Psychological Distress Among International Business Travelers - April 27, 2000

James Striker, PhD, Clinical Psychologist, Joint Bank-Fund Health Services Department

DR. QUICK: Our first speaker is Jim Striker, who is a clinical psychologist in the Joint Bank-Fund Health Services Department here at the World Bank and the IMF.

Jim heads the department's counseling service, consults about work stress and contributes to research on stress. A very nice article that he was lead author on just came out last year.

His previous experience was in community mental health and private practice of psychotherapy and group and organizational consulting. Dr. Striker has consulted to and worked at the Bank and IMF for more than ten years. Please help me welcome Jim Striker.

[APPLAUSE.]

DR. STRIKER: Thank you, Jim.

As Dr. Liese said a few minutes ago, when we made our discovery that psychological stress and psychological health states were a concern for travelers, we were a bit surprised. That might sound kind of funny from an occupational health department. Yet, although we were familiar with the experience of travelers and concerned about their psychological and physical health and the doctors and nurses in our clinic heard stories along the way, we really didn't know that there was a measurable, larger scope of the problem.

So, we decided to ask the travelers in a more formal way just what their experiences were and also to see if we could possibly identify what were the main contributors to their stress. We published the results of this travel survey in an article last year in the April, 1999, issue of Occupational and Environmental Medicine, which I am going to talk about this morning.

That survey took a while to develop and we implemented it here and we got actually quite a good reception. The authors on the study, all of whom but one, are here. There are a couple colleagues here from our Health Services Department, Lorraine Nagy and Bernhard Liese, and then several people from our epidemiology consulting company, Applied Epidemiology, Rose Luippold, Carol Bigelow and Ken Mundt. And this really was a good joint effort.

We have only in the past several years really ventured into this area of doing research on our travelers and the rest of our staff.

Since there were no questionnaires available when we decided to do the survey, no questionnaires that really answered our questions about international travelers, we decided to develop our own, and we did that through a several step process.

First of all, we randomly selected travelers from around the organization and invited them to participate in focus groups. And we got a reasonably good response rate. We had some focus groups and the discussion really centered around, first of all, what were the travelers' experiences before, during and after mission travel. And then what were the things that were most stressful for them?

Out of these focus groups, we developed some themes and some questions that we thought would be very important for our survey. Then, we put these questions together in a survey; we sent it back to the people who were in the focus groups and we had our occupational health staff in our clinic look it over for accuracy, for meaning, for relevance to the travel experience of the travelers.

What we ended up with was a 51-item survey, mostly of scaled items, also some yes or no questions, and a number of write-in responses which we thought were very important, because we knew something about travelers but we wanted to hear a little bit more and learn more than we knew at that point.

We distributed this survey to a random sample of 1,293 travelers in the Bank Group, which was stratified according to age, gender, number of missions and number of days on travel during the previous year. And we sent that out through our inter-office mail, desk to desk, to those potential respondents.

I should say that in the Bank we have done—not we, but the organization has done—a lot of surveys over the years. The response rate is typically on the low side, 25 to 40 percent; 40 percent is actually a good response rate in the Bank. So, to help us with this, to see if we could get a little better response rate, we used a lottery for prizes as an incentive. We had a separate piece of paper in the questionnaire that people could check off and sign their names to and mail separately to us, and we trusted them to say they actually were filling out the questionnaire, and they entered the lottery for some prizes, like dinner at a nice restaurant or tickets to the theater. Our budget was limited but they were nice prizes.

We were hoping that would increase the response rate. And I think that is a very important point here because I think when you are doing surveys in an organization like this, it is a real challenge to get people to send them back, particularly the population that we are looking at. What are they spending most of their time doing? Traveling and writing reports.

So, we were trying to figure a way to get more of them to take notice.

We also guaranteed anonymity. We thought that was very important because of the personal and sensitive nature of a number of the questions. Because of that, I am not able to tell you anything about the people who did not respond. I am sure there are some of you thinking about that already, but we really thought that anonymity would make it more likely that people would send us the survey back.

