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1.  Sickness Absence in the Private Sector of Greece: Comparing Shipyard Industry and National Insurance Data 
Approximately 3% of employees are absent from work due to illness daily in Europe, while in some countries sickness absence exceeds 20 days per year. Based on a limited body of reliable studies, Greek employees in the private sector seem to be absent far less frequently (<5 days/year) compared to most of the industrialized world. The aim of this study was to estimate the levels of sickness absence in the private sector in Greece, using shipyard and national insurance data. Detailed data on absenteeism of employees in a large shipyard company during the period 1999–2006 were utilized. National data on compensated days due to sickness absence concerning all employees (around 2 million) insured by the Social Insurance Institute (IKA, the largest insurance scheme in Greece) were retrieved from the Institute’s annual statistical reports for the period 1987–2006. Sick-leave days per employee and sick-leave rate (%) were calculated, among other indicators. In the shipyard cohort, the employment time loss due to sick leave was 1%. The mean number of sick-leave days per employee in shipyards ranged between 4.6 and 8.7 and sick-leave rate (sickness absenteeism rate) varied among 2% and 3.7%. The corresponding indicators for IKA were estimated between 5 and 6.3 sick-leave days per insured employee (median 5.8), and 2.14–2.72% (median 2.49%), respectively. Short sick-leave spells (<4 days) may account at least for the 25% of the total number of sick-leave days, currently not recorded in national statistics. The level of sickness absence in the private sector in Greece was found to be higher than the suggested by previous reports and international comparative studies, but still remains one of the lowest in the industrialized world. In the 20-years national data, the results also showed a 7-year wave in sickness absence indexes (a decrease during the period 1991–1997 and an increase in 1998–2004) combined with a small yet significant decline as a general trend. These observations deserve detailed monitoring and could only partly be attributed to the compensation and unemployment rates in Greece so other possible reasons should be explored.
PMCID: PMC3366606  PMID: 22690189
sickness absence; sick leave; occupational health; social insurance; employment; compensation; shipyard; industry; Greece
2.  Individual Variations in Sickness Absence 
Records of personal sickness absence, including all spells of one day's duration or more, have been kept at this refinery for more than 20 years. The distributions of sickness spells and also calendar days of absence have been analysed for single years and also for periods of up to 20 years' continuous service for the 1,350 hourly paid male employees. It is shown that both these measures of sickness absence are distributed among the men in an unequal fashion (negative binomial) rather than at random (Poisson) and thus resemble the distribution of industrial accidents first described almost 50 years ago. This pattern of distribution is not related to occupation or to length of service. Analysis of the distribution of lateness and absenteeism for reasons other than sickness or holidays shows that these also follow this pattern. It is postulated that this could be a principle applicable to all forms of industrial absenteeism as well as to accidents.
The personal records of 187 men with continuous service from 1946 to 1965 have been studied to investigate the trends in their sickness absence over this 20-year period. In contrast to the well-recognized pattern that in any one period of time young men have more spells of absence than their older fellows, this secular study shows that sickness spells have not decreased with age. This apparent paradox is explicable by the rising national trend in sickness absence and by a high labour turnover in young men with frequent sickness spells.
PMCID: PMC1008578  PMID: 6028712
3.  Sickness absence and early retirement on health grounds in the construction industry in Ireland 
OBJECTIVE—To establish a detailed pattern of the nature and extent of illnesses and injuries among construction workers in Ireland which cause temporary absence from work, and to identify diseases and disabilities which lead to premature retirement from the industry on health grounds.
METHODS—The population base for the study consisted of construction workers who were members of the Construction Federation operatives pension and sick pay scheme. Records of sickness absence since 1981, stored on computer disks, and records of early retirement on health grounds since 1972, stored on microfiche film, were examined. Pertinent data were extracted and transferred to a database; after cleaning and the exclusion of unvalidated data, records of 28 792 absences and 3098 records of early retirement were available for analysis. Data were analysed with Access 97 and Epi Info.
RESULTS—Over the period of the study the mean annual absences were 7.8/100 workers. Three quarters of absences were among younger workers; however, the rate of absence increased with age, as did the mean duration of absence. Injury was the most frequent reason for absence, followed by infectious disease, then musculoskeletal disorders. The mean annual rate of early retirement on health grounds was 5.3/1000 workers. The median age at retirement was 58 years. Cardiovascular disease and musculoskeletal disorders each accounted for nearly one third of the conditions leading to permanent disability on the grounds of which early retirement was granted. During the period of the study, over 677 000 working days were lost due to sickness absence, and over 24 000 potential years of working lives were lost due to early retirement on health grounds.
CONCLUSIONS—The study has shown patterns of sickness absence and early retirement on health grounds in the Irish construction industry which will contribute to the further development of health promotion strategies for construction workers.

Keywords: construction industry; sickness absence; early retirement
PMCID: PMC1740016  PMID: 10935942
4.  Attitudes towards sickness absence and sickness presenteeism in health and care sectors in Norway and Denmark: a qualitative study 
BMC Public Health  2014;14:880.
In the health and care sector, sickness absence and sickness presenteeism are frequent phenomena and constitute a field in need of exploration. Attitudes towards sickness absence involve also attitudes towards sickness presenteeism, i.e. going to work while sick, confirmed by previous studies. Sickness behavior, reflecting attitudes on work absence, could differ between countries and influence absence rates. But little is known about attitudes towards sickness absence and sickness presenteeism in the health and care sectors in Norway and Denmark. The aim of the present paper is therefore to explore attitudes towards sickness absence and sickness presenteeism among nursing home employees in both countries.
Eight focus group discussions (FGDs) were conducted using a semi-structured interview guide, the main attention of which was attitudes towards sickness absence and sickness presenteeism. FGDs were conducted in two nursing homes in Norway and two in Denmark, with different geographic locations: one in a rural area and one in an urban area in each country. FGDs were recorded, transcribed and analyzed using framework analysis to identify major themes and explanatory patterns.
