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Work 59 (2018) 155–163
DOI:10.3233/WOR-172659
IOS Press
155
Recovery, work-life balance and work
experiences important to self-rated health:
A questionnaire study on salutogenic
work factors among Swedish primary
health care employees
Lina Ejlertssona,b,∗, Bodil Heijbelb,G
¨
oran Ejlertssona,band Ingemar Anderssona
aSchool of Health and Society, Kristianstad University, Kristianstad, Sweden
bDepartment of Clinical Sciences, Malm¨o, Faculty of Medicine, Lund University, Malm¨o, Sweden
Received 27 September 2016
Accepted 9 March 2017
Abstract.
BACKGROUND: There is a lack of information on positive work factors among health care workers.
OBJECTIVE: To explore salutogenic work-related factors among primary health care employees.
METHOD: Questionnaire to all employees (n= 599) from different professions in public and private primary health care
centers in one health care district in Sweden. The questionnaire, which had a salutogenic perspective, included information
on self-rated health from the previously validated SHIS (Salutogenic Health Indicator Scale), psychosocial work environment
and experiences, recovery, leadership, social climate, reflection and work-life balance.
RESULTS: The response rate was 84%. A multivariable linear regression model, with SHIS as the dependent variable,
showed three significant predictors. Recovery had the highest relationship to SHIS (=0.34), followed by experience of
work-life balance (= 0.25) and work experiences (=0.20). Increased experience of recovery during working hours related
to higher self-rated health independent of recovery outside work.
CONCLUSION: Individual experiences of work, work-life balance and, most importantly, recovery seem to be essential
areas for health promotion. Recovery outside the workplace has been studied previously, but since recovery during work was
shown to be of great importance in relation to higher self-rated health, more research is needed to explore different recovery
strategies in the workplace.
Keywords: Positive health, healthy work conditions, employee health, occupational health, health promotion
1. Background
Workplace health promotion has been defined as
the combined efforts of employers, employees and
society to improve the health and well-being of
∗Address for correspondence: Lina Ejlertsson, Department of
Clinical Sciences, Malm¨
o, Faculty of Medicine, Lund Univer-
sity, Jan Waldenstr¨
oms gata 35, 205 02 Malm¨
o, Sweden. E-mail:
lina.ejlertsson@med.lu.se.
people at work and focuses on the factors associated
with safe, motivating and enjoyable work settings
[1, 2]. A health promotion-orientated, sustainable
and organization-wide healthy workplace policy is
an effective way to develop and maintain a healthy
workforce [3].
Employee health has been related to the organiza-
tion and the social climate at work [4], experiences
of positive workplace attributes [5] and sufficient
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156 L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health
time for tasks [6] as well as recovery and work-life
balance [7, 8]. Regarding recovery, most studies so
far have focused on retrieval of energy outside work
settings [9].
Work can influence employees in both positive and
negative ways. For many professional groups work
may be associated with adverse effects, such as stress
and burn out [10, 11]. The well-being of health care
staff is a much discussed subject in many countries.
Employees in health service professions are consid-
ered to be at high risk of stress-related disorders
[12, 13], and numerous studies of the work environ-
ment experience among nursing staff indicate that job
stress as well as job turnover and long-term sick leave
are common [14, 15].
Poor psychosocial work conditions have been
found in primary health care, and this factor prompted
the current study. Investigations of primary health
care in many countries have highlighted a high level
of stress and high job demands as well as poor
mental and physical health for many categories of
staff [16, 17], especially among general practitioners
[18, 19, 20].
The dominant paradigm in work environment
research is the biomedical model, with a focus on risk
factors and shortcomings. There is still a gap between
vision and reality in workplace health promotion,
and a difference in approach to work environment
research [21]. However, there is research with a
more salutogenic approach with focus on positive
domains of health [22]. The concept salutogenesis
(from lat. salus and genesis; i.e. creating health) sets
out from the healthy and from the resources in human
beings and environments [23], which can lead to an
improved health. Work-related enhancing resources,
such as reflective skills, open-mindedness, compre-
hensive view, flexibility and reinforcements, have
been explored in relation to the salutogenic theory
[24]. This type of orientation can be found in a small
number of studies in hospital care regarding the work
experiences and health of the staff [25].
