Journal of Cancer Therapy, 2012, 3, 680-688
http://dx.doi.org/10.4236/jct.2012.325088 Published Online October 2012 (http://www.SciRP.org/journal/jct)
The Relationship between Workplace Stressors and Job
Strain with Psychological Distress among Employed
Malaysian Breast Cancer Survivors
Heng Weay Yong1, Hashim Zailina1*, Jamil O. Z ubaid ah2, Moin Saidi3
1Department of Environmental and Occupational Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Ser-
dang, Malaysia; 2Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia;
3Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.
Received August 7th, 2012; revised September 10th, 2012; accepted September 22nd, 2012
ABSTRACT
Evidence showed occupational factors may contribute distress to breast cancer survivors, however, very few studies
focused on the occupational factors and job strain among breast cancer survivors. This study examined the relationship
between job strain and workplace stressors with psychological distress among employed breast cancer survivors after
the completion of their medical treatment. Study subject were outpatients of 2 hospitals and members of 4 breast cancer
support groups. They were requested to fill up the Job Content Questionnaires (JCQ), the Hospital Anxiety and Depres-
sion Scale (HADS) and the Distress Thermometer (DT) were filled up by the selected respondents. On simple logistic
regression, psychological job demand and job strain were significantly associated with anxiety, distress on HADS-T and
DT at (p < 0.001). While, psychological job demand (p < 0.001), social support (p = 0.047) and job strain (p < 0.001)
were significantly associated with depression. Results showed survivors with high job strain has 4.74 time the odds of
having anxiety (p < 0.001). Survivors with high psychological job demand have 8.08 time the odds of getting depres-
sion (p < 0.001). On the other hand, social support served as a protective factor of depression, (p = 0.041). Survivors
with high psychological job demand were 4.4 time the odds of having distress (HADS-T) (p = 0.012). As a conclusion,
survivors who experienced high psychological job demand, low social support and high job strain were reported with
anxiety, depression or psychological distress.
Keywords: Breast Cancer Survivors; Workplace Stressors; Job Strain; Psychological Distress
1. Introduction
The outcome of job strain is workplace stress which is
considered as a health hazard which arises from inter-
actions of workers and the work demands [1]. Many em-
ployers tend to deny the existence of workplace stress.
From the employers’ perception, workplace stress is a
personal problem. Some argues that one should be able
to cope with it if they are employed as it is voluntary and
it comes with the job, thus, not considered as a work-
place hazard. Through time, more researchers found job
strain to be a significant health hazard [2,3]. It is a seri-
ous health and safety hazard with devastated effects
causing mental illnesses to the workers. It is mainly due
to the poor match between work demand with work abil-
ity and one does not have a reasonable control over work.
Factors from workplace that lead to stress are called
workplace stressors. According to Karasek’s Job Demand
Model, there are 4 key principal factors contributing to
job strain, such as psychological job demand, decision
latitude, social support and job insecurity [4]. Psycho-
logical job demand refers to the workload, work re-
quirements and organizations’ constraints of the workers,
while decision latitude includes two dimensions such as
skill discretion and decision authority. Skill discretion is
the skill and creativity of workers on the job requirement,
while decision authority is the flexibility and possibilities
of workers to make own decision. The third key factor of
workplace stress in job demand model is social support,
which refers to support from co-workers, supervisor or
management levels and also the interpersonal hostility.
The last factor is job insecurity which depends highly on
the market requirement for skills and career possibilities.
Strong relationships were found between job strain
with emotional distress (anxiety, depression), short term
health effects (headache, nausea) and long term health
effects (cardiovascular disease, cancer) [5,6]. Previous
*Corresponding author.

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
681
findings showed workplace related factors such as high
psychological demand, low decision latitude and inter-
personal conflict are common predictor of psychological
distress such as anxiety and depression, fatigue and some
physical illness, while social support served as a protec-
tive factors to psychological distress [7,8]. Job strain and
its associated effects lead to poor work performance and
poor ability to conduct work task but unfortunately, the
presence of job strain is unnoticed [9,10]. In Malaysia, a
study showed that about 52.3% of the breast cancer cases
were below 50 years [11]. Therefore, most of the survi-
vors were capable of returning to work after their treat-
ment. Many survivors continued employments after di-
agnosis and treatment, because they believed that em-
ployment was an important measure of recovery [12].
