Arch Neurosci. 2017 July; 4(3):e13576. doi: 10.5812/archneurosci.13576.

Published online 2017 July 30. Research Article

Assessment of the Psychosocial Work Environment among Health

Care Workers and Its Association with Work and Socioeconomic Status
Mostafa Ghaffari,1,2,3 Hassan Alinaghizadeh,1,4,* Leila Ghalichi,5 Omid Pournik,6 and Eva Vingard1
1
Occupational and Environmental Medicine, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
2
MD, MPH, PhD, Occupational and Environmental Medicine Department, School of Medicine, Iran University of Medical Sciences, Teheran, Iran
3
Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran Iran.
4
MSc, PhD Candidate, Senior Statistician, Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet,
Stockholm, Sweden
5
MD, PhD, Epidemiology Department, School of Public Health, Iran University of Medical Sciences, Teheran, Iran
6
MD, PhD, Community Medicine Department, School of Medicine, Iran University of Medical Sciences, Teheran, Iran
7
MD, PhD, Occupational and Environmental Medicine, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
*
Corresponding author: Hassan Alinaghizadeh, Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet,
Stockholm, Sweden. Tel: +46-704840374, E-mail: farhad.alinaghizadeh@ki.se

Received 2017 May 16; Accepted 2017 July 22.

Abstract

Background: The health care sector constitutes one of the largest sources of employment worldwide.
Objective: The aim of this study was to describe the psychosocial status of health care workers and its association with different
covariates.
Methods: Health care workers from different universities, hospitals, clinics, urban and rural health centers took part in this cross-
sectional study. The medium version of COPSOQ was used to evaluate the association between COPSOQ and covariates. The mul-
tivariate analyses of variance and covariance were employed to determine multivariate and univariate associations between all
psychosocial dimensions and covariates.
Results: Most COPSOQ scores showed a good internal consistency and reliability, with total Cronbach’s alpha of 0.76. The study
population comprised 7,027 health care workers among whom 64% were female. The results indicated that nurses are more exposed
to the psychosocial work environment compared to the other groups of workers within the health care settings.
Conclusions: Nurses had a significantly higher risk regarding almost all the psychosocial factors. Considering that the main short-
age of human resources in our study population belonged to the nursing group, this bad situation is not surprising. Healthcare
workers, especially nurses, are facing various psychosocial factors more than other workers are, because all these factors are in the
healthcare environment at the same time.

1. Background problems, injuries, and illnesses at the workplace (4-6).

Based on one study in the US, about 17.5% of newly quali-
The health care sector constitutes one of the largest fied nurses leave within one year of starting their first job
sources of employment worldwide (1, 2). Based on the (7).
world health organization report (3), health care facilities In the last decade, health care researchers have re-
around the world employ over 60 million workers who vealed an increase in mental stress for healthcare workers
are exposed to a complex variety of health and safety haz- and its short and long term effects on health, sickness ab-
ards, from biological hazards to adverse ergonomic and sence, sickness presence, low quality of life, motivation,
psychosocial factors. In many countries, shortage of health and productivity (8-14).
workers now and in the future is a serious concern. For de- Sickness in healthcare workers is a concern because
veloping countries, this may include migration and brain many of them continue to work despite mental or other
drain when highly qualified workers move abroad. health issues (15, 16). This may have an impact on them-
Healthcare involves many occupations with varied ex- selves, colleagues, and their patients, in both physical and
posures, including doctors, nurses, midwives, health ex- psychosocial terms (17, 18). There is a substantial and grow-
perts, pharmacists, laboratory technicians, managers, of- ing body of evidence linking the psychosocial working en-
fice workers, cooks, catering staff, drivers, and cleaners. In vironment to health (19-21).
most countries, the majority of the workers are female. In the healthcare system in Iran, medical universities
Despite the fact that the health sector has a culture are responsible for not only education and research but
in which health-related surveillance is recognized as im- also for all preventive and curative services in a defined ge-
portant, healthcare workers continue to experience health ographical area. The ministry of health and medical educa-

Copyright © 2017, Archives of Neuroscience. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the
original work is properly cited.
 Ghaffari M et al.

tion is one of the biggest employers, with around 400,000 To avoid selection bias and measurement bias, we in-
persons working in 48 medical universities in the country, cluded all health care workers working at the medical uni-
and meets all the demands for health care and treatment versity and used the validated Persian version of the Copen-
for more than 75 million inhabitants, with facilities rang- hagen psychosocial questionnaire (COPSOQ) (24) to mea-
ing from health centers in small villages to large hospitals sure the psychosocial work environment. The medium ver-
in main cities. sion of the COPSOQ1 consists of 26 scores in 5 dimensions
The health of health care workers in Iran is an impor- including type of production and task (17 questions), work
tant issue that needs more attention. This study was there- organization and job content (19 questions), interpersonal
fore conducted to generate more information and knowl- relations and leadership (24 questions), work-individual
edge about the current health status of Iranian health care interface (8 questions), and health and well-being (26 ques-
workers, with a focus on their psychosocial work environ- tions). Most of the questions have 5 response options: “to
ment. a great extent”, “to some extent, somewhat, a little, very lit-
tle” or “always, often, sometimes, rarely, never/almost nev-
er”. See Table 2 for the content of each score.
2. Objectives
3.3. Statistical Analysis
Descriptive analysis of centrality was used for all 26
The aim of this study was to describe the psychosocial
scores in the instrument; mean, standard deviation (SD),
status of health care workers in Iran and its association
and frequencies were presented. The correlation among
with a number of covariates.
26 scores was driven by Person’s correlation and a highly
significant association among these 26 scores was almost
always observed (results not shown).
3. Design
The original 94 items from COPSOQ were compiled
in 26 scores (25) and the reliability of instrument was
3.1. Study Design and Sample controlled with Cronbach’s alpha. The 5 dimensions (D1-
D5) were used as an outcome in MANCOVA. All calculated
In 2012, a baseline survey was carried out in one of
scores belonging to each of the 5 dimensions of COP-
the main medical universities in Iran. The study included
SOQ were summed and the final sum score was used as
health care workers with a regular job contract at different
a response variable representing each dimension in AN-
university schools, large hospitals, clinics, urban health
COVA/MANCOVA.
centers, and rural health centers. A total of 8,086 health
Multivariate association between socioeconomic sta-
care workers were eligible and invited to participate. They
tus and the psychosocial dimensions at work was con-
received a questionnaire and a return envelope as well as
firmed by Wilks’ Lambda test where all background factors
an information letter about the aim of the study, empha-
were significant.
sizing that participation was voluntary.
Suggested cut-off points for each dimension were pro-
We collected data about age, sex, education, job-tile,
duced. Values above the cut-off point for dimension 1 indi-
shift work, working hours, income, and workplace as a po-
cated a bad situation, and vice versa for other dimensions.
tential confounder.
A univariate comparison was done to confirm if there
was an association between each dimension and all covari-
3.2. Measurement of Psychosocial Work Environment ates. This means that comparisons did not take into ac-
count the effect of other dimensions. Our intention was
One of the validated tools for measuring psychoso- to reject covariates (background and socioeconomics) that
cial occupational exposure is the Copenhagen psychoso- were not significant in both multivariate and univariate
cial questionnaire (COPSOQ), which was developed by Kris- models.
tensen and tested in a national survey in Denmark (10). An insubstantial relationship was observed between
The questionnaire has been developed into three versions demographic and socioeconomic variables but it did not
(long, medium, and short) and includes in its long version cause any multicollinearity problem, which was con-
30 scores of work and health in 141 items (10). This tool trolled by Variance Inflation Factors in the model (26,
has been translated into a number of languages and some 27). The multivariate relationship between linear com-
comparative studies in various countries have been com- binations of the set explanatory variables and D1-D5 was
pleted to compare the psychosocial climate of their work- controlled by nonlinear canonical correlation analysis and
place with that of Denmark (22, 23). an approximation suggested by a number of researchers