To analyze the data, we looked at frequencies of response to questions; we did some content analysis of the written responses; and with some of the variables we chose as outcome variables and contributors to stress, we did a canonical correlation analysis.

QUESTION FROM AUDIENCE: How many did you say you got back?

DR. STRIKER: Very good question. I will tell you in just a minute but I just wanted to go over very briefly what the variables were.

The outcome variables were two questions about stress. The first one was a very general question that was saying overall "how much stress did you experience related to your travel in the past year?" The second was: "How much did you think you suffered from health problems related to that travel stress?" The contributors of the sources of stress were really from three different areas—from work pressures, family and personal matters and from health concerns. And we had one question about work pressure and that was: "How manageable was your work when you came back from travel?", rated from very easily manageable to almost unmanageable.

The family questions and personal life questions, I will read them to you here. "How often were you preoccupied with personal and family concerns? To what extent did you feel isolated from family and friends? And what was the impact of your travel schedule on your family and personal life?"

Finally, we had some health-related questions including one about their concern over a set of symptoms that are characteristic of jet lag. The next was how often did people worry about personal health and safety while traveling, and the last one was whether they thought it was necessary to take a day of rest after travel. That is not something that we thought up ourselves, but that is something that came up in the focus groups and that is why we included that one.

The last item is one we added in one of our analyses, which had to do with time zone travel, because obviously that is an extremely important issue, the effect of time zone travel on functioning. But we were not able to actually measure a number of time zones. What we did was ask people to tell us what their primary region of travel was for the previous year.

And 63 percent of the people had a single region they traveled to. That gave us kind of an imperfect proxy for time zones. We could at least assume that people who said East Asia and South Asia had traveled many time zones and those that said Latin America had traveled very few. So, it was a kind of imperfect proxy.

With regard to the response rate—we will get to some of the results—it was not great. We got 39 percent of these surveys back, which was 498 usable surveys, and that is not very good for most scientific studies. Notwithstanding that, we were pleased in the Bank actually that we got that many back.

And, as you can see from this slide, there were about 70 percent men and about 30 percent women traveling, and the age ranges, we are a middle-aged population; the travelers are middle-aged, and our sample here is very similar to the travelers in the World Bank; 56 percent of them were 45 years of age or older. These proportions are fairly close to what we see in the overall traveling population, even beyond the sample that we sent surveys to.

With regard to travel patterns, there is a pretty even distribution of respondents, except those that traveled the least are the least represented. Also, that is characteristic, at least at the time, of travelers in the Bank— there were fewer that traveled less.

We are little bit over-sampled on those that traveled six missions or more. And that is good because we wanted to know as much as we could about the effects of frequent travel.

In general, just overall—I will get to some of the analyses in just a minute—but overall, we had from the written responses and from some of the questions that people answered a picture of what life is like for the traveler.

First and foremost, it is important to say that we got spontaneous comments in both the focus groups and on the surveys that travelers really do find a lot of meaning in the work that they do while they are traveling. It is very important to them. They are doing the work that they came to the World Bank for. The relationship and the work with the client in the field is very important to them. And they really feel like they are able to focus and get quite a lot done while on mission.

I think that is something important to keep in mind, and I think it is true in most organizations and corporations with regular travelers. These are not people who are complaining about their work; to the contrary, they are motivated to do a lot of work and they are absorbing a great deal at the same time.

Second, clearly, work pressures were high. Third, overall, there is definite impact on family and personal life. And finally, the balance between work and outside life is a real challenge. And you will see the results on a couple of items.

One of the questions we had was an open-ended question for writing in. And when we came near the end of the survey, we decided to let people answer the other questions first and then at the end give them an opportunity to say what are the greatest pressures from travel. We got about 150 people who wrote in answers, and it broke out the way you see it there. About 48 percent said family and personal issues were the greatest pressures having to do with their travel stress. 41 percent said work, and about 10 percent said health.

