employee health and presenteeism
DESCRIPTION
Employee Health and PresenteeismTRANSCRIPT
Employee Health and Presenteeism: A SystematicReview
Alyssa B. Schultz Æ Dee W. Edington
Published online: 25 July 2007� Springer Science+Business Media, LLC 2007
Abstract Introduction Many employers focus on their large and easily measured costof health care, yet until recently they have ignored the impact of health on productivity.Studies of some chronic conditions and some health risk factors suggest that costs of lostproductivity exceed costs of medical care. This review will examine the literature toexplore the link between employee health and on-the-job productivity, also known aspresenteeism. Methods Searches of Medline, CINAHL and PubMed were conducted inOctober 2006, with no starting date limitation with ‘‘presenteeism’’ or ‘‘worklimitations’’ as keywords. A total of 113 studies were found using this method. Eachstudy was evaluated based on the strength of the study design, statistical analyses,outcome measurement, and controlling of confounding variables. Results Literature onpresenteeism has investigated its link with a large number of health risks and healthconditions ranging from exercise and weight to allergies and irritable bowel syndrome.As expected, the research on some topic areas is stronger than others. ConclusionsBased on the research reviewed here, it can be said with confidence that healthconditions such as allergies and arthritis are associated with presenteeism. Moreover,health risks traditionally measured by a health risk appraisal (HRA), especially physicalactivity and body weight, also show an association with presenteeism. The next step forresearchers is to tease out the impact of individual health risks or combinations of risksand health conditions on this important outcome measure.
Keywords Presenteeism � Productivity � Health risks �Health conditions
A. B. Schultz (&) � D. W. EdingtonHealth Management Research Center, University of Michigan,1015 E. Huron St., Ann Arbor, MI 48104-1688, USAe-mail: [email protected]
D. W. Edingtone-mail: [email protected]
J Occup Rehabil (2007) 17:547–579DOI 10.1007/s10926-007-9096-x
123
Introduction
A person’s health may be his or her most important possession. Without it, the basicactivities of life are curtailed or prohibited entirely. One of these basic life activities iswork. Certainly a person’s ability to work is greatly affected by his or her health. As ofApril 2006, 143.7 million adults in the United States were employed [1]. Each one ofthose individuals exists on a continuum of health [2] ranging from optimum health onone extreme all the way to morbidity and death on the other extreme. In the middle,there are a wide variety of symptoms, health problems and diseases that may impedework ability to some degree. Of course, people move on this continuum throughouttheir life.
The worksite health management industry was borne of the need to help employeesstay on the healthy end of the continuum. One of the first steps in that process ismeasuring the health of employees. Since the 1980s the tool of choice for this task hasbeen the health risk appraisal (HRA). While HRAs remain one of the most commonlyused tools in the field of health promotion [3–5] they have changed much since theirinception in the 1980s. The original outcome metric used in HRAs was mortality. Whilethis outcome was deemed valid [3], it was not always easily understood or used byparticipants. Over time, HRA providers converted the mortality risk data into othermeasures which were more relevant to the participant. These often took the form of ahealth score or health index.
Health risk appraisals originally measured traditional health risks like smoking,physical activity, and blood pressure and have grown to include quality of life issues andhealth conditions such as migraine headaches and irritable bowel syndrome. The use ofHRAs continues to evolve as they persist in providing participants with information andmotivation to maintain and improve their health. Aggregate data from the HRAs areused to determine population risk profiles and provide information on new outcomemeasures pertinent to organizations. The HRA can help forecast health-related humancapital risks and establish the relative appropriateness for a variety of individual andworkplace interventions.
Many studies have established the link between health risks and health conditions (asmeasured by HRAs) and health care costs [6–9]. These studies show a clear linkbetween employees with more health risks and higher health care costs. Moreover, ashealth risks change (either increasing or decreasing), there is an associated change incosts [10]. The presence of health risk factors among employees is not only costly toemployers in terms of health care costs, but is also responsible for costs associated with areduction in productivity. Lost productivity can be measured by the costs associatedwith absenteeism: an employee’s time away from work typically consisting of illnessrelated scattered absences, short- and long-term disability, and workers’ compensation[10–14]. While absenteeism and disability are significant components of productivity,costs associated with these components are only part of the total cost associated withlost productivity.
Presenteeism, defined as decreased on-the-job performance due to the presence ofhealth problems, is a second main component of productivity measurement and isbeginning to garner more interest from corporate management, including medicaldirectors [15]. Presenteeism measures the ‘‘decrease in productivity for the much largergroup of employees whose health problems have not necessarily led to absenteeismand the decrease in productivity for the disabled group before and after the absence
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548 J Occup Rehabil (2007) 17:547–579
period’’ [16]. Presenteeism is often measured as the costs associated with reduced workoutput, errors on the job, and failure to meet company production standards. Bank One(now JPMorgan Chase) estimated presenteeism to be as much as 84% of theirproductivity costs, with absenteeism and disability comprising the other 16% [17].
A random sample telephone survey of nearly 29,000 U.S. workers was conducted in2001 and 2002. This survey—the American Productivity Audit—quantified lostproductive time due to health conditions and other reasons. During the previous2 weeks, 38.3% of participants reported unproductive time at work (presenteeism) as aresult of their health on at least one workday [18]. This reduced performance accountedfor 66% or 1.32 h per week of the total lost time, with absenteeism comprising theremainder. In a discussion of health and human capital, Berger and colleagues contendthat the effective U.S. workforce is decreased by 5–10% because of health problemsspread over the whole work force [19].
Objectives of the Review
The purpose of this review is to discuss the link between health risks and healthconditions with on-the-job productivity—also known as presenteeism. Employers havespent many years focusing on their large and easily measured cost of health care (thesecond highest cost for employers after payroll) yet until recently they have ignored theadditional impact of health on productivity. Studies of the impact of some commonchronic conditions suggest that the costs of lost productivity far exceed the costs ofmedical care [20]. Therefore, this review will examine the literature to explore theimportant link between employee health and presenteeism. Studies which explore othertypes of productivity (absenteeism, short-term disability, etc.) are not directly coveredby this review but represent another cost to employers associated with health risks andhealth conditions. Many studies reviewed here measured both presenteeism andabsenteeism but this review only examines the results dealing with presenteeism.
Measuring Presenteeism
How is presenteeism measured? For a few years, the answer was: not easily.Productivity studies were plagued by the difficulty of quantifying output, particularlyin information and service-type jobs. One of the first studies related to presenteeism byBurton et al. (1999) who uniquely gathered objective productivity measures oftelephone customer service operators and compared them with health risk appraisaldata [21]. However, call centers are unique opportunities, and the need for a moregeneral way to measure presenteeism across many types of jobs and organizations led tothe development of several self-report instruments.
A multitude of self-report workplace productivity measurement instruments havebeen created and studied. Several reviews have examined their merits and theadvantages of one instrument over another [22–28]. Some of these questionnairesinclude the Work Limitations Questionnaire (WLQ) [29–34], the Health and WorkPerformance Questionnaire (HPQ) [35–37], the Work Productivity Short Inventory(WPSI) [38, 39], the Stanford Presenteeism Scale (SPS-34 and SPS-13) [40, 41], theWork and Health Interview (WHI) [42], the Health and Labor Questionnaire (HLQ)
123
J Occup Rehabil (2007) 17:547–579 549
[43], the Work Productivity and Activity Impairment Questionnaire (WPAI) [44–46],the Work Performance Scales [47], the Endicott Work Productivity Scale [48], theHealth-Related Productivity Questionnaire Diary [49], the Angina-related Limitationsat Work Questionnaire [50], and others [51, 52]. Furthermore, a subset of the WLQ hasbeen incorporated into a worksite HRA with success in the study of a variety of healthconditions [53] and health risks [54, 55].
Evans cautions all productivity investigators to consider three areas when choosing aquestionnaire: the psychometric properties of the instrument, administration complex-ity, and the setting of the evaluation [56]. The WLQ, the HPQ, the WPSI, the SPS, andthe WHI have all undergone various levels of validity and reliability testing anddisplayed some level of criterion validity and reliability. An expert panel convened bythe American College of Occupational and Environmental Medicine recommends thatpresenteeism measures cover the following aspects of productivity: time not on task,quality of work (mistakes, peak performance, injury rates, etc.), quantity of work, andpersonal factors (social, mental, physical, emotional, etc.) [57]. Whichever instrument ischosen, investigators must interpret their results carefully since different questionnairesmeasure different aspects of presenteeism.
Lofland and colleagues reviewed several productivity loss instruments in 2004 [22].Their review focused on six instruments that provided a metric suitable for conversionto a monetary figure. They found that many instruments are only suitable for use withcertain patient groups, such as those with migraines. Others are applicable to broaderpopulations which might have a variety of health conditions. Also in 2004, Prasad andcolleagues conducted another review of six self-report productivity loss instruments[23]. Their review highlights the validity and reliability testing of each instrument andsuggests that the WPAI and WLQ offer the most significant advantages. However, theHPQ was only recently developed at the time of this review and they note that it holdspromise.
After reviewing the literature to date, it appears that two presenteeism instrumentsare moving to the forefront in popularity. These are the WLQ and the HPQ. Theirrelatively strong validity and reliability testing results make them good choices,particularly since they have been used in a variety of workplace settings and with avariety of health risks and conditions. Many of the other questionnaires reviewed hereare suitable for specific patient populations but these two questionnaires may be themost useful in general employee populations. They both give results that may bequantified monetarily.
Methods
Selection of Studies
Searches of electronic databases were conducted in October 2006, with no starting datelimitation. Medline, CINAHL and PubMed were all searched with ‘‘presenteeism’’ or‘‘work limitations’’ as a keyword, title word, abstract word, full text word or subjectheading. Studies were excluded if they were non-human, not in the English language ornot in a peer-reviewed journal. A total of 119 articles were found using this method.Some studies dealing with health conditions not typically studied in worksite healthmanagement program evaluations (such as epilepsy) were excluded, as were thosedealing with non-working age populations such as the elderly or children, leaving a total
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550 J Occup Rehabil (2007) 17:547–579
of 113 published manuscripts as a result of the literature search. Articles known to theauthor and those found through review of article bibliographies were also included asthe review progressed.
