Progress Report. First FAS Evaluation of Stockholm Stress Center. Stockholm Stress Center

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1 Progress Report First FAS Evaluation of Stockholm Stress Center Stockholm Stress Center

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3 Introductory The Stockholm Stress Center (SSC) is an interdisciplinary centre of excellence for research on work-related stress and health, which was established in October 1, 2009 at Stress Research Institute (SRI), Stockholm University. SSC comprises six collaborating research groups from the Stress Research Institute and the Department of Psychology at Stockholm University and also from the Department of Clinical Neuroscience and the Department of Public Health Sciences at Karolinska Institutet. Within this collaboration the aim is to build a research center with outstanding research in the field of work, stress and health and with the highest quality that can compete internationally. SSC is funded by a grant from the Swedish Council for Working Life and Social Research (FAS) under the additional strengthening of the founding for research on working life, which the government posted in The funding of the center is 15 million SEK for 2009 until 2011, with a possible extension of 5 million SEK per year for an additional 7 years, a total of 50 million SEK. FAS has decided to carry out three evaluations: after 1,5 2 years, after 5 years and after the end of the 10-year grant period. This report is part of the first evaluation with focus on aspects like organisation, leadership, cooperation, preparation for public outreach and the role of the centre in the strategic plan of the university and co-funding arrangements by the university. The evaluation period is from the start of the SSC in 2009 until the end of Questions to Vice-Chancellor a) Please describe the role of the Centre in the overall research profile of the university. Describe the process and criteria used for selecting FAS Centre applicants at your university. The main criterion is innovative approach, internationally well-established partners, contributing to the research image of the University with a new interesting field. All departments and units at the University were invited to submit FAS Centre proposals. In order to select applicants, the Faculty of Social Sciences appointed a group of three international referees to assess and rank the proposals. The three proposals of highest rank were appointed by the Vice-Chancellor to write a full application. b) Describe also the relation between the Centre and the rector regarding matters like reporting of activities of the Centre and financial arrangements. The Vice-Chancellor is ultimately responsible and gets all reports and decisions regarding the center. He is also informed face-to-face about the activities of the center once per year. The Vice-Chancellor has delegated management of the Centre to the Faculty of Social Sciences, which in turn provides the Vice-Chancellor with annual progress reports. Furthermore, the Vice-Chancellor has delegated the disposal of and liability to render accounts for the grant to the project leaders of the FAS Centres. The Faculty of Social Sciences performs an annual follow-up of the financial situation at the Centre. c) Has the FAS Centre had any effects so far on research and higher education at your university (strategic plans, collaborations between research groups, PhD studies or other influence)? In March 2011, the Vice-Chancellor decided on new research areas at Stockholm University, that can be considered leading nationally and have a high status internationally. Stress, Work, Health and Restitution has been designated as one of these leading research areas. A main objective of Stockholm University is to support these leading areas in order to even strengthen their international position. SSC, being a nationally prominent research environment earlier, has by the grant be given the opportunity to develop considerably further in excellence in its field. This development makes the Centre one of the most prominent and high-priority environments within the Faculty of Social Sciences. 2. Questions to Project Leader Organisation and leadership of the FAS Centre a) Describe the organization of the Centre (sections, research groups or projects etc.) Stockholm Stress Centre (SSC) was established as an independent research unit at the Stress Research Institute, Stockholm University by a decision of the Vice-Chancellor. The Centre is run in cooperation between the six collaborating research groups from the Stress Research Institute and the Department of Psychology at Stockholm University and also from the Department of Clinical Neuroscience and the Department of Public Health Sciences at Karolinska Institute. Regulations The Vice-Chancellor of Stockholm University has decided on special regulations for the SSC, which determine the directorship, management, tasks for the Director, resource management, employment, and continued activity of SSC after the grant period. The regulations in Swedish are attached to this report in Appendix E. Cooperation Agreement An agreement on collaborative research within the SSC - between Stress Research on the one hand, and the Department of Psychology and the Karolinska Institute, on the other hand - has been set up and that each university has reviewed and approved of. The agreement stipulates issues related to research collaboration, expected results, distribution of FAS grant, bibliometric rules, reporting, communication, owner ship- and publication rights of research materials, the employ ment of research staff, and the rules for how to resolve possible disputes. The agreement in Swedish is attached to this report as appendix F. 1/28

4 Administration All issues concerning organisation, administration, archives, economy, coordination, external communication, and information relating to SSC, are handled by the Stress Research Institute s administrative staff. The internal communications between SSC and Collaborating Partners have been handled by the website Igoogle and Doodle Calendar for coordination of activities and in addition Google docs for sharing documents. Status Reports Collaborating partners are required to submit status reports every 6 months to SSC, containing project description/updates, list of publications, and information on conferences and other internal and external events related to the SSC. These status reports form the basis for website updates, various information brochures, and for the FAS-evaluation reports 1,5, 3, and 5 years after the grant period. b) Describe how the leadership of the Centre has been carried out and your experiences of this so far? According to the regulations of SSC, the Stress Research Institute s Board of Directors is the highest decision-making body for SSC. Director/Project Manager of the Centre is Professor Torbjörn Åkerstedt, who is also the Director of the Stress Research Institute. Director The Director (project manager) of SSC is responsible for all operations at SSC and for the Cooperation Agreement between the University and contributing research council to be compiled in all parts. The Director is supported by the Stress Research Institute s administrative staff and the SSC Management team. Management team A so-called Management team for the comprehensive and strategic decisions within the SSC, was established from the start and consists of the 6 project leaders and the 6 deputy project leaders from the collaborating partner; Stress Research Institute and Department of Psychology at Stockholm University and Department of Public Health and Department of Clinical Neuroscience at Karolinska Institutet. c) What are the plans for the continuity of leadership over the full project period? The issue has been discussed in the Management team and the plan is to recruit a new SSC leader from one of the team members. Such discussions will start next year. d) What is the decision process for research activities, budget allocations and recruitments of researchers and PhD-students? The Collaborating partners suggests research activities to be discussed by the Management team in order to achieve as large synergy impact as possible. The Management team also decides the budget allocations. According to the provisions for the SSC, the recruitments of researchers and other staff and the admissions of PhD students takes place at the respective Collaborating partner/group/ institution, after discussion in the Management group. e) Is there a scientific board and, if so, what role does it have? The idea to establish this has been discussed within the Management team, but it has so far been decided that there is no need for such a board, mainly since the present partners constitute a strong scientific knowledge base. f) Are any changes concerning organization and leadership planned in the coming years? There are currently no plans to change how the SSC is organized and administered, but rather a need to consolidate the organization. g) Have any changes happened during the first 1-2 years of the functioning of the Centre? There was originally an idea that was mentioned in the FAS application, to establish a small executive group for daily operational decisions, but the idea was never implemented as it has been considered sufficient with the Management team. In case of emergency situations (yet to occur) the Director takes the decisions. The Management team is chaired by the SSC Director and appointed by the Vice Chancellor on proposal of the Stress Research Institute Board. The project leaders and the deputy project leaders are appointed by the Vice-Chancellor of Stockholm University on proposal of the Centre s Director. The term of office for the Director and the Management team is three years, with a possibility to be re-elected. Protocols All meetings with the Stress Research Institute Board and the SSC Management team are recorded and the protocols are available in the Stress Research Institute s archives. The Management team has had eight regular meetings during the evaluation period. In addition, a two-day conference was held in 2010, to allow the Management team in-depth discussions on projects and research. 2/28

