ORIGINAL ARTICLE
Improvement of the Work Environment and Work-Related Stress
A Cross-Sectional Multilevel Study of a Nationally Representative Sample
of Japanese Workers
Kazuhiro Watanabe, MA, Takahiro Tabuchi, MD, PhD, and Norito Kawakami, MD, PhD
Objective: This cross-sectional multilevel study aimed to investigate
the relationship between improvement of the work environment and
work-related stress in a nationally representative sample in Japan.
Methods: The study was based on a national survey that randomly sampled
1745 worksites and 17,500 nested employees. The survey asked the work-
sites whether improvements of the work environment were conducted; and it
asked the employees to report the number of work-related stresses they
experienced. Multilevel multinominal logistic and linear regression analyses
were conducted. Results: Improvement of the work environment was not
significantly associated with any level of work-related stress. Among men, it
was significantly and negatively associated with the severe level of work-
related stress. The association was not significant among women.
Conclusions: Improvements to work environments may be associated with
reduced work-related stress among men nationwide in Japan.
W ork-related stress (ie, stress caused by a hazardous psycho-
social work environment) has been identified as an occu-
pational determinant of the physical and mental health of
workers.1,2 Improvement of the work environment is known to
be an effective preventive measure for improving work-related
stress among workers.3 Improvements target a wide range of task
characteristics, work conditions, and social conditions4 –8 including
major psychosocial work environment components. These com-
ponents can include job demands and controls,9 social supports,10
effort-reward imbalance,11 and other organizational-level factors.
Improvement of the work environment has also become a major
strategy in occupational health to improve work-related stress of
workers, in guidance by the World Health Organization (WHO)/
International Labour Organization,12,13 in regulations by European
countries,14,15 and recently by Japan.16
A positive effect of improving the work environment on
reducing work related stress has been identified in several system-
atic reviews17,18 and well-designed randomized controlled
trials.19,20 On the other hand, the effect was unclear or inconsistent
in many other studies.4,21,22 In reality, intervention programs to
improve the work environment have often failed or been derailed
due to many possible processes and contextual issues.23–25 For
instance, intervention programs may not be effectively implemented
From the Department of Mental Health, Graduate School of Medicine, The
University of Tokyo (Mr Watanabe, Dr Kawakami); Japan Society for the
Promotion of Science (Mr Watanabe); Center for Cancer Control and
Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases,
Osaka (Dr Tabuchi), Japan.
Funding sources: The present study was supported by the Health and Labor
Sciences Research Grant 2015–2017 (H27-Rodo-Ippan-004) from the Min-
istry of Health, Labour and Welfare, Japan. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the
manuscript.
Kazuhiro Watanabe, Takahiro Tabuchi, and Norito Kawakami declare no conflict
of interest in connection with the paper.
Address correspondence to: Norito Kawakami, MD, PhD, 7-3-1 Hongo, Bunkyo-
ku, Tokyo 113-0033, Japan (nkawakami@m.u-tokyo.ac.jp).
Copyright ß 2017 American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0000000000000950
JOEM  Volume 59, Number 3, March 2017
Copyright © 2017 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
as initially designed due to a lack of resources, manpower, and
worker participation.26
Moreover, one approach to improvement may not fit everyone,
which could decrease the effect of a general approach on some
subgroup populations. One such subgroup is women. Studies often
fail to show how improving the work environment effects mental
health outcomes in workplaces or occupations where women are
dominant.27–33 One study, which investigated the effect of improve-
ment of the work environment separately for men and women
reported a lower effect among women.33 If it is found in the current
study that the improvement of the work environment is not effective in
reducing work-related stress, or if a particular subgroup receives less
benefit from it, then this would be an opportunity to rethink a national
strategy to improve work environments. Therefore, the effectiveness
of improving the work environment on work-related stress should be
monitored by surveying a national sample of worksites and employ-
ees, focusing on some important subgroups, such as sex.
In this study, we aimed to investigate the relationship
between improving the work environment and work-related stress
(ie, strong anxiety, worry, and distress related to work and work
life), in a nationally representative sample of worksites and employ-
ees in Japan. To the best of our knowledge, this is the first study to