2 Arch Neurosci. 2017; 4(3):e13576.

 Ghaffari M et al.

(28-30) was used to confirm these associations. All de- difference included: quantitative demands, emotional de-
mographic and socioeconomic variables used in the AN- mands, demands for hiding emotions, sensory demands,
COVA/MANCOVA models were categorized by the Sigma- influence at work, possibilities for development, degree of
restricted parameterization. Effective hypothesis decom- freedom at work, meaning of work, role clarity, role con-
position in multivariate tests of significance was per- flicts, social support, social relations, insecurity at work,
formed by Wilks’ lambda criterion (31) followed by an F- job satisfaction, general health, mental health, vitality, and
test where all covariates indicated a significant multivari- behavioural stress.
ate relation. There were no large differences between the Iranian
A multiple comparison (contrast test) involving and Danish study populations in 8 scores, including: cog-
%SimTests macro with Bonferroni adjustments and PROC nitive demands, commitment to the work place, pre-
MULTTEST in SAS as suggested by Westfall was used to com- dictability, quality of leadership, sense of community, job
pare differences within job title, and partitioned analysis satisfaction, somatic stress, and cognitive stress. In one
of least squares means (32). All estimated least squares scale, feedback at work, the Danish sample had a worse sit-
means (LSM) and 95% CI are presented in Table 3. uation than Iranian health care workers did.
The final analysis included sum scored as a response In the comparison between Iranian Health care work-
variable in five dimensions (D1 - D5) where all scores in each ers and German hospital workers in the scores such as emo-
dimension were summed separately and the assumption tional demands, demands for hiding emotions, commit-
of multivariate normality was confirmed. The multivariate ment to the work place and cognitive stress, Iranian health
analysis of variance and covariance (ANCOVA/MANCOVA) care workers had a better situation and less exposure. How-
were used to determine multivariate and univariate rela- ever, in other scores, such as possibilities for development,
tionships between all the five psychosocial dimensions at degree of freedom at work, meaning of work, role clarity,
the same time by using these values for Sum Scored as out- social support, social relations, insecurity at work, and gen-
come (D1 - D5) and background variables as explanatory eral health, Iranian health care workers had a worse psy-
variables. The results are presented as least squared mean chosocial working environment compared to the German
(LSM ± SE) for both univariate and multivariate relation- hospital workers.
ships. All the statistical analyses were performed using SAS It is interesting that, compared to the German ‘all oc-
9.3 (SAS Institute Inc., Cary, NC). cupation group’, the German hospital workers have a bet-
ter psychosocial working environment in terms of mean-
ing of work, quality of leadership, social support, feedback
4. Results at work, social relations, and insecurity at work, and only
in emotional demands do they have a worse situation com-
7,027 out of the 8,086 invited health care workers re-
pared to other occupations.
sponded to the questionnaires, corresponding to a re-
sponse rate of 79.8 %. Among these, 1,923 questionnaires 4.2. Comparisons Between Occupational Groups in Iran
were excluded due to excessive missing information and
Comparing occupations within the health care set-
5,253 completed questionnaires were analysed. Among
tings, nurses had the least favorable psychosocial work en-
these, 1,832 participants were male (36 %) and 3,303 were fe-
vironment (Table 3). In 13 scores (quantitative demands,
male (64 %). Demographic characteristics of the study pop-
emotional demands, demands for hiding emotions, sen-
ulation are presented in Table 1.
sory demands, role conflict, behavioral stress, somatic
Quantitative measurements (mean and standard devi-
stress, cognitive stress, less influence at work, low degree
ation) of the psychosocial work environment in 26 differ-
of freedom at work, low commitment to the work place,
ent scores are presented in Table 2. The scores for ‘Danish
and less job satisfaction), the nurses had lower values than
national average’, ‘German all occupations’, and ‘German
the average mean for other occupations.
hospital workers’ are also included for comparison. A dif-
Compared to the average employees, physicians were
ference in the mean values of more than 5 points was con-
more exposed to low quality of leadership, less social sup-
sidered relevant.
port, less degree of freedom at work, and low sense of com-
munity.
4.1. International Comparison
Compared to the average employees, health experts
In 17 of the 26 scores, the Iranian health care work- were more exposed to less meaning of work, less pre-
ers reported a bad situation compared to the other pub- dictability, and less role clarity and the unskilled workers
lished references, such as the study on the Danish working were more exposed to less possibility for development, less
population (Table 2). The scores with more than a 5-point social relations, and more insecurity at work.

Arch Neurosci. 2017; 4(3):e13576. 3

 Ghaffari M et al.

