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13 Angold A, Erkanli A, Silberg J, et al. Depression scale scores in 8–17-year-olds: effects of age and gender. J Child Psychol Psychiatry Allied Disciplines 2002;43:1052. 14 Vyas S. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 2006;21:459. 15 Gullone E, Robinson K. The inventory of parent and peer attachment - revised (IPPA-R) for children: a psychometric investigation. Clin Psychol Psychother 2005; 12:67–79. 16 Brumariu LE, Kerns KA. Parent/child attachment and internalizing symptoms in childhood and adolescence: a review of empirical findings and future directions. Dev Psychopathol 2010;22:177. 17 Enders CK, Bandalos DL. The relative performance of full information maximum likelihood estimation for missing data in structural equation models. Struct Equ Modeling 2001;8:430–57.

18 Fergusson DM, Boden JM, Horwood LJ. Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes. Br J Psychiatry 2007;191:335–42. 19 Johansen P. How could MDMA (ecstasy) help anxiety disorders? A neurobiological rationale. J Psychopharmacol 2009;23:389. 20 Johnston J, Barratt MJ, Fry CL, et al. A survey of regular ecstasy users’ knowledge and practices around determining pill content and purity: implications for policy and practice. Int J Drug Policy 2006;17:464–72. 21 BBC News. Ecstasy warning for T in the park. 2013. Available at: http://www.bbc. co.uk/news/uk-scotland-glasgow-west-23263680. (12 October 2013 date last accessed). 22 Rodgers J. Ecstasy use, by itself, does not result in residual neurotoxicity’—a powerful argument? Addiction 2011;106:1269.

......................................................................................................... European Journal of Public Health, Vol. 24, No. 5, 850–856 ß The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckt158 Advance Access published on 11 October 2013

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In search for a public health leadership competency framework to support leadership curriculum–a consensus study Katarzyna Czabanowska1, Tony Smith2, Karen D. Ko¨nings3,4, Linas Sumskas5, Robert Otok6, Vesna Bjegovic-Mikanovic7, Helmut Brand1 1 Department of International Health, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands 2 Centre for Leadership in Health and Social Care, Sheffield Hallam University, Sheffield, UK 3 Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands 4 Graduate School of Health Professions Education, Maastricht University, Maastricht, The Netherlands 5 Department of Preventive Medicine, Institute of Health Research, Lithuanian University of Health Sciences, Kaunas, Lithuania 6 The Association of Schools of Public Health in the European Region (ASPHER), Brussels, Belgium 7 Faculty of Medicine, Centre School of Public Health and Management, University of Belgrade, Belgrade, Serbia Correspondence: Katarzyna Czabanowska, Department of International Health, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands, Tel: +31 43 3881592, Fax: +31 43 38 84 172, e-mail: [email protected]

Background: Competency-based education is increasingly popular, especially in the area of continuing professional development. Many competency frameworks have been developed; however, few address leadership competencies for European public health professionals. The aim of this study was to develop a public health leadership competency framework to inform a leadership curriculum for public health professionals. The framework was developed as part of the Leaders for European Public Health project—supported by the EU Lifelong Learning Programme. Methods: The study was carried out in three phases: a literature review, consensus development panel and Delphi survey. The public health leadership competency framework was initially developed from a literature review. A preliminary list of competencies was submitted to a panel of experts. Two consensus development panels were held to evaluate and make changes to the initial draft competency framework. Then two rounds of a Delphi survey were carried out in an effort to reach consensus. Both surveys were presented through Survey Monkey to members of the Association of the Schools of Public Health in the European Region Working Group on Innovation in Public Health Teaching and Education. Results: The framework was developed consisting of 52 competencies organized into eight domains: Systems Thinking; Political Leadership; Collaborative Leadership: Building and Leading Interdisciplinary Teams; Leadership and Communication; Leading Change; Emotional Intelligence and Leadership in Team-based Organizations; Leadership, Organizational Learning and Development and Ethics and Professionalism. Conclusion: The framework can serve as a useful tool in identifying gaps in knowledge and skills, and shaping competencybased continuing professional development leadership curricula for public health professionals in Europe.

