RESEARCH REPORT

Organisational justice and change in justice as predictors of
employee health: the Whitehall II study
Mika Kivimäki, Jane E Ferrie, Jenny Head, Martin J Shipley, Jussi Vahtera, Michael G Marmot
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article for
authors’ affiliations
. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:
Professor M Kivimaki,
Finnish Institute of
Occupational Health,
Topeliuksenkatu 41 aA,
FIN-00250 Helsinki,
Finland; mika.kivimaki@ttl.
fi

Accepted for publication
28 March 2004
. . . . . . . . . . . . . . . . . . . . . . .

J Epidemiol Community Health 2004;58:931–937. doi: 10.1136/jech.2003.019026

Objective: Organisational justice has been proposed as a new way to examine the impact of psychosocial
work environment on employee health. This article studied the justice of interpersonal treatment by
supervisors (the relational component of organisational justice) as a predictor of health.
Design: Prospective cohort study. Phase 1 (1985–88) measured relational justice, job demands, job
control, social support at work, effort-reward imbalance, and self rated health. Relational justice was
assessed again at phase 2 (1989–90) and self rated health at phase 2 and phase 3 (1991–93).
Setting: 20 civil service departments originally located in London.
Participants: 10 308 civil servants (6895 men, 3413 women) aged 35–55.
Outcome measure: Self rated health.
Main results: Men exposed to low justice at phase 1 or adverse change in justice between phase 1 and
phase 2 were at higher risk of poor health at phase 2 and phase 3. A favourable change in justice was
associated with reduced risk. Adjustment for other stress indicators had little effect on results. In women,
low justice at phase 1 predicted poor health at phase 2 and phase 3 before but not after adjustment for
other stress indicators. Adverse change in justice was associated with worse health prospects irrespective
of adjustments.
Conclusions: The extent to which people are treated with justice in workplaces seems to predict their health
independently of established stressors at work. Evidence on reduced health risk after favourable change in
organisational justice implies a promising area for health interventions at workplace.

A
ccording to established occupational stress models,
high demands, low job control, poor social support,
and an effort-reward imbalance present significant

psychosocial health risks at work.1–3 The study of organisa-
tional justice is a recent attempt to identify new psychosocial
determinants of employee health.4–10 The relational compo-
nent of organisational justice, which is the main focus of this
study, refers to the extent supervisors consider their employ-
ees’ viewpoint, are able to suppress personal biases, and take
steps to deal with subordinates in a fair and truthful manner.
The procedural component of organisational justice involves
the fairness of formal decision-making procedures.
Although organisational justice partly overlaps established

occupational stressors, it may also tap additional elements
that contribute to employee health.4–6 Job demands, job
control, and social support deal with the person’s job
characteristics or situations in which the employee needs
help. Fairness of interpersonal treatment and organisational
procedures capture more basic elements of the social
structure in which these characteristics are operating.11 12

Organisational justice captures the whole range of unfair
treatment at work, not only an imbalance between efforts
and rewards.11 12

Previous studies report lower levels of justice to be
associated with lower wellbeing, higher self reported mor-
bidity, higher medically certified absence, increased mental
health problems, and greater likelihood of maladaptive
coping.4–6 13–17 Research on change in organisational justice
and health is now required to determine the effect of change
in justice. Reduced health risk after an improvement in
justice would be consistent with a causal interpretation and
identify a potential target for workplace interventions.
Failure to observe such an association would suggest that
the link between justice and health may be attributable to
residual confounding by stable health risk factors, for

example, early material and social disadvantage, adulthood
socioeconomic position, and personality.18 Previous studies
have failed to address the question of change in justice. They
have also had short follow up periods ((3 years), such that
the long term health effects of organisational justice, as well
as the effects of change, have yet to be determined.
The prospective Whitehall II study of British civil servants

provided an opportunity for the first large scale examination
of relational justice and heath. To overcome some of the
limitations of previous research, we studied whether the level
of relational justice and change in justice were predictive of
subsequent health status independently of other occupa-
tional stress indicators such as job demands, job control,
social support at work, and effort-reward imbalance. We
explored both short term and long term health effects of
justice.

