The Copenhagen Psychosocial Questionnaire II (COPSOQ II) in Spain A Tool for Psychosocial Risk Assessment at the Workplace

Transcription

1 AMERICAN JOURNAL OF INDUSTRIAL MEDICINE The Copenhagen Psychosocial Questionnaire II (COPSOQ II) in Spain A Tool for Psychosocial Risk Assessment at the Workplace Salvador Moncada, 1 Mireia Utzet, 2 Emilia Molinero, 3 Clara Llorens, 1 Neus Moreno, 1 Ariadna Galtés, 1 and Albert Navarro 2 Aims To describe the second version of the Spanish Copenhagen Psychosocial Questionnaire and to present evidence of its validity and reliability. Methods The original Danish long COPSOQ II questionnaire was adapted to the labor market, cultural, and linguistic setting of Spain and included in the 2010 Spanish Psychosocial Risks Survey. Analysis involved the assessment of psychometric characteristics and associations among psychosocial scales and health scales. Medium and short versions were derived from the long one. Results The long questionnaire was configured with 24 dimensions (92 items); mediumlength questionnaire with 20 dimensions (69 items); and short questionnaire with 14 dimensions (28 items). All scales showed acceptable reliability and concordance between versions. Most associations among psychosocial scales and Mental Health, Stress, and Burnout scales were in the expected direction, except the scale of Influence, that showed some incongruent associations. Conclusion Results support the validity and reliability of Spanish COPSOQ II questionnaires as tools for psychosocial risk assessment at the workplace, however, better scales should be developed specially for the dimension of Influence. Am. J. Ind. Med. 9999:1 11, ß 2013 Wiley Periodicals, Inc. KEY WORDS: psychosocial factors; psychosocial work environment; questionnaires; stress; surveys; Spain INTRODUCTION 1 Union Institute of Work, Environment and Health (ISTAS), Reference Centre on Work Organisation and Health, Barcelona, Spain 2 Universitat Autònoma de Barcelona (UAB), Biostatistics Unit, Faculty of Medicine, Bellaterra, Barcelona, Spain 3 Ministry of Enterprise and Labour of the Government of Catalonia,Barcelona, Spain Contract grant sponsor: Fundaciónpara la Prevención de RiesgosLaborales; Contract grant sponsor: Generalitat de Catalunya. Conflictofintereststatement: Salvador Moncada, as a first Authorof this article,firmly declares that no one ofauthors has stated any conflict of interest of any kind. Disclosure Statement: The authors report no conflicts of interests. Correspondence to: Salvador Moncada, Union Institute of Work, Environment and Health (ISTAS), Reference Centre on Work Organisation and Health. Via Laietana 16, E08003, Barcelona. smoncada@ccoo.cat Accepted18 July 2013 DOI /ajim Published online inwiley Online Library (wileyonlinelibrary.com). The first version of the Copenhagen Psychosocial Questionnaire (COPSOQ I) was developed in 1997 by the Danish National Research Centre for the Working Environment as a standardized questionnaire covering a broad range of psychosocial factors. It included three different length versions: a long version for research; and medium-length and short versions for risk assessment purposes in the workplace, depending on the size of workforce. The COPSOQ I included a majority of the main dimensions of the seven theories in occupational health psychology [Kompier, 2003] but still failed to address some important aspects related to work such as rewards, justice and trust. The COPSOQ II was a response to this limitation and also tried to incorporate aspects arising from the practical experience of using ß 2013 Wiley Periodicals, Inc.

2 2 Moncada et al. COPSOQ I [Pejtersen et al., 2010] while the three-length concept was maintained. After its initial development in Denmark, COPSOQ I and II have been adapted to several languages including Spanish in 2003 and the other main languages spoken in Spain: Catalan, Basque, and Galician (with the names of COPSOQ- Istas21 for the Spanish and Basque; PSQCAT21-COPSOQ for the Catalan, and COPSOQGal21 for the Galician version); and it included two more scales than the original Danish version: Double presence (the need to respond simultaneously to the demands of a paid job and domesticfamily work) and Esteem [Moncada et al., 2005]. In 2010, the questionnaires were slightly modified to include some adjustments made to the Danish COPSOQ II that did not need field work: Social Support scales were modified and the Sensorial demands scale was eliminated [InstitutoSindical de Trabajo, Ambiente y Salud. 