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Introduction rofessional development of public health leaders requires instruction to increase their ability to

Pcompetency-based

address complex and changing demands for critical services1 in ways that improve the health of the population.2 The development, acquisition and assessment of new skills should be supported by adequately tailored educational programmes to improve health

Public health leadership competency framework

and tackle health inequalities, which are becoming a key priority for public health professionals and leaders. In recent years, there has been an increasing interest in competency-based medical education due to its focus on outcomes, emphasis on abilities, de-emphasis of time-based training and the promotion of learnercentredness.3 Competency-based education (CBE) has also been introduced in public health training and education to close the gap between public health educational content and the competencies required in practice. However, still little is known about approaches to CBE in public health. CBE is organized around competencies, or predefined abilities, as outcomes of the curriculum. Competencies are composites of individual attributes (i.e. knowledge, skills and attitudinal or personal aspects) that represent context-bound productivity.4 Many competency frameworks have been developed5–8 to support CBE. With respect to public health, there is a considerable consensus both in the USA and in Europe on what key competency areas should be included in academic public health curricula. Influential documents were produced by the Association of Schools of Public Health Project; the Public Health Faculty/Public Health Foundation; Tier 1, Tier 2 and Tier 3 Core Competencies for Public Health Professionals (adopted 3 May 2010)9 and the Association of the Schools of Public Health in the European Region (ASPHER) Public Health Core Competencies Project.10 In the UK, Public Health Skills and Career Framework11 attempts to define competencies for seven levels of public health employment.12 Such initiatives are an attempt to promote high standards in professional public health practice and serve as a guide to design public health CBE curricula. The focus of this study is on competencies in the area of public health leadership which, given the repeatedly stated need to develop strong leadership skills in public health professionals,13 are of pivotal importance. Competency frameworks have already been developed in the area of public health and medical leadership, which apart from bringing together leadership principles are also useful for planning professional training. However, their focus differs. While the Healthcare Leadership Alliance Competency Directory14 is more oriented towards management and business administration, the National Public Health Leadership Network’s Public Health Leadership Competency Framework15 is geared towards developing leaders who are political-change agents able to use interpersonal skills. Being more focused on senior clinicians and senior managers, the 2005 National Health Service (NHS) Leadership Qualities Framework16 was followed by a new NHS Medical Leadership Competency Framework in calls for bottom-up leadership of innovation.17 However, in 2011, a more comprehensive NHS Leadership Framework of the National Leadership Council18 was launched, which has the NHS Medical Leadership Competency Framework at its centre.19 It includes a vision and strategy, which surprisingly are not included in the first framework. Despite the recent King’s Fund report, ‘No More Heroes’,19 which calls for the replacement of the heroic leadership model with an increased focus on shared leadership, the new framework appears in many ways to be more hierarchical in its assumptions than the previous version.19 Although considerable work has been done in the development of leadership competencies in the field of health worldwide, these frameworks seem very generic and none of them was specifically developed to support the educational curriculum for public health professionals. The aim of this study was to develop a public health leadership competency framework to support the development of competency-based European public health leadership curriculum. The framework was designed in the context of the Leaders for European Public Health (LEPHIE) Erasmus Multilateral Curriculum Development Project, supported by the EU Lifelong Learning Programme.

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Methods The study was carried out in three phases: a literature review, consensus development panel and Delphi survey. The public health leadership competency framework was initially developed from an extensive literature review carried out by two reviewers focusing on literature, which primarily addressed public health leadership in Europe, published in English between 2000 and 2011. PubMed, Cochrane Library, EMBASE and Google Scholar were accessed together with grey literature from a variety of public health and leadership institutions. The European Journal of Public Health was singled out for closer review to develop a broad understanding of leadership roles and competencies for public health professionals in continuous education programmes. Combinations of the following terms were used:      

Public health leadership competencies European public health leadership competencies Public health professionals competencies European public health professional competencies Public health leadership Public health leadership and continuing education