monitor the effectiveness of improving the work environment on
work-related stress at the national level. We investigated the associ-
ation between the improvement of the work environment and the
prevalence of work-related stress by analyzing a national survey
database, adjusting for other types of measures of worker mental
health. We also investigated a possible subgroup difference in the
effectiveness, focusing on sex.
METHODS
Design and Setting
This was a cross-sectional study, based on a national, popu-
lation-based ‘‘Survey on State of Employees’ Health’’ conducted by
the Japanese Ministry of Health, Labour and Welfare (MHLW) in
December, 2012. This survey was conducted every 5 years in order
to obtain useful background data for occupational health adminis-
tration.34,35 Worksites were randomly sampled based on the national
database of worksites, and stratified by worksite scale and industry,
from all 47 prefectures in Japan. Employees who were engaged in
these worksites were then sampled using a multistage sampling
method. Our study is reported according to Strengthening the
Reporting of Observational studies in Epidemiology (STROBE).36
Data were used with permission from the MHLW.
Worksites and Employees
A total of 13,332 worksites and 17,500 employees were
recruited for the survey. Of these worksites, 11,587 (86.9%) were
surveyed only regarding worksite-level information. In the remain-
ing 1745 worksites (13.1%), 17,500 employees were surveyed.
Eligibility criteria of the worksites were (a) registered worksites,
which were categorized under any industry of the ‘‘Japan Standard
Industrial Classification,’’37 and (b) worksites that employed at least
10 employees (excluding public offices). The eligibility criteria of
295
 Watanabe et al
employees were (a) employees who worked in the sampled work-
sites, and (b) full-time or dispatched employees. There were no
exclusion criteria among either worksites or employees. First,
worksite-level questionnaires were sent to those responsible for
‘‘industrial safety and health’’ at the worksites. Second, individual
employees were randomly sampled from the same worksites as were
sampled initially, and were asked to respond to employee-level
questionnaires. For the employee-level data collection, the number
of employees sampled depended on the number employed at the
worksites (5, 10, 15, or 20 employees were sampled from worksites
employing 10 to 29, 30 to 299, 300 to 499, or more than or equal to
500 employees, respectively). The MHLW calculated the survey
weights to represent the total population of Japanese employees,
accounting for non-responses, and sampling probability.38
Variables and Measurements
We measured whether the worksites conducted improvements
of the work environment as an exposure variable, employee-level
work-related stress as an outcome variable, and other confounding
factors as covariates. All variables were measured by self-reported
questionnaires by company representatives (usually human resource
personnel) of the worksites or the employees.
Improvement of the Work Environment
Each worksite representative was asked if his/her worksite
conducted any measure for the mental health of employees. If he/she
responded positively, then he/she was further asked about the
improvements. Improvement of the work environment was measured
by asking a dichotomous question in the worksite-level questionnaire:
‘‘Does your worksite conduct assessment and improvements of the
work environment?’’ When the company representative chose
the ‘‘yes,’’ the company was coded as conducting improvements of
the work environment. Improvement of the work environment could
include organizational-level interventions at work, such as changing
material conditions (eg, vibrations, noise, chemical substances, or
ergonomics), time-related conditions (eg, work speed, shifts, dead-
lines, pace of work, or breaks), psychosocial factors, and processes
and procedures of work (eg, methods of work, order of tasks, team
organization, or structure of the hierarchy).4
Work-Related Stress
Each employee was asked if he/she had any work-related
stress: ‘‘Do you feel strong anxiety, worry, and distress related to
your work and work life?’’ If he/she agreed, he/she was then asked
to choose up to three items from a list of 11 items of cause-specific
work-related stress: (1) qualitative workload, (2) quantitative work-
load, (3) suitability for work, (4) human relationships in the work-
place, (5) promotion and salary increase, (6) personnel reshuffling,
(7) stability of employment, (8) future prospects of the company, (9)
job after retirement and old age, (10) experience with accidents and
disasters, and (11) other. The number of work-related stresses was
used as outcomes: 0 (none), 1 (one), 2 (two), 3 (three). Although the
limit on the number was three, respondents who selected three types
of stress might have had more than three items; in fact, some
employees went against the instructions and chose more than three