2010]. COPSOQ (either I or II in diverse languages) has been used so far in several research projects that have produced more than 100 international published articles; including some comparative studies among selected EU countries [Hasselhorn et al., 2003; Moncada et al., 2010a] and in one project involving all the 27 EU countries plus 3 EFTA countries [Nübling et al., 2011]. As in Denmark and Germany, in Spain the questionnaire has been adopted as a standard for measuring the psychosocial work environment and is being used regularly as a tool for risk assessment in the workplace. The purpose of the present article is to describe the Spanish COPSOQ II, and to clarify and explain the changes made from the previous version COPSOQ I, known as COPSOQ Istas21, and to present evidence of its validity and reliability. METHODS Adaptation of the Danish COPSOQ II to Spanish COPSOQ II The long version of the original questionnaire in Danish COPSOQ II was adapted to the labor market, cultural, and linguistic setting of Spain. The adaptation process was agreed to by the Danish authors and followed the stages proposed in similar studies [Serra-Sutton et al., 2002] and in the previous adaptation of COPSOQ I [Moncada et al., 2005]. The questionnaire dimensions and items were defined in a meeting between Spanish and Danish representatives, and key context differences between Spain and Denmark regarding labor market, industrial relations and working conditions were identified based on a previous study [Moncada et al., 2010a]. In summary, compared to Denmark, Spain has a less egalitarian labor market with higher precariousness and unemployment rates and a stronger tradition of Taylorist-based work organization, more hierarchical, and authoritarian than the Danish model, which is based on flexicurity and the spread of collective and direct workers participation systems [Valeyre et al., 2009; Moncada et al., 2010a]. Translation of the original questionnaire into Spanish was carried out by a translation/back-translation procedure by professional translators, and subsequently checked by the authors, with discussion between authors, and translators in order to reach consensus over differences. This procedure was only applied to new questions and those which had undergone some modification; it was not necessary for questions that did not change from the Spanish COPSOQ Istas21 (corresponding to the Danish COPSOQ I) as these had previously been adapted and validated. The result of this procedure was a test version, and this was included as part of the questionnaire used in the 2010 edition of the Spanish Survey of Psychosocial Risks (see below) in order to assess its validity and psychometric properties. The Spanish COPSOQ II long version included all the questions which presented acceptable psychometric indicators, and was used as the basis for producing the medium and short versions. The versions in Catalan, Basque, and Galician languages were developed later following the same procedure of translation back-translation based on the final Spanish language version of the long questionnaire. Structure of the Questionnaires Spanish versions followed the same rationale as the Danish COPSOQ II and also incorporated expertise gained through the practical use of COPSOQ I since So Spanish COPSOQ II, like its precursor, has three versions long, medium, and short. The total number of psychosocial scales of the Spanish COPSOQ II medium-length questionnaire is 20 (with 69 items), while the long version has 24 (and 89 items) (see Table I). As a general rule, we aimed at a scale length of three to four items for the medium version. In the short questionnaire, the scales were generally based on two questions and also the number of scales was reduced to 14. These scale lengths were optimal for a questionnaire that aims to be used in the practice of occupational health at a shop floor level [Kristensen et al., 2005a] and were established by expert consensus among the Danish authors [Pejtersen et al., 2010]. With respect to the earlier medium-length questionnaire, seven dimensions have not been changed (Meaning of work, Predictability, Role clarity, Role conflicts, Social community at work, Social support from colleagues, and Social support from supervisors); three have been eliminated (Cognitive demands, Social relations, and Control over breaks and holidays, a scale that had previously replaced the original Danish scale Degrees of freedom at work); four new scales have been added (Trust regarding management, Justice; Work pace, that was partially included in the Quantitative

3 Copenhagen Psychosocial Questionnaire II in Spain 3 TABLE I. Dimensions and Number of Items of the Questionnaires of the SpanishVersions of COPSOQ I (COPSOQ Istas21) and COPSOQ II Dimension COPSOQ I (COPSOQ Istas21) COPSOQ II Long Medium Short Test Long Medium Short Double presence Quantitative demands Pace of work ç ç ç Sensorial demands 4 ç ç ç Cognitive demands 8 4 ç 6 6 ç ç Emotional demands Demands for hiding emotions ç Influence Possibilities of development Variation ç ç ç 2 2 ç ç Meaning of work ç Control over breaks and holidays 4 4 ç ç ç ç ç Commitment ç ç Predictability Recognition ç Esteem ç ç ç ç Role clarity Role conflicts 4 4 ç ç Quality of leadership Social relations 2 2 ç ç ç ç ç Social support from colleagues ç Social support from supervisors ç Social community at work ç Insecurity Insecurity over employment ç Insecurity over working conditions Trust regarding management ç Mutual trust between employees ç 3 2 ç ç Justice ç ç ç TOTAL PSYCHOSOCIAL DIMENSIONS a TOTAL PSYCHOSOCIAL ITEMS Satisfaction 4 4 ç ç General health SF ç ç Mental health SF ç ç Vitality SF ç ç ç ç ç Behavioral stress symptoms 4 4 ç ç Somatic stress symptoms 4 4 ç ç ç ç ç Cognitive stress symptoms 4 4 ç ç ç ç ç Burnout ç ç ç TOTAL HEALTH & OUTCOME DDIMENSIONS ç ç TOTAL HEALTH & OUTCOME ITEMS 7 7 ç ç a Dimensions in short version I were differently conceptualized. demands in COPSOQ I, and Recognition, which replaced the previous scale of Esteem); and certain items of six other scales have been modified (Double presence, Quantitative demands, Emotional demands, Demands for hiding emotions, Influence, and Insecurity which has been split into two Insecurity over Employment and Insecurity over Working Conditions). In addition it includes one General Health question, and the Mental Health and Stress scales from

