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Sickness presence, sickness absence, and self-reported health and

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Article  in  International Journal of Workplace Health Management · September 2011

DOI: 10.1108/17538351111172590

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IJWHM
4,3 Sickness presence, sickness
absence, and self-reported health
and symptoms
228
Gunnar Aronsson
Department of Psychology, Stockholm University, Stockholm, Sweden
Klas Gustafsson
Department of Clinical Neuroscience, Karolinska Institutet,
Stockholm, Sweden, and
Christin Mellner
Department of Psychology, Stockholm University, Stockholm, Sweden

Abstract
Purpose – The purpose of this paper is to compare sickness presence (SP) and sickness absence (SA)
regarding the strength of their relationship to health/ill-health. In a previous Canadian study a
stronger association between SP and health/ill-health than between SA and health/ill-health was
shown.
Design/methodology/approach – Five Swedish data sets from the years 1992 to 2005 provided the
study populations, including both representative samples and specific occupational groups
(n ¼ 425-3,622). Univariate correlations and multiple logistic regression analyses were performed.
The data sets contained questions on SP and SA as well as on various health complaints and, in some
cases, self-rated health (SRH).
Findings – The general trend was that correlations and odds ratios increased regularly for both SP
and SA, with SP showing the highest values. In one data set, SRH was predicted by a combination of
the two measures, with an explained variance of 25 percent. Stratified analyses showed that the more
irreplaceable an individual is at work, the larger is the difference in correlation size between SP and SA
with regard to SRH. SP also showed an accentuated and stronger association with SRH than SA
among individuals reporting poor economic circumstances.
Practical implications – The results support the notion that SA is an insufficient, and even
misleading, measure of health status for certain groups in the labor market, which seem to have poorer
health than the measure of SA would indicate.
Orginality/value – A combined measure of sickness presence and absence may be worth
considering as an indicator of both individual and organizational health status.
Keywords Sickness presence, Sick leave, Sickness presenteeism, Self-rated health, Work organization,
Workplace health
Paper type Research paper