Four major significant themes were identified from the FGDs: a) sickness absence and sickness presenteeism, b) acceptable causes of sickness absence, c) job identity, and d) organization of work and physical aspects of the workplace. Our analyses showed that social commitment and loyalty to residents and colleagues was important for sickness absence and sickness presenteeism, as were perceived acceptable and non-acceptable reasons for sickness absence. Organization of work and physical aspects of the workplace were also found to have an influence on attitudes towards sickness absence.
The general interpretation of the findings was that attitudes towards sickness absence and sickness presenteeism among nursing home employees were embedded in situational patterns of moral relationships and were connected to a specific job identity. These patterns were constituted by the perception of colleagues, the social commitment to residents, and they influence on what was deemed as acceptable and non-acceptable reasons for sickness absence. In other words, attitudes towards sickness absence and sickness presenteeism were socially and morally determined at personal levels by an overall concept of work, independent of country.
PMCID: PMC4168251  PMID: 25160059
Sickness absence; Sickness presenteeism; Attitudes; Moral aspects; Concept of work; Focus group discussions
5.  Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality 
BMC Public Health  2012;12:661.
Previous validation studies of sick leave measures have focused on self-reports. Register-based sick leave data are considered to be valid; however methodological problems may be associated with such data. A Danish national register on sickness benefit (DREAM) has been widely used in sick leave research. On the basis of sick leave records from 3,554 and 2,311 eldercare workers in 14 different workplaces, the aim of this study was to: 1) validate registered sickness benefit data from DREAM against workplace-registered sick leave spells of at least 15 days; 2) validate self-reported sick leave days during one year against workplace-registered sick leave.
Agreement between workplace-registered sick leave and DREAM-registered sickness benefit was reported as sensitivities, specificities and positive predictive values. A receiver-operating characteristic curve and a Bland-Altman plot were used to study the concordance with sick leave duration of the first spell. By means of an analysis of agreement between self-reported and workplace-registered sick leave sensitivity and specificity was calculated. Ninety-five percent confidence intervals (95% CI) were used.
The probability that registered DREAM data on sickness benefit agrees with workplace-registered sick leave of at least 15 days was 96.7% (95% CI: 95.6-97.6). Specificity was close to 100% (95% CI: 98.3-100). The registered DREAM data on sickness benefit overestimated the duration of sick leave spells by an average of 1.4 (SD: 3.9) weeks. Separate analysis on pregnancy-related sick leave revealed a maximum sensitivity of 20% (95% CI: 4.3-48.1).
The sensitivity of self-reporting at least one or at least 56 sick leave day/s was 94.5 (95% CI: 93.4 – 95.5) % and 58.5 (95% CI: 51.1 – 65.6) % respectively. The corresponding specificities were 85.3 (95% CI: 81.4 – 88.6) % and 98.9 (95% CI: 98.3 – 99.3) %.
The DREAM register offered valid measures of sick leave spells of at least 15 days among eldercare employees. Pregnancy-related sick leave should be excluded in studies planning to use DREAM data on sickness benefit. Self-reported sick leave became more imprecise when number of absence days increased, but the sensitivity and specificity were acceptable for lengths not exceeding one week.
PMCID: PMC3511193  PMID: 22894644
Agreement; Eldercare sector; Public transfer payment; Register data; Self-report; Sensitivity; Sick leave; Specificity; Validation; Workplace record
6.  Sickness Absence in the Three Principal Ethnic Divisions of Singapore 
Records of sickness for all industrial employees of H. M. Dockyard, Singapore were analysed over a calendar year, 1955-56, with a view to producing a standard rate for sickness absence in the three main ethnic divisions of this area, with particular reference to age.
Other factors, such as form of grade of employment and residence, were considered in order to test their effect, if any, upon sickness absence. The principal diagnostic groups were separated to give a general picture of the trends of sickness.
The reactions of Chinese, Indians, and Malays to disease or to any of the associated factors were found to be totally dissimilar, and the possibility of this being due to chance is so slight as to be negligible.
Comparisons are subsequently made with the one rather scanty record of another organization in South East Asia, and with detailed modern analyses of sickness absence in England. Again it is found that absence rates for inceptions per 1,000 workers and days lost per worker differ entirely both as regards the total and individual disease groups and also in the effect of age. It is evident that the ethnic grouping of the population concerned must be taken into consideration in studies of sickness absence.
PMCID: PMC1038168  PMID: 13880579
7.  Some characteristics of repeated sickness absence 
Ferguson, D. (1972).Brit. J. industr. Med.,29, 420-431. Some characteristics of repeated sickness absence. Several studies have shown that frequency of absence attributed to sickness is not distributed randomly but tends to follow the negative binomial distribution, and this has been taken to support the concept of `proneness' to such absence. Thus, the distribution of sickness absence resembles that of minor injury at work demonstrated over 50 years ago. Because the investigation of proneness to absence does not appear to have been reported by others in Australia, the opportunity was taken, during a wider study of health among telegraphists in a large communications undertaking, to analyse some characteristics of repeated sickness absence.
The records of medically certified and uncertified sickness absence of all 769 telegraphists continuously employed in all State capitals over a two-and-a-half-year period were compared with those of 411 clerks and 415 mechanics and, in Sydney, 380 mail sorters and 80 of their supervisors. All telegraphists in Sydney, Melbourne, and Brisbane, and all mail sorters in Sydney, who were available and willing were later medically examined. From their absence pattern repeaters (employees who had had eight or more certified absences in two and a half years) were separated into three types based on a presumptive origin in chance, recurrent disease and symptomatic non-specific disorder.
The observed distribution of individual frequency of certified absence over the full two-and-a-half-year period of study followed that expected from the univariate negative binomial, using maximum likelihood estimators, rather than the poisson distribution, in three of the four occupational groups in Sydney. Limited correlational and bivariate analysis supported the interpretation of proneness ascribed to the univariate fit. In the two groups studied, frequency of uncertified absence could not be fitted by the negative binomial, although the numbers of such absences in individuals in successive years were relatively highly correlated.