kinds of work-related stress. Our interpretation was that respondents
with three or more types of work-related stresses had a severe level
of work-related stress because individuals who suffered from
multiple sources of work-related stress were supposed to have a
greater risk of mental and physical problems, as the iso-strain model
suggests that the combination of multiple work-related stressors
causes health problems.10
Covariates
As worksite-level confounders, we measured worksite scale,
industry, and other mental health measures at the worksites. Worksite
296 ß 2017 American College of Occupational and Environmental Medicine
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JOEM  Volume 59, Number 3, March 2017
scale was measured as the ordinal variable, classified into seven
categories (10 to 29, 30 to 49, 50 to 99, 100 to 299, 300 to 999,
1000 to 4999, and more than or equal to 5000 employees). The
measurement of industry was based on the ‘‘Japan Standard Industrial
Classification,’’37 classified into 20 categories. Because worksites that
conducted improvements of their work environments could also adopt
other approaches for improving work-related stress, other mental
health measures at the worksites were measured using 15 dichotomous
items. The responsible persons at the worksites indicated which, if any,
of the following items their worksites conducted: (1) location of the
safety and health committee for mental health care, (2) planning and
action for solutions to mental health problems, (3) selection of persons
who were responsible for mental health care, (4) educating and
giving information to employees, (5) educating and giving infor-
mation to managers, (6) educating and giving information to health
care staff at the worksites, (7) mental health care during consul-
tation after a health checkup, (8) facilitation of the off-site oppor-
tunities for mental health care, (9) facilitation of the on-site
opportunities for mental health care, (10) stress check using
questionnaires, (11) support for sick leave employees to return
to work, (12) mental health care utilizing community occupational
health centers, (13) mental health care utilizing prefectural occu-
pational health promotion centers, (14) mental health care utilizing
medical institutions, and (15) mental health care utilizing other
off-site institutions.
As employee-level confounders, sex, age, employment status
(regular, contract, part-time, dispatched, and daily), job type, shift type
(day, night, rotation shift, alternate, and others), and working hours per
day were measured. Job type was broken into seven categories, (1)
sales, (2) services, (3) transport or operation, (4) stationary, construc-
tion, or wrapping, (5) security, (6) management, and (7) other.
Analysis
A multilevel multinominal logistic regression analysis39
was conducted because of the two-level information and hier-
archical data in this study. We used a sample which consisted of
employees nested in worksites, and data which consisted of
worksite-level and employee-level information. If we had applied
conventional regression analyses for worksite-level variables, we
would have not kept the assumption of independency of sampling
data.40 We transformed individual work-related stress into four
categories based on the number of work-related stresses chosen,
and used this as the outcome: 0 (none), 1 (one), 2 (two), 3 (three).
Of the covariates, each confounding variable was transformed
into a dummy variable, except for other mental health measures
at the worksites: worksite scale (10 to 49 [reference group]),
industry (manufacturing [reference group]), sex (men [reference
group]), age (less than or equal to 29 [reference group]), employ-
ment status (regular [reference group]), job type (not manager
[reference group]), shift type (daytime [reference group]),
and working hours per day (less than 8 [reference group]).
Other mental health measures at the worksites were transformed
into a numerical variable—the number of kinds of mental
health measures.
We estimated an unconditional model (model 1), a crude
conditional model (model 2), and an adjusted conditional model
(model 3) in the analysis. An equation for the adjusted conditional
model (model 3) was explained as follows.
Level 1 (employee-level)
  !
Prob R i j ¼ m
log   ¼ hmi j
Prob R i j ¼ 0½none
¼ b0 jðmÞ þ b1 jðmÞ  ðWomenÞij þ b2 jðmÞ  ðAge 3039Þij þ b3 jðmÞ
ðAge 4049Þij þ b4 jðmÞ ðAge 5059Þij þb5 jðmÞ  ðAge  60Þij þ b6 jðmÞ
ðNot regular employmentÞij þ b7 jðmÞ  ðManagerÞij þ b8 jðmÞ
ðNot daytime shiftÞij þ b9 jðmÞ  ðWorking hours 810Þij þ b10 jðmÞ
ðWorking hours  10Þij
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Level 2 (worksite-level)
b0 j ¼ g 00ðmÞ þg 01ðmÞ  ðWorksite scale 5099Þj þ g 02ðmÞ  ðWorksite scale 100299Þj
þg 03ðmÞ  ðWorksite scale 300999Þj þ g 04ðmÞ  ðWorksite scale  1;000Þj
þg 05ðmÞ  ðIndustry serviceÞj þ g 06ðmÞ  ðIndustry othersÞj þ g 07ðmÞ
ðthe N of other mental health measuresÞj þ g 08ðmÞ
ðimprovement of the work environmentÞj þ m0 jðmÞ