I am going to keep things moving here, but I thought it would be useful, since I am reporting mostly numbers, just to read a couple of comments to you that were written in on this survey about travel.

First of all with the family and personal impact, things like "My wife doesn't like it when I go away... I am losing track of my children's development... Keeping in close and frequent touch with my teenaged daughter is very difficult... The kids are miserable and regress in development... My husband gets cranky over the extra work and the extra child care costs."

And one that I think is very important here because we are talking about long-standing patterns of travel and a career of travel "In the long-term it causes you and your family to draw away from one another", which I think is a very, very important theme here. And, you know, these travelers are not people that very easily report vulnerabilities in themselves. They are very resilient people. I think we need to pay attention to things like this in organizations.

And the responses to questions about work pretty much can be summarized in that it is the amount of work, it is the overload, it is the fact of having to accomplish a great deal in a very short period of time, and also having all of your work back at headquarters not only waiting for you when you get there but having to be done through e-mail and telephone while you are away on travel.

Now the health questions, the health concerns that people had, clustered pretty much in terms of fatigue, mental and physical fatigue, and a kind of drain on people's lives. These are some of the content questions, but I think this gives some richness to the numbers that we are looking at here.

What I wanted to show you here are the variable items that we use for analysis, just some frequencies, some percentage responses. This graph shows the percentage of respondents who reported very negative ratings on a five-point Likert scale. That means four and five on a five-point scale. The orange bar represents the overall stress related to travel, and 36 percent of our travelers reported a lot of stress.

The red line there, the sort of unorthodox representation on the graph because I couldn't fit another bar in, represents the proportion of people who reported physical or psychological health problems because of travel and that is around 15 percent.

Then you have in increasing magnitude the negative ratings for jet lag symptoms (22%), concerns about safety and health while traveling (29%), and preoccupation with personal and family matters (31%). Next was a feeling of being isolated from family and friends while traveling (35% experienced this strongly).

Then, we have the big ones, the overall work impact of a heavy workload (55%), and, finally, the negative impact on family and personal life (more than 60% percent of the travelers).

We then did a canonical correlation analysis, looking at the relationship of the set of the variables in the green bars, the sources of stress, with the red and orange ones, the stress outcomes. And we used what a lot of people have questioned me about Ð a very sophisticated statistical technique on some very simple data. And the reason we did that is we wanted to consider all of these variables simultaneously. We didn't want to do just bi-variate correlations. We wanted, if possible, to maybe get what seemed more of a real life kind thing by looking at all these factors simultaneously.

So, we looked at the two stress questions as a group, related to the sources of stress as a group. And those of you who are familiar with multiple regression, this is a multiple regression technique. It just allows us to use multiple outcome variables which is convenient. It makes a little bit of a challenge in interpreting the relationships but it is very useful.

So, what did we find? The canonical correlation which is a regression coefficient, similar to a correlation, was 0.69, and that is the correlation between the set of sources of stress and the outcome variables, which is good. And that correlation coefficient explains 40 percent of the variation between those two variables, their relationship, which is actually substantial, 40 percent.

What we found though was that the coefficients, in other words, the contribution of each of these items to the relationship was moderate to low for each one of those sets of variables. And I will very quickly go over this slide which is clear but not necessarily easily readable. I won't take a lot of time on it.

It lists in rank order basically—it is not in your set of handouts I don't think—it lists in rank order the items, the weighting of each of the predictor items, if you will, to the whole set of predictor items. And you can see the one that correlated the highest is the one that the highest percentage of staff rated very negatively, which is impact on family and personal life. I am not going to go through all of this in detail.

But I think what stands out for us is that among all those variables, three of them that contribute to that relationship in a significant way are psycho-social issues. At the bottom there, it just tells you how much the stress items contributed to the outcome set, and they are pretty close there, although it looks like problems with health added a little more.