All types of repeater were commoner in Sydney than in the other capital city offices, which differed little from each other. Repeaters were more common among those whose absence was attributed to neurosis, alimentary and upper respiratory tract disorder, and injury. Out of more than 90 health, personal, social, and industrial attributes determined at examination, only two (ethanol habit and adverse attitude to pay) showed any statistically significant association when telegraphist repeaters in Sydney were compared with employees who were rarely absent. Though repeating tended to be associated with chronic or recurrent ill health revealed at examination, one quarter of repeaters had little such ill health and one quarter of rarely absent employees had much.
It was concluded that, in the population studied, the fitting of the negative binomial to frequency of certified sickness absence could, in the circumstances of the study, reasonably be given an interpretation of proneness. In that population also repeating varies geographically and occupationally, and is poorly associated with disease and other attributes uncovered at examination, with the exception of the ethanol habit. Repeaters are more often neurotic than employees who are rarely absent but also are more often stable double jobbers.
The repeater should be identified for what help may be given him, if needed, otherwise it would seem more profitable to attack those features in work design and organization which influence motivation to come to work. Social factors which predispose to repeated absence are less amenable to modification.
PMCID: PMC1069458  PMID: 4636662
8.  Personal Factors Associated with Sickness Absence: A Study of 194 Men with Contrasting Sickness Absence Experience in a Refinery Population1 
Men with different patterns of sickness absence behaviour have been identified from a refinery population by simple epidemiological techniques. A detailed clinical study is described of four groups: 56 men with five or more sickness spells in 1964 and a matched control of 56 men; 35 men who had 60 or more days of sickness absence in 1964; and finally 47 men who had not had one day off sick for at least eight years.
Whereas the men who were frequently sick tended to be younger and mostly on day work, those with long periods of sickness were reasonably representative of the whole population, and the men without any sickness absence were older and mostly on shift work. An analysis of records both before and since 1964 showed that the groups had maintained a consistent pattern of sickness absence, but when individuals were considered their behaviour was less consistent. Nevertheless there appeared to be states of sickness absence `liability' and also `resistance' which persisted for a variable length of time from a year or two up to many years.
The pre-employment medical examination proved in retrospect to have been of little predictive value. Absenteeism, lateness, and also occupational injuries were all strongly associated with sickness spells, although the level of overtime was not. Previous episodes of neurotic illness, peptic ulceration, and loss of work due to back pain were also associated with frequent sickness spells, so also were frequent colds and troublesome constipation. An unexpected finding from the physical examination was that over one quarter of those who were never sick had some organic disease.
Although neither the social nor economic circumstances differed between the groups, the attitude of the men towards themselves and their work proved to be of major importance. A memory of an unhappy childhood was more common in both groups with a lot of sickness absence, whilst dislike of the job or frustrated ambition was common in men with frequent spells. Those who were never sick denied all such problems as they denied illness. Personality testing revealed that extroversion was more marked in the frequently sick group, neuroticism in the long sick, and introversion in the never sick.
The validity and significance of the results are discussed and suggestions are made for further investigation.
PMCID: PMC1008718  PMID: 4231051
9.  Are environmental characteristics in the municipal eldercare, more closely associated with frequent short sick leave spells among employees than with total sick leave: a cross-sectional study 
BMC Public Health  2013;13:578.
It has been suggested that frequent-, short-term sick leave is associated with work environment factors, whereas long-term sick leave is associated mainly with health factors. However, studies of the hypothesis of an association between a poor working environment and frequent short spells of sick leave are few and results are inconsistent. Therefore, we aimed to explore associations between self-reported psychosocial work factors and workplace-registered frequency and length of sick leave in the eldercare sector.
Employees from the municipal eldercare in Aarhus (N = 2,534) were included. In 2005, they responded to a work environment questionnaire. Sick leave records from 2005 were dichotomised into total sick leave days (0–14 and above 14 days) and into spell patterns (0–2 short, 3–9 short, and mixed spells and 1–3 long spells). Logistic regression models were used to analyse associations; adjusted for age, gender, occupation, and number of spells or sick leave length.
The response rate was 76%; 96% of the respondents were women. Unfavourable mean scores in work pace, demands for hiding emotions, poor quality of leadership and bullying were best indicated by more than 14 sick leave days compared with 0–14 sick leave days. For work pace, the best indicator was a long-term sick leave pattern compared with a non-frequent short-term pattern. A frequent short-term sick leave pattern was a better indicator of emotional demands (1.62; 95% CI: 1.1-2.5) and role conflict (1.50; 95% CI: 1.2-1.9) than a short-term non-frequent pattern.
Age (= < 40 / >40 years) statistically significantly modified the association between the 1–3 long-term sick leave spell pattern and commitment to the workplace compared with the 3–9 frequent short-term pattern.
Total sick leave length and a long-term sick leave spell pattern were just as good or even better indicators of unfavourable work factor scores than a frequent short-term sick leave pattern. Scores in commitment to the workplace and quality of leadership varied with sick leave pattern and age. Thus, different sick leave measures seem to be associated with different work environment factors. Further studies on these associations may inform interventions to improve occupational health care.
PMCID: PMC3701566  PMID: 23764253
Cross-sectional; Home care services; Psychology, Social; Sick leave; Working environment
10.  Short-term absence from industry: II Temporal variation and inter-association with other recorded factors 
Froggatt, P. (1970).Brit. J. industr. Med.,27, 211-224. Short-term absence from industry. II. Temporal variation and inter-association with other recorded factors. This paper (a) extends the previous analysis (Froggatt, 1970b) of short-term absence from work among groups of male and female industrial personnel and clerks in government service, and (b) studies other recorded variables, particularly lateness, long-term sickness absence, and passes from work both `medical' and `works'.
Multiple regression shows one-day absences to be generally associated with two-day absences, lateness, and medical passes but independent of works passes and long-term sickness absence; and two-day absences to be generally associated with one-day absences and long-term sickness absence but not with lateness or passes from work. Higher order correlations show lateness and works passes, medical passes and works passes, and lateness and age to be (weakly) associated, the last negatively.
