Book pp30 - 60 (2013)

Presenteeism
Presenteeism
The Invisible Cost to Organizations
Hesan Quazi
Nanyang Business School, Singapore
© Hesan Quazi 2013
Foreword © Wee Chow Hou 2013
Illustrations © Bulbul Ahmed 2013
Softcover reprint of the hardcover 1st edition 2013 978-1-137-27566-0
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In memory of my beloved parents and the respected sister
Mrs Hamida Ahmed
This Page Intentionally Left Blank
Contents
List of Illustrations xiii

Foreword xvi
Wee Chow Hou
Acknowledgements xix
1 Introduction 1
2 Presenteeism: A Costly Affair for Employers 7
2.1 What is presenteeism? 7
2.2 Sickness presenteeism 9
2.3 Consequences of sickness presenteeism 10
2.3.1 Consequences of sickness presenteeism in
the United States 10
2.3.2 Consequences of sickness presenteeism in
countries other than United States 15
2.4 Non-sickness presenteeism 19
2.4.1 Personal financial difficulties and
presenteeism 19
2.4.2 Family issues 21
2.4.3 Obesity and presenteeism 21
2.4.4 Emotional exhaustion and presenteeism 25
2.5 Summary 25
Notes 26
References 27
3 Absenteeism and Presenteeism 31
3.1 Research findings 32
3.1.1 Organizational pay policy and absenteeism 32
3.1.2 Wage level, relative wage and job position
and absenteeism 32
3.1.3 Substitution of absenteeism by presenteeism 32
3.1.4 Employee race, diversity and absenteeism 33
3.1.5 Absenteeism in Nordic countries 33
3.1.6 National culture and absenteeism 33
3.1.7 Obesity and absenteeism 34
3.1.8 Findings from other studies 35
vii
viii Contents
3.2 Chartered Institute of Personnel and Development

(CIPD) survey results 36
3.2.1 CIPD studies on sickness-related absence and
associated costs 36
3.2.2 Absence rate and the cost of absence 37
3.2.3 Managing absence 38
3.2.4 Impact of health-promotion programme on
absences 40
3.3 Summary 41
Notes 41
References 42
4 Why Do People Go To Work Even When Unwell? 45
4.1 Introduction 45
4.2 Reasons for going to work while sick 45
4.2.1 Work environment 45
4.2.2 Time pressure 47
4.2.3 Employment conditions 47
4.2.4 Psychological issues 48
4.2.5 Evidence from other empirical studies 48
4.2.6 Stress 51
4.2.7 Depression 51
4.3 Long working hours and their possible impact on
employee health and performance 52
4.3.1 Reasons for long work hours 52
4.3.2 Primary motives for spending long hours
at work 52
4.3.3 Employee motives for working long hours 53
4.3.4 Long working hours and risk of heart attack 53
4.3.5 Long working hours and risk of depression 53
4.4 Working-hours trend in a selected number of countries 54
4.5 Working hours in ‘extreme jobs’ 55
4.6 Effects of long work hours on health 56
4.7 Summary 57
Notes 57
References 57
5 Nature and Extent of Presenteeism in Singapore 61
5.1 Cost of presenteeism to organizations in Singapore:
lost productivity by male and female employees 61
5.2 Why do employees go to work despite being sick? 62
Contents ix

5.2.2 Time pressure 63
5.2.3 Employment conditions 63
5.2.4 Psychological issues 64
5.3 Economic impact of presenteeism 64
5.4 Productivity loss due to sickness presenteeism 64
5.5 Hypotheses 65
5.5.1 Work-related factors and sickness presenteeism 65
5.5.2 Overall work effectiveness and sickness
presenteeism 66
5.5.3 Gender differences and sickness presenteeism 66
5.6 Methodology 66
5.7 Descriptive statistics of the sample 67
5.7.1 Demographics 67
5.7.2 Sickness presenteeism 68
5.7.4 Reasons for going to work unwell 68
5.7.5 Health conditions with which respondents
went to work during last three months 68
5.7.6 Effects of health conditions on work
performance 69
5.7.7 Difficulties experienced while at work
despite being sick 69
5.7.8 Work performance during the last three
months 70
5.8 Test of hypotheses 70
5.9 Cost of sickness presenteeism to organizations 71
5.9.1 Overall sickness presenteeism exhibited by
employees 71
5.9.2 Cost of sickness presenteeism to organizations 71
5.10 Discussions 74
5.11 Conclusions and implications 75
Appendix 5.1 Presenteeism survey in Singapore:
Questionnaire 77
Notes 85
References 85
6 Impact of Chronic and Non-Chronic Health Conditions
on Presenteeism: A Study in Singapore 88
6.1 Introduction 88
x Contents
6.1.1 Psychological factors 88

6.1.2 Economic impact of presenteeism 89
6.1.3 Common SP conditions – classifications
and impact 89
6.2 Hypotheses 90
6.3 Methodology 92
6.3.1 Sample 92
6.3.2 Survey measures 92
Appendix 6.1 The general health climate and employees’
attitude towards health management
survey set 93
6.4 Descriptive statistics 98
6.4.1 Respondents’ demographics 98
6.4.2 Survey results 98
6.4.3 Results of tests of hypotheses 99
6.6 Extent of sickness presenteeism in Singapore as
compared to a few selected studies 102
6.7 Sickness presenteeism experienced by managerial
and non-managerial employees 103
6.7.1 Sickness presenteeism reported by managerial
employees 103
6.7.2 Sickness presenteeism reported by
non-managerial employees 103
6.8 Cost of sickness presenteeism to organization 104
6.8.1 Total annual labour cost per employee 104
6.8.2 Cost of sickness presenteeism 104
6.8.3 Cost of sickness presenteeism in Singapore:
summary 104
6.9 Summary and discussions 106
Notes 110
References 111
7 Why Do Employees Go to Work Despite Being Sick?
An Exploratory Study in Singapore 114
7.1 Literature review and hypothesis formation 114
7.2 Work-related factors 115
7.2.1 Job-related factors 115
7.2.2 Work-related factors: organizational culture
and work environment 117
Contents xi
7.2.3 Personal factors 119

7.2.4 Moderating relationships 120
7.3 Summary of the hypotheses developed for testing 121
7.3.1 Job-related issues 121
7.3.2 Organizational culture and work environment
related issues 121
7.3.3 Personal factors 121
7.3.4 Moderating hypotheses 121
7.4 Methodology 121
7.5 Descriptive statistics 122
7.5.1 Demographics 122
7.5.3 Frequency analysis of presenteeism levels by
different categorizations 124
7.6 Results 125
7.7 Discussions 126
Appendix 7.1 Why do employees go to work despite
being sick? survey questionnaire 129
References 140
8 How Should Presenteeism Behaviour Be Managed? 144

8.1 Introduction 144
8.2 Strategies to manage presenteeism behaviour 145
8.3 Research, case studies and survey findings 148
8.3.1 Evaluation of impact of health on employee
outcomes and the return on
well-being investments 149
8.3.2 Possible ways to reduce presenteeism 153
8.3.3 Models on employee ‘well-being’ 155
8.3.4 Research findings: return on investment 156
8.3.6 Total rewards and employee well-being
survey: WorldatWork 157
8.4 Summary 159
Notes 161
References 162
9 Measuring the Costs of Presenteeism 164

xii Contents
9.2 The work impairment measurement instruments 164

9.2.1 Migraine Work Productivity Loss
Questionnaire (MWPLQ) 165
9.2.2 World Health Organization’s Health and
Work Performance Questionnaire (HPQ) 166
9.2.3 Work Productivity and Activity Impairment
(WPAI) Questionnaire 166
9.2.4 The Work Limitations Questionnaire (WLQ) 167
9.2.5 Health Limitation Questionnaire (HLQ) 167
9.2.6 The Work Productivity Short
Inventory (WPSI) 168
9.2.7 American Productivity Audit (APA) 168
9.2.8 Stanford Presenteeism Scale (SPS-6) 168
9.2.9 Health at Work Survey (WHS) 169
9.3 Designing questionnaires and collecting data 169
9.4 Data analysis 169
9.5 Computing the costs of presenteeism 170
9.6 Computations of ‘on-the-job productivity loss’ due
to chronic and acute health conditions 173
9.7 How to customize your own instrument 173
9.8 Discussions 174
Notes 175
References 175
10 Summary and Discussions 178
10.2 Research findings 179
10.2.1 Case Study 1: Northern Food’s ‘Fit4Life’
Campaign 180
10.2.2 Case Study 2: managing changes at Leeds
University, UK 182
10.2.3 Case Study 3: Workwell in action: how the
company is working fitter 182
10.2.4 Guidelines for managers 183
10.2.5 Savings from investments in presenteeism 185
10.3 Conclusion 186
References 187
Index 189
List of Illustrations
Figures
1.1 Conceptual framework 3

2.1 Types of presenteeism 9
4.1 The Octopus model 46
5.1 Hours affected due to health conditions during
the past three months 70
6.1 Percentage of eligible work time lost due to
sickness presenteeism by health conditions 101
7.1 Levels of presenteeism reported by the respondents 123
7.2 Number of hours missed due to primary
health condition 125
7.3 Productivity loss of respondents who went to work
ill ‘frequently/always’ 125
7.4 Presenteeism level by employment sector 126
8.1 Strategies to manage presenteeism 146
8.2 Components of wellness programmme as
conceptualized by WorldatWork 158
Sketches by Bulbul Ahmed
2.1 Employee has flu, sneezing and infecting others 8

2.2 Employee returns to work after an accident 11
2.3 Employee is too sick to work 12
2.4 Employee is affected by depression 13
2.5 Employee worries about the sick child at home 16
2.6 Employee is sick and tired 21
8.1 Employee training on presenteeism 153
Tables
2.1 Productivity losses due to different health conditions 14

2.2 Estimated costs of lost productivity due to
sickness presenteeism 18
xiii
xiv List of Illustrations
2.3 Summary of consequences of sickness presenteeism

reported in various studies excluding the United States 23
4.1 Comparative statistics on worked hours in selected
countries, 1980–2006 56
5.1 Top five effects of health conditions on
work performance 69
5.2 Top five difficulties experienced at work due to
health conditions 69
5.3 Annual labour cost per employee, by industry and
cost component, 2005 71
5.4 Average benefits for each salary range 72
5.5 Total benefits for each salary range and age group 73
6.1 Comparison of common diseases between Australia
and Singapore 90
6.2 List of health conditions examined 91
6.3 Comparison of productivity loss due to sickness
presenteeism 102
6.4 Computations of annual labour cost per employee,
2009 105
6.5 Sample computation of annual labour cost by
employee based on salary range and age bracket 106
7.1 Medical conditions and their association with
sickness presenteeism (in per cent of respondents) 124
9.1 Sample on annual labour cost per employee, by
industry and major cost component 171
9.2 Sample on average benefits for each salary range
(Singapore) 171
9.3 Sample on cost of sickness presenteeism to
organizations 172
Boxes
2.1 ‘Presenteeism’ as defined by scholars 7

2.2 Selected list of interesting publication titles on
presenteeism 8
2.3 Health conditions commonly included in
presenteeism studies 10
4.1 NFID survey result 47
List of Illustrations xv
4.2 Findings from Finnish studies 47

4.3 Findings from NFID survey 48
4.4 Findings from NFID survey 48
4.5 Reasons for going to work sick 50
8.1 Innovations award for the state of Nebraska 144
8.2 An example of a collaborative partnership among
the major stakeholders 146
8.3 Importance of a strategic approach 147
8.4 Intervention steps to build wellness and to improve
business productivity 147
8.5 Impact of wellness program on business: an example 148
8.6 Abridged version of the steps to follow while
analysing the impact of health on performance 150
8.7 Steps in integrated approach in combating
presenteeism 151
8.8 Effective approach to tackling presenteeism 152
8.9 Case study on financial-service company 153
8.10 International Truck and Engine Corporation:
outcomes of the wellness programme 154
10.1 Northern Foods ‘Fit4Life’ campaign 181
10.2 Workwell model and employee well-being 183
Foreword
It is very refreshing that Hesan’s book addresses the emerging concept

called presenteeism. Presenteeism has been viewed from two different
angles: (a) the practice of coming to work despite illness, injury,
anxiety and so on, which results in reduced productivity (called
‘sickness presenteeism’), and (b) the practice of working long hours
without the real need to do so (called ‘non-sickness presenteeism’).
Literature indicates that presenteeism is an emerging issue in
organizations as it involves one of the biggest drains on employee
productivity. Hesan’s book explores the phenomenon of sickness pres-
enteeism and its impact on employees’ productivity and work-related
conditions. More significantly, Hesan highlights the importance of
strategic approaches to managing presenteeism.
In recent decades, studies have revealed a high prevalence of sick-
ness presenteeism among employees. Such employee behaviour hurts
output, quality of work-life and employee health. Unlike absenteeism,
sickness presenteeism among employees is not always noticeable.
Past studies reported that such employee behaviour costs U.S.
companies over USD150 billion a year, Australian businesses AUD25
billion a year, and Singapore businesses around SGD3.7 billion a
year. Some of the common health conditions that have been studied
by researchers include allergy/flu, asthma, diabetes, hypertension,
arthritis, back, neck and spinal problems, migraine headache and a
few others. However, most of these studies have been conducted in
Western societies which do not accurately reflect the prevalence of
sickness presenteeism in other regions and countries in the world.
Considering the huge drain of lost productive hours due to presen-
teeism, this book titled Presenteeism: The Invisible Costs to Employers by
Hesan is indeed an appropriate and timely contribution to the present
stock of knowledge.
In this book, Hesan reports on the outcomes of the three empirical
studies on presenteeism in Singapore. In the first study, he examined
the nature and extent of presenteeism in organizations operating in
Singapore (Chapter 5). In the second study, Hesan and his associates
examined the extent of lost productivity due to ‘chronic’ and ‘acute’
xvi
Foreword xvii
health conditions. It also examined the productivity losses due to

presenteeism by managerial and non-managerial employees in
Singapore (Chapter 6). The third study explored in depth the reasons
for employees’ going to work despite being sick. From the studies
conducted in Singapore it was found that sickness presenteeism is
also prevalent among working adults in this country.
Hesan also discusses the issue of obesity and presenteeism. Experts
suggest that obese employees lose productive time and argue that
obesity causes or aggravates many health problems, both independ-
ently and in association with other diseases. They also concluded
that human obesity has serious consequences on health, including
increased risk of depression, non-insulin dependent diabetes mellitus,
cancer, rheumatoid and osteoarthritis, hypertension and heart
disease. Furthermore, literature indicates that obese workers tend to
incur greater productivity losses than non-obese co-workers. Another
issue that the author raises is the association of employees’ financial
and other non-sickness related difficulties with presenteeism.
From the literature it has been noted that workers are more likely to
go to work ill during economic downturns for job security, financial
reasons, work environment, time pressure, and various other reasons.
Presenteeism may also occur when there is shortage of skilled labour
of specific types in the market.
In the third study, the authors found that a number of
work-related factors (for example, work environment, stress, time
pressure, depression, employment conditions, sense of duty, long
working hour culture and psychological issues) were likely to influ-
ence the decision of employees going to work even when they were
sick. It was also noted that some of the findings from the studies in
Singapore were similar to those conducted in other countries.
Reduction of lost productive time due to sickness presenteeism has
become important in both public health and business perspectives.
In order to reduce presenteeism, employers may consider adapting
certain strategies for their organizations. In Chapter 8 of the book,
the author discusses in some details a number of options that
employers may consider in trying to manage presenteeism, including
health awareness programs, subsidies for general health screening,
and counselling for employees. It is to be noted that the benefits
of reducing sickness presenteeism are mutual where employees can
balance their health and work better, whereas employers benefit
xviii Foreword
through reduced productivity losses and lower costs incurred by

sickness presenteeism. If such goals are achieved, it could ultimately
result in the creation of a healthy and competitive workforce, and a
healthy working environment that contributes to the development
of a strong foundation for organizational performance.
In conclusion, I highly commend Hesan for writing a very well-
researched and thought-provoking book that is both timely and
appropriate, especially at a time when many companies in Singapore
and the rest of Asia are very concerned with workforce productivity.
His findings and suggestions are indeed very valuable, and I strongly
recommend this book to all employers and human resource direc-
tors. It opens up a new and insightful perspective on how a company
should manage its workforce in order to achieve sustainable and
greater productivity.
Wee Chow Hou (C.H. Wee), PhD, BBM, PPA

Professor of Strategy and Marketing
Head, Division of Marketing and International Business
Senior Fellow, Institute on Asian Consumer Insight
(Former Head, Division of Strategy, Management and
Organization)
Nanyang Business School, Nanyang Technological University
Former Dean (1990–1999), Faculty of Business Administration and
Former Director (1990–1999), Graduate School of Business
National University of Singapore
Acknowledgements
I would like to express my gratitude to my beloved wife for her

support and understanding during the past six months while I was
extremely busy writing the book. I would also like to express my
gratitude to my children and their spouses Habib, Farah, Nazia and
Saidur for their encouragement and moral support.
Special thanks are due to Professor Wee Chow Hou, Head, Division
of Marketing and International Business, Nanyang Business School,
Nanyang Technological University, for writing the Foreword.
I would like to thank my division head, Professor Ang Soon, for her
support and encouragement in completing the book.
Thanks are due to my research students, Amanda Lam, Ong Wan,
Tan Rui Zhi, Kenneth for their contribution in completing the first-
ever empirical research on presenteeism in Singapore. I would also
like to thank the Nanyang Business School for granting research
fund (RCC# 21, 2006) for this and another research project.
I would also like to thank Guo SiSi, Jacqueline, Tan Hong Siang and
Tan Hong Ching for completing the second study on presenteeism in
Singapore. Thanks are also due to Yeo Ciau-Er, Chang Hua Lin and
Phua Wei Zheng, Justin for completing the third study on presen-
teeism. I am very grateful to these six former students for agreeing to
share part of their research output to be included in this book.
I am very grateful to Alice Liu for her time in finalizing the manu-
script for submission, without which it would not have been possible
to finish the book on time. Last but not the least, I would also like
express my thanks to Nicholas Yap for editing the manuscript and
Bulbul Ahmed for preparing the sketches for the book.
xix
1
Introduction
Absenteeism at work is one of the most-measured indicators to deter-

mine the health of an organization. This is based on an assumption
that when employees are at work they are being productive. However,
this assumption gives an inaccurate picture of employees’ health and
workplace productivity. In fact, when employees come to work sick
they are unable to work as productively as healthy workers. Experts
in the field argue that to measure the health and workplace produc-
tivity of an organization both absenteeism and the lost productivity
of employees who come to work sick (called as ‘presenteeism’) need
to be included.
Sickness presenteeism is an emerging issue in organizations, as it
entails one of the biggest drains on productivity. Proponents of this
concept argue that, being present in the workplace while ill could
be even costlier than being absent. This book explores the phenom-
enon of sickness presenteeism in different countries and its impact
on employees’ productivity and work-related conditions.
In recent decades, studies have revealed a high incidence of sick-
ness presenteeism among employees (Aronsson et al., 2000; Elstad
and Vabo, 2008; Hansen and Andersen, 2008). It has become a prev-
alent phenomenon among employers and employees in today’s busi-
ness world (Saarvala, 2006). This negatively affects output, quality
of work-life and employee health (Lowe, 2002). Unlike absenteeism,
sickness presenteeism among employees is not always noticeable, as
one cannot easily tell whether the productivity of the employee who
turns up for work is affected by his or her health conditions (Hemp,
2004).
1
2 Presenteeism
U.S.-based studies have reported that sickness presenteeism costs

U.S. companies over USD150 billion a year (Hemp 2004). Another
study has shown that coming to work with migraine/headache
and allergies, costs U.S. organizations USD12 and USD2.8 billion,
respectively, through lost productivity (Burton et al., 2004). Some
of the common health conditions that have been studied by these
researchers are allergies, flu, asthma, diabetes, hypertension,
arthritis, back and neck pain, migraine/headache and a few others.
The reasons for coming to work despite being sick have been iden-
tified by the researchers as being ‘ill prepared’ to be absent due to
sickness, fear of falling behind, reluctance to use sick leave and a
misguided sense of duty.
Most such studies have been conducted in Western contexts that
may not accurately reflect the prevalence of sickness presenteeism in
other regions/countries in the world. In view of this, we undertook
to carry out a series of empirical studies exploring different facets of
sickness presenteeism issues in Singapore. During the period 2008
to 2012, the author with his final-year business students conducted
three studies in Singapore. In the first study, conducted in 2008, 273
working adults responded to the survey. From this survey, it has been
found that sickness presenteeism is prevalent among working adults
in Singapore. The majority of the respondents cited ‘work commit-
ments’ as the main reason for reporting to work despite being sick.
In line with some other studies, this one also showed that female
employees exhibited significantly higher levels of sickness pres-
enteeism than do their male counterparts. Based on our estimate,
approximately 4 per cent of an employee’s annual eligible work
time is lost due to sickness presenteeism. This loss of productivity
amounts to an average cost of SGD2,096 per annum to organizations
for an employee earning a mean annual base salary of SGD36,000.
This translates to a hidden loss of SGD210,000 per annum for busi-
nesses with only 100 employees, and SGD1.05 million for one with
500 employees.
The second study sought to: (a) understand the extent to which
job-related factors such as job demand, job status, and employees’
awareness impact on presenteeism behaviour; (b) determine whether
there were differences in sickness presenteeism between managerial
and non-managerial level employees; (c) whether awareness of health-
related programmes had any impact on sickness presenteeism; and
Introduction 3
(d) compute the detailed breakdown of costs of sickness presenteeism

for selected medical conditions.
For this study, data was collected from 280 respondents, across
various industries and diverse in age, gender, salary, and job status.
The results showed that a job’s demands have a significant positive
relationship with sickness presenteeism. It was also found that there
were significant difference between sickness presenteeism as expe-
rienced by employees holding managerial positions and by those in
non-managerial levels. Health-awareness programs were found to be
inversely related to sickness presenteeism.
Our analyses on the cost of sickness presenteeism revealed that the
most expensive health conditions were headache, cough and influenza.
For instance, an employee who is 50 years old or under and earning a
mean annual salary of SGD27,000 would cost the employer approxi-
mately SGD920 per year if he or she reports to work despite having a
headache. This means that approximately 3.4 per cent of the employ-
ee’s annual salary will be unearned due to this health condition.
The third study was conducted between January and February 2012,
examined the predictors of presenteeism, including ‘work context’
and ‘personal factors’. It also explored the effects of organizational
What?
Who? Presenteeism Why?
How?
Figure 1.1 Conceptual framework

Source: Developed by the author.
4 Presenteeism
culture and personality on presenteeism and examined in-depth

why the Singaporean employees went to work despite being sick.
Literature indicates that reduction sickness presenteeism has
become important from both public health and business organi-
zations. Based on the findings of these and other similar studies
conducted in other countries, employers may seriously consider
ways to reduce sickness presenteeism in their own organizations. For
example, health-awareness programs, subsidies for general health
screening, and counselling for employees are some of the possible
ways that the employers may pursue to reduce sickness presenteeism
in their own organizations. This is to be noted that the benefits of
reducing sickness presenteeism are mutual whereby employees can
balance their health and work better and employers can reduce
productivity losses and other related costs due to sickness presen-
teeism. Experts argue that if such an goals are achieved, this could
ultimately result in the creation of a healthy and competitive work-
force, and a healthy working environment which contributes to a
strong foundation of organizational performances. This book has
been organized around the theme of the three ‘W’s and one ‘H’ (that
is. ‘What’ is presenteeism? ‘Why’ do employees go to work despite
being sick? ‘How’ is presenteeism behaviour to be managed? ‘Who’
should be taking the lead in managing presenteeism behaviour?)
shown in the conceptual framework below (Figure 1.1).
This book has been organized in ten chapters as listed below.
Besides this introductory chapter, Chapter 2 explains what presen-
teeism is, its impact on employee productivity and the equivalent
(but invisible) costs to the organization and the entire economy.
In this chapter, research findings of a number of studies are
presented. As the concepts of ‘absenteeism’ and ‘presenteeism’ are
closely related, Chapter 3 explains the similarities, dissimilarities
and the interrelationships of these two concepts. Some related
research findings in this regard have also been presented. Chapter 4
addresses the issues of ‘Why’ employees go to work despite being
sick. This chapter also cites examples and research findings from
the literature.
Chapters 5 through 7 present the details of the three studies
conducted in Singapore from 2008 through 2012. For example, in
the first Singapore study, the focus was on understanding the nature
and extent of sickness presenteeism (Chapter 5). In this study, using a
Introduction 5
customized questionnaire, data was collected from adult employees in

Singapore. Based on the data collected, a composite (that is, including
all sicknesses) ‘annual eligible work time lost’ figure was computed
using a metric proposed by one of the experts in the field. This figure
was then monetized using the pay- and benefits-related information
of the employees (respondents of the survey) from the government
and other published statistics. In addition, the study also separately
computed the ‘annual eligible work time lost’ by male and female
employees. Details of computations are also reported. Chapter 6
presents the study that investigated the costs of presenteeism in
Singapore. In this chapter the impact of the impact of ‘chronic’ and
‘acute’ health conditions on presenteeism are computed. This study
also compute the cost of presenteeism for each of 11 health condi-
tions, of which 6 (conditions i.e., allergy, asthma, arthritis, anxiety,
chronic back pain and hypertensions) belong to ‘chronic’ health
conditions and rest 5 (i.e., cough, diarrhoea, fever, headache and influ-
enza) belong to acute conditions. In addition, presenteeism costs for
managerial and non-managerial employees were also computed and
contrasted. The third study (reported in Chapter 7) specifically exam-
ined in-depth why Singaporean employees went to work despite being
sick. This book has been organized in 10 chapters as shown below.
Chapter 1: Introduction
Chapter 2: Presenteeism: A Costly Affair for Employers
Chapter 3: Absenteeism and Presenteeism
Chapter 4: Why Do People Go to Work Even When Unwell?
Chapter 5: Nature and Extent of Presenteeism in Singapore
Chapter 6: Impact of Chronic and Non-chronic Health Conditions
on Presenteeism: A Study in Singapore
Chapter 7: Why Do Employees Go to Work Despite Being Sick? An
Exploratory Study in Singapore
Chapter 8: How Should Presenteeism Behaviour be Managed?
Chapter 9: Measuring the Costs of Presenteeism
Chapter 10: Summary and Discussions
References
G. Aronsson, K. Gustafsson and M. Dallner (2000) ‘Sick but yet at work:
an empirical study of sickness presenteeism’, Journal of Epidemiology and
Community Health, LIV (7), 502–509.
6 Presenteeism
W.N. Burton, G. Pransky, D.J. Conti, C.Y. Chen and D.W. Edington (2004)
‘The association of medical conditions and presenteeism’, Journal of
Occupational and Environmental Medicine, XLVI (6), S38–S45.
J.I. Elstad and M. Vabø (2008) ‘Job stress, sickness absence and sickness pres-
enteeism in Nordic elderly care’, Scandinavian Journal of Public Health, 36
(5), 467–474.
C. Hansen and J. Andersen (2008) ‘Going ill to work – what personal circum-
stances, attitudes and work-related factors are associated with sickness
presenteeism?’ Social Science and Medicine, LXVII, 956–964.
P. Hemp (2004) ‘Presenteeism: at work but out of it’, Harvard Business Review
LXXXII (10), October, 49–59.
G. Lowe (2002) ‘Here is body, absent in productivity’, Canadian HR Reporter,
XV (21), 5, 8.
E. Saarvala (2006) ‘Presenteeism: the latest attack on economic and human
productivity’, Human Resources Management, SCS 0987–049, University of
Toronto, Ontario, Canada.
2
Presenteeism: A Costly Affair
for Employers
2.1 What is presenteeism?
The term presenteeism was coined by Cary Cooper, professor of

