ORIGINAL ARTICLE

Chapter 9. Consequences of being on sick leave

Eva Vingård1, Kristina Alexanderson1 and Anders Norlund2
1
Section of Personal Injury Prevention, Karolinska Institutet, Stockholm, Sweden, 2SBU – The Swedish Council on Technology
Assessment in Health Care, Stockholm, Sweden

Scand J Public Health 2004; 32 (Suppl 63): 207–215

The possible consequences of sick leave can be measured at different levels in society. This chapter focuses on the
consequences from the perspective of the sick-listed individual. Sick leave may have both positive and negative consequences
for the individual, e.g. regarding disease, health, working life, social life, lifestyle, and emotional aspects. Some of these
factors have been investigated in different studies. However, scientific evidence is insufficient since there are too few studies
on the consequences of sickness absence and disability pension. The lack of relevant studies is the most striking observation
from the review of studies on the consequences of being sick listed.

Eva Vingård, Section of Personal Injury Prevention, Karolinska Institutet, PO Box 12 718, SE-112 94 Stockholm, Sweden.
Tel: z46 8 545 7070, fax: z46 8 653 9413. E-mail: eva.vingard@cns.ki.se

INTRODUCTION activities. Likewise, it may be active, e.g. involving

The natural course and the consequences of disease
and injury are known for only some diagnoses. Such
information is relatively poor regarding the most
prominent sick-leave diagnoses, i.e. diseases and
disorders of the musculoskeletal system and psychia-
tric disorders. The consequences of sick leave,
regardless of diagnosis, are even less known. Research
in the area is limited. Methodological problems
associated with this type of research are extensive
and apparent. Distinguishing the consequences of the
disease or injury, per se, and the consequences of the
factors that led to disease and sick leave from
the consequences of sick leave itself is a complex
scientific challenge that requires multidisciplinary
research strategies. Using a randomised study design
is problematic. Randomising one group to sick leave
and another to continued work involves several
difficult, practical, and ethical problems.
Another problem in studying the consequences of
sick leave is that sick leave as an exposure variable is
not uniform. It can vary in several ways and hence
have different consequences. Sick leave may be long-
term or short-term, and an individual may even have
alternating short and long sick-leave spells. The
consequences of full-time sick leave presumably
differ from those of partial sick leave. Sick leave
may be passive if the sick-listed individual has been
prescribed rest, or has not received advice concerning
participation in various rehabilitation activities or
various treatments. Continual contact with the work-
place may be a way for the sick-listed individual to
remain active and maintain a normal daily life. The
reason for sick leave, the sick-listing diagnosis and
how it develops, are of interest for the development of
sick leave. Job demands, work organisation, and the
opportunities for job adaptation available in the work
environment presumably play a role in the duration of
sick leave and thereby on its consequences.
POSSIBLE CONSEQUENCES OF SICK LEAVE
Theoretically, several potential consequences of sick
leave are conceivable, and can be measured for:
. a sick-listed individual or groups of sick-listed
individuals;
. the family of a sick-listed individual;
. the employer;
. the workgroup;
. the health services;
. society;
. the insurer.
This chapter focuses on the consequences for the sick-
listed individual, i.e. the main aspects that a physician
prescribing sick leave should address when discussing
the potential advantages and disadvantages of sick
leave with the patient.