Table 1. Demographic Characteristics of the Study Populationa

Total Females Males P Valueb

Age group, y < 0.001

Under 30 1543 (30) 1154 (35) 389 (21)

Between 31 and 50 2835 (55) 1737 (53) 1098 (60)

More than 51 740 (15) 402 (12) 338 (19)

Education < 0.001

High school and less 1886 (36) 806 (25) 1080 (60)

Technician 597 (12) 419 (13) 178 (10)

Bachelor and MSc 2263 (45) 1873 (57) 390 (21)

PhD 51 (1) 22 (1) 29 (2)

Physician 285 (6) 151 (4) 134 (7)

Job Title < 0.001

Physician 277 (6) 143 (5) 134 (7)

Nurse 1205 (24) 963 (30) 242 (14)

Health expert 885 (18) 696 (22) 189 (11)

Office worker 1406 (28) 914 (28) 492 (28)

Simple worker 1207 (24) 491 (15) 716 (40)

Shift work < 0.001

Day shift 3058 (62) 1986 (62) 1072 (61)

Afternoon shift 67 (1) 36 (1) 31 (2)

Night shift 239 (5) 143 (4) 96 (5)

Two shifts 489 (10) 317 (10) 172 (10)

Three shifts 653 (13) 417 (13) 236 (14)

Not-fixed working hours 395 (8) 282 (9) 113 (6)

Others 50 (1) 19 (1) 31 (2)

Working hours, H/W < 0.001

Full time 44 2558 (52) 1715 (53) 843 (48)

Full time more than 44 1829 (37) 1086 (34) 743 (42)

Part time (20 - 40) 577 (11) 405 (13) 172 (10)

Income, mil Rials < 0.001

Less than 5 3878 (76) 2592 (78) 1286 (70)

Between 5 and 10 1124 (21) 660 (20) 464 (25)

More than 10 133 (3) 51 (2) 82 (5)

Work place < 0.001

University campus 847 (17) 437 (14) 410 (23)

Hospital 2831 (57) 1841 (57) 990 (56)

District health office 303 (6) 185 (6) 118 (6)

Urban health center 900 (18) 676 (21) 224 (13)

Rural health center 107 (2) 77 (2) 30 (2)

a
Values are expressed as No. (%).
b
Chi-square test.

4 Arch Neurosci. 2017; 4(3):e13576.

 Ghaffari M et al.

Table 2. COPSOQ Context and Level of Dimensionsa

Context and Level Scores Number of Study Population German Hospital German All Danish All
of Dimensions Questions (Item) Workers Occupation Occupation

D1: Type of 1. Quantitative 4 58 (19) 57 (17) 59 (18) 47 (19)

production & demands
tasks (Work place)

2. Cognitive 4 63 (18) - 63 (21) 63 (21)

demands

3. Emotional 3 54 (28) 64 (19) 58 (20) 38 (25)

demands

4. Demands for 2 44 (25) 51 (21) 48 (22) 30 (23)

hiding emotions

5. Sensory demands 4 73 (19) - 62 (23) 62 (23)

D2: Work 6. Influence at work 4 44 (20) 41 (20) 45 (22) 55 (24)

organization &
job content

7. Possibilities for 4 58 (22) 70 (16) 69 (18) 72 (19)

development

8. Degree of 4 28 (18) 42 (18) 44 (24) 65 (25)

freedom at work

9. Meaning of work 3 71 (18) 82 (16) 77 (18) 78 (16)

10. Commitment to 4 61 (22) 56 (19) 56 (20) 57 (21)

the work place

D3: Interpersonal 11. Predictability 2 56 (21) 55 (21) 51 (23) 60 (23)

relations &
leadership

12. Role clarity 4 70 (17) 78 (15) 74 (18) 76 (15)

13. Role conflicts 4 44 (23) 47 (20) 47 (20) 37 (18)

14. Quality of 4 58 (25) 55 (25) 47 (26) 55 (21)

leadership

15. Social Support 4 50 (22) 70 (20) 63 (21) 68 (20)

16. Feedback at work 2 44 (25) 45 (21) 39 (23) 39 (23)

17. Social relations 2 52 (20) 70 (20) 45 (28) 68 (30)

18. Sense of 3 81 (17) 77 (18) 74 (18) 82 (17)

community

D4: 19. Insecurity at 4 39 (36) 33 (22) 26 (22) 17 (25)

Work-individual work
interface

20. Job satisfaction 4 65 (16) 62 (15) 62 (16) 68 (17)

D5: Health and 21. General health 5 53 (11) 73 (18) 73 (18) 81 (17)
well-being
(individual)

22. Mental health 5 35 (10) - - 79 (15)

23. Vitality 4 41 (11) - - 64 (19)

24. Behavioural 4 29 (23) - - 17 (17)

stress

25. Somatic stress 4 18 (18) - - 19 (16)

26. Cognitive stress 4 22 (21) 28 (18) 28 (19) 20 (18)

a
Values are expressed as mean (SD).

A multiple comparison adjustment using the Bonfer-

Arch Neurosci. 2017; 4(3):e13576. 5

 Ghaffari M et al.

Table 3. Age Adjusted Univariate Analysis of Covariate Based on Estimated Marginal Means and Standard Errors (SE) of COPSOQ Scores Among Different Job Titles in the Study
Population

Context and Level Scores Mean (SE)a Univariate Testb

Physician Nurse Health expert Office worker Simple worker

D1: Type of production & 1. Quantitative demands 54.7 (1.17) 64.0 (0.61) 53.5 (0.70) 56.3 (0.56) 57.3 (0.58) < 0.01
tasks (Work place)

2. Cognitive demands 69.9 (1.06) 69.0 (0.55) 60.9 (0.63) 62.0 (0.50) 57.9 (0.53) < 0.01

3. Emotional demands 59.8 (1.79) 69.8 (0.82) 53.1 (0.94) 42.3 (0.74) 48.0 (0.78) < 0.01

4. Demands for hiding 45.9 (1.48) 51.7 (0.78) 42.8 (0.88) 38.5 (0.70) 42.2 (0.74) < 0.01
emotions

5. Sensory demands 75.6 (1.18) 81.4 (0.62) 71.4 (0.71) 68.6 (0.57) 69.3 (0.59) < 0.01

D2: Work organization 6. Influence at work 51.9 (1.20) 44.5 (0.63) 43.9 (0.72) 45.0 (0.58) 43.5 (0.61) < 0.01
& job content

7. Possibilities for 71.5 (1.29) 64.2 (0.68) 60.3 (0.77) 57.0 (0.61) 51.7 (0.64) < 0.01
development

8. Degree of freedom at 38.3 (1.07) 25.2 (0.56) 32.7 (0.64) 31.0 (0.51) 24.3 (0.53) < 0.01
work

9. Meaning of work 74.5 (1.14) 72.5 (0.60) 70.5 (0.68) 70.7 (0.54) 71.4 (0.57) < 0.01

10. Commitment to the 65.0 (1.35) 59.9 (0.70) 60.4 (0.80) 62.3 (0.64) 64.4 (0.67) < 0.01
work place

D3: Interpersonal 11. Predictability 55.9 (21.7) 56.4 (20.8) 54.1 (19.7) 56.1 (21.4) 58.1 (22.4) < 0.01
relations & leadership

