Background {#Sec1}
==========

The workplace is an important contributor to a multitude of illnesses and is a determinant of the individual's well-being. Among numerous risks found in the workplace, one entity has emerged lately to be a major public health concern and a challenge to the occupational health research field: the psychosocial risks (PSR). Psychosocial risks appear to be at the center of the intricate architecture of the work conditions.

Previous studies support the influence of negative organizational climate on nurses' health \[[@CR1]\], as well as the interactions between the physical and psychosocial risks factors that can generate musculoskeletal disorders \[[@CR2]\]. The impact of occupational safety climate in hospitals confirms the link between PSR and workers' health \[[@CR3], [@CR4]\]. In Europe, according to the working conditions surveys, the influence of PSR factors in the workplace was the second major change in working environments \[[@CR5]\]. The European Agency for Safety and Health at Work (EU-OSHA), in its report on emerging risks \[[@CR6]\] indicated that there is a strong correlation between variables considered for inclusion in the Occupational Safety Health composite score. An imbalance between the number of industrial accidents and the number of occupational illnesses has also been noted: even if the first is decreasing, the latter is increasing \[[@CR7]\]. In France, indicators defined by experts permit to demonstrate that workplace PSR factors often contribute to the occurrence of health problems: cardiovascular diseases, mental health disorders or musculoskeletal disorders \[[@CR8]\].

As the workforce in the European Union (EU) is ageing and the work intensity is constantly increasing, questions on steps to be taken to keep the workforce active have arisen, bringing out the need for a well-designed employment policy \[[@CR9]\]. The fact that over 40 million people in the EU are suffering of consequences of work-related stress, which translates in over 20 billion € of health and absenteeism costs \[[@CR10]\], goes to underline the economic and social importance of addressing the issue of work-related psychosocial risks.

The European Commission's (EC) guidelines on work-related stress itemized the steps to be taken. The first step was identifying the risk, with its sources and consequences, by the means of monitoring "job content, working conditions, terms of employment, social relations at work, health, well-being and productivity" \[[@CR11]\]. One of the important methods of detecting work-related stress, therefore PSR, is using a risk-perception evaluation, since the individual's subjective experience will be the generator of symptoms and diseases: from transient increase in heart rate and blood pressure to developing cardiovascular diseases, and from minor indicators of anxiety or depression to clinical developments of mental health problems. EC has identified the significant proportion of employees who acknowledge the impact work has on their health, in its *Improving quality and productivity at work. Community strategy 2007*--*2012 on health and safety at work*: "35 % of workers on average feel that their job puts their health at risk" \[[@CR12]\].

Currently, international studies on occupational risks in the public hospitals are infrequent, as are researchers concentrating on psychosocial stress in Moroccan HCWs \[[@CR13]--[@CR16]\], many focusing on ethnic groups living in other countries or on patients with different conditions. The 2008 study of Laraqui et al. \[[@CR17]\] was one of the very few suggesting the need for occupational stress evaluation in Moroccan HCWs, based on findings of high stress prevalence, and the necessity for working conditions improvement.

The objectives of the present study were to assess psychosocial risk perception among Moroccan HCWs using a validated questionnaire and to analyse occupational risk factors' impact in Moroccan public hospitals. Attention was given to different aspects which influence the occurrence of "high strain" situations: ergonomics, working conditions, and to the use of analgesic, hypnotic and sedative medication. The main goal was to develop a model for high strain perception that could be used for crafting and implementing a specific prevention plan.

Methods {#Sec2}
=======

Sample {#Sec3}
------

The study was a cross-sectional multicenter investigation, conducted in Moroccan public hospitals of the three Moroccan regions: northern, central and southern. The northern region included towns above the line which joined the cities of Sidi-Kacem and Taza; the northern region hospitals were those of Kenitra, Oujda and Larache. The southern region included municipalities below the line which joined the cities of Safi and Beni Mellal; the southern region hospitals were those of Agadir and Marrakech. The central region (between the two described lines) or the Casablanca region covered hospitals of Baouafi, Sekkat, Settat and Khouribga. All public hospitals' staff was targeted. Our research obtained the approval of the Nantes Regional Ethics Committee (Comité de Protection des Personnes Ouest IV) on December 7th, 2010, for research on "Work Organisation Cancer and Health" (No. DC 2010-1199). The Moroccan Public Health Ministry's and the Moroccan Occupational Health Ethic Committee (Ref. no 312-10, Casablanca) authorization were obtained before beginning the investigation.