1. Introduction
Sickness absence (SA) represents an individual’s reduced work capacity due to illness.
International Journal of Workplace However, since reduced work capacity can also occur without the presence of disease
Health Management or illness, and, conversely, illness may not necessarily carry with it reduced work
Vol. 4 No. 3, 2011
pp. 228-243 capacity, sickness absence cannot be interpreted as a direct indicator of ill-health.
q Emerald Group Publishing Limited Nonetheless, it is often regarded as an equivalent to ill-health and disease, both in the
1753-8351
DOI 10.1108/17538351111172590 public debate and within research. It has, for instance, even been argued that SA could
be used as an integrated measure of physical, mental, and social functional ability Sickness
within the working force (Marmot et al., 1995; Kivimäki et al., 2003). presence and
However, SA is not the only option for people facing ill-health, as they may instead
choose to go to work in spite of illness, and thus engage in sickness presence (SP). absence
(Sometimes also the term presenteeism is used but that term has more and more been
reserved for on-the-job-productivity loss studies from the United States while most
sickness presence studies come from Europe; for a recent review of the concept of 229
presenteeism and a research agenda see Johns (2010)).
In a broad sense, SA and SP are both rooted in the same general cause: poor health.
SA and SP can be regarded as mutually exclusive alternatives of action in the case of
illness and/or reduced work capacity. Since the first studies on SP appeared about ten
years ago the research has increased rapidly and work-related as well as more
individual determinants for SP have been identified (Aronsson and Gustafsson, 2005;
Hansen and Andersen, 2008). Johansson and Lundberg (2004), in their illness flexibility
model, have described the decision-making process that individuals undergo when ill
in terms of adjustment latitude and demands for presence in their work. Important
factors are to what extent employees have control in their job so they can modify their
work tasks in such a way that they can manage them, despite reduced work capacity
due to ill health.
Previous research has shown that poor health is a strong determinant for SP
(Aronsson and Gustafsson, 2005) but extensive SP may also result in SA and poorer
health. In cross-sectional studies, a strong association has been found between SP and
various self-reported health complaints, as demonstrated, for instance, by a higher
proportion of individuals with back and neck problems as well as with extreme fatigue
being found in groups with high levels of SP. In a Swedish study it was found that
women with a high cardiovascular risk score decreased their SA more than healthy
women during downsizing, possibly indicating risky SP (Theorell et al., 2003). A
British study found that the nine-year incidence of serious coronary events was twice
as high among unhealthy employees who took no absence during a three-year period
than among unhealthy employees with moderate levels of SA (Kivimäki et al., 2003).
Moreover, three recent longitudinal studies have shown the importance of SP in
relation to future health and future SA (Bergström, Bodin, Hagberg, Aronsson and
Josephson et al., 2009a; Bergström, Bodin, Hagberg, Lindh, Aronsson and Josephson
et al., 2009b; Hansen and Andersen, 2009). Most of the research is quantitative but there
are also qualitative studies with the aim to identify and probe into the factors that
foster SP (Dew et al., 2005).
In light of this close relation between SA and SP, a combination of SA and SP
measures ought to be a more accurate indicator of an individual’s health status than
SA alone (Aronsson and Blom, 2010). The greater the SP, and thus the more instances
of ”falsely” healthy individuals, the weaker the expected associations are between
sickness absence and poor health. If SP, on the other hand, is very low, the association
between SA and health can be expected to be higher; however, since some people may
go on sick leave due to reduced work capacity that is not caused by illness, the reverse
could also be the case, which would show a weaker association in bivariate analyses.
In a Canadian study conducted in 2004 by Caverley et al. (2007), SA and SP were
combined in an additive index according to the formula: Total ill-health ðSicknessÞ ¼ f
(Sickness Absenteeism þ Sickness Presence). The assumption was that SA and SP
IJWHM have complementary roles in the prediction of poor health. When SP increases relative
4,3 to SA, it becomes a stronger predictor in several regards. The study by Caverely et al.
(2007) was done after a major downsizing in a company, which could be expected to
result in an increased demand for employee presence at the cost of sickness absence.
This was supported by the fact that the workforce demonstrated Mean values for
health but significantly lower values than expected for sickness absence; i.e. the rates
230 of sick-leave were lower than Canadian average levels.
According to these researchers (Caverely et al., 2007), if this hypothesis, called the
substitutional hypothesis, is correct, it may have important policy implications. One
such implication would be that initiatives taken in order to improve the health of the
employees, can, under certain circumstances, influence SP rather than SA. A second
implication would be that in organizations where SA is exchanged for SP, a decrease in
work performance would follow, resulting in SA becoming a weak indicator of
productivity. A third potential implication is that if SA is substituted by SP, the health
problems of individuals going to work in spite of ill-health will become more similar to
those of individuals on sick-leave. Such a development would not conform with the
perception that the health problems related to SA are more severe than those related to
SP, for it entails that certain individuals attend work with health problems that would
normally warrant their going on sick-leave in order to recover. The lack of rest, in the
long run, can be expected to have detrimental effects for the development of serious
ill-health and disease (Kivimäki et al., 2005, 2006; McEwen, 1998). A fourth implication
and hypothesis is that if SA is substituted by SP, many of the environmental factors
related to SA would then also correlate with presence.
In the study by Caverely et al. (2007), there was support for the hypothesis that total
health/ill-health is a function of SA and SP. The results showed that SA explained 3
percent of the variance in self-rated health, and this figure increased to 13 percent when
SP was included in the model. No interaction effect was found, however. The
conclusion made was that SP is a stronger predictor for self-rated health than SA. The
model was also tested for various health complaints/symptoms. For 7 out of 12
symptoms, SP was found to be a stronger predictor for self-reported health complaints.
SA, on the other hand, turned out to be a better predictor in only one case – whether a
prescribed treatment was followed. In other previous studies of SP, various so-called
work attendance demands have been identified, concerning, for instance, replaceability
at work and the private economic situation of the individual (Aronsson and
Gustafsson, 2005). Replaceability is expressed in several ways – depending on
whether a replacement is available or even sought after in the case of sickness absence,
or whether the work would just pile up for the person on sick-leave (Aronsson and
Gustafsson, 2005; Aronsson et al., 2000; Caverley et al., 2007). Low replaceability can be
a consequence of the nature of one’s work; in knowledge-intensive jobs, for instance, it
can be difficult to find someone else to take over and perform the work on short notice.
Replaceability can also be affected by a company’s management strategy, as can be
witnessed in the fact that many companies that have undergone organizational
slimming have a policy of not taking in extra workers. Given that the labor market
seems to be going in the direction of having more and more of the types of jobs and
work tasks where employees cannot readily be replaced if they go on sick-leave, it is
important that efforts are made to investigate the situations and conditions of the
individuals who are affected by this.
 The purpose of the present study was to test whether the results of Caverley Sickness
et al(2007) study, that SP has a stronger association with health/ill-health than SA, presence and
were replicable with other populations and contexts. For the analyses, several large
databases were used which contained questions on SA and SP as well as on various absence
health complaints and, in some cases, self-rated health as well. Self-rated health has
proved to be a useful concept in clinical settings and has in several prospective studies
shown a strong association with future health status and morbidity (Kivimäki et al., 231
2003; Burström et al., 2001; Singh-Manoux et al., 2007). An increased understanding of
the relation between SP and self-rated health is thus particularly important to the
pursuit of preventing future ill-health.
Two main questions were formulated. The first concerned whether associations
similar to those found in the Canadian study could be found between self-rated health
and SP and between self-rated health and SA in specific professional groups in Sweden
and in Swedish representative materials from different points in time. The second was
whether these associations between self-rated health and both SP and SA, respectively,
were conditioned by factors relating to the work organization and the private financial
situation of the individual. The former question reflects working conditions in respect
to replaceability, while the latter reflects the financial resources available to the
individual.