Females had significantly higher job strain than male
cancer survivors [13]. Many survivors who return to
work experienced difficulties due to physical changes,
psychological distress associated with cancer as well as
the treatment and inadequate work-related support [14].
There is a substantial evidence that occupational and en-
vironmental factors contribute to the burden of distress,
however, few studies had focused on employed breast
cancer survivors. This study examined the relationship
between job strain and workplace stressors with psycho-
logical distress level of breast cancer survivors after re-
turning to work.
2. Materials and Methods
In this study, respondents were made up of breast cancer
survivors who were outpatients of 2 hospitals (Hospital
Kuala Lumpur and Hospital Seberang Jaya) and mem-
bers of 4 breast cancer support groups (Segamat, Johor
Bahru, Bangi and Ipoh). The respondents were required
to complete the Job Content Questionnaires (JCQ), Hos-
pital Anxiety and Depression Scale (HADS) and Distress
Thermometer (DT).
Job Content Questionnaire (JCQ) developed by Karasek
et al. [7] was used to determine the occupational stress-
ors and levels of job strain at the workplace. This ques-
tionnaire was developed based on the demand-control
model. The 25 items of JCQ consisted of 4 scales. They
are the Psychological Job Demand (5 items), Decision
Latitude (9 items), Social Support (8 items) and Job In-
security (3 items). These scales are determinants of job
strain. The demand-control model showed high job strain
occurred when Psychological Job Demand was high
or Decision Latitude was low whereas Social Support
served as the protective factors for job strain. Each item
in the scales were given scores on a 4-point Likert scale
(strongly disagree, disagree, agree and strongly agree; or
often, sometimes, rarely and never). The scores were
then calculated by using formula for the Job Content In-
strument Scale provided in the JCQ.
Psychological distress measured by Hospital Anxiety
and Depression Scale (HADS) and Distress Thermome-
ter (DT). HADS is a 14-items scale designed by Zig-
mond et al. [15] which is used to measure the depression
and anxiety levels. This 14 items questionnaire can be
divided into 2 subscales, in which 7 items measure the
anxiety level (HADS-A) and depression level (HADS-D)
respectively. Each item was scored on a 4-point Likert
scale of 0 - 3, giving each anxiety and depression a maxi-
mum score of 21 respectively and a total maximum score
of 42 for both. Scores of <8 were considered as “non-
cases” or normal while scores of ≥8 are considered as
cases. A total score of ≥15 indicates psychological dis-
tress (HADS-T) [16,17].
Distress Thermometer (DT) with problem checklist is
a screening measurement developed by National Com-
prehensive Cancer Network [18], assesses and identifies
the psychological distress and its contributing factors.
Distress thermometer scale consists of 11 points, which
ranged from 0 for no distressed to 10 for extreme distress.
Respondents were requested to circle the numbers that
represent their distress levels in the past week. Respon-
dents with score of ≥4 were considered as having dis-
tress [19]. The problem checklist consists of 33 items
which are distress contributing factors. These 33 items
are categorized into 5 categories such as practical (4
items), family (3 items), emotional (8 items), spiritual or
religious (3 items) and physical (23 items).
3. Results
3.1. Socio-Demographic Background and
Occupational Information of Respondents
A total of 150 breast cancer survivors made up of 114
(76.0%) hospital outpatients and 36 (24%) members of
breast cancer support group were recruited. The mean
age of respondents were 49.1 (7.1) years. They were
mainly Malay (50.6%), followed by Chinese (44.7%) and
Indian (4.7%). The education levels ranged from no for-
mal to tertiary education, the majority with secondary
education (52.0%). Most were married (76.0%), diag-
nosed with Stage II cancer (57.3%) and more than half
did not have family history of breast cancer (56.7%).
Majority were employed in the private sector (60.0%)
followed by the government sector (24.7%) and self-
employed (25.3%). Most respondents have normal work
hours (94.0%) and did not use chemical in their work-
place (85.3%). They were currently employed for 5.8
(6.4) years and the mean income was RM 2172.8
(1548.4) (Table 1).

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
682
Table 1. Socio-demographic and occupational information
of respondents.