METHODS
Participants
The target population for Whitehall II was all London based
office staff, aged 35–55, working in 20 civil service depart-
ments between 1985 and 1988 at entry into the study. With a
response rate of 73% to the survey at phase 1, the final cohort
consisted of 10 308: 6895 men and 3413 women.19 The true
response rate was higher, however, because around 4% of
those invited were not eligible for inclusion. Although mostly
white collar, respondents covered a wide range of grades (and
salaries) from office support to permanent secretary.

Study design
Baseline screening (phase 1) of the Whitehall II cohort took
place between 1985 and 1988. This involved a clinical
examination and a self administered questionnaire contain-
ing sections on demographic characteristics, health, lifestyle
factors, work characteristics, social support, life events, and

931

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chronic difficulties. In 1989/90 (phase 2), the same ques-
tionnaire data were collected by post. The third data
collection phase was between 1992 and 1993.
In this study, relational justice, occupational stress

indicators, demographic characteristics, and self rated health
were assessed at phase 1. Relational justice and self rated
health were additionally assessed at phase 2 and the latter
also at phase 3.

Measurements
Relational justice
Standard scales of organisational justice were not available at
phase 1 and phase 2,9 but it was possible to construct an
indicator of relational justice with face validity from the
available questionnaire items in the survey instruments. The
five items that deal with relational justice loaded to the same

factor (items loadings .0.40) in a varimax-rotated factor
analysis of the 19 items covering management and organisa-
tion of work, and formed an internally consistent scale of
relational justice (Cronbach a 0.71 at phase 1, 0.73 at phase
2) (see box). We summed the response scores and expressed
this as a percentage of the theoretical maximum (100 refers
to respondents with the highest score for every item of the
scale; 25 refers to respondents with the lowest score for every
item of the scale). We divided the distribution into quartiles,
separately for men and women. The bottom quartile
indicated a low level of relational justice, the top quartile a
high level of relational justice, and the two middle quartiles
an intermediate level. Change in relational justice was
calculated by deducting the phase 2 score from the phase 1
score. Scores in the bottom quartile resulting from this
subtraction indicated adverse change, scores in the top
quartile favourable change, and the middle quartiles no
change.

Occupational stress indicators
The occupational stress indicators used were job demand
scale (Cronbach’s a = 0.67), job control scale (a = 0.84), and
social support at work scale (a = 0.79) from the job content
questionnaire,1 20 and an indicator of effort-reward imbalance
from the ratio of the effort scale (numerator, five items,
a = 0.72) and the reward scale (denominator, 10 items,
a = 0.78) (see appendix).20 21 In all measures, the bottom
quartile indicated a low level, the top quartile a high level,
and the middle two quartiles an intermediate level for each of
these indicators.

Self rated health
The respondents made an assessment of their health over the
past year using a 5 point scale (1 = very good, 2 = good,
3 = average, 4 = poor, 5 = very poor). This measure was
dichotomised and used as an indicator of poor health
(average or worse compared with good or very good).

Table 1 Characteristics of participants*

Men (n = 6236) Women (n = 2906)

Number % Mean (SD) Number % Mean (SD)

Phase 1
Age group (y)
35–39 1813 29 674 23
40–44 1685 27 690 24
45–49 1216 20 649 22
50–55 1522 24 893 31

Grade
Administrative 2447 39 345 12
Professional/executive 3278 52 1182 41
Clerical/support 511 8 1379 47

Relational justice 6236 78.8 (12.5) 2906 79.3 (13.6)
Job demands 6226 60.4 (19.9) 2879 53.0 (20.7)
Job control 6210 68.6 (14.8) 2856 58.1 (20.5)
Social support at work 6221 76.2 (17.7) 2878 74.2 (20.5)
Effort-reward imbalance 6235 1.04 (0.21) 2901 0.99 (0.25)
Poor self rated health
No 4881 78 1635 65
Yes 1355 22 848 35

Phase 2
Relational justice 5412 77.7 (12.5) 2482 77.7 (14.3)
Poor self rated health
No 4276 78 1618 63
Yes 1355 22 959 37

Phase 3
Poor self rated health
No 4475 78 1700 66
Yes 1237 22 859 34

*Those who responded to relational justice questionnaire at phase 1 and rated their health at phase 1 or at phase
2.