bq jðmÞ ¼ g q0ðmÞ;
   
mo j½m e N 0; t 00½m

m ¼ 1 (one), 2 (two), 3 (three). q ¼ 1. . .10.

In addition to the multilevel multinominal logistic

regression analysis, we conducted a multilevel hierarchical linear
modeling analysis39 as a sensitivity analysis, treating the number of
work-related stresses as a continuous variable (0, 1, 2, 3). The
equation for the adjusted conditional model (model 3) was as
follows.
Level 1 (employee-level)
g i j ¼ b0 j þ b1 j  ðWomenÞij þ b2 j  ðAge 30  39Þij þ b3 j  ðAge 4049Þij þ b4 j
ðAge 50  59Þij þ b5 j  ðAge  60Þij þ b6 j  ðNot regular employmentÞij
þb7 j  ðManagerÞij þ b8 j  ðNot daytime shiftÞij þ b9 j
ðWorking hours 810Þij þ b10 j  ðWorking hours  10Þij þ ei j

Level 2 (worksite-level)
b0 j ¼ g 00 þ g 01  ðWorksite scale 5099Þj þg 02 ðWorksite scale 100299Þj þg 03
ðWorksite scale 300  999Þj þg 04  ðWorksite scale  1;000Þj þ g 05
ðIndustry serviceÞJ þ g 06  ðIndustry othersÞj þ g 07
ðthe N of other mental health measuresÞj þ g 08
ðimprovement of the work environmentÞj þ m0 j

bq j ðmÞ ¼ g q0 ðmÞ;
q ¼ 1:::10
ðmo j ½mÞ  N ð0; t 00 ½mÞ

We also conducted subgroup analyses stratified by sex

(men and women). Estimated models were the same as those of
the total sample, except for sex as the covariates in the adjusted
conditional models. The worksites and employees that had
missing values were excluded from each analyzed model. We
described the number of missing samples on all variables used in
the analyses in descriptive statistics. We used Mplus version 7.4
(Los Angeles, CA)41 for each analysis.
RESULTS
Characteristics of Worksites and Employees
Figure 1 shows a participant flowchart. Of the recruited
worksites and employees, 1033 worksites (response rate: 59.2%)
and 9915 employees who were nested in these worksites (response
rate: 56.7%) completed and returned the questionnaires. We
excluded seven worksites that nested only one employee in each
worksite because they were not considered to be appropriate for the
multilevel analyses. Therefore, we analyzed a total of 9908 employ-
ees (6356 men and 3552 women) nested in 1026 worksites. The
number of the nested employees per worksites ranged from 2 to 20
(M ¼ 10.0, standard deviation [SD] ¼ 4.6).
Table 1 shows descriptive statistics of worksites and employ-
ees. Of the worksite-level variables, 200 (19.5%) worksites con-
ducted improvements to their work environment. Regarding the
individual outcome, a total of 3856 (38.9%) employees did not feel
any work-related stress related to their work and work life. Among
employees who had any kind of work-related stress, those who
had three kinds of work-related stress were the most frequent
(28.6%), both in men (30.1%) and women (26.0%). When we
FIGURE 1. A flowchart of worksites and employees. Note. Nj:
the number of worksites, Ni: the number of employees.
treated work-related stress as the continuous variable, mean
scores of the number of work-related stress were 1.36  1.26 in
the total sample, and 1.39  1.27 and 1.32  1.23 in men and
women, respectively. There were no missing values on the work-
site-level variables, but there were eight missing cases on shift
type and 13 missing cases on working hours. These 21 cases were
excluded from the estimation of the adjusted conditional model in
the multilevel analyses.
Multilevel Multinominal and Linear
Regression Analyses
Table 2 shows the relationships between work environment
improvements and work-related stress in the multilevel multinomi-
nal logistic regression analysis, in the crude conditional model
(model 2) and in the adjusted conditional model (model 3). At
first, we estimated the unconditional variances (t00) of intercepts
(g00) of work-related stress (model 1). Variances of the uncondi-
tional model for one, two, and three were 0.07 (95%CI, 0.02,
0.15), 0.08 (95%CI, 0.02, 0.14), and 0.34 (95%CI, 0.25, 0.43),
respectively. In the crude conditional model (model 2), improve-
ment of the work environment had slightly negative, but not
significant, relationships with the number of kinds of work-related
stress among all groups, compared with the employees who had no
work-related stress (Exp [g] ¼ 0.98 for one, Exp [g] ¼ 0.99 for two,
Exp [g] ¼ 0.99 for three). The adjusted conditional model (model 3)
did not indicate the significant relationships either (Exp [g] ¼ 0.94

ß 2017 American College of Occupational and Environmental Medicine 297

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 Watanabe et al JOEM  Volume 59, Number 3, March 2017

TABLE 1. Characteristics of Worksites (N ¼ 1026) and Employees (N ¼ 9908)

Worksite–Level Variables N % Mean SD Missing (%)

Worksite scale 0 (0.0%)

10–49 (REF) 293 28.6 – –
50–99 (scale 1) 97 9.5 – –
100–299 (scale 2) 158 15.4 – –
300–999 (scale 3) 149 14.5 – –
1000 (scale 4) 329 32.1 – –
Industry 0 (0.0%)
Manufacturing (REF) 291 28.4 – –
Services (industry 1) 191 18.6 – –
Others (industry 2) 544 53.0 – –
Improvement of the work environment 0 (0.0%)
No (REF) 826 80.5 – –
Yes 200 19.5 – –
The number of other mental health measures conducted at the worksites – – 3.70 4.01 0 (0.0%)

N (%)
Employee—Level Variables Total (N ¼ 9908) Men (N ¼ 6356) Women (N ¼ 3552) Missing (%)

Age group 0 (0.0%)