# Taylor & Francis 2004. ISSN 1403-4956 Scand J Public Health 32 (Suppl 63)
DOI: 10.1080/14034950410021899
208 E Vingård et al.
Sickness absence is used as an outcome measure in
most studies of sickness absence. From the perspective
used here, we instead address sickness absence and/or
disability pension as exposures, where a consequence
of sickness absence could be increased sickness
absence or more permanent absence such as disability
pension.
Theoretically, sick leave may have positive or
negative consequences for the individual in terms of
the dimensions described below. Most of these
have not been studied, and others may also exist.
Furthermore, it is conceivable that sick leave has no
effect at all on the individual, either desirable or
undesirable.
Disease
. The disease or injury leading to sick leave
may improve during the sick-leave spell, or a
progressive course may be delayed due to the sick
leave, or the disease may become worse because of
sick leave.
. Another disease may appear as a consequence
of sick leave, e.g. a depressed state may develop
from the situation during sick leave, where
death, e.g. due to suicide is the most extreme
consequence.
. For various reasons, sickness absence in itself can
lead to continued, prolonged sick leave and possibly
disability pension.
. Utilisation of health services and pharmaceuticals
may increase or decrease as a consequence of sick
leave or disability pension.
Health
. Health, e.g. in terms of well-being, ability to take
action, sense of meaning, or quality of life may
improve or become worse from a sick-leave spell.
Working life
. Opportunities to participate in rehabilitation activ-
ities, education etc may increase during a sick leave
period.
. Work ability, involving physical, physiological, and
social aspects, may improve or become worse as a
consequence of sick leave.
. A consequence of sick leave may be a greater risk
for full or partial unemployment.
. Sick leave may contribute to both positive and
negative changes in work conditions and work
tasks.
Scand J Public Health 32 (Suppl 63)
. Career opportunities and personal finances may be
influenced.
Social life
. Social contacts and activities with family, friends,
and colleagues may be influenced, for better or
worse, by sick leave. This may also have conse-
quences on social integration and participation in
society.
Lifestyle
. Both increased and decreased utilisation or abuse of
alcohol, drugs, or pharmaceuticals may be conse-
quences of sick leave.
. Exercise, diet, tobacco use, and risk behaviour may
be changed by sick leave.
Emotional aspects
. Stress and boredom may be a consequence of the
situation during sick leave.
. Self-confidence, self-image, and self-awareness may
be influenced, either positively or negatively from
being on sick leave.
Having short, recurrent spells of sick leave or being
placed on long-term sick leave means taking on a
‘‘sick’’ role, in one sense or another. This is often a
prolonged and complicated process, and has been
described recently in two doctoral dissertations using
a qualitative approach (1, 2). Sick listing probably has
different consequences depending on whether an
individual has not yet established a sick role, if the
process has just started, or if a sick role is well
established (the sick role is described in greater detail
in Chapter 1).
STUDIES ON THE CONSEQUENCES OF SICK
LEAVE
Scientific knowledge concerning the potential con-
sequences of sick leave is of major importance.
However, early in our review it became obvious that
very few studies have addressed this topic. Hence, the
inclusion criteria have been expanded in relation to
the other areas studied (see Chapter 2) to also include
studies published as reports and books. Despite this
expanded search, literature addressing ‘‘the conse-
quences of sick leave’’ is quite scarce. All studies that
addressed the consequences of sick leave and/or
disability pension were defined as being relevant.
The systematic search for studies on the economic
consequences of sickness absence was carried out