Irrespective of season, one-day absences were consistently most prevalent on Monday and least so on Friday, with a subsidiary peak for the male groups on Wednesday; two-day absences - as measured by the day each absence starts - were consistently most prevalent on Monday and least so on Thursday (Friday was omitted) and during the summer months. Medical passes were generally independent of the day of the week and the period of the year; lateness was greatest on Friday and during the winter, though the increase was slight; but works passes were relatively prevalent on Friday.
Correlation and regression show the association between numbers of one-day absences taken in two periods of time (each one year) to be marked (r = 0·5 to 0·7), unaffected by transforming to normal functions, and explicable on a linear hypothesis, but the value of r to increase as the periods of time increase and to decrease as the interval between the periods of time lengthens. Similar analyses for two-day absences show r = 0·25 to 0·55, acceptance of a linear hypothesis, and a suggestion that the value of r may increase as the periods of time increase and as the interval between them shortens. More limited examination shows corresponding values of r (for contiguous years) to be of the order 0·25 for medical passes, 0·60 for works passes, but > 0·80 for lateness.
Values of r between each of these factors in turn for all possible pairs of days of the week are reasonably consistent and show r of the order 0·35 for one-day absences, 0·25 for medical passes, 0·40 for works passes, and 0·80 for lateness (values for two-day absences are irregular and in the range 0 to 0·4). The consistency of lateness experience over days and years is very marked, the correlations being among the highest recorded for any event involving human behaviour.
The importance and application of the findings are briefly discussed; detailed consideration is reserved for the third and last paper.
PMCID: PMC1009136  PMID: 5448119
11.  Low back pain and widespread pain predict sickness absence among industrial workers 
The prevalence of musculoskeletal disorders (MSD) in the aluminium industry is high, and there is a considerable work-related fraction. More knowledge about the predictors of sickness absence from MSD in this industry will be valuable in determining strategies for prevention. The aim of this study was to analyse the relative impact of body parts, psychosocial and individual factors as predictors for short- and long-term sickness absence from MSD among industrial workers.
A follow-up study was conducted among all the workers at eight aluminium plants in Norway. A questionnaire was completed by 5654 workers at baseline in 1998. A total of 3320 of these participated in the follow-up study in 2000. Cox regression analysis was applied to investigate the relative impact of MSD in various parts of the body and of psychosocial and individual factors reported in 1998 on short-term and long-term sickness absence from MSD reported in 2000.
MSD accounted for 45% of all working days lost the year prior to follow-up in 2000. Blue-collar workers had significantly higher risk than white-collar workers for both short- and long-term sickness absence from MSD (long-term sickness absence: RR = 3.04, 95% CI 2.08–4.45). Widespread and low back pain in 1998 significantly predicted both short- and long-term sickness absence in 2000. In addition, shoulder pain predicted long-term sickness absence. Low social support predicted short-term sickness absence (RR = 1.28, 95% CI 1.11–1.49).
Reducing sickness absence from MSD among industrial workers requires focusing on the working conditions of blue-collar workers and risk factors for low back pain and widespread pain. Increasing social support in the work environment may have effects in reducing short-term sickness absence from MSD.
PMCID: PMC200978  PMID: 12956891
sickness absence; musculoskeletal disorders; low back pain; widespread pain; blue-collar workers; social support
12.  Risk factors for sickness absence due to low back pain and prognostic factors for return to work in a cohort of shipyard workers 
European Spine Journal  2008;17(9):1185-1192.
The purpose of this study was to determine risk factors for the occurrence of sickness absence due to low back pain (LBP) and to evaluate prognostic factors for return to work. A longitudinal study with 1-year follow-up was conducted among 853 shipyard workers. The cohort was drawn around January 2004 among employees in the shipyard industry. Baseline information was obtained by questionnaire on physical and psychosocial work load, need for recovery, perceived general health, musculoskeletal complaints, sickness absence, and health care use during the past year. During the 1-year follow-up for each subject medical certifications were retrieved for information on the frequency and duration of spells of sickness absence and associated diagnoses. Cox regression analyses were conducted on occurrence and on duration of sickness absence with hazard ratios (HR) with 95% confidence interval (95% CI) as measure of association. During the 1-year follow-up period, 14% of the population was on sick leave at least once with LBP while recurrence reached 41%. The main risk factors for sickness absence were previous absence due to a health problem other than LBP (HR 3.07; 95%CI 1.66–5.68) or previous sickness absence due to LBP (HR 6.52; 95%CI 3.16–13.46). Care seeking for LBP and lower educational level also hold significant influences (HR 2.41; 95%CI 1.45–4.01 and HR 2.46; 95%CI 1.19–5.07, respectively). Living with others, night shift and supervising duties were associated with less absenteeism due to LBP. Workers with a history of herniated disc had a significantly decreased rate of returning to work, whereas those who suffered from hand-wrist complaints and LBP returned to work faster. Prior sick leave due to LBP partly captured the effects of work-related physical and psychosocial factors on occurrence of sick leave. Our study showed that individual and job characteristics (living alone, night shift, lower education, sick leave, or care seeking during the last 12 months) influenced the decision to take sick leave due to LBP. An increased awareness of those frequently on sick leave and additional management after return to work may have a beneficial effect on the sickness absence pattern.