For completeness, all public health leadership frameworks from 2000 to 2011 in English regardless of their land of origin were also reviewed.8,9,11,12,14–18 Two hundred fifty-three (253) references were initially identified. After the initial search and separation of existing competency frameworks, the remaining citations were narrowed to only relevant articles by checking if the studies originated in or involved a European country and by reading the titles and abstracts. Finally, 53 citations were included in the review. Citations and frameworks were reviewed for possible competencies and a list compiled including 119 competencies. This list was edited for duplicates by the same researchers and competencies were organized using a template analysis approach20 that utilized an evidence-based thematic framework by Smith et al.21 for development of the leadership curriculum for public health professionals within the LEPHIE project. The template comprised the following domains: Theory and alternative discourses, Systems Thinking, Political Leadership, Inspiring and Motivating Others, Building and Leading Interdisciplinary Teams, Leadership and Communication, Leading Change and Emotional Intelligence. Two horizontal domains: Professional Networking and Ethics and Professionalism were added by the researchers to embrace specific competencies related to these areas as identified in the literature review. The domains were supposed to correspond to the teaching areas of the public heath leadership curriculum apart from the two horizontal domains that do not have corresponding sessions in the LEPHIE programme but are intertwined in the overall content. The initial draft framework of 92 competencies for public health leadership was then submitted to a panel of experts consisting of seven public health and seven leadership academics from four European Universities—Maastricht University (NL), Medical University Graz (AT), The Sheffield Hallam University (UK) and Lithuanian University of Health Sciences (LT)—and the University of Griffith (AUS) engaged in developing the new European public health leadership curriculum. Two online consensus development panels were held to evaluate and make changes to the initial draft competency framework. Consensus development panels are a qualitative method for obtaining agreement in areas of uncertainty or where there is a lack of definitive information.22,23 They bring professionals together to collaboratively develop consensus definitions and classifications.24 The experts were asked to mark each competency according to its relevance for inclusion in the framework, suggest possible changes in the competency statement and suggest possible changes in the appropriate domain. Specifically, they were asked to address the following questions: ‘Should this competency be

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in this assigned domain?’ ‘If you answered ‘‘yes with changes,’’ please suggest a new statement’; ‘If you answered ‘‘no’’ please explain why’ and ‘Are there other competencies which should be included in this domain?’ After the reviewers evaluated the items individually, the results were pooled to create an amended framework. A total of 73 competencies remained.

Delphi Survey Two rounds of a Delphi survey were then carried out to validate and obtain broader consensus on the domains and competencies in the framework. Our goal was for 80–100% consensus. Both surveys were presented through Survey Monkey, an online survey service, and sent by email to members of the ASPHER Working Group on Innovation and Good Practice in Public Health Education (WGIGP). WGIGP consists of senior public health professionals interested in education and educational leadership. Ten members (of 20 invited) participated in the review. The Delphi method helped to create an environment that allowed for partial anonymity.24 A traditional Delphi process begins with a survey gathering opinions from participants, followed by two or more rounds to reach consensus.24 The number of survey rounds, size of expert pool and degree of consensus required are defined by the researcher, but typically two or more rounds of surveying must be conducted.25 Because we had already completed the consensus development panels, we chose to have two rounds of Delphi surveys in an effort to finalize and obtain a high level of consensus on the public health leadership competency framework. The first round questionnaire consisted of 73 items describing competencies. Participants were asked to respond ‘yes/no/with changes’ on the inclusion and grouping of each competency. Space was also provided to add other competencies that respondents considered suitable for public health leadership. The respondents could also put forward their arguments for or against the proposed competencies. When 10 responses were received after two reminders, the survey was closed and the responses were evaluated. Items with less than 80% consensus were edited to bring them closer in line with the observations of the respondents. The second Delphi survey contained only three items and sought a simple ‘yes/no’ response regarding the edits made in the previous round. This was followed by a yes/no response regarding approval of the framework as a whole. At the end of the procedure, the same investigators reviewed the list by checking the formulation, richness and variation of the competencies. Participants in the consensus panel and Delphi survey were informed of the purpose of this study and were given the opportunity to self-select their participation. The process was conducted in compliance with principles outlined in the Helsinki Declaration.