Material {#Sec4}
--------

The occupational risks questionnaire was distributed. It had 49 questions grouped in four subscales. The first 30 items on work and psychosocial relations (decision latitude, psychological demand and social support---sum of supervisor and coworker support) were extracted from Karasek's Job Demand Questionnaire (JCQ) \[[@CR18]\]. The next items stemmed from a validated French questionnaire \[[@CR19], [@CR20]\]: eight items targeted workplace ergonomics and three items addressed workplace environment risks. The last 8 items focused on passive smoking, alcoholism and medication use (hypnotics, sedatives and analgesics) and were taken from the "Adults Health Barometer" of the French National Institute of Prevention and Health Education.

Procedure {#Sec5}
---------

The questionnaire was distributed and collected upon completion by Moroccan occupational medicine students. They informed the staff on the questionnaire's purpose, items and anonymity. All 4746 employees from the nine public hospitals were considered eligible. All the employees and the Health and Safety Committee was informed of the study and approved it.

Data analysis {#Sec6}
-------------

Moroccan occupational medicine students gathered the data. They used an Excel mask designed by the Medical Evaluation and Therapeutic Education Office of the Medical Information and Public Health Evaluation Department of Nantes University Hospital. Data was analyzed with ASS/STAT 8.2 and SPSS 13.0. Missing answers questionnaires were excluded from the analysis. Descriptive analysis of data was made: answer percentage for qualitative variables, mean and standard deviation for quantitative variables. Job Decision Latitude (JDL), Psychological Job Demand (PJD) and Social Support (SoSu) scores were calculated according to Karasek et al. \[[@CR18]\] and Niedhammer and al. \[[@CR21]\]. Threshold values for high PJD, low JDL and a low SoSu were respectively set to 24, 72 and 22 \[[@CR21]\]. High strain occupations had PJD score over 24 and JDL score under 72. A SoSu score below 22 denoted social isolation. The DETA (French version of CAGE questionnaire for alcoholism screening) score could not be calculated due to the lack of answers to those items.

Bivariate analysis was performed with Chi squared test for categorical variables (e.g.: between medication use and drug consumption), with Student's *t* test for between groups comparison of metric variables and with Pearson's correlation coefficient for comparison of metric variables. Factors influencing the scores were determined by one-way ANOVA and by MANOVA for occupational categories adjustment. Step-by-step logistic regression was used for identifying factors connected to high PJD associated with low JDL.

Results {#Sec7}
=======

Descriptive data {#Sec8}
----------------

Two thousand eight hundred and sixty-three HCWs (60 %) answered the questionnaire. 54 % of the HCWs were women. Mean age was 40.4 ± 10.2 years. Mean work seniority was 11.3 ± 9.9 years. 97 % of HCWs had a permanent employment contract and 79 % worked full-time. The participation rate varied among the different hospitals, with leading scores from Larache (northern Morocco) and Sekkat (Casablanca) hospitals (94 and 91 %) and lowest score (38 %) from Marrakech hospital (southern Morocco). The participation rate was higher in the administration departments (67 %) and lower in surgery and ancillary departments (57 %). The ancillary staff had the highest participation rate (74 %), followed by the custodial staff and the administrative staff (73 and 70 %). The technical staff (27 %), the psychologists (33 %) and the nursing aides (37 %) had the lowest participation in the study (Table [1](#Tab1){ref-type="table"}).Table 1Participation rate by public hospital location, type of department and occupational categoryHCWs (*n*)Respondents (*n*)Participation rate (%)Public Hospital Baoufi Casablanca30818159 Sekkat Casablanca27424891 Settat33623470 Khourigba48034672 Agadir88856263 Marrakech104640038 Kénitra45325857 Oujda65034353 Larache31129194Department Internal Medicine98358960 Administration64643567 Ancillary73341857 Surgery67538257 OBG52932762 Paediatrics24115665 OR-ICU-ER93955659Occupational category Nurse134078859 Physician101367967 Specialist nurse83851161 Administrative48333770 Midwife22615669 Ancillary staff1329774 Other2516928 Custodial staff846173 Nursing aide1294837 Rehabilitation medicine staff623963 Nursing management443068 Technical staff1092927 Social worker291759 Psychologist6233Total4746286360*OBG* obstetrics and gynecology, *OR* operating room, *ICU* intensive care unit, *ER* emergency room