Relational justice scale (Cronbach’s a 0.71 at
phase 1 and 0.73 at phase 2)

Questions

N 1 Do you get consistent information from line manage-
ment (your superior)?

N 2 Do you get sufficient information from line manage-
ment (your superior)?

N 3 When you are having difficulties at work, how often
is your superior willing to listen to your problems?

N 4 Do you ever get criticised unfairly?
N 5 Do you ever get praised for your work?
Response format
1 = never, 2 = seldom, 3 = sometimes, 4 = often. Question 4 is
reverse scored.

932 Kivimäki, Ferrie, Head, et al

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Statistical analysis
We used analysis of variance to assess differences in levels of
relational justice at phase 1 between grades, age groups, and
sexes. We tested associations of relational justice and
occupational stress indicators at phase 1 with self rated

health at phase 2 and phase 3 using logistic regression
analysis, separately for men and women. The first models,
containing relational justice or one stress indicator, gave odds
ratios and 95% confidence intervals adjusted for age in five
year categories, employment grade, and self rated health at

Table 2 Associations of relational justice and other psychosocial work characteristics at phase 1 with poor self rated health at
phase 2 and phase 3 in men. Figures are odds ratios (95% confidence intervals) unless otherwise stated

Exposure at phase 1

Poor self rated health at phase 2 Poor self rated health at phase 3

(1208/5456 men) (1228/5668 men)

Number Model 1* Model 2� Number Model 1* Model 2�

Relational justice
High 1499 1.00 1.00 1552 1.00 1.00
Intermediate 2493 1.06 (0.88 to 1.27) 0.99 (0.83 to 1.20) 2586 1.27 (1.07 to 1.51) 1.27 (1.03 to 1.56)
Low 1464 1.48 (1.22 to 1.80) 1.33 (1.08 to 1.65) 1530 1.43 (1.18 to 1.73) 1.53 (1.18 to 1.98)
Test for trend p,0.001 p = 0.008 p,0.001 p = 0.001

Job demands
Low 1303 1.00 1.00 1342 1.00 1.00
Intermediate 2429 1.12 (0.93 to 1.34) 1.05 (0.86 to 1.29) 2523 1.20 (1.00 to 1.43) 1.13 (0.93 to 1.38)
High 1724 1.34 (1.09 to 1.64) 1.23 (0.97 to 1.56) 1803 1.32 (1.08 to 1.61) 1.20 (0.95 to 1.51)
Test for trend p,0.001 p = 0.057 p = 0.007 p = 0.120

Job control
High 1397 1.00 1.00 1444 1.00 –
Intermediate 2675 1.19 (0.98 to 1.47) 1.19 (0.98 to 1.44) 2772 0.99 (0.83 to 1.19) –
Low 1384 1.38 (1.10 to 1.73) 1.35 (1.07 to 1.71) 1452 1.10 (0.89 to 1.37) –
Test for trend p = 0.005 p = 0.017 p = 0.361

Social support at work
High 1143 1.00 – 1191 1.00 1.00
Intermediate 3116 1.06 (0.88 to 1.28) – 3232 1.20 (1.00 to 1.44) 0.98 (0.78 to 1.22)
Low 1197 1.15 (0.92 to 1.43) – 1245 1.18 (0.96 to 1.46) 0.80 (0.60 to 1.08)
Test for trend p = 0.213 p = 0.145 p = 0.120

Effort-reward imbalance
Low 1392 1.00 1.00 1413 1.00 1.00
Intermediate 2740 1.23 (1.02 to 1.47) 1.22 (0.99 to 1.50) 2851 1.15 (0.97 to 1.38) 1.07 (0.87 to 1.30)
High 1324 1.46 (1.19 to 1.81) 1.14 (0.88 to 1.48) 1404 1.34 (1.10 to 1.64) 1.14 (0.89 to 1.47)
Test for trend p,0.001 p = 0.338 p = 0.004 p = 0.336

Only participants with no missing data in any of the predictors were included in these models. *Adjusted for age, grade, and self rated health at baseline.
�Additionally adjusted for statistically significant predictors in model 1.