Results Based on our literature review, 119 competencies were identified and organized into leadership domains developed by Smith et al.21 The domains were adapted by public health and leadership experts involved in the evaluation process. As a result of the first phase of the consensus development process, the list was narrowed to 85 competencies. ‘Theory and Alternative Discourses’ was removed as being too broad. Based on the responses to the questionnaire used in the second phase of the consensus development panel process, the domains were edited to better reflect considered leadership areas. Inspiring and Motivating Others was merged with Building and Leading Interdisciplinary Teams and Leadership and Communication. Building and Leading Interdisciplinary Teams was rephrased into Collaborative Leadership: Building and Leading Interdisciplinary Teams to better fit the content. Emotional Intelligence domain was reformulated into Emotional Intelligence and Leadership in Team-based Organizations; Leadership,

Organizational Learning and Development was added to fit the competencies that belonged to such a category but placed under other headings. The final 73 competencies were organized into nine domains. In the first Delphi round, 10 participants contributed. Participants reached 100% consensus on eight domain areas. The Professional Networking domain was removed, as the reviewers believed that networking cannot be taught and is too general. However, some of its competencies were identified as strongly related to collaborative leadership and so were subsumed into that category. The competencies that received from 80 to 100% consensus remained and those that received 75% consensus were reformulated according to the suggestions of the reviewers. After revision and editing, the framework, consisting of eight categories and 52 competencies, was presented for a second Delphi round. We reached 100% consensus on the domain areas (table 1). Because the respondents proposed no new competencies in Round 2, we concluded that saturation and consensus had been achieved. A circular structure for displaying the domains was adopted to emphasize the importance of integrating all areas of competency into public health leadership (figure 1). As a result of a systematic review process, a public health leadership competency framework was developed consisting of 52 competencies organized into eight domains: 1) Systems Thinking; 2) Political Leadership; 3) Collaborative Leadership: Building and Leading Interdisciplinary Teams; 4) Leadership and Communication; 5) Leading Change; 6) Emotional Intelligence and Leadership in Teambased Organizations; 7) Leadership, Organizational Learning and Development and 8) Ethics and Professionalism (table 1). The framework reflects the design and architecture of the European Public Health Leadership competency-based curriculum developed in the framework of the LEPHIE project (figure 2). Each domain corresponds to one educational session within public health leadership curriculum.26 The description of the competencies supports the curriculum design and it can be used as a self-assessment instrument for students and working professionals, helping them to reflect and identify gaps in their knowledge and skills.

Discussion Recently WHO Regional Office for Europe has developed the list of 10 Essential Public Health Operations (EPHO). ‘Leadership, governance and initiation, development and planning of public health policy’ was included in the tentative list of EPHO.27 ‘Strategic leadership for health’ was also mentioned among 10 key areas of public health practice in this WHO document. These steps contribute to better positioning of the role of leadership and governance in public health in Europe. Although leadership is a well-known concept and ‘there are almost as many definitions of leadership as there are persons who have attempted to define the concept’,28 our study is an important attempt to define, profile and position public health leadership through a systematically developed, comprehensive and multidisciplinary competency framework. Fifty-two competencies arranged in eight domains can serve as a tool for clarification of the notion of leadership. Such a framework can be tested, on one hand by course designers in the development and evaluation of leadership CBE, and on the other hand by the professionals who can use the framework for self-assessment and personal development planning. Moreover, it could be used at the national level to help evaluate the current state of leadership capacity and practice related to ASPHER competency programme10 and also for evaluation how EPHO relate to public health capacities. Various leadership frameworks do not convincingly identify a form of leadership that is unique to public health. In fact, everything contained in these frameworks can draw direct lineage from generic theories such as Transformational, Charismatic leadership, Emotional Intelligence and Situational leadership.19 On

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Table 1 Public health leadership competency framework Domain Systems thinking

Competency 1. 2. 3. 4. 5. 6. 7.