4 4 Moncada et al. COPSPSQ I have been retained in the long and medium questionnaires, and the Personal Burnout scale from the Copenhagen Burnout Inventory [Kristensen et al., 2005b] has been added. Study Design and Subjects This study was approved by ISTAS Research Committee and met all the requirements of Spanish law concerning health research and protection of personal data. Participants were informed of the voluntary nature of the interviews and provided signed consent prior to participating. Validation of the questionnaires was conducted by including them in the 2010 Spanish Survey of Psychosocial Risks [Moncada et al. Barcelona: ISTAS, 2010], a nationwide cross-sectional study of a representative sample of the wage-earning population in Spain. Inclusion criteria were: people aged 16 to 65 years, resident of Spain and who were engaged in paid work for at least 1 hr during the week prior to the survey interview. Note that this latter criterion includes salaried workers, civil servants, and self-employed workers. The sample size was established, through criteria of feasibility, of 5,110 individuals through a selection strategy consisting of aggregation into five geographical areas and stratification by size of municipality. The questionnaire was administered using CAPI (Computer Assisted Personal Interviewing) in the respondent s home, participation being voluntary, and confidential, participants having given prior consent. Interviewing was conducted in two waves in July and October 2010, the first of 2,550 participants and ten more in the second. Measurements The population survey questionnaire included all the scales, consisting of Likert type items, of the test version of the Spanish COPSOQ II, corresponding to the psychosocial dimensions; one item on General Health, the Mental Health scale of the Spanish version of the SF-36 questionnaire [Alonso et al., 1995]; the Behavioral Symptoms of Stress scale from the Stress Profile [Setterlind and Larson, 1995], and the Personal Burnout scale of the Copenhagen Burnout Inventory [Kristensen et al., 2005b], each consisting of 4 Likert type items. The questionnaire also includes questions for the socio demographic characterization of the participant (sex, age, country of origin, household size, etc.), current occupation, indicators of labor management practices (type of contract, working hours, wages, etc.) (Table II) [Llorens et al., 2010], and the Employment Precariousness scale (EPRES) [Vives et al., 2010]. Population and Sample The response rate, prior to substitutions, was 56%. Characteristics of the sample analyzed are presented in Table III, together with data from the Spanish Survey of the TABLE II. Domains, Dimensions, and Number of Items of the 2010 Survey of Psychosocial Risks in theworkplace (ERP 2010) Domains Dimensions and (in parentheses) number of items in each Psychosocial factors (3) Double presence (4); Quantitative demands (4); Work pace (3); Cognitive demands (6); Emotional demands (5); Demands for hiding emotions (4); Influence (8); Possibilities for development(4); Variation (2); Meaning of work (3); Control over breaks and holidays (3); Commitment to the workplace (4); Predictability (2); Recognition (4); Role clarity (4); Role conflicts (4); Quality of leadership (5); Social support from colleagues (3); Social support from superiors(3); Social community at work (3); Insecurity over employment (2); Insecurity over working conditions (4); Trust regarding management (4), Mutual trust between employees (3); Justice (4). Socio demographic characterization Age (1); Sex (1); Educational level (1); Geographical origin (1); Household size (1); Children under12yrs and dependent persons (2); Domestic and family work (1). Current occupation National Classification of Occupations, 3 digit code (CNO-94) Labor management practices (12) Labor relations: Type of contract (3),Time with firm (1), Downsizing (2); Promotion (2) and Improvements in work conditions (7); Working hours (Ordinary, Overtime, Daily and weekly scheduling, Demands of availability and possibility to adapt, Commuting time) (9); Retribution (quantity, salary structure, variable criteria) (13); Work process: Job content (3), Direct participation (consultation or delegation) (4),Team work (3), Functional mobility (1), Causes of work intensification (5). Job precariousness (13) Temporality (2); Empowerment (3); Vulnerability (abuse of power) (6); Income level (3); Worker s rights (7); Exercise of worker s rights (statutory holidays, annual holidays, leave, medical visits, sick leave) (6). Characterization of the employer Type of enterprise (Public/private/consortium)(1); Size (1); Position in chain of values (position in subcontracting chain, company economic activity - CNAE digit code) (4); Existence of worker representatives (1). Health and well-being (8,10,11) General health (1); Mental health (4); Stress (4); Personal Burn Out (4); Job satisfaction (1).