PMCID: PMC2527417  PMID: 18649089
Low back pain; Sick leave; Prognosis; Recurrence; Return to work
13.  Sickness absence in the Whitehall II study, London: the role of social support and material problems. 
STUDY OBJECTIVE--To investigate the role of social supports, social networks, and chronic stressors: (i) as predictors of sickness absence; and (ii) as potential explanations for the socioeconomic gradient in sickness absence. DESIGN--A prospective cohort study (Whitehall II study) with sociodemographic factors, health and social support measured at baseline, and spells of sickness absence measured prospectively. SETTING--Twenty London based non-industrial departments of the British civil service. PARTICIPANTS--Participants were civil servants (n = 10,308), aged 35-55 years at baseline, of whom 67% (6895) were men and 33% (3413) were women. The overall response rate for Whitehall II was 73% (74% for men and 71% for women). The analysis is based on 41% of the sample who had data on reasons for sickness absence and were administered all social support questions. Only 4.3% of participants did not complete all necessary questions and were excluded. MEASUREMENTS AND MAIN RESULTS--High levels of confiding/emotional support from the "closest person" predicted higher levels of both short and long spells of sickness absence. After adjusting for baseline physical and psychological health the effects were increased, suggesting that high levels of confiding/emotional support may encourage illness behaviour rather than generate illness. Social network measures showed a consistent but less striking pattern. Increased levels of negative aspects of social support resulted in higher rates of sickness absence. Material problems strongly predicted sickness absence, but the effect was diminished once adjustment for the covariables was made, suggesting that health status may be functioning as an intervening variable between chronic stressors and sickness absence. In addition, social support may buffer the effects of chronic stressors. Social support did not contribute to explaining the gradient in sickness absence by employment grade beyond that explained by the baseline covariables. CONCLUSIONS--Sickness absence from work is a complex phenomenon, combining illness and coping behaviours. High levels of confiding/emotional support, although not entirely consistent across samples, may either encourage people to stay at home when they are ill or may be accompanied by more social obligations at home prolonging sickness absence. Negative aspects of close relationships may jeopardize health and hence increase sickness absence.
PMCID: PMC1060150  PMID: 7499989
14.  A Cluster-Randomised Trial Evaluating an Intervention for Patients with Stress-Related Mental Disorders and Sick Leave in Primary Care 
PLoS Clinical Trials  2007;2(6):e26.
Mental health problems often affect functioning to such an extent that they result in sick leave. The worldwide reported prevalence of mental health problems in the working population is 10%–18%. In developed countries, mental health problems are one of the main grounds for receiving disability benefits. In up to 90% of cases the cause is stress-related, and health-care utilisation is mainly restricted to primary care. The aim of this study was to assess the effectiveness of our Minimal Intervention for Stress-related mental disorders with Sick leave (MISS) in primary care, which is intended to reduce sick leave and prevent chronicity of symptoms.
Cluster-randomised controlled educational trial.
Primary health-care practices in the Amsterdam area, The Netherlands.
A total of 433 patients (MISS n = 227, usual care [UC] n = 206) with sick leave and self-reported elevated level of distress.
Forty-six primary care physicians were randomised to either receive training in the MISS or to provide UC. Eligible patients were screened by mail.
Outcome Measures:
The primary outcome measure was duration of sick leave until lasting full return to work. The secondary outcomes were levels of self-reported distress, depression, anxiety, and somatisation.
No superior effect of the MISS was found on duration of sick leave (hazard ratio 1.06, 95% confidence interval 0.87–1.29) nor on severity of self-reported symptoms.
We found no evidence that the MISS is more effective than UC in our study sample of distressed patients. Continuing research should focus on the potential beneficial effects of the MISS; we need to investigate which elements of the intervention might be useful and which elements should be adjusted to make the MISS effective.
Editorial Commentary
Background: People who take sick leave from work as a result of mental health problems very often report that the cause is stress-related. Although stress-related sick leave imposes a significant burden on individuals and economies, few evidence-based therapies exist to prevent sick leave in people who are experiencing stress-related mental health problems. The researchers carrying out this study wanted to evaluate the effectiveness of an intervention for stress-related mental health disorders amongst people who had been on sick leave for less than three months. The intervention involved short training sessions for primary health-care practitioners, during which the practitioners were taught how to diagnose stress-related problems; how to provide information to patients and encourage their recovery and active return to work; and how to give advice and monitor patients' recovery. The researchers carried out a cluster-randomized trial evaluating this training program, in which 46 primary care practitioners were assigned by chance to receive either the training program or to practice usual care. Over the course of the trial, 433 patients with elevated levels of distress and sick leave were included in the study, 227 of whom were treated by practitioners receiving the training program and 206 of whom received usual care. These patients were followed up for 12 months and the primary outcome studied in the trial was the length of sick leave taken until full return to work. Secondary outcome measures included patients' reports of distress, depression, and other symptoms as recorded using specific questionnaires.
What the trial shows: In the trial, data on the primary outcome measure was available for 87% of the patients treated by practitioners receiving the training intervention and 84% of the patients receiving usual care. When these outcomes were analyzed, there was no evidence of a benefit of the training program on amount of sick leave taken. Over the course of the study, the severity of patients' self-reported symptoms fell in both groups, but there was no significant difference in symptom severity between the two groups of patients. A subgroup analysis suggested that more practitioners in the intervention group recognized patients as having stress-related mental health problems. Among the group of patients who were diagnosed as having stress-related mental health problems, those who were treated by practitioners in the intervention group seemed to return to work slightly more quickly than those in the usual care group. However, it is not easy to interpret the findings of this secondary analysis.
Strengths and limitations: Strengths of this study include the procedures for cluster randomization, in which primary care practitioners were randomized, rather than patients. This process ensures that only patients assigned to the intervention arm receive the benefits of the intervention, and avoids “contamination” between intervention and control groups. A further strength includes the blinding of researchers who were collecting data to the intervention that each practitioner had received. The findings of the study, however, are difficult to interpret. No effect of the training intervention was found on the study's primary outcome measure; it is possible that the training intervention does indeed have some benefit, but the benefit may not have been found in this particular trial because of the inclusion of patients with a very wide range of problems; in addition the practitioners may have not had the time or ability to apply what they learnt in the training program.
Contribution to the evidence: Very little evidence exists regarding the effects of training interventions for improving care of patients with stress-related mental health problems. The findings of this trial support those of another study carried out in a primary care setting, which found that training interventions do not seem to reduce length of sick leave. However, another study carried out in an occupational health-care setting, in which patients included in the trial had been recognised as having stress-related mental disorders, did find some benefit of an intervention program.
PMCID: PMC1885369  PMID: 17549228
15.  Patterns of Sickness Absence in a Railway Population 
This investigation was carried out in order to obtain morbidity statistics in a large industrial population with special reference to the effects of ageing.
The population chosen, the “railway research population,” consisted of a sample of Scottish railwaymen, drawn from five of the eight areas in the Scottish Region of British Railways. Only certain occupational grades were studied.