29 yrs (REF) 1,752 (17.7) 965 (15.2) 786 (22.1)
30–39 yrs 2,721 (27.5) 1,738 (27.3) 983 (27.7)
40–49 yrs 2,823 (28.5) 1,859 (29.3) 964 (27.1)
50–59 yrs 1,953 (19.7) 1,329 (20.9) 624 (17.6)
60 yrs 660 (6.6) 465 (7.3) 195 (5.5)
Employment status 0 (0.0%)
Regular (REF) 7,980 (80.5) 5,728 (90.1) 2,252 (63.4)
Not regular 1,928 (19.5) 628 (9.9) 1,300 (36.6)
Job type 0 (0.0%)
Not manager (REF) 8,025 (81.0) 4,643 (73.1) 3,382 (95.2)
Manager 1,883 (19.0) 1,713 (27.0) 170 (4.8)
Shift type 8 (0.1%)
Daytime (REF) 8,797 (88.8) 5,577 (85.3) 3,220 (93.5)
Not daytime shift 1,103 (11.1) 776 (11.9) 327 (9.2)
Working hours per day 13 (0.1%)
<8 hr (REF) 3,850 (38.9) 1,937 (30.5) 1,913 (53.9)
8–10 hr 4,956 (50.0) 3,492 (54.9) 1,464 (41.2)
10 hr 1,089 (11.0) 920 (14.5) 169 (4.8)
Work-related stress 0 (0.0%)
None (REF) 3,856 (38.9) 2,475 (38.9) 1,381 (38.9)
One 1,425 (14.4) 861 (13.6) 564 (15.9)
Two 1.790 (18.1) 1,105 (17.4) 685 (19.3)
Three 2,837 (28.6) 1,915 (30.1) 922 (26.0)
Work-related stress as the continuous variable M ¼ 1.36 (SD ¼ 1.26) M ¼ 1.39 (SD ¼ 1.27) M ¼ 1.32 (SD ¼ 1.23)

REF, reference group in the analyses; SD, standard deviation.


Respondents who had three types of work-related stress were interpreted as those having severe level of stress.

for one, Exp [g] ¼ 0.91 for two, Exp [g] ¼ 0.93 for three). The
number of other mental health measures was not significantly
associated with work-related stress among the total sample (Exp
[g] ¼ 1.00 for one, Exp [g] ¼ 1.00 for two, Exp [g] ¼ 1.00 for three).
Excluding this variable from the model did not alter the findings: the
associations between improvement of work environment and work-
related stress were non-significant (Exp [g] ¼ 0.96 [95%CI, 0.82,
1.12] for one, Exp [g] ¼ 0.93 [95%CI, 0.79, 1.10] for two, Exp
[g] ¼ 0.94 [95%CI, 0.80, 1.11] for three) (data available upon
request).
Table 3 shows results of the sensitivity analysis, treating
work-related stress as a continuous variable. In the unconditional
model (model 1), a random effect of the intercepts (t00) of work-
related stress was significant (t00 ¼ 0.15, 95%CI, 0.12, 0.18,
P < 0.001). In the crude conditional model (model 2), improvement
of the work environment showed a non-significant association with
the number of work-related stress (g08 ¼ 0.01, 95%CI, 0.08, 0.09,
P ¼ 0.889). The adjusted conditional model (model 3) also indicated
a slightly negative, but non-significant relationship (g08 ¼ 0.04,
95%CI, 0.13, 0.06, P ¼ 0.452).
The subgroup analyses on stratified sex indicated different
results from that of the total sample (Table 4). Among 6356 men
nested in 986 worksites, improvement of the work environment
showed a significant and negative association with having three or
more kinds of work-related stress (Exp [g] ¼ 0.83, 95%CI, 0.70,
0.98, P ¼ 0.032 in the crude conditional model [model 2]; Exp
[g] ¼ 0.80, 95%CI, 0.65, 0.99, P ¼ 0.036 in the adjusted conditional
model [model 3]). The number of other mental health measures was
not significantly associated with work-related stress (Exp [g] ¼ 1.00
for one, Exp [g] ¼ 1.00 for two, Exp [g] ¼ 1.00 for three). Excluding
the variable from the model did not alter the findings: the associ-
ations between improvement of work environment and work-related
stress were not significant (Exp [g] ¼ 0.91 [95%CI, 0.77, 1.09] for
one, Exp [g] ¼ 0.91 [95%CI, 0.75, 1.10] for two, Exp [g] ¼ 0.81

298 ß 2017 American College of Occupational and Environmental Medicine

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 JOEM  Volume 59, Number 3, March 2017 Improvement of the Work Environment and Stress

TABLE 2. Relationships Between Improvement of the Work Environment and Work-Related Stress Among Employees (Total
Sample)
Model 2 (Crude Conditional Model) Nj ¼ 1026, Ni ¼ 9908 Model 3 (Adjusted Conditional Model) Nj ¼ 1026, Ni ¼ 9887

For One (Compared For Two (Compared For Three (Compared For One (Compared For Two (Compared For Three (Compared
With None) With None) With None) With None) With None) With None)

Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI)

