Employee Health and Presenteeism

J Occup Rehabil (2007) 17:547579
DOI 10.1007/s10926-007-9096-x
Employee Health and Presenteeism: A Systematic

Review
Alyssa B. Schultz Dee W. Edington
Published online: 25 July 2007

Springer Science+Business Media, LLC 2007
Abstract Introduction Many employers focus on their large and easily measured cost
of health care, yet until recently they have ignored the impact of health on productivity.
Studies of some chronic conditions and some health risk factors suggest that costs of lost
productivity exceed costs of medical care. This review will examine the literature to
explore the link between employee health and on-the-job productivity, also known as
presenteeism. Methods Searches of Medline, CINAHL and PubMed were conducted in
October 2006, with no starting date limitation with presenteeism or work
limitations as keywords. A total of 113 studies were found using this method. Each
study was evaluated based on the strength of the study design, statistical analyses,
outcome measurement, and controlling of confounding variables. Results Literature on
presenteeism has investigated its link with a large number of health risks and health
conditions ranging from exercise and weight to allergies and irritable bowel syndrome.
As expected, the research on some topic areas is stronger than others. Conclusions
Based on the research reviewed here, it can be said with confidence that health
conditions such as allergies and arthritis are associated with presenteeism. Moreover,
health risks traditionally measured by a health risk appraisal (HRA), especially physical
activity and body weight, also show an association with presenteeism. The next step for
researchers is to tease out the impact of individual health risks or combinations of risks
and health conditions on this important outcome measure.
Keywords Presenteeism Productivity Health risks

Health conditions
A. B. Schultz (&) D. W. Edington

Health Management Research Center, University of Michigan,
1015 E. Huron St., Ann Arbor, MI 48104-1688, USA
e-mail: abelaire@umich.edu
D. W. Edington
e-mail: dwe@umich.edu
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Introduction
A persons health may be his or her most important possession. Without it, the basic
activities of life are curtailed or prohibited entirely. One of these basic life activities is
work. Certainly a persons ability to work is greatly affected by his or her health. As of
April 2006, 143.7 million adults in the United States were employed [1]. Each one of
those individuals exists on a continuum of health [2] ranging from optimum health on
one extreme all the way to morbidity and death on the other extreme. In the middle,
there are a wide variety of symptoms, health problems and diseases that may impede
work ability to some degree. Of course, people move on this continuum throughout
their life.
The worksite health management industry was borne of the need to help employees
stay on the healthy end of the continuum. One of the first steps in that process is
measuring the health of employees. Since the 1980s the tool of choice for this task has
been the health risk appraisal (HRA). While HRAs remain one of the most commonly
used tools in the field of health promotion [35] they have changed much since their
inception in the 1980s. The original outcome metric used in HRAs was mortality. While
this outcome was deemed valid [3], it was not always easily understood or used by
participants. Over time, HRA providers converted the mortality risk data into other
measures which were more relevant to the participant. These often took the form of a
health score or health index.
Health risk appraisals originally measured traditional health risks like smoking,
physical activity, and blood pressure and have grown to include quality of life issues and
health conditions such as migraine headaches and irritable bowel syndrome. The use of
HRAs continues to evolve as they persist in providing participants with information and
motivation to maintain and improve their health. Aggregate data from the HRAs are
used to determine population risk profiles and provide information on new outcome
measures pertinent to organizations. The HRA can help forecast health-related human
capital risks and establish the relative appropriateness for a variety of individual and
workplace interventions.
Many studies have established the link between health risks and health conditions (as
measured by HRAs) and health care costs [69]. These studies show a clear link
between employees with more health risks and higher health care costs. Moreover, as
health risks change (either increasing or decreasing), there is an associated change in
costs [10]. The presence of health risk factors among employees is not only costly to
employers in terms of health care costs, but is also responsible for costs associated with a
reduction in productivity. Lost productivity can be measured by the costs associated
with absenteeism: an employees time away from work typically consisting of illness
related scattered absences, short- and long-term disability, and workers compensation
[1014]. While absenteeism and disability are significant components of productivity,
costs associated with these components are only part of the total cost associated with
lost productivity.
Presenteeism, defined as decreased on-the-job performance due to the presence of
health problems, is a second main component of productivity measurement and is
beginning to garner more interest from corporate management, including medical
directors [15]. Presenteeism measures the decrease in productivity for the much larger
group of employees whose health problems have not necessarily led to absenteeism
and the decrease in productivity for the disabled group before and after the absence
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period [16]. Presenteeism is often measured as the costs associated with reduced work
output, errors on the job, and failure to meet company production standards. Bank One
(now JPMorgan Chase) estimated presenteeism to be as much as 84% of their
productivity costs, with absenteeism and disability comprising the other 16% [17].
A random sample telephone survey of nearly 29,000 U.S. workers was conducted in
2001 and 2002. This surveythe American Productivity Auditquantified lost
productive time due to health conditions and other reasons. During the previous
2 weeks, 38.3% of participants reported unproductive time at work (presenteeism) as a
result of their health on at least one workday [18]. This reduced performance accounted
for 66% or 1.32 h per week of the total lost time, with absenteeism comprising the
remainder. In a discussion of health and human capital, Berger and colleagues contend
that the effective U.S. workforce is decreased by 510% because of health problems
spread over the whole work force [19].
Objectives of the Review