5 3. Research programme Work package/sub projects a) Give a short description of the research, its results so far and future plans. Mention specifically new projects that have been initiated. The overall aim of SSC is to increase the understanding of the entire chain of stress, regarding the psychobiological mechanisms of linking new (and old) stressors to long-term health and disease. This interdisciplinary approach is a unique contribution, but there are also several added values due to the collaboration between research groups. One such is that we focus on some of the new work problems of modern society (e.g. boundaryless work or being locked in) and link them, not only to stress, but also to health outcomes, including sleep, fatigue, health perception, and sick leave. The latter is a strong outcome in itself, but is also a factor of risk and exposure, the effects of which are evaluated within the center. Other important foci are serious health outcomes such as cardiovascular diseases, diabetes, cancer, and mortality. Longitudinal epidemiological approaches of large cohorts are central in much of this work, but also psycho-biological field studies. Another added value is the introduction of sleep/restitution as part of the stress mechanism hypothesizing that impaired rcovery is as deleterious as directe effect of stress, as well as fatigue (the most common health symptom in society) and health perception, together with efforts to understand the mechanism for how these factors interact. The latter also includes efforts to demonstrate and understand their psychobiological mechanisms (through, for example, polysomnography, immunology, brain scanning, heart rate variability, actigraphy) in experiments and field studies. A third added value is the integrated studies of treatment and interventions in long-term stress exposure, using indicators of sleep, fatigue, health perception, and stress. A special strength is the close link to occupational health and implementation. A fourth added value is the methodological development of common tools and approaches in most of the areas mentioned above. b) Are there any revisions in the long term plans as formulated in the application for the Centre? There are no revisions but a strong gradual development as collaboration is intensified and new projects spin off collaboration. c) Have there been any delays concerning start-up of research activities? If so, for what reason? The center did not start to formally function until October However, from that point in time, we gave priority to early start of collaborative research projects, even during the period of preparing the application for the FAS center. This also includes unilateral projects that predates the center, but which we have turned into collaborative studies. d) Describe your strategy for recruitment of researcher. The recruitment is based on what is needed for facilitation of collaborative projects and their long-term consolidation. Our work is organized in six thematic work packages (WP) that focus on the above mentioned key issues (see below). Each project is identified by a bolded subproject (SP) title and the status indicated as (P) or (O) (planned or on-going) O+ indicates that the start of the project predates SSC. To save space, we only list the partners that represent the particular node(s) involved (also serving to indicate the collaborative level). The PI may well be another person (see website). The results and list of projects are presented below. New collaborative subjects are indicated by letters and within parentheses at the end of of each study. E = Division of epidemiology (SRI), R = Division of stress and recovery (SRI), W = Division of work and organizational psychology (Department of Psychology), P = Section of Psychology (KI), I = Division of Insurance Medicine (KI) and O = Section of Occupational Health (KI). WP 1. Specific work stressors and health WP leaders: Westerlund, Sverke and Aronsson. This WP focuses on the effects of work-related stress and recovery on health. The subprojects involve projects on identification of the new stressors and their effects, projects on occupational groups with a particular stress situation. In addition, we run projects to understand the effects of stress on some key mediators, like sleep and stressors like work hours. The aim is to determine the contribution of working life stressors to stress reactions, recovery, sickness absence, and long term health. SP 1.1 Modern working life stressors and health and recovery This SP contains a number of projects that will determine the contribution of new stressors, like lack of boundaries, being locked up, redundancy, and job insecurity to stress and health, as well as the role of coping in handling them. Senior Researchers: Aronsson, Sverke, Westerlund, Alexanderson. One study (O) will investigate strategies like segmentation and integration in coping with boundary-less work, particularly with diffuse working hours and mobile work (IT industry) (W). A second study (P) will investigate job insecurity as a predictor of later subjective health, stress, cortisol, diagnosed disease (multilevel modelling of individual and contextual factors will be used). (W+R) A third study (O/P) will encompass three substudies with polysomnograpy (PSG) in the home after low and high stress exposure, to evaluate how psychological sleep is affected by different types of stress. (R+P) A fourth study (P) will investigate the stress and health effects of redundancy and outplacement, before and after the outplacement, in terms of transfer of competence. (W) A fifth study (P) concerns the work life interface, looking at the prospective health/sleep effects of conflict, as well as its positive enhancement (SLOSH). (E+R) 3/28

6 A sixth study (P) is labor market mobility, health and early retirement using a large prospective regional public health study (data collection 2000, 2005 and 2010) and the effects of being locked in are studied, i.e. the experience of not being in the preferred occupation and preferred workplace. (W+E) A seventh study (O) focuses on the particular work organizational effects of different open office plans and their impact on health, cognitive ability, fatigue, and sleep, taking architectural quality, leadership and personality into account (SLOSH plus detailed data collected from office employees and their offices). (E+W) An eighth study (O) concerns the relative importance of genes and environments for burnout, which will be investigated in a classical twin study approach for associations between burnout and demographic, life-style, life events, personality, health, sickness absence and work-related factors while controlling for familial influences. (I+R) A ninth study, (P) investigates the distinction between individual perceptions of job insecurity and job insecurity climate (i.e., collective perceptions among colleagues) in the prediction of health and well-being. (W) A tenth study uses longitudinal data from employees within one organization to assess the development of job insecurity over time as well as how job insecurity trajectories relate to trajectories in health and well-being. (W) An eleventh study (O/P) investigates the incidence and prevalence of depression in relation to working life exposures in Sweden and Denmark, as well as possible mediating mechanisms, including sleep. (E+R) A twelfth study (P) investigates how stress and different indicators of health and health behaviors developed during the recent financial crisis. (R+E) SP 1.2 Stress and recovery in specific occupational groups This SP focuses on identifying stressors, stress, health and recovery in some occupational groups with a particular high level of stress. Senior Researchers: Svartengren, Aronsson, Åkerstedt. One study (P) will investigate the effects of stress in civil contingency agencies on stress in international conflict areas (military intervention) on indicators of sleep, health, physical capacity and work capacity. (O+R) A second study (P) will focus on mental health in nurses, physicians and teachers - groups that seem to undergo deprofessionalization. This study will use SLOSH and a Danish cohort. (W+E+R) In a third study (O) we investigate the psychosocial and other work conditions of physicians through a questionnaire to 1500 participants, partly repeating a study 18 years ago. (W+R) SP 1.3 Work hours, stress, sleep and health Work hours make up the framework for day-to-day living of workers and sets limits and deadlines for each individual s use of his/her time. The aim in this SP is to identify health effects of shift work, and what aspects of work hours in general constitute a problem in terms of health. Senior Resarchers: Kecklund, Åkerstedt, Westerlund, Alexanderson, Aronsson. One study (O/P) will examine whether the work time variables are independently related to health and disturbed sleep, or if they moderate the influence of work stress on health (the SLOSH database and other registers will be used). (R+E) Another study (O) will explore the design of shift systems for health and sleep (national representative sample, N=4000) and characterize good and bad work schedules from a shift workers point of view and whether the attitude to the shift system is related to health perception. (R) A third study (O) will focus on what schedules workers prefer if they have shift systems based on self-rostering. (R) A fourth study (P) investigates the relation between shift work and cancer, using the Swedish Twin registry (in which we have entered accumulated night work exposure 15 years ago) and the cancer registry. (I+R) A fifth study (O/P) involves a series of field studies on sleepy driving in which night driving and shiftwork are key factors. A major focus is on demonstrating the degree of danger associated with night work sleepiness (with VTI). (R) A sixth study (O +) involves effects of maritime watch schedules on sleepiness and risk during a week in bridge simulators (Southampton/Gothenburgh). (R) SP 1.4 Pathways and trajectories This SP broadens the approach to stress-health-recovery through a life-course oriented approach and attempts to explain long-term trends in health or stress in terms of trends or events in possible explanatory factors like work stress. Senior Researchers: Westerlund, Kecklund, Lekander, Åkerstedt, Sverke, Alexanderson. One international collaborative study (O/P) uses longitudinal British, Danish, Finnish, French and Swedish cohort data with many repeat measurements to analyze long-term causal links between stressor and other environmental exposures and health/mortality. Trajectories of health, health-related functioning and behaviours (including sleep) are related to labour market participation, work environment, and major life transitions. (E+I+W) A second study (O/P) focuses on the third age to explain changes in fatigue and subjective health following retirement (which may reduce or increase stress) and aims to examine which aspects of work stress, working hours and health behaviours that may determine the outcomes, including mediating factors such as sleep and inflammation. (E+R+P) 4/28