Employee–level
Gender
Men – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
Women (g10) – – – 1.33 (1.16, 1.54) 1.30 (1.14, 1.49) 1.07 (0.94, 1.21)
Age group
29 yrs – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
30–39 yrs (g20) – – – 1.11 (0.93, 1.33) 1.28 (1.07, 1.54) 1.29 (1.10. 1.52)
40–49 yrs (g30) – – – 1.09 (0.90, 1.32) 1.44 (1.20, 1.72) 1.51 (1.28, 1.77)
50–59 yrs (g40) – – – 0.99 (0.80, 1.21) 1.30 (1.07, 1.58) 1.15 (0.96, 1.37)
60 yrs (g50) – – – 0.81 (0.60, 1.09) 0.64 (0.46, 0.87) 0.45 (0.34, 0.60)
Employment status
Regular – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
Not regular (g60) – – – 0.87 (0.72, 1.05) 0.89 (0.75, 1.05) 0.83 (0.70, 0.98)
Job type
Not manager – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
Manager (g70) – – – 1.11 (0.93, 1.32) 0.90 (0.77, 1.06) 0.92 (0.80, 1.06)
Shift type
Daytime – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
Not daytime (g80) – – – 1.15 (0.93, 1.42) 1.22 (1.00, 1.49) 1.27 (1.07, 1.52)
Working hours per day
<8 hr – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
8–10 hr (g90) – – – 1.13 (0.98, 1.31) 1.32 (1.15, 1.51) 1.45 (1.28, 1.65)
10 hr (g100) – – – 1.72 (1.34, 2.20) 2.27 (1.83, 2.81) 3.23 (2.65, 3.94)
Worksite–level
Worksite scale
10–49 – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
50–99 (g01) – – – 1.08 (0.82, 1.42) 1.12 (0.83, 1.51) 1.25 (0.96, 1.63)
100–299 (g02) – – – 1.11 (0.86, 1.42) 1.41 (1.10, 1.80) 1.25 (1.00, 1.57)
300–999 (g03) – – – 1.05 (0.83, 1.34) 1.44 (1.14, 1.82) 1.11 (0.88, 1.40)
 1000 (g04) – – – 1.05 (0.83, 1.34) 1.29 (1.01, 1.65) 1.05 (0.83, 1.32)
Industry
Manufacturing – – – 1.00 (reference) 1.00 (reference) 1.00 (reference)
Services (g05) – – – 0.96 (0.79, 1.18) 0.78 (0.64, 0.96) 0.92 (0.75, 1.13)
Others (g06) – – – 0.94 (0.82, 1.90) 0.82 (0.70, 0.95) 0.90 (0.77, 1.04)
The N of other mental – – – 1.00 (0.98, 1.03) 1.01 (0.98, 1.03) 1.00 (0.98, 1.03)
health measures (g07)
Improvement of the work environment
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes (g08) 0.98 (0.84, 1.14) 0.99 (0.84, 1.16) 0.99 (0.84, 1.16) 0.94 (0.79, 1.12) 0.91 (0.76, 1.10) 0.93 (0.77, 1.12)
Intercept (g00) 0.99 (1.06, 0.92) 0.76 (0.84, 0.69) 0.30 (0.38, 0.23) 1.25 (1.52, 0.98) 1.31 (1.58, 1.05) 0.80 (1.04, 0.55)
AIC 26038.15 25607.39
McFadden pseudo R2 0.00 0.02

AIC, Akaike information criteria; CI, confidence interval; Exp, exponential; Ni, number of workers; Nj, number of worksites. Robust maximum likelihood estimation was used
using Mplus 7.4.

P < 0.05.

P < 0.01

P < 0.001.

[95%CI, 0.67, 0.97] for three) (data available upon request).
When work-related stress was treated as a continuous variable,
improvement of the work environment had a marginally significant
negative relationship with individual work-related stress in the
crude model (model 2, g08 ¼ 0.08, 95%CI, 0.17, 0.01,
P ¼ 0.075) and in the adjusted conditional model (model 3,
g08 ¼ 0.10, 95%CI, 0.20, 0.00, P ¼ 0.059).
Among 3552 women nested in 905 worksites, improvement of
the work environment showed a significant and positive association
with having three or more kinds of work-related stress (Exp [g] ¼ 1.41,
95%CI, 1.09, 1.82, P ¼ 0.009 in the crude conditional model
[model 2]). However, the association was not significant after adjust-
ing for the covariates (Exp [g] ¼ 1.29, 95%CI, 0.96, 1.74, P ¼ 0.096 in
the adjusted conditional model [model 3]). The number of other
mental health measures was not significantly associated with work-
related stress (Exp [g] ¼ 1.02 for one, Exp [g] ¼ 1.02 for two, Exp
[g] ¼ 1.01 for three) (data available upon request). The association
between improvement of the work environment and work-related
stress remained even after excluding the variable from the model (Exp
[g] ¼ 1.05 [95%CI, 0.80, 1.38] for one, Exp [g] ¼ 1.00 [95%CI, 0.75,
1.33] for two, Exp [g] ¼ 1.35 [95%CI, 1.04, 1.76] for three) (data
available upon request). When work-related stress was treated as a

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 Watanabe et al JOEM  Volume 59, Number 3, March 2017

TABLE 3. Sensitivity Analysis: Relationships Between Improvement of the Work Environment and Work-Related Stress Among
Employees (Total Sample)
Model 1 (Unconditional Model 2 (Crude Conditional Model 3 (Adjusted Conditional
Model) Nj ¼ 1026, Ni ¼ 9908 Model) Nj ¼ 1026, Ni ¼ 9908 Model) Nj ¼ 1026, Ni ¼ 9887