The purpose of this review is to discuss the link between health risks and health
conditions with on-the-job productivityalso known as presenteeism. Employers have
spent many years focusing on their large and easily measured cost of health care (the
second highest cost for employers after payroll) yet until recently they have ignored the
additional impact of health on productivity. Studies of the impact of some common
chronic conditions suggest that the costs of lost productivity far exceed the costs of
medical care [20]. Therefore, this review will examine the literature to explore the
important link between employee health and presenteeism. Studies which explore other
types of productivity (absenteeism, short-term disability, etc.) are not directly covered
by this review but represent another cost to employers associated with health risks and
health conditions. Many studies reviewed here measured both presenteeism and
absenteeism but this review only examines the results dealing with presenteeism.
Measuring Presenteeism
How is presenteeism measured? For a few years, the answer was: not easily.
Productivity studies were plagued by the difficulty of quantifying output, particularly
in information and service-type jobs. One of the first studies related to presenteeism by
Burton et al. (1999) who uniquely gathered objective productivity measures of
telephone customer service operators and compared them with health risk appraisal
data [21]. However, call centers are unique opportunities, and the need for a more
general way to measure presenteeism across many types of jobs and organizations led to
the development of several self-report instruments.
A multitude of self-report workplace productivity measurement instruments have
been created and studied. Several reviews have examined their merits and the
advantages of one instrument over another [2228]. Some of these questionnaires
include the Work Limitations Questionnaire (WLQ) [2934], the Health and Work
Performance Questionnaire (HPQ) [3537], the Work Productivity Short Inventory
(WPSI) [38, 39], the Stanford Presenteeism Scale (SPS-34 and SPS-13) [40, 41], the
Work and Health Interview (WHI) [42], the Health and Labor Questionnaire (HLQ)
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[43], the Work Productivity and Activity Impairment Questionnaire (WPAI) [4446],
the Work Performance Scales [47], the Endicott Work Productivity Scale [48], the
Health-Related Productivity Questionnaire Diary [49], the Angina-related Limitations
at Work Questionnaire [50], and others [51, 52]. Furthermore, a subset of the WLQ has
been incorporated into a worksite HRA with success in the study of a variety of health
conditions [53] and health risks [54, 55].
Evans cautions all productivity investigators to consider three areas when choosing a
questionnaire: the psychometric properties of the instrument, administration complexity, and the setting of the evaluation [56]. The WLQ, the HPQ, the WPSI, the SPS, and
the WHI have all undergone various levels of validity and reliability testing and
displayed some level of criterion validity and reliability. An expert panel convened by
the American College of Occupational and Environmental Medicine recommends that
presenteeism measures cover the following aspects of productivity: time not on task,
quality of work (mistakes, peak performance, injury rates, etc.), quantity of work, and
personal factors (social, mental, physical, emotional, etc.) [57]. Whichever instrument is
chosen, investigators must interpret their results carefully since different questionnaires
measure different aspects of presenteeism.
Lofland and colleagues reviewed several productivity loss instruments in 2004 [22].
Their review focused on six instruments that provided a metric suitable for conversion
to a monetary figure. They found that many instruments are only suitable for use with
certain patient groups, such as those with migraines. Others are applicable to broader
populations which might have a variety of health conditions. Also in 2004, Prasad and
colleagues conducted another review of six self-report productivity loss instruments
[23]. Their review highlights the validity and reliability testing of each instrument and
suggests that the WPAI and WLQ offer the most significant advantages. However, the
HPQ was only recently developed at the time of this review and they note that it holds
promise.
After reviewing the literature to date, it appears that two presenteeism instruments
are moving to the forefront in popularity. These are the WLQ and the HPQ. Their
relatively strong validity and reliability testing results make them good choices,
particularly since they have been used in a variety of workplace settings and with a
variety of health risks and conditions. Many of the other questionnaires reviewed here
are suitable for specific patient populations but these two questionnaires may be the
most useful in general employee populations. They both give results that may be
quantified monetarily.
Methods
Selection of Studies
Searches of electronic databases were conducted in October 2006, with no starting date
limitation. Medline, CINAHL and PubMed were all searched with presenteeism or
work limitations as a keyword, title word, abstract word, full text word or subject
heading. Studies were excluded if they were non-human, not in the English language or
not in a peer-reviewed journal. A total of 119 articles were found using this method.
Some studies dealing with health conditions not typically studied in worksite health
management program evaluations (such as epilepsy) were excluded, as were those
dealing with non-working age populations such as the elderly or children, leaving a total
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of 113 published manuscripts as a result of the literature search. Articles known to the
author and those found through review of article bibliographies were also included as
the review progressed.
Many of the studies found through the literature search were about measuring
presenteeism (N = 36). Another group of studies focused on pharmaceutical treatments
and their association with improved productivity (N = 11). A final group of published
reports (N = 29) were either business publications speculating on the potential costs of
presenteeism or studies which only tangentially discussed on-the-job productivity loss.
These studies are covered briefly in this review. A total of 37 studies from peer-reviewed
journals on the topic of health conditions or health risks were evaluated and presented
in-depth (see Tables 1 and 2).
Quality Assessment
Each of the 37 studies was evaluated using criteria proposed by Kristensen [89] on
the strength of the study design, measurement, statistical analyses, and controlling of
confounding variables. The authors assigned a score of 1 or 0 to each of these four
criteria. For example, if a study used a validated presenteeism measurement tool,
that study received a score of 1 for the measurement criterion whereas a study
using only one non-validated question to assess presenteeism would receive a score
of 0. Similarly, studies which utilized techniques such as logistic regression to
control for confounding variables would receive a score of 1 for the controlling
for confounders criterion. A study which made no effort to control for confounding
variables would receive a 0. After assigning a score to each of the four criteria,
they were summed to create one overall score for each article ranging from 4
(strongest) to 0 (weakest). Information and overall scores of reviewed studies are
shown in Table 1.
Then, for each topic area (such as a given medical condition) the aggregate research
was evaluated based on the quality of each individual study or review, the number of
studies, and the consistency of study results [89]. Scores and notes for topic areas can be
found in Table 2.
Presentation of Results
The reviewed articles are categorized based on health condition or risk. In topic areas
where methodologically strong reviews have already been written, those results are
summarized here but research published after the reviews are presented as an update.
For each topic area, the impact of that health risk or condition is briefly stated, along
with the number of studies found and a brief summary of the quality of the research on
that topic. In some cases, studies are described in detail. However those that are merely
presented for background information, such as prevalence rates of certain conditions,
are not scored and are presented cursorily. Only studies which were published in peerreview journals are included in the review and subsequent tables. Some articles from
non-peer-review journals are included in the background discussion of certain topics.
Ratings of the 37 studies that were scored and presented in-depth can be found in
Table 1 and the ratings for the content areas are presented in Table 2. Finally,
conclusions are presented, with specific suggestions to employers, and areas of future
research are discussed.
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Statistical analyses
Controlling for
confounders
Short-Form Health
Survey (SF-36) of 10
health conditions and
Stanford Presenteeism
Scale (SPS); 10%
random sample also
completed Work
Limitations
Questionnaire (WLQ)
Varied based on
Mathematical formula
Productivity estimates
the studies
multiplying number of
from several published
people with condition
studies were applied to
used to derive
times impaired time due
the prevalence rates of
productivity
to condition divided by
conditions found in
estimates
working hours in a year
their database
Goetzel
Multi-employer
(2004) [59]
database for
prevalence of health
conditions
Other
Regression analysis
conditions,
estimating impact of
job type,
various factors on work
work
impairment; logistic
location, age,
regression used for
ethnicity, sex,
absenteeism analysis.
biometrics
Medical claims analyzed
and work
for cost
hours per
week
Age, gender,
Participants self-reported Logistic regression
other
calculated odds of
health conditions on
conditions
reporting any work
the HRA and included
and health
limitation for all domains
a subset of WLQ
risks
of the WLQ and any
questions to measure
limitation overall
presenteeism
Measurement
Collins
Self-report survey of
(2005) [58]
5369 employees of
Dow Chemical
Company
Studies of multiple health conditions

Burton
HRA survey of 16,651
(2004) [53]
financial services
employees
Study design/
population
Table 1 Summary of reviewed studies

Overall
scorea
4
Several health conditions
(depression, arthritis, back pain,
allergy, heartburn, diabetes and
irritable bowel syndrome) were
associated with significantly
higher odds of reporting a work
limitation
4
Employees with depression and
breathing disorders reported
greatest impairment. Magnitude
of impairment increased with
increasing numbers of
conditions. Out of work
impairment, absenteeism and
medical/pharmaceutical costs,
work impairment represented
the greatest cost for each of the
ten conditions (6.8% of all labor
costs)
3
For the 10 conditions studied,
presenteeism costs ranged from
18% to 89% of total costs
[which includes health care costs
(medical and pharmacy),
absenteeism and presenteeism].
Arthritis, hypertension,
depression, and allergy had the
highest presenteeism costs
Findings
552
Nationally
representative
telephone/mail
survey of 2074
adults
Munir (2005)
[62]
Survey of 610 British

university
employees with a
chronic health
condition
Lerner (2000) National household