separately. Ten studies in this area were found to
be relevant from approximately 130 publications
reviewed (3 – 12). After quality review, two were
judged to be of sufficient quality. One of these was
published as a doctoral dissertation (3) and the other
as a journal article (5).
Regarding the other consequences of sick leave,
over 110 publications were reviewed for relevance,
whereof 14 were found to be relevant. After quality
review, seven of these articles (1, 13 – 18) were found
to have insufficient scientific quality for our purpose.
Hence, we were able to identify only nine relevant
studies of acceptable quality via the search methods
used (2, 3, 5, 19 – 24). Most of these address the
consequences of disability pension. The quality
assessment of the nine studies found that none offered
more than low quality in relation to our purpose. The
following factors were investigated in the nine studies:
Consequences studied in those exposed to sick leave
. Inactivity and isolation
. Suicide
. Career opportunities
. Personal finances
Consequences studied in those exposed to disability
pension
. Quality of life
. Self-reported health
. Health service utilisation
. Substance abuse
STUDIES ON THE CONSEQUENCES OF
SICKNESS ABSENCE
Inactivity and isolation
A cross-sectional study was conducted in 1994 – 1996
in Sweden (25). One hundred women who had been
sick listed for more than two months or who were on
disability pension were asked to participate in an
interview study addressing the consequences of, and
perspectives on, sick leave. Eighty-two women agreed
to participate, whereof most had low education and
were sick listed due to pain diagnoses. Data from the
interviews were analysed qualitatively by a physician
and a sociologist. Initially, most viewed sick leave as
freedom from work. As time passed, however, sick
leave generated new problems, i.e. inactivity and
isolation. In turn, this resulted in greater pain,
restlessness, stress, depressed mood, and a tendency
to become trapped in a negative sick role.
Consequences of being on sick leave 209
Suicide
A register study from Denmark aimed at identifying
causes for suicide (23). Eight hundred and eleven cases
of suicide in Copenhagen during 1982 – 1994 were
compared in different registers with 79,871 controls.
By far the strongest risk factor for suicide in both men
and women was admission to a psychiatric clinic.
Hence, it was likely that a psychiatric disease was
behind the suicide. When controlling for this and
other socio-economic factors in a multivariate statis-
tical analysis, it was found that sickness absence
exceeding three weeks, unemployment, and being
single were independent risk factors for suicide in
men. In women, no factors other than a stay at a
psychiatric clinic were found to be risk factors for
suicide.
Career advancement
An prospective register study from the USA investi-
gated whether managers in a large company who took
time off either because of disease or for family reasons
were less successful in career and salary advancement
(22). The study also investigated the extent to which
consequences differed if the subject took leave for
disease or for other reasons, usually to care for
children. The study group consisted of 11 762
managers. Absence periods were registered between
1990 and 1992 and promotions and salary advance-
ment between 1992 and 1995.
The study found that those who had been absent,
regardless of cause, received lower wages and fewer
promotions. Those with repeated episodes of absence
had the least favourable situation. Neither the
duration of absence nor gender appeared to play a
major role. An assessment of individual work
performance was conducted in 1994, and this was
not influenced by whether or not one had been absent.
Economics
Data from Statistics Sweden (survey of living condi-
tions) were linked and matched with data from the
National Social Insurance Board (RFV) in a pro-
spective econometric study (3). The study group
consisted of a random sample from these sources, in
total 1,688 individuals, whereof half were women. The
study covered a period of nine years and showed that
long-term sick leave had significantly negative effects
on the advancement of income following return to
work, not in terms of the hourly wage, but in the time
worked, which resulted in a lower annual wage.
An econometric study by Hansen included approxi-
mately 12,000 women and equally as many men (5).
The data were acquired from the Statistics Sweden
survey on household income and from RFV for two
Scand J Public Health 32 (Suppl 63)
210 E Vingård et al.
years (7,000 households interviewed per year). Basi-
cally, the findings of the study corresponded to those
presented by Andrén (3), i.e. that long-term sickness