Internal consistency of the study was determined for each subscale; Cronbach's alpha coefficients were 0.596 for JDL, 0.383 PJD, 0.764 for SoSu, 0.737 for workplace ergonomics, 0.45 for environmental risks and 0.516 for medication use. SoSu and PJD scores were weakly correlated (r = −0.025, NS). JDL and PJD scores were correlated (r = 0.110, p \< 0.01), as well as JDL and SoSu scores (r = 0.248; p \< 0.01).

Psychosocial risks {#Sec9}
------------------

JDL, PJD and SoSu scores were diverse among occupational categories (p \< 0.001) (Table [2](#Tab2){ref-type="table"}).Table 2Answer influencing factor: occupational categoryDecision latitudePsychological demandSocial supportOccupational category*n*MeanSDOccupational category*n*MeanSDOccupational category*n*MeanSDTechnical staff2553.910.4Psychologist223.00Technical staff2719.94.1Other5862.19.3Rehabilitation medicine staff3923.13.2Midwife14520.93.3Administrative29762.99.9Nursing aide3923.32.7Other4821.33.4Social worker1362.910.4Administrative29923.63.4Nursing management2721.53.9Custodial staff6064.313.8Social worker1624.03.5Nurse71621.63.6Nursing aide4164.46.8Other5324.12.7Physician64621.63.8Ancillary staff8865.110.6Technical staff2724.22.8Specialist nurse46922.03.7Nursing management2765.47.8Specialist nurse46324.23.3Nursing aide4322.03.6Midwife14265.69.9Ancillary staff8824.43.4Rehabilitation medicine staff3822.03.3Nurse72966.29.4Custodial staff6024.62.5Ancillary staff9522.13.7Specialist nurse46166.98.8Nurse71724.73.2Administrative30222.33.8Physician63069.59.0Physician63025.03.3Social worker1222.63.7Rehabilitation medicine staff3874.59.9Nursing management2625.22.8Custodial staff6023.45.4Psychologist283.09.9Midwife14825.83.1Psychologist226.52.1Total261166.59.8260724.63.3263021.83.8

JDL, PJD and SoSu were independent of gender. JDL and SoSu decreased as the age of respondents increased (JDL correlation coefficient = −0.078, p \< 0.01; SoSu correlation coefficient = −0.075, p \< 0.01), situation persistent after adjustment for occupational category. The same JDL and SoSu pattern was found related to work seniority, but after adjustment for occupational category the situation persisted only for JDL. PJD was independent of age and seniority. JDL and PJD were independent of respondents' employment type and contract. Temporary employees had higher social support (p \< 0.001). Full-time employees scored lower in JDL and SoSu (p \< 0.001), but higher in PJD (p \< 0.001).

Other risks: use of hypnotics or sedatives, use of analgesics, working conditions {#Sec10}
---------------------------------------------------------------------------------

20 % of respondents reported taking hypnotics or sedatives on a regular basis (more than once during the week preceding the investigation), with an equal proportion of men and women. On average they were older (43.2 ± 9.9 years versus 40.3 ± 10.0 years, p \< 0.001). 41 % of respondents reported taking analgesics regularly (more than once during the week preceding the investigation). Most of them were women (43 % women versus 39 % men, p \< 0.05) and were older (41.9 ± 10.1 years versus 40.3 ± 9.9 years, p \< 0.001). Hypnotics or sedatives use significantly correlated to low JDL (p \< 0.001). It also correlated to high PJD (p \< 0.05) and lower SoSu (p \< 0.01). Use of analgesics also correlated significantly to low JDL (p \< 0.05), as well as to high PJD (p \< 0.001) and lower SoSu (p \< 0.05). The questions regarding the alcohol intake could not be used because the survey was accidentally carried out in the month of Ramadan (when, following a religious principle, use of alcohol is prohibited).