Variables No. of subjects (%)
Recruitments of respondents
Hospital
Support group
114 (76)
36 (24)
Age (Mean ± std dev.) 49.11 ± 7.10
Ethnicity
Malay
Chinese
Indian
76 (50.7)
67 (44.7)
7 (4.6)
Marital status
Married
Single
Widowed
Divorced
114 (76.0)
17 (11.3)
13 (8.7)
6 (4.0)
Education level
No formal education
Primary
Secondary
Tertiary
6 (4.0)
29 (19.3)
78 (52.0)
37 (24.7)
Stages of cancer
Stage I
Stage II
64 (42.7)
86 (57.3)
Family history of breast cancer
Yes
No
65 (43.3)
85 (56.7)
Duration of employment (years)
(Mean ± std dev.) 19.34 ± 10.32
Employment
Private
Government
Self-employed
90 (60.0)
37 (24.7)
23 (15.3)
Shift work
Normal hours
Shift work
141 (94.0)
9 (6.0)
Use of chemical at the workplace
No
Yes
128 (85.3)
22 (14.7)
Current employment (years)
(Mean ± std dev.) 5.8 ± 6.4
Salary incomes (RM) (Mean ± std dev.) 2172.8 ± 1548.4
N = 150.
3.2. Prevalence of Work Stressors and Job Strain
Most of the respondents reported high psychological job
demand (52.7%), high decision latitude (50.7%), high
social support (51.3%) and high job insecurity (56.7%).
While, only 26.0% reported high job strain (Table 2).
3.3. Psychological Distress Levels Using HADS
and DT
By using the recommended threshold value of 8 for dis-
order caseness (including borderline cases), 23.3% of the
respondents were classified as anxious and 19.3% as de-
pressed, while 22.0% were distressed (HADS-T ≥ 15)
(Table 3). Table 4 shows the distress levels of re-
spondents according to the DT and its checklist. The
prevalence of distress was 14.7% according to the DT.
The frequencies of items checked in the checklist were
examined by multiple response analysis. The most com-
mon problems associated with distressed (N = 60) were
those related to family (70.0%), followed by emotional
problems such as sad, lonely, angry , remorse and disap-
pointed (65.0%), physical problems and symptoms such
as diarrhea, respiratory difficulties, hot flashes, dryness,
insomnia and tiredness (60.0%), practical problem such
health care, finance, housing and transport (50.0%) and a
few on spiritual or religious such as loss hope or direc-
tion in life (15.0%).
3.4. Relationship between Work Stressors and
Job Strain with Psychological Distress Using
Both HADS and DT
Tables 5-8 showed the statistics on the influence of
Table 2. Distributions of workplace stressors and job strain
of respondents.
Variables n (%) MedianRange
Psychological job demand
High
Low
79 (52.7)
71 (47.3) 32 18 - 45
Decision latitude
High
Low
76 (50.7)
74 (49.3)
58
30 - 80
Social support
High
Low
77 (51.3)
73 (48.7)
24
8 - 32
Job insecurity
High
Low
85 (56.7)
65 (43.3)
9
6 - 12
Job strain
High
Low
39 (26.0)
111 (74.0)
N = 150.

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
683
Table 3. Distributions of psychological distress levels using
HADS.
Variables Frequency (n) Percentage (%)
HADS
Anxiety score
Normal (0 - 7)
Anxious (≥8)
115
35
76.7
23.3
Depression
Normal (0 - 7)
Depressed (≥8)
121
29
80.7
19.3
Psychological Distress
Normal (0 - 14)
Distressed (≥15)
117
33
78.0
22.0
N = 150.
Table 4. Prevalence of distress using DT with checklist.
Variables Frequency (N) Percentage (%)
Psychological distress
Normal
Distressed
128
22
85.3
14.7
Problem checklist categories (N = 60)
Family
Emotional
Physical
Practical
Spiritual/religious
42
39
36
30
9
70.0
65.0
60.0
50.0
15.0
Statistical test-multiple response analysis N = 150.
selected socio-demographic factors, workplace stressors
and job strain on anxiety, depression and distress using
both the HADS and DT scales. Simple logistic regression
analysis of 2 socio-demographic factors and 5 work-
place stressors showed psychological job demand and
job strain were significantly associated with anxiety on
HADS-A (p < 0.001), distress on HADS-T (p < 0.001)
and DT (p < 0.001). While, psychological job demand (p
< 0.001), social support (p = 0.047) and job strain (p <
0.001) were significantly associated with depression on
HADS-D. No significant association found between an-
xiety, depression and distress with job insecurity using
both HADS and DT. Statistics showed socio-demogra-
phic including employment and stage of cancer were not
significantly related to anxiety, depression and distress
using both HADS and DT (p > 0.05).