5 Copenhagen Psychosocial Questionnaire II in Spain 5 TABLE III. Socio Demographic Characterisitics of the Study Population n % EPA a 2009, 4th quarter (%) Sex Women 2, Men 2, Age 16^ ^ ^39 1, ^49 1, ^ ^ Occupation CNO b (1digit) Management of companies and public administration Technical and scientific professionals and intellectuals Technicians and associate professionals Administrative employees Workers of catering services, personal, protection, etc. 1, Skilled agricultural and fishery Artisans and skilled workers in manufacturing Plant and machine operators, assemblers Unskilled workers a Spanish active population survey. b Spanish National classification ofoccupations. Active Population [Instituto Nacional de Estadística, 2012] corresponding to the last quarter of Psychometric and Statistical Analysis The analysis strategy consisted of three phases. First, we checked that the distribution and psychometric behavior of all the items and psychosocial scales were as expected, particularly for the new scales and those which had been modified, compared to the previous COPSOQ Istas21. The second phase consisted of reducing the longest scales to four items. In a third phase, we checked that associations between the psychosocial scales and the General Health question, and the Mental Health, Stress, and Burnout scales were in the directions expected, in other words that the prevalences of poor General Health, poor Mental Health, high Stress and high Burnout were higher among people with psychosocial scores in the tertiles least favorable for health. Long Version A descriptive analysis was performed of all items and the scales constructed from the means for each item across all individuals; scores were standardized to range from 0 to 100 and three score levels were defined corresponding to most favorable for health, intermediate, most unfavorable for health, which we labeled as green, yellow, and red, respectively. As in COPSOQ Istas21, these three levels were defined based on the tertile distributions of each of the scales [Moncada et al., 2005]. Values were considered to be missing if the respondent had left any of the questions of the scale unanswered. Internal reliability of the scales was checked via Exploratory Factor Analysis with direct Oblimin oblique rotation and maximum likelihood extraction method for large groups of psychosocial dimensions, involving five different factor analyses consistent with the analysis performed by Danish authors of COPSOQ I and II [Kristensen et al., 2005a; Pejtersen et al., 2010], the Spanish COPSOQ-Istas21and otherinstruments like the EPRES [Vives et al., 2010] that was developed on the basis of the same Spanish Survey of Psychosocial Risks. Factors were retained based on three criteria: Eigenvalue greater than 1, analysis of the scree plot, and interpretability. Internal consistency of the scales was assessed based on Cronbach s alpha and through the calculation of floor effect, proportion of individuals with scores corresponding to most unfavorable for health, and of ceiling effect, the proportion whose scores corresponded to most favorable for health.

6 6 Moncada et al. Medium-Length Version The Spanish COPSOQ II middle-length version was configured based on the long version. The aim was to find, for each dimension, a maximum of four items which acceptably reproduced the responses obtained from the long version of the scale. In this reduction a priority was to obtain versions with the maximum possible similarity to the Danish COPSOQ II, and the earlier Spanish COPSOQ Istas21. For each scale we analyzed inter-item correlations, correlations of each item with the entire scale, took into consideration the factor analysis performed on the long version, and investigated the effect on Cronbach s alpha of the elimination of each item. Using this information we opted for a preliminary reduction based on statistical criteria. In cases where doubts arose, the various alternatives were tried, and the reduction was implemented prioritizing variability over consistency and comparability with the scales of the Danish COPSOQII and the Spanish COPSOQIstas21. In order to check construct validity, we analysed the associations between the psychosocial dimensions and the health dimensions using age and sex adjusted prevalence ratios (PR) [Lee and Chia, 1993; Stromberg, 1994; Barros and Hirakata, 2003; Schiaffino et al., 2003] and their corresponding 95% confidence intervals, computed between the psychosocial dimensions and the median of the Mental Health, Stress, and Burnout dimensions. Short Version For the Spanish COPSOQ II short version, we first identified the dimensions that were both most conceptually central in psychosocial theory and relevant for the Spanish labor market [Llorens et al., 2010; Moncada et al., 2010a], and subsequently two items from each dimension, giving priority to discriminating power and variability. As for the medium-length version, we attempted to maintain the maximum level of comparability with the Danish COPSOQII and the Spanish COPSOQIstas21. Concordance between short and medium versions was assessed by computing Kappa indexes. All analyses were conducted using SPSS (version 17.0) and R (version ). RESULTS All items presented acceptable discrimination power. All dimensions and items of the three length versions are presented in the Appendix. Table IV presents the Cronbach s alpha, median, mean, and standard deviation, ceiling and TABLE IV. Cronbach s Alpha, Median, Mean, Standard Deviation, Ceiling, and Roof of Psychosocial Dimensions (MiddleVersion) Cronbach s Alpha Median Mean Standard deviation Roof % (n) Celing % (n) Missing n Double presence (39) 20.8 (1,065) 0 Quantitative demands (1) 13.3 (676) 20 Pace of work (297) 1.8 (90) 49 Emotional demands (18) 13.0 (660) 14 Demands for hiding emotions (127) 2.5 (126) 18 Influence (141) 4.1 (211) 23 Possibilities of development (141) 4.9 (247) 18 Meaning of work (7) 16.6 (843) 43 Commitment (41) 5.2 (265) 9 Predictability (74) 12.9 (657) 17 Recognition (34) 13.2 (674) 21 Role clarity (1) 19.6 (1,000) 20 Role conflicts (16) 12.1 (613) 29 Quality of leadership (103) 10.2 (481) 382 a Social support from colleagues (84) 13.3 (608) 533 a Social support from supervisors (94) 18.3 (910) 131 a Social community at work (58) 22.1 (1,016) 511 a Insecurity over employment (469) 12.2 (625) 4 Insecurity over working conditions (965) 1 (50) 11 Trust regarding management (14) 8.0 (409) 22 Justice (39) 6.7 (342) 22 a Most cases are no-answers from people working alone, so not applicable questions rather than missing answers.