12. Role clarity 72.8 (15.6) 70.4 (16.2) 69.8 (15.9) 70.1 (16.9) 70.6 (17.4) 0.07

13. Role conflicts 42.7 (21.4) 49.0 (22.2) 42.0 (21.1) 43.7 (22.9) 42.6 (23.6) < 0.01

14. Quality of leadership 54.1 (24.0) 55.5 (24.8) 54.1 (24.4) 58.0 (25.3) 64.6 (25.3) < 0.01

15. Social Support 48.7 (20.8) 51.0 (21.6) 50.4 (20.4) 49.3 (22.7) 51.5 (23.9) 0.06

16. Feedback at work 40.3 (22.5) 43.7 (24.2) 41.2 (23.4) 41.7 (25.3) 49.9 (27.3) < 0.01

17. Social relations 56.8 (19.6) 49.1 (18.6) 51.9 (18.9) 52.7 (20.8) 51.1 (22.1) < 0.01

18. Sense of community 78.2 (16.6) 79.8 (17.4) 79.7 (17.5) 81.1 (17.7) 83.2 (17.1) < 0.01

D4: Work-individual 19. Insecurity at work 20.8 (29.2) 24.3(31.8) 32.7 (31.8) 43.9 (35.3) 55.9 (37.0) < 0.01
interface

20. Job satisfaction 66.7 (13.9) 61.2(16.3) 63.6 (15.9) 65.6 (15.9) 66.9 (17.6) < 0.01

D5: Health and 21. General health 52.2 (9.1) 52.1 (10.4) 52.5 (10.0) 52.8 (10.5) 53.6 (11.9) < 0.01
well-being (individual)

22. Mental health 36.0 (8.4) 36.1 (10.0) 35.9 (9.4) 35.2 (9.6) 34.6 (10.9) < 0.01

23. Vitality 41.0 (10.1) 40.9 (11.2) 40.4 (10.7) 40.1 (10.8) 40.9 (12.9) 0.33

24. Behavioural stress 26.5 (22.7) 33.2 (24.1) 27.6 (23.0) 26.3 (22.0) 28.3 (24.1) < 0.01

25. Somatic stress 18.1 (17.5) 22.0 (19.9) 16.9 (17.5) 16.1 (17.5) 17.3 (19.4) < 0.01

26. Cognitive stress 24.8 (20.3) 25.8 (21.5) 22.2 (19.7) 20.3 (19.4) 20.8 (21.1) < 0.01
a
All models are adjusted for Age and Gender.Main effect test value.
b
All univariate tests are adjusted for multiple comparison by Bonferroni adjustment.

roni method to adjust p-value was performed within job work place (D1). The cut-off point is 290.92 ± 5.36 mean-
titles, age, and gender and the results are presented in Ta- ing that if the individual has a score greater that his value,
ble 3. The final analysis included Sum Scored as a response he/she has a poor situation at work. Covariates associated
variable in five dimensions (D1-D5) where all items in each with a poor situation were physicians, nurses, females,
dimension were summed separately (Table 4 and Figure 1). working more than 44 hours, self-rated health, and work-
ing at hospital.
The first dimension is type of production and tasks at

6 Arch Neurosci. 2017; 4(3):e13576.

 Ghaffari M et al.

The second dimension is work organization and job care workers. In contrast, the situation is the opposite
content (D2) with a cut-off point of 285.92 ± 5.12. The co- for other scores (emotional demands, demands for hiding
variates associated with a poor situation were older age, emotions, commitment to the work place, and cognitive
males, war history, self-rated health, and work at district stress) where German hospital workers are facing a worse
health office or rural health center. psychosocial working environment compared to the Ira-
The third dimension is interpersonal relations and nian health care workers.
leadership (D5) with a cut-off point of 485.47 ± 8.12. The co- This comparison reveals that the Iran health care sys-
variates associated with a poor situation were males, war tem needs to pay more attention to work organization
history, excellent personal belief in general health, and and job content, interpersonal relations and leadership,
working place at rural health center. as well as the health and well-being of employees. One
The fourth dimension has only two scores: insecurity possible mechanism that could explain the difference in
at work and job satisfaction. The cut-off point for this di- these scores involves the role of strong unions in negoti-
mension is 94.76 ± 2.84. Covariates associated with a poor ation and creating a better working environment for em-
situation were younger age, males, and excellent personal ployees. This role is well defined in developed countries,
belief in general health. A negative association was found which have more experience in this field. In addition, so-
with the job title ‘Nurses’. cial factors such as financial situation and high unemploy-
The last dimension is health and well-being. The cut- ment rate play important roles. A challenging financial sit-
off point for this dimension is 360.10 ± 4.13. We found a uation combined with a high unemployment rate restricts
positive association between this dimension and job title the possibility of raising these issues. In this situation,
as health expert and office worker, males, working hours keeping one’s current job as well as production rate are the
of full time 44 hours, and self-rated health. These items most important issues for both employers and employees,
could explain the health and well-being of Iranian health making it difficult to improve the psychosocial work envi-
care workers. ronment.
Compared to the Danish national average in terms of
the scores of the 26 scores in COPSOQ, the psychosocial
5. Discussion
exposures of Iranian health care workers are significantly
During the past three decades, Iran’s population has higher (more than 5 points difference in each scale’s mean)
doubled from 36 million to 75 million inhabitants and the in at least 16 scores, and in only one scale (feedback at
number of hospital beds has increased from 57,000 beds work) the Iranian health care workers have less exposure.
to 110,000 beds. In addition, during this time the health Most demands on the health care workers included in this
network in the whole country has changed considerably. study are high. One possible explanation for the difference
The number of health centers has increased from 4,000 between the Iranian and Danish groups could be the vol-
to more than 17,000 urban and rural health facilities; this ume of the patients and shortage of health care person-
creates comprehensive access to primary and secondary nel in hospitals and clinics. This is an important issue for
health care services (33). Despite this, the number of jobs those driving future health care policies. The total health
in the health care sector has not kept up with the popula- care system in Iran is under expansion and the volume of
tion increase in recent years and a large number of highly end-users requiring health care services is increasing, with
educated people in health and medicine are seeking em- changes in the population pyramid and aging population.
ployment. Most of the new hospitals and clinics are run Comparing the scores for the 26 scores in COPSOQ be-
with insufficient human resources and this puts pressure tween the occupational groups indicated that nurses had
on the health care employees. Aside from financial aspects, significantly higher scores in most scores. This is not
the psychosocial work environment can be one of the ma- surprising considering that there is a severe shortage of
jor factors driving the health care brain drain from Iran. nurses in Iran, which is a cause of great concern that can
A few large studies have used the COPSOQ instrument explain the high level of ‘intention to leave job’ among
and our results could only be compared with the German nurses.
hospital workers and the Danish national average. Re- The terminology of ‘Nursing shortage’ is usually de-
sults from studies on the German hospital workers showed fined as the gap between the number of available nurses
that, in some scores (possibilities for development, degree and the optimum number of nurses (34). The nurse-to-
of freedom at work, meaning of work, role clarity, social population ratio in USA is 700:10,000 while in Uganda this
support, social relations, insecurity at work, and general ratio is 6:10,000. Both countries have reported a nursing
health), German hospital workers have a better psychoso- shortage (34), indicating that the context of shortage is de-
cial working environment compared to the Iranian health fined by each country’s national structure for health care