absence is associated with poorer wage trends, but
only for women according to Hansen’s study. The
correlation was negative and significant, i.e. the higher
the sickness absence expressed in number of sick-leave
days the greater the reduction in wages. The total
explained variance was moderate (R2 corrected for
degrees of freedom was 0.173). It was the subject’s
own sickness absence that resulted in lower wages
after return to work. However, there was no such
correlation with absence due to caring for a sick child.
For men, sickness absence or absence to care for a
sick child had no effect on wage trends.
SUMMARY
Only a few of the possible consequences of sickness
absence have been investigated. The only study that
addressed consequences such as inactivity, social
isolation, depressed mood, and lower self-confidence
is an explorative, qualitative, cross-sectional study (2,
25). It shows that there is good reason to conduct
studies on such aspects. A retrospective study on the
risk factors for suicide (23), showing sick leave to be a
risk factor in men, is such a study.
The two Swedish studies on career and salary trends
after sickness absence present mixed results. One of
the studies shows that the greater the number of
sickness absence days, the lower the wage trend is for
women (5). The other study found no association
between sickness absence and wage per hour worked,
but between sickness absence and the number of hours
worked (3). Possibly, the lower working time is more a
consequence of the health condition than a conse-
quence of sickness absence. However, the results of
the study are somewhat contradictory.
Evidence
Evidence on the consequences of sickness absence is
insufficient because of too few studies.
DISABILITY PENSION
Quality of life
A Swedish study investigated the association between
disability pension and quality of life, measured as
self-reported, global quality of life (19). The study
group consisted of 450 individuals aged 25 – 59 years
who were placed on full-time disability pension in
1986 – 1990 because of musculoskeletal disorders.
Equally as many control individuals of the same age
without disability pension were selected from the
Scand J Public Health 32 (Suppl 63)
population register. Generally, the disability pension
group reported a lower quality of life than the control
group. Forty-five percent of those on disability
pension, versus 83% in the control group, were
classified as having a good quality of life. Among
those on disability pension, 34% reported that their
quality of life had improved following disability
pension while 25% thought it had deteriorated.
Interviews were used to analyze what the study
participants included in the quality-of-life concept and
the factors that were most important. Family relation-
ships were in first place followed by health, relation-
ships outside the family and economy. Health aspects
were important, and the lower value in the disability
pension group can be explained by the lower self-
reported health in this group, not by the disability
pension itself. Adolescents and immigrants on dis-
ability pension were those reporting the lowest values.
Individuals who reported that they were placed on
disability pension against their will had the lowest
quality of life.
Alcohol consumption and well-being
Seventy-eight alcoholics who received disability pen-
sion between January 1978 and July 1979 were
examined when placed on disability pension and
again after two years (21). Two control groups were
included in the study. One consisted of 30 non-
pensioned alcoholics and the other of 27 individuals
on disability pension for other diagnoses. After
two years, 56, 29, and 23 subjects, respectively were
re-examined.
During the follow-up period, alcohol consumption
had declined somewhat among the alcoholics on
disability pension. They drank less frequently and
consumed lower quantities. Self-reported well-being
had also increased after they had been placed on
disability pension. There were no major medical changes,
and social problems remained. The situation for the two
control groups had not changed more than marginally
between the two points of measurement.
Health, health service utilization, and alcohol
consumption
An interview study from the early 1980s of 96 people
on disability pension aged 45 – 64 years showed that
self-reported health was better following disability
pension (24). Fifty percent of the men and 33% of the
women reported this. Health service utilization also
declined, as did self-reported alcohol consumption.
A prospective Danish register study from 1989 – 1990
investigated health service utilization during the year
prior to application, the year of application and the year
following the application in individuals applying for