7 Copenhagen Psychosocial Questionnaire II in Spain 7 floor effects and missing values for the 21 psychosocial dimensions of the Spanish COPSOQ II medium-length version. Factor analysis identified factors whose items were in agreement with theory, each one explaining over 45% of the variance. The items with unacceptable fit were considered as candidates for elimination. One item in each of the dimensions Recognition, Trust regarding management, and Trust between employees did not load on the expected factor and were eliminated. Items of the Insecurity dimension loaded on different factors, and so we divided this into two: Insecurity over Employment and Insecurity over Working Conditions. Thus the Spanish COPSOQ II long-length version was finally configured as 24 dimensions and 92 items, 3 fewer than the version tested in the 2010 Survey of Psychosocial Risks. The Spanish COPSOQ II medium-length version was configured by reducing three other dimensions (Emotional demands, Influence, and Quality of leadership), eliminating two (Variation and Cognitive demands) which presented high correlations with the dimension Possibilities for development and the rest were maintained unchanged with respect to the long version. The internal consistency of the scales was high, with Cronbach alpha values above 0.7 in 19 of the 24 dimensions, the lowest value being 0.59 for the dimension Predictability. Ceiling and floor effects (scores corresponding to most favorable and least favorable for health, respectively) were also acceptable for all items. The most notable ceiling effect was for the dimension Social community at work (22.1%), and the most notable floor effect for Insecurity over employment (18.9%). Most participants responded to all items, the percentages of missing values being under 1% in all scales except Quality of leadership, Social support from colleagues, Social support from supervisor, and Social community at work which presented between 2 and 10% of missing values, but most cases were no-answers from people working alone, so they were not applicable questions rather than missing answers. The age and sex-adjusted PR between all the psychosocial dimensions and the dimensions of Mental Health, Stress, and Burnout (Table V) generally had the directions expected and presented a gradient of significance of association for the three adjusted PR in the case of the 12 psychosocial dimensions and for two PR in the case of the other seven dimensions. The exceptions were Work Pace, Predictability (the first presenting a significant gradient only for Burnout, while the second only presented a significant gradient for Mental Health), Influence (for which associations showed no gradient for Mental health and were incongruent regarding Stress and Burnout), Possibilities for development and Trust regarding management (with significant gradient for Mental health and incongruent for the other). Kappa indexes between middle and short scales were good for all dimensions, ranging from 0.62 (Quantitative demands) to 0.84 (Recognition). DISCUSSION COPSOQ has become a popular and useful tool for both research and preventive practice in the workplace. Adapted to several languages, its development involves a collaborative research network of more than 20 groups [COPSOQ International Network, 2013] and in Spain it has become one of the most extensively used tools for risk assessment and the only one that provides population-based reference values [Moncada et al., 2008]. Danish and Spanish authors agreed that the Spanish COPSOQ questionnaires should be adapted and the population-based reference values updated at most once every 5 years; changes should be incorporated in any scale presenting any statistical or practical use problem, and new scales reflecting the development of new theories and new perspectives should be added. Furthermore, our intention was for the resultant tool to be specific to the Spanish context while remaining true to the Danish COPSOQ II as far as possible. The present results meet these criteria fairly well. In adapting the COPSOQ II to be used in Spain we assumed the same conceptual framework as used by the Danish version, so that the associations we could find between psychosocial dimensions and the scales of Mental Health, Stress, and Burnout should be in the same directions as those found by the Danish authors and generally supported in the literature, while taking into account certain key differences between Spain and Denmark, mainly related to: the labor market high unemployment, and precariousness in Spain, flexicurity in Denmark; industrial relations labor dispute as a regulatory mechanism in Spain, democratized, and participative labor relations in Denmark; and work organization Taylorism-based and hierarchical in Spain in contrast to a long tradition of employee participation in Denmark [Moncada et al., 2010a]; in summary, a psychosocial work environment more passive (in the meaning of Karasek s Demand Control terminology) and much more insecure in Spain. While recognizing a need for deeper comparative studies, our results appear to be consistent with these contextual differences which, as discussed below, mainly affect the two dimensions of Insecurity and Influence. All scales presented acceptable dimensionality and internal consistency, with some exceptions. Factor analysis generally allocated items in the expected factors, but as Insecurity items loaded on two factors we divided this dimension into two Insecurity over Employment and Insecurity over Working Conditions. This separation is compatible with other studies which suggest that fear of a worsening of valued working