Table 3 Associations of relational justice and other psychosocial work characteristics at phase 1 with poor self rated health at
phase 2 and phase 3 in women. Figures are odds ratios (95% confidence intervals) unless otherwise stated

Exposure at phase 1

Poor self rated health at phase 2 Poor self rated health at phase 3

(920/2501 women) (829/2483 women)

Number Model 1* Model 2� Number Model 1* Model 2�

Relational justice
High 751 1.00 1.00 753 1.00 1.00
Intermediate 1060 1.07 (0.85 to 1.33) 1.05 (0.84 to 1.31) 1029 1.02 (0.82 to 1.28) 0.93 (0.72 to 1.21)
Low 690 1.31 (1.03 to 1.69) 1.26 (0.98 to 1.60) 701 1.32 (1.04 to 1.68) 1.12 (0.82 to 1.55)
Test for trend p = 0.031 p = 0.070 p = 0.022 p = 0.445

Job demands
Low 597 1.00 1.00 587 1.00 1.00
Intermediate 1395 1.30 (1.03 to 1.64) 1.28 (1.02 to 1.61) 1380 1.19 (0.94 to 1.50) 1.17 (0.92 to 1.47)
High 509 1.49 (1.10 to 2.00) 1.42 (1.05 to 1.93) 516 1.45 (1.07 to 1.95) 1.38 (1.02 to 1.87)
Test for trend p = 0.008 p = 0.018 p = 0.015 p = 0.034

Job control
High 601 1.00 – 618 1.00 –
Intermediate 1247 1.05 (0.82 to 1.35) – 1244 1.05 (0.82 to 1.35) –
Low 653 1.26 (0.93 to 1.70) – 621 1.19 (0.88 to 1.62) –
Test for trend p = 0.121 p = 0.250

Social support at work
High 546 1.00 – 531 1.00 1.00
Intermediate 1279 1.04 (0.83 to 1.32) – 1291 1.17 (0.92 to 1.49) 1.15 (0.86 to 1.53)
Low 676 1.09 (0.83 to 1.41) – 661 1.37 (1.05 to 1.80) 1.24 (0.87 to 1.77)
Test for trend p = 0.543 p = 0.021 p = 0.230

Effort-reward imbalance
Low 604 1.00 – 596 1.00 –
Intermediate 1288 1.14 (0.90 to 1.43) – 1258 1.02 (0.81 to 1.29) –
High 609 1.13 (0.86 to 1.49) – 629 1.24 (0.95 to 1.63) –
Test for trend p = 0.386 p = 0.094

Only participants with no missing data in any of the predictors were included in these models. *Odds ratios adjusted for age, grade, and self rated health at
baseline. �Additionally adjusted for statistically significant predictors in model 1.

Change in organisational justice 933

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phase 1 (model 1). We tested for the significance of each
exposure by fitting a linear trend across the three levels.
Further models (model 2) additionally adjusted for each
significant predictor found in model 1. Only participants with
no missing data for any of the predictors were included in
these models. The statistical significance of interactions
between justice and sex was tested in the combined cohort
of men and women by including interaction terms. The
analyses were replicated among those with good or very good
self rated health at phase 1 (the initially healthy sub-cohort).
To test reverse causality, we used repeated measures analysis
of variance to assess whether health at phase 1 predicted
change in justice between phase 1 and phase 2.
The next step tested whether favourable or adverse change

in relational justice between phase 1 and phase 2, compared
with no change, predicted self rated health at phase 2 and
phase 3 after adjustment for age group, grade, self rated
health, relational justice at phase 1, and those occupational
stressors at phase 1 that significantly predicted self rated
health at phase 2 and phase 3. We used SAS statistical
program (SAS Institute, Cary, NC, USA) for all the analyses.

