ORIGINAL ARTICLE

Factors Associated With Presenteeism at Work in Type 2

Diabetes Mellitus
Hadeel Zaghloul, MD, Omar Omar, MSc, Maria Pallayova, MD, PhD,
Sopna Choudhury, BSc, and Shahrad Taheri, MBBS, PhD

presenteeism (physical presence at work, but having decreased

Objective: Our study aimed to identify factors associated with decreased
presenteeism in type 2 diabetes mellitus (T2DM). Methods: Data were
collected from 147 T2DM participants. Questionnaires were completed:
Stanford Presenteeism Scale (SPS-6) assessing health status and employee
productivity, Hospital Anxiety and Depression Scale (HADS) for mental
health, SF-36 for quality of life, Problem Areas in Diabetes (PAID) to
measure diabetes-related emotional distress, and Michigan Neuropathy
Screening Instrument for diabetic neuropathy. Results: PAID score was
negatively related to the SPS-6 score (r ¼ 0.527, P < 0.001). Both anxiety
and depression were negatively correlated with SPS-6 (r ¼ 0.377,
P < 0.001 and r ¼ 0.603, P < 0.001, respectively). Seven out of eight
different categories of SF-36 were significantly associated with SPS-6 score.
Neuropathy was negatively related to presenteeism (r ¼ 0.228, P ¼ 0.07).
Conclusion: Factors related to decreased presenteeism in T2DM include
diabetes-associated stress, poor mental health, poor quality of life, and a
history of neuropathy.
Keywords: mental health, neuropathy, presenteeism, productivity, quality
of life, type 2 diabetes mellitus, work
T ype 2 diabetes mellitus (T2DM) is one of the most prevalent
chronic disorders worldwide with significant health and eco-
nomic consequences. Of great concern is the increasing prevalence
of diabetes in individuals who are key contributors to the workforce
and economy. Indeed, the indirect costs of diabetes have been
estimated to be greater than its direct health care costs.1 Indirect
costs consist of productivity losses related to morbidity and mor-
tality. Productivity losses can be measured in terms of absenteeism
(employees’ intentional or habitual absence from work) and
From the Department of Medicine, Weill Cornell Medicine, New York, New York
(Drs Zaghloul, Pallayova, Taheri); Department of Medicine, Weill Cornell
Medicine - Qatar, Doha, Qatar (Drs Zaghloul, Pallayova, Taheri); Clinical
Research Core, Weill Cornell Medicine - Qatar, Doha, Qatar (Mr Omar, Dr
Pallayova, Ms Choudhury, Dr Taheri); and Birmingham and Black Country
NIHR CLAHRC Theme 8, University of Birmingham, Birmingham, UK (Ms
Choudhury, Dr Taheri).
ST designed the study, oversaw its overall study conduct, and contributed to
analysis, interpretation, and writing. HZ contributed to data analysis, inter-
pretation, and drafting of manuscript. OO and MP contributed to the analysis.
SC contributed to the study conduct and interpretation of findings. All authors
contributed to the final work and approved the manuscript.
The study was funded by the National Institute for Health Research (NIHR)
through the Collaborations for Leadership in Applied Health Research and
Care for Birmingham and Black Country (CLAHRC-BBC) program. The
views expressed in this publication are not necessarily those of the NIHR, the
Department of Health, NHS Partner Trusts, University of Birmingham or
the CLAHRC-BBC Theme 8 Management/Steering Group. The authors are
currently funded by the biomedical research program at Weill Cornell
Medicine – Qatar, supported by Qatar Foundation. The funders had no role
in study design, data collection and analysis, decision to publish, or prepara-
tion of the manuscript.
Data are available from the corresponding author upon reasonable request.
The authors have no financial relationships relevant to this article to disclose.
The authors have no conflicts of interest relevant to this article.
Address correspondence to: Shahrad Taheri, MBBS, PhD, Professor of Medicine,
Weill Cornell Medicine - Qatar, Room C008, Qatar Foundation, Education
City, P.O. Box 24144, Doha, Qatar (staheri@me.com).
Copyright ß 2018 American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0000000000001446
productivity levels and below normal work quality). Reduced levels
of presenteeism have been found to have similar effects on produc-
tivity as absenteeism,2 making it crucial to account for presenteeism
when measuring the indirect costs of illness.
Reduced presenteeism due to chronic health conditions such
as T2DM could hinder an individual’s ability to realize their full
professional potential by affecting performance and morale, and
delaying or preventing promotions.3 Therefore, apart from its
substantial economic impact, presenteeism also affects an individ-
ual’s quality of life.
Although a relationship between chronic illnesses and pro-
ductivity loss has been established, most of the research on cost of
illness has focused on individual health conditions such as
migraine,4 musculoskeletal disorders,5 depression,6 and diabetes7
with little consideration of coexisting conditions and individual
factors that could potentially impact this relationship.8–11 Multi-
morbidity and severity of chronic diseases were shown to be
positively associated with productivity loss, but its evaluation has
been a major limitation in earlier studies.8,12 One recent study
overcame this using the Cumulative Illness Rating Scale (CIRS)
and showed that the more severe the disease state and having
comorbidities was associated with greater productivity loss.13 These
findings were consistent with findings of earlier studies,14,15 but
T2DM was not a major focus.
The relationship between T2DM and presenteeism has been
little studied. A greater understanding of presenteeism and its
impact on work productivity is needed to develop more tailored
and effective interventions to improve quality of life and work
productivity in the increasing number of individuals with T2DM.
Furthermore, understanding what factors drive the relationship
between T2DM and presenteeism is crucial for development of
strategies to combat this rising cost of illness. The aim of our study
was to gain a better understanding of presenteeism and its related
factors in people with T2DM.
PARTICIPANTS AND METHODS
Study Design and Setting
This was a cross-sectional observational study that recruited
participants from participating primary health care centers across
Birmingham, UK. The study was approved by the local research
ethics committee and was performed in accordance with the prin-
ciples of the Declaration of Helsinki. All participants provided
written informed consent before participating in the study.
Participants and Assessments
The study included adult (18 years old) men and women
with clinically established T2DM. Invitation letters with a partici-
pant information leaflet, questionnaire booklet, reply slip, and
prepaid envelope were sent from primary health care centers to
prospective participants. Participants with T2DM were invited to a
research visit to collect anthropometric data and research samples,
to have foot examinations, and complete the Michigan Neuropathy
Screening Instrument (MNSI).16