7 WP 2. Stress, sleep and sickness absence WP leaders: Alexandersson and Åkerstedt. WP 1 focuses largely on specific stressors. This WP instead focuses on stress on some central outcome variables - sleep and sickness absence. Both occur in other SP:s but then as one of several other outcome variables. SP 2.1 Stress and other influences on sleep quality This SP is based on the idea that sleep is a central stress mediated effect on health. The aim of this project is to study the effects on sleep of real life stressors on a questionnaire and physiological level. Senior Researchers: Åkerstedt, Lekander, Aleksanderson, Hillert. The first study (O/P) will use several longitudinal databases (mainly SLOSH and WOLF) to study the long and short term effects of stress on sleep and of sleep on sleepiness/alertness/ health and using registers to investigate effects on diabetes, CVD, burnout, depression and other diseases. (R+P+E) A second study (O/P) will use a seven-week (50-person) diary study of sleep quality, stress and health aiming to predict the day-to-day variation in sleep from prior stress, as well as the effects of sleep on sleepiness. We will also link the daily variation in subjective health to fatigue, pain, fever and other factors. (R+P) databases are used (SLOSH, the national police survey and the working life cohort). (E+W+I) In a fourth study (O) high and low sick-leave organizations are compared with respect to stress-related psychosocial work environment and other factors, in order to identify good work environment characteristics. (O) In a fifth study (O) we investigate how sleep and stress predict return from long-term sickness absence. (R) A sixth study investigates the effects of sick leave on stressrelated and other diseases and mortality in groups with different levels of work load (and other work characteristics and age, gender, etc). Several large registers are used (Whole Sweden (5.4 million participants all people living in Sweden in working ages with annual and detailed data from Statistics Sweden, Board of Health and Welfare and the National Agency for Social Security linked at individual level). (I) In a seventh study the same questions as above will be pursued but using the twin register (60.000) to add heredity. (I) An eighth study (O) develops a web tool to investigate the sickness presenteeism phenomenon in detail: underlying health problems, prevalence patterns, and consequences at the workplace. In addition the aim is to develop integrated tools for management of presenteeism in companies. (E+W+I) A third study (O/P) will encompass three substudies with polysomnography (PSG) (in the home) after low and high stress exposure to evaluate how physiological sleep is affected by different types of stress. (R+P) In a fourth study (O) the effect of mobile phone radiation and its stress- related reactions on the subsequent sleep recording will be investigated. (R+O) In a fifth study (O+) the effects of violent videogames on HRV, actigraphy during playing and subsequent sleep (as well as ratings of stress and sleepquality) will be studied in 12 year olds. (R+O) SP 2.2 Stress-related diagnoses and sickness absence/presence, health and mortality This SP focuses on one of the major outcomes of ill health and relates it to stress. It also brings in sickness presence and the effects of both sickness absence and presence. Senior Researchers: Alexanderson, Westerlund, Aronsson, Åkerstedt. One study (P) links stress-related diagnoses (e.g. CVD or stressrelated mental disorders) to sickness absence and suicide and other causes of death, using detailed prospective data for a cohort of 5.4 million individuals. (I+R) Another study (O) focuses on whether pain thresholds, subjective sleep quality or other factors are associated with sickness absence in 2000 individuals. In a third study (P) we investigate the effects of stress, demands and other work environment factors on sickness presence as well as the prospective health consequences. Large 5/28 WP 3. Psychobiological mechanisms of stress, restitution and health perception (laboratory studies) WP leaders: Lekander and Åkerstedt. A central question in our FAS center is if stress-disturbed sleep is a mediator of later disease and how central concepts like the subjective experience of health, fatigue and subjective stress, respond to stress and relates to immune function, brain activity and connectivity, chronic inflammation, serotonin receptor sensitivity, sleep physiology and its restorative capacity. SP 3.1 Sleep quality, stress and health perception Sleep is thought to be a central mediator of stress related diseaseses. This SP focuses on the link between stress and sleep and the consequences of inadequate sleep. Senior Researechers: Åkerstedt, Lekander, Alexandersson, Kecklund. One study (P) utilizes a longitudinal field study of 400 women recorded with polysomnography (PSG) (home-recording) twice with 10-years between the measurements. Data will be used to study how changes in PSG during aging (and with stress exposure) relate to changes in subjective sleep complaints in women. Also depression, burnout, sleepiness, subjective health, proinflammatory cytokines and sickness absence will be studied. (R+P) A second study (P) will investigate how experimental sleep fragmentation affects sleepiness using functional magnetic resonance imaging (fmri), sleep latency tests, cytokines and endocrine parameters. (R+P)

8 A third subproject (O) investigates acute effects of one night of sleep loss on the same parameters as the previous ones. (P+R) A fourth study (P) will focus on experimental sleep fragmentation in a field setting based on a day-to-day monitoring of sleep using one-electrode PSG (conditional on validation testing of the PSG device). (R+P) A fifth study (O+) investigates the effects of chronic partial sleep loss (4h/day for 5 days) on social interaction and immune, endocrine, health and other parameters. (P+R) SP 3.2 Influence of stress exposure on the autonomous nervous system, immune regulation and transmittor substances. The project is based on the fact that few high quality systembased investigations of how exposures to stress or distress affect homeostasis and regulation in the nervous and the immune systems have been performed. Senior Researchers: Axelssson, Hillert, Lekander, Svartengren, Åkerstedt, Perski. In one study (O) in twins, the impact of hearing related stress and stress sensitivity and genetic factors on sympatho-vagal balance and sleep quality is investigated longitudinally. (O+R+E) A second study (P) will use newly developed methods to measure efficiency of glucocorticoid inhibition (stress hormone sensitivity) on cytokines and regulation of the immune system with eight color flow cytometry (FACS). (P+R) In a third study (P) pain thresholds and sleep quality as predictors of future sickness absence will be studied in subjects with musculoskeletal pain. (O+R) SP 3.3 Inflammation, sickness behavior and subjective health. Stress, infection and disrupted sleep cause inflammatory responses that are interpreted by the brain as sickness signals and activates a hormonal stress response. Such signaling causes behavioural responses of importance for subjective illhealth, but are little investigated in humans. Senior Researchers: Axelsson, Lekander, Åkerstedt, Kecklund. In one study (P) the impact of chronic (allergy) inflammation on brain function (fmri or PET) will be investigated, as well as subjective health, stress, tiredness, pain regulation, appearance and gait. (P+R+E) In another study (O) experimentally induced inflammation will be used to study its effects on the same parameters. (P+R) WP 4. Treatment and intervention for stress reduction WP leaders: Perski and Svartengren. This involves studies of CBT treatment of patients with stressrelated diagnoses and risk groups (for example employees or school children under stress exposure), use of motivation-enhancing talks, interventions with mindfulness, effects of insomnia treatment on pain and secondary prevention occupational health care interventions. It also focuses on problems of sleep and stress. SP 4.1 Stress of patients or non-patiens with high stress Senior Researchers: Perski, Lekander, Kecklund, Åkerstedt. In the first study (O) the results of CBT treatment of burnout in four stress-treatment clinics (1200 patients) will be followed-up after 6, 12, and 24 months (health-questionnaire, work status, sick leave). (R) A second study (O) will evaluate several types (CBT among others) of interventions against stress in high schools (1200 students) in Stockholm. (R+W) In a third study (P) the effect of use of motivational interviewing on stress measures will be studied (with Social services, Södertälje). (R) In a fourth study (O) the effectiveness of CBT (ACT or therapistsupported self-help CBT), together with genetic polymorphisms will be investigated in relation to pain disability, insomnia, brain function (fmri) and inflammation. Also, experimental manipulation of sleep duration is evaluated against upper respiratory tract infections. (P+R+W) SP 4.2 Work place interventions There is a need for research on the effects of interventions in companies and of development of intervention methods for occupational health services, with a focus on improving the work environment, not only treating patients. Senior Researchers: Svartengren, Åkerstedt, Sverke + OHS providers. One study (O) will evaluate how health examinations in OHS are carried out (through a questionnaire) and suggest improvements. (O) A second study (P) will create a network for OSH providers for discussion and exchange of views in order to improve current procedures. (O) SP 3.4 Burnout/exhaustion syndrom The burnout/exhaustion syndrom is considered an end result of longterm exposure to stress. The biological mechanisms are unknown. In this SP we investigate the number of receptors in patients compared with controls. Senior Researcher: Perski. In one study we focus on serotonin receptors. In a second we focus omn GABA, and in a third on histamine. (R+E+Stockholm Brain Institute) 6/28 A third study (P) will use internet-based cognitive behavioral therapy and physical activity by OSH to evaluate if stress, sleep, subjective health, HRV indicators may be used to predict work ability improvement. (O+R) In a forth study (O) carried out in several public organizations and in collaboration with an occupational health service unit we intervene through a series of workshops to implement better balance between demands and control, effort and reward, and work and rest. Leaders as well as employees participate and the design is pretest and two post-test questionnaires and a control group. (W+R)