Arch Neurosci. 2017; 4(3):e13576. 7

 Ghaffari M et al.

Figure 1. Unadjusted Mean for Five Dimensions of Psychosocial Factor for Different Job Titles

350

340

330

320

310

D1
300

290

280

270

260
Office Worker Nurse Physician
Health Expert Simple Worker

320
495

310 490
485
300
480

290 475

D3
D2

470
280
465

270 460
455
260
450

250 445
Office Worker Nurse Physician Office Worker Nurse Physician
Health Expert Simple Worker Health Expert Simple Worker

130 370
368
125
366
120 364
115 362
360
110
358
D5

105
D4

356
100 354
352
95
350
90 348
85 346
344
80 Office Worker Nurse Physician
Office Worker Nurse Physician
Health Expert Simple Worker Health Expert Simple Worker

Error bars represent the 95% confidence Interval for Mean. D1, Type of production & tasks(work place); D2, Working organization & job content; D3, Interpersonal relation &
leadership; D4, Work-individual interface; D5, Health and well-being(individual); Job titles: Office worker, health expert, Nurse, Simple worker, Physician

personnel. A study in Iran in 2009 estimated that there most importance to the turnover in nurses and their inten-
were 90,026 nurses in Iran, but hospitals and health-care tion to leave (40).
facilities need around 220,000 nurses in order to deliver Findings from an Iranian study (41) about perceptions
optimal nursing care and services (35). of nursing practices in Iran showed that Iranian nurses op-
The average density of nurses per 1,000 citizens erate in undesirable working conditions. Most of them are
throughout the world is 4.06, whereas the density of overworked and underpaid compared to other professions
nurses in Iran is 1.31 (36). The results from a study in 2010 with a similar level of knowledge and expertise. They also
indicated that high emotional demands, low meaning of found that the nurses feel that they are forced to put more
work, low commitment to the workplace, and low job sat- effort into administrative duties rather than they focus on
isfaction were constantly predictive factors for nurses in- the patient’s needs.
tending to leave their job (37). In a study among the Eu- Nurses comprise the main group of health care em-
ropean nurses, the three most important factors strongly ployees in Iran and they provide a significant portion of
associated with nurses’ intention to leave were poor pro- patient care; but they do not enjoy the same status in
fessional opportunities, unpleasant work organization, healthcare organizations as others, especially physicians
and low health status (38). Another study from Sweden (42). The consequences can be dissatisfaction, lack of mo-
found that an unsatisfactory salary contributed most to tivation, and low quality of service among nurses, all of
the nurse’s decision to leave (39). One study on nurses in which leading to patient dissatisfaction (42, 43). Our re-
the UK suggested that work environment-related factors sults support the results of previous studies and confirm
rather than individual or demographic factors were still of the poor psychosocial environment among nurses.

8 Arch Neurosci. 2017; 4(3):e13576.

 Ghaffari M et al.

In total, the psychosocial factors at work in our study Surveying within a single special occupational group
are favourable for office workers and unskilled workers (health care workers) has both advantages and disadvan-
when compared to the other groups. In contrast, those tages, since it creates less variation in the traditional psy-
working directly with patients and providing health ser- chosocial risk factors, as the workers experience the same
vices are exposed to more negative psychosocial factors. working conditions. The traditional domains of psychoso-
The vast majority of our study population was female, cial factors, such as quantitative demands and influence,
as was also the case for the health care system in Iran. are work factors that are much more related to job type
Women are the main health care providers at different lev- rather than to work environment and place of work. On the
els, from small health houses in the villages to the big hos- other hand, some domains, such as leadership quality and
pitals in major cities (33). The proportion of female health predictability, are more dependent on the place of work
care workers has increased, not only in Iran but also in and work environment rather than to job type. Our study
most Western countries. This is also the situation for fe- design is also well adapted to detect the factors related to
males in higher medical positions, who have increased to the place of work.
over 50% in the last 20 years in Germany (5).
We can find significant gender differences by compar- 5.1. Conclusions
ing the means of the psychosocial factors at work in our
study. Women have a significantly worse situation com- The present study on the psychosocial work environ-
pared to men in four of five dimensions of the psychoso- ment of Iranian health care workers reveals that health
cial factors at work. Gender differences have also been re- care workers experience substantial adverse psychosocial
ported in other studies (23, 44, 45). Women dominate the exposures. Our study also showed significant differences
health care system in Iran and other countries, making this in the psychosocial work environment among occupa-
gender difference an important issue. Male experts hold tional groups in health care. Nurses had significantly
most of the managerial positions in the health care system, higher scores in most scores. The significant gender differ-
and improving the psychosocial work environment needs ence and the important role of female employees in the Ira-
their serious attention. nian health care system indicate that management should
All previous studies using the COPSOQ instrument place more focus on improving the psychosocial work en-
have focused on analyzing the scores introduced in the in- vironment of the health care system in Iran.
strument. Kristiensen introduced five dimensions into the - What this paper adds
COPSOQ based on the different scores, but these dimen- - Healthcare professionals worldwide are exposed to
sions have not been analyzed in many studies. Our ap- a complex variety of psychosocial factors. The purpose
proach places more attention on five dimensions, creating of this study is to describe the psychosocial status of the
a sum score for each dimension and provides an advanced healthcare workers in Iran and its association with socioe-
analysis of COPSOQ. conomic status.
Our study adds to prior research about the health of - COPSOQ is one of the validated tools for measuring
health care workers by a broader mapping of the psychoso- psychosocial occupational exposure. The questionnaire
cial work environment among health care workers in Iran was developed in three versions (long, medium, and short)
rather than an inventory with a specific focus on stress or and its long version includes 30 scores of work and health
burnout. using 141 items. The medium version of COPSOQ with 26
This study had some additional strengths as well as scores and 94 items was used in this study to evaluate the
limitations. Large samples of health care workers in dif- psychosocial work environment among healthcare work-
ferent occupational groups from different centers create ers and its association with work and socioeconomic sta-
a comprehensive resource for analysis. Moreover, using a tus.
standard validated tool to measure the psychosocial work- - All previous studies using COPSOQ instrument fo-
ing environment among health care workers is another cused on analyzing the scores established into the instru-
strength in this study. Comparing our study population ment. The origin dimensions in COPSOQ are based on the
with populations in Germany and Denmark reported by different scores, but these dimensions have not been ana-
previous studies shows a good external validity, which in lyzed in previous studies. Our approach pays more atten-
turn indicates a possible generalization of our results in tion to these dimensions, creating a new score for each di-
this paper. On the other hand, the study is limited by mension and providing an advanced analysis of COPSOQ.
cross-sectional design as well as some dropouts and un- This in turn provides a cutoff point for each dimension
completed questionnaires apart from the self-reported ex- and makes it easier for future studies to be compared with
posures. meta-analysis.