High strain {#Sec11}
-----------

The respondents with the highest risk (high strain: occupational categories with the riskier combination of low job decision latitude, high psychological job demand and low social support) were midwives and nursing management. High strain occupations also included nurses, physicians and ancillary staff. No occupational category placed itself in the active job quadrant---high demand and high control (Fig. [1](#Fig1){ref-type="fig"}).Fig. 1Psychological job demand (PJD) and job decision latitude (JDL) among Moroccan Health Care Workers. Threshold values for high PJD, low JDL were respectively set to 24, 72. High strain occupations had PJD score over 24 and JDL score under 72

High strain was associated with employment contract and type, occupational category, workplace environment (noise level, lighting) and use of hypnotics and sedatives (p \< 0.001) (Table [3](#Tab3){ref-type="table"}).Table 3High strain and occupational risk factors in Moroccan HCWs: multivariate analysisProblematic context: high strain*n*%*p*Crude ORCrude CIAdjusted ORCIGroup, *n* = 2472 Casablanca region38750\*\*\*11 Northern Morocco399510.620.50--0.751.030.82--1.31 Southern Morocco353381.050.86--1.290.730.56--0.96Gender, *n* = 2453 Female62048\*11 Male512450.890.76--1.051.261.04--1.53Age, *n* = 2440--------0.990.98--0.99Employment contract, *n* = 2462 Permanent109646\*\*\*1---- Temporary37481.090.67--1.75----Employment type, *n* = 2448 Full-time92349\*\*\*1.681.37--2.051.651.24--2.19 Part-time2013611Occupational category, *n* = 2452 Administrative12345\*\*\*11 Nursing management16621.940.80--4.792.100.85--5.23 Specialist nurse181420.870.63--1.200.790.56--1.12 Nurse335491.150.86--1.531.070.77--1.48 Nursing aide16461.020.48--2.180.960.42--2.21 Custodial staff27450.990.54--1.800.950.51--1.78 Midwife94692.711.72--4.292.331.41--3.85 Rehabilitation medicine staff7180.270.11--0.680.240.09--0.62 Social worker6501.210.34--4.371.340.36--5.08 Physician244410.840.62--1.130.650.47--0.91 Ancillary staff45541.430.85--2.421.330.75--2.34 Technical staff12501.210.49--3.000.440.15--1.31 Other21450.980.50--1.901.120.52--2.42Accessibility in the workplace, *n* = 2504 Satisfactory75042\*\*\*11 Unsatisfactory363521.501.26--1.781.241.01--1.53Comfortable work posture, *n* = 2799 Satisfactory37941\*\*1---- Unsatisfactory698471.301.10--1.53----Work plan height, *n* = 2799 Satisfactory41741\*\*\*1---- Unsatisfactory587471----Manual handling, *n* = 2799 Easy48943\*\*1.311.11--1.55---- Difficult495491----Noise level, *n* = 2799 Correct56339\*\*\*1.271.07--1.511 Incorrect5565111.311.08--1.60Lighting or brightness level, *n* = 2799 Correct50138\*\*\*11 Incorrect624521.761.50--2.061.451.19--1.76Ambient temperature level, *n* = 2799 Acceptable40940\*\*\*1---- Unacceptable721481.381.17--1.62----Exposure to hazardous chemicals, *n* = 2799 Satisfactory27947\*1---- Unsatisfactory792460.960.79--1.16----Exposure to radiation, *n* = 2799 Satisfactory18543\*1---- Unsatisfactory881471.170.94--1.45----Safety instructions, *n* = 2799 Present or available28740\*\*1---- Absent or unavailable777471.291.08--1.54----Use of hypnotics or sedatives, *n* = 2835 Yes25053\*\*\*1.501.22--1.851.411.11--1.79 No8114311Use of analgesics, *n* = 2835 Yes49950\*\*\*1.361.15--1.611.371.13--1.66 No5874211*CI* confidence interval, *OR* odds ratio, *p* *p* value for Chi square test\*\*\* *p* \< 0.001, \*\* 0.001 \< *p* \< 0.01, \* 0.01 \< *p* \< 0.05