RESULTS
Baseline characteristics and sample attrition
Of the 10 308 participants, data on relational justice at phase
1 were available for 10 281 employees. Differences in
relational justice between age groups were small (range
78.5–79.1, p = 0.25), but relational justice was higher among
administrative grades (age adjusted mean score 80.0) than
professional/executive grades (78.1) and clerical/support
grades (78.7) (p for difference ,0.001). Women had slightly
higher relational justice (age and grade adjusted mean 79.4)
than men (78.7) (p = 0.02).
Poor self rated health at phase 1 was a significant predictor

of dropping out of the cohort before phase 2 (odds ratio,

adjusted for age, grade and sex, 1.3, 95% confidence intervals
(CI) 1.2 to 1.5). Dropping out was also more likely in
participants with low relational justice compared with those
with intermediate or high justice at phase 1 (odds ratio,
adjusted for age, grade, and health at phase 1, 1.1, 95% CI 1.0
to 1.2). Table 1 presents descriptive statistics of the
participants included in the subsequent analyses.

Level of relational justice and subsequent health
Table 2 shows that in men lower levels of justice and job
control and higher levels of job demands and effort-reward
imbalance were associated with higher risk of poor health at
phase 2 (model 1). With the exception of job control, these
factors also predicted poor health at phase 3. In models
simultaneously adjusting for all significant predictors, lower
justice and higher demands remained as significant pre-
dictors of health at both phases (model 2).
In women, lower relational justice and higher job demands

were associated with increased risk of poor health at phase 2
and phase 3 (table 3, model 1). Lower social support was an
additional predictor of poor health at phase 3. In the fully
adjusted model, only high demands remained as a significant
predictor of health at both phases (model 2). However, no sex
interaction with relational justice was found in models for a
cohort combining men and women (p values for interaction
>0.43).
We replicated analyses in a sub-cohort of 4492 male and

1679 female employees with good health at phase 1 (not
shown in table). In men, age and grade adjusted odds ratios
for low justice were 1.6 (95% CI 1.3 to 2.1) and 1.5 (95% CI
1.2 to 1.9) for incident self rated poor health at phase 2 and
phase 3, respectively. For women, the corresponding odds
ratios were 1.2 (95% CI 0.9 to 1.7) and 1.2 (95% CI 0.8 to 1.6).
Despite slightly lower odds ratios among women, there were
no significant sex interactions (p>0.18).
To examine the possibility of reverse causation, we tested

whether health at phase 1 predicted change in relational
justice (not shown in table). In men, a small decline in justice
between phase 1 and phase 2 was observed for those with
good health (change score 21.5) but not for those with poor
health (change score 20.4; p for health 6 time interac-
tion = 0.01). This reflects regression towards the mean, an

Table 4 Change in relational justice between phase 1 and phase 2 as a predictor of poor self rated health at phase 2 and
phase 3. Figures are odds ratios (95% confidence intervals) unless otherwise stated

Change between phase 1 and
phase 2

Poor self rated health at phase 2 Poor self rated health at phase 3

Number Model 1* Model 2� Number Model 1* Model 2�

Men
Relational justice
Favourable change 1159 0.62 (0.51 to 0.75) 0.61 (0.50 to 0.74) 918 0.75 (0.61 to 0.92) 0.75 (0.61 to 0.93)
No change 3264 1.00 1.00 2566 1.00 1.00
Adverse change 972 1.24 (1.02 to 1.50) 1.23 (1.01 to 1.49) 1354 1.25 (1.02 to 1.54) 1.26 (1.03 to 1.54)
Test for trend p,0.001 p,0.001 p,0.001 p,0.001