Organizational Psychology and Health, Lancaster University.
‘Dictionary.com’ defines presenteeism from two different angles: ‘The
practice of coming to work despite illness, injury, anxiety, etc., often
resulting in reduced productivity’; and ‘The practice of working long
hours at a job without the real need to do so’. In fact, various authors
have described the nature and impact of presenteeism differently to
reflect how they view this type of employee behaviour. Some of their
definitions are presented in Box 2.1.
Box 2.1 ‘Presenteeism’ as defined by scholars
• ‘Going to work despite feeling unhealthy’ (Aronsson et al., 2000; Dew

et al., 2005).
• ‘When employees attend work at times when sickness absence is
justified and perform their work at sub-optimal conditions’ (Caverly
et al., 2007).
• ‘The flip side of absenteeism is reporting to work but performing
poorly because of physical or emotional problems which are far more
costly in dollars, productivity and liability. This phenomenon is
known as Presenteeism’ (Milano, 2005).
• ‘Presenteeism, a situation that arises when sick employees drag their
forlorn carcasses into the office and waste everyone else’s time by
hacking their way through their working day on an empty tank’
(Queenan, 2005).
• ‘When people show up for work, sick, injured, stressed or burned out,
there is a drain on productivity’ (Lowe, 2002).
7
8 Presenteeism
The definition given by Aronsson and Dew and their colleagues

(that is, going to work despite feeling unhealthy) is used in this book.
This definition of presenteeism has been employed by many organi-
zational scholars and is also either explicit or implicit in all related
scholarship published in the occupational health literature (Johns,
2010).
It has been noted that scholars have been using interesting and
thought-provoking titles to their articles on the subject, a sample of
such titles are presented below in Box 2.2.
Box 2.2 Selected list of interesting publication titles on presenteeism
• ‘Present in body, absent in spirit’. (Klobucher, 2011)

• ‘Presenteeism: a new problem in the work place’. (Ramsey, 2006)
• ‘Presenteeism: At work but out of it’. (Hemp, 2004)
• ‘Being there: Can coming to work be a risk’? (Milano, 2005)
• ‘Quality and bottom line can suffer at the hands of the working sick’.
(Ruez, 2004)
• ‘Present and Infect’. (Whysall, 2007)
• ‘Here in body, absent in productivity’. (Lowe, 2002)
Sketch 2.1 Employee has flu, sneezing and infecting others

Presenteeism: A Costly Affair for Employers 9
Presenteeism
Sickness Non-sickness
presenteeism presenteeism
Figure 2.1 Types of presenteeism
As indicated earlier, presenteeism refers to two different types of

employee behaviours. The first type is sickness presenteeism, which
is related to situations when employees come to work with health
or other physical/mental conditions that reduce their on-the-job
productivity. The second type is termed non-sickness presenteeism,
when employees come to work while experiencing life conditions
that are not related to sickness (for example, personal financial diffi-
culties, stress, perceived work-place pressure, legal or family prob-
lems) and performing at below capacity (Milano, 2005). Non-sickness
presenteeism can also be observed when employees spend time at
work for personal matters. For example, Castle (2008) reported that
employees spend about 2.5 to 5 hours per week at work resolving
personal issues.
2.2 Sickness presenteeism
Studies on the phenomenon of sickness presenteeism have become

increasingly widespread. Sickness presenteeism is defined as
‘on-the-job productivity loss that is illness related’ and describes
situations in which employees are physically present at work but
are not fully engaged (Heinen, 2007; Hemp, 2004). Aronsson et al.
(2000)1 describe the phenomenon as one in which people go to their
jobs despite ill health when they ideally require rest and absence
from work. Such behaviour relates to the notion of health and
choice (Dew et al., 2005). The concept of sickness presenteeism rein-
forces the assumption that employees do not take their work lightly
10 Presenteeism
and that the majority of them would like to continue working if

they could (Hemp, 2004). Hemp also argues that illness at work
may severely decrease productivity, making sickness presenteeism
a costly affair for employers. Researchers have identified a number
of health conditions that contribute significantly to presenteeism,
a sample list of which is presented in Box 2.3. The consequences of
sickness presenteeism in terms of productivity loss are discussed in
Section 2.3.
Box 2.3 Health conditions commonly included in presenteeism studies
1. Allergies or sinus pain

2. Arthritis
3. Diabetes
4. Heart disease
5. Hypertension
6. Migraine/Headache
7. Asthma
8. Chronic lower back pain
9. GERD (Acid Reflux disease)
10. Dermatitis or other skin disease
11. Flu in the past two weeks
12. Depression
13. Cancer
14. Respiratory disorder
Sources: Medibank (2007), Mayo Clinic (2008), Goetzel et al. (2004) and Hemp (2004).
2.3 Consequences of sickness presenteeism
2.3.1 Consequences of sickness presenteeism in the

United States
Over the past decade a number of studies have been published on
the cost to organizations of sickness presenteeism, and following are
summary findings from selected articles.
In 2002, Lockheed Martin, an American global aerospace, defence,
security, and advanced technology company, commissioned a pilot
study to assess the impact on productivity of 28 selected medical
conditions of their workers. Researchers from Tufts–New England
Medical Center undertook the study and estimated the annual
cost to Lockheed in lost productivity for those 28 conditions to be
approximately USD34 million2 a year (Hemp, 2004).
Sketch 2.2 Employee returns to work after an accident
Stewart et al. (2003) launched the American Productivity Audit3 to

have an understanding of the impact of health conditions on the U.S.
workforce and quantified the impact of health conditions on the work
of 28,902 adults. The authors measured lost productive time (LPT)
for personal and family health reasons and expressed it in hours and
dollars. Health-related LPT was found to cost employers USD225.8
billion per year (i.e., USD1,685 per employee per year) of which 71
per cent was explained by reduced performance at work whereas,
family health-related work absence accounted for 6 per cent of all
health-related LPT. The study found that LPT varied substantially by
occupation. For example, workers in architecture and engineering
occupations reported the lowest mean LTP (1.35 hours per week).
In contrast, those in personal care and service, building grounds
maintenance and installation and repairs reported LPT per week
that was more than 70 per cent higher than those in occupations
with the lowest LPT. The authors also reported substantial variation
in LPT by different job demand-control environment. For example,
workers in ‘high-demand, low-control’ occupations4 had the lowest
LPT (1.81 hours per week) as compared to those in ‘low-demand,
12 Presenteeism
high-control’ occupations LPT (3.32 hours per week). The study also
reported significant variations in LPT by employee personal habits
(for example, smoking, drinking), family health reasons, and region
of the nation (for example, Midwest, West, Northeast, South).
Goetzel et al. (2004) analysed the cost of presenteeism of ten
medical conditions (allergies, arthritis, asthma, cancer, depres-
sion/sadness/mental illness, diabetes, heart disease, hypertension,
migraine/headache, and respiratory disorders) and reported the
costs (in terms of per employee per year) of each of these conditions.
According to this study, costs associated with the top six condi-
tions were: arthritis (USD252), hypertension (USD247), depression/
sadness/mental illness (USD246), allergies (USD222), migraine/
headache (USD189) and diabetes (USD158). The annual costs of the
remaining four conditions were below USD100 each.
Burton et al. (2004) studied the workplace impairment of more
than 16,000 employees of a large financial services corporation in the
United States to examine the relationship between medical condi-
tions and patterns of reduced work performance. Analyses indicated
Sketch 2.3 Employee is too sick to work

that depression was highly associated with work limitations in time

management, interpersonal/mental function and overall output.
Further, arthritis and low back pain were associated with physical
function limitation.
Marlowe (2007) reported that a study by Dow Chemical on ten
common chronic conditions for 7,800 employees in 2002 revealed
that the cost of presenteeism averaged USD6,272 per employee per
annum as compared to only USD661 for absenteeism.
According to a study published in the Journal of the American
Medical Association (2003), employee depression costs USD35 billion
a year in reduced performance at work, and painful conditions like
arthritis, headaches and back problems cost nearly USD47 billion
(Hemp, 2004).
Ruez (2004) reported that analysis of a database containing infor-
mation on 375,000 employees, for conditions like allergies and head-
aches on the job, showed that productivity losses accounted for more
than 80 per cent of employers’ total illness-related costs.
Sketch 2.4 Employee is affected by depression

14 Presenteeism
Ruez argues that presenteeism is driven by several interrelated

factors that are common in today’s workplace, and identified work-
place stress, depression, work–life conflict, and labour shortage as the
four key drivers of presenteeism.
Stress: Ruez reported that according to the American Institute of
Stress, U.S. industries lost USD300 billion annually due to stress
when measured in terms of absenteeism, lost productivity, turnover
and direct costs, which amounts to USD7,500 per employee.
Depression: According to the National Institutes of Health (NIH),
depression costs employers USD44 billion a year in lost productivity
and such workers reported having lost 5.5 hours per week in produc-
tivity or absenteeism, compared with 1.5 hours per week among
non-depressed workers.
Work-life conflict : Issues from childcare to other personal/family
problems can be a significant driver of presenteeism. Further details
are presented in Section 2.4.
The labour shortage: Labour shortage in certain professions can lead
to presenteeism as a result of employees juggling increased workloads
along with personal and family issues. Further details are presented
in Section 2.4.
According to a 2004 study by Cornell University’s Institute of
Health and Productivity and the health company Medstat, produc-
tivity losses for businesses were estimated to be on average USD225
per employee per year and accounted for as much as 60 per cent
Table 2.1 Productivity losses due to different health conditions
Health condition Lost productivity Source
Diabetes USD158 per employee per Goetzel et al. (2004),

year p. 406
Migraines 5.7 days a month Marcus (2001)
Migraines 1.6 hours a day Goetzel et al. (2004)
Migraines USD12 billion per year Burton et al. (2004)
Allergies USD2.8 billion per year Burton et al. (2004)
Allergies 2.8 hours a day Hummer et al. (2002)
Depression USD44 billion a year National Institutes of
Health (reported in
Ruez, 2004)
Depression/Sadness/ USD246 per employee per Goetzel (2004), p. 406
Mental Illness year
of the total cost of worker illness, which exceeds the cost of absen-
teeism and medical and disability benefits (Margoshes, 2005).
Table 2.1 presents the estimates of productivity losses due to sick-
ness presenteeism by a number of selected health conditions. In
addition, Table 2.2 presents the estimated cost of lost productivity
due to sickness presenteeism at the national (United States) as well
as at organizational levels.
2.3.2 Consequences of sickness presenteeism

in countries other than United States
Australia
A 2007 study by Medibank Private Ltd. (2007) in Australia revealed
that the biggest contributors to the overall productivity loss were
depression (19 per cent), allergies (19 per cent), hypertension (14 per
cent) and diabetes (9 per cent).
United Kingdom
A recent study in the United Kingdom by Cary Cooper and Ellipse
(an insurance company) reported that 80 per cent of the survey
respondents continued to work despite being sick, with damaging
effects on productivity; the study revealed that 72 per cent of the
respondents had gone to work in the past year while sick, and more
than half of them went to work with a contagious illness such as flu
or a cold (Patton, 2012).
A survey of 11,000 staff of the National Health Service (NHS) in
the United Kingdom found high levels of ‘presenteeism’, where staff
continued to go to work when they were stressed as well as not fully
fit to work (O’Reilly, 2009).
Switzerland
Wieser et al. (2011) reported that low back pain (LBP) is the most
prevalent health problem in Switzerland and a leading cause of
reduced work performance and disability. The study reported that
the productivity losses due to such health conditions were at €4.1
billion and that presenteeism was the single most-prominent cost
category. The estimated total economic burden of LBP to Swiss
society was estimated at between 1.6 per cent and 2.3 per cent
of GDP.
16 Presenteeism
Sketch 2.5 Employee worries about the sick child at home
Spain, Germany and Italy

Darbaa et al. (2011) reported that the costs for the health-care
systems in Spain, Germany and Italy for the population with poorly
treated gastroesophageal reflux disease (GERD) were €17 million,
€12 million and €7 million respectively. Total costs to employers
for absenteeism and presenteeism due to poorly treated GERD were
reported as €10 million for Germany and €1 million for Italy. The
authors commented that the costs due to poorly treated GERD repre-
sent a substantial burden for the health-care systems of the two
countries.
Singapore
In the 2009 study on presenteeism, responses of 244 working adults
were used to collect the data, and the proportion of eligible annual
work hours lost was computed using the Goetzel et al. (2004, p. 403)
methodology. The result showed that on the average an employee
lost an equivalent of 3.88 per cent of his or her annual eligible work
time due to presenteeism. This translated into about SGD2,100 per

employee per year (based on an average annual base salary, incen-
tives and benefits of SGD54,017).5 The study also found that female
respondents lost a relatively higher proportion of eligible annual
work hours (4.17 per cent) as compared to their male counterparts,
who lost 3.71 per cent, a difference of about 11 per cent between the
genders. However, in another study the loss of productive time by
female employees due to personal health reasons was 23 per cent
higher than that of their male counterparts (Stewart et al., 2003,
Table 3, p. 1,240).
In a second study, using the responses of 279 working adults,
Guo et al. (2010) computed the on-the-job productivity loss due
to a number of selected health conditions. Besides computing the
losses of productivity for all health conditions, the study also exam-
ined the productivity losses6 of managerial and non-managerial
employees due to a selected number of health conditions. The result
showed that on average, in cases of chronic back pain, flu, fever and
allergies, non-managerial employees lost more productive hours due
to sickness presenteeism than did the managerial group, whereas
the managerial employees were reported to have lost more eligible
working hours due to hypertension and migraine. Further details of
this study is presented in Chapter 6.
New Zealand
A study by Southern Cross research in 2009 estimated the annual
burden to employers due to presenteeism to be NZD1.2 billion.
The study also reported that the average number of days in which
employees went to work when they were too sick to be fully func-
tioning and productive was 11.1 (Tynan, 2011).
Another report prepared by the New Zealand Treasury concluded
that in New Zealand health conditions that result in presenteeism
are depression, back pain, arthritis, heart disease, high blood pres-
sure and gastrointestinal disorders. Evaluated at the average full-
time pay rate, presenteeism costs to the country were estimated at
between NZD700 million (39.3 million work hours lost) and NZD8.2
billion (409 million work hours lost) per year. Taking a midpoint of
the range of the cost figures (that is, NZD4.1 billion) the loss equates
to 2.7 per cent of GDP (Tynan, 2011).
18 Presenteeism
Table 2.2 Estimated costs of lost productivity due to sickness presenteeism
Study Cost to the nation/

Studies Authors location Company Comments
2003 Stewart USA USD225 billion/year For personal

et al. (USD1,685/employee/ and family
year)* health
reasons. Of
this, 71% is
accounted
for reduced
performance
at work
2004 Goetzel USA Presenteeism cost of top
et al. six health conditions
(per employee per year):
arthritis (USD252),
hypertension (USD247),
depression/ sadness/
mental illness (USD246),
allergy (USD422),
migraine/ headache
(USD189) and diabetes
(USD158).
2005 Ruez USA Stress: Due to employee
stress, industries
lose USD300 billion
annually (measured in
terms of absenteeism,
presenteeism, lost
productivity, turnover
and direct costs).
Equivalent of USD7,500
per employee per year.
Depression: This medical
condition costs
employers USD44
billion a year in lost
productivity.
2005 Margoshes Productivity losses
for businesses were
estimated to be on
average USD225 per
employee, per year
Note: *USD225.8 billion for personal and family health related; 71% is explained by
reduced performance at work.
Another 2009 study in New Zealand estimated the annual burden

to employers due to presenteeism to be NZD1.2 billion (60 per cent of
two billion). The study also reported that the average number of days
in which employees went to work when they were too sick to be fully
functioning and productive was 11.1 (Tynan, 2011).
2.4 Non-sickness presenteeism
As discussed earlier in this chapter, non-sickness presenteeism

occurs when employees come to work while physically fine but suffer
from conditions like personal financial difficulties, perceived work-
place pressure, legal and family problems, and performing at below
capacity (Milano, 2005). Non-sickness presenteeism is also observed
when employees spend time at work on personal matters, thereby
losing available work hours. For example, Castle (2008) reported that
employees spend about 2.5 to 5 hours per week at work resolving
personal issues. Non-sickness presenteeism behaviour is also defined
as when an employee is present at his or her place of work for more
hours than is required, especially as a manifestation of insecurity
about one’s job (Oxford Dictionary).
Although little information is available from the literature on the
extent of loss of productivity while employees are present at work
but suffering from one or more of the conditions listed above, some
possible causes of productivity loss at work due to non-sickness pres-
enteeism are discussed below.
2.4.1 Personal financial difficulties and presenteeism

Garman et al. (1996) listed 19 possible impacts on employee perform-
ance due to ‘personal financial difficulties’. A selected few from the
list are discussed below:
1. Absenteeism
2. Taking long breaks
3. Failing to focus on the job
4. Extended discussions with co-workers on financial stress
5. Loss of customers
Absenteeism: Unscheduled absences incur additional expense for

the employer in the form of hiring a replacement or paying overtime
20 Presenteeism
to another employee(s) to finish the job. Such unscheduled absence

requires time from the supervisor or manager in sourcing the replace-
ment, which in turn costs money to the employer.
Besides paying for the substitute employee, the organization may
also have to pay fees to the employment agency for the service.
Sometimes, colleagues of the absent employee may also cover
for him/her, which indirectly costs money to the employer, as the
employee who is covering for the absent employee could not possibly
do his/her own usual job fully.
Taking long breaks: Long breaks result in loss of productivity as the
sick employee is not able to perform his/her task as required.
Failing to focus on the job affects quality and quantity of output : Both
quality and quantity of output are important for an organization as
they could have a negative impact on customer satisfaction. Quantity
of output is also vital for an organization in managing its revenue
and profitability.
Extended discussions with co-workers on financial stress: Impact of
such behaviour is very similar to ‘taking long breaks’, which results
in loss of valuable productive time.
Loss of customers: The argument follows from ‘failing to focus’,
above. An employee who is under financial pressure and is unable
to produce quality output which, if not detected before shipment to
the customer, adversely affects customer satisfaction. If poor-quality
products are continually shipped to customers, the organization
might eventually lose those customers.
Research findings show that as employees fear job loss and repri-
mands for excessive time off, they are more than likely to conduct
personal business while at work. A survey conducted for Cigna in
May 2008 found that there was an average of approximately seven
days of presenteeism per employee due to the employee being present
but being focused on personal business (Gurchiek, 2009).
Thus, presenteeism can affect healthy employees when they are
more focused on personal issues, such as their talking with teachers
concerning a child’s school performance, setting up doctor’s appoint-
ments for family members or themselves and solidifying quality care
for an aging parent. These non-related medical issues can consume
2.4 hours per week of an employee’s work time (Gurchiek, 2009).
Based on a survey, CIO Insight reported that 61 per cent of the
respondents were stressed about their financial situation and
Sketch 2.6 Employee is sick and tired
29 per cent said that their personal financial issues have been a
distraction at work (Prater and Smith, 2011).
2.4.2 Family issues

Milano (2005) argues that employees can also be seriously distracted
by child or elder-care pressures, or by marital strains and thereby lose
productive work time.
2.4.3 Obesity and presenteeism

Obesity causes or aggravates many health problems, both inde-
pendently and in association with other diseases. Researchers
have concluded that obesity has serious consequences on health,
including increased risk for depression (Sundaram et al., 2007), non-
insulin-dependent diabetes mellitus (Mokdad et al., 2003; Sach et al.,
2007), cancer (Gallicchio et al., 2007), rheumatoid and osteoarthritis
(Escalante et al., 2005), hypertension (Fields et al., 2004) and heart
disease (Poirier and Eckel, 2002).
Literature indicates that obese workers tend to incur greater produc-
tivity losses than non-obese workers (Burton and Condi, 1999). Gates
22 Presenteeism
et al. (2008) reported that moderately or extremely obese workers

(body mass index [BMI] ≥35) experienced the greatest health-related
work limitations. This is specifically regarding time need to complete
tasks and the ability to perform physical job demands. These authors
report that obese workers experienced a 4.2 per cent health-related
loss in productivity, which is 1.18 per cent higher than all other
employees.
Gates et al. (2008) claimed that obesity was associated with greater
health-related limitations in the workplace. They argued that job
limitations that are most affected by obesity are those concerning
time and physical demands, whereas mental or interpersonal and
overall output-related demands were not affected by obesity.
Trogdon et al. (2008) have listed some specific information on
obesity and costs of lost productive time. For example, Ricci and
Chee (2005) found that obese employees (BMI≥30) between the ages
of 18 and 65 cost USD9.09 billion per year through lost productive
time due to presenteeism.
Studies conducted at Duke University (2006, 2008) reported
that the costs per person of those who suffer from obesity were as
much as USD16,900 for women and USD15,500 for men. In addi-
tion, presenteeism, among full-time obese workers, was found to be
a major expense for employers, with costs ranging up to USD73.1
billion with 56 per cent for women and 68 per cent for men (Preidt,
2010).
Through a survey of 7,338 working adults, the American Journal of
Health Promotion established that individuals suffering from obesity
and type 2 diabetes lost 11–15 per cent of work time or 5.9 hours
of lost productivity per week (Preidt, 2009). On the other hand,
employees with normal weights had 9 per cent of work time or
approximately 3.6 hours of lost productivity per week (Preidt, 2009).
In addition, the survey revealed that obese individuals with type
2 diabetes indicated that even performing simple activities caused
them to feel weaker.
According to a National Health and Nutrition Examination Survey
(NHANES),7 obesity has become one of the leading health concerns
among the medical and public health communities in the United
States and is now considered to be of epidemic proportions. Rates of
obesity in the United States are tracked through data from the most
recent NHANES found that 33.8 per cent of Americans are obese and
an additional 34.2 per cent are overweight. It has been estimated
Table 2.3 Summary of consequences of sickness presenteeism reported in

various studies, excluding the United States
Country/ Presenteeism cost/Drivers

Year Author(s) organization of presenteeism Comments
2007 Medibank Australia 1. Estimated cost of Study

presenteeism to the conducted in
Australian economy 2005–2006
AUD25.7 billion. (Dollar
2. The biggest contributors figures are in
to the overall 2004–2005
productivity loss are prices).
allergy (19%), followed
by hypertension (14%)
and diabetes (9%).
2008 Quazi et al. Singapore 1. On average an employee Based on the
(study 1) lost the equivalent of responses of
3.88% of his/her annual 244 working
eligible work time due to adults.
presenteeism
2. Based on the sample,
female employees lost
about 11% more of
their eligible annual
work time than the
male employees due to
sickness presenteeism.
2010 Aston, L. United Sickness presenteeism costs
Kingdom more than £15 billion
per year.
2010 Guo et al. Singapore Differences in the extent Based on the
(study 2) of presenteeism responses of
of managerial and 279 working
non-managerial staff: adults.
On the average
non-managerial
employees lost more
productive hours due to
sickness presenteeism
than the managerial
group, due to chronic
back pain, flu, fever and
allergy, whereas the
managerial employees
reported having lost
more eligible working
hours in terms of
hypertension and
migraine.
Continued
24 Presenteeism
Table 2.3 Continued
Country/ Presenteeism cost/Drivers

Year Author(s) organization of presenteeism Comments
2012 Patton United 1. 80% of survey

Kingdom respondents indicated
having continued to
work despite being sick.
2. 72% of respondents went
to work in the past year
while sick.
3. More than half of
respondents went to
work with a contagious
illness (that is, flu or
cold).
2011 Wieser et al. Switzerland 1. Lower back pain (LBP)
is the most prevalent
health problem in
Switzerland and a
leading cause of reduced
work performance and
disability.
2. The estimated economic
burden of LBP is 1.6% to
2.3% of GDP.
2011 New Zealand New Zealand Almost half the respondents Based on
Treasury reported reduced a survey
productivity due to of family
emotional problems income and
or physical health. employment
Estimated cost to the data.
country: between
NZD700 million and
NZD8.2 billion per year.
On the average, this
amounts to about 2.7 %
of GDP.
2011 Tynan New Zealand 1. The impact of
presenteeism’s cost
burden on employers
is estimated at NZD1.2
billion.
2. The average number of
days employees went to
work when too sick to
be fully productive: 11.1
per year.
that annually an estimated 112,000 preventable deaths occur due

to obesity. The dramatic increases in obesity and its related medical
disorders are a relatively recent occurrence. Before the 1980s, only
about 13 per cent of adults were considered obese. While obesity
rates in the past decade have been relatively stable, they remain
extremely high. Therefore, while quantifying the productive time
lost due to presenteeism and absenteeism, it would be appropriate to
include obesity as one of the health conditions that contributes to
the invisible loss of productivity.
2.4.4 Emotional exhaustion and presenteeism

Demerouti et al. (2009) confirm that emotional exhaustion and
presenteeism are reciprocal, since Time 1 (T1) exhaustion led to
Time 2 (T2) presenteeism, which in turn caused more exhaustion at
Time 3 (T3). As predicted, because of efforts to compensate for the
negative effects of progressive energy depletion (on performance),
emotional exhaustion led over time to inappropriate non-use of
sick leave, which in turn resulted in enhanced feelings of exhaus-
tion. The authors assume that appropriate use of sick leave is health-
promoting insofar as it provides the opportunity for physical and
mental recuperation after strain or illness (Aronsson et al., 2000).
Aronsson and Gustafsson (2005) suggest that over time the percep-
tion of high job demand induces pressure to work through sickness.
This finding is important from the perspective of job design and
underscores that presenteeism does not result solely from internal
stress but also from work-related pressures. All reported relation-
ships between job demand, presenteeism and burnout were inde-
pendent of the general health of employees. Employees with a worse
health status at Time 1 reported more presenteeism over time but
not more burnout. Thus, over time general health influences the
decision to work when sick and can be viewed as a starting point for
deciding between staying sick at home or going to work (Johansson
and Lundberg, 2004).
2.5 Summary
This chapter has described what is meant by the term presenteeism,

types of presenteeism, medical conditions that are associated with
sickness presenteeism and the consequences of such employee
26 Presenteeism
behaviour. Under the section on consequences of presenteeism,

the nature and extent of productivity losses were discussed when
employees came to work sick. The information was presented in two
parts, one on the evidence from the United States and the other on
data from several selected countries.
It has also been noticed that the various monetary figures on cost
of presenteeism were reported by several authors for the same health
condition. This could be due to a number of factors, such as variation
of research methodology, sample size, health condition of the sample,
age distribution of the sample, the time when the study was conducted
and the costing methodology used. For example, in the process of
monetizing the loss of productive time, some authors may have used
only average base pay of the employees, whereas others included total
compensation (base pay + incentive + benefits). Further, if the studies
were carried out in two different periods, costs would vary due to
the changes in employee pay and benefits, to inflation and other
related factors. It is noted that no study has yet tried to align the costs
reported in different studies on the same health conditions.
Further, when the cost of presenteeism is reported from countries
other than the United States, besides the variables used, there may
be a number of others that might influence the cost of presenteeism
(for example, pay scale, currency exchange rate, employee benefits,
etc.). Data collection, data analysis methodologies and other local
conditions may also influence the outcome of a study on the subject.
Therefore, the best indicator to use would be to compare data from
various studies expressed as a percentage of the GDP of the nation in
question.
In summary, this chapter paints a picture that there is a cost to
employers when employees come to work despite being sick. This is a
hidden cost, as many organizations do not maintain records on: how
many employees attend work while sick; the details on their sickness
and the extent of lost productive hours per episode of sickness for
chronic and acute health conditions; and how many hours are lost
per employee per year because of chronic health conditions.
Notes
1. Dew et al. (2005), ‘Choosing’ to work when sick: Workplace
Presenteeism’.
2. Based on the average Lockheed salary of roughly USD45,000 per year.
3. American Productivity Audit (APA) is a telephone survey of a random

sample of 28,902 U.S. workers, designed to quantify the impact of health
conditions on work.
4. High-demand conditions include inadequate time to meet job demands
and excessive workload while low-control conditions include unskilled
labor and reduced decision-making autonomy (R. Karasek’s job-demand
control [JD-C] model)
5. Annual base pay of SGD36,000 plus incentives and benefits.
6. Computed using the Goetzel et al. methodology (2004, p. 403)
7. The National Health and Nutrition Examination Survey (NHANES) is a
programme of studies designed to assess the health and nutritional status
of adults and children in the United States. The survey is unique in that
it combines interviews and physical examinations. NHANES is a major
programme of the National Center for Health Statistics (NCHS). NCHS is
part of the Center for Disease Control and Prevention (CDC) and has the
responsibility for producing vital and health statistics for the United States.
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3
Absenteeism and Presenteeism
Absenteeism is defined as the failure to report for scheduled work

