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01.12.2015 | Research article | Ausgabe 1/2015 Open Access

BMC Public Health 1/2015

Psychosocial job conditions, fear avoidance beliefs and expected return to work following acute coronary syndrome: a cross-sectional study of fear-avoidance as a potential mediator

BMC Public Health > Ausgabe 1/2015
Mia Söderberg, Annika Rosengren, Sara Gustavsson, Linus Schiöler, Annika Härenstam, Kjell Torén
Wichtige Hinweise

Competing interests

We declare that we have no financial or non-financial competing interests.

Authors’ contribution

The final manuscript has been read by all co-authors, which also have met all requirements for authorship according to the following: MS has drafted the manuscript, coordinated the data collection process, and carried out statistical analyses and interpretation of data. AR has contributed to the data collection, especially in designing the content of questionnaire, interpretation of data and reviewing the manuscript. SG contributed with statistical knowledge, especially regarding the mediator analyses and reviewed the manuscript. LS contributed with interpretation of data and reviewing the manuscript. AH has made substantial contributions in reviewing the manuscript and interpretation of data, especially regarding gender aspects and the concept of attribution towards adverse events. KT has made substantial contributions to collection of data, study design, interpretation of data and drafting of the manuscript. All authors read and approved the final manuscript.



Despite improvements in treatment, acute coronary syndrome remains a substantial cause for prolonged sick absences and premature retirement. Knowledge regarding what benefits return to work is limited, especially the effect of psychological processes and psychosocial work factors. The purposes of this cross-sectional study were two-fold: to examine associations between adverse psychosocial job conditions and fear-avoidance beliefs towards work, and to determine whether such beliefs mediated the relationship between work conditions and expected return to work in acute coronary syndrome survivors.


Study inclusion criteria: acute myocardial infarction or unstable angina diagnosis, below 65 years of age, being a resident in the West county of Sweden and currently working. In all, 509 individuals (21.8 % women) accepted study participation and for whom all data of study interest were available for analysis. Psychosocial work variables; job demand-control and effort-reward imbalance, were assessed with standard questionnaire batteries. Linear regression models were used to investigate relationships between psychosocial factors and fear-avoidance, and to evaluate mediator effects for fear-avoidance. Both total sample and gender stratified analyses were calculated.


Fear-avoidance beliefs about work were associated to psychosocial job environments characterized by high strain (β 1.4; CI 1.2–1.6), active and passive work and high effort-reward imbalance (β 0.6; CI 0.5–0.7). Further, such beliefs also mediated the relationship between adverse work conditions and expected time for return to work. However, these results were only observed in total sample analyses or among or male participants. For women only high strain was linked to fear-avoidance, and these relationships became non-significant when entering chosen confounders.


This cross-sectional study showed that acute coronary syndrome survivors, who laboured under adverse psychosocial work conditions, held fear-avoidance beliefs towards their workplace. Furthermore, these beliefs mediated the relationships between - high strained or high effort-reward imbalanced work - and expected return to work. However, mentioned results were primarily found among men, which could results from few female study participants or gender differences in return to work mechanisms. Still, an earlier return to work might be promoted by interventions focusing on improved psychosocial work conditions and cognitive behavioural therapy targeting fear-avoidance beliefs.
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