Women
Relational justice
Favourable change 556 0.84 (0.66 to 1.08) 0.84 (0.65 to 1.08) 487 0.79 (0.61 to 1.03) 0.79 (0.60 to 1.03)
No change 1385 1.00 1.00 1075 1.00 1.00
Adverse change 523 1.31 (1.03 to 1.66) 1.30 (1.02 to 1.65) 601 1.19 (0.93 to 1.54) 1.26 (0.97 to 1.63)
Test for trend p = 0.003 p = 0.001 p = 0.013 p,0.001

Only participants with no missing data in any of the predictors were included in these models. *Odds ratios adjusted for age, grade, relational justice at phase 1,
and self rated health at phase 1. �Additionally adjusted for all significant phase 1 predictors of self rated health shown in tables 2 and 3.

Key points

N The justice of interpersonal treatment by supervisors
predicts employee health independently of established
occupational stressors

N Low and declining justice increases risk of poor health
N High and increasing justice is associated with reduced

health risk

N These associations seem slightly stronger in men than
women

Policy implications

The focus of workplace health interventions should be
broadened to cover justice in managerial treatment.

934 Kivimäki, Ferrie, Head, et al

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opposing trend against the hypothesis of reverse causation. In
women, no interaction between health at phase 1 and time
on change in justice was observed (p = 0.67). Thus, reverse
causation is unlikely to explain the observed association
between relational justice and subsequent self rated health.

Change in justice as a predictor of health
Results in table 4 indicate that favourable change compared
with no change in relational justice between phase 1 and
phase 2 was associated with lower risk of poor health at
phase 2 and phase 3. This association was statistically
significant only for men. Adverse change in justice was
associated with higher risk of poor health both in men and
women. Analysis of a cohort combining men and women
revealed no sex interaction with change in justice on health
at phase 2 (p for interaction = 0.14) and health at phase 3 (p
value = 0.40). Additional adjustment for the other occupa-
tional stressors at phase 1 that predicted health at phase 2
and phase 3 had little effect on these findings.

DISCUSSION
This prospective study showed low and declining levels of
relational justice to predict decreasing health in a large well
characterised cohort of men and women in the British civil
service. Favourable change in the extent to which employees
were treated with justice was associated with reduced health
risk in men. These associations were largely replicable across
two different follow up periods (three and six years, on
average), and were not attributable to other occupational
stressors or reverse causation.
Research of organisational justice is very recent compared

with the large number of analyses published on the demand-
control model and the effort-reward imbalance model.1–3 20 21

There are conceptual differences in proposed health relevant
features of work between these three models. The primary
focus of the demand-control model is on task level
characteristics whereas the other two models emphasise
work related social contexts and processes.1–3 7–12 According to
the effort-reward imbalance model, health risk derives from
the mismatch between high efforts spent at work and low
rewards received in turn. Rewards comprise money, social
approval, job security, and career opportunities.3 The justice
model is not limited to this specific exchange process
between efforts and rewards. Instead, it aims at capturing
the whole range of unfair treatment at work as experienced
or witnessed by the employees.7–12 Indeed this study suggests
that justice of interpersonal treatment may have a unique
effect on employee health that cannot be accounted for by
factors such as job control, job demands, social support, and
effort-reward imbalance.
A sense of justice is valued by people across a wide variety

of settings,12 22 23 and even highly cooperative non-human
species, such as monkeys, have been shown to manifest
inequity aversion.24 Perceptions of unfairness have previously
been related to health risk factors such as increased
psychological distress,5 17 heightened levels of unfavourable
serum lipids,25 and raised blood pressure.26 In this study, we
found a 30%–50% excess risk of poor health among men with
low relational justice after three and six years of follow up.
The corresponding figures for women were lower (10%–30%),
but the sex difference was not statistically significant. This
issue deserves further attention in future studies of justice, as
experiences and reactions to work conditions often differ
between men and women. In prior longitudinal studies, with
smaller samples and shorter follow ups, the associations
between relational justice and health have been weaker than
in this study.5