Many of the studies found through the literature search were about measuringpresenteeism (N = 36). Another group of studies focused on pharmaceutical treatmentsand their association with improved productivity (N = 11). A final group of publishedreports (N = 29) were either business publications speculating on the potential costs ofpresenteeism or studies which only tangentially discussed on-the-job productivity loss.These studies are covered briefly in this review. A total of 37 studies from peer-reviewedjournals on the topic of health conditions or health risks were evaluated and presentedin-depth (see Tables 1 and 2).
Quality Assessment
Each of the 37 studies was evaluated using criteria proposed by Kristensen [89] onthe strength of the study design, measurement, statistical analyses, and controlling ofconfounding variables. The authors assigned a score of 1 or 0 to each of these fourcriteria. For example, if a study used a validated presenteeism measurement tool,that study received a score of ‘‘1’’ for the ‘‘measurement’’ criterion whereas a studyusing only one non-validated question to assess presenteeism would receive a scoreof ‘‘0’’. Similarly, studies which utilized techniques such as logistic regression tocontrol for confounding variables would receive a score of ‘‘1’’ for the ‘‘controllingfor confounders’’ criterion. A study which made no effort to control for confoundingvariables would receive a ‘‘0’’. After assigning a score to each of the four criteria,they were summed to create one overall score for each article ranging from 4(strongest) to 0 (weakest). Information and overall scores of reviewed studies areshown in Table 1.
Then, for each topic area (such as a given medical condition) the aggregate researchwas evaluated based on the quality of each individual study or review, the number ofstudies, and the consistency of study results [89]. Scores and notes for topic areas can befound in Table 2.
Presentation of Results
The reviewed articles are categorized based on health condition or risk. In topic areaswhere methodologically strong reviews have already been written, those results aresummarized here but research published after the reviews are presented as an update.For each topic area, the impact of that health risk or condition is briefly stated, alongwith the number of studies found and a brief summary of the quality of the research onthat topic. In some cases, studies are described in detail. However those that are merelypresented for background information, such as prevalence rates of certain conditions,are not scored and are presented cursorily. Only studies which were published in peer-review journals are included in the review and subsequent tables. Some articles fromnon-peer-review journals are included in the background discussion of certain topics.Ratings of the 37 studies that were scored and presented in-depth can be found inTable 1 and the ratings for the content areas are presented in Table 2. Finally,conclusions are presented, with specific suggestions to employers, and areas of futureresearch are discussed.
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J Occup Rehabil (2007) 17:547–579 551
Tab
le1
Su
mm
ary
of
rev
iew
ed
stu
die
s
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Stu
die
so
fm
ult
iple
hea
lth
con
dit
ion
sB
urt
on
(20
04
)[5
3]
HR
Asu
rve
yo
f1
6,6
51
fin
an
cia
lse
rvic
es
em
plo
ye
es
Pa
rtic
ipa
nts
self
-re
po
rte
dh
ea
lth
con
dit
ion
so
nth
eH
RA
an
din
clu
de
da
sub
set
of
WL
ue
stio
ns
tom
ea
sure
pre
sen
tee
ism
Lo
gis
tic
reg
ress
ion
calc
ula
ted
od
ds
of
rep
ort
ing
an
yw
ork
lim
ita
tio
nfo
ra
lld
om
ain
so
fth
eW
LQ
an
da
ny
lim
ita
tio
no
ve
rall
Ag
e,
ge
nd
er,
oth
er
con
dit
ion
sa
nd
he
alt
hri
sks
Se
ve
ral
he
alt
hco
nd
itio
ns
(dep
ress
ion
,a
rth
riti
s,b
ack
pa
in,
all
erg
y,
he
artb
urn
,d
iab
ete
sa
nd
irri
tab
leb
ow
el
syn
dro
me
)w
ere
ass
oci
ate
dw
ith
sign
ifica
ntl
yh
igh
er
od
ds
of
rep
ort
ing
aw
ork
lim
ita
tio
n
4
Co
llin
s(2
00
5)
[58
]S
elf
-re
po
rtsu
rve
yo
f5
36
9e
mp
loy
ees
of
Do
wC
he
mic
al
Co
mp
an
y
Sh
ort
-Fo
rmH
ea
lth
Su
rve
y(S
F-3
6)
of
10
he
alt
hco
nd
itio
ns
an
dS
tan
ford
Pre
sen
tee
ism
Sca
le(S
PS
);1
0%
ran
do
msa
mp
lea
lso
com
ple
ted
Wo
rkL
imit
atio
ns
Qu
esti
on
na
ire
(WL
Q)
Re
gre
ssio
na
nal
ysi
se
stim
ati
ng
imp
act
of
va
rio
us
fact
ors
on
wo
rkim
pa
irm
en
t;lo
gis
tic
reg
ress
ion
use
dfo
ra
bse
nte
eis
ma
nal
ysi
s.M
ed
ica
lcl
aim
sa
na
lyze
dfo
rco
st
Oth
er
con
dit
ion
s,jo
bty
pe
,w
ork
loca
tio
n,
ag
e,
eth
nic
ity
,se
x,
bio
me
tric
sa
nd
wo
rkh
ou
rsp
er
we
ek
Em
plo
yee
sw
ith
de
pre
ssio
na
nd
bre
ath
ing
dis
ord
ers
rep
ort
ed
gre
ate
stim
pa
irm
en
t.M
ag
nit
ud
eo
fim
pa
irm
en
tin
cre
ase
dw
ith
incr
ea
sin
gn
um
ber
so
fco
nd
itio
ns.
Ou
to
fw
ork
imp
air
me
nt,
ab
sen
tee
ism
an
dm
ed
ica
l/p
ha
rma
ceu
tica
lco
sts,
wo
rkim
pa
irm
en
tre
pre
sen
ted
the
gre
ate
stco
stfo
re
ach
of
the
ten
con
dit
ion
s(6
.8%
of
all
lab
or
cost
s)
4
Go
etze
l(2
00
4)
[59
]M
ult
i-e
mp
loye
rd
ata
ba
sefo
rp
rev
ale
nce
of
he
alt
hco
nd
itio
ns
Pro
du
ctiv
ity
est
ima
tes
fro
mse
ver
al
pu
bli
she
dst
ud
ies
we
rea
pp
lie
dto
the
pre
va
len
cera
tes
of
con
dit
ion
sfo
un
din
the
ird
ata
ba
se
Ma
the
ma
tica
lfo
rmu
lam
ult
iply
ing
nu
mb
ero
fp
eo
ple
wit
hco
nd
itio
nti
me
sim
pa
ire
dti
me
du
eto
con
dit
ion
div
ide
db
yw
ork
ing
ho
urs
ina
ye
ar
Va
ried
ba
sed
on
the
stu
die
su
sed
tod
eri
ve
pro
du
ctiv
ity
est
ima
tes
Fo
rth
e1
0co
nd
itio
ns
stu
die
d,
pre
sen
tee
ism
cost
sra
ng
ed
fro
m1
8%
to8
9%
of
tota
lco
sts
[wh
ich
incl
ud
esh
ea
lth
care
cost
s(m
ed
ica
la
nd
ph
arm
acy
),a
bse
nte
eis
ma
nd
pre
sen
tee
ism
].A
rth
riti
s,h
yp
ert
ensi
on
,d
ep
ress
ion
,a
nd
all
erg
yh
ad
the
hig
he
stp
rese
nte
eis
mco
sts
3
123
552 J Occup Rehabil (2007) 17:547–579
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Kes
sle
re
ta
l.(2
00
1)
[60
]N
ati
on
ally
rep
rese
nta
tiv
ete
lep
ho
ne
/ma
ilsu
rve
yo
f2
07
4a
du
lts
Ou
to
fth
ep
ast
30
da
ys
ho
wm
an
yd
ay
sw
ere
yo
uto
tall
yu
na
ble
tow
ork
or
carr
yo
ut
no
rma
la
ctiv
itie
sb
eca
use
of
ph
ysi
cal
or
me
nta
lh
ea
lth
(wo
rklo
ss)
or
ha
dto
cut
ba
cko
nth
ose
act
ivit
ies
(wo
rkcu
tba
ck)
Reg
ress
ion
an
aly
sis
of
ass
oci
atio
nb
etw
een
an
yo
f1
2h
eal
thco
nd
itio
ns
an
dw
ork
loss
or
wo
rkcu
tba
ck
Oth
er
con
dit
ion
s,a
ge
,se
x,
ed
uca
tio
n,
occ
up
ati
on
al
sta
tus
22
%o
fre
spo
nd
en
tsh
ad
at
lea
sto
ne
he
alt
h-r
ela
ted
wo
rklo
sso
rw
ork
cutb
ack
da
yin
pa
stm
on
th.
Incr
easi
ng
rate
so
fim
pa
irm
en
ta
sso
cia
ted
wit
hg
rea
ter
nu
mb
ers
of
he
alt
hco
nd
itio
ns
3
Ler
ne
r(2
000
)[6
1]
Na
tio
nal
ho
use
ho
ldsu
rve
yo
f9
40
em
plo
ye
dp
eo
ple
Du
rin
gth
ep
ast
4w
ee
ks,
ho
wm
uch
dif
ficu
lty
ha
vey
ou
ha
dd
oin
gth
efo
llo
win
gw
ork
act
ivit
ies
be
cau
seo
fa
ny
on
go
ing
he
alt
hp
rob
lem
so
rh
ea
lth
con
cern
s?