9 WP 5. Development and implementation of methods mortality registers, detailed data on sickness absence and employment, as well as data on the employers financial results. WP leaders: Alexandersson and Westerlund. This is a common theme of all above WPs and tasks in order to facilitate collaboration and create synergetic effects through ensuring that key variables for the center is used in new studies, that instruments are shared and kept in working order and that studies of development and validation important for work in the center are carried out. SP 5.1 Providing service and availability One activity involves making available a questionnaire bank for measuring stress, burnout, and sleep and circadian (around-the-clock). A second activity provides a bank of actigraphs and physiological recorders for use by partners. This includes maintenance and some training of users. Senior researchers: Sverke, Westerlund, Kecklund. (P+R+O+I+W+E) SP 5.2 Improvement of methods These activities uses ongoing studies to evaluate measures on questionnaires for stress, burnout, sleepiness, sleep quality, sickness absence and presence. It also involves evaluations of measures of HR, HRV, immune parameters, endocrine variables, PSG and other indicators of sleep quality particularly in relation to stress. This work involves development of algorithms for better precision (for HRV, for example, or PSG analysis) as well as implementation of new statistical approaches to epidemiological data. A fourth activity is validation of the one-electrode PSG vs full PSG. A fifth activity investigates with HRV and sleep measures in twins under stress. Senior researchers: Hillert, Åkerstedt, Svartengren. (W+E+R+I+O) SP 5.3 Establishing and maintaining large databases A great asset of the center, in an international perspective, is our large, (both in terms of participants and number of variables per person), and unique prospective cohort databases. Senior researchers: Alexanderson, Westerlund, Sverke. The groups of SSC have made strategic investments in establishing such databases. Some of them are: - The LifeGene study, a national collaborative project designed to build up a resource to enable new research on the relationships among heredity, environment and lifestyle in a study base aiming for Swedes. - SLOSH, a nationally representative occupational cohort of 18,915 persons is followed prospectively with extensive questionnaires about work, non-work (e.g. retirement or unemployment), health, and private life every second year since 2006 and register data linked both prospectively and retrospectively. In the future we plan to add medical screening data for some participants. - The RALF database comprising all participants in the Swedish Work Environment Surveys from 1989 onwards, including the SLOSH participants, plus all participants in the WOLF (WOrk Lipids and Fibrinogen) studies, in total over 160,000 persons with both questionnaire data and comprehensive register linkages, including the prescribed drug, inpatient, and 7/28 - All Sweden the cohort of all 5.4 million people aged living in Sweden in Detailed register data for each of the years 1990 to 2009 have been obtained regarding socio demographics, morbidity, mortality, and sickness absence (from Statistics Sweden, Board of Health and Welfare and the National Agency for Social Security). The corresponding data have been obtained for the cohorts of 2000 and For about 100,006 of these there is also survey data regarding self-reported health, life style, sleep, etc. The database provides unique possibilities to study associations between e.g. specific diseases and various outcomes in different subgroups: Data for 60,000 twins from the Swedish Twin Registry, including survey data, is linked to register data. Data from the quality registries of all 80,000 people who have had specific cardiac interventions is linked to different register data. - Working Life Survey, data from three repeated surveys to 5000 employees SP 5.4 Brain imaging One focus of SSC is brain/immune mechanisms linking to stress and recovery to disease. Several fmri and PET studies are planned. However, brain imaging requires specialized knowledge in several areas. To provide a long-term support, we have established a group with a fmri/pet specialists (oneis being recruited). Senior Researchers: Lekander and Åkerstedt. (P+R) SP 5.5 Sleep laboratory An important part of SSC is the study of recovery/sleep in relation to stress. For this purpose we have established a sleep laboratory with equipment and technical support. Senior Researchers: Åkerstedt and Hillert. (R+O+P) SP 5.6 Analysis of multiple repeat data Many of the studies conducted within the centre, both experimental and observational, comprise data with many repeat measurements for each participant. This confers major advantages statistically and regarding the possibilities to draw causal conclusions. We endeavor to apply the best available statistical methods to analyse these data, including own methodological development. Senior researchers: Westerlund, Åkerstedt, and Sverke. (E+W+R) WP 6. Management and dissemination WP leaders: Administration at SRI and all partners In this WP the other WPs and tasks are coordinated, economical transactions carried out, work progress is monitored by the board, dissemination is carried out (reports for public consumption, presentation of results to the public (stress research days, organization of scientific meetings, popular reports in Swedish, lectures and contacts with mass media. Detailed description of activities is found in the first half of this document.

10 Results Since the delay between the start of a project and submission/publication of a scientific paper is at least two years for a short project, most results below represent pre-center research work. Evening stress ratings predicts subsequent reduction in reported sleep quality in a 7 week sleep diary study (subm). Increased work demands and inability to stop thinking of work in the evening predicts increases in reported sleep impairement during a five year period (in press). Stress at bedtime increases psychological sleep fragmentation, particularly in sensitive individuals (manuscript). Entering shift work is associated with increased sleep problems (Akerstedt et al 2010). Early morning work is associated with reduced sleep duration, sleep quality and alertness (Åkerstedt et al 2010). Improved sleep and reduced fatigue predicts reduced longterm (90 days) sickness absence (Åkerstedt et al 2010). Exposure to GSM phone radiation in the evening supresses slow wave sleep (Lowden et al 2010). Day sleep is associated with elevated levels of IGFBP1, and reduced glucose levels (Rehman et al 2010). Sleepiness (reports, eye blink duration, EEG signs of sleepiness, lateral variability) during simulated driving shows strong increases with time awake and closeness to the circadian trough (Åkerstedt et al 2010). Combination of mathematical models and EEG and EOG variables predict driving behavior during sleepiness in a simulator (Sandberg et al 2010). Night driving on real roads leads to long eye blinks, and very high levels of reported sleepiness, as well as to reduced driving speed and a movement towards the left of the land (Sandberg, in press). An experimental model of sickness causes pain, subjective stress, tiredness and decreased self-rated health (Lekander 2011, abstract). Stress hormone (glucocorticoid) receptor expression can be studied in human leukocytes with a high through-put assay (FACS; Kramar 2010, abstract). Stress during pregnancy (loss of child) does not increase risk for asthma in the offspring (Fang, submitted). Comorbid insomnia can be efficiently treated with therapist supported self-help bibliotherapy (Jernelöv, submitted). Short natural sleep is associated with higher T cell and lower NK cell activities (Fondell, in press). Affectivity and stress relates to inflammation in pre-term delivery (Fransson 2011, abstract). Feeling tired overlaps with looking sick (Sundelin, 2010, abstract). Sleep history affects perceived attractiveness and health (Axelsson, 2010). Physical acitivity decreases risk for respiratory tract infections, especially during high stress (Fondell, 2010). Leptin is differentially associated with self-rated health in men and women (Andreasson, 2010). When using different dimensions of burn-out in studies of public employees, we found that there was a variation in how they could predict risk of long-term sickness absence (Voss) Physicians with a PhD, engaged in research, teaching and clinical work, use a wide variety of strategies to cope with stress, most of them at an individual level. (Lindfors 2011) A combined measure of sickness presence and absence may be worth considering as an indicator of both individual and organizational health status. (Aronsson) Health-related and sociodemographic risk factors for disability pension due to low back disorders can be identified early in life and they seem to be independent from genetic influences and early environmental effects. (Pietikäinen 2011)) Self-reported data of long-term sickness absence and disability pension may be useful in studies when register information is not at hand, however register data is preferred, also, the response style was not influenced by genetic factors. (Svedberg 2010) Resources for good performance and being satisfied with the quality of one s own work were rather strongly associated with long-term health (Aronsson & Blom, 2010). Sickness presenteeism is more strongly associated with illhealth than sickness absence is and the more irreplaceable an individual is at work, the larger difference (Aronsson et al, in press 2011). Sickness presenteeism was a significant risk factor for future sick leave three years later and appears to be an indepen dent risk factor for future fair/poor general health (Bergström et al 2009 a,b) Sickness absence was higher in mothers than in women without children, the relative risks decreased by age, with no effect after the age of 35 years. The relation was nonlinear with the highest relative risks for mothers of one child (Floderus, in press 2011) Sleep problems i childhood predicts development of allergy in adolescence (Jernelöv, submitted). 8/28