Ever since the WHO health promotion confer-
ence in Ottawa, Canada, in 1986 [2], a salutogenic
approach has gradually developed. This approach has
led to the conclusion that the way we view the world
affects our ability to cope with stress and that positive
feelings help us cope when we are confronted with
negative situations [22].
There is a general lack of information about salu-
togenic work factors, that are evident in health care
settings and especially in primary health care. The
aim of the present study was to explore work-related
factors important to health among primary health
care employees to increase the knowledge base on
how to develop relevant workplace health promotion
strategies.
2. Methods
2.1. Setting
While primary health care systems differ in con-
struction depending on where in the world you live,
the primary goal is the same; to provide health care to
residents on equal terms, regardless of their age, sex,
income or education. Primary health care in Swe-
den – with public and private health care centers –
offers tax-funded non-institutional care, and provides
citizens with medical treatment, nursing care and
rehabilitation services. Various professional teams
such as physicians, nurses, psychologists and phys-
iotherapists deliver these services. A cross- sectional,
questionnaire study was conducted in public as well
as private primary health care centers (PHCCs), in
both urban and rural areas. All 26 PHCCs within
one health care district in southern Sweden opted to
participate.
2.2. Respondents
The sample included health care employees from
a variety of professional groups: physicians, nurses
(registered nurse, assistant nurse), paramedical staff
(psychologists, counsellors, occupational therapists,
physiotherapists, dieticians), and administrative staff
(such as medical secretaries and receptionists). Total
N = 599. Staffs on long-term sick leave or maternity
leave were excluded, as well as all the managers and
owners of the PHCCs.
2.3. Questionnaire and procedure
The salutogenic perspective formed the basis for
the questionnaire and included: health, psychosocial
work environment and experiences, recovery, leader-
ship, social climate, reflection and work-life balance.
The questionnaire was based on two previously
validated and psychometrically tested instruments,
SHIS (Salutogenic Health Indicator Scale) measur-
ing indicators of health, e.g. respondents’ feelings
and experiences of their physical, mental and social
well-being [25], and WEMS (Work Experience Mea-
surement Scale) [26].
L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health 157
Five sub-indices of WEMS were used (See
Table 1). Both instruments were constructed through
theoretical analysis of various dimensions of health.
Questions on salutogenic work conditions comple-
mented these measures. Apart from a literature review
on the relationship between work-related factors
and health, these questions were mainly developed
through the analyses of five focus group interviews
and four individual interviews in seven of the partic-
ipating PHCCs to secure a high content validity (for
results, contact the author). The study can be con-
sidered to have high content validity, also due to the
evaluation by subject matter experts of whether the
questions were essential and useful, i.e. covered all
aspects of the theoretical definition of each concept.
For most of the questions, a symmetric Likert-type
scale was used, where the respondents specified their
level of agreement or disagreement. The statements
were positively phrased. The response alternatives
ranged from 6 = totally agree to 1 = totally disagree.
A semantic differential with six steps was used in two
of the question groups. Demographic data were also
collected.
A pilot study was conducted to examine the face
validity of the instruments, i.e., to determine that
the questionnaire covered the concept it purported to
measure in a comprehensible way. Different profes-
sions in primary health care – from health care centers
not participating in the main study – completed the
questionnaire, while commenting on the questions
and their responses to the questions, a method called
cognitive think-aloud interviewing [27]. This resulted
in some minor changes to the questionnaire. The final
questionnaire was distributed in the autumn of 2013.
One of the authors (L.E.) attended work group
meetings in the majority of the centers, and the
employees completed the questionnaire on the spot.
Absent employees were given the questionnaire and
a prepaid reply envelope afterwards by the manager.
In the remaining centers, the manager distributed
the questionnaires to the employees who then indi-
vidually and anonymously sent in the questionnaire
by mail in the prepaid envelope. A single reminder,
rather than a series of personal reminders were sent
to all employees to maintain confidentiality.