Understand current public health issues and engage in systemic change to address them. Synthesize and integrate divergent viewpoints for the good of an organization. Understand reflective leadership and demonstrate that all leadership begins from within. Facilitate the development of servant leadership capacity including selflessness, integrity and perspective mastery. Recognize the relevance of adaptive leadership and use it in the appropriate circumstances. Recognize the relevance of leading from behind and use this in the appropriate circumstances. Identify opportunities for growth, innovation, change and development of the organization.

Political leadership

8. 9. 10. 11. 12. 13. 14. 15.

Foresee potential impacts and consequences of decision-making in both internal and external situations. Understand and apply effective techniques for working with boards and governance structures. Evaluate and determine appropriate actions regarding critical political issues. Promote the European and national public health agenda. Translate broad strategies into practical terms for others. Build alliances, partnerships, and coalitions to improve the health of the community or population being served. Identify and engage stakeholders in interdisciplinary projects to improve public health. Advocate and participate in public health policy initiatives at the local, national and/or international levels.

Collaborative leadership: building and leading interdisciplinary teams

16. Provide an environment conductive to opinion sharing. 17. Model effective group process behaviours including listening, dialoguing, negotiating, rewarding, encouraging, and motivating. 18. Model effective team leadership traits including integrity, credibility, enthusiasm, commitment, honesty, caring, and trust. 19. Understand and manage expectations. 20. Offer opportunities for collaborative learning and quality improvement.

Leadership and communication

21. 22. 23. 24.

Leading change

28. 29. 30. 31. 32. 33.

Emotional intelligence and leadership in team-based organizations

34. Demonstrate awareness of the impact of your own beliefs, values, and behaviours on your own decision-making and the reactions of others. 35. Demonstrate empathy and concern for people as individuals while ensuring that organizational goals and objectives are met. 36. Be aware of the impact of your own behaviours and reactions on the behaviours and reactions of others. 37. Demonstrate personal responsibility and accountability for the achievement of a given task. 38. Respond appropriately to the positive criticism of others about your own behaviour or performance. 39. Demonstrate resilience and the ability to call upon personal resources and energy at times of threat or challenge.

Leadership, organizational learning and development

40. 41. 42. 43. 44. 45. 46.

Ethics and professionalism

47. Adhere to ethical legal and regulatory standards. 48. Encourage a high level of commitment to the purposes and values of the organization. 49. Make a clear declaration of any conflict of interest that is likely to affect your leadership or decision-making and take appropriate action to minimize this. 50. Respect diverse cultures and build upon the strength of diversity to bring about innovation and added value in the work environment. 51. Practice and promote professional accountability and social responsibility. 52. Actively work towards reducing inequalities in access to public health.

Demonstrate effective written and oral communication, and presentation skills. Recognize and use non-verbal forms of communication when putting across your own perspective on a situation. Effectively share information and responsibility at different organizational levels in pursuit of population-based goals. Use the media to communicate routinely with target audiences regarding public health needs, objectives, accomplishments, and critical crises-related information. 25. Share views in a non-judgmental, non-threatening way. 26. Exercise the sensitivity needed to communicate with diverse cultures and disciplines. 27. Effectively use negotiation skills to mediate disputes and find appropriate and workable solutions. Facilitate reassessment and adaptation of mission to match vision. Manage staff to effectively deal with change. Serve as a driving force for change, including strategies of change. Make strategic decisions based on recognized values, priorities and resources. Identify and communicate new system structures as needs are identified and opportunity arises. Ensure that organizational practices are aligned with changes in the public health system and the larger social, political, and economic environment.