[61]
survey of 940
employed people
Kessler et al.
(2001) [60]
Study design/
population
Table 1 continued
22% of respondents had at 3

least one health-related
work loss or work
cutback day in past
month. Increasing rates
of impairment associated
with greater numbers of
health conditions
4
Nearly one-third of adults
with chronic health
problems reported recent
moderate to severe
difficulty on the job in at
least one of three areas.
As number of conditions
increased, so did odds of
having a work limitation
40% of employees with a
2
self-reported health
condition reported a
work limitation in at
least one of the three
areas
Other conditions, age,

sex, education,
occupational status
Age, gender, job type,

smoking, education,
ethnicity, full-time
status
Overall
scorea
Findings
Controlling for
confounders
Condition severity,
Logistic regression
What extent do you
condition symptoms
modeling impact of
experience problems
(pain/fatigue), other
each of eight conditions
at work related to
conditions, age, sex,
on reporting a specific
physical, cognitive and
job type
type of work limitation
social work demands.
4-point scale ranging
from all the time to
never
Regression analysis of
Out of the past 30 days
association between
how many days were
any of 12 health
you totally unable to
conditions and work
work or carry out
loss or work cutback
normal activities
because of physical or
mental health (work
loss) or had to cut back
on those activities
(work cutback)
During the past 4 weeks, Logistic regression
analyzed 10 health
how much difficulty
condition groups and
have you had doing
their association with
the following work
physical, psychosocial
activities because of
and environmental
any ongoing health
work limitations
problems or health
concerns?
Measurement

553
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123
Burton
(2001) [21]
Allergy
Bunn (2003)
[64]
Wang (2003)
[63]
Measurement
Health risk appraisal

survey of 634
telephone customer
service
representatives
Survey of 10,714
manufacturing
employees
Age, gender, fall or

spring survey period,
comorbidities
Logistic regression
controlled for age,
gender, work
experience, number
of health risks
Regression analysis of 5
comparison groups
based on reported
severity of allergies;
separate analysis of
allergy medication use
Chi-square analysis of
pollen levels and
productivity. Chisquare analysis of
medication groups and
productivity. Separate
analysis using logistic
regression to analyze
odds of meeting
productivity standards
Objective measurement
of productivity
compared with daily
pollen counts. Selfreport of allergy
medication usage
All health and productivity 4

measures grew worse as
allergy symptoms
increased. Losses were
substantially higher in
the moderate and severe
allergy groups
Stepwise decline in
4
productivity was seen
among allergic
employees as pollen
levels increased. Those
taking medication had
significantly higher
productivity than the nomedication group
3 of 13 conditions (arthritis, 3
asthma and COPD/
emphysema) were
associated with
significant elevations in
presenteeism. No
analysis of additive effect
of number of conditions.
Inclusion of all health
conditions as model
covariates may have
overshadowed the effect
of any one condition
individually
Age, sex, education,

occupation, other
conditions
Effect of health
conditions on work
performance estimated
using ANCOVA
pooled across 4
occupations (airline
reservationists, phone
company customer
service agents,
automotive executives
and railroad engineers)
Overall
scorea
Findings
Controlling for
confounders
Subset of SF-36, WLQ,

allergy questionnaire,
absenteeism, injuries,
workers
compensation, and
health care utilization
Health and Work

Telephone survey of
Performance
2350 employees in 4
Questionnaire (HPQ)
occupations
assessed presenteeism.
Health conditions
assessed using
checklist from
National Health
Interview Study
Study design/
population
Table 1 continued
554
Burton
(2006) [68]
Studies
included in
Burton
(2006
review)
[67]
Arthritis
Backman
(2004
review)
[66]
Lamb (2006)
[65]
Measurement
16,651 employees
participating in
HRA
Logistic regression
Subset of WLQ
analysis to find odds of
questions to assess
reporting any work
presenteeism; selflimitation
report of arthritis and
whether or not
employees were
under care or taking
medication for
condition
1
Presenteeism and
absenteeism occur early in
the course of rheumatoid
arthritis. Interventions
may prevent disability and
job loss. Factors associated
with work limitations
include the demands of
work, barriers within the
work environment and
work accommodations
provided
3
Most studies from patients

perspective rather than
employer. Many with
rheumatoid arthritis are
unable to work, potentially
limiting population
available for study
4
All four domains of WLQ
Age, gender, other
significantly impacted by
conditions and health
arthritis while physical
risks
work domain was most
affected
3
Allergic employees were
unproductive 2.3 hours per
workday while
experiencing symptoms
Age, gender, other

conditions
Comparison of
presenteeism and
absenteeism associated
with allergies vs. other
health conditions
Overall
scorea
Findings
Controlling for
confounders
Studies on rheumatoid
arthritis and disability
and presenteeism
Productivity loss in
38 studies of
studies was disability,
rheumatoid arthritis
absenteeism or
and workplace
presenteeism
productivity
Non-systematic
review of literature
Wellness screenings of Work Productivity

Short Inventory
8,267 employees at
(WPSI)
47 locations
Study design/
population
Table 1 continued

555
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Measurement
Web-based survey of
1,039 employees
Diabetes
Lavigne
Telephone survey of
(2003) [73]
472 employed
residents of New
York
Stewart
Phone survey of
(2003) [72]
28,902 workers
(American
Productivity Audit
[APA])
Chronic pain
Allen (2005)
[71]
Tobit regression analysis

Osterhaus model used to
to model work
assess work efficiency and
efficiency losses while
the Health and Labor
not feeling well
Questionnaire (HLQ) also
used
Linear regression
SF-36 and Brief Pain
Inventory to assess pain, 12
items from WLQ to assess
presenteeism
Work and Health Interview Linear regression
(WHI) assessed reduced
performance at work due
to health conditions
Manufacturing employees
Muchmore
Multi-employer
association between
had measured productivity
(2003) [69]
database analysis of
arthritis diagnosis and
output, ICD-9 data used to
28,130 employees
annual productivity
classify employees with
arthritis and associated
joint disorders
Chi-square analysis
WHI to assess lost
Ricci (2005) Random telephone
comparing lost
productive time, arthritis
[70]
survey of 420
productive time for
criteria taken from First
employed US adults
workers with and
National Health and
(APA)
without arthritis pain
Nutrition Examination
flare-ups
Survey (NHANES-I)
Study design/
population
Table 1 continued
Other health
conditions, age,
gender, ethnicity,
exercise, job
characteristics
Diabetic employees
showed a reduction in
work productivity
compared to nondiabetics. Longer time
since diabetes diagnosis
was significantly
associated with greater
efficiency losses
4
Pain from headaches,
Demographics,
arthritis, back pain and
occupational and
other musculoskeletal
employment
problems caused
characteristics, health
productivity loss among
habits
13% of the US workforce
2
Each of the four WLQ
subscales impacted more
as pain severity increased
Arthritic workers with pain 2

exacerbations in previous
two weeks reported
greater arthritis-related
lost productive time
(24.4% vs. 13.3%) than
those without flare-ups
None in chi-square
analysis
Age, gender
Adjusted annual output per 3

person was 4% lower for
those with arthritis.
Hourly output was not
significantly different
Age, gender, ethnicity,

job characteristics,
health plan, other
health conditions
Overall
scorea
Findings
Controlling for
confounders
556
Longitudinal study of
7,055 employed
respondents of
Health and
Retirement Study
Studies
included in
Wahlqvist
(2006
review)
[76]
Mental health
Adler (2004)
[77]
Observational study
of 69 patients with
dysthymia
compared to 175
controls
Review of 8 studies of
GERD and
productivity
Gastro-intestinal
Dean (2005)
2-phase survey of
[75]
1,776 bank
employees
Tunceli
(2005) [74]
Study design/
population
Table 1 continued
WLQ measured
presenteeism. Part of
Health and Work
Study
None in the
bootstrapping
analysis
Age, gender, medical