2.4. Analysis
The questions on the Salutogenic Health Indica-
tor Scale (SHIS) formed one single index, and five
sub-indices were made from the Work Experience
Measurement Scale (WEMS). In addition five more
indices were constructed and used in the regression
analysis. The subject areas, which are presented in
Table 1, were primarily chosen on empirical grounds,
i.e., drawn from the results of the interview study
and theoretically based findings in previous research.
Due to different numbers of statements in each index,
their values have been transformed to obtain the scale
0–100, where 0 is the most negative value and 100
the most positive. The reliability, i.e. the internal
consistency, of the indices was calculated with the
Cronbach’s alpha (CA) coefficient. To be accepted as
an index, the CA coefficient had to be higher than 0.70
[28]. All the indices were created based on the logi-
cal connection between the different question areas,
i.e. each question contained several items in the same
field, and these items were included in the index based
on an optimization of CA. One single question – on
work-life balance – accompanied the indices: “I am
satisfied with my life situation with regard to work-
life balance”. A Likert-type scale where 6 = totally
agree and 1 = totally disagree was used.
A multivariable linear regression model was used
to determine which variables were associated with
SHIS as an indicator of self-rated health. The relation-
ship between the independent variables was analyzed
using bivariate correlation (Table 2). The selec-
tion of independent variables to be included in the
model was based on correlations, r> 0.40, (Pearson)
between SHIS and the independent variables. The
model was adjusted by sex, age and working time
(>80% and ≤80%). To study the impact of different
professional groups, four additional regression mod-
els were studied. Multi-collinearity of the data was
excluded (normal variance inflation factor, VIF) and
the residuals were tested and shown to have a normal
distribution. A comparison of the impact on SHIS of
various levels of recovery outside work (3 groups)
and during working hours (3 groups) was tested by
one-way ANOVA. In all tests, the significance level
was set at 0.05. Statistical analyses were carried out
using SPSS 21.0.
2.5. Ethics
Prospective participants were given information,
either personally and/or through a written infor-
mation sheet, about the purpose of the study, the
confidentiality of their responses.
Participation was voluntary and participants had a
right to withdraw from the study at any time. The
study was conducted in agreement with the Swedish
Law of Research Ethics, SFS 2003 : 460, which is
158 L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health
Table 1
Indices used in the study
Index No. of Scale type (Examples of) statementsaCronbach’s
statements alpha
SHIS 12 Semantic differential In the last 4 weeks, I have. . .felt alert/tired,
exhausted; felt happy, optimistic/depressed, sad;
felt well/sick.
0.94
Supportive working
conditions (WEMS)
7 Likert-type scale We encourage and support each other at work. I get
feedback on the work I do.
0.90
Work experiences
(WEMS)
6 Likert-type scale I feel that my work is meaningful. I am happy when
I go to work.
0.86
Leadership (WEMS) 6 Likert-type scale My boss is available when I need him/her. My boss
helps us divide our work in a fair way.
0.92
Time experience
(WEMS)
3 Likert-type scale I have enough time during my normal working
hours to do my job without time pressure (stress).
0.87
Autonomy (WEMS) 4 Likert-type scale I decide when to do the various work tasks. I decide
how to do my work.
0.85
Recovery 4 Likert-type scale I feel I get time for recovery during working hours. I
feel
0.83
I get time for recovery outside work. I feel that my
everyday life gives me enough recovery. I feel that
my time spent on getting to work/home from work
gives me recovery.
Energy at work 3 Likert-type scale I feel that my job gives me new energy. I feel that
my job gives me more energy than what it takes
from me. I feel that we give each other energy
between co-workers.
0.80
Reflection 3 Likert-type scale I take time to reflect on work-related events. I have a
good understanding of what gives my job
meaning. Self- reflection helps me see my job as
meaningful.
0.73
Attributes that
characterize the
workplace
8 Semantic differential Characteristics which reflect my workplace:
positive/negative, safe/unsafe, humble/haughty,
trustful/distrustful, fun/boring, open/closed,
solution oriented/problem oriented,
flexible/inflexible.