Lo
gis
tic
reg
ress
ion
an
aly
zed
10
he
alth
con
dit
ion
gro
up
sa
nd
the
ira
sso
cia
tio
nw
ith
ph
ysi
cal,
psy
cho
soci
al
an
de
nv
iro
nm
en
tal
wo
rkli
mit
ati
on
s
Ag
e,
ge
nd
er,
job
typ
e,
smo
kin
g,
ed
uca
tio
n,
eth
nic
ity
,fu
ll-t
ime
sta
tus
Nea
rly
on
e-t
hir
do
fa
du
lts
wit
hch
ron
ich
ea
lth
pro
ble
ms
rep
ort
ed
rece
nt
mo
de
rate
tose
ver
ed
iffi
cult
yo
nth
ejo
bin
at
lea
sto
ne
of
thre
ea
rea
s.A
sn
um
ber
of
con
dit
ion
sin
cre
ase
d,
sod
ido
dd
so
fh
av
ing
aw
ork
lim
ita
tio
n
4
Mu
nir
(20
05)
[62]
Su
rve
yo
f6
10
Bri
tish
un
ive
rsit
ye
mp
loy
ees
wit
ha
chro
nic
he
alt
hco
nd
itio
n
Wh
at
ex
ten
td
oy
ou
ex
pe
rie
nce
pro
ble
ms
at
wo
rkre
late
dto
ph
ysi
cal,
cog
nit
ive
an
dso
cia
lw
ork
de
ma
nd
s.4
-po
int
sca
lera
ng
ing
fro
m‘‘
all
the
tim
e’’
to‘‘
ne
ver’
’
Lo
gis
tic
reg
ress
ion
mo
de
lin
gim
pa
cto
fe
ach
of
eig
ht
con
dit
ion
so
nre
po
rtin
ga
spe
cifi
cty
pe
of
wo
rkli
mit
ati
on
Co
nd
itio
nse
ver
ity
,co
nd
itio
nsy
mp
tom
s(p
ain
/fa
tig
ue
),o
the
rco
nd
itio
ns,
ag
e,
sex
,jo
bty
pe
40
%o
fe
mp
loy
ees
wit
ha
self
-rep
ort
ed
he
alt
hco
nd
itio
nre
po
rted
aw
ork
lim
ita
tio
nin
at
lea
sto
ne
of
the
thre
ea
rea
s
2
123
J Occup Rehabil (2007) 17:547–579 553
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Wa
ng
(20
03
)[6
3]
Te
lep
ho
ne
surv
ey
of
23
50
em
plo
ye
esin
4o
ccu
pa
tio
ns
He
alt
ha
nd
Wo
rkP
erf
orm
an
ceQ
ues
tio
nn
air
e(H
PQ
)a
sse
sse
dp
rese
nte
eis
m.
He
alt
hco
nd
itio
ns
ass
ess
ed
usi
ng
che
ckli
stfr
om
Nat
ion
al
He
alt
hIn
terv
iew
Stu
dy
Eff
ect
of
he
alt
hco
nd
itio
ns
on
wo
rkp
erf
orm
ance
est
ima
ted
usi
ng
AN
CO
VA
po
ole
da
cro
ss4
occ
up
atio
ns
(air
lin
ere
serv
ati
on
ists
,p
ho
ne
com
pa
ny
cust
om
er
serv
ice
ag
en
ts,
au
tom
oti
ve
ex
ecu
tiv
es
an
dra
ilro
ad
en
gin
ee
rs)
Ag
e,
sex
,e
du
cati
on
,o
ccu
pa
tio
n,
oth
er
con
dit
ion
s
3o
f1
3co
nd
itio
ns
(art
hri
tis,
ast
hm
aa
nd
CO
PD
/e
mp
hy
sem
a)
we
rea
sso
ciat
ed
wit
hsi
gn
ifica
nt
ele
va
tio
ns
inp
rese
nte
eis
m.
No
an
aly
sis
of
ad
dit
ive
eff
ect
of
nu
mb
ero
fco
nd
itio
ns.
Incl
usi
on
of
all
he
alt
hco
nd
itio
ns
as
mo
de
lco
va
riat
es
ma
yh
ave
ov
ers
ha
do
we
dth
ee
ffe
cto
fa
ny
on
eco
nd
itio
nin
div
idu
all
y
3
All
erg
yB
un
n(2
003
)[6
4]
Su
rve
yo
f1
0,7
14
ma
nu
fact
uri
ng
em
plo
ye
es
Su
bse
to
fS
F-3
6,
WL
Q,
all
erg
yq
ue
stio
nn
aire
,a
bse
nte
eis
m,
inju
rie
s,w
ork
ers
com
pe
nsa
tio
n,
an
dh
eal
thca
reu
tili
zati
on
Reg
ress
ion
an
aly
sis
of
5co
mp
ari
son
gro
up
sb
ase
do
nre
po
rte
dse
ve
rity
of
all
erg
ies;
sep
ara
tea
nal
ysi
so
fa
lle
rgy
me
dic
ati
on
use
Ag
e,
ge
nd
er,
fall
or
spri
ng
surv
ey
pe
rio
d,
com
orb
idit
ies
All
he
alt
ha
nd
pro
du
ctiv
ity
me
asu
res
gre
ww
ors
ea
sa
lle
rgy
sym
pto
ms
incr
ea
sed
.L
oss
es
we
resu
bst
an
tia
lly
hig
he
rin
the
mo
de
rate
an
dse
ve
rea
lle
rgy
gro
up
s
4
Bu
rto
n(2
00
1)
[21
]H
ea
lth
risk
ap
pra
isa
lsu
rve
yo
f6
34
tele
ph
on
ecu
sto
me
rse
rvic
ere
pre
sen
tati
ve
s
Ob
ject
ive
me
asu
rem
en
to
fp
rod
uct
ivit
yco
mp
are
dw
ith
da
ily
po
lle
nco
un
ts.
Se
lf-
rep
ort
of
all
erg
ym
ed
ica
tio
nu
sag
e
Ch
i-sq
ua
rea
nal
ysi
so
fp
oll
en
lev
els
an
dp
rod
uct
ivit
y.
Ch
i-sq
ua
rea
na
lysi
so
fm
ed
ica
tio
ng
rou
ps
an
dp
rod
uct
ivit
y.
Se
pa
rate
an
aly
sis
usi
ng
log
isti
cre
gre
ssio
nto
an
aly
zeo
dd
so
fm
ee
tin
gp
rod
uct
ivit
yst
an
da
rds
Lo
gis
tic
reg
ress
ion
con
tro
lle
dfo
ra
ge
,g
en
der
,w
ork
ex
pe
rie
nce
,n
um
ber
of
he
alt
hri
sks
Ste
pw
ise
de
clin
ein
pro
du
ctiv
ity
wa
sse
en
am
on
ga
lle
rgic
em
plo
ye
es
as
po
lle
nle
ve
lsin
cre
ase
d.
Th
ose
tak
ing
me
dic
ati
on
ha
dsi
gn
ifica
ntl
yh
igh
er
pro
du
ctiv
ity
tha
nth
en
o-
me
dic
ati
on
gro
up
4
123
554 J Occup Rehabil (2007) 17:547–579
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Lam
b(2
00
6)
[65]
We
lln
ess
scre
en
ing
so
f8
,267
em
plo
ye
es
at
47
loca
tio
ns
Wo
rkP
rod
uct
ivit
yS
ho
rtIn
ven
tory
(WP
SI)
Co
mp
ari
son
of
pre
sen
tee
ism
an
da
bse
nte
eis
ma
sso
cia
ted
wit
ha
lle
rgie
sv
s.o
the
rh
ea
lth
con
dit
ion
s
Ag
e,
ge
nd
er,
oth
er
con
dit
ion
sA
lle
rgic
em
plo
ye
es
we
reu
np
rod
uct
ive
2.3
ho
urs
pe
rw
ork
da
yw
hil
ee
xp
eri
en
cin
gsy
mp
tom
s
3
Art
hri
tis
Ba
ckm
an
(20
04
rev
iew
)[6
6]
No
n-s
yst
em
atic
rev
iew
of
lite
ratu
reS
tud
ies
on
rhe
um
ato
ida
rth
riti
sa
nd
dis
ab
ilit
ya
nd
pre
sen
tee
ism
––
Pre
sen
tee
ism
an
da
bse
nte
eis
mo
ccu
re
arl
yin
the
cou
rse
of
rhe
um
ato
ida
rth
riti
s.In
terv
en
tio
ns
ma
yp
rev
en
td
isa
bil
ity
an
djo
blo
ss.
Fa
cto
rsa
sso
cia
ted
wit
hw
ork
lim
ita
tio
ns
incl
ud
eth
ed
em
an
ds
of
wo
rk,
ba
rrie
rsw
ith
inth
ew
ork
en
vir
on
me
nt
an
dw
ork
acc
om
mo
dati
on
sp
rov
ide
d
1
Stu
die
sin
clu
ded
inB
urt
on
(20
06
rev
iew
)[6
7]
38
stu
die
so
frh
eum
ato
ida
rth
riti
sa
nd
wo
rkp
lace
pro
du
ctiv
ity
Pro
du
ctiv
ity
loss
inst
ud
ies
wa
sd
isa
bil
ity,
ab
sen
tee
ism
or
pre
sen
tee
ism
––
Mo
stst
ud
ies
fro
mp
ati
en
t’s
pe
rsp
ect
ive
rath
erth
an
em
plo
ye
r.M
an
yw
ith
rheu
ma
toid
art
hri
tis
are
un
ab
leto
wo
rk,
po
ten
tia
lly
lim
itin
gp
op
ula
tio
na
va
ila
ble
for
stu
dy
3
Bu
rto
n(2
00
6)
[68
]1
6,6
51
em
plo
ye
esp
art
icip
ati
ng
inH
RA
Su
bse
to
fW
LQ
qu
est
ion
sto
ass
ess
pre
sen
tee
ism
;se
lf-
rep
ort
of
art
hri
tis
an
dw
he
the
ro
rn
ot
em
plo
ye
esw
ere
un
der
care
or
tak
ing
me
dic
ati
on
for
con
dit
ion
Lo
gis
tic
reg
ress
ion
an
aly
sis
tofi
nd
od
ds
of
rep
ort
ing
an
yw
ork
lim
ita
tio
n
Ag
e,
ge
nd
er,
oth
er
con
dit
ion
sa
nd
he
alth
risk
s
All
fou
rd
om
ain
so
fW
LQ
sign
ifica
ntl
yim
pa
cte
db
ya
rth
riti
sw
hil
ep
hy
sica
lw
ork
do
ma
inw
as
mo
sta
ffe
cte
d
4
123
J Occup Rehabil (2007) 17:547–579 555
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Measu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Mu
chm
ore
(20
03
)[6
9]
Mu
lti-
em
plo
yer
da
tab
ase
an
aly
sis
of
28
,13
0e
mp
loy
ee
s
Ma
nu
fact
uri
ng
em
plo
ye
es
ha
dm
ea
sure
dp
rod
uct
ivit
yo
utp
ut,
ICD
-9d
ata
use
dto
cla
ssif
ye
mp
loy
ees
wit
ha
rth
riti
sa
nd
ass
oci
ate
djo
int
dis
ord
ers
Re
gre
ssio
na
na
lysi
so
fa
sso
cia
tio
nb
etw
een
art
hri
tis
dia
gn
osi
sa
nd
an
nu
al
pro
du
ctiv
ity
Ag
e,
ge
nd
er,
eth
nic
ity
,jo
bch
ara
cte
rist
ics,
he
alth
pla
n,
oth
er
he
alth
con
dit
ion
s
Ad
just
ed
an
nu
al
ou
tpu
tp
er
pe
rso
nw
as
4%
low
er
for
tho
sew
ith
art
hri
tis.