comorbidities
Non-parametric statistics
(bootstrapping) used to
calculate confidence
interval for differences
in productivity
impairments
Linear regression to
analyze measures of
presenteeism for
patients compared to
controls
Patients with dysthymia

had significantly
greater presenteeism
(6.3% vs. 2.8%)
compared to controls
Employees with IBS

reported a 15% greater
loss in work
productivity due to
gastrointestinal
symptoms than
employees without IBS
Presenteeism losses due
to GERD ranged from
640% in these studies,
equating to 2.4
16.6 hours of work loss
per week
Among both men and

women, individuals
with diabetes were
significantly more
likely (OR = 3.6) to
have a work limitation
than non-diabetics
Gender, health status,

job characteristics
Probit regression
estimated effect of
diabetes in wave 1 on
health-related work
limitations in wave 2
Asked if subjects had any

impairments or health
problems at the time
of the interview that
limited the kind or
amount of paid work
they could do
Work Productivity and
Activity Impairment
Questionnaire
(WPAI) to assess
presenteeism. Rome II
criteria used to assess
IBS
Seven studies used
WPAI or GERDspecific WPAI
Findings
Controlling for
confounders
Measurement
Overall
scorea

557
123
123
Measurement
Controlling for
confounders
Findings
Overall
scorea
Adler (2006)
[78]
Longitudinal
observational study
of 286 depressed
patients compared
to 2 control groups
4
Regression models of five Age, gender, work and Depression group had
WLQ used to assess
health characteristics
significant work
condition groups
presenteeism and
limitations compared to
(dysthymia, major
Patient Health
controls. Even after
depressive disorder,
Questionnaire-9
patients were deemed
double depression,
measured depression
clinically improved,
control, and controls
at 6, 12 and 18 months
work limitations
with rheumatoid
remained
arthritis)
3
Annual at-work
Regression analysis of at- Age, tenure, gender,
Kleinman
Retrospective analysis ICD-9 data used to
productivity was
marital status,
work productivity
classify employees
(2005) [79]
of large multisignificantly lower for
ethnicity, job
(units processed per
with bipolar disorder
employer database
employees with BPD
characteristics, region
hour worked)
(BPD) and other
compared to all other
mental health
groups
conditions. On-the-job
productivity was
objectively measured
for manufacturing
employees
4
Productivity was most
Part of Health and Work ANOVA used to analyze Age, gender
Lerner (2004) Longitudinal
impacted by depression
condition-group
Study. The WLQ
[31]
observational study
severity. Certain jobs had
differences in the four
measured
(N = 389) of
greater association with
WLQ scale scores.
presenteeism. Mental
patients with
depression-related work
Linear regression
health assessed by
dysthymia and/or
limitations than others
models tested the
screening process and
depression
effects of certain job
PHQ-9
compared to
characteristics
controls
Study design/
population
Table 1 continued
558
Burton
(1999) [16]
HRA study of 564

telephone
customer-service
reps
Studies of multiple health risks

Boles (2004) HRA study of 2,264
[82]
employees
nationwide
Musculo-skeletal
Hagberg
Questionnaire taken
(2002) [81]
by 1,283 Swedish
computer workers
Lerner (2004) Six-month study

[80]
(N = 451) of
depressed
employees
compared to
controls
Study design/
population
Table 1 continued
On-the-job productivity
measured objectively
WPAI used to measure

presenteeism. On-line
HRA collected health
risk data
Presenteeism assessed
by: have the
musculoskeletal
symptoms influenced
your productivity at
computer work during
the preceding
month? If yes, asked
to report % decrease
Age, work conditions,

education, lifestyle
factors
Chi-square analysis of
failure to attain
productivity standard
by health risk
None in chi-square
analysis
Greater productivity losses

were seen as the number
of risks increased.
Significant presenteeism
losses seen among those
with poor diet,
overweight, lack of
exercise, stress, and lack
of emotional fulfillment
Employees with more
health risks had worse
productivity than those
with fewer risks
Workers reporting a
productivity loss due to
musculoskeletal
problems estimated
17 hours lost per month
Patients with dysthymia or 4

depression lost between
6 and 10% productivity
compared to 4% for
healthy controls. All four
WLQ sub-scales were
significantly worse
compared to healthy
controls
Age, gender, medical

comorbidities
Overall
scorea
Findings
Controlling for
confounders
ANOVA compared mean ANOVA controlled for

age, gender, other
productivity loss for
health risks
people with and
without each risk
factor. Regression
analysis studied impact
of number of health
risks
Proportional hazards
model
Part of Health and Work ANOVA tested

differences between
Study. WLQ assessed
the groups
presenteeism. Patientadministered
depression screening
instrument used to
assess dysthymia and
major depressive
disorder
Measurement

559
123
123
Stewart
(2003) [18]
American
Productivity Audit
of 28,902 workers
nationwide
WHI used to assess

presenteeism and
health risks
Survey of 683 workers Telephonic HRA to

assess health risks,
questions from the
HPQ measured
presenteeism
Pronk (2004)
[84]
health risks and lost
productive time
Demographic,
occupational,
employment
characteristics and
other health risks
4
Moderate and vigorous
exercise levels, better
cardiorespiratory fitness
and lower BMI were
associated with improved
work outcomes
compared to others
Smokers were twice as
3
likely to report lost
productive time than
non-smoking workers
Age, gender, baseline

Repeated measures
risks
regression model of
presenteeism at time 1
and time 2 and risk
change
Age, sex, education
exercise,
cardiorespiratory
fitness, and weight with
presenteeism
Online HRA measured

health risks; WPAI
used to measure
presenteeism
Change study of 500

wellness program
participants
Pelletier
(2004) [83]
4
As the number of health
risks increased or
decreased over time,
there was a
commensurate change in
the percent of employees
reporting a limitation
and in the percent
productivity loss. Each
health risk was
associated with a 1.9%
change in productivity
loss
Employees who reduced at 4
least one risk factor
improved presenteeism
by 9%
Age, gender, baseline

health risks, baseline
medical conditions,
baseline productivity
loss
Regression model of the

relationship between
changed health risks
and changed
productivity loss
Longitudinal study
of change in
presenteeism
among 7,026 twotime HRA
participants
Subset of WLQ used to

measure presenteeism
among these bank
employees
Overall
scorea
Findings
Controlling for
confounders
Measurement
Burton
(2006) [55]
Study design/
population
Table 1 continued
560
Panel Study of
Income Dynamics
of 4290 employed
adults
Tunceli
(1999) [87]
Physical activity
Burton
HRA study of 5,379
(2005) [88]
employees at
corporate locations
with fitness centers
Random national
telephone survey
of 7,472 employed
adults
17,952 employed
adults from NHIS
2002 dataset
Ricci (2005)
[86]
Overweight
Hertz (2004)
[85]
Study design/
population
Table 1 continued
Subset of WLQ
measured
presenteeism. Fitness
determined by being a
member of the
corporate fitness
center
Presenteeism measured
by: Do you have any
physical or nervous
condition that limited
the type or amount of
work you can do?
Logistic regression
models comparing
presenteeism among
fitness center
participants and nonparticipants
Age, gender, health

risks, work location
Overall WLQ score was

2
significantly better for
participants than nonparticipants. Nonparticipants significantly
more likely to report
work limitation on 3 of 4
WLQ domains
3
Obesebut not
overweightworkers
were significantly more
likely to report a work
limitation than normal
weight workers
2
Overweight and obese
women were significantly
more likely to report a
work limitation
compared to normal
weight women. Results
for men were not
statistically significant
Age, gender, education,
salary, region,
smoking, alcohol use
Overall
scorea
Obese workers significantly 3

more likely to report a
work limitation (6.9%
compared to 3.0% for
normal weight workers),
similar to the effect of
20 years of aging
Findings
Age, gender
Controlling for
confounders
Age, gender, smoking,