Considering the risk factors in our model, stress level can be quantified by an equation: HS = a × PJD + b × JDL + c × SoSu + α (employment contract) + β (employment type) + γ (occupational category) + δ (work environment) + λ (care equipment availability), where HS = high strain, PJD = psychological job demand, JDL = job decision latitude, SoSu = social support.

Discussion {#Sec12}
==========

This is the first cross-sectional multicenter study to assess PSR perception and to estimate occupational stress in Moroccan public hospitals. It showed a good participation rate. We believe that hospital HCWs' very strong desire to participate in the survey (94 % participation rate in Sekkat Casablanca and 91 % participation rate in Larache) speaks in itself about awareness and need for change in working conditions. There were not many studies on Moroccan HCWs' PSR perception, aside of the work of Laraqui et al. \[[@CR17]\], who first focused on national, multicenter PSR evaluation in Moroccan hospitals, and found a 21.7 % prevalence of stress. Karasek's model of PSR assessment differentiated three work dimensions: psychological demands, decision latitude and social support. By placing the worker at the core of the working systems, it has found high international audience. Though Karasek's JCQ was translated, tested and used in many different countries \[[@CR21]--[@CR24]\], most of the investigations included one or two occupational categories. Previous studies in healthcare focused mainly on nurses, probably because they were a more homogenous and easier to access group, as opposed to the more sensitive group of physicians. Due to its specific high workload and responsibilities, the latter group is a complex target. There are even studies who excluded physicians because of the difficulty in obtaining response \[[@CR24]\]. As Robert Karasek has already stated in his 1998 study on psychosocial job assessment through JCQ \[[@CR18]\], one of the problems with demanding job holders was their reluctance to participate in research projects, which resulted in underreporting and scientific substantiation weakening in the cause-effect correlation. Having that in mind and the 69 % of high-strain (low JDL, high PJD and low SoSu) HCWs in our study, a 60 % participation rate in the health care sector and a 67 % rate of responsiveness in physicians are dependable data for analysis, as the second of our investigation strengths is the size and diversity of the HCWs' group.

Significantly more Moroccan HCWs have high strain jobs compared to French university hospital HCWs \[[@CR19]\]. Whereas the French study found many active jobs: physician, nursing management and midwife, the Moroccan study brought to attention a crowded high-strain quadrant in the JDL-PJD diagram (Fig. [1](#Fig1){ref-type="fig"}). This included all of the above occupations, alongside nurses and even custodial staff, which were passive category in the French survey. In reverse, none of the Moroccan HCW jobs qualified as active. There might be a cultural mark involved, but the main reasons were economic and organizational: Moroccan physician and nurse staffing was insufficient, the doctors' activity was always intense and had great time pressure, the staff was poorly paid and had low degree of job independence, many HCWs had to have a second job because of low pay, the technical equipment was often inadequate, outdated or faulty. Among the main perceived occupational risks, HCWs indicated also aggression, additional workload, musculoskeletal disorders and stress. Though physician and nurse were considered active jobs \[[@CR18]\], there are many investigations with opposite results. Columbian nurses had high demands but also high control \[[@CR25]\]. The 2004 French report \[[@CR26]\] on public hospital HCWs showed great level of job autonomy in physicians, but a much lower one on nurses and nursing aides. The 2011 Italian study on risk factors in health care professionals \[[@CR27]\] showed low JDL and SoSu scores for ancillary workers, but no significant variation in PJD, which is consistent with our findings. But differences in job demands are not unusual between countries and thus cultures. Pisanti et al. \[[@CR28]\] brought evidence of higher pressure in Italian nurses as opposed to Dutch nurses, also consistent with the difference between PJD scores in our Moroccan nurses. But there are many elements to influence job perception and thus job satisfaction: the difficult climate of economic crisis leaves its mark on job security, even if all three scores of PJD, JDL and SoSu are high enough to place the nurse in the active jobs category \[[@CR24]\].