0.96
Relationship with
co-workers
3 Likert-type scale I try to be an inspiration to my co-workers. I feel
that my co-workers trust me. I feel that my
co-workers allow me to be seen and heard.
0.82
aFor the previously published index SHIS and sub-indices of WEMS, examples on statements are given. For the new indices all items are
presented.
Table 2
Bivariate correlations (Pearson´s correlation coefficient) between the independent variables
Supportive Work Time Attributes that Relationship Energy at Recovery Reflection Work-life
working experience experience characterize with co- work balance
conditions (WEMS) (WEMS) the workplace workers
(WEMS)
Supportive working –
conditions (WEMS)
Work experience (WEMS) 0.665 –
Time experience (WEMS) 0.408 0.333 –
Attributes that characterize 0.811 0.631 0.407 –
the workplace
Relationship with 0.609 0.491 0.350 0.595 –
co-workers
Energy at work 0.597 0.607 0.426 0.641 0.538 –
Recovery 0.410 0.371 0.512 0.400 0.387 0.551 –
Reflection 0.331 0.439 0.395 0.368 0.374 0.462 0.521 –
Work-life balance 0.318 0.347 0.439 0.289 0.315 0.435 0.595 0.364 –
L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health 159
Table 3
Respondents by sex, age, profession and working time
nPercent
Sex
Women 430 86
Men 68 14
Age
34 years and younger 54 11
35–54 years 276 55
55 years and older 170 34
Profession
Physician 99 20
Nurse 232 46
Administrative staff 83 17
Paramedical staff 86 17
Working timea
1–50% 44 9
51–80% 165 33
81–100% 288 58
a100% working time corresponds to 40 hours/week.
in line with the ethical guidelines of the Helsinki
Declaration [29]. The principle of voluntariness was
met by the respondents’ informed consent to partici-
pate in the survey. Precautions were made to ensure
the anonymity of participating employees as well as
participating PHCCs, and all data was treated confi-
dentially.
3. Results
The response rate was 84% (n= 501). The major-
ity of the respondents, 86%, were women, the largest
occupational group was nursing (46%), and the
majority of respondents were between 35–54 years
of age (55%) (Table 3).
On a scale 0–100 the respondents’ mean SHIS
value was 66.3 (SD 18.6). There were no significant
differences in SHIS scores for sex, age or professional
group.
A linear regression model, with the index of
SHIS as the dependent variable, showed that recov-
ery had the highest relationship to SHIS (= 0.34).
Also, experiencing a work-life balance (= 0.25) and
having positive work experiences (= 0.20) were
significant predictors of SHIS (Table 4). The total
model was statistically significant and explained
52.7% of the variance. These three variables recovery,
work-life balance and work experiences, were also
the most important ones in all four professional
groups when specific regression models for each
group were used (data not shown).
As recovery was related to SHIS as shown in
Table 4, the SHIS index for various combinations of
recovery during working hours and outside work is
shown in Table 5. It is evident that self-rated health
(SHIS index) for various combinations of recovery
during working hours and outside work was related
to higher self-rated health independent of the level of
recovery outside work suggesting that not only recov-
ery outside work but also recovery during working
hours is related to self-rated health.
4. Discussion
This salutogenic-oriented study of primary health
care employees showed that recovery, work-life bal-
ance and work experiences were all independently
related to self-rated health as measured by the Salu-
togenic Health Indicator Scale (SHIS).
Recovery, measured as a combination of recov-
ery during working hours and outside work, had the
highest relationship to respondents’ perceived health
status. Recovery can be defined as a process of psy-
chophysiological unwinding after effort expenditure.
Employees with long working hours have been shown
to have more need for recovery from work [30]. A
recent study showed that need of satisfaction at work
was related to a positive recovery state at the end of the
workday [31]. It is contended that if recovery during
working hours is inadequate, as most often is the case,
a need for recovery after work is particularly vital
[9]. Health care staff members are confronted with
all kinds of strain throughout the workday, including
emotional, physical and cognitive demands. Recov-
ery is essential for a healthy and balanced life and
for the ability to stay engaged and recharge personal
energy resources [32].