To our knowledge, evidence on the health effects of
changing justice has not previously been reported. We found

that an adverse change in relational justice was associated
with a 20%–30% excess risk of poor health and a favourable
change with a 15%–40% lowering of the risk. Confounding by
stable third factors (for example, childhood socioeconomic
circumstances, and personality) is an unlikely explanation for
effects when the exposure captures change in a risk factor.18

The magnitude of the observed effects are comparable to
those found for established occupational stressors. For
example, decreasing job control and increasing job demands
were associated with a 10%–40% increase in health problems
in the Whitehall II cohort and in a study of Finnish municipal
employees.20 27 In the latter study the reference category was
an increase in control and a decrease in demands whereas in
this study we used ‘‘no change’’ as the reference, an approach
leading to more conservative estimates.

Strengths and weaknesses of the study
In this study, sample attrition was slightly greater among
unhealthy participants and those experiencing low relational
justice than among the other employees. This is likely to
produce a ‘‘healthy worker’’ effect and constrict variation in
the exposure, both leading, if anything, to underestimation
rather than overestimation of the association between
relational justice and subsequent health. Exposure and
outcome were measured by self reports, a potential source
of inflated associations in cross sectional data. However,
because we adjusted our analyses for baseline health, an
artificial inflation of associations would have occurred only if
common-method variance had affected the second and third
surveys but not the first survey.
Standard measures of relational justice were not available

at the time of the baseline survey and thus our justice
measure had to be derived from existing questions. Some of
the items were those also included in the social support scale.
Despite this, the effect of justice seems not to be attributable
to social support. The associations between social support at
work and health were weaker than those for relational
justice, corresponding to earlier studies using standard scales
for organisational justice.4–6 Of the five questions that
comprise our justice measure, the item that best describes
the concept and is not included in the social support scale
(‘‘Do you ever get criticised unfairly?’’), was the strongest
predictor of poor health in men and women and across both
follow up periods.
Our justice measure captured aspects such as the extent

supervisors are able to suppress personal bias and deal with
employees in a fair and truthful manner. In contrast, the
measure did not include items that cover whether supervisors
consider their subordinates’ viewpoints in decision making.
As such supervisory consideration has been strongly corre-
lated with the other aspects of relational justice in previous
studies, this may not be a major source of bias.4–6 However,
consideration of subordinates’ viewpoints partly overlaps
with the concept of job control (participation in decision
making).1 Thus, it is possible that our study overestimates the
independence of the health effects of relational justice and
job control. On the other hand, previous investigations with
the standard scales indicate this is unlikely as the impact of
organisational justice on health has been independent of job
control.4–6

We measured health using overall subjective health
ratings. Self rated health has predicted mortality in the
Whitehall II study and among other adult populations in
Britain, USA, Scandinavia, Japan, and Australia.28–32

Comparisons with other health measures suggest that self
rated health may be an even more inclusive and accurate
measure of overall health status than medical records or self
reports of these records.29 The direction for future research is
to examine associations between organisational justice and

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other health measures, such as sickness absence, mental
health problems, and specific diseases. If stress is behind the
health toxic effect of low justice, then stronger associations
would be expected with indicators of impaired immune
function, mental health problems, and cardiovascular dis-
orders than for other health outcomes.33 Assessing employee
health with objective indicators of diseases, in addition to self
reported measures, would also be a step forward.

Policy implications
Large scale intervention studies to decrease occupational
stress have remained comparatively rare and they have often
had an individualistic focus.34–36 The justice theory may
provide complementary elements for workplace interven-
tions. According to the theory, fair decision making should be
consistently applied, unbiased and open, and reflect respect-
ful and considerate treatment of individuals by their super-
visors.7–10 The evidence in this study suggests that improving
the fairness of decision making will have a favourable effect
on the health of employees.

ACKNOWLEDGEMENTS
We thank all participating civil service departments and their
welfare, personnel, and establishment officers; the Occupational
Health and Safety Agency; the Council of Civil Service Unions; all
participating civil servants in the Whitehall II study; all members of
the Whitehall II study team.