Ho
url
yo
utp
ut
wa
sn
ot
sign
ifica
ntl
yd
iffe
ren
t
3
Ric
ci(2
005
)[7
0]
Ra
nd
om
tele
ph
on
esu
rve
yo
f4
20
em
plo
ye
dU
Sa
du
lts
(AP
A)
WH
Ito
ass
ess
lost
pro
du
ctiv
eti
me
,a
rth
riti
scr
ite
ria
tak
enfr
om
Fir
stN
atio
na
lH
ea
lth
an
dN
utr
itio
nE
xa
min
atio
nS
urv
ey
(NH
AN
ES
-I)
Ch
i-sq
ua
rea
nal
ysi
sco
mp
ari
ng
lost
pro
du
ctiv
eti
me
for
wo
rke
rsw
ith
an
dw
ith
ou
ta
rth
riti
sp
ain
fla
re-u
ps
No
ne
inch
i-sq
ua
rea
nal
ysi
sA
rth
riti
cw
ork
ers
wit
hp
ain
ex
ace
rbat
ion
sin
pre
vio
us
two
we
ek
sre
po
rte
dg
reat
er
art
hri
tis-
rela
ted
lost
pro
du
ctiv
eti
me
(24
.4%
vs.
13
.3%
)th
an
tho
sew
ith
ou
tfl
are
-up
s
2
Ch
ron
icp
ain
All
en
(20
05)
[71]
We
b-b
ase
dsu
rve
yo
f1
,039
em
plo
ye
es
SF
-36
an
dB
rief
Pa
inIn
ven
tory
toa
sse
ssp
ain
,12
ite
ms
fro
mW
LQ
toa
sse
ssp
rese
nte
eis
m
Lin
ea
rre
gre
ssio
nA
ge
,g
en
de
rE
ach
of
the
fou
rW
LQ
sub
sca
les
imp
act
ed
mo
rea
sp
ain
sev
eri
tyin
cre
ase
d
2
Ste
war
t(2
00
3)
[72
]P
ho
ne
surv
ey
of
28
,90
2w
ork
ers
(Am
eri
can
Pro
du
ctiv
ity
Au
dit
[AP
A])
Wo
rka
nd
He
alt
hIn
terv
iew
(WH
I)a
sse
sse
dre
du
ced
pe
rfo
rman
cea
tw
ork
du
eto
he
alth
con
dit
ion
s
Lin
ea
rre
gre
ssio
nD
em
og
rap
hic
s,o
ccu
pa
tio
na
la
nd
em
plo
ym
en
tch
ara
cte
rist
ics,
he
alth
ha
bit
s
Pa
infr
om
he
ada
che
s,a
rth
riti
s,b
ack
pa
ina
nd
oth
er
mu
scu
losk
ele
tal
pro
ble
ms
cau
sed
pro
du
ctiv
ity
loss
am
on
g1
3%
of
the
US
wo
rkfo
rce
4
Dia
bet
esL
avig
ne
(20
03
)[7
3]
Te
lep
ho
ne
surv
ey
of
47
2e
mp
loy
ed
resi
de
nts
of
New
Yo
rk
Ost
erh
au
sm
od
el
use
dto
ass
ess
wo
rke
ffici
en
cya
nd
the
He
alt
ha
nd
Lab
or
Qu
est
ion
na
ire
(HL
Q)
als
ou
sed
To
bit
reg
ress
ion
an
aly
sis
tom
od
el
wo
rke
ffici
en
cylo
sse
sw
hil
en
ot
fee
lin
gw
ell
Oth
er
he
alth
con
dit
ion
s,a
ge
,g
en
de
r,e
thn
icit
y,
ex
erc
ise
,jo
bch
ara
cte
rist
ics
Dia
be
tic
em
plo
ye
essh
ow
ed
are
du
ctio
nin
wo
rkp
rod
uct
ivit
yco
mp
are
dto
no
n-
dia
be
tics
.L
on
ger
tim
esi
nce
dia
be
tes
dia
gn
osi
sw
as
sig
nifi
can
tly
ass
oci
ate
dw
ith
gre
ate
re
ffici
en
cylo
sse
s
2
123
556 J Occup Rehabil (2007) 17:547–579
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Measu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Tu
nce
li(2
00
5)
[74
]L
on
gitu
din
alst
ud
yo
f7
,055
em
plo
ye
dre
spo
nd
ents
of
He
alt
ha
nd
Ret
ire
me
nt
Stu
dy
Ask
ed
ifsu
bje
cts
ha
da
ny
imp
air
me
nts
or
he
alt
hp
rob
lem
sa
tth
eti
me
of
the
inte
rvie
wth
at
lim
ite
dth
ek
ind
or
am
ou
nt
of
pa
idw
ork
the
yco
uld
do
Pro
bit
reg
ress
ion
est
ima
ted
eff
ect
of
dia
be
tes
inw
av
e1
on
he
alt
h-r
ela
ted
wo
rkli
mit
ati
on
sin
wa
ve
2
Ge
nd
er,
he
alt
hst
atu
s,jo
bch
ara
cte
rist
ics
Am
on
gb
oth
me
na
nd
wo
men
,in
div
idu
als
wit
hd
iab
ete
sw
ere
sig
nifi
can
tly
mo
reli
ke
ly(O
R=
3.6
)to
ha
ve
aw
ork
lim
ita
tio
nth
an
no
n-d
iab
eti
cs
2
Ga
stro
-in
test
ina
lD
ea
n(2
005
)[7
5]
2-p
ha
sesu
rve
yo
f1
,776
ba
nk
em
plo
ye
es
Wo
rkP
rod
uct
ivit
ya
nd
Act
ivit
yIm
pai
rme
nt
Qu
esti
on
na
ire
(WP
AI)
toa
sse
ssp
rese
nte
eis
m.
Ro
me
IIcr
iteri
au
sed
toass
ess
IBS
No
n-p
ara
me
tric
sta
tist
ics
(bo
ots
tra
pp
ing
)u
sed
toca
lcu
late
con
fid
en
cein
terv
alfo
rd
iffe
ren
ces
inp
rod
uct
ivit
yim
pa
irm
en
ts
No
ne
inth
eb
oo
tstr
app
ing
an
aly
sis
Em
plo
yee
sw
ith
IBS
rep
ort
eda
15
%g
reat
er
loss
inw
ork
pro
du
ctiv
ity
du
eto
ga
stro
inte
stin
al
sym
pto
ms
tha
ne
mp
loy
ees
wit
ho
ut
IBS
3
Stu
die
sin
clu
ded
inW
ah
lqv
ist
(20
06
rev
iew
)[7
6]
Re
vie
wo
f8
stu
die
so
fG
ER
Da
nd
pro
du
ctiv
ity
Se
ve
nst
ud
ies
use
dW
PA
Io
rG
ER
D-
spec
ific
WP
AI
––
Pre
sen
tee
ism
loss
es
du
eto
GE
RD
ran
ge
dfr
om
6–
40%
inth
ese
stu
die
s,e
qu
ati
ng
to2
.4–
16
.6h
ou
rso
fw
ork
loss
pe
rw
ee
k
4
Men
tal
hea
lth
Ad
ler
(20
04
)[7
7]
Ob
serv
ati
on
al
stu
dy
of
69
pa
tie
nts
wit
hd
yst
hy
mia
com
pa
red
to1
75
con
tro
ls
WL
Qm
ea
sure
dp
rese
nte
eis
m.
Pa
rto
fH
ea
lth
an
dW
ork
Stu
dy
Lin
ea
rre
gre
ssio
nto
an
aly
zem
ea
sure
so
fp
rese
nte
eis
mfo
rp
ati
en
tsco
mp
are
dto
con
tro
ls
Ag
e,
ge
nd
er,
me
dic
al
com
orb
idit
ies
Pa
tie
nts
wit
hd
yst
hy
mia
ha
dsi
gnifi
can
tly
gre
ate
rp
rese
nte
eis
m(6
.3%
vs.
2.8
%)
com
pa
red
toco
ntr
ols
4
123
J Occup Rehabil (2007) 17:547–579 557
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Ad
ler
(20
06
)[7
8]
Lo
ng
itu
din
al
ob
serv
ati
on
alst
ud
yo
f2
86
de
pre
sse
dp
ati
en
tsco
mp
are
dto
2co
ntr
ol
gro
up
s
WL
Qu
sed
toa
sse
ssp
rese
nte
eis
ma
nd
Pa
tie
nt
He
alt
hQ
ues
tio
nn
air
e-9
me
asu
red
de
pre
ssio
na
t6
,1
2a
nd
18
mo
nth
s
Reg
ress
ion
mo
de
lso
ffi
ve
con
dit
ion
gro
up
s(d
yst
hym
ia,
ma
jor
de
pre
ssiv
ed
iso
rde
r,d
ou
ble
de
pre
ssio
n,
con
tro
l,a
nd
con
tro
lsw
ith
rhe
um
ato
ida
rth
riti
s)
Ag
e,
ge
nd
er,
wo
rka
nd
he
alt
hch
ara
cte
rist
ics
De
pre
ssio
ng
rou
ph
ad
sig
nifi
can
tw
ork
lim
ita
tio
ns
com
pa
red
toco
ntr
ols
.E
ve
na
fte
rp
ati
en
tsw
ere
de
eme
d‘‘
clin
ica
lly
imp
rov
ed
’’,
wo
rkli
mit
ati
on
sre
ma
ine
d
4
Kle
inm
an
(20
05
)[7
9]
Re
tro
spe
ctiv
ea
nal
ysi
so
fla
rge
mu
lti-
em
plo
ye
rd
ata
ba
se
ICD
-9d
ata
use
dto
cla
ssif
ye
mp
loy
ee
sw
ith
bip
ola
rd
iso
rde
r(B
PD
)a
nd
oth
er
me
nta
lh
ea
lth
con
dit
ion
s.O
n-t
he
-jo
bp
rod
uct
ivit
yw
as
ob
ject
ive
lym
ea
sure
dfo
rm
an
ufa
ctu
rin
ge
mp
loy
ees
Reg
ress
ion
an
aly
sis
of
at-
wo
rkp
rod
uct
ivit
y(u
nit
sp
roce
sse
dp
er
ho
ur
wo
rke
d)
Ag
e,
ten
ure
,g
en
de
r,m
ari
tal
sta
tus,
eth
nic
ity
,jo
bch
ara
cte
rist
ics,
reg
ion
An
nu
al
at-
wo
rkp
rod
uct
ivit
yw
as
sig
nifi
can
tly
low
er
for
em
plo
ye
es
wit
hB
PD
com
pa
red
toa
llo
the
rg
rou
ps
3
Ler
ne
r(2
004
)[3
1]
Lo
ng
itu
din
al
ob
serv
ati
on
alst
ud
y(N
=3
89
)o
fp
ati
en
tsw
ith
dy
sth
ym
iaa
nd
/or
de
pre
ssio
nco
mp
are
dto
con
tro
ls
Pa
rto
fH
ea
lth
an
dW
ork
Stu
dy
.T
he
WL
Qm
ea
sure
dp
rese
nte
eis
m.