11 The odds of poor self-rated health and fatigue increased with increasing number of children in employed women, and in women working 40 h or more (Floderus et al 2009). The levels and increase in job insecurity and general mental health complaints relate reciprocally over time. (Näswall et al, 2009) Job insecurity is unrelated to physiological indicators of stress cross-sectionally. (Näswall et al, 2009) Negative work-related health attributions (beliefs that the job impairs one s health) is a stronger predictor than actual health status of employees work-related attitudes and behavior (Göransson, Näswall, Sverke, 2009) Hospital privatization is associated with more negative consequences among middle level employees (nurses) than among top level (physicians) and low level (assistant nurses) employees (Falkenberg, Näswall, Sverke, Sjöberg, 2009) The relation between job insecurity and exit behavior is stronger among individuals with high levels of employability (Berntson, Näswall, Sverke, 2010) Both quantitative (worry about job loss) and qualitative (worry about loss of valued job features) are associated with impaired well-being and burnout, even after controlling for job characteristics and negative affectivity (De Witte, De Cuyper, Handaja, Sverke, Näswall, Hellgren, 2010) The effect of job insecurity on subsequent work-family conflict is mediated by workload, among men but not among women (Richter, Näswall, Sverke, 2010) The negative relationship between job insecurity and affective commitment to change is stronger for individuals reporting low employability than among those with greater opportunity for finding new employment (Kalyal, Berntson, Baraldi, Näswall, Sverke, 2010) Decision authority, support and conflicts at work are predictive of depressive symptoms in the general Swedish working population. Magnusson Hansson et al 2009 Sleep improved after retirement in the French GAZEL cohort study. Vahtera, Westerlund et al, Using a nested case-control study in the Whitehall II study we found no evidence that working while ill acts as a shortterm trigger for coronary events. Westerlund et al The prevalence of suboptimum self-rated health increased with age, but decreased substantially at retirement in the French GAZEL cohort study. Westerlund et al Subjective insecurity was associated with higher levels of working while ill, and this association was stronger among older employees. Heponiemi et al, Longitudinal analyses of repeat data in the Whitehall II cohort suggest that health status improves after statutory and voluntarily retirement. Jokela et al, This short version of the ERI questionnaire provides a psychometrically useful tool for epidemiological studies. Leineweber et al, Psychiatric sickness absence records could help identify individuals at risk of premature mortality and serve to monitor workers health. Melchior et al, There is a remarkably persistent association between sickness absence and future long-term self-rated health status for the majority of diagnostic categories for sickness absence. Vahtera et al, Managerial leadership was associated with employee stress, health, and sickness absence independently of the Demand- Control-Support model. Westerlund et al, Retirement is followed by a sharp decrease in mental and physical fatigue as well as in depression, but no effects of retirement on chronic diseases were observed. Westerlund et al, The association between sickness absence of more than 30 days over 3 years and future long-term self-rated health appears to differ little by occupational position. Ferrie et al, Sickness presenteeism was high among Swedish police officers, and it was associated with work environment particularly among subjects with good general health. Leineweber et al, Covert coping was strongly related to increased risk of hardend-point cardiovascular disease. Leineweber et al, Trajectories of recorded purchaces of antidepressant medication are consistent with the hypothesis that retirement is beneficial for mental health. Oksanen et al, Findings indicate a more beneficial long-term health effect of an art-based leadership development compared to a conventional approach. Romanowska et al, Retirement is associated with a decrease in headache prevalence, particularly among persons with a high amount of work stress or proneness to over-react to stress. Sjösten et al, Weight continues to increase in the transition between midlife and old age; this increase is greater in lower socioeconomic groups. Dugravot et al, Prevalence of hearing problems is far more common than previously estimated and is associated with socioeconomic status and noise exposure history. Hasson et al, /28

12 4. Collaboration a) Describe the collaboration within and outside the university, nationally and internationally The center in itself is based on collaboration between the partners. The collaboration within the center is based on the ideas in grant application, but has developed into a series of consolidated axes of collaboration. One such is the fmri-psg-sleep loss fatigue axis, (P+R) with field studies and experiments on psychobiological mechanisms. Another axis is that based on major registers on helath and sickness absence (I+E+W+R). A third axis is that on boundaryless work (E+W+R). A fourth axis is that between sickness absence (W+O). A fifth axis is that on stress and sleep (O+R). The sixth axis is the methodological collaboration on questionnaires and diaries with all partners involved. A seventh axis is the one on technical collaboration on the measurement of sleep and stress (P+O+R). There is also intense collaboration with other groups at the department of Psychology, the Center for Health Equity Studies (a FAS center), the department of Computer Science all at SU. At Karolinska Institutet, the main collaborators are Stockholm Brain Institute, Institute of Environmental Medicine, department of Clinical Neuroscience, Aging Research Center. We have started collaboration with the FAS Centre for Musculoskeletal Research at the University of Gävle, with Chalmers University of Technology, Lund University (HumLab), Umeå University (Hammarström), Royal institute of Technology (Eklund), Uppsala University (e.g., Vingård), Gothenburg University (e.g., Härenstam and Hensing), Gävle University (Richter), Umeå University (Sandström) and Mälardalen University (e.g., Isaksson). The fact that the Work Life Cohort data are administered by Mälardalen University, there will be close collaboration with Anders Wikman, the cohort data coordinator who is also linked to one of the SSC Partner. The international collaboration is intense. Among the universities are University College London (Marmot), University of Bordeaux (Philip), Warsash Maritime Academy (Clarke), Finnish Institute of Occupational Health (Härmä), The French National Institute for Public Health and Medical Research (Goldberg, Singh-Manoux), University of Naples (Ficca), University of Bergen (Bjorvatn), University of Swansea (Tucker), MacMaster University, University of Leuven (de Witte)), St. Mary s University, Canada (Kelloway), University of Alberta (Anita Kozyrsky), Tampere University, Finland ( Kinnunen), University of Turku, Helsinki (Vachtera), Utrecht University (Schaufeli), University of Valencia (Peiró), University of British Columbia (Miller and Chen), University of Hamilton, Kanada och Charitée, Tyskland (Arck), Århus university, Danmark (Zachariae), the Danish National Research Centre for the Working Environment (Rugulies), University of Copenhagen (Hulveij, Rod) and Semmelweis University, Budapest (Kopp). A particular collaboration is that with research groups who have large cohort studies; the Finnish twin cohort, University of Helsinki as well as with researchers of the Whitehall II, GA- ZEL, and Finish Public Sector Study (including the ten Town Study. b) Have new collaboration projects been initiated since funding was received? During the relatively short time since the inauguration, several cross-nodal collaborations have been instigated in the center. These new collaborations comprise all work packages, several of the subprojects and specifically a new work-package devoted to methodological quality ascertainment and development. To some extent, the collaborations are sprung from the fact that between-group use of expertise has been stimulated in existing projects. In addition, several new projects that involve theme-leaders or collaborators from the different nodes are now launched or planned. New collaborative projects within the center regard e.g. studies of stress/work load or sleep fragmentation and related effects of brain function and social interaction (P+R), studies of the role of sleep and stress response to upper respirtatory tracts infections (P+R), several collaborations on large register studies (I+E+R), and field studies of stress (O+R). Please, see the list of projects for details. We have also established a work package, which especially focuses on methodological collaborations and quality ascertainment (see description of projects). In brief it includes integration of our different databases, organization of collaborative use of equipment (EEG recorders, EKG recorders, actigraphy monitors) with some center-financed acquistion of equipment. The methods (W+P) also includes several collaborative projects on developing common use of questionnaires, collaborative methods on stress measuring methods. A seminar is scheduled for discussion of biological measurements in stress research, and seminars regarding statistical methods in longitudinal research have been performed during A new collaboration partner is Norbert Semmer, Bern University, in a project on illegitimate tasks and stress in professional work. There is a new collaboration with P.O Östergren, Lund university concerning long-term health effects of being in a locked-in position on the labour market. c) Is there any collaboration with industry or other parts of society such as public authorities, unions etc? There is intense collaboration with various companies, public authorities and unions. Occupational health projects collaborate with many OSH providers and member companies. Work hour projects collaborate with scheduling companies (TimeCare AB, Jeppesen AB, SAS) and the Civil Aviation Authority, as well as Volvo Technology, Volvo AB, Autoliv AB, The Swedish Road and Transport Research Institute (VTI), Trafikverket, the Swedish Public Employment Service, Social Insurance Agency, the Stockholm County Council, Health Insurance providers and various Labour Unions. 10/28