(Johns, 2002). Reason for an unscheduled absence could be either
medical or non-medical (Aronsson, Gustafasson and Dallner, 2000;
Lowe, 2002; Simpson, 1998). In the past, managers used to assume
that work attendance equated to performance, which is actually not
true (refer to Chapter 2 for an explanation on this issue). Some authors
also argue that significant productivity losses due to absenteeism do
not result from major or chronic health issues alone but can be asso-
ciated with common health problems (Barnes et al., 2008). Gosselin,
Lemyre and Corneil (2013) argue that health-related loss of produc-
tivity can be traced equally to workers showing up at work as well as
to workers choosing not to.
Sickness absenteeism is a widely researched workplace health
problem that has long been seen as a cost to employers. However,
according to a 2005 publication, the amount of attention devoted
to sickness presenteeism as opposed to sickness absenteeism
showed that the number of published articles dealing with sickness
presenteeism was only 1 per cent of the number dealing with sick-
ness absenteeism (Dew, Keefe and Small, 2005).
Literature indicates that absenteeism may result from different
types of health conditions, including chronic, acute and common
health conditions, and stress, obesity and other related employee
health conditions. In this chapter research findings on the nature
and extent of financial and non-financial losses to organizations due
to absenteeism are presented.
31
32 Presenteeism
3.1 Research findings
3.1.1 Organizational pay policy and absenteeism

There is increasing interest in the economics of absenteeism. This
is due to growing awareness that the economic and social costs of
absenteeism in the form of sickness benefits, health care and early
retirement are substantial (Pouliakas and Theodoropoulos, 2012).
Research shows that the direct cost of absenteeism for the U.K.
economy has been going up since the mid-1980s. For example, £6
billion per year in the 1980s (Brown and Sessions, 1996) to £11.6
billion in 2003 (Barham and Begum, 2005) to £17 billion in 2009
(CIPD). In the past, researchers focused on the job contract that
could impact on cost of absence, such as basic wage and sick pay
replacement rate, but they did not examine the impact on absence
rates of performance-related pay schemes. In a study on the subject,
Pouliakas and Theodoropoulos (2012) reported that firms that
employ performance-related pay (PRP) schemes tied to the assess-
ment of individual merit and performance have significantly lower
absence rates. This negative relation becomes stronger in firms that
offer PRP to a greater proportion of their non-managerial workforce
and in those firms in which the share of workers’ earnings subject to
variable pay is greater.
3.1.2 Wage level, relative wage and job position

and absenteeism
Pfeifer (2010) examined the impact of wages and job levels on worker
absenteeism behaviour. The author examined the extent to which
absolute wage levels, relative wages compared with colleagues, and
the position in a firm’s hierarchy affected workers’ absenteeism
behaviour. The analysis of monthly wages and monthly absenteeism
of employees in a German company provided evidence that workers
are less absent if they enjoy a higher absolute wage, a higher relative
wage and are employed at a higher hierarchical level.
3.1.3 Substitution of absenteeism by presenteeism

MacGregor, Cunningham and Caverley (2008) point out that
according to previous research presenteeism might be on the rise
because the employees are substituting sickness presence for sickness
absence. They argue that if the total number of sick days is defined
Absenteeism and Presenteeism 33
as the sum of sick days absent and sick days present then for constant
levels of health, reducing sickness absence can only be achieved by a
corresponding increase in sickness presence.
3.1.4 Employee race, diversity and absenteeism

A study by Avery et al. (2007) on the relationships between race,
organizational diversity cues and absenteeism examined the roles
of two diversity cues related to workplace diversity and absenteeism
among 659 Black, White and Hispanic employees of a U.S. company.
The outcome of the research revealed that Blacks reported signifi-
cantly more absences than did their White counterparts. However,
this difference was found to be more distinct when the employees
believed that their organizations placed little value on diversity.
3.1.5 Absenteeism in Nordic countries

A study on absenteeism in the Nordic countries reported that Danish
employees are less absent than employees in Norway, Finland and
Sweden. Further, the study reported that employees working in the
public sector, specifically in the municipalities, demonstrated a
higher level of absence compared to the private sector. According
to an analysis based on gender, in all Nordic countries women are
found to be more absent than men. However, if the manager is a
woman and so are the employees, then the level of absence is higher
in Denmark, Norway, and Finland compared to men in the same
situation (Lokke, Eskildsen and Jensen, 2007).
3.1.6 National culture and absenteeism

Like presenteeism, absenteeism is also a costly employee behaviour.
To examine the relationship between national culture and absen-
teeism, Parbotteeah, Addae and Kullen (2005) examined the effect of
national culture on absenteeism, using a large sample from 24 coun-
tries. Based on the Hofstede cultural dimensions, the authors postu-
lated that uncertainty avoidance, power distance, individualism and
masculinity will be negatively related to absenteeism. Similarly, based
on the GLOBE1 cultural dimension, the authors also hypothesized
positive relationships between societal collectivism and assertive-
ness and absenteeism. After statistical testing, some of the proposed
hypotheses were found to have been supported. For example, the
negative relationship between ‘power distance’ and ‘absences’ was
34 Presenteeism
supported. The analysis also supported the negative relationship

between ‘individualism’ and ‘absences’. From the GLOBE cultural
dimensions, the hypothesized positive relationship with societal
collectivism and absences was also supported. In summary, this
study has demonstrated that some of the national cultural dimen-
sions have either positive or negative relationships with absences.
This means that the managers need to note that employee absen-
teeism behaviour will vary among national cultures.
3.1.7 Obesity and absenteeism

Literature shows that obesity has a significant positive association
with absenteeism. In the Belgian workforce, for example, body fat
distribution has been found to be associated with high annual sick
leave incidences and long spells of absence. Further, in a financial
institution, workers with high BMI showed additional health risks,
short-term absences because of disability and illness, and higher
health-care costs than workers who were not overweight. Obese
workers were found to be 1.7 times more likely to experience a high
level of absenteeism (Schulte et al., 2007).
Obesity has serious consequences on human health, including
increased risk for depression, non-insulin-dependent diabetes
mellitus, cancer, rheumatoid arthritis and osteoarthritis, hyperten-
sion and heart disease (Gates et al., 2008). Authors have reported
the costs of health-related productivity losses and absenteeism per
worker, based on a mean hourly wage of USD21.44. The absen-
teeism cost per year for moderately or extremely obese workers was
computed as USD1,575.41 as compared to USD1,142.76 for all other
workers.
In a review of literature on indirect costs of obesity, Trogdon et al.
(2008) listed a number of studies that reported the relationship
between obesity and absenteeism. Results from a few of these studies
follow:
1. Popkin et al. (2006) reported their findings on a nationally repre-

sentative sample from China that the cost of sick leave attribut-
able to overweight and obesity in China was USD44.80 billion per
year (based on 2007 USD).
2. Wolf and Colditz (1998) used nationally representative samples
from the United States and estimated the costs of lost productivity
attributed to obesity (BMI≥30) was 3.9 billion and reflected

39.2 million days of lost work
3. Ricci and Chee (2008) examined the costs of obesity (using
Caremark American Productivity Audit) of employees ages 18–65
and reported the annual cost of absenteeism as USD4.47 billion.
4. Based on a nationally representative sample of U.S. adults aged
18–65 employed as full time employees, the annual excess
costs of absenteeism among obese II (35≤BMI<40) and obese
III (BMI≥40) were USD710 and USD481 respectively. However,
among females, annual excess costs of absenteeism for obese
II and obese III were much higher as compared to their male
counterparts, amounting to USD1,033 and USD888 respectively
(Fikelstein et al., 2005)
3.1.8 Findings from other studies

A study in the United Kingdom found that sickness absence costs
U.K. employers £8.4 billion each year (Aston, 2010).
The Southern Cross Health Society of New Zealand (Tynan,
2011) estimated the impact of absenteeism on the society to be
$0.80 billion. This study also found that average time off work due to
sickness absenteeism was 4.2 days per person per year.
Goetzel et al. (2004) estimated the number of average absence
days per year due to health conditions and the costs for each of
these conditions in the United States. For example, according to the
authors’ estimate, depression/sadness/mental illness were respon-
sible for about 26 days per year of absence per employee, followed
by ‘any cancer’ (17 days); respiratory disorders (15 days); asthma
(12 days); and migraine/headache (11 days). In summary, the average
number of days lost per year per employee due to absenteeism was
10.4 costing U.S. employers the equivalent of USD1, 920 per year per
employee suffering from such health conditions.
In an ‘employee benefits’ study, Sullivan (2008) reported that
45 per cent of the respondents on average took fewer than five days
off due to sickness a year, and another 40 per cent took between
6–10 sick days off a year. In terms of long-term absences, only 4
per cent reported to have taken 11–15 days of sick leave. The survey
revealed that only 42 per cent of the organizations record the cost
of sick absences. Of the organizations that record the costs of absen-
teeism, 41 per cent reported that the absenteeism costs for their
36 Presenteeism
organization was 1–2 per cent of payroll, whereas 31 per cent indi-
cated 3–5 per cent and another 10 per cent reported 6–10 per cent.
Makrides et al. (2011) examined the relationship between health
risks and absenteeism and drug costs through a comprehensive
workplace wellness program. They studied 11 health risks, changes
in drug claims and short-term and general illness costs calculated
across four risk-change groups. The wellness score was estimated
using appropriate statistical tests. The results showed 31 per cent at
risk, and nine risks were associated with higher drug costs. Employees
moving from low-risk to high-risk groups showed the highest
relative increase in drug costs (81 per cent). However, employees
moving from high-risk to low-risk categories had the lowest per cent
(24 per cent) of decrease. However, the low-high risk group had the
highest increase in absenteeism costs (160 per cent). With each risk
level increase, absenteeism costs increased by CAD248 per year with
average decrease of 0.07 risk factors and savings of CAD6,979. These
results indicate that both high risk reduction and low risk mainte-
nance are important to monitor the trend of drug costs.
Abdullah and Lee (2012) report the relationships between employees
who had attended a wellness programme and those who had not
with employees’ job satisfaction, stress and absenteeism. This study
was conducted at a major telecommunications company in Malaysia.
Findings revealed that higher satisfaction was reported by those
respondents who attended wellness programmes than those who did
not attend. The findings also showed that less employee-perceived
stress was reported by the respondents who had attended the well-
ness programme than by those who did not attend. Similarly, lower
employee absenteeism was found among those who had attended
the programme than those who did not.
3.2 Chartered Institute of Personnel and

Development (CIPD) survey results
3.2.1 CIPD studies on sickness-related absence and

associated costs
In the 2012 absence-management study of the CIPD survey reports
a set of findings based on its 13 national survey on absence-manage-
ment trends. Some of the salient findings on causes of absence are
highlighted as follows:
The most common short-term absences were found to be due to

minor illnesses (for example, colds, flu, stomach upsets, headaches
and migraines, etc.) followed by musculoskeletal injuries, back pain
and stress. However, the most common causes of long-term absence
were stress, acute medical conditions, mental health, musculoskel-
etal injuries and back pain. Further, the report also noted that
musculoskeletal injuries and back pain were particularly common
for manual workers, but stress was most common for non-manual
workers who are working in the public and non-profit sectors.
The survey found that the most common cause of stress was
workload related, followed by management style, relationships at
work, family relationships, and major organizational change and/or
restructuring. Stress is particularly common in the public and non-
profit sectors. The public sector is also more likely to rank mental ill
health and musculoskeletal injuries among its top five causes.
3.2.2 Absence rate and the cost of absence

In the United Kingdom, the average per cent of lost working time
was computed to be 3.4 per cent in 2012, which was slightly lower
than that of 2011 (i.e., 3.8 per cent). The corresponding number of
days lost per employee per year was 7.7 and 8.7 for 2012 and 2011,
respectively. The reported median cost of absence per employee per
year for 2011 and 2012 was £673 and £600 respectively.
In 2007, CIPD and ‘Active Health Partners’ published a report on
managing employee absence in order to examine the issues relating
to sickness absence and its management in U.K. organizations. The
researchers analysed databases from 40 different organizations
comprising over 80,000 individual absence spells associated with
30,000 individual employees. The key findings of this study were as
follows:
• Average number of working days lost per absence event was 6.35
for the public sector as compared to 4.89 for the private sector.
• More than 60 per cent of all spells of absenteeism were accounted
for by four reasons: gastrointestinal problems (20.4 per cent),
infection (16.4 per cent), non-medical factors (14.2 per cent)
and musculoskeletal (10.8 per cent). However, absence due to
musculoskeletal problems rises from an average of 5.89 days for
under-25 employees to 22.06 days for those 65 and over.
38 Presenteeism
• In terms of productive time lost due to absence, the top two condi-
tions were found to be musculoskeletal problems and mental
health problems.
• The average spells for absence for mental health problems, stress
and depression were found to be 20.84 days, 21.48 days and
29.83 days respectively.
• Based on this absence management survey, CIPD reported that the
average cost of sickness absence in the UK was £600 per employee
per year.
3.2.3 Managing absence

Davis et al. (2009) report, ‘Steps to a Healthier Austin’, Texas, was
funded by the Centres for Disease Control and Prevention in order
to implement chronic disease-prevention and health-promotion
activities. The authors report on how ‘Steps to a Healthier Austin’,
in partnership with ‘Health and Lifestyle Corporate Wellness, Inc.’
provided a worksite wellness programme for the Capital Metropolitan
Transportation Authority, Austin’s local transit authority. Health
and lifestyles provided consultations with wellness coaches and
personal trainers, a 24-hour company fitness centre, personalized
health assessments and preventive screenings. The programme
expanded to include healthier food options, cash incentives, health
newsletters and workshops, dietary counselling, smoking-cessation
programmes, and a second fitness centre. Participants in the well-
ness programme reported improvements in physical activity, health-
food consumption, weight loss and blood pressure. Capital Metro’s
total health-care costs increased by progressively smaller rates from
2003 to 2006 and then decreased from 2006 to 2007. Absenteeism
decreased by approximately 25 per cent after the implementation
of the programme, and the overall return on organization’s invest-
ment was reported to be 2.43.
According to the ‘CIPD and Simplyhealth 2012’ annual survey, 95
per cent of the 498 organizations surveyed reported to have written
new absence/attendance management polices and put them in
place. The most common change was the introduction of a new or
revised absence-management policy. The top five policies in these
organizations were: (a) new or revised absence-management policy’
(51 per cent); (b) introducing/or revising monitoring procedures
(42 per cent); (c) reinforcing the existing employee absence policy
(37 per cent); (d) absence rate becoming a key performance indicator
(23 per cent); and (e) involvement of occupational health and profes-
sionals (21 per cent).
Regarding management of short-term absence, the most common
policy used by the majority of organizations was conducting return-
to-work interviews followed by trigger mechanisms to monitor
attendance, giving sickness absence information to line managers
and implementing disciplinary procedures for unacceptable absences.
The report also indicates that line managers take primary respon-
sibility for managing short-term absence (70 per cent of organiza-
tions). About 60 per cent of employers reported that their managers
are trained in absence management (81 per cent in the public sector).
The most effective approaches for managing short-term absence
were return-to-work interviews and trigger mechanisms to review
attendance.
Methods used to manage long-term absence were return-to-work
interviews, occupational health involvement and giving sickness-ab-
sence information to line managers (CIPD and Simplyhealth, 2012).
‘WellnessProposals.Com’, a corporate wellness consultant, identi-
fied a number of reasons for which chronic diseases flourish in the
United States. For example:
1. Lack of time in a fast-paced society and a growing number of fast-

food restaurants.
2. Restaurants and fast-food outlets serving extremely large portions
of food high in fat, saturated fat, trans fat, cholesterol, calories
and sodium, but low in fibre and nutrients necessary for health.
3. Vending machines, snack bars, cafeterias with few healthy
choices.
4. Increased inactivity due to modern labour-saving devices and lack
of sidewalks and walking trails.
5. Tobacco smoking or chewing, etc.
Experts and researchers argue that there has been little progress
during the past decade in reducing deaths related to the above-
listed risk factors, and they highlight that worksites are crucial to
improving the health of their workers. There are a number of bene-
fits that the employees can enjoy by adopting wellness programmes
such as weight reduction, improved physical fitness, increased
40 Presenteeism
stamina, lower level of stress, increased well-being, self-image and

self-esteem.
Researchers argue that by adopting the wellness programmes
employers can also benefit in enhanced recruitment and retention
of healthy employees, in reduced health-care costs, decreased rates
of illness and injuries, and reduced employee absenteeism, improved
morale and increased productivity.
According to a 2002 report by the U.S. Department of Health
and Human Services, employers can also be benefitted by having
the worksite well-being services – in reduced health-care costs (by
20–55 per cent), reduced short-term sick leave (by 32 per cent) and
improved productivity (by 2–52 per cent) (WellnessProposals.Com).
3.2.4 Impact of health-promotion programme on absences

Bertera (1990) studied the effects of workplace health-promotion
programmes on absences among full-time employees in a large,
multi-location, diversified industrial company and reported that
blue-collar employees at the intervention sites experienced, over
two years, a 14 per cent decline in disability days. Savings due
to lower disability costs at intervention sites offset programme
costs in the first year and, by the end of second year, showed a
return of USD2.05 for every dollar invested by this company in the
programme.
The Johnson & Johnson Family of Companies introduced its
worksite health-promotion programme in 1979. The programme
evolved and is still in place after more than 30 years. The authors
of this volume evaluated the programme’s effect on employees’
health risks and health-care costs for the 2002–2008 period.
Measured against similar large companies, Johnson & Johnson
experienced an average annual growth in total medical spending
that was 3.7 percentage points lower. Company employees bene-
fited from meaningful reductions in rates of obesity, high blood
pressure, high cholesterol, tobacco use, physical inactivity and poor
nutrition. Average annual per-employee savings were USD565 in
2009 dollars, producing a return on investment equal to a range of
USD1.88 – USD3.92 saved for every dollar spent on the programme.
Because the vast majority of U.S. adults participate in the workforce,
comparably positive effects from similar programmes could lead to
better health and to savings for the nation as a whole (Henke et al.,
2011).
Marzec et al. (2008) studied the effects of environmentally focused
interventions on health risks and absenteeism. In a governmental
employer setting, the authors conducted an observational study of
one worksite and its employees from 2005–2007. The three-month
average for hours of sick time decreased from 12.7 to 11.6 for the
larger eligible population.
3.3 Summary
In this chapter, issues related to absenteeism and costs related to such

employee behaviour are discussed. Also, research findings on ante-
cedences to absenteeism are discussed. For example, absenteeism
may be caused by organizational pay policy, employee wage levels,
relative wage and job positions. Besides, it has also been reported by
researchers that absenteeism may also be caused by employee race
and diversity, national culture, health, obesity and other conditions.
Some of the studies reported in the chapter indicated the extent of
financial loss incurred by the organizations.
It was discussed earlier that monitoring only the cost of absen-
teeism may not give employers a true estimate of cost, as employees
might be substituting sick absenteeism days by sick presenteeism
days. Therefore, to get a true picture of the cost of absenteeism,
it is appropriate to review the cost of presenteeism as well. For a
comprehensive understanding of costing absenteeism, refer to the
book, Costing Human Resources: The Financial Impact of Behavior in
Organizations (fourth edition) by Wayne Cascio, published by South
Western College Publishing.
Note
1. GLOBE: The Global Leadership and Organizational Behavior Effectiveness
Research Project was conceived in 1991 by Robert J. House of the Wharton
School of Business, University of Pennsylvania. In 2004, its first compre-
hensive volume was published, titled Culture, Leadership, and Organizations:
The GLOBE Study of 62 Societies, and based on results from about 17,300
middle managers from 951 organizations. A second major volume, Culture
and Leadership across the World: The GLOBE Book of In-Depth Studies of 25
Societies, became available in early 2007.
42 Presenteeism
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www.wellnessProposals.Com, accessed on 13 May 2013.
4
Why Do People Go to Work
Even When Unwell?
4.1 Introduction
Studies have shown that employees go to work, despite being sick, for
various reasons. For example, workers were found to be more likely
to go to work ill during economic downturns for job security, finan-
cial reasons, work environment, time pressure, and other reasons.
Presenteeism may also occur when there is a shortage of skilled
labour of specific types in the market.
4.2 Reasons for going to work while sick
Several factors influence the occurrence of presenteeism in organiza-

tions. A number of work-related factors that may influence an employ-
ee’s decision to turn up ill at work are presented in Figure 4.1.
4.2.1 Work environment

Employee work environment plays a significant role in driving pres-
enteeism. Some authors described work environment as a ‘battle-
ground’, or a ‘sanctuary’ where it differs across aspects such as pressures
faced by employees and the way in which employees cope, control
and make choices (Dew et al., 2005). Barnes et al. (2008) suggest
that perceptions of work in terms of clarity of roles, job demand
and control, and the quality of one’s relationship with manage-
ment and colleagues are related to sub-optimal work performance.
A study by Caverly et al. (2007) reported that work-related factors
such as job security, relationships with supervisors and colleagues
45
46 Presenteeism
Psychological
issues
Work
Stress
environment
Time Reasons
for going Depression
pressure
to work ill
Employment Long working

conditions hours culture
Sense of
duty
Figure 4.1 The Octopus model
are significantly correlated with presenteeism. Further, the influence

of teamwork and pressure from colleagues also act as a driver to be
present at work despite feeling unwell (Grinyer and Singleton, 2000).
A study by Hansen and Andersen (2008) found that when higher
levels of co-operation in performing work tasks are required, higher
levels of sickness presenteeism are displayed as employees are more
dependent on each other for the completion of tasks. This finding
is also supported by Luz and Green (1997), who found that group
cohesiveness might restrain employees from being absent from work.
Another reason is that employees tend to be more concerned about
having fellow colleagues carrying extra workload for them during
their absence, so they turn up for work despite feeling ill. Yet another
factor is that where there is strong emphasis on teamwork in the work
environment, informal support and caring for colleagues, employees
may be concerned that their colleagues may perceive their absence as
malingering. Therefore, they are tempted to report to work sick out
of loyalty to their colleagues (Dew et al., 2005).
Why Do People Go to Work Even When Unwell? 47
4.2.2 Time pressure

Sickness presenteeism is usually high when there is difficulty in
finding replacements since, in such a situation, work that is not done
or completed must be done by the employee concerned on his or her
return (Dew et al., 2005).
Box 4.1 NFID survey result
In a survey conducted by the National Foundation of Infectious Diseases

(NFID), 60 per cent of the respondents felt pressured to go to work as they
were concerned that their work may not get done, making it as one of the
top causes of presenteeism.
Source: Preziotti and Pickett (2006).
The above finding is consistent with that reported by Caverly et al.

(2007), who argue that the main cause of presenteeism is the fact
that employees are not able to find and secure additional resources
that could assist them on a given work assignment or project while
absent and as such higher levels of presenteeism will be exhibited.
The authors also argue that, with a lack of replacement and the need
to meet deadlines, presenteeism flourishes.
4.2.3 Employment conditions

Review of absence from work showed that a lack of external demand
in job-market conditions reduces absence from work. Job insecurity
is considered to be the most plausible explanation for sudden drops
in sickness absenteeism rates during periods of lay-offs (Luz and
Green, 1997).
In a study Patton (2012) reported that during economic downturns
one-third of workers are more likely to go to work ill. About half of
those who were willing to go to work sick indicated that the most
important reason for their decision was job security.
Box 4.2 Findings from Finnish studies
Two Finnish studies reported that an ‘epidemic of good health’ broke out
after a round of lay-offs had been announced in the study sites.
Source: Musich et al. (2006).
It is suggested that employees put in longer hours to appear dili-

gent when they feel insecure in their positions. Such employee
48 Presenteeism
behaviour can be viewed as promoting presenteeism (Worall and

Cooper, 2002).
Benefits received by employees can also affect the level of presen-
teeism exhibited – for example, unavailability of adequate sick and
family leave may induce presenteeism. Organizational attendance
policies may also encourage presenteeism. For example, when an
organization chooses to reward and encourage full attendance or to
implicitly reprimand employees when they do not turn up for work,
this would encourage employees to go to work despite being sick.
Box 4.3 Findings from NFID survey
One NFID survey found that 25 per cent of their respondents did not get
paid for sick days and 24 per cent of them got minimal or no sick time
off and 20 per cent feared that their bosses would be angry if they did
not turn up for work, thus inducing pressure on employees to report to
work sick.
4.2.4 Psychological issues

Psychological reasons may also be symptoms of a larger issue of pres-
enteeism prevalent in almost every workplace. Some employees may
feel guilty for missing work, which may be attributed to their strong
commitment to their jobs, which in turn increases the likelihood of
sickness presenteeism (Hansen and Andersen, 2008).
Box 4.4 Findings from NFID survey
An NFID survey also found that 48 per cent of the respondents felt guilty
for missing work.
4.2.5 Evidence from other empirical studies

Milano (2005) reports that nearly half of all American employees
admit being at work at least one to four days per year when they are
too ill or stressed to be productive. A survey by CIGNA Corporation
revealed that 25 per cent of the respondents came to work sick because
they needed money and 38 per cent cited a sense of duty towards
their company (Casale, 2008). Johns (2007) points out that one of
the reasons for presenteeism is associated with job insecurity related
to company downsizing or restructuring. Johns further suggests that
presenteeism might occur when employees think that the option of

absenteeism is not available or is perceived to be more costly.
MacGregor et al. (2008) reported that the number-one reason
for employees coming to work instead of being absent is that the
employees knew they had no backup for the work for which they
were responsible. When they returned to work, they would have
even more to do (Caverly et al., 2007). In addition to the perceived
personal costs of having more to do, employees felt they could not
find replacement personnel, had meetings to attend and work they
had to personally handle. Coming to work while ill was a better
option than their being absent. These authors also argue that stressful
life events are related to presenteeism to the same degree as they
are to absenteeism. This argument is consistent with the notion that
workers may have been substituting presenteeism for absenteeism.
Supervisors, managers and foremen have always worried about
absenteeism. Excessive absences are bad for employee morale and
bad for business. To counter such behaviour, supervisors try out
all possible ways to reduce absenteeism. Ramsey (2006) argues that
some managers may have gotten too good at getting workers to show
up and, as a consequence, more and more employees come to work
even when they are sick and should stay home. The other side of the
issue is that unchecked presenteeism can be as bad as, or worse than,
the consequences of excessive absenteeism. Employees with conta-
gious medical conditions could spread infection, and illness could
expand out of control and in a short time a healthy workplace could
turn toxic and become a hotbed of sickness. People become infected,
infect others, get well, then become infected all over again. It is a
self-perpetuating cycle that can drag down efficiency and effective-
ness at all levels of the organization (Ramsey, 2006).
For some employees, attending work while sick may have more to
do with a sense of duty than because of financial difficulty or lack of
personal or sick leave. Many employees attend work because they do
not want to disappoint their team members. According to a study by
Gurchiek (2009), two-fifths of workers attributed their work ethic and
dedication to be based on the belief that their company/co-workers
need them to be at work despite being ill or having other issues, while
about one-fourth of them did so because of financial needs.
Ramsey (2006) lists a number of reasons for which employees come
to work despite being sick (see Box 4.5).
50 Presenteeism
Box 4.5 Reasons for going to work sick
• Fear of falling behind: Employees feel that missing work due to sick-
ness might put them behind schedule.
• An ‘Iron Man Mentality’: Some employees believe that missing work
for sickness is a sign of weakness. To them, it is more important to
show that they are invincible.
• Reluctance to use sick leave: Employees would like to accumulate their
sick leave especially when they have the opportunity to cash them in.
• The ‘Indispensable Man Theory’: Some employees think that their
organization cannot run without their presence.
• Wishful thinking: Some people keep on hoping that they will get bet-
ter without missing work.
• Misguided sense of duty: They are highly conscientious and worried
about letting down their fellow workers, their bosses and the whole
organization if they miss work due to illness.
Source: Ramsey (2006).
Similar to Ramsey’s findings reported in Box 4.5, Prater and Smith