Foster an environment of trust. Develop and mentor potential future leaders within the organization. Advocate for learning opportunities within the organization. Create and communicate a shared vision for the future and inspire team members to achieve it. Encourage others to feel ownership in the public health mission in the organization. Assist others to clarify thinking, create consensus, and develop ideas into actionable plans. Offer opportunities for collaborative learning and quality improvement.

the contrary, our framework promotes a collaborative and shared leadership and embraces specific public health leadership attributes such as the ability to identify and engage stakeholders in interdisciplinary projects to improve public health; to ensure that organizational practices are aligned with changes in the public health system and the larger social, political and economic environment and ability to build alliances, partnerships and coalitions to improve the health

of the community or population being served. We hope that this framework will help develop the public health leaders of tomorrow, ‘social entrepreneurs who are willing to take the risk and spot an opportunity and go for it’.2 Given that other leadership frameworks appear to be focused on a heroic model of improving the strategic thinking of senior leaders and in view of a recent public health leadership debate featured in the Lancet,29–31 the public health

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leadership competency framework, especially developed to support CBE and training of modern public health leaders, can serve as a useful tool in the process of shifting the focus to a more collaborative, shared leadership style, which is appropriate for leading teams containing a variety of disciplinary specialists working across organizational boundaries. It can also contribute to the development of ‘adaptive leadership: leading in contexts where there is considerable uncertainty and ambiguity, and where there is often imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it’.32

Figure 1 Public health leadership competency framework model

Leadership is still not common in most public health training programmes29 at undergraduate, postgraduate and continuing professional development (CPD) level, which is confirmed by the results of the recent ASPHER Survey.33 Given the increasing debate on the importance of leadership in public health, public health education in Europe can be thought of as behind the times. Faced with the current need to develop Public Health leaders, providers of public health education should consider incorporating leadership into public health curricula and widening the offer by offering a PhD track in public health leadership. The competency framework developed in this study could provide a helpful resource for them to do so. The public health leadership competency framework has been developed in a systematic manner using qualitative approaches like consensus building panels and Delphi technique, which are very useful in identifying key competences and themes, but they preclude firm conclusions and have limited representativeness.34 It should be noted that some researchers regard Delphi and other consensus building techniques as methods of ‘last resort’, as they rely on the opinions of a group rather than direct scientific evidence.35 Moreover, consensus building based on WGIGP participants may bias or restrict the results to particular educational contexts of its members. There is also the risk that in our desire to obtain consensus, we may have given insufficient attention to the dissenting voice. We note that our interpretations of the leadership competencies in public health were dependent on the model of analysis of our data and, therefore, reflect the views and concerns of the experts involved. From this perspective, their views about health care management and leadership may have not been neutral, but rather based on their own concepts, constructions of the role of leadership in public health. Application and evaluation of the framework are the next steps in our on-going efforts.

Figure 2 Relation of competency domains to the sessions in the curriculum

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Conclusion

10 ASPHER. Provisional Lists of Public Health Core Competencies. Brussels: Association of Schools of Public Health in the European Region, 2008.

Eight thematic groups of competencies were finally agreed on covering various aspects of public health leadership including systemic, political, change, organizational learning and communication issues. Despite some limitations, we believe that the framework can serve as a useful tool in identifying gaps in knowledge and skills, and shaping adequate competency-based CPD curricula for public health professionals in Europe and beyond if we take into account the specific contexts of public health systems.

11 Birt C. Towards a European Framework for Public Health Competencies. Paper presented at the Impact of EU Accession on Public Health, Croatia, Andrija Stampar School of Public Health, 2011. Available at: http://www.epha.org/a/4373 (5 October 2013, date last accessed).

Acknowledgements The authors thank colleagues and partners from the LEPHIE project, members of the ASPHER’s WGIGP for reviewing the competencies as a part of a Delphi survey and Ms Esther Slits and Ms Amanda Potter for the support in the review process.

Funding This study was supported by the European Commission Lifelong Learning Programme in the framework of ERASMUS Multilateral Curriculum Development project: LEPHIE. Project n 510176-LLP1-2010-1-NL-ERASMUS-ECDCE. This publication reflects the views only of the authors, and the Commission cannot be held responsible for any use that may be made of the information contained herein. Conflicts of interest: None declared.