Arch Neurosci. 2017; 4(3):e13576. 9

 Ghaffari M et al.

References a meta-analysis. Scand J Work Environ Health. 2006;32(6):431–42.

[PubMed: 17173200].
1. Hongoro C, McPake B. How to bridge the gap in human re- 21. Belkic K, Schnall P, Landsbergis P, Baker D. The workplace and cardio-
sources for health. Lancet. 2004;364(9443):1451–6. doi: 10.1016/S0140- vascular health: conclusions and thoughts for a future agenda. Occup
6736(04)17229-2. [PubMed: 15488222]. Med. 2000;15(1):307–21. [PubMed: 10702092] v-vi.
2. WHO . Chapter 4 - Selected occupational risks. ; 2004. 22. Moncada S, Pejtersen JH, Navarro A, Llorens C, Burr H, Hasle P, et
3. WHO . Migration of Health Care Workers. ; 2010. al. Psychosocial work environment and its association with socioe-
4. Serdar T, Derek L, Unic A, Marijancevic D, Markovic D, Primorac A, conomic status. A comparison of Spain and Denmark. Scand J Pub-
et al. Occupational exposures in healthcare workers in University lic Health. 2010;38(3 Suppl):137–48. doi: 10.1177/1403494809353825.
Hospital Dubrava–10 year follow-up study. Cent Eur J Public Health. [PubMed: 21172779].
2013;21(3):150–4. [PubMed: 24344541]. 23. Nubling M, Stossel U, Hasselhorn HM, Michaelis M, Hofmann F. Mea-
5. Fuss I, Nubling M, Hasselhorn HM, Schwappach D, Rieger MA. Work- suring psychological stress and strain at work - Evaluation of the
ing conditions and Work-Family Conflict in German hospital physi- COPSOQ Questionnaire in Germany. Psychosoc Med. 2006;3:Doc05.
cians: psychosocial and organisational predictors and consequences. [PubMed: 19742072].
BMC Public Health. 2008;8:353. doi: 10.1186/1471-2458-8-353. [PubMed: 24. Arsalani N, Fallahi-Khoshknab M, Josephson M, Lagerstrom M.
18840296]. Iranian nursing staff’s self-reported general and mental health
6. Chou LP, Li CY, Hu SC. Job stress and burnout in hospital employees: related to working conditions and family situation. Int Nurs Rev.
comparisons of different medical professions in a regional hospital 2012;59(3):416–23. doi: 10.1111/j.1466-7657.2012.00987.x. [PubMed:
in Taiwan. BMJ Open. 2014;4(2):e004185. doi: 10.1136/bmjopen-2013- 22897195].
004185. 25. Kristensen TS. A new tool for assessing psychosocial factors at work:
7. Kovner CT, Brewer CS, Fatehi F, Jun J. What does nurse turnover rate The Copenhagen Psychosocial Questionnaire. Copenhagen: National
mean and what is the rate? Policy Politics Nurs Pract. 2014;15(3-4):64– Institute of Health; 2000.
71. 26. Belsley DA, Kuh E, Welsch RE. Regression diagnostics: Identifying in-
8. Vingard E, Alfredsson L, Hagberg M, Kilbom A, Theorell T, Walden- fluential data and sources of collinearity. John Wiley & Sons; 2005.
strom M, et al. To what extent do current and past physical and psy- 27. Ramsey JB. Tests for specification errors in classical linear least-
chosocial occupational factors explain care-seeking for low back pain squares regression analysis. J Royal Statistic Soc. 1969:350–71.
in a working population? Results from the Musculoskeletal Interven- 28. Hotelling H. Relations between two sets of variates. Biometrika.
tion Center-Norrtalje Study. Spine (Phila Pa 1976). 2000;25(4):493–500. 1936;28(3/4):321–77.
[PubMed: 10707397]. 29. Rao CR. Linear statistical inference and its applications, second Edi-
9. Lohela M, Bjorklund C, Vingard E, Hagberg J, Jensen I. Does a tion. Statistics WSiPa. New York: John Wiley & Sons; 1973.
change in psychosocial work factors lead to a change in em- 30. Kshirsagar AM. Multivariate Analysis, New York: MarcelDekker. New
ployee health? J Occup Environ Med. 2009;51(2):195–203. doi: York: Marcel Dekker; 1972.
10.1097/JOM.0b013e318192bd2c. [PubMed: 19209041]. 31. Wilks SS. Certain generalizations in the analysis of variance.
10. Kristensen TS, Hannerz H, Hogh A, Borg V. The Copenhagen Psy- Biometrika. 1932:471–94.
chosocial Questionnaire–a tool for the assessment and improvement 32. Westfall PH, Young SS. Resampling-based multiple testing: Examples
of the psychosocial work environment. Scand J Work Environ Health. and methods for p-value adjustment. 279. John Wiley & Sons; 1993.
2005;31(6):438–49. [PubMed: 16425585]. 33. Iran National statistics . Iran National statistics book. Iran: Ministry
11. Ghaffari M, Alipour A, Farshad AA, Jensen I, Josephson M, Vingard E. of Health statistics; 2004.
Effect of psychosocial factors on low back pain in industrial work- 34. Buchan J. Evidence of nursing shortages or a shortage of evidence?
ers. Occup Med (Lond). 2008;58(5):341–7. doi: 10.1093/occmed/kqn006. J Adv Nurs. 2006;56(5):457–8. doi: 10.1111/j.1365-2648.2006.04072_2.x.
[PubMed: 18296687]. [PubMed: 17078821].
12. Vaez M, Josephson M, Vingard E, Voss M. Work-related violence and its 35. Zarea K, Negarandeh R, Dehghan-Nayeri N, Rezaei-Adaryani M.
association with self-rated general health among public sector em- Nursing staff shortages and job satisfaction in Iran: issues and
ployees in Sweden. Work. 2014;49(1):163–71. doi: 10.3233/WOR-131715. challenges. Nurs Health Sci. 2009;11(3):326–31. doi: 10.1111/j.1442-
[PubMed: 24004771]. 2018.2009.00466.x. [PubMed: 19689643].
13. Haladay DE, Blorstad AL, McBrier NM, Denegar CR, Lengerich EJ. Back 36. World Health Organization . The world health report 2006: working
pain among health care workers in Pennsylvania 2002-2006. Work. together for health. World Health Organization; 2006.
2012;41(1):93–8. doi: 10.3233/WOR-2012-1288. [PubMed: 22246309]. 37. Li J, Fu H, Hu Y, Shang L, Wu Y, Kristensen TS, et al. Psychoso-
14. Nayeri ND, Salehi T, Noghabi AA. Quality of work life and produc- cial work environment and intention to leave the nursing profes-
tivity among Iranian nurses. Contemp Nurse. 2011;39(1):106–18. doi: sion: results from the longitudinal Chinese NEXT study. Scand J Pub-
10.5172/conu.2011.39.1.106. [PubMed: 21955271]. lic Health. 2010;38(3 Suppl):69–80. doi: 10.1177/1403494809354361.
15. McKevitt C, Morgan M, Dundas R, Holland WW. Sickness absence and [PubMed: 21172773].
’working through’ illness: a comparison of two professional groups. 38. Hasselhorn HM, Tackenberg P, Kuemmerling A, Wittenberg J, Simon
J Public Health Med. 1997;19(3):295–300. [PubMed: 9347453]. M, Conway PM, et al. Nurses’ health, age and the wish to leave
16. Rosvold EO, Bjertness E. Physicians who do not take sick leave: haz- the profession–findings from the European NEXT-Study. Med Lav.
ardous heroes? Scandinavian J Soc Med. 2001;29(1):71–5. 2006;97(2):207–14. [PubMed: 17017351].
17. Rabin S, Feldman D, Kaplan Z. Stress and intervention strategies in 39. Fochsen G, Sjogren K, Josephson M, Lagerstrom M. Factors contribut-
mental health professionals. Br J Med Psychol. 1999;72 ( Pt 2):159–69. ing to the decision to leave nursing care: a study among Swedish
[PubMed: 10397421]. nursing personnel. J Nurs Manag. 2005;13(4):338–44. doi: 10.1111/j.1365-
18. Attridge M. A quiet crisis: The business case for managing employee 2934.2005.00546.x. [PubMed: 15946173].
mental health. Human Solutions; 2008. 40. Coomber B, Barriball KL. Impact of job satisfaction components on
19. Stansfeld S, Candy B. Psychosocial work environment and men- intent to leave and turnover for hospital-based nurses: a review
tal health–a meta-analytic review. Scand J Work Environ Health. of the research literature. Int J Nurs Stud. 2007;44(2):297–314. doi:
2006;32(6):443–62. [PubMed: 17173201]. 10.1016/j.ijnurstu.2006.02.004. [PubMed: 16631760].
20. Kivimaki M, Virtanen M, Elovainio M, Kouvonen A, Vaananen A,
Vahtera J. Work stress in the etiology of coronary heart disease–