Even though studies have reported a link between
recovery and physical and mental conditions, most
research has focused on recovery outside work. One
study recently described how physical and psycho-
logical distance from work and work-related feelings
or thoughts is central to the recovery experience
[33]. Almost no published studies on recovery during
working hours have been reported [34]. However, one
study revealed that taking micro-breaks throughout
the workday reduced fatigue and increased vitality
[35]. Results from a Dutch health care study showed
that recovery opportunities (one item on the nine-item
scale concerned recovery during working hours), had
positive effects on health complaints [36].
Results of the present study showed that recov-
ery during working hours had a substantial impact
on respondents’ perceived health. However, more
160 L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health
research is needed to explore recovery during work-
ing hours and the implication on different kinds of
recovery strategies in the workplace.
A significant relationship between work-life bal-
ance and health was found in the current study. This
result is supported by the conclusion that work-life
balance is of major importance when it comes to
workforce retention and other work-related factors in
health care settings [37]. For example, in that study
[37] nurses and midwifes reported high demands in
relation to rewards as well as significant lower qual-
ity of life compared to a standard population. The
dialectic relationship between working life and pri-
vate life has been described [4], and the participating
nurses highlighted the fact that a good day at work
made them better prepared to handle different situ-
ations in their private life, and vice versa. Similar
results were shown in a study of physicians, where
a significant relationship between work, family con-
flict and job stress, as well as perceived job demands,
was found [38]. In line with Kroth et al. [39], one
conclusion is that it is essential for managers to sup-
port a work-life balance among the employees to
create healthy work environments in a health care
organization.
In the current study, the third significant variable
connected to self-rated health was work experiences.
For example, to be able to come to work with joy
and to experience work as meaningful and challeng-
ing. An essential factor when creating a healthy work
environment was that the manager made sure that the
employees enjoy their work in a pleasant (fun) atmo-
sphere [39]. Experiencing work as challenging and
stimulating was directly related to employee health
status in the present study. This is in line with previous
studies concerning job satisfaction, motivation and
positive reinforcement [15, 40]. A good work envi-
ronment has positive effects on the individual, their
feelings about being useful, competent and enthusi-
astic about their work is crucial to retention.
Work should be seen as the positive resource it
can be, as work is closely associated with the indi-
vidual´s health. A healthy workplace is essential to
gaining the most energy from employees [39]. These
findings correspond well with the verified relation-
ship between health promotion and well-being, which
several literature reviews have brought to light [41,
42]. Apart from the current study in primary health
care, studies in hospitals have shown that health
care settings contain many positive characteristics,
Table 4
Results from a multivariable linear regression model with the SHIS index as the dependent variable.
Adjusted by sex, age and working time
Standardized Unstandardized pVIF
coefficients coefficients (B)
beta () (95% CI)
Recovery 0.34 0.90 (0.65, 1.15) 0.000 2.26
Work-life balance 0.25 2.39 (1.61, 3.18) 0.000 1.68
Work experience (WEMS) 0.20 0.47 (0.25, 0.68) 0.000 2.24
Attributes that characterize the workplace 0.08 0.10 (–0.05, 0.26) 0.195 3.49
Energy at work 0.07 0.26 (–0.11, 0.62) 0.166 2.39
Supportive working conditions (WEMS) –0.07 –0.12 (–0.33, 0.08) 0.245 3.60
Relationship with co-workers 0.05 0.12 (–0.09, 0.32) 0.260 1.89
Reflection 0.03 0.12 (–0.24, 0.47) 0.523 1.61
Time experience (WEMS) 0.01 0.03 (–0.20, 0.26) 0.898 1.55
Adjusted R2= 0.527; ANOVA (F = 44.5; p= 0.000); Factors presented in order of their contribution to the model.
VIF =variance inflation factor. Variables not included in the model: leadership (WEMS), autonomy (WEMS).