13 5. Communication Does the Centre have a communication strategy? The communication guidelines for the SSC are included in Stress Research Institute s Communication Plan for The Stress Research Institute s communication work is based on the Institute s strategic plan and the joint policy documents available to the university s communications activities. The strategic policy regarding Stockholm Stress Center is to internally communicate the center s role and current activities and externally communicate new research results to identified target groups. How has the task to communicate the objectives of the Centre with surrounding society been organised? The communication objective of the Stockholm Stress Center has so far been primarily the center s establishment at Stress Research Institute and its purpose, and to produce educational materials about the center to distribute at given times. Future focus will be to summarize the results in the center and to communicate them through the website, newsletters and media. An information brochure and a website with information on SSC s activities have been implemented as well as a popular yearly Stress research theme day at Aula Magna, Stockholm University. A quarterly newsletter and a scientific seminar at the Nobel Forum, Karolinska Institute are in the pipeline for The center also organizes the 20th Symposium on 20th International Symposium on Shiftwork and Working Time (for the International Committée on Occupational Health) - www. shiftwork2011. Results from work within Stockholm Stress Center will furthermore be disseminated through Stockholm Competence Center for Occupational Health Services and the Master program Occupation and Health. Activities Completed communication activities - Implementation of the inauguration of the SSC - Press release on the establishment of the SSC - Internal information to employees through the Institute s internal newsletter - Creation of a website: - Production and dissemination of an information brochure on SSC - Arranging the popular Stress research theme day in Aula Magna, hosted by the Stress Research Institute in collaboration with SSC and the collaborating partners. Planned communication activities for 2011/2012: - Rescheduling of the SSC website to a new form site a more explicit resident on the website for SSC - Distribution of a SSC newsletter 4 times per year - Production and distribution of various information materials of SSC publications and projects - Arranging 20th International Symposium on shiftwork and Working Time - Distribution of press releases regarding new research outcomes within the SSC - Arranging a scientific seminar at the Karolinska Institutet hosted by SSC. Have resources been allocated for planning, carrying out and monitoring the communication activities? Regarding planning, carrying out and monitoring the communication activities, the SSC has allocated 10% of a full-time employment for an Information Officer, which is SEK for 2010 and SEK for What are the plans for development of a website? Does the Centre have its own website? A specific website for the SSC, se, was launched in 2009, within the website of Stress Research Institute. The website contains information of the SSC and its activities, the collaborating groups, publications, current projects and events within the SSC such as workshops, seminars and conferences. On the website there are also links to each Collaborating partner s own website. Press clippings The senior researchers linked to the Stockholm Stress Center participate frequently as experts in newspaper articles, television and radio to disseminate research results. Total published between ; 1241 pcs. press clippings in which a member of the Management team occur. Press clippings per member of the Management team for the SSC, in number. Alexanderson Kristina 11 Aronsson Gunnar 70 Axelsson John 24 Hillert Lena 15 Kecklund Göran 50 Lekander Mats 37 Mittendorfer-Rutz Ellenor 2 Näswall Katharina 0 Svartengren Magnus 10 Sverke Magnus 2 Westerlund Hugo 245 Åkerstedt Torbjörn 775 Totalt antal pressklipp 1241 Data is based on press clippings from the Retriever, which is SSC s supplier of media coverage. The coverage includes press, online newspapers, blogs and broadcast media, both nationally and internationally. Further information We have no further information to submit. 11/28

14 Appendix A Participating persons List of all persons participating in SSC activities since the start of Center until end of 2010 (regardless of funding source). Name Title* Starting date Works % FTE** months Aili, Katarina Doctoral Student Alexanderson, Kristina Professor ,2 Andersson, Martin Researcher Aronsson, Gunnar Professor ,52 Axelsson, John Senior Researcher Baltzer, Maria Research Assistant ,05 Eek Nixon, Oliver Research Assistant ,5 0,1 Eriksson, Ulla-Lena Administrative Assistant ,5 Garheden, Christian IT-support ,5 Groten, Wim Associate Professor ,75 Gustavsson, Klas Post-Doc Hasson, Dan Senior Researcher ,5 Hillert, Lena Associate Professor ,2 Hinas, Elin Statistician Ingvar, Martin Professor ,5 Jansson, Catarina Researcher Karshikoff, Bianka Doctoral Student Kecklund, Göran Associate Professor ,2 Kjeldgård, Linnea Statistician Klevegren, Veronica Financial Officer ,75 Knorring von, Mia Doctoral Sudent ,5 Kramar, Marija Doctoral Student Lagergren, Sofia Information Officer ,5 Leineweber, Constanze Data Manager ,41 Lekander, Mats Professor ,2 Lindholm, Christina Senior Researcher Ljungquist, Therese Senior Researcher Lowden, Arne Associate Professo r ,5 Lund, Göran Research Assistant Låstad, Lena Doctoral Student Löfgren, Anna Post-Doc ,50 Magnusson Hansson, Linda Senior Researcher ,25 Marklund, Staffan Professor Mellner, Christin Senior Researcher ,5 Mittendorfer Rutz, Ellenor Senior Researcher Narusyte, Jurgita Post-Doc Nixon Andreasson, Anna Post-Doc ,2 Nordenskiöld, Louise Administrative Manager Nyman, Teresia Post-Doc ,25 Näswall, Katharina Associate Professor ,4 Olgart Höglund, Caroline Associate Professor Osika, Walter Post-Doc ,5 Perski, Alexander Associate Professor ,2 Petersen, Helena Research Assistant Rehman Ur, Javaid Research Assistant Sahlander, Karin Post-Doc ,5 Samuelsson, Åsa Doctoral Student Schraml, Karin Research Assistant Stoetzer, Ulrich Post-Doc ,25 Sundelin, Tina Doctoral Student ,5 Svartengren, Magnus Professor ,2 12/28

15 Svedberg, Pia Researcher Sverke, Magnus Professor ,2 Theorell, Töres Professor Emeritus ,5 Vaez, Marjan Researcher ,5 Westerlund, Hugo Professor ,2 Wiberg, Michael Statistician ,5 Wikman, Anders Associate Professor ,3 Voss, Margaretha Senior Researcher ,75 Zetterström, Katharina Doctoral Student Åkerstedt, Torbjörn Professor Åström Paulsson, Sofia MD ,4 Persons participating, in total 62 * E.g., Professor, Associate professor (docent), Senior researcher (forskare), Junior researcher (forskarassistent), Postdoc, Doctoral student, Other research staff (forskningsingenjör, forskningsassistent, programmerare, statistiker etc), Administrative personnel. ** FTE = Full time equivalent (e.g., 50% = 6 months) 13/28

16 Appendix B Financial Report Table 1. Economic report covering the time period since start of the centre until end of Type of cost Grant from FAS (SEK) University contribution in kind - SEK ** University contribution in direct funds - SEK Other external contributions - SEK *** Personell * Professors Other academics Doctoral students Other research Administrative Infrastructure Equipment, etc. Other Overhead inclusive premises Total * As listed in Table 1 of Appendix A ** Approximate equivalent Table 2. Sources of external contributions received during the time period since start of the centre until end of Funding organization Amount received during time period - SEK Eg: FAS program support 1 0 FAS program support 2 0 FAS project VR project Total Table 3. Expected contributions from external sources and the university during the next two years ( ). Funding organization Amount expected - SEK Eg: FAS program support 1 0 FAS project University - direct funds University - in kind * * Approximate equivalent 14/28

17 Appendix C List of Publications (published from Centre partners from 2009 on.) The Center became operative on October Publications from (short) collaborative studies can, therefore, not be expected until Thus, the publications listed below are mainly unilateral and the work contained in them derive from projects that predate the Center. Many of the later ones, have, however, been finalized for publication during the first year of operation of the center. Original Articles 2011 Aronsson G, Gustafsson K, Mellner C (2011) Sickness presenteeism, sickness absenteeism and self-rated health in the Swedish working population. International Journal of Workplace Health Management, (inpress) Bergman P, Åborg C, Johansson G, Svartengren M (2011) Developing working conditions to manage sickness abscence. Manuscript in thesis, Bernhard-Oettel C, De Cuyper N, Schreurs B, De Witte H (2011) Relations of Job Insecurity and Fairness Perceptions to Well-being and Organizational Attitudes: The Role of Security expectations. /International Journal of Human Resource Management, 22(9): Clinton M, Bernhard-Oettel C, Rigotti T, De Jong J (2011) Expanding the Temporal Context of Research on Non- Permanent Work: Previous Experience, Duration of and Time Remaining on Contracts and Employment Continuity Expectations. Career Development International, 16(2): Dawson D, Ian Noy Y, Härmä M, Akerstedt T, Belenky G (2011) Modelling fatigue and the use of fatigue models in work settings. Accid Anal Prev, 43(2): Enblom A, Lekander M, Hammar M, Johnsson A, Onelov E, et al (2011) Getting the grip on nonspecific treatment effects: emesis in patients randomized to acupuncture or sham compared to patients receiving standard care. PLoS ONE, 6:e14766 Ferrie J, Kivimäki M, Westerlund H, Head J, Melchior M, Singh-Manoux A, Zins M, Goldberg M, Alexanderson K, Vahtera J (2011) Differences in the association between sickness absence and long-term sub-optimal health: a 14-year followup in the GAZEL cohort. OEM Jan 17: PMID: Floderus B, Hagman M, Aronsson G, Marklund S, Wikman A (2011) Medically certified sickness absence with insurance benefits in women with and without children. European Journal of Public Health, (in press) Fondell E, Axelsson J, Franck K, Ploner A, Lekander M, Balter K, Gaines H (2011) Short natural sleep is associated with higher T cell and lower NK cell activities. Brain, Behavior, and Immunity (in press) Grubel J, Kecklund G (2011) The Impact of Organizational Changes on Work, Stress, Sleep, Recovery and Health. J-STAGE (accepted) Hallsten L, Voss M, Stark S, Vingård E, Josephson M (2011) Job burnout and job wornout as risk factors for long-term sickness absences. WORK, 38(2): Hultin H, Hallqvist J, Alexanderson K, Johansson G, Lindholm C, Lundberg I, Möller J (2011) Work-related psychosocial events as triggers of sick leave - results from a Swedish case-crossover study. BMC Public Health, 2011:11 Johnsson A, Tenenbaum A, Westerlund H (2011) Improvements in physical and mental health following a rehabilitation programme for breast cancer patients. European Journal of Oncology Nursing, 15(1):12-5 Labriola M, Holte KA, Bang Christensen K, Feveile H, Alexanderson K, Lund T (2011) The attribution of work environment in explaining gender differences in long-term sickness absence among a cohort of 5,026 employees in Denmark. Results from the prospective DREAM study. Occupational and Environmental Medicine, (accepted) Leineweber C, Westerlund H, Theorell T, Kivimäki M, Westerholm P, Alfredsson L (2011) Covert coping with unfair treatment at work and risk of incident myocardial infarction and cardiac death among men: prospective cohort study. Journal of Epidemiology Community Health, 65(5):420-5 Lekander M, von Essen J, Schultzberg M, Nixon Andreasson A, Garlind, A, Hansson, L-O Nilsson L-G (2011) Cytokines and cognition across the adult life span in women. Scandinavian Journal of Psychology, (in press) Lidwall U, Marklund S (2011) Trends in long-term sickness absence in Sweden : the role of economic conditions, legislation, demography, work environment and alcohol consumption. International Journal of Social Welfare, 2(20): Lindfors S, Boman J, Alexanderson K (2011) Strategies used to handle stress by academic physicians at a university hospital. Work, (accepted) Lowden A, Åkerstedt T, Ingre M, Wiholm C, Hillert L, Kuster N, Nilsson JP, Arnetz B (2011) Sleep after mobile phone ex- 15/28