8 8 Moncada et al. TABLE V. Age and sex adjusted Prevalence Ratios (apr) among psychosocial dimensions of the middle version questionnaire to Mental Health, Stress andburnout Psychosocial dimension Tertile label Mental health Stress Burn out apr CI (95%) apr CI (95%) apr CI (95%) Double presence Green Yellow 1.81 (1.58^2.08) 1.63 (1.41^1.87) 1.48 (1.30^1.68) Red 3.39 (2.99^3.85) 2.71 (2.38^3.09) 2.30 (2.04^2.60) Quantitative demands Green Yellow 1.62 (1.41^1.86) 1.57 (1.37^1.81) 1.31 (1.15^1.48) Red 3.20 (2.82^3.62) 2.55 (2.24^2.90) 2.05 (1.83^2.31) Pace of work Green Yellow 1.16 (1.03^1.31) 1.75 (1.52^2.02) 1.77 (1.54^2.02) Red 1.19 (1.04^1.35) 2.32 (2.01^2.67) 2.51 (2.19^2.88) Emotional demands Green Yellow 2.03 (1.82^2.27) 1.81 (1.64^2.00) 1.41 (1.27^1.56) Red 3.03 (2.73^3.36) 2.58 (2.35^2.83) 0.96 (1.78^2.15) Demands for hiding emotions Green Yellow 1.18 (1.06^1.33) 1.58 (1.39^1.79) 1.44 (1.28^1.62) Red 1.07 (0.95^1.20) 1.88 (1.65^2.13) 1.64 (1.46^1.85) Influence Green Yellow 1.40 (1.24^1.58) 1.08 (0.96^1.21) 0.98 (0.88^1.10) Red 1.38 (1.22^1.56) 0.82 (0.72^0.93).82 (0.73^0.93) Possibilities of development Green Yellow 1.28 (1.13^1.45) 0.95 (0.85^1.08) 1.01 (0.90^1.14) Red 1.40 (1.24^1.58) 0.86 (0.76^0.97) 0.96 (0.85^1.08) Meaning of work Green Yellow 1.26 (1.11^1.43) 1.07 (0.94^1.21) 1.09 (0.97^1.22) Red 2.17 (1.93^2.42) 1.20 (1.07^1.35) 1.15 (1.02^1.28) Predictability Green Yellow 1.55 (1.35^1.79) 1.36 (1.18^1.55) 1.33 (1.17^1.52) Red 2.18 (1.90^2.50) 1.38 (1.21^1.58) 1.38 (1.22^1.57) Recognition Green Yellow 1.18 (0.99^1.39) 1.13 (0.97^1.32) 1.16 (1.00^1.34) Red 2.57 (2.26^2.91) 1.51 (1.33^1.71) 1.46 (1.29^1.65) Role clarity Green Yellow 1.44 (1.259^1.65) 1.24 (1.09^1.41) 1.13 (1.00^1.27) Red 2.58 (2.276^2.93) 1.45 (1.27^1.64) 1.30 (1.16^1.46) Role conflicts Green Yellow 1.82 (1.59^2.08) 1.49 (1.30^1.70) 1.36 (1.20^1.54) Red 2.78 (2.46^3.15) 2.22 (1.96^2.51) 1.85 (1.65^2.08) Quality of leadership Green Yellow 1.31 (1.14^1.50) 1.22 (1.07^1.40) 1.14 (1.00^1.30) Red 1.99 (1.78^2.24) 1.57 (1.39^1.77) 1.38 (1.24^1.55) Social support from colleagues Green Yellow 1.34 (1.15^1.56) 1.31 (1.13^1.52) 1.19 (1.04^1.37) Red 2.20 (1.90^2.54) 1.61 (1.39^1.86) 1.36 (1.19^1.55) Social support from supervisors Green Yellow 1.34 (1.17^1.54) 1.14 (1.00^1.31) 1.16 (1.02^1.31) Red 1.95 (1.71^2.21) 1.52 (1.33^1.73) 1.53 (1.35^1.73) Social community at work Green Yellow 1.35 (1.17^1.56) 1.22 (1.06^1.40) 1.11 (0.98^1.26) Red 2.57 (2.27^2.91) 1.64 (1.45^1.86) 1.35 (1.20^1.51) (Continued )

9 Copenhagen Psychosocial Questionnaire II in Spain 9 TABLE V. (Continued.) Psychosocial dimension Tertile label Mental health Stress Burn out apr CI (95%) apr CI (95%) apr CI (95%) Insecurity over employment Green Yellow 1.70 (1.49^1.93) 1.43 (1.25^1.64) 1.29 (1.14^1.47) Red 1.85 (1.63^2.09) 1.72 (1.52^1.96) 1.69 (1.50^1.90) Insecurity over working conditions Green Yellow 1.78 (1.56^2.04) 1.42 (1.25^1.61) 1.29 (1.15^1.46) Red 2.99 (2.64^3.39) 2.01 (1.78^2.28) 1.78 (1.59^2.00) Trust regarding management Green Yellow 1.41 (1.23^1.60).93 (0.80^1.08).86 (0.75^0.98) Red 2.30 (2.01^2.62) 1.32 (1.13^1.54) 1.11 (0.96^1.28) Justice Green Yellow 1.41 (1.24^1.60) 1.32 (1.16^1.50) 1.23 (1.09^1.39) Red 2.09 (1.85^2.35) 1.57 (1.39^1.77) 1.49 (1.33^1.67) Psychosocial dimension tertile labels: green : most favorable for health; yellow : intermediate; red : most unfavorable for health. conditions, such as wage levels or work schedules, is subsidiary to the fear of increased job instability or of losing the job entirely [Ferrie et al., 2008; Vives et al., 2010], something which could be particularly relevant in a context of high unemployment and high job precariousness, such as that in Spain. The appropriateness of this separation was checked through analyses of associations and the contrasting of its distributions in terms of the different employment and job conditions, labor management practices, and population socio demographic characteristics, analyses which yielded consistent results (not shown). In fact, in a previous study which compared Spain and Denmark, the authors also divided the Insecurity dimension into two Job insecurity and Concern about employability, as a result of the differential analysis of items which found country-related differences for this dimension [Moncada et al., 2010a]. Regarding internal consistency, two of the mediumlength scales presented Cronbach alpha values slightly under 0.7 (Quantitative demands and Insecurity over Employment), and another had a value under 0.60 (Predictability); Cronbach alpha scores for the Spanish COPSOQ II long scales were generally higher. Almost none of the scales presented notable ceiling or floor effects, the only exceptions being the ceiling effects of around 20% for Double