2. Method
2.1 Materials, participants, and variables
Five large data sets were used. The data collections took place between 1992 and 2005.
The oldest material, “Academics in the 90’s,” is from 1992 and is comprised of a
random sample of 3,622 individuals who were both employed in jobs that required an
academic degree and members of unions that represented academic workers. The
response rate was 69 percent (Aronsson et al., 1992). Of the sample, 55 percent were
older than 44 years. This sample contained questions relating to SA, SP, and
self-reported health problems (Table I).
The second study population, “Schools in development,” consists of primary
through high school level teachers, and the data collection was conducted between
1992 and 1995. The questionnaire was sent out to 472 teachers and the response rate
was 90 percent ðn ¼ 425Þ (Aronsson et al., 2003). The mean age of the sample was 46
years. Questions on SA, SP, and self-reported health problems were included (Table I).
The third set of data material, “Burn-out in Sweden,” is based on a representative
sample of employees ðn ¼ 3136Þ and was collected in 2000 by Statistics Sweden
(Hallsten, 2005; Hallsten et al., 2002). The response rate was 69 percent. The mean age
was 42 years. Questions on SA and SP were included, along with three questions on
specific health problems and self-rated health, and one question which asked whether
employees had to catch up on piled-up work after returning from sick-leave (regarded
as an aspect of work organization) (Table I and Table II).
The fourth set, “Working life cohort,” was collected in 2004 by the National Institute
for Working Life in Sweden (NIWL). The study group consisted of a random sample of
2,767 employees between the ages of 25 and 50. The response rate was 59 percent
(Berntson et al., 2005). The mean age was 38 years. The questionnaire included
questions on SA and SP, as well as four questions on specific health problems that
might have been experienced within the preceding 3 months and self-rated health.
IJWHM
Sickness Sickness
4,3 absence presence t-value

Academics in the 1990s (n ¼ 3622)