disability pension (20). The study covered 144 patients
diagnosed with chronic pain, in most cases of a non-
specific nature. Health service utilization was high in
the year prior to disability pension application,
declined during the application time and declined
further in those who were granted pension. The
individuals who did not receive disability pension or
did not receive pension at the level for which they had
applied increased their utilization of health services
again.
SUMMARY
The results from these few studies point in different
directions as regards quality of life and well-being.
The study populations in the different studies are
selected in different ways, regarding both diagnosis
and gender. The largest study clearly showed that the
consequences varied among individuals, 34% reported,
e.g. that their quality of life had improved and 25%
reported that it had deteriorated.
Evidence
Evidence on the consequences of disability pension is
insufficient because of too few studies.
DISCUSSION
As discussed, sickness absence has consequences at
different structural levels. Here the focus is on
consequences for the sick-listed individual, i.e. the
type of consequences, advantages and disadvantages
that the sick-listing physician must directly address.
Sick leave is a relatively common prescription/
intervention for disease, injury, and ill health. There
may be several reasons that one chooses sick
leave, e.g.:
. The disease or injury makes it impossible for the
patient to work.
. Sick leave enables rest and recovery.
. Sick leave enables the patient to participate in
examinations, treatment, and/or rehabilitation
interventions.
. Because of the disease, e.g. infection, the patient
should not be at the workplace even if the work
ability is not impaired.
. Conditions at the workplace cause disease in the
patient.
The scope and consequences of sick leave are
influenced by, e.g. factors in society, such as norms,
labor market conditions, the social situation of the
individual, and the attitudes of health care providers
toward the disease or injury and its treatment. These
Consequences of being on sick leave 211
background variables change over time and are
different in different societies and social groups. The
available scientific studies should therefore be viewed
as part of the period and context within which they
have been conducted.
It is often suggested in the current debate that long-
term sick leave has a negative impact on the
individual. From a scientific standpoint this assertion
is poorly supported. Neither has it been demonstrated
that the current level of sick leave has a positive effect
on health.
Regarding the factors investigated in the studies
included here, questions can be raised about gener-
alisability and the strength of the associations.
Regarding career opportunities and economy, avail-
able studies indicate a negative impact from sick leave.
However, studies are few and of low quality, and
hence there is no evidence supporting an association.
The Danish study that investigated risk factors for
suicide was well executed, but it reflects the limitations
of register studies (23). The evaluation of what the
study subjects were exposed to is relatively general
and covers only some of the information available
in official registries. The number exposed was not
reported, only the odds ratios. Regarding the
association with sickness absence, it is unclear whether
the sickness absence itself, or the underlying disease
for which the individual is sick listed, is of
importance.
In a study of alcoholics, improved well-being and
quality of life was a consequence of disability pension
(21). According to another study of individuals with
musculoskeletal disorders, the consequences of dis-
ability pension were lower quality of life for some, and
better quality of life for others (19). Since self-
perceived health is such an important part of the
quality-of-life measure used, it is difficult to isolate the
consequences for quality of life relative to sick leave
or disability pension per se, from the consequences
from the disease that led to the sick leave or disability
pension. Being placed on disability pension against
one’s will had the greatest negative consequences.
In two studies, health service utilization declined
when sick leave progressed to disability pension (20,
24). This can reflect the fact that applicants must
prove their functional impairment by seeking care
prior to the application. Likewise, when it is not
approved, they must visit a physician to receive
further sickness certificates. Also, the psychological
stress of sick listing, and uncertainty about having it
prolonged or having the application rejected, may
cause problems that require more health services.
In people with severe alcohol abuse, alcohol intake
declined after being placed on disability pension (21).
There may be many reasons for this, but the most
Scand J Public Health 32 (Suppl 63)
212 E Vingård et al.
prominent is thought to be the increased security and
social position that disability pension brings to this
vulnerable group. Another study also reported lower
alcohol consumption after subjects were placed on
disability pension (24). The extent to which this is a
consequence of disability pension itself, of having less
money, of another social life, of reduced tolerance
due to advanced alcoholism, or due to other serious
disease that makes alcohol consumption impossible,
has not been studied.
CONCLUSIONS AND SUMMARY
The few studies available on the consequences of sick
leave are mainly small, low-quality, register studies
conducted years ago, and in most cases directed at
the consequences of disability pension. The factors
studied in relation to the consequences of sick leave
for the individual are: personal finances, career
opportunities, inactivity, isolation, quality of life,
self-reported health, health service utilization, and
substance abuse. In all of these studies, the association
with sick leave is not beyond dispute. There are too
few studies in each area to build a foundation of
scientific evidence demonstrating either positive or
negative consequences of sick leave or disability
pension for the individual.
The research field addressing ‘‘consequences of sick
leave’’ is inadequately investigated. However, this field
is difficult to study since the consequences of the
underlying functional impairments or diseases that
lead to sick leave are difficult to distinguish from the
consequences of the sick leave itself. Furthermore,
sick leave and disability pension can be of different
levels and duration, which further complicates
research efforts.
Scand J Public Health 32 (Suppl 63)
The few studies that have been conducted have
several qualitative deficiencies. However, from the
studies available, there is reason to assume that
the consequences can vary with the individual’s
situation in terms of diagnosis, age, gender, ethnicity,
co-morbidity, and life situation. The consequences
studied need to be more clearly operationalised. The
study design should be developed in terms of
differentiating the consequences of sick leave/disability
pension from the consequences of, e.g. disease or
injury that led to sick leave. To be useful, the exposure
factors, i.e. sickness absence or disability pension,
need to be further clarified as regards, e.g. degree and
duration as well as type of activity/intervention during
sick leave.
Many practicing physicians prescribe sick leave
every day. The intervention is costly for society and
for most individuals. Hence, it is remarkable that
there is virtually no evidence-based information for
decision making or about the consequences of sick
leave itself.
Need for specific knowledge
Most of the studies assessed have measured the
consequences of sick leave at a very general level.
Both physicians and patients need more scientific
information at a more specific level. What are the
potential positive and negative consequences for
patients – considering age, gender, occupation,
work tasks, and with a particular disease and degree
of severity – of being sick listed, e.g. one versus three
weeks? Full time or part time? When can one expect
to see the potentially negative effects? How can they
be identified and counteracted? It is also possible that
the consequences vary substantially among different
individuals.
 Table 9.I. Studies of consequences of being sickness absent or on disability pension