Presence, Social community at work, and Role clarity. Such an effect may be expected for Double presence given the high degree of labor market segregation and unequal gender-based sharing of domestic and family tasks in Spain. Even so, the ability of the Spanish scales to detect changes over time would appear not to be compromised, although this aspect should be evaluated through test retest studies. Associations with Mental health, Stress, and Burnout were in the expected directions and in most cases gradients were found. Few results were incongruent, the most important concerning Influence: the lowest Influence was not associated with Burnout or Stress; and medium and low levels of Influence overlapped their association with mental health; similar results to those found in 2005 when validating the COPSOQ Istas21 in Spain [Moncada et al., 2005]. We should consider various factors to understand these results. As we discussed in 2005, Spain is a country with lower levels of influence at work [Llorens et al., 2010; Moncada et al., 2010a] so that small differences in the score of Influence exist between the intermediate ( yellow ) and lowest ( red ) tertiles, tending to equalize the PR among Influence and the median of Mental Health, Stress, and Burnout. Consistently, adjusted PRs were also weak for other dimensions related to active work, that is Possibilities for development, Meaning of work, and Commitment to the Workplace. On the other hand, distribution of scores by occupational classes, gender and age groups were as expected: the lower the job qualification, the lower the level of Influence; also, women have lower influence than men, as do the youngest workers (data not shown). So we decided to keep Influence in the final version since we could explain our results and its relevance to health and to the understandability of the psychosocial work environment is well established. The Double presence scale has three items which are very similar but not identical to three others in the Danish Work-family conflict scale. We focused on time and tasks but not in private life work conflict. This scale was not in the Danish COPSOQ I but we developed a preliminary version included in the Spanish COPSOQ Istas21 with the name of

10 10 Moncada et al. Double presence being understood as reflecting the need to respond simultaneously to the demands of a paid job and domestic-family work. In the workplace, it is also associated with labor management practices related to the availability of time for paid work, prolonged and atypical work schedules, and heightened demands [Moreno et al., 2010]. It should be noted that all the results obtained for this dimension is satisfactory. We decided to eliminate the scale of Variation from the Spanish COPSOQ II medium-length version since it presented a too high correlation with the scale of Possibilities for development. This scale, like the Mutual trust between employees scale, was retained in the long version so that the particular selection of dimensions may be made to reflect researchers specific interests when using the questionnaire. All other scales which were new or additional, in comparison with the Spanish COPSOQ Istas21 namely Work pace, Rewards, Trust, and Justice yielded expected and acceptable results. These results were also consistent with other dimensions, although we agree that company-level analyses, rather than individual-based analysis, should be conducted on these dimensions in other studies. One strength of the present study is that it is based on a representative sample of wage earners in Spain. Weaknesses are the somewhat low response rate (56.0%) and the effect that the current economic crisis that started in 2008 could have on both the study sample composition and the answers people may give to some of the questions. We found no evidence of differential response rates according to geographical area, occupational class, gender or age group; and the study population did not differ from that which was expected considering the Active Population Survey of the same period [Instituto Nacional de Estadística, 2012]. The field work was done in a context of employment destruction in Spain and we have some evidence from other studies that in this process people working under more precarious conditions were pushed out of the labor market and so were prevented from forming part of the sample for this study. This means our study could be affected by something akin to the healthy worker effect or survival effect due to this process. In fact, temporary work in Spain decreased from 29.3% to 24.9% between 2008 and 2010 [InstitutoNacional de Estadística, 2012]. But, on the other hand, the same context of crisis may deteriorate working conditions, increase peoples fears, and influence expectations and perception of the working environment. A more in-depth analysis of comparisons between the 2010 and 2005 editions of the Psychosocial Risks Survey could help us to understand these issues. In the meantime, our present results support the validity of the Spanish COPSOQ II questionnaires in Spain as a tool for measuring psychosocial risks in the workplace. Nevertheless, we think better alternatives of some