Table 5 shows that job strain is the only predictor for
anxiety. Results showed that survivors with high job
strain have 4.74 times the odds of having anxiety com-
pared to those with low job strain (p < 0.001). Table 6
shows survivors with high psychological job demand to
have 8.08 times the odds of getting depression (p <
0.001). On the other hand, social support was a protec-
tive factor for depression (p = 0.041).
Tables 7 and 8 shows psychological job demand was
predictor for both distress using HADS-T and DT while
job strain is the predictor for distress on DT. Survivors
with high psychological job demand were 4.4 times the
odds of having distress (HADS-T) (p = 0.012). Table 8
shows that survivors with high psychological job demand
were 6.09 times the odds of having distressed (p = 0.032)
and survivors with high job strain were 3.17 times the
odds of having distressed (p = 0.037) on DT. These re-
sults reflected a good overall fitness of the model when
Hosmer-Lemeshow test (p > 0.05) and the area under the
ROC curve (AUC) were at least 70% in the accuracy
discrimination of cases (Tables 5-8).
4. Discussion
Psychological morbidity including anxiety, depression
and distress are common health issues among cancer
survivors and can further lead to the hospitalization of
distress patients. Thus, there is a need to identify the
causes and psychological morbidity of survivors. This
study showed the prevalence of anxiety (7.3%), depress-
sion (4.7%) and distress (22%) among respondents using
the HADS while 14.7% distressed on DT and this preva-
lence were lower than other local studies [20,21] and
overseas studies [22,23]. The difference between the
prevalence may be due to the difference in the selection
of respondents. This study was among patients who had
completed all their medical treatments, however, others
were among breast cancer patients who were undergoing
chemotherapy. Findings showed the breast cancer pa-
tients suffered incredible stress during their treatment
thus their distress level were higher, whereas those who
had completed the active treatment were less stressed
[24,25]. Previous study found that the prevalence of
anxiety and depression among employed survivors were
lower than the unemployed because they felt that they
had better chance of improving their social position and
securing more social support [26].
Those with anxiety would normally have the coexis-
tence of depression [27]. Similar findings occurred
among the Malaysian breast cancer survivors as well,
where 15.3% of the respondents with anxiety were de-
pressed at the same time. However, this prevalence was
lower as compared to a data from a National Morbidity
Survey which showed that the prevalence of patients
with coexistence of depression and anxiety were 51%
[27], however, another local study found a prevalence of
12.5% for coexistence of depression and anxiety among
cancer patients [21].

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
684
Table 5. Predictor of anxiety using HADS-A models.
SLR1 MLR2
Variables
b Crude OR (95% CI)p b Adjusted OR (95% CI) p
Employment
Government
Private
Self-employed
0.00
–0.72
–0.31
1
0.49 (0.20, 1.16)
0.74 (0.23, 2.34)
-
0.102
0.603
-
-
-
Stage of cancer
Stage I
Stage II
0.00
0.62
1
1.87 (0.84, 4.16)
-
0.128
-
- -
Psychological Job Demand
Low
High
0.00
1.41
1
4.09 (1.71, 9.76)
-
0.002**
- - -
Decision Latitude
Low
High
0.00
0.04
1
1.04 (0.49, 2.22)
-
0.918
- - -
Social Support
Low
High
0.00
–0.60
1
0.13 (0.26, 1.19)
-
0.550
- - -
Job Insecurity
Low
High
0.00
–0.28
1
0.76 (0.36, 1.62)
-
0.476
- - -
Job Strain
Low
High
0.00
1.56
1
4.74 (2.10, 10.70)
-
<0.001***
0.00
1.56
1
4.74 (2.10, 10.70)
-
<0.001***
1SLR = Simple Logistic Regression; 2MLR = Multiple Logistic Regression; **Significant at p < 0.01;***Significant at p < 0.001; N = 150;
Hosmer-Lemeshow test, (p = 0.277), and area under the ROC curve (73.2%) were applied to check the model fitness.