Sickness presence 0.272 * * –
Have you experienced any of the following over the past
12 months? Stomach achea 0.114 * * 225 * * 5.69 * * *
232 Cold 0.356 * * 0.317 * * 22.15 *
Dry skin, eyes, nose, mouth or throat 0.094 * * 0.182 * * 4.47 * * *
Headache 0.128 * * 0.255 * * 6.56 * * *
Work-related back or neck pain 0.087 * * 0.228 * * 7.22 * * *
Work-related musculoskeletal problems 0.078 * * 0.199 * * 6.16 * * *
Work-related sadness 0.122 * * 0.232 * * 5.65 * * *
Work-related sleeping difficulties 0.069 * * 0.250 * * 9.32 * * *
More tiredness than usual due to work 0.114 * * 0.314 * * 10.51 * * *
Worry and restlessness due to work 0.069 * * 0.247 * * 9.16 * * *
Schools in development (n ¼ 409)
Sickness presence 0.334 * * –
Do you feel worried and restless due to work?b 0.166 * * 0.172 * * 0.11
Are you troubled by headaches?b 0.211 * * 0.309 * * 1.81
Do you get stomach aches?b 0.219 * * 0.240 * * 0.38
Do you feel burned-out by your work?b 0.185 * * 0.297 * * 2.06 *
Do you have trouble sleeping because thoughts about work
are keeping you awake?b 0.131 * * 0.200 * * 1.23
Burn-out in Sweden 2000 (n ¼ 3084)
Sickness presence 0.282 * * –
How would you rate your own health?c 0.276 * * 0.400 * * 6.38 * * *
Have you, over the past 3 months, had . . . sleeping
difficultiesd 0.149 * * 0.339 * * 9.37 * * *
[. . .] joint and muscular pains? 0.207 * * 0.334 * * 6.29 * * *
[. . .] heartburn or upset stomach? 0.146 * * 0.313 * * 8.16 * * *
Working life cohort 2004 (n ¼ 2277)
Sickness presence 0.332 * * –
How would you rate your present health?e 0.241 * * 0.301 * * 2.63 * *
Have you, over the past 3 months, . . . had disturbed sleep?d 0.155 * * 0.287 * * 5.70 * * *
[. . .] felt physically tired after the working day? 0.226 * * 0.320 * * 4.13 * * *
[. . .] felt mentally tired after the working day? 0.138 * * 0.307 * * 7.33 * * *
Have you, after the working day, had upper back or neck
pain?d 0.189 * * 0.265 * * 3.27 * *
Boundaryless work 2005 (n ¼ 1871)
Sickness presence 0.220 * * –
How would you rate your own health?f 0.277 * * 0.266 * * 20.41
How would you rate your own health compared to other
people of your age?g 0.219 * * 0.224 * * 0.18
Table I.
Correlations (Spearman’s Notes: *p , 0.05; * *p , 0.01; * * *p , 0.001; values that are italicised represent significant differences,
rho) between sickness for t . 1.96, p , 0.05; t . 2.58, p , 0.01; t . 3.29, p , 0.001; aNo, never (1), No, seldom (2), Yes, sometimes
absence, sickness (3), Yes, rather often (4), Yes, most of the time (5); bNever (1), Seldom (2), Sometimes (3), Rather often (4), Very
presence, and often (5); cGood (1), Rather good (2), It varies (3), Rather poor (4), Poor (5); dMore seldom or not at all (1),
self-reported health A couple of days per month (2), One day per week (3), A couple of days per week (4), Every day (5); eVery
problems/self-rated good (1), Rather good (2), Neither good or poor (3), Rather poor (4), Very poor (5); fVery good (1), Good (2),
general health Fair (3), Poor (4), Very poor (5); gVery good (1), Rather good (2), The same (3), Rather poor(4), Very poor (5)
 Working life cohort
Burn-out in Sweden 2000a 2004b Boundaryless work 2005c
n ¼ 3081 n ¼ 2273 n ¼ 1871
Variable n OR CI OR CI ORd CI

Sickness absenteeism
None day 1423-727-700 1 1 1
, 1 week 840-887-646 0.97e 0.77-1.22 1.29 0.92-1.81 1.13 0.87-1.48
1-2 weeks 338-366-288 1.63 1.25-2.14 1.60 1.08-2.36 2.24 1.64-3.07
3-4 weeks 179-122-102 3.05f 2.15-4.31 2.47 1.50-4.07 3.74 2.38-5.89
.1 month 251-171-135 4.97 3.62-6.82 4.72 3.08-7.21 3.98 2.67-5.94
Sickness presenteeism
Never 920-658-736 1 1 1
Once 521-454-810 1.11 0.80-1.54 1.68 1.06-2.66 1.83 g 1.43-2.35
2-5 times 1181-849-223 2.67 2.09-3.40 2.79 1.90-4.11 2.82 h 2.00-3.97
. 5 times 459-312-102 10.18 7.65-13.56 7.66 5.06-11.62 6.48 4.05-10.36
Nagelkerke R2 0.257 0.171 0.136
Chi 2, (df ¼ 7) 596.25 * 235.85 * 186.59 *
Notes: *p , 0.001; >aGood/rather good ¼ 0; poor/rather poor/it varies ¼ 1; bVery good/rather good ¼ 0; very poor/rather poor/neither good or
poor ¼ 1; cVery good/good ¼ 0; very poor/poor/fair ¼ 1; dAdjusted for age; e , 5 days, f2 weeks up to 1 month, g1-2 occasions, h3-5 occasions
absence

Multiple logistic
Sickness

are shown
ratios (OR) and
dichotomized a,b,c in the
dependent variable of
regression with the

confidence intervals (CI)

three data sets. Odds
presence and

self-rated health
233

Table II.
IJWHM Moreover, it was also asked whether the employees could put their work off until later
4,3 in the case of sick leave (Table I and Table II).
The fifth study group, “Boundaryless work,” was collected in 2005, and consists of a
random sample of employees ðn ¼ 1889Þ between the ages of 21 and 64. The mean age
was 44 years. The response rate was 63 percent (Allvin et al. (forthcoming). The data
set also included questions on SA and SP, along with two questions on self-rated health
234 (Table I and Table II).

