) 1.8 (1.3–2.5)a 3.1 (2.1–4.6) 3.0 (2.0–4.4)a 1.3 (0.9–1.8) 1.8 (1.0–3.0)
1.4 (0.9–2.0)b 2.1 (1.3–3.4)b
Work-home imbalance 1.3 (0.95–1.8) 1.4 (0.99–1.9)b 1.3 (0.8–1.9) 1.3 (0.9–2.1)b 1.3 (0.9–1.8) 1.3 (0.8–2.2)

Notes: Crude estimates and estimates adjusted for age, smoking, company’s gender equality, employment hours, blue collar work and number of children below 18 years in the family are given as
odds ratios (OR) and 95% confidence intervals. Different combinations between work exposures and engagement in domestic work are given for strata 2–4 in variables showing significant
interaction.
221
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222

Table 7. Logistic regression analyses showing univariate associations and the most fitted multivariate model between emotional exhaustion and exposure to engagement in
domestic work and exposure to psychosocial and physical work factors and work home imbalance.

Univariate associations Multivariate model

Interaction Men Men Women Women
Variables strata crude adjusted crude adjusted Interaction Men Women
Age (years) 1.0 (1.0–1.0) 1.0 (1.0–1.0) 1.0 (0.9–1.0) 1.0 (0.9–1.0)
Smoking (no/yes) 1.3 (0.8–2.2) 1.2 (0.7–2.0) 0.5 (0.2–1.0) 1.0 (0.5–1.9)
Company’s gender equality index 0.8 (0.5–1.2) 0.8 (0.5–1.2) 0.7 (0.5–1.2) 0.7 (0.6–1.2) 0.7 (0.4–1.3) 1.3 (0.7–2.6)
Employment hours (part-time/fulltime) 1.3 (0.8 –2.0) 1.2 (0.8–1.9) 1.2 (0.9–1.6) 1.1 (0.8–1.5) 1.0 (0.5–1.9) 1.1 (0.7–1.8)
Occupational status (white collar/blue collar) 2.0 (1.4–2.7) 2.0 (1.4–2.7) 2.8 (1.9–4.8) 2.8 (1.9–4.2) 1.4 (0.9–2.3) 1.6 (0.9–3.0)
Number of children 518 years 1.1 (0.8–1.4) 1.0 (0.8–1.3)b 0.9 (0.6–1.2) 0.9 (0.7–1.4)b 0.9 (0.8–1.2) 1.2 (0.8–1.7)
High engagement in domestic work 1.2 (0.8–1.7) 1.3 (0.9 –1.9)b 0.9 (0.6–1.3) 1.2 (0.8–1.8)b
Work demands (low/high) 6.0 (4.2–8.4) 6.0 (4.2–8.4)a 6.1 (4.0–9.3) 6.0 (4.0–9.1)a 4.5 (2.9–6.7)
6.1 (4.3–8.7)b 5.1 (3.3–7.8)b
Low work demands þ high engagement in 2 1.5 (0.9–2.6) 1.7 (0.9–3.3) 0.8 (0.5–1.4) 0.9 (0.4–2.0) 1.9 (0.7–5.3)
domestic work
High work demands þ low engagement in 3 7.1 (4.8–10.5) 7.6 (5.0–11.5) 5.3 (3.2–8.8) 4.8 (2.8–8.1) 3.9 (2.1–6.9)
domestic work
High work demands þ high engagement in 4 5.5 (3.5–10.1) 6.2 (3.3–11.5) 6.9 (3.5–13.5) 6.2 (2.6–14.8) 1.4 w 10.3 (3.5–29.0)
domestic work
Work control (high control/low control) 2.6 (1.8–3.7) 2.5 (1.7–3.6)a 2.1 (1.4–3.0) 2.1 (1.4–3.1)a