(2011) also reported a number of reasons cited by the respondents to
their survey.
Sickness and/or sick leave related reasons:

• not sick enough to use a sick day (42 per cent)1
• did not want to use their available sick days (17 per cent)
• did not have any sick days left to use (11 per cent)
Sense of duty and concern for colleagues

• sense of duty (29 per cent)
• did not want to burden colleagues (12 per cent)
• to prevent work from piling up (16 per cent)
• an approaching deadline (9 per cent)
Possible retaliation from supervisors/managers

• fear of losing job (21 per cent)
• may be viewed as a slacker if they stay home (18 per cent)
• fear of being penalized (12 per cent)
• still on probationary status (2 per cent)
Others
• needed money or had some financial obligations to meet
(41 per cent)
• nobody can do my job (8 per cent)

• could not find a replacement worker (17 per cent)
• were self-employed (8 per cent)
• have a scheduled meeting with clients (5 per cent)
• being in management positions and having subordinates
(4 per cent)
4.2.6 Stress
Prolonged exposure to stress can cause health problems, such as
severe headaches, stomach issues, back pain, neck pain and depres-
sion. For some employees suffering from emotional and phys-
ical stress, it becomes difficult to perform well on the job. If not
managed properly, stress creates pressure on individuals and fami-
lies, causing an individual to become easily agitated and less likely
to exhibit emotional control. Employees suffering from work- and
non-work-related stress may come to work for one or more reasons
mentioned above but then do not perform up to standards.
According to a study by the American Institute of Stress, stress
accounts for approximately 550 million days of absenteeism annually
in the United States. In the early 2000s, stress used to cost U.S. indus-
tries USD300 billion annually when assessed in terms of absenteeism,
lost productivity, turnover and direct costs. Further, according to the
American Psychological Association, stress-related costs annually
amount to USD7,500 per employee per annum (Ruez, 2004).
4.2.7 Depression
As in the case of stress, employees suffering from depression also come
to work due to some of the reasons cited above by Ramsey (2006) and
Prater and Smith (2011) and lose productivity. For example, according
to an estimate of the National Institutes of Health, depression costs
employers USD44 billion a year in lost productivity (Ruez, 2004).
Ruez (2004) argues that due to work–life conflict employees may
lose productivity. For example, employees may have a sick child or
parents at home requiring the employee’s presence, but due to organ-
ization policy and work pressure they are unable to leave the job as
and when necessary. It is obvious that in a situation like this the
employee may not be able to concentrate on his or her job.
A labour shortage may lead to burnout situations, especially in
some professions (e.g., health-care staff). Such employees try to
52 Presenteeism
manage increased workloads along with personal and family issues

that leave little time to care for their own health (Ruez, 2004). Under
such circumstances, overworked employees are presumed to perform
at a below normal standards.
When employees insist on working while sick (especially during
the flu season), outbreaks of illness only become worse and last
longer. As more people are affected and infected, performance
throughout the organization suffers as well. In fact, sick employees
who show up for work, do themselves, their co-workers and supe-
riors, no favours.
4.3 Long working hours and their possible impact

on employee health and performance
Researchers have pointed out that the long work-hour culture has
also impacted on many nations and organizations and also directly
influences the decision of employees to spend long hours at work
that may not be necessary.
4.3.1 Reasons for long work hours

Porter (2004) suggests that there are several reasons why people work
hard, and the actual hours worked are a function of a number of
factors. For example:
• hours desired by the worker

• hours demanded by the employer
• the institutional environment in which working-hour decisions
are made: legal, workplace norms and the larger economic envi-
ronment (Golden, 1998)
• possible reasons for working long hours may also be due to
economic recession, organizational downsizing and restructuring
and levels of family income (Burchell, 2002)
4.3.2 Primary motives for spending long hours at work

Research has identified four primary motives of employees working
long hours:
• joy of work
• avoiding job insecurity or negative sanctions from supervisor
• employers’ demands (Burke and Fiksenbaum, 2008)

• working long hours may in fact be a prerequisite to achieve senior
leadership positions, according to Jacobs and Gerson (1998) and
Wallace (1997)
4.3.3 Employee motives for working long hours

The positive reasons for working long hours may result in:
• more pay
• self-actualization
• a sense of commitment to colleagues and clients
• work enjoyment
Other motivations for working long hours could also include:
• avoiding sanctions
• dealing with employment insecurity
Burke and Fiksenbaum (2008) argue that although working long

hours may increase one’s competitiveness in the short-term, it may
not be sustainable and may prove to be counterproductive in the
long run. Moreover, working long hours may influence the employ-
ee’s physical and mental health and well-being by increasing stress,
and each of these reasons may have both desirable and undesirable
consequences for the individual, the organization or both. Some of
these arguments are listed below.
4.3.4 Long working hours and risk of heart attack

A study by the University College London team reports that working
more than 11 hours a day rather than the usual 9 to 5 markedly
increases the risk of heart disease. This finding is based on a study
of over 7,000 civil service employees whose health had been tracked
since 1985. The team also report that over the course of the 11-year
study, 192 of the participants suffered heart attacks (BBC News,
5 April 2011).
4.3.5 Long working hours and risk of depression

Working 11 hours a day can lead to severe depression. Staff members
who put in 11 or more hours a day at the office are more than twice
54 Presenteeism
as likely to suffer a major depressive episode than those working for

the British Civil Service standard of seven to eight hours a day. This
finding is based on a six-year-long study on the working habits of over
2,000 U.K. civil servants regarding how their work patterns related to
major depressive symptoms. This study was conducted by researchers
from Queen Mary, University of London, University College of
London, the University of Bristol, McGill University in Canada and
the Finnish Institute of Occupational Health. According to the report,
the link between long working days and depression persisted even
after the researchers controlled for factors such as job strain, the level
of support at the workplace, alcohol use, smoking and chronic phys-
ical diseases. However, researchers found that many of the subjects
who worked long hours are men at high grades with challenging jobs
and with relatively low levels of depression (McMillen, 2012; Cohen,
2012). A similar study in Hong Kong also found that among people
who work more than 50 hours per week, 35 per cent showed symp-
toms of depression. When working-week hours dropped to below 50,
the incidence of mental distress declined (Siu, 2013).
4.4 Working-hours trend in a selected number

of countries
A review of the historical trend in annual working hours in selected

countries noted that in 1870, the Netherlands, Germany and France
had very long working hours, exceeding 3,000 hours per year (57.72
hours per week), whereas the United States, the United Kingdom
and Australia had relatively much shorter working hours per year.
The practice of long working hours has since dropped significantly
and the numbers spread has narrowed to between 2,213 (the United
Kingdom) and 2,371 (the Netherlands). However, since the 1970s
these trends have started showing widening gaps. For example, in
the year 2000 the United States had the longest working hours, at
around 1,900 hours per year (approximately 38 hours per week),
which was closely followed by Australia and the United Kingdom.
The Netherlands, however, had the lowest annual working hours
with little over 1,300 hours per year (Lee et al., 2007).
Over the years, the working-hour trends of countries around
the world have declined further. The 2007 International Labour
Organization (ILO) report, ‘Working Time Around the World’,
confirmed that the 40-hour work week is now the dominant standard
internationally for normal hours of work, but substantial regional
differences remain (refer to Table 4.1). However, there are still a few
countries in which large proportions of workers work more than 48
hours per week. For example, according to the 2004–2005 ILO report,
about 50.9 per cent of Peru’s workers are employed more than 48
hours per week, followed by South Korea at 49.9 per cent of workers,
Thailand, 46.7 per cent and Pakistan, 44.4 per cent.3 Table 4.1 shows
the trend in working hours for a number of selected countries.
4.5 Working hours in ‘extreme jobs’
There are jobs in which employees work 70 hours a week or more,

termed by Hewlett and Luce (2006) as ‘extreme jobs’. These employees
are high-wage earners with jobs having at least five characteristics of
work intensity. Some of these characteristics are unpredictable work
flow, fast-paced work under tight deadlines, the job responsibility
amounts to more than one job, work-related events outside regular
work hours, availability to clients 24/7, responsibility for profit and
loss, and the like.
Hewlett and Luce (2006) carried out surveys of high-wage earners
in the United States and high-earning managers and professionals
working in large multinational organizations. Their surveys revealed
four distinct characteristics that created the most intensity and pres-
sure for these executives:
• unpredictability (91 per cent)

• fast pace with tight deadlines (86 per cent)
• work-related events outside business hours (66 per cent)
• 24/7 client demands (61 per cent)
The extreme job holders indicated a number of reasons for doing

such work:
• love their jobs (U.S. sample, 66 per cent, and global sample, 76
per cent)
• job is stimulating and challenging (over 85 per cent)
• working with high quality colleagues (about 50 per cent)
• high pay (about 50 per cent)
56 Presenteeism
Table 4.1 Comparative statistics on worked hours in selected countries,

1980–2006. (Approximate) Hours worked per year
Country 1870 (a) 1980 (b) 2006 (b)
USA 3000 (60.0)* 18204(36.4)* 1804 (36.08)*

Japan 2120 (42.4) 1780 (35.6)
United Kingdom 2800 (56.0) 1800 (36.0) 1740 (34.8)
Canada 1775 (34.9) 1740 (34.8)
Spain 1800 (36.0) 1600 (32.0)
Belgium 1760 (35.2) (1983) 1575 (31.5)
Netherland 3300 (66.0) 1540 (31.4) (1987) 1400 (28.0)
South Korea 2880 (57.6) 2300 (46.0)
Denmark 1650 (33.0) 1575 (31.5)
France 3050 (61.0) 1850 (37.0) 1555 (31.1)
Germany 3200 (64.0) 1750 (35.0) 1440 (28.8)
Norway 1580 (31.6) 1410 (28.2)
Sweden 1520 (30.4) 1570 (31.4)
Note: (a) These figures have been taken from Lee et al. (2007), p. 25.
(b) The average annual hours actually worked for 1980 and 2006 were read from the
charts (charts 1 through 5, pp. 14–15, 17–18 and 20) reported in Fleck (2009). The
annual working hours for these two years are based the OECD (Organization for
Economic Co-operation and Development) statistics reported in charts 1 through 5 of
the article.
Source: Fleck (2009). Figures in parenthesis (computed by the author) indicate number
of hours per week based on the assumption of 50 work weeks per year.
Further, individuals holding such jobs told that they had to give
up something for doing extreme jobs. For example, among other
things, they forego their:
• home maintenance (about 70 per cent)

• relationship with children (about 50 per cent)
• relationship with their spouses/partners (over 45 per cent)
4.6 Effects of long work hours on health
A number of negative effects of long working-hours culture on

human health have been identified by researchers, such as:
• impact on cardiovascular system through chronic exposure to

increase in blood pressure and heart rate (Uehata, 1991*)
• sudden death due to long hours and insufficient sleep (Kanai,
2006*)
• adverse health effects and increased safety risks (Harrington,

2001*; Cooper, 1996*)
• poor psychological health (Kirkcaldy et al., 2000*; Sparks et al.,
1997*)
• excessive fatigue (Rosa, 1995*)
• burnout (Barnett et al., 1999*)
• work–family conflict (Crouter et al., 2001*) and fatigue, worry, and
irritability (Grzywicz and Marks, 2000*; Geurts et al., 1999*).
* Source: Cited in Burke and Fiksenbaum (2008, pp. 9–10).
4.7 Summary
The present chapter discusses various issues that influence employees

to come to work despite being sick, and the impact of such employee
behaviour on lost productive time. The possible reasons for which
employees come to work despite being sick are examined. Work envi-
ronment, time pressure, employment conditions and psychological
factors are identified as the primary causes of presenteeism. Besides
these, issues related to stress, depression, long working hours and
presenteeism are discussed. In particular, the positive and negative
aspects of working long hours are explored. Research evidence from
literature linking these issues with presenteeism is also presented.
While discussing issues related to long work hours, the trend of
working hours in a number of countries is also discussed.
Notes
1. Figures in parentheses represent the proportion of total respondents who
participated in the survey.
2. Assuming 50 working weeks per year.
3. Published in the Times of India on 9 June.
4. OECD Statistics (Approximate numbers).
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5
Nature and Extent of
Presenteeism in Singapore
Three studies were conducted on the nature and extent of presen-

teeism in Singapore between 2008 and 2011. The first was conducted
between August 2008 and February 2009. Two hundred and forty-
four working adults participated in this study, of which 159 (65 per
cent) were reported to have gone to work despite being sick. The
second study was conducted between August 2009 and February
2010. Two hundred and eighty working adults took part, of which 268
(96 per cent) reported to have engaged in presenteeism behaviour. The
third study, conducted from August 2011 to February 2012, involved
462 working adults. Each of these studies focused on slightly different
issues of presenteeism. Extracts of these three studies are presented
separately in Chapters 5, 6 and 7. This present chapter is based on the
first Singapore study, between August 2008 and February 2009.
5.1 Cost of presenteeism to organizations in Singapore:

lost productivity by male and female employees1
According to the Health Promotion Board of Singapore (2007),

common ailments that Singaporeans suffer from include aller-
gies, diabetes, headaches, backaches, anxiety/stress, cough and
fever. These ailments are consistent with the top health conditions
commonly associated with sickness presenteeism as identified in the
literature. However, a literature review also indicates that a sizeable
proportion of Singaporeans suffer from eczema (Shahidullah et al.,
1995). Besides eczema, fever and cough are the two other medical
conditions commonly suffered by Singaporeans (Health Promotion
61
62 Presenteeism
Board, 2007). Therefore, these three additional health conditions

have been included in this study.
Evidence from the literature suggests that presenteeism is poten-
tially more financially impactful than absenteeism. For example,
Marlowe (2007) reported that a study by Dow Chemical on ten
common chronic conditions for 7,800 employees in 2002 revealed
that the cost of presenteeism averaged USD6,272 per employee per
annum as compared to only USD661 per annum for absenteeism.
Based on this example, it can be argued that organizations can reap
huge benefits by paying more attention to measuring and managing
presenteeism in the workplace.
The top health conditions commonly associated with sickness pres-
enteeism in the United States are: allergy, arthritis, diabetes, heart
disease, hypertension, migraine/headache, and asthma/respiratory
infections (Goetzel et al., 2004). Among these ten conditions examined
in the United States the highest presenteeism costs of illnesses were
from hypertension, heart disease, depression and arthritis. Another
study, in Australia, revealed that the biggest contributors to the overall
productivity loss due to health conditions were caused by allergies (19
per cent), followed by hypertension (14 per cent) and diabetes (9 per
cent). Other health conditions examined by presenteeism researchers
also included throat conditions (Goetzel et al., 2004), backaches,
stress/anxiety and flu (Hemp, 2004; Medibank, 2007).
5.2 Why do employees go to work despite being sick?
Several factors influence the presenteeism behaviour of employees;

as such, the identification and understanding of these underlying
causes are important for organizations. Literature indicates that ‘work
environment’, ‘time pressure’ and ‘employment conditions’ are the
primary work-related factors that can influence an employee’s deci-
sion to turn up ill at work. These three factors are elaborated below.

The work environment plays a major role in driving presenteeism.
Dew et al. (2005) described work environment as a ‘battleground’, a
‘ghetto’ or a ‘sanctuary’ where it differs across aspects such as pres-
sures faced by employees and the way in which employees cope,
control and make choices.
Nature and Extent of Presenteeism in Singapore 63
Perceptions of work, including clarity of roles, job demand and

control, and the quality of relationships are related to sub-optimal
work performance (Barnes et al., 2008). Grinyer and Singleton (2000)
pointed to the influence of teamwork and pressure from colleagues on
the employee’s decision to turn up ill at work. The study by Hansen
and Andersen (2008) found that when higher levels of cooperation in
performing work tasks are required, higher levels of sickness presen-
teeism are displayed as employees are more dependent on each other
in the completion of tasks. This finding is also supported by Luz and
Green (1997), who found that employee cohesiveness might restrain
absence from work. Also, employees tend to be more concerned about
having colleagues carrying an extra workload for them during their
absence, so they turn up for work despite feeling ill.
5.2.2 Time pressure

Sickness presenteeism is high when there is difficulty in finding
replacements (Dew et al., 2005). In such a situation, work not
performed because of absence must be caught up with by the person
concerned on his/her return. A survey conducted by the National
Foundation for Infectious Diseases (NFID) found that in the United
States 60 per cent of the respondents felt pressured to go to work, as
they were concerned that their work might not get done, making this
one of the top causes of presenteeism (Preziotti and Pickett, 2006).
This finding is consistent with that of Caverley et al. (2007), who
found that the main cause of presenteeism was employees not being
able to find and secure additional resources that could assist them
on a given work assignment or project while absent. The authors also
argued that with a lack of replacement and the need to meet dead-
lines, higher levels of presenteeism will be exhibited.
5.2.3 Employment conditions

In a review of certified absence from work, Luz and Green (1997)
found that a lack of external job demand in the marketplace reduces
employee absence from work. In addition, job insecurity was shown
to be the most plausible explanation for the sudden drop in sick-
ness absenteeism rates during periods of lay-offs. Two Finnish studies
reported that an ‘epidemic of good health’ broke out after a round of
lay-offs had been announced in the study sites (Virtanen, 1994). It
is argued that employees will be compelled to work harder and put
64 Presenteeism
in longer hours to appear diligent when they feel insecure in their

positions (Worall and Cooper, 2002). Such behaviours can be viewed
as promoting presenteeism (Dew et al., 2005).
Further, benefits received by employees can also affect the level of
presenteeism. The NFID survey found that 25 per cent of their respond-
ents did not get paid for sick days and 24 per cent of them got minimal
or no sick time off, while 20 per cent feared that their bosses would be
angry if they did not turn up for work, thus inducing pressure on sick
employees to report for work (Preziotti and Pickett, 2006).
5.2.4 Psychological issues

Psychological reasons may be symptoms of a larger issue prevalent in
almost every workplace. For example, 48 per cent of the respondents
in a NFID survey felt guilty for missing work (Preziotti and Pickett,
2006). This can be attributed to their strong commitment to work
that increases the likelihood of sickness presenteeism (Hansen and
Andersen, 2008).
5.3 Economic impact of presenteeism
Marlowe (2007) argued that better health leads to enhanced produc-

tivity, while poor health degrades it. When employees report to work
sick, there is a detrimental effect on their job productivity and work
quality because employee health status is linked to productivity. In a
survey of 29,000 employed adults, one in eight respondents (12.5 per
cent) reported for work in pain or physical discomfort at least once
in any two-week period (Milano, 2005). This implies that produc-
tivity loss due to poor health condition for an employee may occur
approximately once every fortnight.
5.4 Productivity loss due to sickness presenteeism
It is apparent that when employees are inclined to report to work

unwell, they accomplish little or no work for several workdays each
year (Heinen, 2007). Therefore, it can be argued that the assumption
of showing up at work is tantamount to getting the job done may be
flawed. Sick employees tend to lose concentration, take longer to get
work started, repeat tasks, accomplish nothing at all that day or feel
fatigued more easily, resulting in productivity loss.
As most research on presenteeism was conducted in Western

countries, certain findings may not be entirely generalizable to
other parts of the world. For example, a study examining how
managers handle different work events in 47 countries reported
that managers in countries with high-power distance, collec-
tivism, hierarchy, and masculinity relied more on vertical sources
of guidance, such as formal rules and procedures or advice from
superiors (Smith et al., 2002). On the other hand, managers in
countries with strong individualism, egalitarianism, femininity,
and autonomy cultures favoured more participative forms of guid-
ance, such as ideas and opinions of subordinates. Overall, the find-
ings indicate that cultural values influence managerial behaviour
and organizational communication (Francesco and Gold, 2005).
Therefore, it can be argued that cultural differences may influence
the nature and extent of presenteeism behaviour, which may vary
from culture to culture. In addition, most studies do not report
the differences in the extent of presenteeism exhibited by female
and male employees. In view of the above-mentioned gaps in the
literature, the proposed Singapore study seeks to understand the
nature and extent of productivity loss due to sickness presenteeism
in Singapore.
Understanding the major predictors of sickness presenteeism
along with the extent of productivity loss, organizations may be
interested in paying more attention to such hidden sources of
productivity loss and to developing strategies to deal with this
important issue.
5.5 Hypotheses
Based on a review of literature on the subject, the following three

hypotheses were developed:
5.5.1 Work-related factors and sickness presenteeism

We postulate that a supportive work environment will have a negative
relationship with the degree of prevalence of sickness presenteeism.
Hypothesis 1: There is a significant negative relationship between

a supportive work environment and the level of sickness presen-
teeism in an organization.
66 Presenteeism
5.5.2 Overall work effectiveness and sickness presenteeism

Studies have shown that there is a negative relationship between the
severities of health conditions and the ability to handle workload,
concentration and work output without mistakes (Hemp, 2004).
Further, sickness presenteeism also has a negative effect on the quan-
tity and quality of work completed (Hummer et al., 2002). Employees
exhibiting sickness presenteeism would have an increased poten-
tial for errors and reduced attention span (Middaugh, 2007). Such
health conditions may also create the need to repeat a task, or cause
employees to work more slowly. Therefore, we postulate that there
is a negative relationship between sickness presenteeism and work
effectiveness.
Hypothesis 2: There is a significant negative relationship between

overall work effectiveness and the level of sickness presenteeism
exhibited by employees.
5.5.3 Gender differences and sickness presenteeism

There are differences in the manner in which male and female
employees respond to factors in their work environment. Authors
have found that women are more aware than men of the work
culture, particularly relating to gender and of its potential impact on
performance. Men, on the other hand, are more likely to feel comfort-
able with prevailing attitudes and practices, which they perceive as
gender-neutral and ‘normal’ (Simpson, 1998). Some authors report
that women exhibit significantly higher average percentages of
presenteeism compared with men (Kanter, 1977; Freeman, 1992).
Therefore, we hypothesize that in Singapore, female employees will
demonstrate higher levels of productivity loss due to presenteeism
than men.
Hypothesis 3: The level of sickness presenteeism exhibited by

female employees will be significantly higher than that of their
male counterparts.
5.6 Methodology
The Singapore study adopted cross-sectional survey research to
examine the phenomenon of sickness presenteeism in working adults
in Singapore. A detailed questionnaire was developed drawing upon

several self-report-based productivity measurement instruments: for
example, Migraine Work Productivity Loss Questionnaire (MWPLQ),
Work Productivity and Activity Impairment: General Health (WPAI:
GH), and Health and Work Questionnaire (HWQ).
The questionnaire was structured to collect demographic informa-
tion, the current work environment of the respondents, and the prev-
alence and possible predictors of sickness presenteeism. The survey
was conducted from September to November 2008. Respondents
were required to answer questions based on a recall period of the
previous three months. The short recall period ensured maximum
accuracy of information because participants were recalling within a
specific time period and not for a longer period.
For employees who suffered from sickness presenteeism within
this recall period of three months, three work-related questions were
asked regarding their ability to operate effectively at work: difficul-
ties experienced; effects of health conditions; and work performance.
The responses collected via the questionnaire were used to estimate
productivity losses based on the amount of time that an individual
is impaired in his or her daily work (the sample questionnaire is
attached in Appendix 5.1).
The draft questionnaire was pilot-tested, via e-mail, with 20 working
adults. Feedback received from these subjects was used to refine the
questionnaire. The amended questionnaire was distributed randomly
to working adults in Singapore, 244 of whom completed it.
Instead of computing the presenteeism losses of specific ailments,
this study adapted the formula used by Goetzel et al. (2004) in
computing the loss of productivity. The combined loss of produc-
tivity due to all of the reported health conditions was computed.
5.7 Descriptive statistics of the sample
5.7.1 Demographics
Of the total 244 respondents, 57 per cent were females; 67 per cent
of whom were within the age group of 35 and below. Less than half
of the respondents (42 per cent) worked for the service industry and
16 per cent for manufacturing. About 30 per cent of the respondents
were professionals, 29 per cent held administrative positions and
68 Presenteeism
28 per cent were in the category of executives. Close to 80 per cent

of the respondents worked five days a week and 53 per cent worked
between 41 and 50 hours per week. Almost half of the respondents (44
per cent) earned a gross income between SGD2,000 and SGD4,000 per
month.
5.7.2 Sickness presenteeism

In line with the objectives of the study, data were collected on the
causes of presenteeism, frequency of health problems affecting
employees and the effects of these conditions on their productivity.