Information was obtained over a period of one year by means of a detailed monthly return of (a) sickness absence data and (b) job changes. Indices of sickness absence were defined. The sickness absence experience of the railway research population was compared with that of other populations. It is a healthier group than the total insured population but differs in some respects from that of London Transport.
The nature of sickness absence within the railway research population was then studied. It was shown in all but one measure used that sickness tends to increase with age, the most important factor being the increase of long episodes. Examination of the frequency distribution of the duration of sickness episodes revealed that sickness absence tends to be taken in terms of weeks off rather than days off.
Analysis of the daily variation in sickness absence showed that the total absence rate increased from Monday to Friday. There was a well defined tendency for sickness to start on Mondays, and in longer episodes an additional tendency to start on Fridays. This was interpreted in terms of morale, both positive and negative.
Marked differences of the same order of magnitude as those due to age were noted in the sickness experience of the various grades, related to both conditions of work and responsibility.
The reasons for job changes were analysed and the grades to which men were transferred were identified. The choice of suitable grades for older workers was discussed.
It was concluded that working conditions might be important factors in the type of sickness absence experienced and that comparisons with other populations might be helpful in this context. More detailed work was also called for on the psychological as well as physical aspects of the work situation for both the individual and the grade.
PMCID: PMC1037951  PMID: 13851172
16.  Self-reported treatment, workplace-oriented rehabilitation, change of occupation and subsequent sickness absence and disability pension among employees long-term sick-listed for psychiatric disorders: a prospective cohort study 
BMJ Open  2012;2(6):e001704.
To examine whether self-reported treatments, workplace-oriented rehabilitation and change of occupation were associated with subsequent sickness absence and disability pension among long-term sick-listed for psychiatric disorders.
A prospective cohort study.
Setting and participants
5200 employees (80% from the Swedish municipalities and county councils and 20% manual workers from the Swedish industry) were randomly selected who in 1999 in the register of AFA Insurance had a new spell of long-term sickness absence due to a psychiatric disorder. Of these, 99 were excluded (duplicates and deaths, persons living abroad, with protected personal information), and 5101 received a questionnaire in 2001. 3053 individuals responded (60%). After the exclusion of employees with no sick leave in 1999 according to the Swedish social insurance agency, aged 62 years and older, with disability pension 1999–2001, no self-reported treatment, and with missing information on the covariates, our final study group was 2324 individuals. Logistic regression analyses were performed.
Outcome measures
Sickness absence (>90 days) and disability pension (>0 day).
45% had sickness absence and 18% a new disability pension in 2002. Drug treatment and physiotherapy, respectively, were associated with increased odds of sickness absence (OR 1.56, 95% CI 1.28 to 1.90; OR 1.43, 95% CI 1.21 to 1.69), and disability pension (OR 1.79, 95% CI 1.34 to 2.41; OR 1.75, 95% CI 1.40 to 2.18). Workplace-oriented rehabilitation and change of occupation, respectively, reduced the odds of sickness absence (OR 0.70, 95% CI 0.59 to 0.83; OR 0.35, 95% CI 0.27 to 0.45).
We found a pattern of poorer outcome of drug treatment and physiotherapy compared with other treatments (psychotherapy, workplace-oriented rehabilitation and complementary or alternative medicine) in terms of increased odds of sickness absence and disability pension. Workplace-oriented rehabilitation and/or change of occupation were associated with reduced odds of sick leave. Studies with a randomised controlled trial design are needed to examine the effect on sick leave of a workplace-oriented intervention.
PMCID: PMC3533007  PMID: 23117569
Rehabilitation Medicine; Public Health
17.  Studies on influenza vaccine in industry 
Postgraduate Medical Journal  1973;49(569):169-174.
Large scale studies of influenza vaccination in industry have recently been started. The studies are of two types:
(a) Vaccination was offered to a factory and a record maintained of sickness absence of all employees, both the vaccinated volunteers and the non-volunteers. In five different factories, the average acceptance rate was 42%.
An analysis of the volunteers in one factory indicated that acceptance of vaccination was highest in middle-aged married women and low in younger and older men.
(b) In the Post Office telecommunications branch vaccination was offered to 26,317 employees in eighty-eight units in different parts of the country; 42% of these accepted vaccination. Ninety-eight other units, employing 25,202 employees, are acting as unvaccinated controls. Sickness absence is being recorded in both groups of units.
In both these groups of studies it is aimed to compare the absence experience of the immunized and non-immunized groups for a prolonged period, both when influenza is and is not occurring.
Preliminary findings are presented of the absence figures for January and February 1972, during which time a mild outbreak of influenza occurred, with only a small effect on sickness absence. Vaccinated persons in factories had lower absence rates than the non-vaccinated persons, and telecommunications units in which vaccination was offered experienced lower absence rates with less respiratory absence.
The significance of these findings is discussed.
PMCID: PMC2495387  PMID: 4802598
18.  Shiftwork and Sickness Absence Among Police Officers: The BCOPS Study 
Chronobiology international  2013;30(7):930-941.