Key points  The public health leadership competency framework can serve as a useful tool in identifying gaps in knowledge and skills, and shaping adequate competency-based CPD curricula for public health professionals.  The study is an important attempt to define profile and position public health leadership through the systematically developed, comprehensive and multidisciplinary competency framework.  The framework can be used by public health professionals as a tool for self-assessment and personal development planning.

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......................................................................................................... European Journal of Public Health, Vol. 24, No. 5, 856–861 ß The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckt132 Advance Access published on 12 September 2013

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The impact of the HDI on the association of psychosocial work demands with sickness absence and presenteeism Johanna Muckenhuber1, Nathalie Burkert1, Thomas E. Dorner2, Franziska Großscha¨dl1, Wolfgang Freidl1 1 Department of Social Medicine and Epidemiology, Medical University Graz, Universita¨tsstr. 6/1, A-8020 Graz, Austria 2 Center for Public Health, Medical University Vienna, Wa¨hringer Straße 13a/3.Stock, A-1090 Wien, Austria Correspondence: Johanna Muckenhuber, Department of Social Medicine and Epidemiology, Medical University Graz, Universita¨tsstr. 6/1, A-8010 Graz, Austria, Tel: +43 316 380 7762, Fax: +43 316 380 9665, e-mail: [email protected]

Background: The purpose of this study was to determine whether psychosocial work demands have a different impact on sickness absence and presenteeism in countries with a high vs. countries with a low Human Development Index (HDI). Methods: This article is based on an analysis of the fifth European Working Conditions Survey. We investigated single items as well as complex constructs and indices. Sickness absence and presenteeism were measured as outcome variables. Following the model of Karasek and Theorell, we measured the HDI at the macro level and psychosocial job demands at the micro level as independent variables. Results: The multivariate multilevel analysis reveals a significant association between the HDI and the number of days recorded for sickness absence. In countries with a higher HDI, people report a lower number of days with sickness absence. Higher psychosocial job demands are associated with poorer health. There are significant cross-level interaction effects between psychosocial job demands and the HDI for these associations. Psychosocial job demands are stronger associated with sickness absence and presenteeism in high-HDI than in low-HDI countries. Conclusions and implications for public health: We argue that Public Health Actions that are connected to work characteristics need to take into consideration the level of HDI of the countries. In low- and high-HDI countries, different actions could be necessary to reach the needs of the working population.

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Introduction Purpose The purpose of this study was to determine whether psychosocial work demands have a different impact on health in countries with a high compared with countries with a low Human Development Index (HDI). The HDI is a composite index that measures the years of schooling and expected years of schooling, life expectancy at birth and the gross national income per capita.1,2 The HDI measures human progress and quality of life at the global level and is used for comparison of governmental policies, among others regarding health care and education.3 Economic resources are known to be important determinants of health.4,5 Additionally, a high level of economic and social development is known to be positively related to individual and collective health.6–9 However, research has found differing results when considering associations between HDI and health. It has been reported that in regions with a low HDI compared with a high HDI, there is a higher prevalence

of major depressive episodes,10 a higher occurrence of sleep complaints,11 a higher rate of infant mortality12 and a higher mortality to incidence rate in kidney cancer.13 Shah presents a curvilinear relationship between HDI and elderly suicide rates, with low rates in very low-HDI and in very high-HDI countries.14 The demand/control model of Karasek and Theorell15 assumes a negative impact on health from psychological and physical job demands, but a positive impact on health from decision latitude. Research supports these assumptions. Negative effects on health16,17 have been attributed to psychosocial job demands, and associations between Karasek’s job demands and psychological distress have been reported.18,19 Haeusser et al. state that job demands and job control are mostly associated with psychological well-being.17 There is contradictory evidence about the effect job strain—a combination of high job demands and low job control15 —has on physical health and health behaviour. For example, no association was found between job strain and breast cancer, but women with a higher level of job strain showed a lower attendance of breast cancer screening.20 It is thought that an interaction exists between job