Coefficient (95%CI) P Coefficient (95%CI) P Coefficient (95%CI) P

Employee–level
Gender (REF: men)
Women (g10) – – 0.04 (0.02, 0.10) 0.212
Age group (REF: 29 years)
30–39 yrs (g20) – – 0.13 (0.05, 0.21) 0.001
40–49 yrs (g30) – – 0.21 (0.13, 0.29) <0.001
50–59 yrs (g40) – – 0.07 (0.02, 0.16) 0.106
60 yrs (g50) – – 0.34 (0.46, 0.23) <0.001
Employment status (REF: regular)
Not regular (g60) – – 0.09 (0.16, 0.01) 0.034
Job type (REF: not manager)
Manager (g70) – – 0.04 (0.11, 0.03) 0.249
Shift type (REF: daytime)
Not daytime (g80) – – 0.13 (0.04, 0.22) 0.003
Working hours (REF: <8 hr)
8–10 hr (g90) – – 0.19 (0.13, 0.25) <0.001
10 hrs (g100) – – 0.56 (0.47, 0.65) <0.001
Worksite–level
Worksite scale (REF: 10–49)
50–99 (g01) – – 0.13 (0.01, 0.26) 0.066
100–299 (g02) – – 0.13 (0.02, 0.24) 0.022
300–999 (g03) – – 0.09 (0.03, 0.21) 0.130
1000 (g04) – – 0.05 (0.06, 0.17) 0.361
Industry (REF: manufacturing)
Services (g05) – – 0.07 (0.17, 0.03) 0.170
Others (g06) – – 0.08 (0.16, 0.01) 0.029
The N of other mental health measures (g07) – – 0.00 (0.01, 0.02) 0.570
Improvement of the work environment (REF: No)
Yes (g08) – 0.01 (0.08, 0.09) 0.889 0.04 (0.13, 0.06) 0.452
Intercept (g00) 1.36 (1.32, 1.39) <0.001 1.36 (1.32, 1.39) <0.001 1.10 (0.99, 1.23) <0.001
Random intercept (t00) 0.15 (0.12, 0.18) <0.001 0.15 (0.12, 0.18) <0.001 0.12 (0.10, 0.15) <0.001
Residual variance (eij) 1.44 (1.41, 1.47) <0.001 1.44 (1.41, 1.47) <0.001 1.39 (1.36, 1.43) <0.001
AIC 32,399.26 32,401.24 31,995.68

AIC, Akaike information criteria; CI, confidence interval; Ni, number of workers; Nj, number of worksites; REF, reference group in the analyses; Robust maximum likelihood
estimation was used using Mplus 7.4.

continuous variable, improvement of the work environment
showed a significant and positive association with work-related
stress among women, in the crude conditional model (model 2,
g08 ¼ 0.15, 95%CI, 0.02, 0.28, P ¼ 0.021); it was not significant in
the adjusted model (model 3, g08 ¼ 0.09, 95%CI, 0.05, 0.24,
P ¼ 0.219).
DISCUSSION
Conducting improvements in the work environment was not
significantly associated with employee-level work-related stress in the
total sample. However, sex-stratified analyses indicated contrasting
results for men and women. Among men, a significant negative
association was observed between improvement of the work environ-
ment and severe levels (ie, three or more sources) of work-related
stress. The association was not significant among women. Improve-
ment of the work environment may be associated with the reduction of
work-related stress among men, but not women, in Japan. These
results were the first findings that monitored the effectiveness of
improving the work environment on work-related stress at the national
level, and suggested that we should consider and address, the differ-
ence in its effectiveness between men and women in the real world.
Among men, a significant negative relationship was observed
between improvement of the work environment and having severe
work-related stress, as compared with having no work-related stress.
This result indicated that the prevalence of having severe work-
related stress could be reduced by approximately 20% by improving
the work environment (Exp [g] ¼ 0.80). This result was in line with
previous intervention studies reporting that improving the work
environment could reduce work-related stress among men.33,42
However, since we used a representative sample of worksites, most
of the improvements of the work environment were supposed to be
‘‘everyday’’ activities, rather than those based on well-designed
projects often involving outside experts as seen in the publi-
cations.19,43 It is important to note that the present study suggests
that everyday activities that improve the work environment are
associated with reducing work-related stress of men nationwide
in Japan.
On the other hand, worksite-level improvement of the work
environment was not significantly associated with work-related
stress for women workers. Rather, a non-significant, but slightly
positive, association was observed, after adjusting for the other
covariates. As suggested by previous findings,27– 33 the effect of
improving the work environment, in its current form as conducted in
Japan, might be less clear for women. A sex difference in the effect
of improving the work environment could be caused by several
factors. One possible reason for this result was the difference in job