Work environment was predicted to have some influence over one’s
inclination to go to work while sick. Data reveal that most of the
respondents (83 per cent) were satisfied with their work environ-
ment and 76 per cent enjoyed going to work. Their working relation-
ships with colleagues and supervisors were generally good, with the
majority (90 per cent) agreeing that their colleagues were friendly
and helpful and that supervisors encouraged and supported them
(75 per cent). The majority (78 per cent) also reported that there were
no conflicts with their colleagues.
5.7.4 Reasons for going to work unwell

Some of the reasons cited by the respondents for going to work even
though they were sick were: work commitments (76 per cent), need
to meet deadlines (59 per cent), the illness was not serious enough to
make them stay at home (55 per cent), concern about work not being
done (47 per cent) and negative feelings about colleagues covering
their duties (37 per cent).
5.7.5 Health conditions with which respondents went to

work during last three months
About two thirds (65 per cent) of the respondents reported that they
had been to work despite feeling unwell during the past three-month
period. Among the 14 health conditions studied, cough (48 per cent),
throat conditions (32 per cent), fever (32 per cent) and headaches/
migraines (31 per cent) were among the top four illnesses with which
they went to work.
Table 5.1 Top five effects of health conditions on work performance
Frequency of responses (%)
Somewhat Agree, Agree,

Effects of health conditions Strongly Agree
1. Workload heavier than usual. 58.0

2. Could still produce high-quality work. 55.0
3. Could not do work as carefully as usual. 53.0
4. Unable to take pleasure in work. 51.0
5. Accomplished less than what I could. 51.0
Table 5.2 Top five difficulties experienced at work due to health conditions
Frequency of responses (%)
Moderate, High and Very

Difficulties Experienced High Difficulty
1. Focusing on work. 72.0

2. Concentrating on work. 70.0
3. Getting started at the beginning of the day. 69.0
4. Thinking clearly. 68.0
5. Pacing oneself to get through the day. 67.0
5.7.6 Effects of health conditions on work performance

According to this survey, 58 per cent of the respondents indicated that
when they were at work while sick, the workload appeared to be heavier
than usual. Fifty three per cent could not do the work as carefully,
51 per cent accomplished less than what they could do under normal
health conditions, and 51 per cent were unable to take pleasure at
work. Refer to Table 5.1 for the top-five effects of performance.
5.7.7 Difficulties experienced while at work despite being sick

Due to the effects of the health conditions, 72 per cent of the
respondents reported that it was particularly hard for them to focus,
and 70 per cent said they had difficulty concentrating on their work.
Further, 69 per cent also found it difficult to get started at the begin-
ning of the day. Table 5.2 displays the top-five reported difficulties
experienced at work due to the effects of health condition(s).
70 Presenteeism
5.7.8 Work performance during the last three months

About 69 per cent of the respondents indicated that while at work
despite being sick during the past three months, approximately two
to four hours of their working time was lost (refer to Figure 5.1).
5.8 Test of hypotheses
Hypothesis 1: In this hypothesis it was postulated that there was

a negative relationship between factors in the work environment
and the level of sickness presenteeism.
Statistical analysis supported this hypothesis by showing a
significant negative relationship between work environment and
Hypothesis 2: This hypothesis proposed that there was a negative
relationship between overall work effectiveness and the level of
Multiple regression analysis supported this hypothesis showing
that sickness presenteeism negatively affected work effectiveness.
Hypothesis 3: It was predicted in this hypothesis that the hours
lost due to sickness presenteeism exhibited by female employees
will be different from that of their male counterparts. As in the
first two hypotheses, Hypothesis 3 also showed significant differ-
30
27.0
24.5
25
20
17.6
20
10 8.8
6.9 6.3
5.7
5 3.2
0.0
0
0hour 1hour 2hours 3hours 4hours 5hours 6hours 7hours above 7
hours
Figure 5.1 Hours affected due to health conditions during the past three
months (Y-axis: Per cent of respondents)
ences between the level of presenteeism of male and female

employees.
5.9 Cost of sickness presenteeism to organizations
5.9.1 Overall sickness presenteeism exhibited by employees

In computing the cost of sickness presenteeism, we used the formula
proposed by Goetzel et al. (2004). Of the 244 respondents, 159 of
them reported that they had come to work unwell during the past
three months. Based on the survey, the respondents usually worked
an average 8.3 hours per day when feeling well. Details for the steps
of computing the cost of presenteeism are presented below.
5.9.2 Cost of sickness presenteeism to organizations

To compute the cost of sickness presenteeism to organizations, the
estimated on-the-job productivity loss reported in the earlier section
was converted into monetary value.
Table 5.3 below shows the annual labour cost per employee. Part of
the table was used for the calculation of the total benefits received by
each employee. The calculations are as follows:
Total Benefits (shown in Table 5.3) = Average Benefits + Employer’s

Central Provident Fund (CPF) Contribution
Average Benefits (excluding CPF related benefits) = Annual Wage
Supplement (AWS)/Bonus + Non-Wage Cost + Annual Leave + Sick
Leave (shown in Table 5.4 below)
Table 5.3 Annual labour cost per employee, by industry and cost component,
2005
Wage cost (SGD) Non-Wage Cost (SGD)
Basic
Wage,
Total Overtime Medical
Labour and Other Employer’s Cost and Net Other
All Cost Regular AWS/ CPF Other Training Labour
Industries ($) Total Payments Bonus2 Contributions Levy3 Insurance 4 Cost5 Cost
Total 47,213 44,187 33,771 7,035 3,382 357 574 521 1,574
Source: Extracted from the Singapore Yearbook of Manpower Statistics, Ministry of Manpower
(2005, Table 2.10, p. 55).
72 Presenteeism
Table 5.4 Average benefits for each salary range

Salary Average
range benefits
(S$ per Mid- AWS/ Non-wage Annual Sick (S$ per
month) Point Bonus6 cost7 leave8 leave9 year)
< 2,000 1,000 7,035 3,026 672 240 10,973

2,001– 3,000 7,035 3,026 2,016 720 12,797
4,000
4,001– 5,000 7,035 3,026 3,360 1,200 14,621
6,000
6,001– 7,000 7,035 3,026 4,704 1,680 16,445
8,000
8,001– 9,000 7,035 3,026 6,048 2,160 18,269
1,0000
10,001– 11,000 7,035 3,026 7,392 2,640 20,093
12,000
>12,000 13,000 7,035 3,026 8,736 3,120 21,917
The total annual income includes the gross annual income and
the total benefits received by the employee. Using the respective
percentages of the eligible work time lost per annum shown in the
earlier sections, the cost of sickness presenteeism to organizations for
different genders of employees has been computed.
When an employee (regardless of gender) aged 50 and below,
earning a mean salary of SGD3,000 per month reports to work sick,
3.88 per cent of his/her eligible work time per annum is lost due to
sickness presenteeism. This amounts to an average cost SGD2,096
per annum to the organization concerned when an employee goes
to work ill. This is almost half a month’s salary foregone each year
due to the effects of health conditions on the employee, which is on
top of other potential sources of productivity losses. Table 5.6 below
shows the details.
Plugging the relevant numbers into the formula mentioned above,
time lost per year due to sickness presenteeism by all the respondents
who reported having gone to work despite being sick was 3.88 per
cent. Similar calculations showed that the loss of productivity due
to sickness presenteeism was 3.71 per cent for male employees and
4.17 per cent for the female employees. Therefore, according to this
study, sickness presenteeism exhibited by the female employees was
12.4 per cent higher than that of their male counterparts. This
Table 5.5 Total benefits for each salary range and age group
Employer’s
Average CPF Total
Salary range Mid- point Age group benefits contribution10 benefits
< 2,000 1,000 50 and 10,973 1,740 12,713

below
51–55 1,260 12,233
56–60 900 11,873
Above 60 600 11,573
2,001–4,000 3,000 50 and 12,797 5,220 18,017
below
51–55 3,780 16,577
56–60 2,700 15,497
Above 60 1,800 14,597
4,001–6,000 5,000 50 and 14,621 8,700 23,321
below
51–55 6,300 20,921
56–60 4,500 19,121
Above 60 3,000 17,621
Table 5.6 Cost of sickness presenteeism to organizations (in Singapore

dollars)
Cost Of Sickness
Presenteeism
Total
Annual Overall Male Female
Monthly Age Income (3.88%) (3.71%) (4.17%)
Salary range Mid-point group USD USD USD USD
< 2,000 1,000 50 and 24,713 959 917 1,031

below
51–55 24,233 940 899 1,011
56–60 23,873 926 886 996
Above 60 23,573 915 875 983
2,001–4,000 3,000 50 and 54,017 2,096 2,004 2,253
below
51–55 52,577 2,040 1,951 2,192
56–60 51,497 1,998 1,911 2,147
Above 60 50,597 1,963 1,877 2,110
4,001–6,000 5,000 50 and 83,321 3,233 3,091 3,474
below
51–55 80,921 3,140 3,002 3,374
56–60 79,121 3,070 2,935 3,299
Above 60 77,621 3,012 2,880 3,237
74 Presenteeism
finding also supports Hypothesis 3 that female employees

exhibit higher levels of sickness presenteeism than their male
counterparts.
5.10 Discussions
Past research has shown that sickness presenteeism has a significant

impact on employees’ productivity and causes negative economic
impact on businesses. Although the earlier studies identified aller-
gies, diabetes, heart disease, hypertension and headaches/migraine
as the top health conditions commonly associated with sickness
presenteeism, the present study found flu, cough, throat condi-
tions, fever and headaches/migraine as the top-five ailments in the
Singapore sample. In this study, diabetes and heart diseases were not
found to be in the top-five health conditions associated with sick-
ness presenteeism in Singapore. This could be due to the fact that the
survey population was relatively young (67 per cent were below the
age of 35). Similar to presenteeism studies in other countries, head-
aches/migraine was also found in the present study to be among the
top health conditions.
In this study, the top three reasons cited as the cause for coming
to work while ill were ‘work commitment’, ‘the need to meet dead-
lines’ and ‘the illness is not serious’, whereas the reasons cited in
the NFID (National Foundation for Infectious Diseases) survey
were different from this study. The NFID study reported different
reasons for employees going to work sick: ‘having concerns about
their work not getting done’, ‘having minimal or no sick time
off’ or ‘fearing that their bosses will be angry’ (Preziotti and
Pickett, 2006). The difference in findings in these two studies
could be due to cultural and value differences, as well as to differ-
ences in job content and HR policies of the organizations of the
respondents.
In general, this study reveals that the health conditions
commonly associated with sickness presenteeism in Singapore are
relatively minor, and chronic illnesses such as diabetes, hyper-
tension, heart disease and arthritis were not the major contribu-
tors to this phenomenon. A majority of the respondents reported
at least two to three hours of productivity loss during the three
months of the recall period (Figure 5.1) due to the effects of health
conditions.
As noted earlier, sickness presenteeism results in lack of concen-
tration, lower quality work and poor teamwork, which ultimately
results in lower output per hour worked (Greer et al., 2008). Through
Hypothesis 2, this study confirmed that personal impairments faced
by employees reduced their efficiency and overall performance.
This is consistent with the studies of (Milano, 2005; Lavinge et al.,
2003).
In Hypothesis 3, it is stated that the level of sickness presenteeism
exhibited by female employees will be significantly different from
males. The calculation of productivity loss due to presenteeism
shows a higher percentage for female employees as compared to their
male counterparts. Literature suggests that women’s careers have
always progressed in less orderly routes, characterized by changes
in direction, organization and career breaks (Burke and McKeen,
1994). Another study argued that women face greater pressures to
perform at work, especially in male-dominated cultures in corpora-
tions. In male-dominated organizations, women with children are
seen to experience work-time pressures most keenly and have the
greatest difficulty reconciling the conflicting demands of home and
work (Simpson, 1998). Further, authors argue that additional pres-
sures to perform and uncertainty in their career paths have led to
higher levels of presenteeism as a form of resistance, which results in
females exhibiting higher levels of sickness presenteeism than males
(Kanter, 1977).
5.11 Conclusions and implications
The findings from this study showed that sickness presenteeism is

prevalent in Singapore, resulting in loss of valuable productive time
which, in turn, results in hidden financial losses. Being an Asian
society with predominantly Confucian values, hard work and
presence in the workplace are Singaporean virtues. To avoid being
labelled as less hard-working, many employees choose to report to
work even when sick.
Besides helping employers understand the reasons behind
sickness presenteeism and cost estimations of sick employees’
76 Presenteeism
productivity losses, excellent management of presenteeism can

lead to: productivity improvements, increases in employee moti-
vation, loyalty and enhancement of employer branding. The
Institute for Health and Productivity Management, USA states
that investments to reduce presenteeism are rare, although they
offer greater opportunities to get ahead of the competition as
compared to investments in traditional areas such as training
(Hemp, 2004).
Hummer et al. (2002) argue that when employers focus on
managing presenteeism as an important part of health-care bene-
fits, their employees’ health can be transformed from a cost burden
to a competitive advantage. Therefore, to manage presenteeism
effectively it is important for employers to have a good under-
standing of presenteeism and its major contributors within their
organizations to implement changes that will help reduce presen-
teeism (Ventresca, 2008). Firstly, employers can be more involved
in employees’ health-care matters. Information about particular
ailments should be readily available to employees to understand
how they are impaired in work performance. It would be helpful
to teach employees how to better manage their illnesses (Hemp,
2004). A review on the return on investment (ROI) of corporate
health and productivity management initiatives recommended
the use of multiple corporate programmes that include health risk-
appraisal surveys to identify people at high risk for poor health,
the process of prioritizing sick into risk-appropriate intervention
programmes, tailored communication and health education, self-
care materials and appropriate follow-up to monitor progress. ROI
estimates ranged from USD1.49 to USD5.81 in savings per dollar
spent on worksite health-promotion programmes (Goetzel et al.,
1998; Ozminkowski and Goetzel, 1999; Aldana, 2001; Chapman,
2005). Efforts to reduce presenteeism in organizations still depend
largely on management. It is crucial for them to believe that healthy
employees are an asset that merits investment (Hemp, 2004) and
commit to address sickness presenteeism before the hidden costs
can be reduced.
Appendix 5.1
Presenteeism survey in Singapore: Questionnaire

PERSONAL INFORMATION
1. What is your gender?
• Male
• Female
2. What is your marital status?
• Single
• Married
• Divorced
• Widowed
3. What is your age?
• < 25
• 25–35
• 36–45
• 46–55
• > 55
4. What is your employment type?
• Full Time
• Part Time
JOB INFORMATION
5. Please select the industry that your company is in.
• BioMedical
• Gas/Oil
• Finance
• Food & Beverages
• Manufacturing
• Retail
• Services Transportation & Logistics
• If others, please specify:
6. Please select the occupational group which you belong to.
• Administrative & Support
• Technicians
• Executives
• Managers
• Professional
78 Presenteeism
• Directors
7. Please select your gross monthly income range.
• < SGD 2000
• SGD 2001 – SGD 4000
• SGD 4001 – SGD 6000
• SGD 6001 – SGD 8000
• SGD 8001 – SGD 10000
• SGD 10001 – SGD 12000
• > SGD 12000
8. How many days do you work every week?
• 1 day
• 2 days
• 3 days
• 4 days
• 5 days
• 6 days
• 7 days
9. On average, how many hours do you work every week?
• < 20 hours
• 20–30 hours
• 31–40 hours
• 41–50 hours
• > 50 hours
WORK ENVIRONMENT
10. Please select the option that best describes your working
environment.
Strongly Somewhat Somewhat Strongly

disagree Disagree disagree Neutral agree Agree agree
(a) My ☐ ☐ ☐ ☐ ☐ ☐ ☐
colleagues
are friendly
and helpful
(b) I get along ☐ ☐ ☐ ☐ ☐ ☐ ☐
well with my
colleagues
Continued
(c) I am satisfied ☐ ☐ ☐ ☐ ☐ ☐ ☐
with my
work
environment
(d) My ☐ ☐ ☐ ☐ ☐ ☐ ☐
supervisor
will
encourage
and support
me when I
encounter
difficulties
at work
(e) I can confide ☐ ☐ ☐ ☐ ☐ ☐ ☐
in my
supervisor
when I have
problems
(f) I do not have ☐ ☐ ☐ ☐ ☐ ☐ ☐
conflicts
with my
colleagues
(g) I enjoy going ☐ ☐ ☐ ☐ ☐ ☐ ☐
to work
HEALTH CONDITIONS
11. On average, how often have you been to work despite feeling
unwell each year?
• Never
• Occasionally
• Sometimes
• Often
• Always
If your answer to the above question is NEVER, please

proceed to end the survey. Thank you.
12. Please indicate the frequency of you experiencing these health

problems each year and still reporting to work.
80 Presenteeism
Never Occasionally Sometimes Often Always
(a) Allergies ☐ ☐ ☐ ☐ ☐
(b) Anxiety/Stress ☐ ☐ ☐ ☐ ☐
(c) Arthritis ☐ ☐ ☐ ☐ ☐
(d) Asthma/ ☐ ☐ ☐ ☐ ☐
Respiratory
Problems
(e) Backaches ☐ ☐ ☐ ☐ ☐
(f) Cough ☐ ☐ ☐ ☐ ☐
(g) Diabetes ☐ ☐ ☐ ☐ ☐
(h) Eczema ☐ ☐ ☐ ☐ ☐
(i) Fever ☐ ☐ ☐ ☐ ☐
(j) Flu ☐ ☐ ☐ ☐ ☐
(k) Heart Diseases ☐ ☐ ☐ ☐ ☐
(l) Headaches/ ☐ ☐ ☐ ☐ ☐
Migraine
(m) Hypertension ☐ ☐ ☐ ☐ ☐
(n) Throat ☐ ☐ ☐ ☐ ☐
Conditions
13. On average, how many DAYS in a year do you suffer from these
health conditions? (If you have never experienced the health
condition(s), ignore the particular field.)
• Allergies
• Anxiety/Stress
• Arthritis
• Asthma/Respiratory
Problems
• Backaches
• Cough
• Diabetes
• Fever
• Flu
• Heart Diseases
• Headaches/Migraine
• Hypertension
• Throat Conditions
• Eczema
• Others
14. Please select the reason(s) for going to work despite feeling unwell.
(You may select more than one reason.)
• I have to go to work because of work commitments.

• There is a need to meet with deadlines.
• I am concerned about my work not getting done if I take
leave.
• I have too much work to clear and cannot afford to go on
leave.
• My salary/bonus is dependent on my attendance at work.
• I feel guilty for missing work.
• I am not paid for taking sick leave.
• My illness is not serious and I can still go to work.
• I have minimal/no sick time off.
• There is no one to replace me if I were to go on sick leave.
• I have to work long hours to appear diligent.
• I do not have any more sick leave to take.
• I want to save my sick leave for later part of the year.
• My supervisor commented that I am sick too often.
• I do not feel good when my colleagues have to take over my
workload during my absence.
• Attendance at work is one of the indicators for my
performance.
• Supervisors will form a negative impression of me if I take too
much leave.
15. During the last THREE MONTHS, have you been to work despite
feeling unwell?
• Yes
• No
If your answer to the above question is NO,

please proceed to end the survey. Thank you
16. You have been to work despite feeling unwell during the last three
months. Please select the health problem(s) that you suffered
from within the last THREE MONTHS.
• Allergies
• Anxiety/Stress
• Arthritis
82 Presenteeism
• Asthma/Respiratory Problems
• Backaches
• Cough
• Diabetes
• Eczema
• Fever
• Flu
• Heart Diseases
• Headaches/Migraine
• Hypertension
• Throat Conditions
Very Low Low Moderate High Very High

(a) Getting started ☐ ☐ ☐ ☐ ☐
at the beginning
of the day
(b) Pacing yourself ☐ ☐ ☐ ☐ ☐
to get through
the day
(c) Thinking clearly ☐ ☐ ☐ ☐ ☐
(d) Concentrating ☐ ☐ ☐ ☐ ☐
on your work
(e) Focusing on your ☐ ☐ ☐ ☐ ☐
work
(f) Doing your work ☐ ☐ ☐ ☐ ☐
without making
errors
(g) Doing things ☐ ☐ ☐ ☐ ☐
that require
physical strength
(h) Controlling your ☐ ☐ ☐ ☐ ☐
emotions
(i) Working in noisy ☐ ☐ ☐ ☐ ☐
areas
(j) Working near ☐ ☐ ☐ ☐ ☐
bright/flashing
lights
17. The following questions ask about the difficulty you had because
of the health problem(s) experienced during the last THREE
MONTHS. Select the option that best describes the difficulty
experienced during the entire period of time when you had these
health problem(s).
Scale:
Very Low (0–20 per cent),
Low (21–40 per cent),
Moderate (41–60 per cent),
High (61–80 per cent),
Very High (81–100 per cent).
18. The following question is on the effect of your health problem(s)

on your ability to work and perform regular activities within the
last THREE MONTHS. Please select your answer carefully.
Strongly Somewhat Somewhat Strongly

disagree Disagree disagree Neutral agree Agree agree
(a) I was unable ☐ ☐ ☐ ☐ ☐ ☐ ☐

to take
pleasure in
my work.
(b) My workload ☐ ☐ ☐ ☐ ☐ ☐ ☐
seems
heavier than
usual.
(c) I am unable ☐ ☐ ☐ ☐ ☐ ☐ ☐
to finish
my tasks on
time.
(d) I could still ☐ ☐ ☐ ☐ ☐ ☐ ☐
produce
high-quality
work.
(e) I was limited ☐ ☐ ☐ ☐ ☐ ☐ ☐
in the kind
of work I
could do.
(f) I accom- ☐ ☐ ☐ ☐ ☐ ☐ ☐
plished less
than what I
would like.
(g) I could not ☐ ☐ ☐ ☐ ☐ ☐ ☐
do my work
as carefully
as usual.
(h) I was still as ☐ ☐ ☐ ☐ ☐ ☐ ☐
efficient as I
usually am
in my work.
84 Presenteeism
19. This question is on your performance during the last THREE

MONTHS when you had this illness(es). Rate each question on
a scale from 1 to 10 where 10 reflects the highest level that you
think you could possibly achieve and 1 being the lowest level you
have ever experienced at work.
My worst ever ………………………………………..My best

ever
1 2 3 4 5 6 7 8 9 10
(a) Overall ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
amount
of work
completed
(b) Overall ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
quality of
work
(c) Overall ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
efficiency in
completion
of work
(d) Overall ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
effective-
ness
(e) Overall ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
work
performance
20. Based on the health condition(s) experienced by you during

the last THREE MONTHS, on average, how many hour(s) a day
does your work get affected?
• 0 hour
• 1 hour
• 2 hours
• 3 hours
• 4 hours
• 5 hours
• 6 hours
• 7 hours
• >7 hours
Notes
1. This study was funded by a research grant by the Nanyang Business School,
Nanyang Technological University (ID# RCC21/2006). The present author
was the principal investigator on the project. M.C. Lam, X.W. Ong and R.Z.
Tan, final-year business students, actively participated in the project and
used the data collected for their undergraduate final-year research project
under the supervision of the author, Department of Strategy, Management
and Organization of the Nanyang Business School.
2. Includes performance bonus for employees.
3. Includes Foreign Workers’ and Skills Development Fund Levies.
4. Includes medical and dental benefits, premium for workmen’s compen-
sation insurance, medical and life insurance.
5. Net training cost refers to the net amount incurred after deducting cost
recovered from the SDF. (It includes course fees, rental of premises/
facilities for training purposes and other monetary allowances given to
trainees as well as cost of training materials incurred in providing struc-
tured on-the-job training).
6. AWS/Bonus figure is taken from table 20.
7. Non-wage cost is derived from the sum of levy, medical cost and other
insurance, net training cost and other labour cost in table 20.
8. For detailed calculations of cost of annual leave, refer to Appendix J,
p. 88.
9. For detailed calculations of cost of sick leave, please refer to Appendix J,
p. 88.
10. For detailed calculations of employer’s CPF contribution, please refer to
Appendix J, p. 88–89.
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6
Impact of Chronic and
Non-chronic Health Conditions
on Presenteeism: A Study in
Singapore
6.1 Introduction
This was a study conducted between August 2009 and February

2010, in which 279 working adults participated. Of this sample, 268
(96 per cent) reported to have engaged in presenteeism behaviour.
The cost of presenteeism for each of the health conditions examined
was included in the study, which primarily focused on the impact
of chronic and non-chronic health conditions on presenteeism. The
study also examined the extent of presenteeism between executive
and non-executive employees.
Details on what is presenteeism and why employees in Singapore
go to work despite being sick were discussed in Chapters 2 and 5
and as such this chapter will skip the information presented earlier
and directly move to other issues related to sickness presenteeism,
including: hypothesis development, data collection, data analysis
and the computation of cost of presenteeism for chronic and acute
health conditions in Singapore.
6.1.1 Psychological factors

The psychological influence on sickness presenteeism is known as
‘individual boundarylessness’, a personality characteristic that makes
it difficult for people to reject others’ wishes and demands (Aronsson
and Gustafsson, 2005). Similarly, Siegrist (1996) described it as ‘over-
commitment’. It can thus be concluded that a strong commitment to
88
Impact of Chronic and Non-chronic Health Conditions 89
work will increase the likelihood of sickness presenteeism (Hansen

and Andersen, 2008). Work commitment or meeting is also one of top
five reasons cited by employees for sickness presenteeism (Caverley
et al., 2007).
6.1.2 Economic impact of presenteeism

Many employers do not realize the hidden cost of presenteeism,
which may be far more expensive than other health-related costs.
Presenteeism’s cost can be estimated based on employees’ salaries
and is the dollars lost to illness-related reductions in productivity
(Hemp, 2004). The author has found that even less-severe conditions
can impair on-the-job performance.1 In a study, Lockheed Martin
assessed the impact of 28 medical conditions on workers’ productivity
and found that those conditions cost the company approximately
USD34 million annually. Further, Stewart et al. (2003) estimated the lost
productive time (LPT) of U.S. workers for personal and family health
reasons as USD225.8 billion per year, of which 71 per cent (that is,
USD160.3 billion) is explained by reduced performance at work.
Goetzel et al. (2004) also reported that the overall economic burden
of presenteeism is highest for hypertension (USD392 per eligible
employee per year), followed by heart disease (USD368), depression,
other medical illnesses (USD348) and arthritis (USD327).
6.1.3 Common Sickness Presenteeism (SP)

conditions – classifications and impact
The National Health Surveillance Survey conducted by the Singapore
Ministry of Health (MOH) in 2007 found that the common health
conditions suffered by Singaporeans included hypertension, high
blood cholesterol, diabetes mellitus, asthma, arthritis and chronic
back pain. These conditions are similar to the 12 common health
conditions identified by Ruez (2004) and Medibank (2007) shown in
Table 6.1. Similar health conditions have been further classified, into
acute and chronic conditions (refer to Table 6.2). For acute conditions,
the symptoms are severe and onsets can be sudden such that they
could arise, change or worsen rapidly. Chronic conditions, however,
develop and worsen over an extended period of time (Blaivas, 2009).
Past studies have also highlighted the impact of presenteeism
on both productivity loss and costs resulting from each condition.
90 Presenteeism
Table 6.1 Comparison of common diseases between Australia and

Singapore
Twelve
common Some common
medical ailments in
Top five causes conditions Non-communicable Singapore
of presen- in Australia disease in Singapore (Health
teeism, U.S. (Medibank, Ministry of Health Promotion
(Ruez, 2004) 2007) (Singapore), 2007) Board, 20007)
Headache Allergies Alcohol Consumption Allergies

Cold/Flu Arthritis Asthma Athlete’s Foot
Fatigue/ Asthma Arthritis and Chronic Anxiety/Stress
Depression Joint Symptoms
Digestive Back, neck Cigarette Smoking Backache
problems and spinal
problems
Arthritis Cancer Diabetes Mellitus Cold
Depression Hypertension Cough
Diabetes High Blood Chickenpox
Mellitus Cholesterol
Heart Disease Obesity Constipations
Hypertension Cuts and Bruises
Migraines/ Dermatitis
Headaches
Respiratory Diarrhoea
disorders
Skin Diabetes
conditions Mellitus
Dizziness
Flu
Fever
Headaches
Influenza
Irritable Bowel
Syndrome
For this study, a number of hypotheses have been developed and

subsequently tested to understand the relationship between various
variables.
6.2 Hypotheses
Based on literature presented in the earlier chapters of the book, the

following hypotheses were developed:
Table 6.2 List of health conditions examined
Health
Chronic/Acute conditions Explanation
Allergy Allergy was diagnosed by physicians as one

of the most frequent chronic diseases
(World Health Organization, 2007).
Asthma Asthma is regarded as common chronic
disease (Health Promotion Board,
Singapore, 2009; World Health
Organization, 2008).
Arthritis Arthritis was diagnosed by physicians as
one of the most frequent chronic disease
Chronic Anxiety Anxiety was diagnosed by physicians as
one of the most frequent chronic disease
Back Pain Back pain is part of the chronic diseases
worldwide that are attributable to
occupational risk (World Health
Diabetes Diabetes is regarded as common chronic
Singapore, 2009; World Health
Hypertension Hypertension is considered as a chronic
Singapore, 2009).
Cough Acute cough is one of the most common
complaints among patients visiting health-
care professionals (Peter et al., 2009). In
this study, cough is being classified as an
acute condition.
Acute Diarrhoea There is a rise in the number of Singaporeans
being affected by acute diarrhoea (Khalik,
2009). Half of the deaths in diarrhoea cases
are due to acute watery diarrhoea (World
Health Organization, 1999). Thus, it is
regarded as an acute condition.
Fever Fever usually goes away within a few days
(Mayo Clinic, 2009). It can be considered
as an acute condition.
Headache Headache usually last hours or days of which
the mean frequency in the Singapore
population studies is about once a month
(Singapore Sleep Society, 2010). It can be
regarded as an acute condition.
Influenza Influenza is classified as an acute viral
infection that spreads easily from person to
person (World Health Organization, 2009).
92 Presenteeism
H1: Job demand is positively correlated with sickness

presenteeism.
H2: There is a significant difference between sickness presenteeism
experienced by managerial and non-managerial employees.
H3(a): Employee self-awareness of the impact of sickness
presenteeism is negatively correlated with actual sickness
presenteeism.
H3(b): Employees’ awareness of sickness presenteeism cost to
employers is negatively correlated with sickness presenteeism.
H3(c): Employee health-awareness programme is negatively corre-
lated with sickness presenteeism.
H4: Sickness presenteeism is positively correlated to work
difficulty.
As in the literature, this study used a three-month recall period as

a reference point for the respondents to remember the details of their
health conditions and the frequency of their presence at work even
when sick. The three months’ data were converted to an equivalent
annual number of sickness episodes, and then the impact of sickness
presenteeism in terms of lost productivity and the equivalent costs
were computed.
6.3 Methodology
6.3.1 Sample
The sample data was collected using a pre-tested on-line survey ques-
tionnaire for the working adults. The survey was made available to
prospective subjects through a direct link and a total of 279 respond-
ents completed the questionnaire.
6.3.2 Survey measures

This study was designed based on a number of instruments available
on the Web. Job demand was measured by a six-item scale based on
an original scale by Furda (1995) and on two items from the Guttman
scale.2 These items were scored on a five-point Likert scale,3 ranging
from (1) ‘Never’ to (5) ‘Always’. For ‘Employee Awareness’ measure-
ment, a three-item scale developed by the Nanyang Business School
research team was also scored on a five-point Likert scale, ranging
from (1) ‘Strongly Disagree’ to (5) ‘Strongly Agree’.
In measuring employees’ work difficulty, 14 items from the

‘Migraine Work and Productivity Loss Questionnaire’ (MWPLQ)
were used and scored on a five-point Likert scale, ranging from (1)
‘Very Low’ to (5) ‘Very High’. The sample questionnaire is attached
in Appendix 6.1.
Appendix 6.1
The General Health Climate and Employees’ Attitude Towards

Health Management Survey Set
PERSONAL INFORMATION
1. Which age group do you belong to?
2. Gender: M/F (circle as applicable)
€ 25–29 € 30–34 € 35–39 € 40–44 € 45–49
€ 50–54 € 55–59 € 60–64 € 65-above
3. What is your marital status?
Single Married Separated Divorced Widowed
WORK-RELATED INFORMATION
4. What is your employment status?
Full-time Part-time
5. Which business sector do you belong to? (tick where applicable)
Finance Gas/Oil Food & Beverages Manufacturing

Retail Service Transportation Education
Others, please specify:
94 Presenteeism
6. Which job status do you belong to? (tick where applicable)
Non-Managerial Managerial
7. What is your monthly gross income?