Shiftwork, regarded as a significant occupational stressor, has become increasingly prevalent across a wide range of occupations. The adverse health outcomes associated with shiftwork are well documented. Shiftwork is an integral part of law enforcement, a high-stress occupation with elevated risks of chronic disease and mortality. Sickness absence is an important source of productivity loss and may also serve as an indirect measure of workers’ morbidity. Prior studies of shiftwork and sickness absenteeism have yielded varying results and the association has not been examined specifically among police officers. The objective of this study was to compare the incidence rate of sick leave (any, ≥3 consecutive days) among day-, afternoon-, and night-shift workers in a cohort of police officers and also examine the role of lifestyle factors as potential moderators of the association. Participants (N = 464) from the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) study examined between 2004 and 2009 were used. Daily work history records that included the shift schedule, number of hours worked, and occurrence of sick leave were available for up to 15 yrs starting in 1994 to the date of the BCOPS study examination for each officer. Poisson regression analysis for ungrouped data was used to estimate incidence rates (IRs) of sick leave by shift, and comparison of IRs across shifts were made by computing incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). Sick leave occurred at a higher rate on the night shift (4.37 per 10 000 person-hours) compared with either day (1.55 per 10000 person-hours) or afternoon (1.96 per 10000 person-hours) shifts. The association between shiftwork and sickness absence depended on body mass index (BMI). For overweight individuals (BMI ≥ 25 kg/m2), the covariate-adjusted incidence rate of sick leave (≥1 day) was twice as large for night-shift officers compared with those working on the day (IRR = 2.29, 95% CI: 1.69–3.10) or afternoon (IRR= 1.74, 95% CI: 1.29–2.34) shift. The IR of three or more consecutive days of sick leave was 1.7 times larger for those working on night shift (IRR = 1.65, 95% CI: 1.17–2.31) and 1.5 times larger for those working on afternoon shift (IRR= 1.50, 95% CI: 1.08–2.08) compared with day shiftworkers. For subjects with normal BMI (<25 kg/m2), the incidence rates of sick leave did not differ significantly across shifts. In conclusion, shiftwork is independently associated with sickness absence, with officers who work the night shift having elevated incidence of sick leave. In addition, overweight officers who work the night shift may be at additional risk for sickness absence.
PMCID: PMC4624272  PMID: 23808812
BMI; police officers; shiftwork; sick leave; ungrouped poisson regression
19.  Low back pain predict sickness absence among power plant workers 
Low back pain (LBP) remains the predominant occupational health problem in most industrialized countries and low-income countries. Both work characteristics and individual factors have been identified as risk factors. More knowledge about the predictors of sickness absence from LBP in the industry will be valuable in determining strategies for prevention.
The aim of this longitudinal study was to investigate whether individual, work-related physical risk factors were involved in the occurrence of LBP sickness absence.
A follow-up study was conducted among 489 workers, aged 18–65 years, at Kosovo Energetic Corporation in Kosovo. This cross-sectional study used a self-administered questionnaire to collect data on individual and work-related risk factors and the occurrence of LBP sickness absence. Logistic regression models were used to determine associations between risk factors and the occurrence of sickness absence due to LBP.
Individual factors did not influence sickness absence, whereas work-related physical factors showed strong associations with sickness absence. The main risk factors for sickness absence due to LBP among production workers were extreme trunk flexion (OR = 1.71, 95% CI = 1.05–2.78) as well as very extreme trunk flexion (OR = 6.04, 95% CI = 1.12–32.49) and exposure to whole-body vibration (OR = 1.75, 95% CI = 1.04–2.95).
Reducing sickness absence from LBP among power plant workers requires focusing on the working conditions of blue-collar workers and risk factors for LBP. Increasing social support in the work environment may have effects in reducing sickness absence from LBP.
PMCID: PMC2992865  PMID: 21120081
Low back pain; occupational; physical risk factors; sick leave
20.  Implementation of the Participatory Approach to increase supervisors’ self-efficacy in supporting employees at risk for sick leave; design of a randomised controlled trial 
BMC Public Health  2013;13:750.
The burden of sick leave for society and organisations underlines the urgent need to prevent sick leave. An effective workplace intervention for organisations to shorten sick leave episodes is the Participatory Approach (PA). In this study, we hypothesize that implementation of the PA for supervisors within organisations may prevent sick leave as well. However, implementation of the PA within an organisation is difficult, and barriers at different levels (employee, supervisor and organisational) exist. Therefore, the primary aim of this study is to evaluate the effectiveness of a multifaceted implementation strategy of the PA.
In a cluster randomised controlled trial (RCT) a multifaceted implementation of the PA will be compared with a minimal implementation strategy of the PA. Participating organisations are a university medical centre, a university and a steel factory. Randomisation will take place at department level. Intervention departments will receive a multifaceted implementation strategy of the PA, which incorporates a working group, supervisor training, and supervisor coaching. Control departments will receive the minimal implementation strategy of the PA, consisting of written information only. The primary outcome measure is self-efficacy of supervisors in joint problem solving to improve work functioning of employees with health complaints and to prevent sick leave. A secondary outcome measure at supervisor level is self-efficacy in communicating with employees about situations of reduced work functioning or being at risk for sick leave. Secondary outcome measures at employee level are attitude, self-efficacy, and social influence, with regard to addressing situations of reduced work functioning or being at risk for sick leave, as well as work functioning, psychological well being, and sick leave. Measurements will take place at baseline, and after six and twelve months follow-up. A process evaluation will be performed as well.
This study will be relevant for all organisations with employees at risk for sick leave in health care, education, and industry. Study results will give an insight into the effectiveness of the multifaceted implementation strategy of the PA for supervisors to improve work functioning of employees with health complaints, and to prevent sick leave.
Trial registration
PMCID: PMC3751359  PMID: 23941563
Participatory Approach; Sick leave; Supervisors; RCT
21.  Interaction of Physical Exposures and Occupational Factors on Sickness Absence in Automotive Industry Workers 
Global Journal of Health Science  2015;7(6):276-284.
Increased sickness absence in recent years has been a trouble making issue in industrial society. Identify the causes of sickness absence and its influencing factors, is an important step to control and reduce its associated complications and costs. The aim of this study was to evaluate main factors associated with the incidence of sickness absence.
In 2012, a cross-sectional study on 758 employees of a car accessories producing company was applied and relevant information about the number of days and episodes of sickness absence, Disease resulting in absence from work, personal features, occupational factors and physical exposures were collected. To determine risk factors associated with sickness absence, Logistic regression analysis was used.
The most common diseases leading to sickness absence in order of frequency were Respiratory diseases, musculoskeletal disorders, gastrointestinal diseases and injuries at work. Musculoskeletal disorders increased the danger of long term absence by 4/33 times. Blue collar and shift works were the most important occupational factors associated with the incidence of sickness absence. The main physical factors that affect incidence of sickness absence were frequent bending-twisting and heavy lifting.
Identifying controllable factors of sickness absence and trying to prevent and modify them such as compliance of ergonomic principals to decrease physical can be effective in reducing sickness absence.