Multivariate probit
exercise, selfmodels of effect of
reported health
obesity in 1986 on work
limitations in 1999
Weighted prevalence of
NHLBI BMI criteria
work limitations
used to assess weight
estimated and
status. Work limitation
compared among four
determined by: are
weight categories
you limited in the kind
or amount of work you
can do because of a
physical, mental, or
emotional problem?
Logistic regression to
WHI used to assess
model the odds of
health and
reporting any lost
productivity
productive time
Measurement

561
123
123
Telephonic HRA to
assess health risks,
questions from the
HPQ measured
presenteeism
Survey of 683
workers
4
Moderate and vigorous
exercise levels, better
cardiorespiratory fitness
and lower BMI were
associated with improved
work outcomes
compared to others
Age, sex, education
Regression analysis
of exercise,
cardiorespiratory
fitness, and weight
with presenteeism
Overall
scorea
Findings
Controlling for
confounders
Score is sum of 1 or 0 assigned to study design, statistical analyses, outcome measurement and controlling for confounders. Highest possible score is 4
Pronk (2004)
(also
shown
above) [84]
Measurement
Study design/
population
Table 1 continued
562
Arthritis
Chronic pain
Diabetes
Gastro-intestinal
Mental health
Musculoskeletal
Studies of
multiple
health risks
Exercise
Overweight
Studies of
multiple
health
conditions
Allergy
Consistency
of results
This area of research is strong. Studies are methodologically strong and show
that a variety of health conditions are associated with presenteeism. As
number of conditions increases, so does likelihood and magnitude of
presenteeism
Only three studies but quality is high with valid measurement of presenteeism.
Consistent findings that allergies negatively impact workplace productivity
Lots of research, particularly on rheumatoid arthritis. Studies are moderate to
high quality. Many studies are in patient populations rather than the
workplace setting
Only two studies in this area so consistency of results cannot be assessed. One of
two studies did not control for confounding variables
Weak area because only two studies of moderate quality. Diabetes is gaining in
prevalence and is worthy of more study regarding impacts on presenteeism
Lots of investigation in this area, likely due to interest of pharmaceutical
companies. Quality is high and results show that gastro-intestinal problems
are associated with presenteeism
Research on this topic is of high quality with consistent results showing
association with presenteeism for a variety of mental health conditions
Only one study on this topic despite large body of research on musculoskeletal
pain and other workplace outcomes. Study did not use validated measure of
presenteeism
High quality area of research consistently showing that those with greater
numbers of health risks have more presenteeism compared to workers with
few health risks
Too few studies specifically on exercise. Fitness center study did not measure
actual exercise levels
Quality of studies is moderately high but only three specifically on weight. Two
of three studies show that obese workers have greater likelihood of
presenteeism than normal weight workers. Third study found this for women
but not significant result for men
Notes
Overall
scorea
Overall score of topic area is sum of 1 or 0 assigned to quality of individual studies, number of studies and consistency of results. Highest possible score is 3
Number
of
studies
Quality of
individual
studies
Table 2 Summary of topic areas

563
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564
Results
Studies of Presenteeism and Multiple Health Conditions
Impact: Health conditions such as diabetes, depression and arthritis have been found to
be associated with productivity losses at the worksite and have been the focus of the
bulk of presenteeism research so far [53]. Quantity of studies: A total of seven studies
were reviewed in depth [53, 5863]. Quality of research: The literature covering
presenteeism and multiple health conditions is relatively strong. For the most part, the
seven studies are methodologically strong and show that a variety of health problems
are associated with decreases in productivity at work. Results consistently show that
individuals with multiple health conditions report greater presenteeism than those with
few or no conditions.
Two nationwide studies identified the percent of workers with chronic health
problems who experience presenteeism. Results ranged from 22% of respondents with
some time lost [60] to nearly one-third of adults whose health problems interfered with
their work tasks [61]. A study at a British university found that 40% of employees with a
self-reported chronic illness reported a work limitation in at least one of three areas
(physical, cognitive and social) [62].
Additionally, studies often measured the impact of each additional chronic condition.
One found that each additional chronic condition reported by an individual was
associated with significantly higher odds of reporting a work limitation on the physical,
psychosocial and environmental scales of presenteeism [61]. At Dow Chemical
Company, the magnitude of work impairment increased with the number of conditions
reported by 5,369 employees in five company locations who participated in an on-line
survey which included the Stanford Presenteeism Scale (SPS) and the Short-Form
Health Survey (SF-36) [58].
Studies of Presenteeism and Specific Health Conditions
Allergies
Impact: Allergic disorders are as common among the US workforce as back pain and
hypertensionaffecting about 12% of working women and 10% of working men [90].
Seasonal allergies have been shown to have an association with workplace productivity.
Quantity of studies: Three peer-reviewed studies were found on the topic of allergies and
presenteeism [21, 64, 65]. Quality of research: The quality of these studies is moderate to
high. Each of the studies employs a good design and valid measurement of the variables
of interest. They are consistent in their findings, that allergies have a negative impact on
workplace productivity. As will be discussed in a later section, several studies have
investigated the impact of allergy medications on the ability to mitigate this impact on
productivity.
In one study of telephone customer service operators, objective measures of
productivity (handle time of phone calls and time taken between phone calls) were
compared against ragweed pollen levels during the study time period. A stepwise
decline in productivity was seen as pollen levels increased [21]. A study of manufacturing company employees also found that all health and productivity measures (general
health, physical health, vitality, mental health, overall effectiveness at work, ability to
work required hours, concentration, ability to handle workload, ability to work without
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mistakes, ability to bend and twist and days less than 100% resulting from allergies/
asthma) grew worse as allergy symptom increased [64]. In a study of more than 8,000
employees at 47 locations, those with allergic rhinitis reported being unproductive 2.3 h
per day when experiencing symptoms [65].
In the study of customer service operators, those taking medication for their allergies
had significantly higher productivity than the no-medication group [21], indicating the
importance for receiving appropriate treatment for this condition. In certain occupations, the sleep-inducing effects of some antihistamines can have serious consequences.
An Australian study of commercial truck drivers found that the incidence of accidents
increased significantly among drivers who used antihistamines to treat allergy symptoms
[91].
Arthritis
Impact: Arthritis is one of the most common chronic conditions in the U.S. [92] and has
received much attention in presenteeism research. Some of the research in this area has
been conducted in the medical setting, such as physicians offices. These types of studies
often measure productivity both on-the-job and in unpaid capacities, such as the ability
to do housework [93]. Quantity of studies: Five publications were found. Two of them
were literature reviews on the topic of rheumatoid arthritis. Quality of research: The
quality of the individual studies to date has been high. Of the primary reports reviewed
here, only one was conducted at a corporation. The others were large-scale database
analyses or nationwide telephone surveys. While those studies certainly have merit,
more work in this area needs to be done in worksite settings to ascertain the impact to
employers.
In the literature reviews of rheumatoid arthritis and work outcomes, authors found
that that work loss occurs early in the course of the disease but that interventions and
appropriate treatment may prevent the high rates of loss of employment that is often
seen among these patients [66]. A systematic review of 38 studies measuring work
disability, absenteeism and presenteeism did not include any studies that quantified the
effect of arthritis from an employer point of view; they were all from the patients
perspective [67].
Individuals with rheumatoid arthritis are often unable to work, which may limit the
number of employees available for study in terms of presenteeism at any given
employer. However, a multi-employer database found arthritis or other joint conditions
affected 15.5% of employees at some time during a 4-year study [69]. This is similar to
the 14.7% prevalence found in a random telephone sample of employed US adults [70]
and 15% of employees with arthritis in a financial services corporation [68].
Arthritic workers with pain exacerbations in the previous 2 weeks reported greater
arthritis-related lost productive time (24.4% vs. 13.3%, P < .01) than workers without
exacerbations [70]. The greatest impact on productivity was found in the physical work
domain of the WLQ [68].
Chronic Pain
Impact: Pain is a feature of many medical problems and is a major driver of increased
medical costs and utilization. A telephone survey of nearly 29,000 working adults using
the Work and Health Interview estimated that pain from headaches, arthritis, back pain
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and other musculoskeletal problems caused productivity loss among 13% of the U.S.
workforce at a cost of $62.1 billion per year [72]. A total of 76.6% of this cost was
attributed to presenteeism and the remainder to absenteeism. Quantity of studies: Only
two studies on chronic pain and presenteeism were found in this review [71, 72]. Quality
of research: With only two studies, the consistency of results cannot be assessed. One of
the two studies did not control for any confounding factors so the quality of literature in
this area is low. Much work still needs to be done in the area of chronic pain and
presenteeism.
When comparing employees based on the severity of their pain, authors found that
the ability to perform work on each of the four WLQ subscales (time, output, mentalinterpersonal and physical) was impacted more as pain severity increased [71].
Moreover, a measure of overall effectiveness at work was significantly impacted by
the presence of pain among employees. Employees experiencing pain were significantly
more likely to be smokers, overweight, at risk for alcohol use, and be sedentary
compared to the employees without pain [71]. This study provides evidence for the
importance of worksite health promotion programs that have typically addressed those
risk factors.
Diabetes
Impact: Diabetes-related productivity losses have been estimated to be nearly half of its
associated medical costs ($40 billion compared to $92 billion in the U.S. in 2002) [94]. In
addition, the increased prevalence of diabetes among younger individuals means a
larger impact for employers in the future [95]. Quantity of studies: This literature review
found only two studies specifically dealing with diabetes and presenteeism [73, 74].
Quality of research: The individual studies reviewed here were found to score
moderately well based on study design, statistical analyses, outcome measures and
controlling of confounding variables. As a topic, the research on diabetes and
presenteeism is weak. More studies using validated presenteeism instruments are
needed to assess the impact of this medical condition which is gaining in prevalence and
likely has a large impact on workplace outcomes.
Longitudinal data from the Health and Retirement Study were used to investigate
the relationship between diabetes and productivity among employed adults aged 5161
[74]. Among both men and women, the presence of work limitations was significantly
more likely (OR = 3.6) among individuals with diabetes compared to those without.
Another study of employees with type 2 diabetes found similar results [73]. That is,
diabetic employees showed a reduction in work productivity compared to non-diabetics.
This reduction increased along with the duration of a persons diabetes.
Gastro-intestinal Conditions
Impact: Digestive diseases are the cause of a significant burden on many Americans and
results in more than $40 billion of health care expenditures each year [96].
Gastro-intestinal conditions such as irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD), have also received a fair amount of attention in the
presenteeism literature. This may be due to the potential benefits of pharmaceutical
treatments which have become available in recent years. Quantity of studies: While
there is only one study on IBS identified in this review, there were eight studies of
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gastroesophageal reflux disease reviewed by Wahlqvist et al. [76]. Quality of research:

The quality of these studies is generally quite high. Therefore this topic area is rated
with a high score.
Versions of the WPAI have been created specifically for use with patients with IBS
[46] or GERD [97]. Initially, most research on IBS was on patient populations, so Dean
et al. examined IBS in an employed population and measured presenteeism with the
WPAI. Employees with IBS reported work productivity losses of 21% because of GI
symptoms, compared to 6% among employees without IBS [75]. In a review of GERD
study results, presenteeism losses due to GERD ranged from 6% to 40%, estimated at
2.416.6 h of work loss per week [97].
Mental Health
Impact: The National Comorbidity Survey found that 59% of the 30 million U.S. adults
with lifetime prevalence of major depressive disorder (MDD) were severely impaired in
their ability to perform social roles and, on average, were unable to work 35 days in the
past year [98]. Furthermore, researchers estimated that $32 billion in lost productive
work time is attributed to depression [99]. Quantity of studies: Five studies on this topic
were found. Quality of research: The research in this area is very high quality,
particularly the studies published by Adler et al. [77, 78] and Lerner et al. [31, 80]. Each
of their studies achieved the high score while another study in this area received a
moderate to low score. Overall, the research in this topic area also received a high score
due to the quality of the individual studies, the relatively large number of studies and
the consistency of the results.
When 69 patients diagnosed with dysthymia but not MDD were compared to 175
depression-free controls, the patients had significantly greater on-the-job productivity
loss (6.3% vs. 2.8%, P < .001) compared to controls, as measured by the WLQ [77].
While absence rates were not significantly different, patients had less stable work
histories and a greater frequency of significant problems at work. In a study combining
patients with dysthymia and MDD presenteeism losses were between 6% and 10%
compared to 4% among the healthy controls [80]. Depressed patients were significantly
limited in their ability to perform mental and interpersonal tasks, time management,
and total work output (all P < .001) [80].
The effects of depression on productivity get worse as the severity of depression
increases [31]. Furthermore, productivity at some types of jobs was impacted more by
depression than other jobs [31]. Depressed individuals in a sales, service, or support job
were impaired in their ability to handle mental and interpersonal demands compared to
controls. The WLQ scales of time and output were significantly worse when employees
had jobs involving judgment and communication skills. A high level of interaction with
customers was associated with poor mental-interpersonal and physical scale scores [31].
In another study, WLQ-measured work limitations persisted even after employees
depression symptoms improved [78].
Bipolar disorder (BPD) is a serious mental health issue affecting about 5.7 million
American adults in a given year [97] and is more prevalent in the working ages of 18 to
54 than in older age groups [100]. In a manufacturing setting, the association of BPD
with presenteeism was measured in terms of the number of units processed per hour
worked using real output data [79]. Results showed that employees with BPD processed
significantly fewer units per year compared to healthy employees but that their hourly
productivity rate was not statistically different.
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Langleib and Kahn [101] point out that many corporations do not yet understand the
high presenteeism cost of mental health issues among their employees. They reason that
it is crucial to provide quality mental health care benefits to help employees and to
moderate costs, particularly since it has been shown that those who receive appropriate
care for their anxiety or depression have less disability and greater productivity.
Musculoskeletal Problems
Impact: The studies in the literature focusing on presenteeism and musculoskeletal
injuries is surprisingly sparse. There is a plethora of information related to return-towork and injury prevention. In an effort to begin measuring work loss, a 16-item version
of the WLQ was validated and assessed in a group of employees reporting
musculoskeletal pain. The instrument did show signs of validity and reliability although
the authors raised some concern about the output demand scale of the WLQ [102].
Quantity of studies: Only one presenteeism study of moderate quality investigating
musculoskeletal problems was found in this review [81]. Quality of research: This studys
lack of a validated presenteeism measurement and the use of a single question to assess
work limitations point to the need for more research in this area.
Hagberg and colleagues asked Swedish computer workers if musculoskeletal
symptoms influenced their productivity during the preceding month [81]. If they
answered yes, employees were then asked to estimate the percentage reduction in
productivity compared with the month before. These workers estimated that the mean
loss of productivity among those with musculoskeletal complaints amounted to nearly
17 h per month, exceeding the loss due to sickness absence. However, the 1-month
recall period in this study is relatively long compared to the presenteeism instruments
used in other studies, potentially introducing a large recall bias. Stewart and colleagues
tested three versions of the WHI with varying recall periods and determined that
2-weeks may be the best for minimizing reporting error [103].
Studies of Presenteeism and Multiple Health Risks
Impact: Several studies have established that health risks are associated with
productivity losses, both in terms of absenteeism [1114] and presenteeism [16, 65, 82,
104, 105]. Presenteeism was measured objectively in a study of telephone customer
service representatives [16]. This study demonstrated that health risks not only have an
impact on days lost from work but also on the loss of productivity while at work. As the
number of health risks increased, the employees productivity decreased [16]. Quantity
of studies: Six studies were located in the literature search. Quality of research: The
quality of research in this area is high. It has been demonstrated by the six studies
reviewed here that the health risks that have long been associated with health care costs
and increased risks of disease are also associated with workplace limitations. In general,
the more health risks an individual has, the greater the impact on their workplace
productivity. This line of research provides impetus to organizations to help employees
be as healthy as possible through the promotion of healthy lifestyle behaviors.
In a study of 2,264 employees of a large national corporation, individuals with more
health risks reported greater productivity losses [82]. Of the 10 health risks studied
(poor diet, BMI, cholesterol, exercise, stress, preventive services, fulfillment, blood
pressure, smoking, diabetes and alcohol use) the odds of any productivity loss were most
significant for individuals with diabetes and stress [82]. Results from the American
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Productivity Audit also found that smokers were twice as likely to report lost productive
time than non-smokers [18].
Three risk factors for cardiovascular disease, physical activity, cardiorespiratory
fitness, and obesity, were studied to test their association with work performance and
interpersonal relationships with coworkers [84]. Moderate and vigorous levels of
physical activity were associated with higher overall job performance compared to
sedentary employees. Better cardiorespiratory fitness was also associated with a higher
quantity of work performed and extra effort exerted while obesity was associated with a
lower level of getting along with co-workers and a higher number of work loss days [84].
While it was shown several years ago that changes in health risks are associated with
changes in health care costs [106, 107], that association was only recently studied in the
workplace outcome of presenteeism [55]. As the number of health risks (as measured by
an HRA) increased or decreased over time, there was a commensurate change in the
percent of employees reporting any workplace limitation and the percent productivity
loss (as measured by a short version of the WLQ). Each health risk changed either up or
down was associated with a 1.9% increase or decrease in productivity loss. Another
study examined the association between changes in health risks and changes in
productivity as measured by the WPAI-GH [83]. In this study, employees who reduced
one risk factor improved their presenteeism by 9% and reduced their absenteeism by
2% after controlling for a variety of factors.
Studies of Presenteeism and Specific Health Risks
Overweight
Impact: Obesity, a key risk factor for many health conditions, is extremely costly for
employers. Health problems attributed to obesity [88, 108111] are reportedly costing
U.S. businesses $12.7 billion directly [112] and $100 billion indirectly [113, 114].
Furthermore, the obesity epidemic may be responsible for an increase in the disability
prevalence rates [115, 116], among Americans as the onset of obesity and diabetes at a
younger age may impact disability rates [116]. Quantity of studies: While much research
has been done to assess the health care cost impact of obesity to U.S. employers, only
three studies have measured the association with presenteeism. Quality of research:
While the study methodologies are sound, none of the three studies reviewed here used
a validated presenteeism instrument and therefore the quality of research in this area is
low to moderate.
The NHANES III dataset was used to examine the association between obesity,
cardiovascular risk factors and work limitations among employed individuals [85]. It
was reported that obese workers (BMI 30 kg/m2) had the highest prevalence of
work limitations [6.9% vs. 3.0% among normal-weight workers (18.5 kg/m2 BMI
24.9 kg/m2)]. When individuals were classified by age, it was found that obesity has a
similar effect on worker limitations as 20 years of aging. The weakness of this study is
that workplace limitation was only measured by a single question (Are you limited in
the kind or amount of work you can do because of a physical, mental, or emotional
problem?) rather than a validated presenteeism measure.
Lost productive time was examined in overweight and obese individuals in a random
national telephone survey of adult U.S. workers. Obese workers (BMI 30 kg/m2) were
significantly more likely to report lost productivity in the previous 2 weeks than normal
weight workers [18.5 kg/m2 BMI 24.9 kg/m2 (42.3% vs. 36.4%, P < .0001)] [86].
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Finally, data from the Panel Study of Income Dynamics also found that, among
employed women, being overweight or obese was associated with increased work
limitations compared to normal weight women [87]. The results for men were not
statistically significant. However, this study did not use a validated instrument for
measuring work limitations, rather they inquired about any physical or nervous
condition that limited the type or amount of work.
Physical Activity
Impact: A sedentary lifestyle is associated with higher risks of overweight, cardiovascular disease, some cancers, and all-cause mortality [117, 118]. Given the large body of
research on physical activity and health care costs, it is surprising that so few studies to
date have specifically measured presenteeism related to physical activity. Quantity of
studies: Two studies were found. Quality of research: The quality of presenteeism
research in this area is low. There are too few studies to assess consistency of results and
the quality of the individual studies is relatively low.
The association between corporate fitness center participation and presenteeism was
investigated among 5,379 employees at corporate sites with fitness centers [119] by using
the eight-item version of the WLQ as part of an HRA used in previous studies to assess
presenteeism [53, 54]. When fitness center participants were compared with
non-participants (and logistic regression controlled for age, gender, location and health
risks) the non-participants were significantly more likely to report a work limitation in
three of the four WLQ domains (time, physical, and output). The overall WLQ score for
work impairment was also significantly greater among fitness center non-participants,
after controlling for confounding variables [119].
Future research should measure the amount of exercise rather than simply comparing
fitness center participants and non-participants since there is likely a wide range of
exercise frequency and intensity among participants. Also, given the low percentage of
workers who utilize fitness centers (16% in this study [119]) and the fact that these
studies are not randomized trials, research is needed to determine whether use of the
centers is the etiology of reduced work impairment, or whether the people who elect to
participate have other characteristics that cause them to have less work impairment.
The second study which measured presenteeism and physical activity was mentioned
previously as it dealt with physical activity, cardiorespiratory fitness and obesity [84].
The results from this study showed that moderate and vigorous levels of physical activity
were associated with higher job performance in terms of work time. Furthermore,
measured cardiorespiratory fitness (VO2max) was also associated with an improvement
in the amount of work performed. More studies of this nature are needed to examine
the link between physical activity levels and presenteeism.
Presenteeism and Pharmaceutical Treatment
As mentioned previously, some health conditions may be associated with large
decrements in on-the-job productivity while their medical care cost may be relatively
low. Examples of such possible conditions are migraine headaches and allergies.
Fortunately, many pharmaceutical agents, whether used for prevention or treatment,
are quite effective against many of these conditions. A review of studies showing the
association between pharmaceuticals and worker productivity was published by Burton
et al. [120]. Treatment for allergies, depression and migraine headache all showed
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associations with improved on-the-job productivity. Many other classes of drugs for
treatment of conditions such as respiratory infection, diabetes, and asthma showed
positive associations with decreased absenteeism, another facet of productivity costs.
The authors note a surprising lack of research on the association between presenteeism
and treatment for arthritis.
Migraine is one condition which exhibits a very large impact on employers. The
prevalence of migraine peaks between the ages of 35 and 45prime working ages for
most people [121]. One study found that 93% of the total economic burden of migraine
in the United States was attributable to work loss while direct medical costs are just a
minor fraction of the total cost [122]. The average migraneur reports losing the
equivalent of 4.9 workdays annually due to presenteeism and 3.2 workdays due to
absenteeism because of migraine symptoms [123].
Studies have found improvement in workplace productivity among migraine sufferers
[124126], those with seasonal allergies [20, 64, 127] and IBS [128]. Results of these
studies support the proactive pharmacologic management of conditions such as
migraine. Education can be provided to employees to optimize self-management and
appropriate use of all types of treatments.
Discussion
Future Research Questions
What is the next step for researchers in this field? Many questions have yet to be
answered. First and foremost is this question: is health related presenteeism real?
Intuitively, almost everyone would agree that one cannot be fully productive each and
every minute of the work day. However, in many jobs it is impossible to know when
work is not getting done (such as in a knowledge-based job). In some cases another
employee may pick up the slack caused by an unproductive employee. In other cases, if
someone is not performing at 100%, they may make up the work at a later time or take
work home. There are also many reasons for lost productivity which have nothing to do
with health including time wasted on e-mail or surfing the Internet, personal issues, and
talking with co-workers or on the phone. Is presenteeism just a cost of doing business
which all companies deal with? Future research in this area should also consider the fact
that presenteeism and absenteeism are often inter-related. Koopmanschap notes that an
intervention might be successful in reducing absence but only at the expense of a rise in
presenteeism if the health problem is not properly dealt with [129].
Many of the self-report presenteeism instruments have undergone validity and
reliability testing, but the quality of those studies varies. All instruments would benefit
from further validation, especially compared with an objective measure of productivity.
Furthermore, it would benefit the field greatly if researchers could agree on standard
presenteeism metrics as has occurred in other fields so that research on presenteeism is
comparable across studies. This is especially evident when one attempts to compare
studies using the different self-reported presenteeism instruments currently available. The
best one can do is to evaluate the relative estimates between those with the risk or
condition of interest and the comparison group.
Another question facing presenteeism researchers is how or even if the results can be
translated to a dollar amount. It is tempting to place a dollar value on the presenteeism
results in any given study. Many studies have presented very large presenteeism costs
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572
based on their self-reported presenteeism findings. When an employee is only 80%