C. Ahlgren et al.

2.2 (1.5–3.3)b 1.2 (0.7–2.0)b

Work support (high support/ low support) 3.7 (2.7–5.2) 3.8 (2.7–5.4)a 4.2 (2.9–6.3) 4.2 (2.8–6.3)a
3.8 (2.7–5.4)b 3.7 (2.5–5.6)b
High support þ high engagement in 2 1.0 (0.5–1.9) 1.2 (0.6–2.4)b 1.2 (0.6–2.2) 1.1 (0.5–2.7)b 0.9 (0.4–2.0) 0.4 (0.2–0.9)
domestic work
Low support þ low engagement in 3 3.6 (2.4–5.2) 3.6 (2.4–5.4)b 4.3 (2.7–7.1) 3.8 (2.3–6.4)b 2.1 (1.3–3.3) 3.2 (1.8–5.7)
domestic work
Low support þ high engagement in 4 4.6 (2.7–8.0) 5.2 (3.0–9.0)b 4.1 (2.3–7.3) 4.3 (2.3–8.0)b 1.5 m 1.2 w 3.3 (1.6–6.7)
domestic work
a a
Heavy physical work (no/yes) 3.5 (2.5–4.9) 3.6 (2.5–5.1) 3.0 (2.1–4.5) 3.2 (2.1-4.7) 1.8 (1.1–3.1) 2.0 (1.1–3.6)
3.9 (2.5 (6.0)b 2.2 (1.4–3.7)b
Work-home imbalance 3.2 (2.3–4.4) 3.5 (2.5–5.0)b 4.3 (2.8–6.7) 5.1 (3.2.8.1)b 2.4 (1.6–3.6) 4.3 (2.7–7.8)

Notes: Crude estimates and estimates adjusted for age, smoking, company’s gender equality, employment hours, blue collar work and number of children below 18 years in the family are given as
odds ratios (OR) and 95% confidence intervals. Different combinations between work exposures and engagement in domestic work are given for strata 2–4 in variables showing significant
interaction.
 Ergonomics
with the work demand variable in women and the
work support variable in both men and women. High
engagement in domestic work did not increase the risk
for emotional exhaustion when work demands were
low (Stratum 2). High work demands in combination
with low engagement in domestic work resulted in [OR
4.8 (2.8–8.1)] (Stratum 3) and exposure to both high
work demands and high engagement in domestic work
(Stratum 4) gave [OR 6.2 (2.6–14.8)] (Table 7).
Increased risk for emotional exhaustion was also
found in both women and men when low support at
work interacted with high engagement in domestic
work with raised odds ratio from [OR 3.8 (2.3–6.4)] in
Stratum 3 to [OR 4.3 (2.3–8.0)] in Stratum 4 in women
and [OR 3.6 (2.4–5.4)] in Stratum 3 to [OR 5.2 (3.0–
9.0)] in Stratum 4 in men (Table 7). Multivariate
modelling resulted in partly different models for men
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and women. In men variables with significant increased
odds ratios were high work demands [OR 4.5 (2.9–
6.7)], constrained physical heavy work [OR 1.8 (1.1–
3.1)], interaction between low work support and low
engagement in domestic work (Stratum 3) [OR 2.1
(1.3–3.8)], and low work support and high engagement
in domestic work (Stratum 4) [OR 3.3 (1.6–6.7)] and
experienced work-home imbalance [OR 2.4 (1.6–3.6)].
Bringing the social support variable and the work
demand variable together in a multivariate model in
women indicated a shared variance between the
variables. The interaction effect between low social
support at work and high engagement in domestic
work (Stratum 4) was not in the model, but in Stratum
2 (high support at work and high engagement in
domestic work) the risk for emotional exhaustion was
lowered to [OR 0.4 (0.2–0.9)] compared to the
reference category (high support at work and low
engagement in domestic work). In parallel interaction,
variables between high work demands and engagement
in domestic work increased substantially from [OR 3.9
(2.1–6.9)] for high work demands and low engagement
in domestic work (Stratum 3), and [OR 10.0 (3.5–29.0)]
for high work demands and high engagement in
domestic work (Stratum 4). Other variables included
in the multivariate model for women were constrained
physical heavy work [OR 2.0 (1.1–3.6)] and experi-
enced work-home imbalance [OR 4.3 (2.7–7.8)]
(Table 7).
4. Discussion
In this study of white- and blue-collar employees,
unequal sharing of household work and child care was
evident with women using more time than their
partners in both areas. Men in the study had longer
working hours in employed work, but adding the
household work and child care indices to employment
223
rate resulted in a higher total work index in women.