• Less than SGD 1500
• SGD 1501–SGD 3000
• SGD 3001–SGD 4500
• SGD 4501–SGD 6000
• SGD 6001–SGD 7500
• SGD 7501–SGD 9000
• SGD 9001–SGD 10500
• SGD 10501–SGD 12000
• More than SGD 12000
8. How many days do you work in a week? (Inclusive of overtime)
• 1 day 2 days 3 days
• 4 days5 days 5½ days
• 6 days 7 days
9. On an average, how many hours do you work a day? If you have
more than one job, please report on your main job only.
Please specify: ___________ hours
HEALTH-RELATED INFORMATION
10. Please indicate how much you agree or disagree with each of the
following statements:
Strongly Strongly
disagree Disagree Neutral Agree agree
(a) I understand that if I am € € € € €

sick, I am not supposed to
report to work.
(b) I understand that if I € € € € €
report to work despite
being sick, it will cost my
employer
(c) In my worksite, there are € € € € €
programmes that educate
workers about employee
health related issues
11. How often did you report to work despite being sick or unwell
during the last 3 months?
____________ day/s
(If the above question does not apply to you (i.e., zero days), you may stop
the survey here).
12. Please indicate how often did you report to work despite being
sick and unwell in the PAST THREE MONTHS with one or more
of the following health conditions?
Allergy € € € € €
Asthma € € € € €
Arthritis € € € € €
Anxiety € € € € €
Chronic Back € € € € €
Pain
Cough € € € € €
Diabetes € € € € €
Mellitus
Diarrhoea € € € € €
Fever € € € € €
Headaches € € € € €
Hypertension € € € € €
Influenza (E.g. € € € € €
Flu)
13. On average, how many DAYS in the past 3 months did you suffer
from the health conditions listed below? (If you have never expe-
rienced the health condition(s), ignore the particular field.)
Days in past THREE MONTHS
Allergy
Asthma
Arthritis
Anxiety
Chronic Back Pain
Cough
Diabetes Mellitus
Diarrhoea
Fever
Headaches
Hypertension
Influenza
96 Presenteeism
14. Please select the reason(s) for going to work despite being sick.
(You may select more than one reason.)
• I have to go to work because of work commitments.
• There is a need to meet deadlines.
• I am concerned about my work not getting done if I take
leave.
• I have too much work to clear and cannot afford to go on
leave.
• I feel guilty for missing work.
• My illness is not serious and I can still go to work.
• There is no one to replace me if I don’t come to work.
• I do not have any more sick leave to take.
• I want to save my sick leave for later part of the year.
• My colleagues commented that I am sick too often.
• I do not feel good when my colleagues have to take over my
workload during my absence.
• Attendance at work is one of the performance indicators for
my job.
• Supervisors will form a negative impression of me if I take too
much sick leave.
(a) Requires € € € € €
working fast
(b) Requires € € € € €
working hard
(c) Great deal of € € € € €
work to be done
(d) Excessive work € € € € €
(e) No time to € € € € €
finish with
specific
deadlines
(f) Conflicting € € € € €
demands (i.e.,
working on
more than one
job)
(g) Hectic job (i.e., € € € € €
busy and full of
things to do)
(h) Psychologically € € € € €
demanding job
15. Please indicate the frequency with which you had experienced
the following job demands in the past THREE MONTHS:
16. The following questions ask about the difficulty you experi-
enced because of health problem(s) during the past THREE
MONTHS. Select the options that best describe your situation
Scale: Very Low (0–20%), Low (21–40%), Moderate (41–60%),
High (61–80%), Very High (81–100%)
Very low Low Moderate High Very high
(a) Getting started at € € € € €

the beginning of
the day
(b) Pacing yourself to € € € € €
get through the
day
(c) Thinking clearly € € € € €
(d) Concentration on € € € € €
work
(e) Focusing on work € € € € €
(f) Doing work without € € € € €
making errors
(g) Doing things that € € € € €
requires physical
strength
(h) Controlling € € € € €
emotions.
(i) Working in noisy € € € € €
areas.
(j) Working near € € € € €
bright/flashing
lights
(k) Working fast and € € € € €
not slowing down
(l) Finishing all of the € € € € €
work
(m) Accomplishing € € € € €
as much work as
possible
(n) Not missing too € € € € €
much work
98 Presenteeism
17. Based on the health condition(s) experienced by you during the

last THREE MONTHS, on average, how many hour(s) a day was
your work affected?
End of the survey
Hours per day
Allergy
Asthma
Arthritis
Anxiety
Chronic Back Pain
Cough
Diabetes Mellitus
Diarrhoea
Fever
Headaches
Hypertension
Influenza
6.4 Descriptive statistics
6.4.1 Respondents’ demographics

Of the 279 respondents, 39 per cent were male, with 82 per cent of
these 39 years old and below. Sixty (60) per cent were single, and the
rest were married; 21 per cent of the respondents held managerial
positions, and the rest non-managerial positions. The respondents
were from different industries, with half of them from service and
manufacturing industries and the rest from automobile, real estate,
shipping, and telecommunications sectors.
The majority of the respondents, 74 per cent, worked five days a
week and 21 per cent worked more than five days a week; 42 per
cent of the respondents earned a gross monthly income between
SGD1,501 and SGD3,000 and 24 per cent earned between SGD3,001
and SGD4,500.
6.4.2 Survey results

Respondents were asked to recall the number of days during the last
three months when they reported to work despite being sick. From
the frequency analysis under ‘employee awareness’, it was noted that

79 per cent of respondents were aware that they were not supposed
to go to work when sick, and 45 per cent were aware that it would
cost their employers if they did go to work when sick. Furthermore,
46 per cent indicated that there were programmes at their respective
workplaces educating workers about health-related issues.
Analysis revealed that headache, flu, cough, fever and stomach
problems were the top five health conditions with which the
respondents came to work. The top five reasons cited for going to
work despite being sick were:
1. Work commitments (35 per cent)

2. Illness is not serious (28 per cent)
3. Needed to meet deadlines (27 per cent)
4. Concerns about work not getting done (23 per cent) and
5. Can’t afford to go on leave due to huge amount of work to be
completed (15 per cent).
The top five difficulties faced by the respondents when they came
to work despite being sick were:
1. Getting started at the beginning of the day (1.44)4

2. Working in noisy areas (1.39)
3. Did not accomplish as much as required (1.37)
4. Lack of concentration (1.37) and
5. Unable to think clearly (1.34).
6.4.3 Results of tests of hypotheses
In Hypothesis 1, it was proposed that job demand is positively and

significantly correlated with sickness presenteeism. Regression anal-
ysis supported this hypothesis confirming that an increase in job
demand would result in an increase in actual sickness presenteeism.
In Hypothesis 2, it was postulated that there is a significant differ-
ence between sickness presenteeism experienced by managerial and
non-managerial employees. Our analysis confirmed this hypothesis,
indicating that there is a statistically significant difference between
the extent of sickness presenteeism experienced by managerial and
non-managerial employees.
100 Presenteeism
In Hypothesis 3(a), it was hypothesized that there is a significant

but negative relationship between employee self-awareness of impact
of sickness presenteeism and actual sickness presenteeism. Our anal-
ysis did not support this hypothesis.
In Hypothesis 3(b), it was postulated that employees’ awareness of
employers’ sickness presenteeism costs is negatively correlated with
actual sickness presenteeism. As in the case of Hypotheses 3(a), our
analysis did not find any such relationship between the specified
variables.
In Hypothesis 3(c) it was hypothesized that an employee health-
awareness programme is negatively correlated with sickness pres-
enteeism. Our analysis supported this hypothesis, indicating that
an increase in employees’ awareness level of health-awareness
programme would decrease in actual sickness presenteeism.
In Hypothesis 4, it was postulated that there will be a positive
and significant relationship between sickness presenteeism and the
extent of work difficulty. Statistical analysis supported this hypoth-
esis, indicating that increase in sickness presenteeism would result in
a ‘felt increase’ of the extent of work difficulty.
6.5 Cost of sickness presenteeism to organizations
Of the 279 respondents, 268 (96 per cent) of them reported having
experienced sickness presenteeism during the past three months.
Most of them had been affected by headache, influenza and
cough.
In the sample, 45 per cent of the respondents were reported to
be suffering from chronic health conditions (for example, allergy,
asthma, arthritis, chronic back pain, diabetes mellitus, hypertension
and anxiety) and the rest from acute health conditions (for example,
cough, fever, headache/migraine, flu and diarrhoea). Using the data
collected, mean hours per day per person impaired by each of the
specific conditions were computed. Of the chronic health conditions,
back pain was found to have the highest impact (1.82 hours) per week
followed by anxiety (1.08 hours), allergy (1.06 hours), asthma (0.97
hours) and arthritis (0.28 hours). Interestingly, those with diabetes
mellitus did not report any loss of hours at work.
Among those suffering from acute health conditions, fever showed
the highest amount of loss of hours per day (4.49 hours) followed by
headache/migraine (4.40 hours), flu (3.91 hours), cough (3.47 hours)

and diarrhoea (1.56 hours).
The mean number of days per employee affected during the three-
month period for each of the above-mentioned health conditions
were also computed. Of the chronic health conditions, back pain
showed the highest number of days impaired (1.87 days), followed
by anxiety (1.07 days), hypertension (0.58 days), asthma (0.57 days),
arthritis (0.54 days) and allergy (0.48 days). However, in the case of
the number of days lost due to acute health conditions, the affected
employees revealed that on average they lost 3.14 days for cough
followed by headache/migraine (2.64 days), flu (2.25 days), fever
(1.42 days) and diarrhoea (1.24 days).
To compute the percentage of eligible work time lost due to sick-
ness presenteeism, all the above conditions were separately applied
to the presenteeism metric (Goetzel et al., 2004). These numbers
were then used to compute the annual work time lost due to sickness
presenteeism.
Figure 6.1 below shows that headache was the most significant
health condition affecting employees’ eligible work time, followed
by cough and influenza. Annually, 2.14 per cent (that is, 11.66 hours)
of productive time was lost when one reported for work when having
headache.
A comparison between acute and chronic health conditions shows
that acute conditions such as cough, fever, headache, and influenza
2.50
2.1379
1.8048
Percentage
2.00
1.4341
1.50
1.00 0.8549
0.50 0.0494 0.3221 0.2136

0.0428 0.0127 0.1094 0.0259
0.00
a
nz
h
y
is
es
in
ve
ug
rg
et
lue
m
io
oe
rit
Pa
ch
xi
ns
Inf
le
th
Fe
th
Co
rrh
An
da
Al
As
Ar
te
ck
ia
er
ea
Ba
D
yp
H
c
H
i
on
hr
C
Figure 6.1 Percentage of eligible work time lost due to sickness presenteeism
by health conditions
102 Presenteeism
are more significant in affecting employees’ work time than are

chronic conditions.
6.6 Extent of sickness presenteeism in Singapore as

compared to a few selected studies
A comparison was conducted between the productive time losses due

to sickness presenteeism from past literature and the findings from
this study. Table 6.3 shows that the productivity losses for a number
of health conditions reported by Hemp (2004), Medibank (2007) and
Goetzel et al. (2004) were higher than those from the present study,
with the exception of headache and chronic back pain, where the
reported figures by Medibank (Australia) were lower than in this
study.
Interestingly, it was noted that the respondents in Singapore with
the diabetes mellitus condition did not report any productivity
Table 6.3 Comparison of productivity loss due to sickness presenteeism

From Literature
Goetzel
Classification Hemp Medibank et al.
of conditions Conditions (2004) (2007) (2004) This study
Chronic Allergy 4.1% 0.4826% 10.9% 0.0428%

conditions Asthma 5.2% 0.2032% 11% 0.0494%
Arthritis 5.9% 0.1016% 11.2% 0.0127%
Anxiety *NA 0.1094%
Chronic Back 5.5% 0.2032% Not 0.3221%
Pain included
in this
study
Diabetes *NA 0.2286% 11.4% 0%
Hypertension *NA 0.3556% 6.9% 0.0259%
Acute Cough *NA 1.8048%
conditions
Diarrhoea *NA 0.2136%
Fever *NA 0.8549%
Headache 4.9% 0.1524% 20.5% 2.1379%
Influenza 4.7% *NA 1.4341%
*NA = Not available from these sources.

loss due to sickness presenteeism, which is inconsistent with the

literature.
6.7 Sickness presenteeism experienced by managerial

and non-managerial employees
The percentage of eligible work time lost due to sickness pres-

enteeism for managerial and non-managerial employees was
calculated.
6.7.1 Sickness presenteeism reported by managerial employees

Of the 279 total respondents, 59 (21 per cent) were in the managerial
cadre, of which 16 (27 per cent) reported to have gone to work despite
being sick during the last three months. Using a similar methodology
adopted earlier for all employees, the annual percentage of produc-
tive time lost due to sickness presenteeism by managerial employees
was calculated. Results showed that acute conditions like headache,
cough and influenza were the three most significant conditions
affecting managerial employees’ annual work time. These health
conditions accounted for an annual productive time loss of 3.12 per
cent (that is, 18.97 hours), 2.71 per cent (16.23 hours) and 0.82 per
cent (4.94 hours) respectively.
6.7.2 Sickness presenteeism reported by non-managerial

employees
Of the 220 non-managerial respondents, 101 (46 per cent) reported
to have gone to work while not feeling well. Using the same
methodology discussed earlier, the loss of productive time due
to sickness presenteeism for non-managerial employees was also
computed. Acute conditions like influenza, cough and fever were
the three most significant conditions affecting non-managerial
employees’ work time, accounting for 1.63 per cent (8.67 hours),
1.43 per cent (7.62 hours) and 1.30 per cent (6.75 hours) respec-
tively per year.
In summary, it was found that managerial employees experienced
more productive time loss than did non-managerial employees due
to hypertension (0.46 hours), cough (16.23 hours) and headaches
(18.97 hours). On the other hand, non-managerial employees expe-
rienced more productive time loss due to health conditions such as
104 Presenteeism
allergy (0.25 hours), diarrhoea (1.01 hours), fever (6.75 hours) and
influenza (8.67 hours).
6.8 Cost of sickness presenteeism to organization
6.8.1 Total annual labour cost per employee

The cost of sickness presenteeism to organizations was computed by
converting the percentage of time lost into monetary value. To do so,
employees’ total annual gross incomes and total annual benefit costs
were computed using the following steps:
• Step 1: Total Annual Gross Income = Monthly Gross Income X

12 months.
• Step 2: Total Annual Benefits Cost = Annual wage Supplement
(AWS)/Bonus + Non-wage cost + Annual Leave + Sick Leave +
Employer’s Central Provident Fund (CPF5) contributions.
• Step 3: Total Annual Labour Cost = Total Gross Income + Total
Annual Benefits Cost.
Table 6.4 below shows the detailed calculations, and Table 6.5 shows
further details of labour cost per employee according to income
range and age group.
6.8.2 Cost of sickness presenteeism

Applying the percentage of productive time lost (calculated earlier) to
the total labour cost, the cost of sickness presenteeism to the organi-
zations per employee per condition was computed. For example, an
employee who is 50 years old or below, earns a mean monthly salary
of SGD2,251, and reports to work despite being sick, will result an
annual cost of SGD920, SGD777 and SGD617 for headache, cough,
and influenza respectively. In simple terms, approximately 41 per
cent, 35 per cent and 27 per cent of a month’s salary is forgone for
these health conditions respectively.
6.8.3 Cost of sickness presenteeism in Singapore: summary

There are two main findings in this study. Firstly, an employee who
reported to work despite having an acute condition is likely to cost
more than those with chronic conditions: for example, an employee
who is 50 years of age or younger and earning SGD3,750 per month,
Table 6.4 Computations of annual labour cost per employee, 2009
Wage cost Non-wage cost
Basic
wage,
Overall Overtime Employer’s Medical
industry Total and other CPF cost and Net Other
(SSIC labour Total regular AWS/ contribu- other training labour
2005) Cost wage cost payment Bonus tion Total Levy insurance Cost cost
TOTAL 50,539 46,838 35,351 8,128 3,359 3,701 571 616 494 2,019
Source: Singapore Yearbook of Manpower Statistic (2009), table 2.9, p. 67.

106 Presenteeism
Table 6.5 Sample computation of annual labour cost by employee based on

salary range and age bracket
Total annual
labour cost
Gross (Refer to
Monthly salary income step 3 above)
range Mid-point ($) Age group (SGD) ($) (SGD) ($)
$1,501–$3,000 2,251 50 and below 27,006 43,055.00

51–55 27,006 42,965.05
56–60 27,006 42,898.00
Above 60 27,006 42,841.00
$3,001–$4,500 3,751 50 and below 45,006 63,868.00
51–55 45,006 63,717.62
56–60 45,006 63,605.00
Above 60 45,006 63,511.00
$6,001–$7,500 6,751 50 and below 81,006 105,493.00
51–55 81,006 105,223.00
56–60 81,006 105,020.00
Above 60 81,006 104,852.00
$10,501–$12,000 11,251 50 and below 135,006 167,931.00
51–55 135,006 167,481.00
56–60 135,006 167,144.00
Above 60 135,006 166,862.00
would cost the organization SGD920 per year for headache through
lost productivity.6 On the other hand, if the same employee came
to work with chronic back pain, the cost to the employer due to lost
productivity would be only SGD139 per year.7
Secondly, there is a difference between the extent of the cost of
lost productivity due to sickness presenteeism experienced by mana-
gerial and non-managerial employees. Such costs for managerial
employees are higher in conditions like headache, hypertension and
cough than for non-managerial employees who exhibited a higher
cost on the remaining conditions.
6.9 Summary and discussions
This study has examined the prevalence of sickness presenteeism in

organizations and its impact on employees’ productivity. As reported
by Goetzel et al. (2004), the overall economic burden of illness was
highest for conditions such as hypertension, depression/sadness/
mental illness, heart disease and arthritis. Conversely, results from

this study showed that headache, cough, and influenza were the
three conditions causing the highest productivity loss. This study
also revealed that diabetes mellitus did not reveal any hidden
cost to the employers, which is contrary to the results reported by
other authors. For example, Goetzel (1994) reported that the esti-
mated annual cost of presenteeism due to diabetes was USD158 per
employee per year. Lavinge et al. (2003) also reported that diabetic
employees showed a reduction in work productivity compared to
non-diabetics. Tunceli et al. (2005) also reported that among both
men and women, individuals with diabetes were significantly more
likely to have work limitations than non-diabetics. According to
SingHealth (2010), employees with diabetes have to seek long-term
medication and treatments (for example, tablets and injections of
insulin), and face a risk of further chronic and acute complications,
including low blood sugar which makes one irritable, confused, weak
and also to suffer from blurred vision.
The study did not reflect any sickness presenteeism costs for a
number of health conditions for managerial employees who are
suffering from asthma, arthritis or anxiety. Contrary to the find-
ings of this study, Ricci et al. (2005) reported that arthritis workers
with pain exacerbations in the previous two weeks reported greater
arthritis-related lost productivity time of 24.4 per cent versus 13.3
per cent than those without flare-ups but, in reality, this condition
might affect employees’ productivity when at work. Such differences
may be due to data-collection sampling errors and also to the lack
of complete awareness of the respondents about their own health
conditions.
This study is, however, consistent with a study which reported
that presenteeism due to acute conditions reduces more ‘equivalent
hours’ over an eight-hour shift than do chronic conditions (Pauly
et al., 2008). Rizzo et al. (1998) reported that the labour productivity
losses from chronic backache differed by gender and other socio-
demographic characteristics. The aggregate labour productivity
losses due to chronic backache were quite large and the annual losses
amounted to approximately USD28 billion in the United States
(measured in 1996 dollars). Further, Lerner et al. (2001) reported that
nearly one-third of adults with chronic health problems experienced,
as a result, moderate to severe difficulty on the job. The author also
108 Presenteeism
reported that as the number of chronic conditions increased, so did

the odds of having work limitations.
Past studies have shown positive relationship between job demand
and sickness presenteeism (Caverley et al., 2007; Demerouti et al.,
2001). Based on the analysis, Hypothesis 1 supported this relation-
ship and revealed that ‘speed to get work done’ and ‘quantity of work
to be done’ were the two main job demands faced by respondents.
The reasons could be that employees are inclined to invest efforts to
meet job demands to keep their performance at their desired level
(Demerouti et al., 2001). Moreover, according to a local study, heavy
workloads and deadlines resulted in employees not being able to go
on leave (Tan, 2007). Thus, higher pressure to meet job demands may
in turn cause a higher propensity to go to work despite being sick.
This study has shown that the types of sickness presenteeism
experienced by managerial and non-managerial employees are
significantly different (in terms of productive time lost). Specifically,
managerial employees experience a higher percentage of time lost
(0.68 per cent) due to presenteeism as compared to non-manage-
rial employees (0.55 per cent). Such differences can be attributed
to challenges faced by managerial employees which compel them
to work longer hours. For example, managers work up to 60 hours
or per week than non-managerial employees (Singapore Statistics,
2005). Job insecurity is one of the challenges, and managers react
by working longer hours in order to demonstrate commitment to
the job and gain an advantage over others (Goffee and Scase, 1992).
Further, managerial employees also come to work even when sick as
they face pressure from their colleagues (Simpson, 2006), resulting
in higher levels of presenteeism as compared to non-managerial
colleagues.
A significant inverse relationship between health-awareness
programmes and sickness presenteeism has also been observed in
this study, in which the analysis showed that presenteeism behav-
iour could be reduced with awareness programmes on the impact
of employees coming to work despite being sick. This finding is
consistent with previous studies highlighting the value of educating
employees about sickness presenteeism (Hemp 2004; Samuel and
Wilson, 2007; Schultz and Edington, 2007).
Based on a meta evaluation of 56 peer-reviewed journal articles on
worksite health-promotion programmes, Chapman (2005) reported
that, for every dollar invested, an average of 26.8 per cent reduction
in sick-leave absenteeism, an average 26 per cent reduction in health
costs, and average of 32 per cent reduction in workers’ compensa-
tion and disability management claims costs and an average of $5.81
savings were was achieved. Hemp (2004) also stressed that such
programmes ensured that illness would not go undiagnosed or misdi-
agnosed, and employees would learn how to better manage illness.
Sickness presenteeism also has a significant positive relationship
with overall work difficulty, which is consistent with the Middaugh
(2006) study that found employees who came to work sick are required
to focus additional time and effort to complete tasks, resulting in
reduced on-the-job productivity.
Sickness presenteeism has received attention worldwide due to its

prevalence and significant expenses to organizations. Thus, this
study adds value by exploring the nature and extent of sickness
presenteeism in Singapore. After understanding the various reasons
behind the hidden loss of productivity and the possible ways to mini-
mize such losses, organizations can refine their policies and practices
to track and reduce occurrences of such employee behaviour (refer to
Chapter 8 for detailed discussions).
In Singapore, the Health Promotion Board initiated the Integrated
Screening Programme (ISP) at general practitioner clinics. Targeting
Singaporeans aged 40 years and above, the ISP made tests for diabetes
and hypertension affordable (Health Promotion Board, 2009;
Ministry of Health, Singapore, 2008). This programme encourages
employees to pay more attention to their own health.
Lastly, we pointed out that, in the Western context, work commit-
ment is the top reason behind sickness presenteeism (Caverley et al.,
2007); however, according to our study in Singapore, job demand has
also been found to be significantly correlated with sickness presen-
teeism. To counter such situations, employee education and counsel-
ling sessions could be implemented by organizations to communicate
to the employees that, although fulfilment of job assignments are crit-
ical, employees reporting to work sick has negative consequences for
the organization. In literature, it has also been suggested that organi-
zations could have motivational-interviewing–based health coaching
110 Presenteeism
on employees’ physical and mental health status. Butterworth et al.