So, we got a significant correlation between the predictors and the outcomes, which we think is important. Basically, we got a reinforcement of what we found in our focus groups, which was very interesting, and it told us about the power of focus groups and focus group discussions, how much you can get from that kind of discussion.

One of the things that did not correlate, that did not contribute to the stress was the time zone travel, you know, what region of the world people traveled to. We are not sure why. It was unexpected; we thought that would contribute. Maybe we just didn't measure it well, didn't define it very well. Maybe also there is some issue of having adapted travelers, and maybe in going regularly to different regions of the world, they found ways to cope with the jet lag and things like that.

A final thing, though, is maybe it has something to do with the environments they are going to. It might be different going to Latin America versus Central Asia to do the work. Also, there are different managers; the stress might have something to do with the way the work is managed which might have confounded the effect of destination.

Well, this gets us down to the last couple of minutes here, but really if travelers are so stressed, then what do they do about it? How do they cope? We have heard all kinds of stories here about the experiences of travelers. We are seeing from a survey that people report these types of problems.

Well, mostly our travelers say they rely on themselves; that is how they cope. And they rely on themselves on their business trips by exercising, taking rest when they can, making calls home, having e-mail connection with home. Telephone calls were very, very important to our staff. A number of them said they wished there were more and that more were authorized really from the field.

Also, a number of people engaged in what I call family rituals, for example having some kind of special meal with their spouse or partner or with the kids before they go. One staff member said that he writes little notes to his four-year old child and that child reads them every day or every other day and can read something from Dad while he is away. Another one said the child gives him something special to pack in his suitcase. So, there are various ways that the travelers have figured out to cope with the emotional impact on the family.

And I have to tell you we have learned a great deal from our travelers because they really are experts at this. They are not all stressed over the edge, but I think the fact that they are experts is important for all of us as occupational health professionals to learn from.

Finally, I want to show you what they say about relying on themselves. We asked two questions about maintaining work-life balance. The green bars are the answers to: "Whom do you actually rely on to maintain good balance between work and the rest of your lifeÉ yourself, family/friends, your manager, or the institution?" The orange ones are responses to : "Whom do you think you should rely on?" And you might just take a second to look at that slide.

There is a definite shift in whom they do rely on and whom they think they should be able to rely on. More than 80 percent of them said they rely on themselves. When we asked them whom they should, almost 50 percent said the institution.

And what would they like from the institution? Well, first they would like guaranteed and approved time off after mission travel. Most of the travelers said, you know, we don't take it, we are so busy. The work culture and our managers don't really support it, even though it is an option.

The second thing was having a more realistic workload. And I think this has a lot to do with how the work is managed when you are traveling on mission and you have a lot of work back at the office. And there is not an easy answer here about what to do about that. And I think that is why it is so important that we have HR professionals here and management experts, because we are not just talking about health issues, but we are also talking about the management of work. The third one is something we all would like less of and that is paperwork and administrative requirements. The last one is some more control over the scope and length of their mission travel.

So, finally, what does that imply with respect to an occupational health strategy? First of all, the first action has to be education, education not only of the travelers but education of occupational health professionals and education of the institution. We do here in the World Bank—and I hope you all do in your organizations—at intervals communicate upward to senior management what we are finding out with our health research. That is key for any changes that occur.

Down at the level of direct occupational health and self-care, it really I think requires a team, and the team is the occupational health professional and the traveler, bringing expertise and experience together in what are good approaches to stress management, what are good approaches to life management and decision-making.

And finally, and this is the trick and the challenge for all of us, evaluating the impact of what you do. I don't have any answers about that, but that is something we are working on here.

Thank you very much.

Disclaimer: These Proceedings have been produced from transcripts made from audio tapes. Efforts were made to check the accuracy of information with the various authors, but this accuracy is not guaranteed. If there is information that you believe requires correction, please send a message to our e-mail address.