10 Arch Neurosci. 2017; 4(3):e13576.

 Ghaffari M et al.

41. Nikbakht Nasrabadi A, Emami A. Perceptions of nurs- [PubMed: 16451429].

ing practice in Iran. Nurs Outlook. 2006;54(6):320–7. doi: 44. Andreassen CN, Eriksen JG. The psychosocial work environment
10.1016/j.outlook.2006.06.001. [PubMed: 17142150]. among physicians employed at Danish oncology departments in
42. Rahimaghaee F, Nayeri D, Mohammadi E. Iranian nurses perceptions 2009. A nationwide cross-sectional study. Acta Oncol. 2013;52(1):138–
of their professional growth and development. Online J Issues Nurs. 46. doi: 10.3109/0284186X.2012.702926. [PubMed: 23033812].
2011;16(1):10. 45. Hooftman WE, van der Beek AJ, Bongers PM, van Mechelen W. Is there
43. Dehghan Nayeri N, Nazari AA, Salsali M, Ahmadi F, Adib Hajbagh- a gender difference in the effect of work-related physical and psy-
ery M. Iranian staff nurses’ views of their productivity and man- chosocial risk factors on musculoskeletal symptoms and related sick-
agement factors improving and impeding it: a qualitative study. ness absence? Scandinavian J Work Environ Health. 2009;35(2):85–95.
Nurs Health Sci. 2006;8(1):51–6. doi: 10.1111/j.1442-2018.2006.00254.x. doi: 10.5271/sjweh.1316.

Arch Neurosci. 2017; 4(3):e13576. 11

 Ghaffari M et al.