High strain in nurses is also not uncommon and the reasons outlined by researchers reside as well in gender disparity: women report lower levels of decision latitude \[[@CR18]\]. The 2008 study on Moroccan HCW's found stress to be prevalent in female workers and in paramedics \[[@CR17]\]. We did not find any gender influence on high-strain scores. However there are grounds for high strain in women: cultural elements, tradition, or increased workload (based on unclear competencies) forced on nurses \[[@CR29]\]. Moroccan women have a different social status, since Moroccan traditional family structure gives them the household responsibilities, which may increase their general stress level \[[@CR30]\]. Social status and high or low level of education can also influence understanding of any questionnaire content and purpose and may affect answer, bringing in bias \[[@CR31]\].

Another study purpose was to build a ground basis for organizational and work environment changes, to decrease occupational stress and increase job control and social support. It has already been shown that, among many consequences, high JDL and SoSu enhanced safety participation \[[@CR32]\]. After an intervention plan would be implemented in all Moroccan public hospitals, an evaluative re-analysis of PSR would be not only necessary but of high utility \[[@CR33]\].

Our study showed no positive correlation between age and high strain (0.99 adjusted OR, CI: 0.98--0.99), similar to results from larger and more heterogeneous groups \[[@CR18]\], though JDL and SoSu were decreasing with age, which is similar to the French study results \[[@CR20]\]. We must consider the risk of cardiovascular disease (CVD) that comes with age, one which is already linked to job strain \[[@CR34]\]. In a meta-analysis of fourteen prospective cohort studies, Kivimäki et al. suggested an average of 50 % excess risk of coronary heart disease when occupational stress was present \[[@CR35]\]. A connection between occupational stress and inflammation appears to exist, the latter triggering CVDs \[[@CR36]\].

Since we found no explanation for temporary HCWs having higher SoSu and for senior workers having lower SoSu, there is need for further investigation. Full-time employees experienced more stress than part-time employees, which was consistent with findings from previous studies \[[@CR19], [@CR20]\]. There was certainly more pressure and the perceived responsibility increases in full-time contract. Longer working time enhanced work load and stress, as its imprints on scores proved: lower JDL (65.5 ± 9.6), lower SS (21.6 ± 3.9) and higher PJD (24.7 ± 3.3).

Moroccan HCWs took significantly more hypnotics and sedatives (20 %) and analgesics (40 %) than French HCWs (9 and 25 %) \[[@CR20]\]. The use of medication was significantly associated to high strain (p \< 0.001). Medication use in Moroccan HCWs proved to be much higher than other reports from hospital environments. Virtanen et al. conducted a study in 21 Finnish hospitals and found lower usage rate: 5 % for anxiolytic and hypnotic medication and 16 % for pain killers \[[@CR37]\]. Use of sedatives and hypnotics was linked to alternative shifts, night work, stress, workload and fatigue. Analgesics use associated with musculoskeletal disorders. Alcohol intake in Moroccan HCWs could not be analyzed because of the alcohol prohibition of Ramadan month. This was not taken into account when the study was designed and led to a study limitation.