Me
nta
lh
eal
tha
sse
sse
db
ysc
ree
nin
gp
roce
ssa
nd
PH
Q-9
AN
OV
Au
sed
toa
nal
yze
con
dit
ion
-gro
up
dif
fere
nce
sin
the
fou
rW
LQ
sca
lesc
ore
s.L
ine
ar
reg
ress
ion
mo
de
lste
ste
dth
ee
ffe
cts
of
cert
ain
job
cha
ract
eri
stic
s
Ag
e,
ge
nd
erP
rod
uct
ivit
yw
as
mo
stim
pa
cte
db
yd
ep
ress
ion
sev
eri
ty.C
ert
ain
job
sh
ad
gre
ate
ra
sso
ciat
ion
wit
hd
ep
ress
ion
-rel
ate
dw
ork
lim
ita
tio
ns
tha
no
the
rs
4
123
558 J Occup Rehabil (2007) 17:547–579
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Ler
ne
r(2
004
)[8
0]
Six
-mo
nth
stu
dy
(N=
45
1)
of
de
pre
sse
de
mp
loy
ees
com
pa
red
toco
ntr
ols
Pa
rto
fH
ea
lth
an
dW
ork
Stu
dy
.W
LQ
ass
ess
ed
pre
sen
tee
ism
.P
ati
en
t-a
dm
inis
tere
dd
ep
ress
ion
scre
en
ing
inst
rum
en
tu
sed
toa
sse
ssd
yst
hy
mia
an
dm
ajo
rd
ep
ress
ive
dis
ord
er
AN
OV
Ate
ste
dd
iffe
ren
ces
be
twee
nth
eg
rou
ps
Ag
e,
ge
nd
er,
me
dic
al
com
orb
idit
ies
Pa
tie
nts
wit
hd
yst
hy
mia
or
de
pre
ssio
nlo
stb
etw
een
6a
nd
10
%p
rod
uct
ivit
yco
mp
are
dto
4%
for
he
alt
hy
con
tro
ls.
All
fou
rW
LQ
sub
-sca
les
we
resi
gn
ifica
ntl
yw
ors
eco
mp
are
dto
he
alt
hy
con
tro
ls
4
Mu
scu
lo-s
kel
eta
lH
ag
be
rg(2
00
2)
[81
]Q
ue
stio
nn
air
eta
ke
nb
y1
,28
3S
we
dis
hco
mp
ute
rw
ork
ers
Pre
sen
tee
ism
ass
ess
ed
by
:‘‘
ha
ve
the
mu
scu
losk
ele
tal
sym
pto
ms
infl
ue
nce
dy
ou
rp
rod
uct
ivit
ya
tco
mp
ute
rw
ork
du
rin
gth
ep
rece
din
gm
on
th?
’’If
ye
s,a
ske
dto
rep
ort
%d
ecr
ea
se
Pro
po
rtio
na
lh
aza
rds
mo
de
lA
ge
,w
ork
con
dit
ion
s,e
du
cati
on
,li
fest
yle
fact
ors
Wo
rke
rsre
po
rtin
ga
pro
du
ctiv
ity
loss
du
eto
mu
scu
losk
ele
tal
pro
ble
ms
est
ima
ted
17
ho
urs
lost
pe
rm
on
th
2
Stu
die
so
fm
ult
iple
hea
lth
risk
sB
ole
s(2
00
4)
[82]
HR
Ast
ud
yo
f2
,264
em
plo
ye
esn
ati
on
wid
e
WP
AI
use
dto
me
asu
rep
rese
nte
eis
m.
On
-lin
eH
RA
coll
ect
ed
he
alth
risk
da
ta
AN
OV
Aco
mp
are
dm
ea
np
rod
uct
ivit
ylo
ssfo
rp
eo
ple
wit
ha
nd
wit
ho
ut
ea
chri
skfa
cto
r.R
eg
ress
ion
an
aly
sis
stu
die
dim
pa
cto
fn
um
ber
of
he
alt
hri
sks
AN
OV
Aco
ntr
oll
edfo
ra
ge
,g
en
der
,o
the
rh
ea
lth
risk
s
Gre
ate
rp
rod
uct
ivit
ylo
sse
sw
ere
see
na
sth
en
um
be
ro
fri
sks
incr
ea
sed
.S
ign
ifica
nt
pre
sen
tee
ism
loss
es
see
na
mo
ng
tho
sew
ith
po
or
die
t,o
ve
rwe
igh
t,la
cko
fe
xe
rcis
e,
stre
ss,
an
dla
cko
fe
mo
tio
na
lfu
lfill
men
t
4
Bu
rto
n(1
99
9)
[16
]H
RA
stu
dy
of
56
4te
lep
ho
ne
cust
om
er-
serv
ice
rep
s
On
-th
e-j
ob
pro
du
ctiv
ity
me
asu
red
ob
ject
ive
lyC
hi-
squ
are
an
aly
sis
of
fail
ure
toa
tta
inp
rod
uct
ivit
yst
an
da
rdb
yh
eal
thri
sk
No
ne
inch
i-sq
ua
rea
na
lysi
sE
mp
loye
es
wit
hm
ore
he
alt
hri
sks
ha
dw
ors
ep
rod
uct
ivit
yth
an
tho
sew
ith
few
er
risk
s
3
123
J Occup Rehabil (2007) 17:547–579 559
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Bu
rto
n(2
00
6)
[55
]L
on
git
ud
ina
lst
ud
yo
fch
an
ge
inp
rese
nte
eis
ma
mo
ng
7,0
26tw
o-
tim
eH
RA
pa
rtic
ipa
nts
Su
bse
to
fW
LQ
use
dto
me
asu
rep
rese
nte
eis
ma
mo
ng
the
seb
an
ke
mp
loy
ees
Reg
ress
ion
mo
de
lo
fth
ere
lati
on
ship
be
twee
nch
an
ged
he
alt
hri
sks
an
dch
an
ged
pro
du
ctiv
ity
loss
Ag
e,
ge
nd
er,
ba
seli
ne
he
alt
hri
sks,
ba
seli
ne
me
dic
al
con
dit
ion
s,b
ase
lin
ep
rod
uct
ivit
ylo
ss
As
the
nu
mb
ero
fh
ea
lth
risk
sin
cre
ase
do
rd
ecr
ea
sed
ov
er
tim
e,
the
rew
as
aco
mm
ensu
rate
cha
ng
ein
the
pe
rce
nt
of
em
plo
ye
es
rep
ort
ing
ali
mit
ati
on
an
din
the
pe
rce
nt
pro
du
ctiv
ity
loss
.E
ach
he
alt
hri
skw
as
ass
oci
ate
dw
ith
a1
.9%
cha
ng
ein
pro
du
ctiv
ity
loss
4
Pe
lle
tie
r(2
00
4)
[83
]C
ha
ng
est
ud
yo
f5
00
we
lln
ess
pro
gra
mp
art
icip
an
ts
On
lin
eH
RA
me
asu
red
he
alth
risk
s;W
PA
Iu
sed
tom
ea
sure
pre
sen
tee
ism
Rep
ea
ted
me
asu
res
reg
ress
ion
mo
de
lo
fp
rese
nte
eis
ma
tti
me
1a
nd
tim
e2
an
dri
skch
an
ge
Ag
e,
ge
nd
er,
ba
seli
ne
risk
sE
mp
loye
es
wh
ore
du
ced
at
lea
sto
ne
risk
fact
or
imp
rov
ed
pre
sen
tee
ism
by
9%
4
Pro
nk
(20
04)
[84]
Su
rve
yo
f6
83
wo
rke
rsT
ele
ph
on
icH
RA
toa
sse
ssh
ea
lth
risk
s,q
ue
stio
ns
fro
mth
eH
PQ
me
asu
red
pre
sen
tee
ism
Reg
ress
ion
an
aly
sis
of
ex
erc
ise
,ca
rdio
resp
irat
ory
fitn
ess
,a
nd
we
igh
tw
ith
pre
sen
tee
ism
Ag
e,
sex
,e
du
cati
on
Mo
de
rate
an
dv
igo
rou
se
xe
rcis
ele
vels
,b
ett
er
card
iore
spir
ato
ryfi
tne
ssa
nd
low
er
BM
Iw
ere
ass
oci
ate
dw
ith
imp
rov
ed
wo
rko
utc
om
es
com
pa
red
too
the
rs
4
Ste
war
t(2
00
3)
[18
]A
me
rica
nP
rod
uct
ivit
yA
ud
ito
f2
8,9
02
wo
rke
rsn
ati
on
wid
e
WH
Iu
sed
toa
sse
ssp
rese
nte
eis
ma
nd
he
alth
risk
s
Reg
ress
ion
an
aly
sis
of
he
alt
hri
sks
an
dlo
stp
rod
uct
ive
tim
e
De
mo
gra
ph
ic,
occ
up
ati
on
al,
em
plo
ym
en
tch
ara
cte
rist
ics
an
do
the
rh
ea
lth
risk
s
Sm
ok
ers
we
retw
ice
as
lik
ely
tore
po
rtlo
stp
rod
uct
ive
tim
eth
an
no
n-s
mo
kin
gw
ork
ers
3
123
560 J Occup Rehabil (2007) 17:547–579
Tab
le1
con
tin
ue
d
Stu
dy
de
sig
n/
po
pu
lati
on
Me
asu
rem
en
tS
tati
stic
al
an
aly
ses
Co
ntr
oll
ing
for
con
fou
nd
ers
Fin
din
gs
Ov
era
llsc
ore
a
Ov
erw
eig
ht
He
rtz
(20
04)
[85]
17
,95
2e
mp
loy
ed
ad
ult
sfr
om
NH
IS2
00
2d
ata
set
NH
LB
IB
MI
crit
eri
au
sed
toa
sse
ssw
eig
ht
sta
tus.