2.2 Measures of SP and SA

SP was measured using the question: “Have you, within the past 12 months, gone to
work when, for health reasons, you should have stayed at home on sick-leave?” The
possible responses were: No, never (1); Yes, once (2); Yes, 2-5 times (3); More than five
times (4); and Have not been sick during the past 12 months (5). Response categories 1
and 5 were combined in the subsequent analyses.
When measuring SP in “Academics in the 90’s” and “Schools in development,” the
following scales were used: No occasion (1); Once (2), A couple of times (3); and Several
times (4); with the former, and No time (1); Once (2); A few times (3); and A couple of
times (4), with the latter.
SA was measured using the question: “How many days over the past 12 months
have you been away from work due to sickness (sick-leave, health care, treatment or
investigation)?” The possible responses were: None (1); Less than a week (2); 1-2 weeks
(3); 2-4 weeks (4); 1-3 months (5); and More than 3 months (6).
In the “Working life cohort,” response categories 5 and 6 were combined in the
logistic regression analysis in order to correspond with the other materials which had
5-point response scales (Table II).

2.3 Health problems and self-rated health

Questions on health problems were included in the “Academics in the 90’s,” “Schools in
development,” “Burn-out in Sweden” and “Working life cohort” data sets (Table I). The
three population-based sets, “Burn-out in Sweden,” “Working life cohort,” and
“Boundaryless work,” each contained a question on self-rated general health as well.
Moreover, a question on how one rates their general health in comparison to others of
the same age group was also included in “Boundaryless work” (Table I). This
self-rating served as a dependent variable and was dichotomized in the logistic
regression analyses (Table II).

2.4 Work-organizational variables

The following three data sets were stratified according to questions of work
replaceability (the other two sets did not contain questions on this topic).
(1) “Burn-out in Sweden” included “If you have been on sick-leave for at least one
week, how much of your work do you have to catch up on after returning to
work?” with the response scale: None or very little (1), Less than half (2), More
than half (3), and More or less all of it (4).
(2) The “Working life cohort” included “In what way are you able to adjust your
work when feeling ill?” and “Can you perform only the most necessary work
tasks and postpone the rest?” with the response scale: Always (1), Most of the
time (2), Usually not (3), Never (4), and Irrelevant (5).
 (3) “Boundaryless work” included “If you are on sick-leave for more than one week, Sickness
does someone else take over your work?” with the response scale: Never (1), presence and
Usually not (2), Usually (3), and Always (4).
absence
The results are presented in Figure 1, which shows the contrasts between individuals
with high and low replaceability (according to response alternatives 1 and 4,
respectively, from “Burn-out in Sweden” and the “Working life cohort,” and response 235
alternatives 4 and 1 from “Boundaryless work”).

2.5 Private financial situation

The data from “Burn-out in Sweden” and the “Working life cohort” were also stratified
according to private financial situation by the question “If you suddenly found yourself
in a situation where you needed to come up with sums of 13,000 (“Burn-out in Sweden”)
and 14,000 (“Working life cohort”) SEK within a week (approx. $ 1,625 and $ 1,750),
would you be able to do it?” with the response scale: Yes (1) and No (2). See Figure 2.

2.6 Statistical analyses

In the first step, the univariate correlations between SP, SA, and self-reported health
complaints/self-rated health were calculated using Spearman’s rho. In addition,
significance tests of the differences in t-values between the two correlation coefficients
of SP and SA, respectively, as related to the various measures of self-reported health
were performed according to the formula below (Ferguson and Takane, 1989):

Figure 1.
Correlation coefficients
between self-rated health
and both sickness absence
and sickness presence,
respectively, in the three
population-based samples
and t-test of differences
between SA and SP
coefficients
IJWHM
4,3

236

Figure 2.
Correlation coefficients
between self-rated health
and both sickness absence
and sickness presence,
respectively, in two of the
population-based samples
and t-test of differences
between SA and SP
coefficients

pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ðr 12 2 r 13 Þ ðN 2 3Þð1 þ r 23 Þ
t ¼ pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
2ð1 2 r 12 2 2 r 13 2 2 r 23 2 þ 2r 12 r 13 r 23 Þ

r 12 ¼ health – SP; r 13 ¼ health – SA; r 23 ¼ SP – SA

In the second step, SP and SA were analyzed in the three population-based samples,
“Burn-out in Sweden,” the “Working life cohort,” and “Boundaryless work,” with
regard to the dependent variable of self-rated health, using multiple logistic regression.
Self-rated health was dichotomized, and SP and SA served as each other’s controls in
the models. Finally, in order to study the work-organizational variable of replaceability
and the variable of private economic situation, the univariate associations with SP, SA
and self-rated health were calculated using Spearman’s rho (Figure 1 and 2).