Table 4. Univariate and Multivariate Tests of Significance for Each Dimension of COPSOQ; Sigma-Restricted Parameterization and Effective Hypothesis Decomposition of All
Background Variables in Association with Each Dimension of COPSOQ are Presented by LS-Means and SE (LS-Means ± SE)

Univariate Analysis of Variance and Covariance (LS-Means ± SE)a Multivariate Analysis

D1- Type of P Value D2- Work P Value D3- P Value D4- Work- P Value D5- Health P value Multivariate Partial
Production Organization Interpersonal Individual and Tests (Wilks Eta-Squared
and Tasks and Job Relations & Interface Well-Being Lambda)b (Effect Size)
(Work Place) Content Leadership (Individual)

P Value

Overall mean 290.92 ± 5.36 285.92 ± 5.12 485.47 ± 8.12 94.76 ± 2.84 360.10 ± 4.13
(Suggested
cut-off
point)c

Age 0.18 < 0.01 0.80 < 0.01 0.40 < 0.01 0.010

1 287.53 ± 5.81 279.45 ± 5.55 486.85 ± 8.79 100.58 ± 3.07 362.02 ± 4.47
Equal
or
less
than
30(Ref)

2 Be- 292.92 ± 5.38 284.66 ± 5.15 483.99 ± 8.16 91.55 ± 2.85 359.04 ± 4.15
tween
31and
50

3 292.29 ± 6.18 293.65 ± 5.91 485.56 ± 9.16 92.12 ± 3.27 359.22 ± 4.77
Equal
or
more
than
51

Job title < 0.01 0.31 0.28 < 0.01 < 0.01 < 0.01 0.025

1 300.95 ± 8.02 292.71 ± 7.66 480.36 ± 12.15 100.80 ± 4.23 354.13 ± 6.18
Physi-
cian(Ref)

2 317.70 ± 3.48 287.17 ± 6.20 482.89 ± 9.82 81.23 ± 3.43 355.20 ± 5.00
Nurse

3 280.29 ± 6.70 286.67 ± 6.40 484.60 ± 10.15 93.68 ± 3.54 365.91 ± 5.17
Health
Ex-
pert

4 Of- 272.71 ± 6.68 283.98 ± 6.39 483.66 ± 10.13 97.70 ± 3.54 365.34 ± 5.16
fice
Worker

5 282.91 ± 6.81 279.04 ± 6.51 495.82 ± 10.32 100.34 ± 3.60 359.89 ± 5.25
Sim-
ple
worker

Gender 0.14 < 0.01 0.05 < 0.01 < 0.01 < 0.01 0.019

1 293.12 ± 5.65 281.23 ± 5.41 481.06 ± 8.57 91.95 ± 2.99 352.47 ± 4.36
Women(ref)

2 288.71 ± 5.47 290.61 ± 5.23 489.87 ± 8.29 97.56 ± 2.89 367.72 ± 4.22
Men

Shift Work < 0.01 0.11 0.19 0.48 0.13 < 0.01 0.007

1 Day 275.49 ± 4.53 290.61 ± 4.34 487.19 ± 6.87 97.61 ± 2.40 362.63 ± 3.50
Time
(Ref)

4 294.37 ± 5.89 289.89 ± 5.63 491.53 ± 8.93 96.31 ± 3.12 359.77 ± 4.54
Two
Shifts

5 294.37 ± 5.76 284.69 ± 5.50 485.30 ± 8.73 93.11 ± 3.04 363.61 ± 4.44
Three
Shifts

Working < 0.01 0.35 0.34 < 0.01 0.06 < 0.01 0.007
Hours

1 Full 290.30 ± 5.52 288.42 ± 5.28 484.37 ± 8.37 91.31 ± 2.92 362.42 ± 4.26
time
44H/week
(Ref)

2 299.20 ± 5.53 286.50 ± 5.29 481.17 ± 8.38 92.48 ± 2.93 357.17 ± 4.27
Full
time
more
than
44H/W

12 Arch Neurosci. 2017; 4(3):e13576.

 Ghaffari M et al.

3 283.23 ± 6.32 282.84 ± 6.04 490.86 ± 9.58 100.47 ± 3.34 360.69 ± 4.87
part
time
(20-
40H/W)

War History 0.89 < 0.01 < 0.01 0.16 0.78 < 0.01 0.006

1 Yes 290.62 ± 6.29 293.67 ± 6.01 494.80 ± 9.53 93.13 ± 3.33 360.56 ± 4.85

2 No 291.20 ± 5.24 278.16 ± 5.01 476.13 ± 7.94 96.38 ± 2.77 359.63 ± 4.04
(Ref)

Personal < 0.01 < 0.01 < 0.01 0.01 < 0.01 < 0.01 0.044
belief on
General
Health

1 Ex- 285.17 ± 5.63 296.44 ± 5.38 505.58 ± 8.53 97.50 ± 2.98 382.41 ± 4.34
cel-
lent(Ref)

2 292.24 ± 5.45 286.77 ± 5.21 486.54 ± 8.25 94.502.88 359.37 ± 4.20

Good

3 Not 295.33 ± 5.94 274.54 ± 5.67 464.28 ± 9.00 92.26 ± 3.14 338.51 ± 4.58
good
or
bad

Income 0.07 0.12 0.07 0.09 0.03 < 0.01 0.004

1 287.37 ± 5.09 279.91 ± 4.87 476.38 ± 7.72 96.35 ± 2.69 354.81 ± 3.93
Less
than
5
mil-
lion
Rials

2 Be- 294.51 ± 5.49 283.30 ± 5.25 485.64 ± 8.32 92.86 ± 2.90 354.02 ± 4.23
tween
5
and
10
mil-
lion
Rials

3 290.85 ± 8.98 294.54 ± 8.58 494.38 ± 13.61 95.04 ± 4.75 371.45 ± 6.93
More
than
10
mil-
lion
Rials
(Ref)

Work Place < 0.01 < 0.01 0.02 0.18 0.10 < 0.01 0.013

1 283.30 ± 5.80 283.07 ± 5.55 471.84 ± 8.79 97.74 ± 3.07 361.86 ± 4.48
Uni-
ver-
sity
cam-
pus
(Ref)

2 309.68 ± 5.01 279.46 ± 4.79 475.91 ± 7.59 94.54 ± 2.65 363.93 ± 3.86
Hos-
pital

3 291.29 ± 6.99 290.81 ± 6.68 495.58 ± 10.59 98.13 ± 3.70 364.62 ± 5.39
Dis-
trict
Health
of-
fice

4 Ur- 296.18 ± 5.80 274.82 ± 5.55 479.97 ± 8.80 93.01 ± 3.07 357.66 ± 4.48
ban
health
cen-
ter

5 Ru- 274.10 ± 9.96 301.43 ± 9.53 504.03 ± 15.10 90.34 ± 5.27 352.40 ± 7.69
ral
health
cen-
ter

Abbreviation: LS-mean: least square mean.

a Main effect test value. All univariate tests are adjusted for multiple comparisons by Tuky-Kramer adjustment.
b Statistic multivariate analyses of variance are Wilks’ Lambda.
c Overall mean: Indicating intercept from ANOVA/ANCOVA model that is equal to an overall mean of each dimension in the study population.

Arch Neurosci. 2017; 4(3):e13576. 13