scales should be developed, especially regarding Influence. It should be stressed that this new Spanish COPSOQ II maintains a high level of concurrence with its first 2005 version (COPSOQ-Istas21) and the 2010 Danish and English COPSOQ II, so it can be used for Spanish comparisons and international comparisons as well. Spanish labor social agents and occupational and health professionals may download the tool together with the user manuals, software, and support materials from the ISTAS and COPSOQ websites ( and and its Catalan equivalent from the Catalan Government ( website to use them at the shop floor level to improve psychosocial risk assessment and the development of preventive actions. If used in other countries where the Spanish language is spoken, users should be aware of the structural, social, cultural, and linguistic differences among countries. ACKNOWLEDGMENTS We would particularly like to thank Jan Hyld Petersen and Tage S. Kristensen for their advice and support in the adaptation process. We also thank the unknown reviewers and Paul Landsbergis for their very useful comments to improve this article. REFERENCES Alonso J, Prieto L, Anto JM The Spanish version of the SF-36 health questionnaire: An instrument for measuring clinical results. Med Clin (Barc) 104(20): Barros AJ, Hirakata VN Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 20(3):21. COPSOQ international network. (n.d.) Retrieved from copsoq-network.org/. Ferrie J, Weterlund H, Virtanen M, Vahtera J, Kivimäki M Flexible labor markets and employee health. SJWEH Supplements 6: Hasselhorn HM, Tackenberg P, Muller BH Premature departure from nursing in germany as a growing problem for the health care system A review. Gesundheitswesen 65(1): Instituto Nacional de Estadística [INE] Encuesta de Población Activa. Retrieved from Instituto Sindical de Trabajo, Ambiente y Salud [ISTAS] Manual del método CoPsoQ-istas21 (versión 1.5). Retrieved from copsoq.istas21.net/ Kompier M Job design and well-being. In: Schabracq, MJ, et al. The handbook of work and health psychology p Sussex: John Wiley & Sons. Kristensen TS, Hannerz H, Hogh A, Borg V The Copenhagen psychosocial questionnaire A tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health 31(6): Kristensen TS, Borritz M, Villadsen E, Christensen KB The copenhagen burnout inventory: A new tool for the assessment of burnout. Work Stress 19(3):

11 Copenhagen Psychosocial Questionnaire II in Spain 11 Lee J, Chia KS Estimation of prevalence rate ratios for cross sectional data: An example in occupational epidemiology. Br J Ind Med 50(9): Llorens C, Alós R, Cano E, Font A, Jódar P, López V, Navarro A, Sánchez A, Utzet M, Moncada S Psychosocial risk exposures and labour management practices. An exploratory approach. SJPH 38(Suppl 3): Moncada S, Llorens C, Navarro A, Kristensen T ISTAS21 COPSOQ: Versión en lengua castellana del cuestionario psicosocial de Copenhague. Archivos De Prevención De Riesgos Laborales 8(1): Moncada S, Llorens C, Font A, Galtés A, Navarro A Exposición a riesgos psicosociales entre la población asalariada en españa ( ): Valores de referencia de las 21 dimensiones del cuestionario COPSOQ ISTAS21. RevEsp Salud Pública 82: Moncada S, Pejtersen J, Navarro A, Llorens C, Burr H, Hasle P, Bjorner J Psychosocial work environment and its association with socio economic status. A comparison of spain and denmark. SJPH 38: Moncada S, Utzet M, Llorens C, Galtés A, Moreno N Encuesta de riesgos psicosociales en el trabajo en España, Trabajo de campo para la producción de la versión española del Copenhagen Psychosocial Questionnaire. Madrid: Fundación de Prevención de Riesgos Laborales. Moreno N, Moncada S, Llorens C, Carrasquer P Double presence, paid work, and domestic-family work. New Solut 20(4): Nübling M, Vomstein M, Haug A, Nübling T, Adiwidjaja A European-wide survey on teachers work related stress Assessment, comparison and evaluation of the impact of psychosocial hazards on teachers at their workplace. Brussels: ETUCE. Pejtersen J, Kristensen T, Borg V, Bjorner J The second version of the copenhagen psychosocial questionnaire. SJPH 38(Suppl 3):8 24. Schiaffino A, Rodriguez M, Passarín M, Regidor E, Borrell C, Fernández E Odds ratio o razón de proporciones? Su utilización en estudios transversales. Gac Sanit 17(1): Serra-Sutton V, Herdman M, Rajmil L, Santed R, Ferrer M, Siméoni MC, Auquier P Cross-cultural adaptation to Spanish of the Vécuet Santé Perçue de l Adolescent (VSP-A): a generic measure of the quality of life of adolescents. Rev EspSalud Publica 76(6): Setterlind S, Larson G The stress profile: A psychosocial approach to measuring stress. Stress Med 11: Stromberg U Prevalence odds ratio v prevalence ratio. Occup Environ Med 51(2): Valeyre A, Lorenz E, Cartron D, Csizmadia P, Gollac M, Illésy M, Makó C Working conditions in the European Union: Work Organisation. Dublin: European Foundation for the Improvement of Living and Working Conditions. Vives A, Amable M, Ferrer M, Moncada S, Llorens C, Muntaner C, Benavides FG, Benach J The employment precariousness scale (EPRES): Psychometric properties of a new tool for epidemiological studies among waged and salaried workers. Occup Environ Med 67(8):