18 posure in subjects with mobile phone-related symptoms. Bioelectromagnetics, 32:4-14 Löfgren A, Silén C, Alexanderson K (2011) How physicians have learned to handle sickness-certification cases. Scandinavian Journal of Public Health, 39: Oksanen T, Vahtera J, westerlund H, Pentti J, Sjösten N, Virtanen M, Kawachi I, Kivimäki M (2011) Is retirement beneficial for mental health? Longitudinal analysis of antidepressant use before and after retirement. Epidemiology, (accepted) Pietikäinen S, Silventoinen K, Svedberg P, Alexanderson K, Huunan-Seppälä A, Koskenvuo K, Koskenvuo M, Kaprio J, Ropponen A (2011) Health related and sociodemographic risk factors for disability pension due to low back disorders: a 30 year prospective Finnish twin cohort study. JOEM, (accepted) Rod NH, Vahtera J, Westerlund H, Kivimaki M, Zins M, Goldberg M, Lange T (2011) Sleep Disturbances and Cause- Specific Mortality: Results From the GAZEL Cohort Study. American Journal of Epidemiology, 1;173(3):300-9 Romanowska J, Larsson G, Eriksson M, Wikström BM, Westerlund H, Theorell T (2011) Health Effects on Leaders and Co-Workers of an Art-Based Leadership Development Program. Psychother Psychosom, 80:78 87 Schüz J, Elliott P, Auvinen A, Kromhout H, Poulsen AH, Johansen C, Olsen JH, Hillert L, Feychting M, Fremling K, Toledano M, Heinävaara S, Slottje P, Vermeulen R, Ahlbom A (2011) An international prospective cohort study of mobile phone users and health (Cosmos): Design considerations and enrolment. Cancer Epidemiol, 35:37-43 Sjösten NM, Nabi H, Westerlund H, Singh-Manoux A, Dartigues JF, Goldberg M, Zins M, Oksanen T, Salo P, Pentti J, Kivimäki M, Vahtera J (2011) Influence of retirement and work stress on headache prevalence: A longitudinal modelling study from the GAZEL Cohort Study. Cephalalgia. Jan 10, (Epub ahead of print) 2010 Axelsson J, Sundelin T, Ingre M, van Someren, EJW, Olsson A, Lekander M (2010) Beauty sleep: Sleep history affects perceived attractiveness and health. British Medical Journal, 341:c6614 Andreasson A, Jernelöv S, Robert Szulkin, Undén AL, Brismar K, Lekander M (2010) Associations between leptin and subjective health in men and women. Gender Medicine, 7(3):261-9 Aronsson G, Blom V (2010) Work conditions for workers with good long-term health. International Journal of Workplace Health Management, 3: Baraldi S, Jawaid Kalyal H, Berntson E, Näswall K, Sverke M (2010) The Importance of Commitment to Change in Public Reform: An Example from Pakistan. Journal of Change Management, 10(4): Bejerot E, Hasselbladh H (2010) Soft Power, Trojan Horses and Professional Autonomy The Transformation of Quality Registers in Swedish Health Care (Accepted) Berntson E, Näswall K, Sverke M (2010) The moderating role of employability in the association between job insecurity and exit, voice, loyalty and neglect. Economic and Industrial Democracy, 31(2): Berntson E, Marklund S (2010) Employability and work-related health. In Marklund S and Härenstam A. (Eds.). The dynamics of organizations and healthy work. Arbetsliv i omvandling 2010:5 Blom V, Johnson M, Patching G (2010) Physiological and behavioral reactivity when one s self-worth is staked on competence. Individual Differences Research, (in press) Blom V (2010) Contingent self-esteem, stressors and burnout in working women and men. WORK: A Journal of Prevention, Assessment, and Rehabilitation, (in press) Burström K, Egmar AC, Lugnér A, Eriksson M, Svartengren M (2010) A Swedish child-friendly pilot version of the EQ-5D instrument the development process. Eur J Public Health. Apr 29, [Epub ahead of print] Burström K, Svartengren M, Egmar (2010) Testing a Swedish child-friendly pilot version of the EQ-5D instrument initial results. Eur J Public Health. Apr 29, [Epub ahead of print] Christensson A, Runeson B, Dickman P, Vaez M (2010) Change in depressive symptoms over higher education and professional establishment - a longitudinal investigation in a national cohort of Swedish nursing students. BMC Public Health,10:343 Christensson, Vaez M, Dickman P, Runeson B (2010) Selfreported depression in first-year nursing students in relation to socio-demographic and educational factors: A nationwide cross-sectional study in Sweden. Soc Psychiatry Psychiatr Epidemiol, Mar 7; DOI: /s y De Witte H, De Cuyper N, Handaja Y, Sverke M, Näswall K, Hellgren J (2010) Associations between quantitative and qualitative job insecurity and well-being: A Test in Belgian banks. International Studies of Management and Organization, 40:40-56 Dugravot A, Sabia S, Stringhini S, Kivimaki M, Westerlund H, Vahtera J, Guéguen A, Zins M, Goldberg M, Nabi H, Singh- 16/28