3. Results
The correlation analyses mainly showed consistent significant and positive
associations between various health problems and both SP and SA, respectively
(Table I). The coefficients were in general higher between SP and health problems than
between SA and health problems, as indicated by the t-tests. Thus, the results were in
line with those in the study by Caverley et al. (2007). Regarding self-rated health, the
results went mainly in the same direction in respect to the data from “Burn-out in
Sweden” and the “Working life cohort.” However, this was not the case in regard to
“Boundaryless work,” where the correlations were relatively high but at the same level Sickness
for both SA and SP. presence and
In order to further analyze the associations between SP, SA, and self-rated health,
stepwise logistic regression analyses were performed (Table III). The results showed
absence
that self-rated health was predicted by a combination of SP and SA, where the highest
explained variance was found within the “Burn-out in Sweden” data material. SA
explained 12.2 percent of the variance and when SP was added in the analysis, the 237
explained variance increased to 25.7 percent. The pattern was similar in the two other
population-based data sets, the “Working life cohort” and “Boundaryless work,”
although the explained variance was lower. Age and gender had no significant
contribution in the data sets “Burn-out in Sweden” and “Working life cohort” (not
shown in the table) but in the “Boundaryless” study group age had a significant effect
ð p ¼ 0:001Þ: In the following we have thus controlled for age in the analyses of the
“Boundaryless” group.
The initial univariate logistic regression analyses showed higher odds ratios
between self-rated health and SP than between self-rated health and SA. In order to
clarify the association between SP and SA, multiple logistic regression analyses were
then performed, with these variables serving as each other’s controls in the analyses.
As can be seen in Table II, the odds ratios increased in a regular way for each point on
the scale for both SP and SA. This reflects the risks for ill-health, with the highest odds
ratios being found among those who were on sick-leave for more than one month and
among those who were present at work while sick on more than five occasions over the
preceding year. Moreover, SP showed the highest odds ratios in all of the three
population-based data sets, with the highest explained variance being found in
“Burn-out in Sweden” material. No significant interaction effect emerged between SP
and SA in any of the data sets.

Independent variable Chi2 p Nagelkerke R 2

Burn-out in Sweden 2000

Sickness absence 268.58 ,0.001 0.122
Sickness presence 327.67 ,0.001 0.257
Sickness absence * Sickness presence 13.73 n.s 0.262
Total 609.98
Working life cohort 2004
Sickness absence 119.99 ,0.001 0.089
Sickness presence 115.87 ,0.001 0.171
Table III.
Sickness absence * Sickness presence 20.46 n.s 0.185
Stepwise logistic
Total 256.32
regression of self-rated
Boundaryless work 2005 health, where sickness
Sickness absence 116.78 ,0.001 0.087 absence, sickness
Sickness presence 69.81 ,0.001 0.136 presence, the interaction
Sickness absence * Sickness presence 11.83 n.s. 0.144 term (sickness absence *
Sex 0.002 n.s 0.144 sickness presence),
Age 25.42 ,0.001 0.162 gender and age were
Total 223.83 added sequentially
IJWHM In Figure 1 the test of the work-organizational variable of replaceability is presented,
4,3 showing the stratification of this variable within the three population-based data sets.
The questions regarding this variable were, as described in the method section,
formulated somewhat differently in the different data sets. The analyses revealed
similarities as well as differences. In regard to SP, its association with self-rated health
was consistently found to go in the expected direction in all of the data sets: the less
238 replaceable the individual was at work, the stronger the association was between SP
and self-rated health.
For SA, in “Burn-out in Sweden” and the “Working life cohort”, no significant
results were found when stratifying according to the variable of replaceability. Instead,
the correlation coefficients in the stratified groups were similar to each other as well as
to the coefficients in the unstratified materials (see Table I).
In the “Boundaryless work” data set, however, there was differentiation. SA and
self-rated health showed significantly higher associations with each other in the group
with replaceable work tasks ðr ¼ 0:340Þ as compared to the group with low
replaceability ðr ¼ 0:24Þ: This indicates that SA is a weaker indicator of general health
status for individuals and groups with low replaceability/high demands for presence.
We also carried out separate analyses for younger and older respondents. In the older
group that tendency was strengthened, with a correlation of 0.20 between SA and
self-rated health among those with low replaceability as compared to 0.34 in the group
with high replaceability.
Figure 2 shows how the associations are influenced by the stratification as regards
private financial situation. First, the associations with self-rated health were stronger,
both for SP and SA, in the group reporting a poor economic situation. Second, the
associations between SP and (ill-) health were stronger than the ones between SA and
(ill-) health.