productive on a given day, for example, does that automatically translate into a loss of
20% of the value of that employee to the companys bottom line? In some jobs this may
very well be the case, but in other jobs that is unlikely. Also, the type of productivity loss
varies (such as the interpersonal domain of the WLQ compared to the physical domain).
Does one type of presenteeism translate to dollars more than another? These are just
some of the critical questions facing the field.
What Can Employers Do?
In the meantime, what can employers do about presenteeism? Whether or not there are
effective treatment options for a given medical condition, employers must implement
educational programs for their employees, to prevent undiagnosed or misdiagnosed
illnesses in the workplace, which will allow employees to better manage their health
conditions. In addition to lower-cost educational programs, it is also necessary for
employers to spend additional money on improving health risks or medical conditions in
order to improve workplace productivity [19, 130134].
Sullivan reported on results of a survey of 60 corporations and found that the use of
productivity information for making health-related decisions was only frequent and
systematic among 14% of respondents [135]. Health and productivity management
(HPM) is the recognition that better management of employee health and its related
impact on productivity outcomes may drive economic growth and profits. Using HPM, it
was found, is made difficult by a lack of data systems, perceived low quality of evidence
and resistance by senior management. However, as time goes by, this strategy will likely
gain more attention and more acceptance [135].
Spending money on appropriate pharmaceutical treatment is likely cost-effective, as
prior research indicates drug treatment for a variety of health conditions reportedly
leads to significant improvement in productivity [120, 136]. Specifically, one study
estimates that the increase in the ability to work which can be attributable to new
pharmaceutical treatments is 2.5 times greater than the cost of those drugs [137].
Corporations should keep this in mind when constructing drug-reimbursement plans.
While it is important for employee health programs to target the highest-risk workers
and the groups with the highest direct and indirect costs, it is of equal importance to offer
program opportunities to the vast majority of employees who are medium or low risk. This
may be a more profitable and successful strategy than the high-risk strategy which has been
in place for three decades [138]. By focusing just on the small percentage of employees who
are at high-risk or have a health condition, the vast majority of an employee population
gets ignored. Taking a more comprehensive population management approach may help
keep healthy employees from becoming high-risk in the future [15].
Conclusions
Research on presenteeism is still relatively new. Most of the review papers that can be
found dealing with presenteeism are about measuring presenteeism. The ability to
accurately and reliably measure presenteeism in the workplace is an important and
necessary first step in establishing the link between health and productivity. However, to
date, there is still no generally accepted best method of measuring presenteeism. While
one or two measurement instruments have become most commonly used, there has
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been no consensus among the many presenteeism researchers about common