19 Manoux A (2010) Do socioeconomic factors shape weight and obesity trajectories over the transition from midlife to old age? Results from the French GAZEL cohort study. American Journal of Clinical Nutrition, 92(1):16-23 Elfving B, Åsell M, Lüning Bergsten C, Alexanderson K (2010) Exploring activity limitations an sick leave among patients with spinal pain participating in multidisciplinary rehabilitation. Disability and Rehabilitation, 32(4)292-9 Fondell E, Lagerros YT, Sundberg CJ, Lekander M, Bälter O, Rothman KJ, Bälter K (2010) Physical activity, stress, and self-reported upper respiratory tract infection. Medicine and Science in Sports and Exercise. Jun 23, (Epub ahead of print) Hasson D, Lindfors P, Gustavsson P (2010) Trends in self-rated health among nurses: a 4-year longitudinal study on the transition from nursing education to working life. Journal of Professional Nursing, 26(1):54-60 Hasson D, Theorell T, Westerlund H, Canlon B (2010) Prevalence and characteristics of hearing problems in a working and non-working Swedish population. Journal of Epidemiology and Community Health, 64(5): Heponiemi T, Elovainio M, Pentti J, Virtanen M, Westerlund H, Virtanen P, Oksanen T, Kivimäki M, Vahtera J (2010) Association of Contractual and Subjective Job Insecurity With Sickness Presenteeism Among Public Sector Employees. Journal of Occupational and Environmental Medicine, 52(8): Hjelmstedt A, Shenoy ST, Stener-Victorin E, Lekander M, Bhat M, Leena KB, Waldenström U (2010) Acupressure to reduce labour pain. A randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica, 89(11): Hultin H, Hallqvist J, Alexanderson K, Johansson G, Lindholm C, Lundberg I, Möller J (2010) Low level of adjustment latitude - a risk factor for sickness absence. European Journal of Public Health, 1-7 Härmä M, Kecklund G (2010) Shift work and health - how to proceed? Scandinavian Journal of Work, Environment and Health, 36(2):81-4 Isaksson K, De Cuyper N, Bernhard-Oettel C, De Witte H (2010) The role of the formal employment contract in the range and fulfilment of the psychological contract; Testing a layered model. European Journal of Work and Organizational Psychology, 19(6): Jokela M, Ferrie JE, Gimeno D, Chandola T, Shipley MJ, Head J, Vahtera J, Westerlund H, Marmot MG, Kivimäki M (2010) From Midlife to Early Old Age: Health Trajectories Associated With Retirement. Epidemiology, 21(3): Kalyal HJ, Sverke M (2010) The role of trust in decision makers as a moderator between qualitative job insecurity and afffective commitment to change. Pakistan Journal of Psychological research, 25:65-78 Kalyal H, Berntson E, Baraldi S, Näswall K, Sverke M (2010) The moderating role of employability on the relationship between job insecurity and commitment to change. Economic and Industrial Democracy, 31: Klepczyska Nyström A, Svartengren M, Grunewald J, Pousette C, Rödin I, Lundin A, Sköld CM, Eklund A, Larsson BM (2009) Health effects of a subway environment in healthy volunteers. Experimental data. Eur Respir J, 36(2):240-8 Larsson BM, Grunewald J, Sköld CM, Lundin A, Sandström T, Eklund A, Svartengren M (2010) Limited airway effects in mild asthmatics after exposure to air pollution in a road tunnel. Respir Med, 104(12): Leineweber C, Westerlund H, Hagberg J, Svedberg P, Luokkala M, Alexanderson K (2010) Sickness presenteeism among Swedish police officers. Journal of occupational rehabilitation, 21(1):17-22 Leineweber C, Wege N, Westerlund H, Theorell T, Wahrendorf M, Siegrist J (2010) How valid is a short measure of effort-reward imbalance at work? A replication study from Sweden. Occupational and Environmental Medicine, 67(8): Lekander M, von Essen J, Schultzberg M, Nixon Andreasson A, Garlind A, Hansson L-O, Nilsson L-G (2010) Cytokines and cognition across the adult life span in women. Scandinavian Journal of Psychology (accepted) Lindholm C, Arrelöv B, Nilsson G, Löfgren A, Hinas E, Skåner Y, Ekmer A, Alexanderson K (2010) Sickness-certification practice in different clinical settings; a survey of all physicians in a country. BMC Public Health, 10:752 Lidwall U, Marklund S (2010) Trends in long-term sickness absence in Sweden the role of economic conditions, legislation, demography, work environment and alcohol consumption, International Journal of Social Welfare, DOI: Lovseth LT, Aasland OG, Fridner A, Jónsdóttir LS, Marini M, Linaker OM (2010) Confidentiality and physicians health. A cross sectional study of university hospital physicians in four European cities [HOUPE-study]. Journal of Occupational health, 52: Malmberg B, Kecklund G, Karlson B, Persson R, Flisberg P, Orbaek P (2010) Sleep and recovery in physicians on night call: a longitudinal field study. BMC health services research, 15;10(1):239 17/28

20 Melchior M, Ferrie JE, Alexanderson K, Goldberg M, Kivimaki M, Singh-Manoux A, Vahtera J, Westerlund H, Zins M, Head J (2010) Does sickness absence due to psychiatric disorder predict cause-specific mortality? A 16-year follow-up of the GAZEL occupational cohort study. American Journal of Epidemiology, 15:172(6):700-7 Mussener U, Svensson T, Alexanderson K (2010) Sickness Absence, Social Relations and Self-Esteem A qualitative study of the importance of relationships with family, workmates and friends among persons initially long-term sickness absent due to back diagnoses, (Work) Nabe-Nielsen K, Kecklund G, Ingre M, Skotte J, Diderichsen F, Garde AH (2010) The importance of individual preferences when evaluating the associations between working hours and indicators of health and well-being. Applied Ergonomics, 41(6): Niederkrotenthaler T, Floderus B, Alexanderson K, Rasmussen F, Mittendorfer-Rutz E (2010) Exposure to parental mortality and markers of morbidity, and the risks of attempted and completed suicide in offspring: an analysis of sensitive life periods. JECH Online First, October 5, /jech Nyman T, Mulder M, Iliadou A, Svartengren M, Wiktorin C (2010) High heritability for concurrent low back and neckshoulder pain - a study of twins. Spine (Phila Pa 1976). Dec 29. (Epub ahead of print) Rehman JU, Brismar K, Holmbäck U, Akerstedt T, Axelsson J (2010) Sleeping during the day: effects on the 24-h patterns of IGF-binding protein 1, insulin, glucose, cortisol, and growth hormone. European journal of endocrinology, 163(3): Richter A, Näswall K, Sverke M (2010) Job insecurity and its relation to work-family conflict: Mediation with a longitudinal data set. Economic and Industrial Democracy, 31(2): Ridefelt P, Larsson A, Rehman J, Axelsson J (2010) Influences of sleep and the circadian rhythm on iron-status indices Clinical Biochemistry Clin Biochem, 43(16-17): Riva R, Mork PJ, Westgaard RH, Ro M, Lundberg U (2010) Fibromyalgia Syndrome is Associated with Hypocortisolism. International Journal of Behavioral Medicine, 17(3): Robstad Andersen G, Aasland OG, Fridner A, Lövseth TL (2010) Harassment among university hospital physicians in four European cities. Results from a cross-sectional study in Norway, Sweden, Iceland and Italy [the HOUPE study]. Work, 37: Sjöstrand C, Savic I, Laudon-Meyer E, Hillert L, Lodin K, Waldenlind E (2010) Migraine and olfactory stimuli. Curr Pain Headache Rep, 14: Stevens RG, Hansen J, Costa G, Haus E, Kauppinen T, Aronson KJ, Castano-Vinyals G, Davis S, Frings-Dresen MH, Fritschi L, Kogevinas M, Kogi K, Lie JA, Lowden A, Peplonska B, Pesch B, Pukkala E, Schernhammer E, Travis RC, Vermeulen R, Zheng T, Cogliano V, Straif K (2010) Considerations of circadian impact for defining shift work in cancer studies: IARC Working Group Report. Occup Environ Med. Oct 20, (Epub ahead of print) Svedberg P, Ropponen A, Lichtenstein P, Alexanderson K (2010) Are self-report of disability pension and long-term sickness absence accurate? Comparisons of self-reported interview data with national register data in a Swedish twin cohort. BMC Public Health, 10:763 Svensson T, Mussener U, Alexanderson K (2010) Sickness Absence, Social Relations, and Self-Esteem - A qualitative study of the importance of relationships with family, workmates, and friends among persons initially long-term sickness absent due to back diagnoses. Work, 37(2): Sverke M, De Witte H, Näswall K, Hellgren J (2010) European perspectives on job insecurity: Editorial introduction. Economic and Industrial Democracy, 31(2): Teixeira L, Lowden A, Roberta Moreno C, Turte S, Nagai R, Do Rosario Latorre M, Valente D, Marina Fischer F (2010) Work and excessive sleepiness among Brazilian evening high school students. International Journal of Occupational and environmental Health, 16: Tucker P, Brown M, Dahlgren A, Davies G, Ebden P, Folkard S, Hutchings H, Åkerstedt T (2010) The impact of junior doctors worktime arrangements on their fatigue and well-being. Scandinavian Journal of Work Environment and Health, 36(6): Vadeby A, Forsman A, Kecklund G, Åkerstedt T, Sandberg D, Anund A (2010) Sleepiness and prediction of driver impairment in simulator studies using a Cox proportional hazard approach. Accident Analysis and Prevention, 42(3): Vahtera J, Westerlund H, Ferrie J, Head J, Melchior M, Singh- Manoux A, Zins M, Goldberg M, Alexanderson K, Kivimäki M (2010) All-cause and diagnosis-specific sickness absence as a predictor of sustained sub-optimal health: a 14-year follow-up in the GAZEL cohort. J Epidemiol Community Health, 64(4):311-7 Von Knorring M, de Rijk A, Alexanderson K (2010) Managers perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare. BMC Health Services Research,10:271 Westerlund H, Vahtera J, Ferrie JE, Singh-Manoux A, Pentti J, Melchior M, Leineweber C, Jokela M, Siegrist J, Goldberg M, Zins M, Kivimäki M (2010) Effect of retirement on major chro- 18/28

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