The same pattern, with women doing more household
work and child care in addition to paid work, is found
in a number of studies, in which hours per weeks in
domestic work was used (Lundberg et al. 1994,
Gjerdingen et al. 2000, Väänänen et al. 2004,
Berntsson et al. 2006, Krantz and Lundberg 2006).
Contrary to our expectations, our study found no
association between high scores on the domestic work
load index or the number of children younger than 18
years in the family and symptoms of neck/shoulder
disorders, low back disorder or emotional exhaustion
in women or men. These results are consistent with
several other studies (Josephson et al. 2003,
Nordenmark 2004b, Berntsson et al. 2006, Krantz and
Lundberg 2006), and supports the multiple role theory,
which states that engagement in several arenas is
beneficial for health (Nordenmark 2004b). On the
other hand, the results contrast with studies conducted
in the same context, showing that having children in
the family increases symptoms of ill health in women
(Floderus et al. 2008) and fatigue in both women and
men (Nordenmark 2004a). Differences in the studied
symptom variables and populations may partly explain
the differing results. Among mothers who work full-
time, Floderus et al. (2008) found a strong association
between poor self-rated health and the number of
children, but a weaker association when fatigue was
used as the outcome measure. The exposure contrast in
relation to number of children was small in our study
as more than 80% of the employees had one or two
children and only 11 employees had more than three
children.
However, when combining engagement in
domestic work with work exposure variables in order
to study interaction effects we found increased risks
for low back disorders and emotional exhaustion in
women and emotional exhaustion in men when
exposure was high in both arenas. For example both
women and men, with high engagement in domestic
work and simultaneously facing low support at work
had increased risks for emotional exhaustion
compared to those with low work support and low
engagement in domestic work. Similarly, estimates of
the associations between low back disorders and low
support and low control at work increased when they
were combined with high engagement in domestic
work.
These results lend support for the role stress theory,
stating that high exposure in several arenas cause
health problems due to overload (Lundberg et al. 1994,
Nordenmark 2004a). Interactive effect between
domestic work and work exposure as a cause for
ill-health has also been shown in other studies using
a general symptom scale (Kranz and Östergren 2001)
 224 C. Ahlgren et al.
and self-rated health, (Mellner et al. 2006) as health
outcome measures. In the study by Mellner et al. (2006),
high engagement in domestic work was not separately
associated with low self-rated health, but gave a three-
fold increase in poor self-rated health when combined
with job strain. Thus, our data support both the
multiple role theory as well as the role-stress theory.
In order to promote employee health, measures
should be taken to decrease conflict between work and
family demands. For example, making workplaces
more supportive and family-friendly and a more equal
distribution of household work should be encouraged.
No interaction between high engagement in domes-
tic work and neck/shoulder disorders were found,
despite that work-home imbalance increased the risk.
Shortcomings in the exposure assessment in our study
may have contributed to these findings. Among work
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exposure factors associated with chronic neck/shoulder
pain, the highest evidence (moderate) was found for
repetitive arm/shoulder movements (Palmer and Smed-
ley 2007). Associations between repetitive arm/hand
movement and neck/shoulder complaints have been
demonstrated by direct measurements in the work
place (Nordander et al. 1999, 2009). Exposure to
repetitive work was not included in our questionnaire.
All health outcomes were associated with physical
and psychosocial exposure at work and were in line
with results from other studies (Bongers et al. 1993,
Hoogendorn et al. 2000, Punnett and Herbert 2000,
Magnusson et al. 2008).
High numbers of both white- and blue-collar
women worked part-time. Reduced working hours
can be chosen for different reasons. In white-collar
women part-time work could have been chosen due to
young children in the family, as these women had the
highest rate of young children. The Swedish social
security system gives parents the right to reduce their
working hours by 25% until a child is 7 years of age
with an 80% compensation for lost hours (Informa-
tion from Försäkringskassan 2010). This policy is
referred to as a parental insurance, but has become
more of a maternal insurance since it is women who
use the option of the time. Reduction in work hours
may also be a coping strategy to reduce strain in
physically strenuous work. Blue-collar women had
older children but did part-time work to the same
extent as white-collar women. They had high
prevalence of both neck/shoulder and low back
disorders, with no difference between part-time and
full-time working women. This indicates that they
might have chosen part-time work for health reasons;
the cross-sectional study design does not allow us to
evaluate this hypothesis. In other Swedish studies
on work and health, women expressed a desire to
work less than full-time, even with older children
(Nordenmark 2004a, Floderus et al. 2008). This
points to that many Swedish women experience strain
from combining work and family demands. The fact
that women, and not men, with small children
reduce working hours shows that traditional gender
attitudes about child care and household work as
primarily a woman’s responsibility are still prevalent
despite Sweden’s strong gender equality policy.