Wo
rkli
mit
ati
on
de
term
ine
db
y:
‘‘a
rey
ou
lim
ite
din
the
kin
do
ra
mo
un
to
fw
ork
yo
uca
nd
ob
eca
use
of
ap
hy
sica
l,m
en
tal,
or
em
oti
on
al
pro
ble
m?
’’
We
igh
ted
pre
va
len
ceo
fw
ork
lim
ita
tio
ns
est
ima
ted
an
dco
mp
are
da
mo
ng
fou
rw
eig
ht
cate
go
ries
Ag
e,
ge
nd
erO
be
sew
ork
ers
sig
nifi
can
tly
mo
reli
ke
lyto
rep
ort
aw
ork
lim
ita
tio
n(6
.9%
com
pa
red
to3
.0%
for
no
rma
lw
eig
ht
wo
rke
rs),
sim
ilar
toth
ee
ffe
cto
f2
0y
ea
rso
fa
gin
g
3
Ric
ci(2
005
)[8
6]
Ra
nd
om
na
tio
na
lte
lep
ho
ne
surv
ey
of
7,4
72e
mp
loy
ed
ad
ult
s
WH
Iu
sed
toa
sse
ssh
eal
tha
nd
pro
du
ctiv
ity
Lo
gis
tic
reg
ress
ion
tom
od
el
the
od
ds
of
rep
ort
ing
an
ylo
stp
rod
uct
ive
tim
e
Ag
e,
ge
nd
er,
ed
uca
tio
n,
sala
ry,
reg
ion
,sm
ok
ing
,a
lco
ho
lu
se
Ob
ese
—b
ut
no
to
ve
rwe
igh
t—w
ork
ers
we
resi
gn
ifica
ntl
ym
ore
lik
ely
tore
po
rta
wo
rkli
mit
ati
on
tha
nn
orm
al
we
igh
tw
ork
ers
3
Tu
nce
li(1
99
9)
[87
]P
an
el
Stu
dy
of
Inco
me
Dy
na
mic
so
f4
29
0e
mp
loy
ed
ad
ult
s
Pre
sen
tee
ism
me
asu
red
by
:‘‘
Do
yo
uh
ave
an
yp
hy
sica
lo
rn
erv
ou
sco
nd
itio
nth
at
lim
ite
dth
ety
pe
or
am
ou
nt
of
wo
rky
ou
can
do
?’’
Mu
ltiv
ari
ate
pro
bit
mo
de
lso
fe
ffe
cto
fo
be
sity
in1
98
6o
nw
ork
lim
ita
tio
ns
in1
99
9
Ag
e,
ge
nd
er,
smo
kin
g,
ex
erc
ise
,se
lf-
rep
ort
ed
he
alt
h
Ov
erw
eig
ht
an
do
be
sew
om
enw
ere
sig
nifi
can
tly
mo
reli
ke
lyto
rep
ort
aw
ork
lim
ita
tio
nco
mp
are
dto
no
rma
lw
eig
ht
wo
me
n.
Res
ult
sfo
rm
en
we
ren
ot
sta
tist
ica
lly
sig
nifi
can
t
2
Ph
ysi
cal
act
ivit
yB
urt
on
(20
05
)[8
8]
HR
Ast
ud
yo
f5
,379
em
plo
ye
esa
tco
rpo
rate
loca
tio
ns
wit
hfi
tne
ssce
nte
rs
Su
bse
to
fW
LQ
me
asu
red
pre
sen
tee
ism
.F
itn
ess
de
term
ine
db
yb
ein
ga
me
mb
er
of
the
corp
ora
tefi
tne
ssce
nte
r
Lo
gis
tic
reg
ress
ion
mo
de
lsco
mp
ari
ng
pre
sen
tee
ism
am
on
gfi
tne
ssce
nte
rp
art
icip
an
tsan
dn
on
-p
art
icip
an
ts
Ag
e,
ge
nd
er,
he
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123
J Occup Rehabil (2007) 17:547–579 561
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123
562 J Occup Rehabil (2007) 17:547–579
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123
J Occup Rehabil (2007) 17:547–579 563
Results
Studies of Presenteeism and Multiple Health Conditions
Impact: Health conditions such as diabetes, depression and arthritis have been found tobe associated with productivity losses at the worksite and have been the focus of thebulk of presenteeism research so far [53]. Quantity of studies: A total of seven studieswere reviewed in depth [53, 58–63]. Quality of research: The literature coveringpresenteeism and multiple health conditions is relatively strong. For the most part, theseven studies are methodologically strong and show that a variety of health problemsare associated with decreases in productivity at work. Results consistently show thatindividuals with multiple health conditions report greater presenteeism than those withfew or no conditions.
Two nationwide studies identified the percent of workers with chronic healthproblems who experience presenteeism. Results ranged from 22% of respondents withsome time lost [60] to nearly one-third of adults whose health problems interfered withtheir work tasks [61]. A study at a British university found that 40% of employees with aself-reported chronic illness reported a work limitation in at least one of three areas(physical, cognitive and social) [62].
Additionally, studies often measured the impact of each additional chronic condition.One found that each additional chronic condition reported by an individual wasassociated with significantly higher odds of reporting a work limitation on the physical,psychosocial and environmental scales of presenteeism [61]. At Dow ChemicalCompany, the magnitude of work impairment increased with the number of conditionsreported by 5,369 employees in five company locations who participated in an on-linesurvey which included the Stanford Presenteeism Scale (SPS) and the Short-FormHealth Survey (SF-36) [58].
Studies of Presenteeism and Specific Health Conditions
Allergies
Impact: Allergic disorders are as common among the US workforce as back pain andhypertension—affecting about 12% of working women and 10% of working men [90].Seasonal allergies have been shown to have an association with workplace productivity.Quantity of studies: Three peer-reviewed studies were found on the topic of allergies andpresenteeism [21, 64, 65]. Quality of research: The quality of these studies is moderate tohigh. Each of the studies employs a good design and valid measurement of the variablesof interest. They are consistent in their findings, that allergies have a negative impact onworkplace productivity. As will be discussed in a later section, several studies haveinvestigated the impact of allergy medications on the ability to mitigate this impact onproductivity.
In one study of telephone customer service operators, objective measures ofproductivity (handle time of phone calls and time taken between phone calls) werecompared against ragweed pollen levels during the study time period. A stepwisedecline in productivity was seen as pollen levels increased [21]. A study of manufac-turing company employees also found that all health and productivity measures (generalhealth, physical health, vitality, mental health, overall effectiveness at work, ability towork required hours, concentration, ability to handle workload, ability to work without
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mistakes, ability to bend and twist and days less than 100% resulting from allergies/asthma) grew worse as allergy symptom increased [64]. In a study of more than 8,000employees at 47 locations, those with allergic rhinitis reported being unproductive 2.3 hper day when experiencing symptoms [65].
In the study of customer service operators, those taking medication for their allergieshad significantly higher productivity than the no-medication group [21], indicating theimportance for receiving appropriate treatment for this condition. In certain occupa-tions, the sleep-inducing effects of some antihistamines can have serious consequences.An Australian study of commercial truck drivers found that the incidence of accidentsincreased significantly among drivers who used antihistamines to treat allergy symptoms[91].
Arthritis
Impact: Arthritis is one of the most common chronic conditions in the U.S. [92] and hasreceived much attention in presenteeism research. Some of the research in this area hasbeen conducted in the medical setting, such as physicians’ offices. These types of studiesoften measure productivity both on-the-job and in unpaid capacities, such as the abilityto do housework [93]. Quantity of studies: Five publications were found. Two of themwere literature reviews on the topic of rheumatoid arthritis. Quality of research: Thequality of the individual studies to date has been high. Of the primary reports reviewedhere, only one was conducted at a corporation. The others were large-scale databaseanalyses or nationwide telephone surveys. While those studies certainly have merit,more work in this area needs to be done in worksite settings to ascertain the impact toemployers.
In the literature reviews of rheumatoid arthritis and work outcomes, authors foundthat that work loss occurs early in the course of the disease but that interventions andappropriate treatment may prevent the high rates of loss of employment that is oftenseen among these patients [66]. A systematic review of 38 studies measuring workdisability, absenteeism and presenteeism did not include any studies that quantified theeffect of arthritis from an employer point of view; they were all from the patient’sperspective [67].
Individuals with rheumatoid arthritis are often unable to work, which may limit thenumber of employees available for study in terms of presenteeism at any givenemployer. However, a multi-employer database found arthritis or other joint conditionsaffected 15.5% of employees at some time during a 4-year study [69]. This is similar tothe 14.7% prevalence found in a random telephone sample of employed US adults [70]and 15% of employees with arthritis in a financial services corporation [68].
Arthritic workers with pain exacerbations in the previous 2 weeks reported greaterarthritis-related lost productive time (24.4% vs. 13.3%, P < .01) than workers withoutexacerbations [70]. The greatest impact on productivity was found in the physical workdomain of the WLQ [68].
Chronic Pain
Impact: Pain is a feature of many medical problems and is a major driver of increasedmedical costs and utilization. A telephone survey of nearly 29,000 working adults usingthe Work and Health Interview estimated that pain from headaches, arthritis, back pain
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and other musculoskeletal problems caused productivity loss among 13% of the U.S.workforce at a cost of $62.1 billion per year [72]. A total of 76.6% of this cost wasattributed to presenteeism and the remainder to absenteeism. Quantity of studies: Onlytwo studies on chronic pain and presenteeism were found in this review [71, 72]. Qualityof research: With only two studies, the consistency of results cannot be assessed. One ofthe two studies did not control for any confounding factors so the quality of literature inthis area is low. Much work still needs to be done in the area of chronic pain andpresenteeism.