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 JOEM  Volume 60, Number 12, December 2018 Presenteeism and Type 2 Diabetes

Participants were also asked to complete the following
validated questionnaires as part of the questionnaire booklet:
Stanford Presenteeism Scale (SPS-6) to assess health status and
employee productivity,17 Mental Health Inventory (MHI-5) and
Hospital Anxiety and Depression Scale (HADS) for assessing
mental health, SF-36 to measure quality of life, and the Problem
Areas in Diabetes (PAID) questionnaire to measure emotional
distress specific to diabetes.
The Stanford Presenteeism Scale (SPS-32) was developed to
assess the relationship between health problems and productivity
levels in working populations.18 An item reduction strategy was
implemented to yield a shortened six-item scale (SPS-6), which
when administered produces a Total Presenteeism Score.17 The
SPS-6 was used to assess presenteeism in our study with score
ranges from 6 to 30. A high score indicates a high level of
presenteeism (greater capacity to concentrate on and accomplish
one’s work duties despite health conditions).
Sample size for a Spearman correlation was determined using
power analysis. The power analysis was performed using an alpha
level of 5%, power of 80%, and several effect sizes (r ¼ 0.25,
r ¼ 0.30, and r ¼ 0.35) for 2-tailed tests. On the basis of these
assumptions, the estimated required sample size was determined to
be n ¼ 124 for r ¼ 0.25, n ¼ 85 for r ¼ 0.30, and n ¼ 62 for r ¼ 0.35.
Statistical Analysis
Most of the continuous data were skewed. Continuous
variables were summarized using medians and interquartile ranges.
Categorical variables were summarized using frequencies and per-
centages. Spearman rank correlation coefficient was used to measure
correlations between SPS score and other scores. The Mann–Whitney
U test was used to compare the SPS scores for participants with
complications and participants without complications. Statistical
analyses were performed using Stata Special Edition Version 13.1
(StataCorp LP, College Station, Texas). A 2-sided P value of less than
0.05 was considered to be statistically significant.
RESULTS
The SPS-6 was completed by 147 participants. As summa-
rized in Table 1, the majority of participants were men (69.4%) and
the median reported duration of diabetes was 6 years. Some
questionnaire response rates were lower than others. MNSI, HADS,
and SF36 were only completed by around half the participants.
However, PAID and MHI questionnaires were completed by almost
all the participants. There was no difference in most outcomes
between full-time and part-time staff. Only PAID was significantly
higher in the full-time staff compared with part-time staff (P < 0.001)
Diabetic Problems and Distress
As shown in Fig. 1, there was a highly negative significant
correlation between the total PAID score and SPS-6 score
(r ¼ 0.3706, P < 0.001). Hence, people were more likely to be
present at work if they had less problems associated with their
diabetes. All the individual items of the PAID questionnaire dem-
onstrated significant association with SPS-6 score except for items
2, 14, and 15. Item 2 asked about ‘‘Feeling discouraged with your
diabetes treatment plan?’’, item 14 asked about ‘‘Not ‘‘accepting’’
your diabetes? ‘‘and Item 15 asked about ‘‘Feeling unsatisfied with
your diabetic physician?’’.
Mental Health
Both anxiety and depression from HADS showed a signifi-
cant negative correlation with SPS (r ¼ 0.527, P < 0.001 and
r ¼ 0.603, P < 0.001 respectively). Reporting greater anxiety or
depression was associated with decreased presenteeism.
There was evidence that the higher the MHI score, the higher
the presenteeism. MHI score showed a significant positive associa-
tion with SPS score (r ¼ 0.522, P < 0.001). This agrees with find-
ings using the HADS questionnaire.
Neuropathy (MNSI)
Neuropathy, measured by MNSI questionnaire, showed a
negative trend with presenteeism (r ¼ 0.228, P ¼ 0.07).
Quality of Life
Figure 1 shows that quality of life was closely associated with
presenteeism. Seven out of the eight categories of SF-36 were
significantly associated with SPS score. People who reported better
quality of life were likely to report greater presenteeism.
DISCUSSION
In summary, the findings of our study highlight some of the
factors that are associated with lower productivity levels measured