Part-time work could have different meanings in
different jobs, as well as for women and men, and is
not necessarily less strenuous work. Working part-time
in a career could be divergent from the workplace
norm and demand more effort to compensate as well as
result in fewer career opportunities. Women working
part-time in professional careers report exerting extra
effort in order to prove they are competent despite
their part-time status (Webber and Williams 2008).
Part-time work could also mean being called to work
at peak times, as found among educational workers
(Seiffert et al. 2007). In such work situations,
psychological demands are high during the whole work
shift and possibilities for recovery low. Furthermore,
the unpredictable work schedules could also negatively
affect time off work as the employees constantly are
on duty. Two to four per cent of blue-collar men and
women had short part-time working hours (less than
20 hours per week), but this was almost non-existent
among white-collar workers.
5. Study limitations
The companies were not randomly selected, but
selected with respect to differences in gender equality.
This limits our ability to generalise the results. The
study had a cross-sectional design, so that the direction
of the associations cannot be established. The response
rate was slightly below 50% and women, older
employees and employees with higher education were
over-represented, further limiting our ability to
generalise. A healthy worker effect cannot be
disregarded. Judging from early retirement figures in
Sweden (Statistics Sweden 2008), a healthy worker
effect would have been more likely among blue-collar
workers. In case of a stronger healthy worker effect
among blue-collar workers the associations between
risk factor at work and health outcome variables found
in our study, would be underestimated, as women in
blue-collar work had the highest prevalence’s for all
symptom variables and men in blue-collar work had
higher prevalences than men in white-collar work.
Categorisation of white- and blue-collar works was
based on occupational titles. The system was originally
developed in male-dominated occupations and has
been criticised for categorising women’s occupations
with less accuracy (Arber 1989, Drever et al. 2004).
 Ergonomics
This may result in an unknown proportion of women
being classified as white-collar workers while they face
similar work exposures to those classified as blue-collar
workers. This could have contributed to the smaller
difference in work exposures and health outcome
variables found between female white- and blue-collar
workers than among male white- and blue-collar
workers.
Both exposure and health outcome variables were
self-reported. This raises questions about validity and
reliability. Self-reported exposure assessments might
not be representative of the actual exposure. In a
comprehensive literature review, Stock et al. (2005)
present data on validity and reproducibility of most
physical measurements. They found good agreement
between questionnaires and interviews in relation to
manual handling of objects weighing 10 kg or more.
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Responses on questions concerning duration or
frequency of the trunk in forward bent positions
were also found to have moderate agreement with
interviews (Stock et al. 2005). The authors conclude
that indices combining several questions on physical
exposure might be better than single items at capturing
the real exposure. The variable on physical exposure
used in our study was based on an index of variables
with at least moderate validity. We assert that they
should have sufficient validity.
The demand/control questionnaire aim to measure
the psychosocial climate of specific work places and
has been found to be a more accurate measure on
organisational level than on individual level (Söder-
feldt et al. 1997). Our population represented 21
companies between which psychosocial climates could
have differed substantially and high exposure at one
work-place could have been up balanced by better
conditions in another. However, the different preva-
lences found between white- and blue-collar workers in
our study are also found in the study by Magnusson
et al. (2008). They might represent a more general
difference between white- and blue-collar work places.
Multilevel analysis as used by Söderfeldt et al. (1997)
could have given more detailed information on the
associations, but our restricted study population did
not allow that kind of analyses.
Questions have been raised as to whether the
demand-control questionnaire is accurate and applic-
able for jobs in social service and modern jobs
(Marshall et al. 1997), and whether jobs classified as
active learning jobs might be different for women
and men (Waldenström and Härenstam 2009). These
questions have primarily been raised in relation to
job strain, a combination of high work demands and
low control. We used the variables separately which
might have reduced these risks. However, we cannot
exclude that such divergences influenced our results,
225
as white-collar men were overrepresented in the
population.