Results showed psychological job demand were sig-
nificant predictor of depression (OR = 8.08, p < 0.001),
distress (OR = 4.4, p = 0.012) using HADS-D and
HAD-T respectively as well as DT (OR = 6.09, p =
0.032). High psychological job demand was capable of
inducing depression and psychological distress. Similar
to other studies which found that psychological job de-
mand as an indicator for psychological morbidity dis-
orders among workers and significant association found
between job demand with psychological distress or men-
tal illnesses [8,9,28]. Workers with high psychological
job demand tend to get psychological distress, which
seemed to also occur among breast cancer survivors [29].
Evidence showed decision latitude was significantly
associated with psychological morbidity either with psy-
chological job demand or on its own. Although, previous
researches showed decision latitude was related with
psychological disorders and served as a protective factor
for distress [8] however, in this study, decision latitude
was not a predictor and was not significantly related to
anxiety, depression or distress as found by Bultmann, et
al. [30].
Majority of respondents reported high level of social
support (51.3%), which meant that there were supports
from their co-workers or supervisors. In this study, sig-
nificant association was found between social support
with depression and it served as a protective factor for
depression (OR = 0.39, p = 0.041). Similar to other stud-
ies [28,31], who also found that high social support was a
protective factor as a buffered effect on psychological
distress. Besides, Kawakami et al. [28] showed worksite
support was an important factor which would influence
job strain and also mental health. Workplace problems
are usually related to poor interaction with colleagues
and lack of support from co-workers and employers [32].
Positive social support encouraged them to return to
work and hence reduced the risk of work disability or
distress, as shown in some studies [33]. Those with high
social support would have a low distress and better qual-
ity of life [34].

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
685
Table 6. Predictor of depression using HADS-D models.
SLR1 MLR2
Variable b Crude OR (95% CI)p b Adjusted OR (95% CI) p
Employment
Government
Private
Self-employed
0.00
–0.70
–0.29
1
0.50 (0.20, 1.25)
0.75 (0.22, 2.56)
-
0.138
0.646
- - -
Stage of cancer
Stage I
Stage II
0.00
0.43
1
1.53 (0.66, 3.57)
-
0.323
- - -
Psychological Job
Demand
Low
High
0.00
2.05
1
7.76 (2.54, 23.64)
-
<0.001***
0.00
2.09
1
8.08 (2.62, 24.96)
-
<0.001***
Decision Latitude
Low
High
0.00
–0.12
1
0.89 (0.40, 1.99)
-
0.774
- - -
Social Support
Low
High
0.00
–0.86
1
0.42 (0.18, 0.99)
-
0.047*
0.00
–0.93
1
0.39 (0.16, 0.96)
-
0.041*
Job Insecurity
Low
High
0.00
–0.08
1
1.08 (0.48, 2.44)
-
0.86
- - -
Job Strain
Low
High
0.00
1.66
1
5.24 (2.22, 12.41)
-
<0.001***
- - -
1SLR = Simple Logistic Regression, 2MLR = Multiple Logistic Regression, *Significant at p < 0.05, ***Significant at p < 0.001, N = 150, Hos-
mer-Lemeshow test, (p = 0.289), and area under the ROC curve (78.5%) were applied to check the model fitness.
Table 7. Predictor of psychological distress using HADS-T models.
SLR1 MLR2
Variables b Crude OR (95% CI)p b Adjusted OR (95% CI) p
Employment
Government
Private
Self-employed
0.00
–0.60
–0.42
1
0.55 (0.23, 1.33)
0.66 (0.20, 2.22)
-
0.184
0.498
- - -
Stage of cancer
Stage I
Stage II
0.00
0.51
1
1.66 (0.74, 3.72)
-
0.222
- - -
Psychological Job Demand
Low
High
0.00
1.98
1
7.25 (2.62, 20.08)
-
<0.001***
0.00
1.48
1
4.40 (1.38, 13.99)
-
0.012*
Decision Latitude
Low
High
0.00
0.04
1
1.04 (0.48, 2.26)
-
0.912
- - -
Social Support
Low
High
0.00
–0.78
1
0.46 (0.21, 1.02)
-
0.054
- - -
Job Insecurity
Low
High
0.00
–0.11
1
0.90 (0.41, 1.95)
-
0.781
- - -
Job Strain
Low
High
0.00
1.70
1
5.49 (2.39, 12.61)
-
<0.001***
- - -
1SLR = Simple Logistic Regression, 2MLR = Multiple Logistic Regression,*Significant at p < 0.05, ***Significant at p < 0.001, N = 150, Hos-
mer-Lemeshow test, (p = 0.182), and area under the ROC curve (77.0%) were applied to check the model fitness.