4. Discussion
The present study aimed to investigate and compare the associations between various
measures of self-reported health, such as self-rated general health status (SRH) and
both SP and SA, respectively. In the previously mentioned study by Caverley et al.
(2007), which was performed on a public sector organization that had undergone
downsizing, it was found that SRH was more strongly associated with SP than with
SA. SRH has, in several prospective studies, also shown significant relationships with
future ill- health and disease (Kvivimäli et al., 2003). From a prevention and
health-promotion perspective, the identification of how behavioral factors such as SP
and SA co-vary with SRH is of particular interest.
The present study was based on a larger and more occupationally differentiated
group of data materials than the Canadian study (Caverley et al., 2007). The material
also stretches over a long period of time, from 1992 to 2005. Furthermore, in addition to
SRH, it was also possible to investigate how SP and SA were related to various
self-reported health problems and symptoms.
The results from the Canadian study (Caverley et al., 2007) – which found that SP is
more strongly associated with ill-health than SA – were replicated in this Swedish
study. The same main patterns were consistently found within all of the five
investigated sets of data, with few exceptions. An examination was also made whether
the associations changed when the study groups were stratified according to the
work-organizational factor of replaceability as well as according to private financial Sickness
situation. These analyses could be carried out in three of the five data sets, namely presence and
“Burn-out in Sweden,” the “Working life cohort,” and “Boundaryless work.”
For SP and replaceability at work, the correlation went in the expected direction: the absence
more irreplaceable an individual was at work, the stronger the association between SP
and self-rated health.
When SA and self-rated health were examined, however, no significant results 239
emerged in two of the data sets, “Burn-out in Sweden” and the “Working life cohort”.
The coefficients were approximately the same for SP and SA. In the “Boundaryless
work” data set, SA and self-rated health were more strongly associated in the group
reporting replaceable work tasks than in the group with low replaceability. Thus, the
measure of SA can, for the latter group, be said to be a poor indicator of health.
Finally, when stratifying according to private financial situation, the results went in
the expected direction: the strongest association between SP and self-rated health was
found in the economically constrained group.
Taken together, the results of the present study support the notion that SA is an
insufficient measure of health status for certain groups in the labor market. Indeed, it
can even be a misleading measure for certain groups. This is becoming the case as
various circumstances force individuals, more or less voluntarily, to choose SP rather
than SA when ill. Through the stratified analyses, it was possible to identify the
conditions under which the measure of SA is particularly misleading. The tentative
conclusion that can be made is that the traditional measure of SA is not neutral when it
comes to certain categories, as was identified in the cases relating to work organization
and private finances. Thus, certain groups in the labor market seem to have poorer
health than the measure of SA would indicate.
Practical implications can be drawn from the results of this study and the testing of
the substitutional hypothesis. Since it has been observed that attempts to decrease SA
might result in increased SP, nothing is gained in this regard from a health perspective.
In order to get a more in-depth sense of these relationships, not only for the benefit of
research but also for its potential practical ramifications, SP needs to be added to the
traditional measure of SA.
It should, however, be pointed out that the samples investigated here only included
active employees. Presumably, in a representative population sample, including
individuals on long-term sick leave and disability pension, the association between SA
and health would be stronger. SP, for obvious reasons, cannot be studied within groups
consisting of individuals on long-term sick leave or disability pension.
Among the data sets included in this study, the highest level of SA that could be
indicated on the scales was “1 month or more.” This did not provide the greatest
opportunity for distinctly indicating longer time periods. Had there been more choice
on the upper end of the scale, a stronger association between SA and self-rated health
may have emerged. A problem with this, however, is that, from a statistical viewpoint,
it would require very large samples in order to include enough individuals with long
durations of sickness absence.
The three different measures of replaceability investigated were all found to have
influenced the association between SP and self-rated health. This implies that
replaceability is a rather robust factor. This measure could be developed, however, in
future studies by differentiating more between both the various kinds of replaceability
IJWHM and the reasons behind it. For instance, with the measures we used, it was not possible
4,3 to differentiate between low replaceability due to a slimmed organization, and low
replaceability due to there not being a competent substitute worker available.
As pointed out previously, the measure of SA is often used in practical settings as
an indicator of health status, for example, when companies and organizations are
attempting to reduce sickness absence to a certain level. It has even been suggested