When comparing employees based on the severity of their pain, authors found thatthe ability to perform work on each of the four WLQ subscales (time, output, mental-interpersonal and physical) was impacted more as pain severity increased [71].Moreover, a measure of overall effectiveness at work was significantly impacted bythe presence of pain among employees. Employees experiencing pain were significantlymore likely to be smokers, overweight, at risk for alcohol use, and be sedentarycompared to the employees without pain [71]. This study provides evidence for theimportance of worksite health promotion programs that have typically addressed thoserisk factors.
Diabetes
Impact: Diabetes-related productivity losses have been estimated to be nearly half of itsassociated medical costs ($40 billion compared to $92 billion in the U.S. in 2002) [94]. Inaddition, the increased prevalence of diabetes among younger individuals means alarger impact for employers in the future [95]. Quantity of studies: This literature reviewfound only two studies specifically dealing with diabetes and presenteeism [73, 74].Quality of research: The individual studies reviewed here were found to scoremoderately well based on study design, statistical analyses, outcome measures andcontrolling of confounding variables. As a topic, the research on diabetes andpresenteeism is weak. More studies using validated presenteeism instruments areneeded to assess the impact of this medical condition which is gaining in prevalence andlikely has a large impact on workplace outcomes.
Longitudinal data from the Health and Retirement Study were used to investigatethe relationship between diabetes and productivity among employed adults aged 51–61[74]. Among both men and women, the presence of work limitations was significantlymore likely (OR = 3.6) among individuals with diabetes compared to those without.Another study of employees with type 2 diabetes found similar results [73]. That is,diabetic employees showed a reduction in work productivity compared to non-diabetics.This reduction increased along with the duration of a person’s diabetes.
Gastro-intestinal Conditions
Impact: Digestive diseases are the cause of a significant burden on many Americans andresults in more than $40 billion of health care expenditures each year [96].Gastro-intestinal conditions such as irritable bowel syndrome (IBS) and gastroesoph-ageal reflux disease (GERD), have also received a fair amount of attention in thepresenteeism literature. This may be due to the potential benefits of pharmaceuticaltreatments which have become available in recent years. Quantity of studies: Whilethere is only one study on IBS identified in this review, there were eight studies of
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gastroesophageal reflux disease reviewed by Wahlqvist et al. [76]. Quality of research:The quality of these studies is generally quite high. Therefore this topic area is ratedwith a high score.
Versions of the WPAI have been created specifically for use with patients with IBS[46] or GERD [97]. Initially, most research on IBS was on patient populations, so Deanet al. examined IBS in an employed population and measured presenteeism with theWPAI. Employees with IBS reported work productivity losses of 21% because of GIsymptoms, compared to 6% among employees without IBS [75]. In a review of GERDstudy results, presenteeism losses due to GERD ranged from 6% to 40%, estimated at2.4–16.6 h of work loss per week [97].
Mental Health
Impact: The National Comorbidity Survey found that 59% of the 30 million U.S. adultswith lifetime prevalence of major depressive disorder (MDD) were severely impaired intheir ability to perform social roles and, on average, were unable to work 35 days in thepast year [98]. Furthermore, researchers estimated that $32 billion in lost productivework time is attributed to depression [99]. Quantity of studies: Five studies on this topicwere found. Quality of research: The research in this area is very high quality,particularly the studies published by Adler et al. [77, 78] and Lerner et al. [31, 80]. Eachof their studies achieved the high score while another study in this area received amoderate to low score. Overall, the research in this topic area also received a high scoredue to the quality of the individual studies, the relatively large number of studies andthe consistency of the results.
When 69 patients diagnosed with dysthymia but not MDD were compared to 175depression-free controls, the patients had significantly greater on-the-job productivityloss (6.3% vs. 2.8%, P < .001) compared to controls, as measured by the WLQ [77].While absence rates were not significantly different, patients had less stable workhistories and a greater frequency of significant problems at work. In a study combiningpatients with dysthymia and MDD presenteeism losses were between 6% and 10%compared to 4% among the healthy controls [80]. Depressed patients were significantlylimited in their ability to perform mental and interpersonal tasks, time management,and total work output (all P < .001) [80].
The effects of depression on productivity get worse as the severity of depressionincreases [31]. Furthermore, productivity at some types of jobs was impacted more bydepression than other jobs [31]. Depressed individuals in a sales, service, or support jobwere impaired in their ability to handle mental and interpersonal demands compared tocontrols. The WLQ scales of time and output were significantly worse when employeeshad jobs involving judgment and communication skills. A high level of interaction withcustomers was associated with poor mental-interpersonal and physical scale scores [31].In another study, WLQ-measured work limitations persisted even after employees’depression symptoms improved [78].
Bipolar disorder (BPD) is a serious mental health issue affecting about 5.7 millionAmerican adults in a given year [97] and is more prevalent in the working ages of 18 to54 than in older age groups [100]. In a manufacturing setting, the association of BPDwith presenteeism was measured in terms of the number of units processed per hourworked using real output data [79]. Results showed that employees with BPD processedsignificantly fewer units per year compared to healthy employees but that their hourlyproductivity rate was not statistically different.
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Langleib and Kahn [101] point out that many corporations do not yet understand thehigh presenteeism cost of mental health issues among their employees. They reason thatit is crucial to provide quality mental health care benefits to help employees and tomoderate costs, particularly since it has been shown that those who receive appropriatecare for their anxiety or depression have less disability and greater productivity.
Musculoskeletal Problems
Impact: The studies in the literature focusing on presenteeism and musculoskeletalinjuries is surprisingly sparse. There is a plethora of information related to return-to-work and injury prevention. In an effort to begin measuring work loss, a 16-item versionof the WLQ was validated and assessed in a group of employees reportingmusculoskeletal pain. The instrument did show signs of validity and reliability althoughthe authors raised some concern about the output demand scale of the WLQ [102].Quantity of studies: Only one presenteeism study of moderate quality investigatingmusculoskeletal problems was found in this review [81]. Quality of research: This study’slack of a validated presenteeism measurement and the use of a single question to assesswork limitations point to the need for more research in this area.
Hagberg and colleagues asked Swedish computer workers if musculoskeletalsymptoms influenced their productivity during the preceding month [81]. If theyanswered yes, employees were then asked to estimate the percentage reduction inproductivity compared with the month before. These workers estimated that the meanloss of productivity among those with musculoskeletal complaints amounted to nearly17 h per month, exceeding the loss due to sickness absence. However, the 1-monthrecall period in this study is relatively long compared to the presenteeism instrumentsused in other studies, potentially introducing a large recall bias. Stewart and colleaguestested three versions of the WHI with varying recall periods and determined that2-weeks may be the best for minimizing reporting error [103].
Studies of Presenteeism and Multiple Health Risks
Impact: Several studies have established that health risks are associated withproductivity losses, both in terms of absenteeism [11–14] and presenteeism [16, 65, 82,104, 105]. Presenteeism was measured objectively in a study of telephone customerservice representatives [16]. This study demonstrated that health risks not only have animpact on days lost from work but also on the loss of productivity while at work. As thenumber of health risks increased, the employee’s productivity decreased [16]. Quantityof studies: Six studies were located in the literature search. Quality of research: Thequality of research in this area is high. It has been demonstrated by the six studiesreviewed here that the health risks that have long been associated with health care costsand increased risks of disease are also associated with workplace limitations. In general,the more health risks an individual has, the greater the impact on their workplaceproductivity. This line of research provides impetus to organizations to help employeesbe as healthy as possible through the promotion of healthy lifestyle behaviors.
In a study of 2,264 employees of a large national corporation, individuals with morehealth risks reported greater productivity losses [82]. Of the 10 health risks studied(poor diet, BMI, cholesterol, exercise, stress, preventive services, fulfillment, bloodpressure, smoking, diabetes and alcohol use) the odds of any productivity loss were mostsignificant for individuals with diabetes and stress [82]. Results from the American
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Productivity Audit also found that smokers were twice as likely to report lost productivetime than non-smokers [18].
Three risk factors for cardiovascular disease, physical activity, cardiorespiratoryfitness, and obesity, were studied to test their association with work performance andinterpersonal relationships with coworkers [84]. Moderate and vigorous levels ofphysical activity were associated with higher overall job performance compared tosedentary employees. Better cardiorespiratory fitness was also associated with a higherquantity of work performed and extra effort exerted while obesity was associated with alower level of getting along with co-workers and a higher number of work loss days [84].
While it was shown several years ago that changes in health risks are associated withchanges in health care costs [106, 107], that association was only recently studied in theworkplace outcome of presenteeism [55]. As the number of health risks (as measured byan HRA) increased or decreased over time, there was a commensurate change in thepercent of employees reporting any workplace limitation and the percent productivityloss (as measured by a short version of the WLQ). Each health risk changed either up ordown was associated with a 1.9% increase or decrease in productivity loss. Anotherstudy examined the association between changes in health risks and changes inproductivity as measured by the WPAI-GH [83]. In this study, employees who reducedone risk factor improved their presenteeism by 9% and reduced their absenteeism by2% after controlling for a variety of factors.
Studies of Presenteeism and Specific Health Risks
Overweight
Impact: Obesity, a key risk factor for many health conditions, is extremely costly foremployers. Health problems attributed to obesity [88, 108–111] are reportedly costingU.S. businesses $12.7 billion directly [112] and $100 billion indirectly [113, 114].Furthermore, the obesity epidemic may be responsible for an increase in the disabilityprevalence rates [115, 116], among Americans as the onset of obesity and diabetes at ayounger age may impact disability rates [116]. Quantity of studies: While much researchhas been done to assess the health care cost impact of obesity to U.S. employers, onlythree studies have measured the association with presenteeism. Quality of research:While the study methodologies are sound, none of the three studies reviewed here useda validated presenteeism instrument and therefore the quality of research in this area islow to moderate.
The NHANES III dataset was used to examine the association between obesity,cardiovascular risk factors and work limitations among employed individuals [85]. Itwas reported that obese workers (BMI ‡ 30 kg/m2) had the highest prevalence ofwork limitations [6.9% vs. 3.0% among normal-weight workers (18.5 kg/m2 £ BMI £24.9 kg/m2)]. When individuals were classified by age, it was found that obesity has a
similar effect on worker limitations as 20 years of aging. The weakness of this study isthat workplace limitation was only measured by a single question (Are you limited inthe kind or amount of work you can do because of a physical, mental, or emotionalproblem?) rather than a validated presenteeism measure.