(2006) argue that this is a proven and effective health intervention
approach which addresses multiple behaviours, health risks and
illness self-management in a cost-effective manner.
In conclusion, the world is always faced with many challenges and,
as Singapore continues to progress, she must maintain a strong and
healthy workforce. Studies have proven that sickness presenteeism
is the latest attack on economic and human productivity which
impairs output, quality of work-life and employee health (Saarvala,
2006). Authors in the field have also argued that controlling sick-
ness presenteeism is important from both public health and busi-
ness perspectives. Hence, this study has made a small contribution
in showing the impact of sickness presenteeism on organizations
and on the quality of life of the employees when they come to work
despite being sick.
Notes
This study was conducted by, S.J. Guo, H.S. Tan and H.C. Tan as part of
their undergraduate final year research project under the supervision of the
present author, Department of Strategy, Management and Organization of the
Nanyang Business School, Nanyang Technological University, Singapore.
1. Source: D. Lerner, W.H. Rogers, and H. Chang, at Tufts New England
Medical Center.
2. In statistical surveys conducted by means of structured interviews or ques-
tionnaires, a subset of the survey items having binary (e.g., YES or NO)
answers forms a Guttman scale (named after Louis Guttman) if they can be
ranked in some order so that, for a rational respondent, the response pattern
can be captured by a single index on that ordered scale. In other words, on
a Guttman scale, items are arranged in an order so that an individual who
agrees with a particular item also agrees with items of lower rank-order.
3. A Likert scale is a psychometric scale commonly involved in research that
employs questionnaires. It is the most widely used approach to scaling
responses in survey research, such that the term is often used inter-
changeably with rating scale, or more accurately the Likert-type scale
(Wikipedia).
4. Weighted score of the measurement scale (1 to 5).
5. Central Provident Fund (CPF) is a compulsory comprehensive savings
plan for working Singaporeans and permanent residents, primarily to
fund their retirement, health care and housing needs.
6. Cost to the organization = Annual labour cost per employee x percent of
eligible work time lost for the specific health conditions (details not shown).
7. Same as above.
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7
Why Do Employees Go to
Work Despite Being Sick? An
Exploratory Study in Singapore
This chapter presents the details of the third study, focusing only on
why employees in Singapore go to work when sick, and analysing three
specific types of factors: job-related, work-related and personal.
7.1 Literature review and hypothesis formation
This exploratory study in Singapore examined the predictors of

presenteeism’s ‘work context’ and ‘personal factors’. Constructs in past
research that have a significant correlation with presenteeism have
been included in this study to ensure a meaningful investigation –
for example, job demands were found to be positively related to pres-
enteeism (Caverley etal., 2007; Demerouti et al., 2009). At the same
time, this study explored the effects of organizational culture and
personality on presenteeism. It also investigated the effects of collec-
tivism and power distance on presenteeism. Amongst the limited
study involving culture, Dew and colleague’s research in 2005 on a
private hospital found that loyalty to colleagues and a strong team-
work ethos encouraged attendance during illness. Similarly, when
the organization culture is tense and prone to conflict, employees
are inclined to withdraw effort from their tasks and thus indulge in
absenteeism (Chen et al., 2010).
On the other hand, personality has been found to exhibit a modest
relationship with absenteeism, but certain personality traits such as
‘individual boundarylessness’ has been found to induce presenteeism
114
Why Do Employees Go to Work Despite Being Sick? 115
(Aronsson and Gustafsson, 2005). Johns (2008) has also argued that
employees who are highly conscientious are more prone to attend
to work when sick. The inclusion of culture and personality factors
might shed some new light on the study of presenteeism. The above-
mentioned predictors of presenteeism are examined in the following
section.
7.2 Work-related factors
7.2.1 Job-related factors

Work-related factors contributing to sickness presenteeism include:
job demands, attendance-rewarding policies, job autonomy, job secu-
rity, task significance, ease of replacement, organizational culture
(collectivism and power distance) and, lastly, support in the working
environment (supervisor and organizational support). Job demand
refers to the physical, cognitive, and social features of a job that
requires protracted physical and psychological effort (Johns, 2010).
When job demand is high, employees can be inclined to attend to
work even when sick in order to maintain high levels of performance
(Demerouti et al., 2009).
Hypothesis 1(a): Job demand is positively correlated with

presenteeism.
It was found that employees were more likely to come to work in order
to avoid disciplinary action that might be taken against them (Munir
et al., 2008). In fact, attendance-management policies could increase
levels of presenteeism when the organization chooses to reward and
encourage full attendance or to implicitly reprimand employees when
they do not come to work despite being on sick leave. In the same
vein it could be hypothesized that employees will choose to come to
work even when ill so as to reap the rewards of job attendance.
Hypothesis 1(b): Policies that reward attendance are positively

correlated with presenteeism.
Another factor in the work context involves job autonomy – the

extent to which a job allows freedom, independence, and discretion
116 Presenteeism
to schedule work, make decisions and select the methods used to

perform tasks (Caldwell and O’Reilly, 1990). When employees have
higher job autonomy, they are more likely to report for work when ill
because they can modify their work tasks such that they could carry
on despite being sick (Hansen and Andersen, 2008).
Hypothesis 1(c): Job autonomy is positively correlated with

presenteeism.
According to Vahtera et al. (2004) and Johns (2011), permanency of

employment is used to measure job security, under the assumption
that a permanent worker should experience a higher level of job
security vis-à-vis temporary or part-time employees. With higher
levels of job security, employees are less worried about losing their
jobs, and are thus less likely to turn up for work when sick. In
addition, most research involving non-permanent employees
conclude that such employees do not demonstrate less absence,
and such behaviour suggests higher levels of presenteeism (Barling
and Cooper, 2008). This could be so because employees with low
levels of job security may feel easily replaceable, therefore causing
them to turn up for work even when sick to prove their commit-
ment and desire to work, ultimately exhibiting higher levels of
presenteeism.
Hypothesis 1(d): Job security is negatively correlated with

presenteeism.
Task significance reflects the degree to which a job and its assign-
ments have substantial impact on the lives of people, regardless of
whether those people are in the immediate organization or in the
world at large (Hackman and Oldham, 1976). Aronsson et al. (2000)
and McKevitt et al. (1997) found an association between employees
in occupations characterized by high task significance (for example,
caregivers) and the level of presenteeism. Thus, employees’ perceived
task significance would likely compel sickness presenteeism as they
view their work tasks as important duties (Johns, 2011).
Hypothesis 1(e): Task significance is positively correlated with

presenteeism.
Ease of replacement, another work-related construct associated with

presenteeism, is defined as the extent to which work missed has to be
made up upon returning to work (Johns, 2010). It consists of two aspects:
replacement by substitutes and replacement by colleagues (Böckerman
and Laukkanen, 2009). Employees with low ease of replacement feel
obliged to attend work despite ill health in order to complete their work
tasks that would otherwise be left undone (Biron et al., 2006).
Hypothesis 1(f): Ease of replacement of work is negatively corre-

lated with presenteeism.
7.2.2 Work-related factors: organizational culture and

work environment
Culture is a set of values, beliefs and attitudes ingrained to provide
guidance for individuals as to what behaviours are acceptable in
the workplace (Hofstede, 1984). In a study, Parboteeah et al. (2005)
reported a correlation between Hofstede’s culture dimensions and
absenteeism, where it could also be assumed that certain facets of
culture (for example, collectivism and power distance) are associated
with presenteeism.
Collectivism is defined as the extent to which individuals prefer to
act as members of a group and are motivated to maintain a positive
image of their group (Chen et al., 2010). Collectivists value cooper-
ation among co-workers, and see themselves as socially associated
with one another (Ramesh and Gelfan, 2010). Consequently, they
attend work despite being sick in order to meet work obligations
and avoid burdening fellow members of their team.
Power distance is defined as the degree to which people agree that
power is unequally shared (Hofstede, 2001). Smith and Hume (2005)
found that employees in high power distance organizations refrain
from disagreeing with their managers or questioning authority.
Further, in such organizations communication occurs in a top-down
manner, with little communication in the reverse direction (Naresh,
2009). As such, employees may be inclined to report to work when
sick because they are reluctant to negotiate alternative work arrange-
ments with their supervisors.
Hypothesis 2(a): Both ‘collectivism’ and ‘power distance’ are

positively correlated with presenteeism.
118 Presenteeism
Further, a supportive work environment has shown to positively

impact employee behaviours, consequently reducing turnover
intentions and increasing job satisfaction (Kathryne and Arla,
2007). As such, it is proposed that an environment with supervisory
and organizational support might help reduce presenteeism behav-
iour of employees, which is in itself a type of counter-productive
behaviour. However, literature (Kottke and Sharafinski, 1988; Shore
and Tetrick, 1991) has drawn the conclusion that perceived organi-
zational support is related to, but distinct from, supervisor support
(Rhoades and Eisenberger, 2002). Therefore, for this study, super-
visor support and organizational support are categorized as two
separate variables.
Supervisor support refers to behaviours of supervisors perceived
by employees as actions that provide a sense of caring, assisting in
the achievement of pre-determined goals, or those that promote
employee well-being (Rooney, 2004). Several studies on presenteeism
have proposed solutions which involve supervisory intervention,
such as creating a work climate that does not punish absence from
work when sick (Le Blanc and Demerouti, 2009). Therefore, when
supervisory support is low, employees perceive that their supervisors
may not be tolerant towards their sickness absence and thus choose
to come to work.
Organizational support is defined as the extent to which employees
perceive how their organizations value their contribution and care
about their well-being (Eisenberger et al., 1990). This was found to
reduce absenteeism, possibly due to employees’ increased affective
attachment to their organizations (Eisenberger et al., 1986). In their
research, Caverley et al. (2007) found that many work factors associ-
ated with absenteeism are also related to presenteeism. Therefore,
organizational support could be hypothesized to correlate posi-
tively with presenteeism. It could be that with high organizational
support, employees feel valued and therefore may reciprocate by
working hard, coming to work even when they are sick.
Hypothesis 2(b):
2(b) (i): Supervisory support is negatively correlated with
presenteeism.
2(b) (ii): Organizational support is positively correlated with
presenteeism.
7.2.3 Personal factors

Presenteeism can also be seen as a form of workaholism – a
personality-based addiction encouraged through the pressures and
demands of the business (Prentice, 2005). Schaufeli et al. (2009)
define workaholism as an irresistible inner drive to work excessively.
When examining the link between personality and presenteeism,
two out of the five facets of personality, that is ‘conscientious-
ness’ and ‘neuroticism’, were theorized to have some relatedness
to presenteeism (Johns, 2011). However, this study focuses on
conscientiousness only. Conscientiousness demonstrates a nega-
tive relationship to absenteeism. Therefore, it could be argued that
employees having such a personality dimension may substitute
absenteeism with presenteeism by coming to work with ill health.
Conscientiousness refers to a personality dimension that includes
dependability, cautiousness, organization and responsibility. It has
been widely agreed upon by personality psychologists that conscien-
tiousness predicts longevity, reduces mortality risk and is a protective
mechanism against cardiovascular diseases and cancer. This suggests
that personality influences behaviours that result in health disorders
and therefore its probable subsequent behaviours (Friedman and
Schustack, 2009) such as presenteeism.
Further, Johns (2010) noted that at least some presenteeism
‘connotes perseverance in the face of adversity’ and, as a result,
conscientious people might be inclined to come to work while ill,
suggesting a positive relationship between both variables.
Hypothesis 3(a): Conscientiousness is positively correlated with

presenteeism.
Other than the personality dimension indicated above, individual

boundarylessness is another personal factor found to be related to
presenteeism. Individual boundarylessness is a term coined to clas-
sify people who find it hard to decline others’ requests, even when
they themselves face excessive demands (Aronsson and Gustafsson,
2005). When an individual experiences a heavy workload and yet is
unable to express his refusal to people’s requests, he will have to take
it upon himself to complete these jobs. This results in a higher possi-
bility of employees having to work while unwell (that is, exhibiting
presenteeism).
120 Presenteeism
Hypothesis 3(b): Individual boundarylessness is positively corre-

lated with presenteeism.
7.2.4 Moderating relationships

Apart from the above hypothesized bivariate relationships, it is of
interest to this study to investigate several moderating relation-
ships, specifically between job demand and presenteeism. In the
earlier section, certain facets of employee personality were found
to moderate the relationship between work stresses and counter-
productive work behaviours (Bowling and Eschleman, 2010). Past
research on counter-productive work behaviours (CWB) involving
personality found that conscientiousness plays a prominent role in
inducing CWB. Therefore, this study seeks to investigate the impor-
tance of this personality dimension in the relationship between job
demand and presenteeism.
It is hypothesized that higher job demand would bring about
higher levels of presenteeism only if the employees are conscientious
(that is, conscientious employees will strive to complete work within
their responsibility, thus they would go to work even when sick in
order to finish their work tasks).
Hypothesis 4(a): The relationship between job demand and pres-

enteeism is moderated by employees’ conscientiousness.
In addition to the above, supervisory support has been found to

moderate several workplace behaviours. For instance, Karasek et al.
(1982) found that supervisory support moderates the relation-
ship between task characteristics and mental strain, specifically
discussing job demand as one of the task characteristics. To the
extent that mental strain and presenteeism both exhibit high corre-
lations with job demand, it is hypothesized that higher job demand
would result in higher levels of presenteeism only if supervisors are
not supportive of employees taking sick leave when they are feeling
unwell (that is, employees who are sick will go to work when there is
a high levels of job demand, as their supervisors are not supportive
of their taking sick leave when there is a large amount of work to
be done).
Hypothesis 4(b): The relationship between job demand and

presenteeism is moderated by the level of supervisory support.
In summary, the following hypotheses have been developed, which

will be tested in the latter part of this section.
7.3 Summary of the hypotheses developed for testing
7.3.1 Job-related issues
Hypothesis 1(a): Job demand, job autonomy and task significance

are positively correlated to presenteeism.
Hypothesis 1(b): Organizational policies that reward attendance
are positively correlated with presenteeism.
Hypothesis 1(c): Job security and ease of replacement are nega-
tively correlated with presenteeism.
7.3.2 Organizational culture and work environment

related issues
Hypothesis 2(a): Collectivism and power distance are positively

correlated with presenteeism.
Hypothesis 2(b): Supervisory support is negatively correlated
with presenteeism.
Hypothesis 2(c): Organizational support is positively correlated
with presenteeism.
7.3.3 Personal factors
Hypothesis 3(a): Conscientiousness and individual boundaryless-

ness are positively correlated to presenteeism.
7.3.4 Moderating hypotheses
Hypothesis 4(a): The relationship between job demand and pres-

enteeism is moderated by employees’ conscientiousness.
Hypothesis 4(b): The relationship between job demands and
presenteeism is moderated by the level of supervisory support.
7.4 Methodology
This study adopted a cross-sectional method of research to examine

the drivers of sickness presenteeism in Singapore. A survey ques-
tionnaire was designed to collect necessary data to test the hypoth-
eses. The questionnaire consisted of 29 questions adopted from
several reliable instruments, including the Stanford Presenteeism
122 Presenteeism
Scale (SPS-13) which is also used by other authors. The respondents

were asked to answer the questions based on a recall period of three
months to ensure the accuracy of information collected.
Prior to launching the survey, a draft questionnaire was pilot tested
with 30 working adults, and the feedback received was incorporated
in the final version of the questionnaire. Besides the respondents’
demographic information, related information on job-related factors
(that is, job demands, attendance-rewarding policy, job autonomy,
job security, task significance and ease of replacement), organi-
zational culture (that is, collectivism, power distance, supervisory
support and organizational support) and personal factors (that is,
conscientiousness, and boundarylessness).
The survey was administered between January and February 2012,
and 462 usable questionnaires were collected for analysis. Of these,
380 respondents (82 per cent of the total sample) reported to have
exhibited presenteeism behaviour.
7.5 Descriptive statistics
7.5.1 Demographics
Of the total respondents, 225 were male (49 per cent), about
90 per cent of whom were Singaporeans. The majority of the respond-
ents (63 per cent) were between 19 and 29 years of age, followed by
24 per cent in the 30 to 39 years age group; 75 per cent of the
respondents had diploma or higher level education; 79 per cent
worked in the private sector, with the remaining 21 per cent holding
jobs in the public sector. Respondents worked in various industries,
with about 38 per cent employed in the financial and professional
services sector, followed by about 10 per cent in wholesale/retail and
8 per cent in information/communication.
About 80 per cent of the respondents were full-time employees
and the rest on part-time contracts or self-employed. The majority of
the respondents were working on a five-day work-week (64 per cent),
whereas, 28 per cent worked more than five days a week. About 60
per cent of the respondents earned between SGD2,000 and SGD4,999
per month.

The survey questionnaire collected useful information from the
respondents with regard to their experiences with presenteeism. As
mentioned earlier, the Stanford Presenteeism Scale (SPS-13) was used

to extract information pertaining to presenteeism experienced by
the respondents.
From the frequency analysis under ‘level of presenteeism’, it was
noted that in the past three months about 82 per cent of the respond-
ents had gone to work despite feeling unwell. Of those who had gone
to work despite being sick, 45 per cent did so ‘occasionally’, 29 per
cent did so either ‘always’ or ‘frequently’, and 9 per cent did so ‘half
the time’ (refer to Figure 7.1).
Frequency analysis was conducted to assess the association of the
various reported primary conditions with the level of presenteeism
exhibited. According to the analyses, the top three medical condi-
tions with the highest presenteeism levels were found to be influ-
enza, cough and migraine/chronic headache. These findings are in
line with other local studies on presenteeism (Guo et al., 2010; Lam
et al., 2009). A detailed breakdown of the respondents’ presenteeism
frequency ratings related to the various conditions is presented in
Table 7.1.
Based on the primary health conditions reported by respondents,
about half were still able to perform at 81–100 per cent of their usual
performance level, while 38 per cent reported productivity levels
of 61–80 per cent. Only about 2 per cent reported low productivity
levels of 0–20 per cent.
About two-thirds of respondents reported missing 0 to 5 hours
of work in the past three months due to their primary health
50.0
44.6
45.0
40.0
35.0
% of respondents
30.0
25.0
20.0 17.7 16.7
15.0 12.1
10.0 8.9
5.0
0.0
Never Occasionally Half the time Frequently Always
Frequency of presence at work despite unwell in the past 3 months
Figure 7.1 Levels of presenteeism reported by the respondents

124 Presenteeism
Table 7.1 Medical conditions and their association with sickness presen-
teeism (in per cent of respondents)
Frequency ratings on level of sickness presenteeism
Health Half the Total

conditions Never Occasionally time Frequently Always score
Allergies 1.7 1.5 0.4 0.4 1.1 3.4

Angina 0 0 0 0 0.2 0.2
Arthritis/ 0 0.4 0 0.2 0.2 0.8
Joint pain
Asthma 0.2 0.9 0 0 0.2 1.3
Back/Neck 1.1 4.5 0.4 1.5 0.9 8.4
disorder
Cough 4.1 8.9 2.6 4.3 2.4 22.3
Depression 0.2 1.1 0 0 0 1.3
anxiety
Diabetes 0.2 0.2 0 0.2 0 0.6
Diarrhoea 0.6 1.9 0.2 0.6 0.2 3.5
Fever 2.4 2.4 1.1 0.6 0.6 7.1
High blood 0.4 0.6 0 0 0 1.0
pressure
Influenza 3.5 11.7 2.4 5.0 3.9 26.5
Migraine/ 0.4 6.5 0.2 1.7 1.3 10.1
Headache
Stomach/ 0.9 1.9 0.6 0.4 0.9 4.7
Bowel
disorder
Others 1.9 1.9 0.9 1.5 0.2 6.4
conditions, while about a quarter reported missing 6 to 15 hours of

work (Figure 7.2).
Out of the total 462 respondents, 133 (29 per cent) reported going
to work ‘frequently’ or ‘always’ despite being ill in the past three
months. Analysis of productivity loss of these 133 respondents
showed that about one-third reported low productivity loss percent-
ages of 0–20 per cent, and close to 40 per cent reported productivity
losses of 41–100 per cent (refer to Figure 7.3 for details).
7.5.3 Frequency analysis of presenteeism levels by

different categorizations
There was no apparent difference in the general trends of levels of
presenteeism between the employment sectors. For both private and
70.0
61.7
60.0
% of respondents
50.0
40.0
30.0
20.0 14.9
9.3
10.0 5.8
3.7 2.2 1.1 1.3
0.0
0–5 hours 6–10 hours 11–15 16–20 21–25 26–30 31–35 others
hours hours hours hours hours
No. of hours missed
Figure 7.2 Number of hours missed due to primary health condition
35.0 33.1
30.1
30.0
% of respondents
25.0 20.3
20.0
15.0
15.0
10.0
5.0 1.5
0.0
0–20 21–40 41–60 61–80 81–100
% of productivity loss
Figure 7.3 Productivity loss of respondents who went to work ill ‘frequently/
always’
public sectors, the modal presenteeism level reported was ‘occasion-

ally’ 43 per cent for private and 52 per cent for government (refer to
Figure 7.4 for details).
7.6 Results
This section reports the statistical results of the data collected. For
Hypotheses 1, 2 and 3, bivariate regressions were conducted between
the independent variables and presenteeism. For Hypotheses 4(a)
and 4(b), moderated multiple regressions were conducted to test for
the impact of the hypothesized moderating variables on the relation-
ship between job demand and presenteeism.
Upon conducting the regression analyses, a number of hypoth-
eses (that is, job demand, task significance, power distance and
126 Presenteeism
60.0
51.5
50.0
42.7
% of respondents
40.0
30.0
19.0 16.5 17.2 Private
20.0
13.0 10.2 11.614.1 Govt.
10.0 4.0
0.0
Never Occasionally Half the time Frequently Always
Level of presenteeism
Figure 7.4 Presenteeism level by employment sector
conscientiousness) were positively and significantly related to pres-

enteeism. Also, ease of replacement and supervisory support were
negatively correlated as postulated. The remaining hypotheses were,
however, unsupported. Further, Hypothesis 4(a), which postulated a
moderating influence of employees’ conscientiousness with regard
to the relationship between job demand and presenteeism, was not
supported. Similarly, Hypothesis 4(b), which postulated that the
relationship between job demand and presenteeism is moderated
by the level of supervisory support, was also not supported.
7.7 Discussions
This study has examined drivers of sickness presenteeism in a

systematic way to draw conclusions as to the applicability of these
predictors. According to the data analysis, six of the constructs had
shown to be factors correlated to presenteeism. Specifically, five of
the bivariate relationships (job demand, task significance, ease of
replacement, power distance and conscientiousness) were highly
significant ( p < 0.01).
Similar to the conclusions arrived at by many previous studies,
job demand was found to exhibit a positive relationship with pres-
enteeism (Caverley et al., 2007; Demerouti et al., 2009). Next, past
research on task significance was found to affect the behaviours and
attitudes of many employees (Grant, 2008; Humphrey et al., 2007;
Johns et al., 1992). In this study, perceived task significance was
also found to be positively correlated with presenteeism, suggesting
that presenteeism is influenced by employees’ perception of the
importance of their work.
A third construct, ease of replacement, was found to have a nega-

tive association with presenteeism, and this result is in line with
a previous empirical study conducted by Aronsson et al. (2000).
Employees are more likely to come to work when sick if they know
that their tasks would pile up during their absence rather than be
completed by a colleague (Johns, 2011). Next, despite a lack of litera-
ture on the effects of organizational culture on presenteeism, our
hypothesis regarding power distance was found to be supported.
A logical explanation could be the employees’ unwillingness to
approach their supervisors to negotiate work arrangements because
of management practices.
Of the personality constructs tested, conscientiousness was found
to be correlated with presenteeism. This suggests that conscientious
employees who are dependable (Mount and Barrick, 1995), reliable
and responsible (Goldberg, 1990) could be motivated to attend work
when ill due to that trait of responsibility (Johns, 2011). Lastly, super-
visory support was also found to be correlated with presenteeism ( p
< 0.05). This finding is useful in that it is one of the possible avenues
by which organizations can attempt to reduce presenteeism. Since
employees often view their supervisors as agents of the organiza-
tion, they see their supervisors’ favourable/unfavourable orienta-
tion towards them as being indicative of the organization’s support
(Eisenberger et al., 2002). Thus, organizations can use these agents
(that is, the supervisors) to reduce presenteeism and the accompa-
nying adverse implications.
Since the publication of Hemp’s (2004) article on presenteeism in

Harvard Business Review, the construct has received much attention.
The first study on the cost of presenteeism in Singapore (mentioned
earlier in this chapter) reported figures that made some researchers
want to understand clearly the nature and extent of the presenteeism
behaviour of Singapore employees. The second study undertaken by
Guo et al. (2010) found that headache conditions (the third most
common illness associated with presenteeism in Singapore) had an
associated cost of SGD920 per year per employee.
The results of this (that is, the third study) research could also be
potentially very useful in aiding an organizations’ leadership in their
128 Presenteeism
bid to reduce presenteeism and avoid the hefty cost of lost produc-
tivity. Specifically, this study found six variables which demonstrated
significant correlations with presenteeism behaviour exhibited by
employees in the Singapore workforce. Organizations could look
into some of these constructs to develop practical solutions to curb
presenteeism.
Supervisory support, which was found to be positively corre-
lated with presenteeism in this study, is a probable point of entry
for companies to tackle presenteeism. Many studies have concluded
that supervisory behaviours have a strong impact on employees’
morale, psychological well-being and work behaviours (Fleishman
and Harris, 1962; Stout, 1984; Gilbreath and Benson, 2004). In addi-
tion, supervisors act as an agents of change for the organization,
and employees view their supervisors’ attitudes toward them as an
indication of the organization’s support (Eisenberger et al., 1986).
Therefore, organizations can step in to ensure that supervisors engage
in appropriate behaviours toward their subordinates, both in terms
of affective and practical support. For instance, a supervisor should
refrain from penalizing employees who take sick leave (of course,
malingering behaviours should not be condoned) and rather show
concern for sick employees and provide assistance in managing or
adjusting their workload. A supervisor who truly cares for his subor-
dinates within and beyond just work commitments helps employees
maintain balance, thereby helping them reduce stress and presen-
teeism (Gilbreath and Karimi, 2012).
Support from supervisors is important because they are a
particularly accessible leverage point to make changes to the work-
place (Bunker and Wijnberg, 1985). For instance, supervisors could
be trained to effectively manage the job demands of employees and
perhaps put in place contingency plans to increase ease of replace-
ment to help with the work of ill employees. Thus, it can be seen
that supervisors could address other significant correlates of pres-
enteeism to effectuate a wholesome approach in managing work-
place presenteeism. Supervisors could also pay more attention to
conscientious employees, showing genuine concern for their well-
being and encouraging them to take medical leave if the condition
calls for it. When supervisors take a personal interest in employees’
well-being, communication between them is likely to improve and
power distance greatly reduced. Employees could be less averse to
approaching their supervisors to negotiate work arrangements when

ill, thus reducing presenteeism.
Naturally, it is insufficient to expect only the supervisors to reduce
presenteeism. Employees ought to be informed of the negative rami-
fications of presenteeism and advised to take sick leave when the
illness calls for it. This could help conscientious employees and those
who view their work as highly important (that is, high task signifi-
cance) frame their comparison of the relative importance of work
and health, thus preventing them from coming to work when ill.
In conclusion, the hidden costs of presenteeism are huge, and
organizations ought to give this workplace behaviour more atten-
tion. The causes of presenteeism found in this local study hopefully
would assist companies to deal more effectively with presenteeism.
This would contribute to the development of a productive work-
force, the most important asset in resource-scarce Singapore, thereby
driving organizational performance and company success.
Note
This study was conducted by H.L. Chang, W.Z. Phua and C.E. Yeo
as part of their undergraduate final year research project under the
supervision of the author, Department of Strategy, Management and
Organization, Nanyang Business School, Nanyang Technological
University, Singapore.
Appendix 7.1
Why do employees go to work despite being sick? survey

questionnaire
1. What is your current employment status?
• Not employed
• Self-employed
• Part-time
• Full-time
2. How many days do you work a week?
• 1
• 2
• 3
• 4
130 Presenteeism
• 5
• 5.5
• 6
• Others; please specify:
3. On average, how many hours do you work in a day?
(If you have more than 1 job, please report on your main job
only)
• 5
• 6
• 7
• 8
• 9
4. What is the range of salary that you draw?
• Under $2,000
• $2,000–$3,499
• $3,500–$4,999
• $5,000–$6,499
• $6,500–$7,999
• $8,000–$9,499
• $9,500–$10,999
• Above $11,000
5. What is the size of your company? (Number of employees in your
company)
• Micro (Less than 20 employees)
• Small (20–50 employees)
• Small-Medium (51–200 employees)
• Medium (201–500 employees)
• Large (More than 500 employees)
6. Does your company reward full attendance through any financial
rewards or intangible recognitions? (e.g., getting an extra bonus
at the end of the year because you did not consume any Medical
Leave/and Annual Leave.)
• Yes
• No
7. Does your company allow the conversion of unused Annual
Leave into cash?
• Yes
• No
8. How many days of Paid Annual Leave are you entitled to in a

year?
• 1–3
• 4–6
• 7–9
• 10–12
• 13–15
9. How many days of Medical Leave are you entitled to in a year?
• 1–3
• 4–6
• 7–9
• 10–12
• 13–15
10. On average, how often have you gone to work despite feeling
unwell in the past 3 months?
• Never
• Occasionally
• Half the time
• Frequently
• Always
11. Did you experience any of the following health conditions in
the past 3 months?
• Allergies
• Angina (severe chest pain)
• Arthritis or joint pain/stiffness
• Asthma
• Back or neck disorder
• Breathing disorder–bronchitis or emphysema
• Cough
• Depression anxiety or emotional disorder
• Diabetes
• Diarrhoea
• Fever
• Heart or circulatory problems–artery disease
• High blood pressure
• Influenza (Common flu)
• Migraines/Chronic headaches
132 Presenteeism
• Stomach or bowel disorder