PMCID: PMC4803885  PMID: 26153180
sickness absence; physical exposure; risk factors; shift work; blue collar
22.  Structured Early Consultation with the Occupational Physician Reduces Sickness Absence Among Office Workers at High Risk for Long-Term Sickness Absence: a Randomized Controlled Trial 
Objective To examine the efficacy of structured early consultation among employees at high risk for future long-term sickness absence, in the prevention and/or reduction of sickness absence. The focus of the experiment was the timing of the intervention, that is, treatment before sickness absence actually occurs. Methods In the current prospective randomized controlled trial (RCT), employees at high risk for long-term sickness absence were selected based on responses to a 34-item screening questionnaire including demographic, workplace, health and psychosocial factors associated with long-term sickness absence (>28 days). A total of 299 subjects at risk for future long-term sickness absence were randomized in an experimental group (n = 147) or in a control group (n = 152). Subjects in the experimental group received a structured early consult with their occupational physician (OP), in some cases followed by targeted intervention. The control group received care as usual. Sickness absence was assessed objectively through record linkage with the company registers on sickness absence over a 1 year follow-up period. Results Modified intention-to-treat analysis revealed substantial and statistically significant differences (p = 0.007) in total sickness absence duration over 1 year follow-up between the experimental (mean 18.98; SD 29.50) and control group (mean 31.13; SD 55.47). Per-protocol analysis additionally showed that the proportion of long-term sickness absence spells (>28 days) over 1 year follow-up was significantly (p = 0.048) lower in the experimental (9.1%) versus control group (18.3%). Conclusions Structured early consultation with the OP among employees at high risk for future long-term sickness absence is successful in reducing total sickness absence.
PMCID: PMC2668565  PMID: 18196446
Epidemiology; Occupational health intervention; Prevention; Sick leave
23.  Fatigue as a predictor of sickness absence: results from the Maastricht cohort study on fatigue at work 
Occupational and Environmental Medicine  2003;60(Suppl 1):i71-i76.
Objectives: To investigate whether there is a relationship between fatigue and sickness absence. Two additional hypotheses were based on the theoretical distinction between involuntary, health related absence and voluntary, attitudinal absence. In the literature, the former term is usually used to describe long term sickness absence, the latter relates to short term sickness absence. In line with this, the first additional hypothesis was that higher fatigue would correspond with a higher risk of long term, primarily health related absence. The second additional hypothesis was that higher fatigue would correspond with a higher risk of short term, primarily motivational absence.
Methods: A multidimensional fatigue measure, as well as potential sociodemographic and work related confounders were assessed in the baseline questionnaire of the Maastricht cohort study on fatigue at work. Sickness absence was objectively assessed on the basis of organisational absence records and measured over the six months immediately following the baseline questionnaire. In the first, general hypothesis the effect of fatigue on time-to-onset of first sickness absence spell during follow up was investigated. For this purpose, a survival analysis was performed. The effect of fatigue on long term sickness absence was tested by a logistic regression analysis. The effect of fatigue on short term sickness absence was investigated by performing a survival analysis with time-to-onset of first short absence spell as an outcome.
Results: It was found that higher fatigue decreased the time-to-onset of the first sickness absence spell. Additional analyses showed that fatigue was related to long term as well as to short term sickness absence. The effect of fatigue on the first mentioned outcome was stronger than the effect on the latter outcome. Potential confounders only weakened the effect of fatigue on long term absence.
Conclusions: Fatigue was associated with short term but particularly with long term sickness absence. The relation between fatigue and future sickness absence holds when controlling for work related and sociodemographic confounders. Fatigue as measured with the Checklist Individual Strength can be used as a screening instrument to assess the likelihood of sickness absence in the short term.
PMCID: PMC1765725  PMID: 12782750
24.  Influenza vaccination—acceptance in an industrial population 
Smith, J. W. G., Pollard, R., Fletcher, W. B., Barker, R., and Lewis, J. R. (1974).British Journal of Industrial Medicine,31, 292-297. Influenza vaccination—acceptance in an industrial population. Influenza vaccination was offered in a pharmaceutical factory of approximately 6 000 employees in December 1971 and again in December 1972. The rate of acceptance of vaccination was 42% in 1971 but fell to only 27% in 1972, and was highest among middle-aged married women and lowest among young men. Only 57% of employees who were vaccinated in 1971 and were still employed in 1972 accepted vaccination on the second occasion. Re-vaccination was commoner in staff (64%) than in works employees (52%) in all age and sex categories, and was commoner in older than in younger employees. Only 6% of employees who did not accept vaccination in 1971 accepted the vaccine in 1972. Among new employees who were not in the factory in December 1971 the acceptance rate was 21% in 1972.
Between January 1971 and 1972 vaccinated employees left the factory less commonly (15%) than those who had not accepted vaccination (22%). Loss of working time in April to September 1972, i.e., when it is unlikely that influenza would have influenced the returns, was 21% higher among non-vaccinated employees than in vaccinated employees, the difference being due to certified illness of more than three days' duration.
The benefit to be derived from offering influenza vaccination to a factory or office population will depend, among other factors, on the proportion of employees who accept the offer and on the characteristics of this volunteers group. The low take-up rate (27%) observed in the second year suggests that annual influenza vaccination is unlikely at the present time to have a marked effect on absence during outbreak periods. In comparison with the non-volunteers in the present study, the volunteers included a higher proportion of married women, older persons, and staff employees and were less inclined to leave employment, and lost less working time from certificated sickness absence. The value of offering vaccine may therefore be greatest in an established office employing a high proportion of older women. The differences between the volunteers and non-volunteers, particularly the better sickness absence record of the former, indicates that the effect of influenza vaccination cannot reliably be assessed only from a comparison of absence returns between vaccinated and unvaccinated employees.
PMCID: PMC1009600  PMID: 4425631
California Medicine  1959;91(6):348-354.
There are many nonmedical factors that contribute to employee absenteeism in industry. An employee's total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.
The role of a private physician in determining and certifying the true state of a patient's health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners.
PMCID: PMC1577980  PMID: 14418976

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