Author, Year
(Ref no.) Design
Country Data Study period Exposure Outcome No. in study population Results Quality

Andrén 2001 Prospective cohort. 1983 – 1991 Sick leave Annual salary, 1,688 randomly Long-term sick leave Low
(3) Sweden Register hours worked, selected, with influences income
hourly wage sickness benefit after return-to-work,
insurance, 16 – 64 y not due to lower
hourly wage but due to
less time worked
Edén 1998 Case – control. 1986 – 1990 Disability Quality of life 450 on disability pension Quality of life Low
(19) Sweden Survey Interviews pension 450 controls in a survey lower in those with
and later interview of 29 disability pension
subjects with higher than in controls.
quality of life and Quality of life improved
26 subjects with lower after disability pension
quality of life
Hansen 2000 Prospective cohort. 1991 – 1992 Sick leave Annual salary 7,000 households/year Longer sick leave Low
(5) Sweden Register resulted in lower
salary for women
but not for men
after return-to-work.
No effect on salary

Consequences of being on sick leave

for women or men
from absence due
to sick child
Höjstedt Prospective cohort. 1989 – 1990 Disability Utilisation of 144 pain patients Consumption of Low
1999 (20) Register pension health services applying for health services
Scand J Public Health 32 (Suppl 63)

Denmark disability pension decreased after a

positive decision on
disability pension
Hörnquist Prospective cohort. 1978 – 1979 Disability Alcohol 78 alcoholics on disability Alcohol consumption Low
1983 (21) Surveys, pension consumption pension 30 alcoholics declined and well-being
Sweden clinical trials, and well-being not on disability pension increased after
laboratory testing (controls) 27 on disability disability pension
pension without alcohol
problems (controls)

213
Scand J Public Health 32 (Suppl 63)

214
E Vingård et al.
Table 9.I. (Continued )

Author, Year
(Ref no.) Design
Country Data Study period Exposure Outcome No. in study population Results Quality
Judiesch 1999 Prospective cohort. 1990 – 1995 Sick listing Career 11 762 managers Absence periods Low
(22) USA Register had negative effect
on career
Ockander 2001 Cross-sectional. 1994 – 1996 Sick-listingw60 Inactivity and 82 women with long-term Sick leave eventually Low
(25) Sweden Interview, survey, days or isolation sick leave or disability resulted in inactivity,
qualitative analyses disability pension pain, and isolation
pension
Qin 2000 Retrospective 1982 – 1994 Sick leavew3 Suicide 811 suicide cases Sick leave increased Medium
(23) Denmark case – control. weeks 79,871 controls suicide risk in men
Register but not in women
Svenman 1984 Cross-sectional. 1979 – 1980 Disability Health, activity, 96 on disability pension, Somewhat better Low
(24) Sweden Structured pension economy, 45 – 64 y health after disability
interviews alcohol use pension, otherwise no
differences

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