Table 5
Mean (SD) for the SHIS index for various combinations of the variables recovery during working hours and recovery outside work
Recovery during working hoursa
Group 5-6 Group 3-4 Group 1-2 pb
Recovery outside workaGroup 5-6 82.9 (13.8) (n= 76) 74.4 (13.9) (n= 104) 66.6 (15.3) (n= 59) 0.000
Group 3-4 68.2 (19.0) (n= 10) 62.5 (14.1) (n= 103) 56.8 (16.9) (n= 84) 0.013
Group 1-2 – (n=0) –(n= 1) 43.6 (9.7) (n= 35) na
aFor the statements I feel I get time for recovery during working hours and I feel I get time for recovery outside work, respectively, three
groups where made from the response alternatives ranging from totally agree (6) to totally disagree (1): group 5-6 (highest), group 3-4 and
group 1-2 (lowest). bOne-way ANOVA to test the hypothesis of a relationship between SHIS and recovery during working hours in groups
with different report of recovery outside work.
L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health 161
for example to experience meaningfulness, autonomy
and social support at work [26]. These factors are
essential to future work towards good health for all
employees.
One strength of the present study is the high par-
ticipation rate, which is essential for drawing valid
conclusions. A number of steps were taken to increase
intrinsic motivation among the potential participants.
Lately, it has been considered important to include
motivation theories in survey research [43]. All com-
prising efforts in the implementation of the study, the
salutogenic perspective of the survey, and the promise
to each PHCC that the results of therespective PHCC
would be reported back as a foundation for subse-
quent interventional efforts at the health care center,
were all motivational. Since the response rate was 84
percent, the potential dropout effects on the findings
are considered small.
Another strength is the high validity. Two validated
instruments were used, SHIS [25] and WEMS [26]
which were complemented by questions developed
in a procedure from individual and focus group inter-
views via an expert panel to a pilot study to ensure
high content and face validity. All indices used had
high reliability in terms of their internal consistency.
Apart from the high response rate and the high valid-
ity, the representative selection of primary health care
centers and their employees contributed to reduce
selection bias.
Finally, a strong factor was the level of SHIS (mean
66.3). This was similar to what has previously been
reported for hospital employees [25]. This suggests
that the sample in the current study is highly rep-
resentative of the working experience of health care
professionals.
In every work-related study, the effect of selection
bias must be kept in mind [44]. As an individual must
be relatively healthy to be employable, the employees
in any work force are supposedly healthier than the
general population. The interpretation of the results
should include these considerations. Results were
obtained from self-report which may introduce some
information bias; on the other hand, the short recall
time in the questionnaire may reduce the bias. Social
desirability in responding may introduce some bias
as well.
We chose to study self-rated health in relation to
work environment and the employees´ own expe-
riences related to work. Confounders like sex, age
and working time were adjusted for, but other fac-
tors such as life-style, household composition and
ongoing morbidity were not considered, which can
be seen as a limitation. Another limitation is the
cross-sectional design of the study, which precludes
drawing any causal conclusions. On the other hand,
being one of the first studies ever in primary health
care focusing on work experiences and health from a
salutogenic perspective, it is possible to draw impor-
tant conclusions regarding the relationship between
health and work experiences, even if causality could
not be confirmed.
5. Conclusion
To the best of our knowledge there are few
published studies on salutogenic work factors, under-
lining the importance of researching this area. There
were three areas of special importance to employee
health, to which the management and the employees
should pay close attention: recovery, work-life bal-
ance and work experiences. It appears that recovery
during working hours is of great value in relation to
high self-rated health, regardless of recovery outside
work. These findings could form the basis for fur-
ther study into how to use a salutogenic approach
when developing workplace health promotion in
other workplace contexts. However, more research
is needed to explore different recovery strategies in
the workplace.
Acknowledgments
The study was funded by Kristianstad Univer-
sity with financial support from the Scania Regional
Council and the Association of General Practitioners
in Sweden.
Conflict of interest
The authors declare that they have no conflict of
interest.
Authors’ contributions
LE was the main author of the manuscript and
involved in all aspects of the study. BH, GE and IA
contributed in the design and planning of the study,
the data interpretation and writing of the manuscript.
GE and IA also contributed in performing the statisti-
cal analyses. All authors read and approved the final
manuscript.
162 L. Ejlertsson et al. / Recovery, work-life balance and work experiences important to self-rated health
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