TABLE 1. Baseline Characteristics of Study Participants (n ¼ 147) Categorized by Employment Type

Full-Time Staff Part-Time Staff Total Sample
Characteristic (n ¼ 105) (n ¼ 42) P (n ¼ 147)

Age in years, median (IQR) 54 (50–61) 63 (58–69) <0.0001 56 (51–64)

Males, n (%) 74 (71.8) 26 (63.4) 0.322 100 (69.4)
Duration of diabetes in years, median (IQR) 5 (3–12) 6 (3–10) 0.806 6 (3–11)
Total SPS score, median (IQR) 26 (21–30) 26 (23–30) 0.330 26 (21–30)
Total MHI score, median (IQR) 72 (55–80) 72 (56–84) 0.758 72 (56–84)
Total PAID score, median (IQR) 16 (6–34) 6 (4–19) 0.003 13 (4–26)
Total MNSI score, median (IQR) 2 (0–4) 1 (0–2) 0.238 2 (0–3)
Total HADS anxiety score, median (IQR) 6 (3–9) 5 (3–8) 0.404 6 (3–8)
Total HADS depression score, median (IQR) 3 (2–6) 2 (1–6) 0.591 3 (1–6)
SF36 physical functioning, median (IQR) 85 (70–98) 80 (65–100) 0.819 85 (70–100)
SF36 role limitation due to physical health, median (IQR) 63 (0–100) 50 (25–100) 0.894 50 (0–100)
SF36 physical role limitation due to emotional problems, median (IQR) 100 (0–100) 100 (50–100) 0.634 100 (33–100)
SF36 energy/fatigue, median (IQR) 60 (30–80) 70 (43–80) 0.432 65 (35–80)
SF36 emotional well-being, median (IQR) 80 (64–92) 80 (72–92) 0.977 80 (64–92)
SF36 social functioning, median (IQR) 88 (63–100) 100 (75–100) 0.137 94 (63–100)
SF36 pain, median (IQR) 68 (55–90) 80 (68–90) 0.147 70 (58–90)
SF36 general health, median (IQR) 53 (35–80) 70 (55–85) 0.200 60 (35–80)

HADS, Hospital Anxiety and Depression Scale; IQR, interquartile range; MHI, Mental Health Inventory; MNSI, Michigan Neuropathy Screening Instrument.

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 Zaghloul et al JOEM  Volume 60, Number 12, December 2018

Total PAID
PAID 1
PAID 2
PAID 3
PAID 4
PAID 5
PAID 6
PAID 7
PAID 8
PAID 9
PAID 10
PAID 11
PAID 12
PAID 13
PAID 14
PAID 15
PAID 16
PAID 17
PAID 18
PAID 19
PAID 20
Total MNSI
Total HADS Anxiety
Total HADS Depression
MHI
SF36 physical functioning
SF36 role limitations physical
SF36 role limitation emotional
SF36 energy/fatigue
SF36 emotional well being
SF36 social functioning
SF36 pain
SF36 general health

-1 -.5 0 .5 1

FIGURE 1. Spearman correlations between total SPS score and questionnaire/questionnaire items.