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 JOEM  Volume 59, Number 3, March 2017 Improvement of the Work Environment and Stress

TABLE 4. Relationships Between Improvement of the Work Environment and Work-Related Stress Among Workers
(Gender-stratified)
Work-Related Stress as a Categorical Variable

Model 2 (Crude Conditional Model) Nj ¼ 986, Ni ¼ 6356 Model 3 (Adjusted Conditional Model)y Nj ¼ 986, Ni ¼ 6346

For One (Compared For Two (Compared For Three (Compared For One (Compared For Two (Compared For Three (Compared
With None) With None) With None) With None) With None) With None)
Men Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI)

No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes (g08) 0.96 (0.80, 1.14) 0.97 (0.81, 1.17) 0.83 (0.70, 0.98) 0.92 (0.76, 1.12) 0.91 (0.74, 1.12) 0.80 (0.65, 0.99)
AIC 16,576.92 16,307.15
Model 2 (Crude Conditional Model) Nj U 905, Ni U 3552 Model 3 (Adjusted Conditional Model)y Nj U 904, Ni U 3541

For One (Compared For Two (Compared For Three (Compared For One (Compared For Two (Compared For Three (Compared
With None) With None) With None) With None) With None) With None)
Women
Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI) Exp (g) (95%CI)
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes (g08) 1.07 (0.82, 1.41) 1.07 (0.79, 1.38) 1.41 (1.09, 1.82) 0.99 (0.72, 1.37) 0.94 (0.68, 1.30) 1.29 (0.96, 1.74)
AIC 9,426.97 9,327.52

Sensitivity Analysis: Work-Related Stress as a Continuous Variable

Model 2 (Crude Conditional Model) Nj ¼ 986, Model 3 (Adjusted Conditional Model)y

Ni ¼ 6356 Nj ¼ 986, Ni ¼ 6346

Men Coefficient (95%CI) P Coefficient (95%CI) P

Yes (g08) 0.08 (0.17, 0.01) 0.075 0.10 (0.20, 0.00) 0.059
AIC 20,962.03 20,696.35

Model 2 (Crude Conditional Model) Nj U 905, Model 3 (Adjusted Conditional Model)y

Ni U 3552 Nj U 904, Ni U 3541
Women Coefficient (95%CI) P Coefficient (95%CI) P
Yes (g08) 0.15 (0.02, 0.28) 0.021 0.09 (S0.05, 0.24) 0.219
AIC 11,466.64 11,331.18

AIC, Akaike information criteria; CI, confidence interval; Exp, exponential; Ni, number of workers; Nj, number of worksites. Robust maximum likelihood estimation was used
using Mplus 7.4.
y
Adjusted by age, employment status, job type, shift type, and working hours, worksite scale, industry, and the number of other mental health cares.

P < 0.05.

P < 0.01.

type categories between men and women. For example, Dahl-
Jorgensen and Saksvik28 argued that the effects of their organiz-
ational intervention might be decreased due to the lack of stability in
the workforce where participants were predominantly part-time
women, and when they were not planning to stay in the job long
term. On the other hand, Mikkelsen and Saksvik30 suggested that
worksite supervisors, who had an important role in the organiz-
ational stress reduction program, were predominantly men, and
would consider men a major target population if their subordinates
had been predominantly men. Women, therefore, are more likely to
be a minority in the worksites, and receive less benefit from
improvement of the work environment. The other possible reason
is that women were less affected by workplace psychosocial factors
than men did. For instance, a previous intervention study reported
that the intervention improved the psychosocial work environment,
but did not improve depression among nurses in Japan.27 The
finding challenges the current national strategy promoting improve-
ment of the work environment as a measure of worksite mental
health in Japan.16 Programs and procedures for improving the work
environment should be reviewed from a sex equality perspective and
then improved if necessary.
There are several limitations in the study. Given that this
study design was cross-sectional, a causal relationship could not be
addressed. A selection bias due to the low valid response rate
(59.2% for the worksite-level surveys and 56.7% for the
employee-level surveys) might underestimate the relationship
between the improvement of the work environment and work-
related stress. For instance, worksites that conducted few mental
health measures, and whose employees felt severe work-related
stress, can be reluctant to participate in the survey. Because
measurements of the exposure, outcome, and covariates were all
self-reported, and were not statistically validated, some systematic
bias and random error were incorporated in the values. The coef-
ficients may be confounded by factors that we could not measure in
the study. Most plausible moderator/confounders can be types of
improvement of the work environment: employee-participatory
approach and supervisor-directed approach. Although both types
could be effective on work-related mental health,19,33 several

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 Watanabe et al
previous studies30,44,45 recommended the employee-participatory
approach because employees in the workplace understand both the
problems and their solutions.19 Many other confounders, which
determine the effects of improving the work environment, were also
suggested, such as lack of support from employers and manag-
ers,46,47 and external conditions that were beyond their control.48
These limitations need to be addressed in future research.
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