Lost productive time was examined in overweight and obese individuals in a randomnational telephone survey of adult U.S. workers. Obese workers (BMI ‡ 30 kg/m2) weresignificantly more likely to report lost productivity in the previous 2 weeks than normalweight workers [18.5 kg/m2 £ BMI £ 24.9 kg/m2 (42.3% vs. 36.4%, P < .0001)] [86].
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Finally, data from the Panel Study of Income Dynamics also found that, amongemployed women, being overweight or obese was associated with increased worklimitations compared to normal weight women [87]. The results for men were notstatistically significant. However, this study did not use a validated instrument formeasuring work limitations, rather they inquired about ‘‘any physical or nervouscondition that limited the type or amount of work.’’
Physical Activity
Impact: A sedentary lifestyle is associated with higher risks of overweight, cardiovas-cular disease, some cancers, and all-cause mortality [117, 118]. Given the large body ofresearch on physical activity and health care costs, it is surprising that so few studies todate have specifically measured presenteeism related to physical activity. Quantity ofstudies: Two studies were found. Quality of research: The quality of presenteeismresearch in this area is low. There are too few studies to assess consistency of results andthe quality of the individual studies is relatively low.
The association between corporate fitness center participation and presenteeism wasinvestigated among 5,379 employees at corporate sites with fitness centers [119] by usingthe eight-item version of the WLQ as part of an HRA used in previous studies to assesspresenteeism [53, 54]. When fitness center participants were compared withnon-participants (and logistic regression controlled for age, gender, location and healthrisks) the non-participants were significantly more likely to report a work limitation inthree of the four WLQ domains (time, physical, and output). The overall WLQ score forwork impairment was also significantly greater among fitness center non-participants,after controlling for confounding variables [119].
Future research should measure the amount of exercise rather than simply comparingfitness center participants and non-participants since there is likely a wide range ofexercise frequency and intensity among participants. Also, given the low percentage ofworkers who utilize fitness centers (16% in this study [119]) and the fact that thesestudies are not randomized trials, research is needed to determine whether use of thecenters is the etiology of reduced work impairment, or whether the people who elect toparticipate have other characteristics that cause them to have less work impairment.
The second study which measured presenteeism and physical activity was mentionedpreviously as it dealt with physical activity, cardiorespiratory fitness and obesity [84].The results from this study showed that moderate and vigorous levels of physical activitywere associated with higher job performance in terms of work time. Furthermore,measured cardiorespiratory fitness (VO2max) was also associated with an improvementin the amount of work performed. More studies of this nature are needed to examinethe link between physical activity levels and presenteeism.
Presenteeism and Pharmaceutical Treatment
As mentioned previously, some health conditions may be associated with largedecrements in on-the-job productivity while their medical care cost may be relativelylow. Examples of such possible conditions are migraine headaches and allergies.Fortunately, many pharmaceutical agents, whether used for prevention or treatment,are quite effective against many of these conditions. A review of studies showing theassociation between pharmaceuticals and worker productivity was published by Burtonet al. [120]. Treatment for allergies, depression and migraine headache all showed
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associations with improved on-the-job productivity. Many other classes of drugs fortreatment of conditions such as respiratory infection, diabetes, and asthma showedpositive associations with decreased absenteeism, another facet of productivity costs.The authors note a surprising lack of research on the association between presenteeismand treatment for arthritis.
Migraine is one condition which exhibits a very large impact on employers. Theprevalence of migraine peaks between the ages of 35 and 45—prime working ages formost people [121]. One study found that 93% of the total economic burden of migrainein the United States was attributable to work loss while direct medical costs are just aminor fraction of the total cost [122]. The average migraneur reports losing theequivalent of 4.9 workdays annually due to presenteeism and 3.2 workdays due toabsenteeism because of migraine symptoms [123].
Studies have found improvement in workplace productivity among migraine sufferers[124–126], those with seasonal allergies [20, 64, 127] and IBS [128]. Results of thesestudies support the proactive pharmacologic management of conditions such asmigraine. Education can be provided to employees to optimize self-management andappropriate use of all types of treatments.
Discussion
Future Research Questions
What is the next step for researchers in this field? Many questions have yet to beanswered. First and foremost is this question: is health related presenteeism real?Intuitively, almost everyone would agree that one cannot be fully productive each andevery minute of the work day. However, in many jobs it is impossible to know whenwork is not getting done (such as in a knowledge-based job). In some cases anotheremployee may pick up the slack caused by an unproductive employee. In other cases, ifsomeone is not performing at 100%, they may make up the work at a later time or takework home. There are also many reasons for lost productivity which have nothing to dowith health including time wasted on e-mail or surfing the Internet, personal issues, andtalking with co-workers or on the phone. Is presenteeism just a cost of doing businesswhich all companies deal with? Future research in this area should also consider the factthat presenteeism and absenteeism are often inter-related. Koopmanschap notes that anintervention might be successful in reducing absence but only at the expense of a rise inpresenteeism if the health problem is not properly dealt with [129].
Many of the self-report presenteeism instruments have undergone validity andreliability testing, but the quality of those studies varies. All instruments would benefitfrom further validation, especially compared with an objective measure of productivity.Furthermore, it would benefit the field greatly if researchers could agree on standardpresenteeism metrics as has occurred in other fields so that research on presenteeism iscomparable across studies. This is especially evident when one attempts to comparestudies using the different self-reported presenteeism instruments currently available. Thebest one can do is to evaluate the relative estimates between those with the risk orcondition of interest and the comparison group.
Another question facing presenteeism researchers is how or even if the results can betranslated to a dollar amount. It is tempting to place a dollar value on the presenteeismresults in any given study. Many studies have presented very large presenteeism costs
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based on their self-reported presenteeism findings. When an employee is only 80%productive on a given day, for example, does that automatically translate into a loss of20% of the value of that employee to the company’s bottom line? In some jobs this mayvery well be the case, but in other jobs that is unlikely. Also, the type of productivity lossvaries (such as the interpersonal domain of the WLQ compared to the physical domain).Does one type of presenteeism translate to dollars more than another? These are justsome of the critical questions facing the field.
What Can Employers Do?
In the meantime, what can employers do about presenteeism? Whether or not there areeffective treatment options for a given medical condition, employers must implementeducational programs for their employees, to prevent undiagnosed or misdiagnosedillnesses in the workplace, which will allow employees to better manage their healthconditions. In addition to lower-cost educational programs, it is also necessary foremployers to spend additional money on improving health risks or medical conditions inorder to improve workplace productivity [19, 130–134].
Sullivan reported on results of a survey of 60 corporations and found that the use ofproductivity information for making health-related decisions was only ‘‘frequent andsystematic’’ among 14% of respondents [135]. Health and productivity management(HPM) is the recognition that better management of employee health and its relatedimpact on productivity outcomes may drive economic growth and profits. Using HPM, itwas found, is made difficult by a lack of data systems, perceived low quality of evidenceand resistance by senior management. However, as time goes by, this strategy will likelygain more attention and more acceptance [135].
Spending money on appropriate pharmaceutical treatment is likely cost-effective, asprior research indicates drug treatment for a variety of health conditions reportedlyleads to significant improvement in productivity [120, 136]. Specifically, one studyestimates that the increase in the ability to work which can be attributable to newpharmaceutical treatments is 2.5 times greater than the cost of those drugs [137].Corporations should keep this in mind when constructing drug-reimbursement plans.
While it is important for employee health programs to target the highest-risk workersand the groups with the highest direct and indirect costs, it is of equal importance to offerprogram opportunities to the vast majority of employees who are medium or low risk. Thismay be a more profitable and successful strategy than the high-risk strategy which has beenin place for three decades [138]. By focusing just on the small percentage of employees whoare at high-risk or have a health condition, the vast majority of an employee populationgets ignored. Taking a more comprehensive population management approach may helpkeep healthy employees from becoming high-risk in the future [15].
Conclusions
Research on presenteeism is still relatively new. Most of the review papers that can befound dealing with presenteeism are about measuring presenteeism. The ability toaccurately and reliably measure presenteeism in the workplace is an important andnecessary first step in establishing the link between health and productivity. However, todate, there is still no generally accepted best method of measuring presenteeism. Whileone or two measurement instruments have become most commonly used, there has
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been no consensus among the many presenteeism researchers about commonmeasurement tools or metrics, or about their reliability or validity.
So far, no study has been able to unequivocally estimate a total dollar cost associatedwith presenteeism for corporations. The first step in this line of research is to study thetypes of health risks and health conditions which are associated with presenteeism.Several of the presenteeism measurement instruments yield results which may beconverted into a dollar amount. However, calculating the cost of presenteeism is still anabstract concept for many, since there are no receipts or bills to pay when an employeeis experiencing presenteeism as there are with health care costs or other workplaceoutcomes like disability or workers’ compensation. A recent review of 20 presenteeismsurvey instruments found that none had been validated for estimating the cost of lostproductivity due to health problems [139].
The current method which many studies use is to convert the percent decrement inproductivity into a number of hours per week that an average individual is unproductive(for example, if an employee’s presenteeism is 20%, they are unproductive 8 h out of the40 h work week). Then multiply that number by the average hourly wage and benefits costfor an employee and finally multiply that by the number of employees with a given healthcondition. However, it is still unclear if those calculations are accurate and whether or notan employee experiencing presenteeism is truly 0% effective during those hours.
Certain employee population groups have received more attention in the presentee-ism literature than others, such as nurses, a frequently-studied financial servicescorporation, and manufacturing employees. Also much of the research in this field hasbeen sponsored by pharmaceutical companies who have a drug solution for thecondition. This is not a major problem but it does somewhat explain the predominanceof studies related to medical conditions and the smaller number of studies related tohealth risks and behaviors. With such a diverse workforce today, researchers would bewise to conduct studies in a broad range of populations, particularly in employees thatdeal with information or service occupations, and a broad range of health risks andmedical conditions.
Based on the research reviewed here, it can be said with confidence that many healthconditions are associated with presenteeism. Moreover, health risks also show anassociation with presenteeism. The next step for researchers is to tease out the impact ofindividual health conditions and risks on this important outcome measure. Certainhealth risks or health conditions likely have more of an impact on presenteeism incertain types of jobs than in others. It will be important to be able to prioritize risks andconditions so employers know where to target their efforts. Above all, it can be said thatkeeping healthy employees healthy is always an effective strategy.
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