Though PJD was lower in Moroccan HCWs, it still held a high score, and when associated to low JDL it concentrated a higher percentage of high strain HCWs (44 %) than the ones reported in other studies: 16.5 % in Taiwanese HCWs \[[@CR23]\], 25 % in European workers \[[@CR38]\]. This raises high concern and we feel it calls for an urgent intervention. As for the different occupational categories, it must be noted that Moroccan physicians were at a higher level of strain than physicians from any other country. In our study they were not an active occupation (Fig. [1](#Fig1){ref-type="fig"}). Work overload, insufficient staffing, poor doctor-patient relationship, low hospital budget are all triggers of occupation status deterioration. All studies on perceived stress focusing on or including doctors have placed them in the high demand-high control job category. This indicates higher risk degree in Moroccan doctors for developing CVDs and mental disorders. Higher depression rates compared to general population have been reported in physicians with high work demands \[[@CR39]\]. At the other end, Moroccan rehabilitation medicine staff was classified as having a passive job, similar to findings in other reports \[[@CR39], [@CR40]\], which attested a much lower degree of independence.

Limitations and future research {#Sec13}
-------------------------------

Our study has encountered a number of limitations. The weak points of self-reporting must be first restated. There is no solution to avoid or limit individual variation in PSR perception. The target is a personal, subjective sensation and understanding and not an objective quantification. But there is sufficient evidence that perception is at the origin of changes in well-being and of ill health, and prevention of health alterations is occupational medicine's ultimate goal. Participants in the study have not been randomly selected. Reasons for unresponsiveness were not requested. Results may have been influenced by exclusion of subjects due to missing item answers. Karasek's demand-control model leaves out the effort-reward balance and the patient-caregiver relationship, and there is no data on absenteeism, presenteeism and patient admission rates, factors to be taken into account in future investigation. The questionnaire version used in Morocco wasn't perfectly identical to the one used in the French studies (see Additional file [1](#MOESM1){ref-type="media"}) \[[@CR19], [@CR20]\], because some workstation ergonomics items weren't identical and therefore not mentioned. We don't know whether job musculoskeletal injury with concomitant sedative/hypnotic and/or analgesic use preceded high strain or if high strain caused those things. However, the study provides an accurate picture of PSR in Moroccan public hospitals. It brings forward a map of stressful occupations and it points out priorities for action. Future analysis could highlight more factors to influence occupational stress and improve our mathematical formula.

Conclusions {#Sec14}
===========

The aim of this study was to carry out a multicenter investigation focused on assessing PSR perception and occupational risk in Moroccan public hospitals. Our results show that Moroccan HCWs, physicians included, have high strain activity. There were no active occupations found after PSR analysis, which show HCW's low level of work control. Use of hypnotics, sedatives and analgesics is at high level in Moroccan HCWs and correlates with high strain. Since sedative use is high, it would be important to know whether the analgesic use is primarily NSAIDs/Tylenol vs opioids, then this is future investigation that should be done. Further research with an enlarged study pool and a more exhaustive analysis would bring more information on PSR and HCWs' health and would help design better occupational safety and health policy, aimed at enhancing and consolidating HCWs well-being at work.

Additional files {#Sec15}
================

Additional file 1.French version of the questionnaire

DT draw the design, implemented the project in France and then in Morocco. He contributed to the methods, the questionnaire creation, he contributed to discussion and manuscript revision; he mentored DIG in research internship in the Department of Occupational Medicine and Occupational Hazards, University Hospital of Nantes and mentored the Moroccan occupational medicine students studying for a university degree in occupational medicine. DIG contributed to methods, to data analysis, interpretation and discussion, wrote and revised the manuscript. CJ and BG contributed to data analysis and interpretation. CJ commented on drafts of the manuscript and revised it critically. BKD advised on and contributed to data analysis and interpretation; PL, LM and YR contributed to the creation and validation of the French version of the Questionnaire. AC, CV, CG have supported the study and commented on drafts of the manuscript. CEHL supported the study, mentored the Moroccan occupational medicine students and commented on drafts of the manuscript. All authors read and approved the final manuscript.

Acknowledgements {#d30e3067}
================

The authors acknowledge the participation and help of the Moroccan occupational medicine students. DIG's contribution to the study is part of research carried out within the framework of POSDRU/CPP107/DMI1.5/S/76851 project, co-financed by the European Social Fund through the Sectoral Operational Programme Human Resources Development 2007--2013.

Compliance with ethical guidelines {#d30e3072}
==================================

**Competing interests** The authors declare that they have no competing interests.