CONTRIBUTORS
MK, guarantor for the paper, with JEF, JH, MJS, JV and MGM
designed the hypothesis, analysed the data, and wrote the paper.
MGM is the director of the Whitehall II study.

Authors’ affiliations
. . . . . . . . . . . . . . . . . . . . .

M Kivimäki, J Vahtera, Finnish Institute of Occupational Health and
University of Helsinki, Finland
J E Ferrie, J Head, M J Shipley, M G Marmot, International Centre for
Health and Society, Department of Epidemiology and Public Health,
University College London Medical School, UK

Funding: the Whitehall II study has been supported by grants from the
Medical Research Council; British Heart Foundation; Health and Safety
Executive; Department of Health; National Heart Lung and Blood Institute
(HL36310), US, NIH: National Institute on Aging (AG13196), US, NIH;
Agency for Health Care Policy Research (HS06516); and the John D and
Catherine T MacArthur Foundation Research Networks on Successful
Midlife Development and Socio-economic Status and Health. MK, also
working at the University of Helsinki, Finland, and JV were supported by
the Academy of Finland (projects 77560, 104891, and 105195) and
the Finnish Environment Fund, JEF is supported by the MRC (Grant
number 47413), MJS by a grant from the British Heart Foundation, and
MGM by an MRC Research Professorship.

Conflicts of interest: none declared.

APPENDIX

ITEMS OF THE OCCUPATIONAL STRESS SCALES
Job demands
‘‘Do you have to work very fast?’’; ‘‘Do you have to work very
intensively?’’; ‘‘Do you have enough time to do everything?’’
(reverse scored); ‘‘Do different groups at work demand
things from you that you think are hard to combine?’’

Job control
‘‘Do you have the possibility of learning new things through
your work?’’; ‘‘Does your work demand a high level of skill or
expertise?’’; ‘‘Does your job require you to take the
initiative?’’; ‘‘Do you have to do the same thing over and
over again?’’ (reverse scored); ‘‘Does your job provide you
with a variety of interesting things?’’; ‘‘Is your job boring?’’
(reverse scored); ‘‘Do you have a choice in deciding HOW you

do your work?’’; ‘‘Do you have a choice in deciding WHAT
you do at work?’’; ‘‘Others take decisions concerning my
work.’’ (reverse scored); ‘‘I have a good deal of say in
decisions about work’’; ‘‘I have a say in my on work speed.’’;
‘‘My working time can be flexible.’’; ‘‘I can decide when to
take a break.’’; ‘‘I have a say in choosing with whom I
work.’’; ‘‘I have a great deal of say in planning my work
environment.’’

Social support at work
‘‘Do you get sufficient information from line management
(your superior)?’’; ‘‘Do you get consistent information from
line management (your superior)?’’; ‘‘When you are having
difficulties at work, how often do you get help and support
from your colleagues?’’; ‘‘When you are having difficulties at
work, how often are your colleagues willing to listen to your
work related problems?’’; ‘‘When you are having difficulties
at work, how often do you get help and support from your
immediate superior?’’; ‘‘When you are having difficulties at
work, how often is your superior willing to listen to your
problems?’’

Effort scale
‘‘Do you have to work very fast?’’; ‘‘Do you have to work very
intensively?’’; ‘‘Do you have enough time to do everything?’’;
‘‘Does your work demand a high level of skill and
expertise?’’; ‘‘Does your job require you to take initiative?’’

Reward scale
‘‘Do you ever get praised for your work?’’; ‘‘Does your job
provide you with a variety of interesting things?’’; ‘‘Do you
consider your job very important?’’; ‘‘Do your colleagues
consider your job very important?’’; ‘‘When you are having
difficulties at work, how often do you get help and support
from your colleagues?’’; ‘‘When you are having difficulties at
work, how often do you get help and support from your
immediate superior?’’; ‘‘How satisfied are you with your
usual take home pay?’’; ‘‘How satisfied are you with your
work prospects?’’; ‘‘How satisfied are you with the way your
abilities are used?’’; ‘‘How satisfied are you with the interest
and skill involved in your job?’’

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