by decreased presenteeism in those with T2DM. The factors identi-
fied included stress associated with diabetes, poor mental health
with increased anxiety and depression, poor quality of life, and
having a history of neuropathy as a complication of T2DM.
Work productivity is a significant issue for individuals with
chronic disorders. Previous studies have established that diabetes is
associated with decreased presenteeism.7,19 Tunceli et al used second-
ary data collected in the first two waves (1992 and 1994) of the Health
and Recruitment Study. They prospectively assessed the relationship
between having diabetes and health-related work limitations. Men and
women with diabetes were found to be 5.4 and 6 percentage points more
likely to experience work limitations than those without diabetes.19
Furthermore, they examined the relationship between diabetes and
health-related reasons for not working in individuals who had been
working in the first wave, but not the second. They found that
nonworking individuals with diabetes were more likely to report
disability than nonworking individuals without diabetes [odds ratio
(OR) 2.1, 95% confidence interval (95% CI) 1.1 to 3.8]. They were also
more likely to report leaving their jobs because of poor health (OR 3.1,
95% CI 2.1 to 4.7) and being work disabled (OR 3.6, 95% CI 2.4 to 5.5).
These findings provide evidence of decreased probability of subsequent
employment for people with diabetes.
Another study used a method developed by Osterhaus et al20
to calculate efficiency losses while working.7 The study indicated
that in the previous 2 weeks, a significantly larger percentage of
employees who had diabetes worked while feeling unwell than the
percentage of those who did not have diabetes (60% vs 42.5%,
P ¼ 0.007). The model showed that the duration of diabetes was
particularly important with a decline in productivity of about 1 hour
per month since the date of diagnosis. Other factors that were found
to mediate the relationship between diabetes and productivity
included education, gender, race, and depression. However, no
score for depression was calculated.
The various drivers of the relationship between diabetes and
work productivity are yet to be identified. The average SPS-6 score
for participants with T2DM in our study was 25 (26 for men and
23.5 for women). SPS-6 has been used in the context of other
conditions. One study, using SPS-6, found that the level of pre-
senteeism in county health employees (n ¼ 175) using the SPS-6
scale to average 23.0  3.9 in men and 22.9  4.2 in women.17
These levels are lower than those observed in our study, but as the
authors did not specify any pre-existing medical conditions, it is
difficult to compare findings. Another study investigating presen-
teeism in workers with arthritis found the mean presenteeism score
to be 13.3  5.2 (n ¼ 244).21 A third study was conducted on a
sample of workers (n ¼ 80) suffering from shoulder or elbow
disorders found that the mean SPS-6 score was 17.8  5.2.22 These
studies suggest that conditions associated with pain result in reduced
presenteeism. Interestingly, we found in our cohort that the presence
of neuropathy had a negative impact on presenteeism.
The PAID questionnaire aims to identify diabetes-related
emotional distress focusing on concepts such as depression, mood,
social support, health beliefs, self-care behaviors, and coping
strategies in people with diabetes. Emotional distress measured

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 JOEM  Volume 60, Number 12, December 2018
by the PAID questionnaire has been found to be associated with poor
medication adherence,23 HbA1c levels,23 depressive symptoms,24
as well as quality of life.24 Our study observed a highly significant
negative correlation between the total PAID score and the SPS score
(r ¼ 0.328, P < 0.0001). Thus, emotional stress related to T2DM is
associated with reduced presenteeism.
We found that presenteeism was significantly associated with
anxiety, depression, and poor mental health. The poorer the par-
ticipant’s mental health, the lower was their presenteeism score and
hence potential productivity at work. The relationship was observed
using two validated questionnaires, which suggests a robust associ-
ation. This is also in line with our findings with the PAID question-
naire, which has also been shown to be related to mental wellbeing
in diabetes.
Finally, we examined the association between quality of life
(QOL; SF-36 questionnaire) and found that seven of eight aspects of
quality of life were significantly associated with presenteeism. The
better the QOL the subject with type diabetes had, the more likely they
were to report presenteeism. Other studies investigating productivity
loss due to lower QOL had findings in agreement with our study.25
CONCLUSION
Our study benefits from being the first study to assess key
factors associated with presenteeism in a sample of people with
T2DM. There are several important limitations to our work. These
include the reliance on self-reports. Also, we did not collect data on
the type of work, which could have shed some light on the
influences of certain factors on presenteeism. The cross-sectional
nature of our study makes it difficult for us to make causal
inferences.
As diabetes becomes more prevalent, its effects on work
productivity are increasingly important. Addressing issues such as
diabetes distress, depression and anxiety, and neuropathy would be
important strategies to increase presenteeism in those with T2DM.
This requires greater efforts by health care professionals providing
care for those with T2DM to address these key problems. Similarly,
employers need to recognize key challenges for employees for type
2 diabetes and provide appropriate support, without discrimination
and stigma, to ensure that employees with T2DM have fulfilling
working lives.
In summary, our results show that there are several key
factors associated with presenteeism in those with T2DM. Future
studies should examine these associations prospectively and
develop and test strategies to address any reduced presenteeism
in T2DM to ensure improved quality of life and fulfilment for
affected individuals, while reducing the economic impact of T2DM.
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