measurement tools or metrics, or about their reliability or validity.
So far, no study has been able to unequivocally estimate a total dollar cost associated
with presenteeism for corporations. The first step in this line of research is to study the
types of health risks and health conditions which are associated with presenteeism.
Several of the presenteeism measurement instruments yield results which may be
converted into a dollar amount. However, calculating the cost of presenteeism is still an
abstract concept for many, since there are no receipts or bills to pay when an employee
is experiencing presenteeism as there are with health care costs or other workplace
outcomes like disability or workers compensation. A recent review of 20 presenteeism
survey instruments found that none had been validated for estimating the cost of lost
productivity due to health problems [139].
The current method which many studies use is to convert the percent decrement in
productivity into a number of hours per week that an average individual is unproductive
(for example, if an employees presenteeism is 20%, they are unproductive 8 h out of the
40 h work week). Then multiply that number by the average hourly wage and benefits cost
for an employee and finally multiply that by the number of employees with a given health
condition. However, it is still unclear if those calculations are accurate and whether or not
an employee experiencing presenteeism is truly 0% effective during those hours.
Certain employee population groups have received more attention in the presenteeism literature than others, such as nurses, a frequently-studied financial services
corporation, and manufacturing employees. Also much of the research in this field has
been sponsored by pharmaceutical companies who have a drug solution for the
condition. This is not a major problem but it does somewhat explain the predominance
of studies related to medical conditions and the smaller number of studies related to
health risks and behaviors. With such a diverse workforce today, researchers would be
wise to conduct studies in a broad range of populations, particularly in employees that
deal with information or service occupations, and a broad range of health risks and
medical conditions.
Based on the research reviewed here, it can be said with confidence that many health
conditions are associated with presenteeism. Moreover, health risks also show an
association with presenteeism. The next step for researchers is to tease out the impact of
individual health conditions and risks on this important outcome measure. Certain
health risks or health conditions likely have more of an impact on presenteeism in
certain types of jobs than in others. It will be important to be able to prioritize risks and
conditions so employers know where to target their efforts. Above all, it can be said that
keeping healthy employees healthy is always an effective strategy.
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J Occup Rehabil (2007) 17:547579