As to the outcome variables, the constructions of
indices of ordinal health outcome data on neck/
shoulder, low back disorders or emotional exhaustion
could be questioned. However, as there is no natural
cut-off between sick/unhealthy and healthy in either of
the outcomes, an index seemed more accurate. The
Cronbach’s alphas were also sufficiently high ranging
from 0.77 to 0.86. A dichotomisation at the 75th
percentile was used to assure separate cases from
non-cases but might have led to underestimation of
exposure effects. Due to the cross-sectional design of
the study miss-classification of exposure cannot be
excluded, i.e. that employees with disorders judge their
work place more negative.
The household work index and child care index do
not measure actual time spent on work tasks but
rather engagement in the tasks relative to the partner
and adjusted for family size. This could result in
differences in actual time spent performing the tasks
between employees with the same score. It would
have been more accurate to use actual time spent in
different tasks although there are shortcomings in
those data as well. The concordance between
questionnaire responses on time doing domestic work
tasks and answers in structured interviews was found
to be low (Wiktorin et al. 1999). An explanation
could be that household chores and child care is
mostly done in parallel and time use in each is
difficult to estimate.
Not only differences between women and men has
to be taken into account when interpreting information
of engagement in household chores and child care in
relation to health but also differences between women
with different gender ideologies. Considering, women
and men in our study answered the questions
according to stereotypical expectations (women do
more housework and child care), women may have
overestimated their engagement in housework and
men underestimated their engagement. Press and
Townsley (1998) reported that both men and women
overestimate their time doing housework when filling
in questionnaires and that gender ideology affects the
direction of overestimation. Women with a gender
equality ideal are more accurate in their reports of
housework than women with a traditional gender
ideal because normative gender expectations are less
important to them. For the same reason, men with
gender equality ideals tend to over-report more than
traditional men (Press and Townsley 1998). Studies
indicate that highly educated women and men have
stronger gender ideology than those with lower
education (Nordenmark 2004c, van der Lippe et al.
2006). No data on gender equality ideals were included
 226 C. Ahlgren et al.
in our study, but if educational level is taken as a proxy
for gender ideology and the results applied to our
study, a smaller difference in household work index
and child care index between white- and blue-collar
men and an increased difference between white- and
blue-collar women should result. However, men in our
study differed primarily in total work load because
white-collar men almost exclusively worked full-time,
while part-time work was more frequent in blue-collar
men. White-collar women had a higher average child
care index than blue-collar women, but they also were
more likely to have small children. Thus, we cannot
claim that differences in gender ideology affect the
household or child care work scores.
Our findings of a higher household work index and
child care index among women are in line with studies
that use actual time, so over-reporting should not have
Downloaded by [University of Delaware] at 23:56 31 May 2013
introduced a major bias. However, considering the
complex associations between measurements of actual
time spent in household work and child care, gender
ideology and perception of fairness the field need to be
developed especially when considering the relation to
health outcome. Engagement in housework and child
care is not considered as burden of most individuals
but as joyful activities which give satisfaction and
could out balance negative work exposure effects.
6. Conclusions
Women in both white- and blue-collar work had a
higher total work load than men when engagement in
domestic work was added to employed work. Women
also had higher prevalence’s of neck/shoulder and low
back disorders compared to men. However, the higher
work load was not separately associated with increased
symptoms of neck/shoulder disorders, low back
disorders or emotional exhaustion. Adverse physical
and psychosocial work factors were, on the other
hand, associated with all of the ill health outcomes and
the highest estimates were for emotional exhaustion
and high work demands. High domestic work load
interacted with low work control and low social
support at work and gave higher associations with
low back disorders in women than for work exposure
variables alone. Similarly, high domestic work load
combined with high demands and low social support at
work were stronger risk factors for emotional exhaus-
tion in both women and men than the work exposure
factors separately. Perceived work-home imbalance is
suggested to be a mediating factor.
Acknowledgements
The study was supported by grants from VINNOVA (The
Swedish Governmental Agency for Innovation Systems) and
Umeå Center for Global Health, Umeå University.
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