240 that sickness absence be used as an integrated measure of physical, mental, and social
functional ability within the workforce (Marmot et al., 1995). Based on the results of the
present study as well as other research on SP, it can be concluded that measures of SA
alone can only provide limited information about the health of an individual or
organization. A decrease in SA does not necessarily imply improved health, but could,
rather, be a result of organizational measures, which reduce SA at the expense of
increased SP, i.e. substitution. A degree of caution is therefore needed when
interpreting the effects of measures as well as the changes in sickness absence levels.
Thus, our results strongly support the findings in the study by Caverley et al. (2007).
A combined measure would provide a sounder foundation for both research and
practical health-promoting work. Health, or ill health, is more properly reflected in a
combined measure such as an additive index using the formula Total ill health
ðSicknessÞ ¼ fðSA þ SPÞ: The findings of our study could even be said to give support
for an argument against using SA as a measure of global health within the workforce.
The measure of SP, however, could be developed in several ways. It is presently
constructed according to the number of occasions present. One way would be to, as in
the Stanford Presenteeism scale (Koopman et al., 2002), develop additional questions
with which to measure SP. By also asking employees about their SP in terms of the
number of days present, it would then be possible to make group distinctions, for
example, between those who were present while sick on only a few, albeit extended,
occasions and those who were present while sick on many occasions, albeit only for a
limited number of days. Also, it would be interesting to develop measures that could
capture the severity of the health problems experienced in connection with SP (Schultz
and Edington, 2007). On a broader methodological level, in order to get a better idea of
what underlies SP and its implications, it would be useful to adopt a method such as
the critical incidence type suggested by Caverley et al. (2007). The respondents would
be expected to identify a specific day or period of SP and give a description of their
health problems at that time; this would be accompanied by an explanation not only of
why they went to work in spite of the illness but also of the type and degree of
difficulties that arose at work due to their health condition.
As the present study was based on cross-sectional data, it would also be fruitful to
conduct a prospective study comparing the predictive value of SP and SA in relation to
the development of health/ill-health over time. Caverley et al. (2007) suggest that if the
substitutional hypothesis is correct, then the health problems of individuals reporting
SP will be similar to those of individuals reporting SA. A second hypothesis is that
many of the environmental factors that are related to SA should also correlate with SP.
These issues should provide adequate fodder for further investigations as they attempt
to create a more accurate basis for evaluating the measure of SP.
Finally, a reflection regarding our findings can be made from a broader perspective.
Working life, both in Sweden and globally, seems to be becoming increasingly
polarized, with one group, the poor working group, being economically marginalized,
and the other group consisting of a growing number of well-educated individuals who Sickness
hold knowledge-intensive jobs and are able to influence when and where they work. It presence and
is within these two growing groups that the use of SP as a strategy for handling health
problems seems to be most frequent. We have not been able to identify any studies of absence
SP from developing countries with weaker social insurance system and weaker work
environment legislation. One hypothesis for further research is that the extent of SP
may be considerably higher in such a context. This highlight the question of whether 241
the measure of SA alone is sufficient or even misleading as an indicator of
health/ill-health for a growing proportion of people in today’s working life.

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Further reading
Burström, B. and Fredlund, P. (2001), “Self rated health: is it as good a predictor of subsequent
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About the authors Sickness
Gunnar Aronsson, PhD, is Professor in Work and Organizational Psychology at the Department
of Psychology, Stockholm University. Earlier, he was Professor in Psychology at the Swedish presence and
National institute for working life research from 1990 to 2007 when the institute was closed. absence
Currently, he participates in research on transfer of learning in work life, illegitimate tasks as
stressors, sickness presenteeism and individual strategies in boundaryless work. Gunnar
Aronsson is the corresponding author and can be contacted at: Gunnar.Aronsson@
psychology.su.se 243
Klas Gustafsson, PhD, is a Researcher at the Department of Clinical Neuroscience, Division of
Insurance Medicine, Karolinska Institutet, Stockholm, Sweden. He received his PhD from the
Department of Psychology at Stockholm University. His research interests include occupational
health, sickness absence and sickness presenteeism.
Christin Mellner, PhD, is a Researcher at the Department of Psychology, Stockholm
University. Her research mainly concerns modern work organization in relation to sickness
absenteeism, sickness presenteeism, self-rated health, medically unexplained symptoms,
rest/recovery, performance-based self-esteem, and coping strategies.

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