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
686
Table 8. Predictor of distress using DT models.
SLR1 MLR2
Variables
b Crude OR (95% CI) p b Adjusted OR (95% CI) p
Employment
Government
Private
Self-employed
0.00
–0.91
0.01
1
0.40 (0.14, 1.14)
1.01 (0.29, 3.56)
-
0.087
0.991
- - -
Stage of cancer
Stage I
Stage II
0.00
0.79
1
2.21 (0.81, 6.01)
-
0.12
- - -
Psychological Job Demand
Low
High
0.00
2.46
1
11.70 (2.62, 52.13)
-
0.001**
0.00
1.81
1
6.09 (1.17, 31.77)
-
0.032*
Decision Latitude
Low
High
0.00
–0.03
1
0.97 (0.39, 2.40)
-
0.946
- - -
Social Support
Low
High
0.00
–0.95
1
0.39 (0.15, 1.01)
-
0.053
- - -
Job Insecurity
Low
High
0.00
0.12
1
1.12 (0.45, 2.82)
-
0.804
- - -
Job Strain
Low
High
0.00
1.98
1
7.21 (2.73, 19.07)
-
<0.001***
0.00
1.16
1
3.17 (1.07, 9.05)
-
0.037*
1SLR = Simple Logistic Regression, 2MLR = Multiple Logistic Regression, *Significant at p < 0.05, **Significant at p < 0.01, ***Significant at p <
0.001, N = 150, Hosmer-Lemeshow test, (p = 0.833), and area under the ROC curve (84.1%) were applied to check the model fitness.
In general population, high job strain was a common
contributor to mental disorders such as anxiety, depres-
sion or distress [6,7]. However, job strain after returning
to work among cancer survivors was not given attention
with few studies focused on these. To date, only one
study by Gudbergsson et al. [13] was carried out on job
strain among primary-treated cancer survivors. The study
found job strain was not related with survivorship but
with socio-demographic, anxiety and personality trails.
Similarly, this study showed 26% of the employed sur-
vivors had high job strain which was a significant pre-
dictor for anxiety and distress. However, none of the
socio-demographic variable or cancer history was related
to job strain and psychological distress. Just as other
studies which found cancer diagnosis stage not signifi-
cantly related to distress or psychiatric morbidity [21].
Little attention was given on job strain and distress by
medical practitioners during their treatment follow-up,
made it difficult to identify and recognized these prob-
lems among the cancer survivors. There might be also be
other environmental factors which influenced psycho-
logical morbidity such as family and diseases factors.
This study had limitations in which the results were
based on self-reported measures, thus, method bias, which
resulted in shared variance of the measurement attributed
to instrument rather than association between constructs
might occurred. Sampling bias might also occur because
unrandomized sampling. Work-related information on
cancer cases are not easily available due to high unem-
ployed rate of survivors, Only 150 survivors participated
in this study. Besides these, respondents may have high
tendency of denial or not being honest about their dis-
tress conditions to avoid being treated as mentally ill
patients.
Improvement over treatment and diagnosis had led
more researches to focus on psychological morbidity;
however, factors contributing to distress were not em-
phasized. Future study should focus the detail aspects of
job strain among cancer survivors who return to work
after their treatment. An effective intervention and
awareness on survivors’ needs so as to overcome their
distress level should be recommended to the health care

The Relationship between Workplace Stressors and Job Strain with Psychological Distress among
Employed Malaysian Breast Cancer Survivors
687
workers, physician or social workers, to reduce the
prevalence of distress or workplace stress as well as to
encourage more survivors to return to work after cancer
diagnosis and treatment, and at the same time increase
their quality of life.
5. Conclusion
As a conclusion, among all workplace stressors studied,
only psychological job demand, social support and job
strain were factors that influenced distress among sur-
vivors. Survivors who experienced high psychological
job demand, low social support and high job strain were
reported with psychological distress. Psychological job
demand and job strain were significant predictor for
anxiety, depression, distress on both HADS-T and DT
scales. While, social support served as a protective factor
for depression.
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