• Not applicable
12. Which of the above health condition do you consider your
primary condition (the condition that has affected you most in
the past 3 months)?
13. In thinking about how your primary condition (as identified in
Q12) affected your ability to do your job, how often in the past
3 months:
Half the
Always Frequently time Occasionally Never
• Were you able to

finish hard tasks?
• Did you find
your attention
wandering?
focus on achieving
work goals?
• Did you feel
energetic enough
to work?
• Were the stresses
of your job hard to
handle?
• Did you feel
hopeless about
finishing your
work?
focus on finding
a solution when
unexpected
problems arose in
your work?
• Did you need to
take breaks from
your work?
work with other
people on shared
tasks?
• Were you tired
because you lost
sleep?
14. Given your primary health condition (as identified in Q10),

what percentage of your usual productivity level were you able
to achieve while working over the last 3 months?
• 0%–20%
• 21%–40%
• 41%–60%
• 61%–80%
• 81%–100%
15. Because of your primary condition (as identified in Q10), how
many hours of work did you miss in the past 3 months?
• 0–5
• 6–10
• 11–15
• 16–20
• 21–25
• 26–30
• 31–35
16. In the past 3 months, how many days in a week did you work
OT (Over-time) on average?
• 0
• 1
• 2
• 3
• 4
17. In the past 3 months, how many hours of OT (Over-time) did
you do in a week on average?
• 0–4
• 5–8
• 9–12
• 13–16
• 17–20
18. If you are absent from work for up to a week, what proportion
of your tasks must you take up again on your return?
• None
• A small proportion
• Somewhat less than half
134 Presenteeism
• Somewhat more than half

• Virtually all
19. I see myself as someone who:
Yes No
• Tends to find fault with others

• Does a thorough job
• Is depressed, blue
• Is helpful and unselfish with others
• Can be somewhat careless
• Is relaxed, handles stress well
• Starts quarrels with others
• Is a reliable worker
• Can be tense
• Has a forgiving nature
• Tends to be disorganized
• Worries a lot
• Is generally trusting
• Tends to be lazy
• Is emotionally stable, not easily upset
• Can be cold and aloof
• Perseveres until the task is finished
• Can be moody
• Is considerate and kind to almost everyone
• Does things efficiently
• Remains calm in tense situations
• Is sometimes rude to others
• Makes plans and follows through with them
• Gets nervous easily
• Likes to cooperate with others
• Is easily distracted
20. How far do you agree with the following statements?
Neither
Strongly agree nor Strongly
agree Agree disagree Disagree disagree
• My job is hectic.
• My job is
psychologically
demanding.
• My job requires
working fast.
Continued
• My job requires
working hard.
• My job requires a
great deal of work
to be done.
• My job has a lot
of excessive work.
• My job has very
tight deadlines.
• My job has
conflicting
demands.
• If I am absent
from work,
someone else can
fill in for me.
• If I am absent
from work, the
work just piles up
until I get back.
• My job is not very
significant or
important in the
bigger scheme of
things.
• My job is one
where a lot of
other people in
my organization
(e.g., colleagues,
customers,
suppliers) can be
affected by how
well my work gets
done.
• The results of my
work significantly
affect the lives
and well-being of
other people.
• I find it hard to
say no to others’
wishes and
expectations.
Continued
136 Presenteeism
• My job allows me
to make decisions
about what
methods I use
to complete my
work.
• My job gives
me considerable
opportunity for
independence
and freedom
in how I do the
work.
• My job allows
me to decide on
my own how to
go about doing
work.
Neither
Agree
Strongly nor Strongly
Agree Agree Disagree Disagree Disagree
• Employees in my own
organization like to
work in a group rather
than by themselves.
• If a group is slowing me
down, it is better for
me to leave it and work
alone.
• To be superior, a man
must stand alone.
• One does better work
alone than in a group.
• I would rather struggle
through a personal
problem by myself
than discuss it with my
friends.
Continued
• An employee should
accept the group’s
decision even when
personally he or she
has a different opinion.
• Problem solving by
groups gives better
results than problem
solving by individuals.
• The needs of people
close to me should
get priority over my
personal needs.
• In society, people are
born into extended
families or clans who
protect them in shared
necessity for loyalty.
• Only those who depend
upon themselves get
ahead in life.
• Managers should make
decisions without
consulting their
subordinates.
• In work related matters,
managers have a right
to expect obedience.
from their subordinates
• Employees who often
question authority
sometimes keep their
managers from being
effective.
• Once top-level
executive’s decision is
made, people working
for the company should
not question it.
• Employees should not
express disagreements
with their managers.
• Managers should be
able to make the right
decisions without
consulting with others.
Continued
138 Presenteeism
• Managers who let their

employees participate
in decisions lose power.
• A company’s rules
should not be broken
(even when the
employee thinks it is
in the company’s best
interest).
Neither
Strongly agree nor Strongly
agree Agree disagree Disagree disagree
• My company
values my
contribution to its
well- being.
• My company fails
to appreciate any
extra effort from
me.
• My company
would ignore any
complaint from
me.
• My company
really cares about
my well-being.
• Even if I did the
best job possible,
my company
would not notice.
• My company cares
about my general
satisfaction at
work.
• My company
shows very little
concern for me.
Continued
• My company
takes pride in my
accomplishments
at work.
• My supervisor is
willing to listen
to my personal
problems.
• My supervisor can
be relied on when
things get tough at
work.
• My supervisor
goes out of his way
to make my life
easier for me.
• It is easy to talk to
my supervisor.
23. What industry is your company in?

• Manufacturing
• Construction
• Wholesale & Retail Trade
• Transport & Storage
• Hotels & Restaurants
• Information & Communication
• Financial Services
• Real Estate & Leasing Services
• Professional Services
• Administrative & Support Services
• Community, Social & Personal Services
24. Do you work in the government or the private sector?
• Government
• Private
25. What is your nationality?
• Singaporean
• Others; please specify how long you have been working in
Singapore: ___________ years
26. What is your duration of employment with your current
company?
140 Presenteeism
• Less than 1 year

• 1–3 years
• 4–6 years
• 7–9 years
27. What is your highest educational qualification?
• PSLE
• GCE ‘N’/‘O’ Levels or Equivalent
• GCE ‘A’ Levels or Equivalent
• Diploma
• Bachelor’s Degree
• Master’s Degree
• PhD/Doctorate
28. What is your age group?
• 19–24
• 25–29
• 30–34
• 35–39
• 40–44
• 45–49
• 50–54
• 55–59
29. What is your gender?
• Male
• Female
This is the end of the survey. Thank you for your time and
participation
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8
How Should Presenteeism
Behaviour Be Managed?
8.1 Introduction
When employers focus on managing presenteeism as an important

part of an organization’s health-care benefits, they can transform
employees’ health from a cost burden to a competitive advantage
(Hummer et al., 2002). The realization of the high cost of presen-
teeism has also prompted more and more employers to depend on
comprehensive health initiatives to build a successful and produc-
tive workforce. This development is exemplified in the case of the
U.S. state of Nebraska, which received the 2011 ‘Innovations Award’
from the Council of State Governments (refer to Box 8.1). Nebraska
received this award for a breakthrough programme which inspired
18,000 state employees and 6,000 spouses to get active, lose weight
and become proactive about preventive care.
Box 8.1 Innovations Award for the State of Nebraska
It is evident from the literature that the most successful organizations have
recognized that good health and well-being are affected by all aspects of
the employee experience, and then address it in different ways and embed
it in the culture of the organization. (Shutler-Jones and Tideswell, 2011)
Source: www.prweb.com (2011).
This chapter aims to present an overview of the strategies that have

been adopted by a number of employers to manage presenteeism as
well as of the outcomes of implementation of the strategies. In addi-
tion to this, research findings and case studies on managing presen-
teeism are presented.
144
How Should Presenteeism Behaviour Be Managed? 145
8.2 Strategies to manage presenteeism behaviour
Authors argue that a comprehensive, integrated health-enhancement

strategy can lower health risks, reduce the occurrences of illness,
improve productivity and lower total health-related costs. The domi-
nant components of the solution are a substantial commitment to
prevention and a culture of health rather than of treatment and cure.
Loeppke (2008) suggests three prevention strategies for employers
to manage presenteeism effectively, classifying these strategies
as primary, secondary and tertiary. The primary strategy includes
health promotion, health education, lifestyle management, safety
engineering, job ergonomics and organizational design, nutri-
tion, prenatal care, immunizations and other wellness services.
The secondary strategy includes screening and early detection
programmes, health coaching, biometric testing and proactive work
disability-prevention programmes (such tests and programmes can
identify conditions earlier than they would typical clinical trials). The
tertiary prevention strategy includes disease management, quality
care management, return-to-work programmes, disability manage-
ment and vocational rehabilitation. This strategy can help provide
earlier interventions and limit the impact of serious medical condi-
tions on daily life and work. Such a strategy can also help protect
or restore productive lifestyles, and also reduce future health-care
costs. A comprehensive and integrative strategy in managing pres-
enteeism should go beyond physical health and focus on an ‘inte-
grated well-being approach’ which includes the whole individual.
Loeppke further argues that workplace health initiatives should be
appropriately positioned to leverage coordinated health and produc-
tivity enhancement strategies that can deal with the whole person
in an integrated manner across the entire health continuum (refer
to Figure 8.1).
Loeppke (2008) stressed the need for integrated solutions and
argued that employers need a healthy workforce to yield a productive
outcome. According to this author, employers are realizing that there
is a need for a strategy that would allow them to acquire the value
of better health for their people rather than just pay for the volume
of more health-care services. The information in Box 8.2 shows an
example of how an innovative employer motivated the primary
stakeholders in achieving the goal of reducing presenteeism.
146 Presenteeism
Health promotion, health education, lifestyle

Primary management, safety engineering, job ergonomics,
organizational design, nutrition, prenatal care,
Strategy to manage
immunizations and other wellness services.

presenteeism
Screening and early detection programs, health

Secondary coaching, biometric testing and proactive work
disability prevention programs.
Diease management, evidence-based quality care

Tertiary management, return to work programs, disability
management and vocational rehabilitation.
Figure 8.1 Strategies to manage presenteeism

Source: Adapted from the article ‘The value of health and the power of prevention’ by
R. Loeppke (2008).
Box 8.2 An example of a collaborative partnership among the major

stakeholders
In order to enlighten the physicians and employees about the link

between health and productivity, an innovative employer communicated
with the physicians and the employees before the initiative started as well
as throughout the initiative. They were also informed that if the employer
realized savings in the per member per year medical/pharmacy costs, then
for every one dollar of medical/pharmacy costs saved, the bonus pool for
the employees and physicians would also be credited with one dollar of
health-related productivity savings.
Source: Loeppke (2008).
In the same vein as Loeppke’ s suggestion for a comprehensive and

integrated health-enhancement strategy, Aston (2010) argues that a
proactive approach to wellness and engagement is an essential part
of responsible business practice, which could have a major impact on
company profitability. This author also suggests that ‘wellness and
engagement’ together support good employee performance over a
sustained period.
Box 8.3 presents the findings of a U.K.-based study showing
evidence of the usefulness of a strategic approach to wellness.
Box 8.3 Importance of a strategic approach
Based on a survey of more than 28,000 employees in 15 countries, Right

Management Consultancy found that businesses that took a strategic
approach to wellness and engagement were more innovative, more able
to retain their staff, and more productive overall.
Source: Report delivered to the World Economic Forum in January 2010. Cited in
Aston (2010).
Tynan (2011) has advocated a secondary level strategy (refer to

Figure 8.1), which includes screening and early detection, health
coaching, biometric testing and proactive disability-prevention
programmes and the like. In this regard the author suggests that
the ‘lifestyle’ diseases, including type 2 diabetes, can be managed
better or even prevented through healthy lifestyle practices. Since
employees spend a great deal of time at the workplace, this could
be an ideal place to initiate interventions to make small, routine
changes necessary to build wellness and improve business produc-
tivity. In this context, Tynan has suggested a number of steps for
managers to consider (shown in Box 8.4).
Box 8.4 Intervention steps to build wellness and to improve business

productivity
1. Carry out a diagnostic exercise to assess workplace culture of your

organization.
2. Carry out a workplace health audit.
3. Implement initiatives to target the ‘problem’ areas identified.
4. Provide an annual workplace flu vaccination.
Source: Tynan (2011).
The intervention steps listed in Box 8.4 are briefly elaborated below.
Carrying out a diagnostic exercise is necessary to assess the work-
place culture of the organization to determine whether such health
conditions are contributing towards presenteeism or absenteeism.
The workplace health audit is also necessary to gain an overview of
health risks within an organization and to identify areas for improve-
ment. Implementation of the identified initiatives could include poli-
cies like flexible working hours or work-from-home options, on-site
General Practitioner (GP) clinics, subsidized health insurance, smok-
ing-cessation workshops, nutrition workshops, annual vaccinations,
148 Presenteeism
workplace fitness programmes and sporting challenges. Providing an

annual flu vaccination, either through an on-site clinic or vouchers
for staff to get the vaccination at their local medical centre, is also an
effective policy. Although costs of implementation are an issue, the
author assured that the costs of implementing initiatives like these
have been shown to pay for themselves. Refer to Box 8.5, which
presents the findings of a New Zealand-based study (Tynan, 2011).
Box 8.5 Impact of wellness programme on business: an example
In just the second year of running, the New Zealand Southern Cross
Health Society’s in-house wellness programme reduced its unplanned
staff absence by around 15 per cent.
Source: Tynan (2011).
From the information presented below, it appears that Paton

(2010) and Gurchiek (2009) are advocating for a tertiary strategy that
focuses primarily on disease management, evidence-based quality
care management, return-to-work programmes, disability manage-
ment and vocational rehabilitation.
Paton (2010) argues that there is a strong case for employers to be
taking a more innovative approach to health and well-being and not
getting overly focused on absence and attendance. The author argues
that early-stage, case-managed1 interventions could make a difference,
and the idea of the ‘fit note’2 (that is, a doctor’s note) may help, because
it will generate a formalized and structured debate between general
practitioners, employers and an occupational health department about
exactly what the ‘sick present’ workers can and cannot do.
According to Gurchiek (2009), another strategy that managers
could also consider to create a healthy work environment is encour-
aging employees to take leave and remain home when they are not
feeling well. This can be done by communicating the expectation
that management prefer employees to stay home when sick to ensure
a quicker recovery and lessen the likelihood of spreading contagious
illness such as cold and flu.
8.3 Research, case studies and survey findings
The following sections highlight excerpts from a number of selected

studies on managing absenteeism and presenteeism.
A review of the 11,000 NHS (National Health Service3) staff by the

Royal Mail Group found high levels of presenteeism and made a range
of recommendations for improving the health and well-being of NHS
employees. The report indicated that by implementing the recom-
mended steps, NHS could potentially save more than £555 million a
year and improve the quality of patient care. The recommendations
included the following:
1. Inclusion of staff health and well-being measures and perform-

ance monitoring in the NHS governance frameworks.
2. Publication and monitoring of key health and well-being statis-
tics, including annual data on sickness absence.
3. A national minimum standard of occupational health (OH) serv-
ices across the NHS.
4. An improved provision of wellness and early intervention services
for staff (O’Reilly, 2009).
8.3.1 Evaluation of impact of health on employee outcomes

and the return on well-being investments
Shutler-Jones and Tideswell (2011) argue that to date relatively few
organizations have carried out a comprehensive evaluation of the
impact of and return on their well-being investments. Therefore,
they suggest that the managers who are planning to make a case
for investing in the well-being of their employees could use existing
research evidence, which highlights both the potential benefits for
organizations that could be realized if managed properly and the
significant risk if well-being and engagement are not taken seri-
ously. Benchmarking best practices of the competitive organizations
on well-being practices could also be very credible evidence when
convincing senior management.
To assess and manage health conditions of the employees, Schultz
et al. (2009) suggest taking a number of steps on a regular basis to
analyse the impact of health on work performance and other perti-
nent outcome measures such as absenteeism, injuries and health-care
costs. An abridged version of the steps is presented in Box 8.6. Some
of the recommended steps listed merit elaboration. First, the authors
recommend that health risk appraisals (HRAs4) should be offered at
a regular intervals. In fact, such appraisals allow management to
know the risk profiles of the employees and decide on appropriate
150 Presenteeism
health and wellness interventions for them. Second, the authors

also suggest that management review the HR and benefits policies
of the organization. It has been discussed in earlier chapters that
HR policies, like sick-leave benefits (Prater and Smith, 2011), varia-
ble-pay schemes (Pouliakas and Theodoropoulos, 2012), and work–
life conflict (Ruez, 2004) do influence the level of presenteeism.
The third step in the list is the ‘review of the work environment and
ergonomics’ of the organization, since work environment includes
co-workers, air quality, ergonomic seating, management room for
personal development, child care, parking, noise and even the size
of one’s office and the like. Therefore, management is required to
assess the adequacy of its work environment at regular intervals and
adjust HR and other related policies and, if necessary, ensure that
the elements of the work environment are at a satisfactory level so
that the employees are healthy and productive. Ergonomic seating at
the workplace is also a vital issue for employee productivity, as inad-
equate seating could be a source of back and neck pain and other
health-related problems. Employers share an understanding that a
healthy work environment is key to the success of organizations.
They need to understand that a healthy work environment not only
benefits employees through improved health and wellness but also
benefits customers, shareholders and communities.
Box 8.6 Abridged version of the steps to follow while analysing the
impact of health on performance
Steps:
1. Institute regular health risk appraisals (HRAs).
2. Analyse impact of health on work performance.
3. Revise policies and benefits policies.
4. Develop employee loyalty programme.
5. Ensure that programmes help healthy employees stay healthy.
6. Implement targeted lifestyle and disease-management programmes.
7. Initiate programmes that help healthy employees to remain healthy.
8. Evaluate work environment and ergonomics.
9. Focus on ‘on-the-job’ productivity issues.
10. Help manage and improve employee access to appropriate
medication.
11. Evaluate coverage for mental-health benefits.
12. Develop a work environment that discourages working while ill.
13. Integrate all health, wellness and preventive programmes to help all
employees remain productive.
Source: Shutler-Jones and Tideswell (2011).
Ruez (2004) suggested an integrated approach in combating pres-

enteeism and recommended 11 steps for its implementation (refer to
Box 8.6). Of these, only four are similar to the recommendations of
Schultz et al. (2009). An abridged version of these steps is shown in
Box 8.7.
Box 8.7 Steps in integrated approach in combating presenteeism
Steps:
1. Survey employees about the causes of their presenteeism.
2. Analyse the impact of health risks and chronic illness on
employees.
3. *Examine human resource policies and benefits plan.
4. Develop strategy to analyse and strengthen employee
commitment.
5. *Target lifestyle and disease-management programmes.
6. Offer health-education programmes and resources to employees.
7. Increase leadership commitment to employee health and
productivity.
8. *Have the ergonomic team evaluate the work environment.
9. Evaluate the company’s mental-health coverage.
10. Examine the side effects of the medicines employees are using.
11. *Foster a work environment that discourages excessive overtime and
coming to work sick.
12. Develop work environment that discourages working while ill.
13. Integrate all health, wellness and preventive programmes to help all
employees remain productive.
Note: * These points are similar to those in Shutler-Jones and Tideswell (2011).
Source: Ruez (2004).
Willingham (2008) suggests that the most common approach

to dealing with presenteeism is health promotion using wellness
programmes through the integration of health and productivity
management. In fact, by managing presenteeism, employers can
have both a healthier workforce and a fiscally encouraging bottom
line.
Whysall (2007) argues that the most effective approach to tack-
ling presenteeism is to understand and link health and related non-
health factors causing presenteeism and recommends a number of
steps to follow (refer to Box 8.8).
152 Presenteeism
Box 8.8 Effective approach to tackling presenteeism
1. Identify the extent of presenteeism within your organization and

other major health conditions that are associated with it.
2. Assess the psychological factors.
3. Examine the absence of management programmes or policies that
may encourage presenteeism.
4. Assess the psychosocial factors, such as perceived job security, super-
visor support and management style.
5. Examine communication issues.
6. Target the most costly conditions within your particular work unit or
organization.
Source: Whysall (2007).
Human resource professionals who consider presenteeism worth

addressing may take a number of remedial steps to do it successfully.
For example, they need to educate managers about presenteeism by
making them aware of the problem and the impact on productivity
in order to motivate them to encourage employees to take time off
or to send sick employees home from work. Besides, management
also needs to distribute information on presenteeism and its impli-
cations and conduct necessary training for the employees. However,
it is to be noted that employers who do not provide paid sick leave
or who have strict absence-control policies will find it more difficult
to encourage employees to take sick leave. Such employers should
consider providing leave or revising their absence-control policies to
reduce the threat of discipline problems and allow workers to take
sick time more freely, suggest Samuel and Wilson (2007).
These authors also suggest that in addition to elective solutions, in
the United States some legislative sick-leave requirements are already
in place. Also, several U.S. states have Temporary Disability Insurance
(TDI) programmes to provide wage replacement for non-work related
illnesses or injuries. In addition to TDI, American leave statutes such
as the Family and Medical Leave Act (FMLA) mandate that employers
provide leave for covered employees. It is to be noted that TDI has a
one-week waiting period before benefits accrue and are designed to
address long-term illnesses. It is to be noted that FMLA is typically
unpaid (Samuel and Wilson, 2007).
8.3.2 Possible ways to reduce presenteeism

Employees come to work with various personal and job-related
concerns. As such, to determine which of these concerns could
Sketch 8.1 Employee training on presenteeism
actually impact presenteeism, managers are expected to learn the

employees’ concerns and allocate resources to tackle those prob-
lems. In order to mitigate presenteeism, experts have recommended
a few cost-effective approaches to deal with such problems. These
include educating employees on issues related to presenteeism and
their options, making the workplace more appealing, encouraging
wellness programmes, changing workplace culture, and empow-
ering supervisors to help resolve the issues for the employees to
get them back to being 100 per cent productive. Box 8.9 presents
an example of a financial institution that adapted creative ways to
reduce presenteeism.
Box 8.9 Case study on a financial services company
A financial services company in the United States found that about 10 per
cent of its employees suffered from irritable bowel syndrome. This health
condition created discomfort and resulted in frequent restroom trips,
which reduced their productivity by about 20 per cent. To handle this
situation, the bank sponsored a series of one-hour group sessions with
a gastroenterologist to give these employees advice on coping with their
medical condition.
Source: Milano (2005).
154 Presenteeism
Case study: International Truck and

Engine Corporation
In early 2005, International Truck and Engine Corporation ran

various disease-management programmes for diabetes, asthma,
cardiovascular illness and other problems. An ergonomics
specialist helped adjust an employees’ workspace to lessen phys-
ical difficulties. Also, at each location of the company, a doctor
or registered nurse ran an on-site clinic. All factory sites also had
a fitness/rehabilitation centre, plus musculoskeletal education
programmes that helped workers cope with arthritis and related
conditions.
As evidence of International Truck’s efforts to minimize pres-
enteeism, it is noted that after a survey the company found that
seasonal allergies were a problem for more than 20 per cent of its
employees. To deal with the situation, the company offered its
employees free consultation with an allergy specialist during the
peak allergy season.
It is further noted that the company established a culture that
supported healthy lifestyle choices and rewarded employees for
making these choices. WELCOA (Wellness Council of America,
2006) indicated that visionary leadership, effective programmes,
supportive policies and integration of wellness into the business
objectives of the organization, would continue to drive the health-
promotion efforts at this company in the years to come.
Box 8.10 International Truck and Engine Corporation: outcomes of the

wellness programme
According to the company statement, voluntary participation in wellness

programmes at International Truck and Engine Corporation was good,
and turnover was at that time very low among the company’s blue-collar
employees. It was reported that workers’ compensation costs were down
11 per cent, disability was down by about 30 per cent and absenteeism
about 20 per cent, compared to the previous year. According to a company
executive, they believed that preventive programmes did have a major
impact on their ability to keep people healthy at work, and more produc-
tive. The organization believed that these investments kept its health care
costs under control.
Source: Milano (2005).
Margoshes (2005) suggests that among the options available to

help minimize the impact of presenteeism are employee assistance
programmes (EAP). Insurance company agents can play a key role
by acknowledging the significant impact that presenteeism has on
an organization and by recommending programmes that focus on
wellness, education and workplace accommodations. For example,
the author reports that EAPs have proven to be beneficial in helping
employees deal with a variety of mental or nervous issues that
diminish their ability to focus on being productive at work.
‘Workplace accommodations’ also can be a factor in dwindling
productivity. Margoshes reports that an employee’s ability to be fully
productive may be enhanced by ergonomic or other workplace accom-
modations. Employees with back pain have benefited from ergonomic
enhancements to their work stations or from the anti-fatigue mats.
Computer glare guards, replacing fluorescent lighting with more
appropriate lighting and the use of environmental sound machines
that help mask workplace noise are common accommodations used
by employers to help people with frequent migraine headaches.
Margoshes (2005) also suggests that active management of chronic
health issues through disease-management programmes – such as
those for heart disease, asthma, and diabetes – has proven successful in
helping reduce hospital visits, medical costs and lost time. Margoshes
explains that health risk assessments (HRAs) are voluntary question-
naires that help employees identify whether they may be at risk for a
variety of health conditions such as heart disease, obesity and other
chronic diseases. HRAs also provide employees with a variety of
resources, such as disease-management programmes, fitness or smok-
ing-cessation programmes, to help them better manage their health.
Sometimes, even the most basic education can go a long way in
preventing work-place illnesses. Flu and colds are among the top
five causes of presenteeism. Employers should educate employees on
simple ways to minimize the spreading of viruses, such as washing
hands regularly and avoiding close contact with sick employees.
8.3.3 Models on employee ‘well-being’

The ‘Business in the Community’ (BITC) is a British business-com-
munity outreach charity promoting responsible business, corporate
social responsibility and corporate responsibility. BITC works with
156 Presenteeism
over 800 U.K. companies committed to improving their impact on

society, and operates throughout the United Kingdom. Its aim is to
positively shape business impact on the environment, in the market-
place, in the workplace and in the community.
The BITC ‘Workwell Model’ is developed by business for busi-
ness and based on robust evidence. The model demonstrates the
benefits of taking a strategic approach to wellness and engagement
and provides practical support to businesses. The model highlights
the need for employees to take responsibility for their own health
and well-being. Organizations could also use the BITC ‘case study
template’ to share their own experiences of how promoting health
and well-being has delivered benefits to the employees as well as the
organizations concerned.
8.3.4 Research findings: Return on investment

In a critical meta-analysis of the literature on costs and savings
associated with work-place wellness programmes, Baicker et al.
(2010) found that medical costs fall by about USD3.27 for every
dollar spent on such programmes. The authors also argue that,
although both further exploration of the mechanisms at work and
broader applicability of the findings are needed, the return on
investment suggest that the wider application of such programmes
could prove beneficial for budgets and productivity as well as for
health outcomes.
Another study, by Merrill et al. (2011) report that over the study
period of five years the cost savings in lower prescription drug and
medical costs was USD3.57 million, or USD3.85 for each dollar spent
on the programme.
Tynan (2011) reported that the investments by New Zealand’s
Southern Cross Health Society in their in-house wellness programme
reduced its unplanned staff absence by around 15 per cent annually
(refer to Box 8.5 for more details).

The National Business Coalition on Health reported the results
of a survey that evaluated the quality and efficiency of employer-
based health-care plans and disclosed that more health plans were
reducing barriers to essential treatments. For example, for patients
with diabetes, 27 per cent of health plans waived co-payments for
essential drugs and equipment, and 33 per cent reduced co-payments.

For hypertension, 20 per cent of health plans waived co-payments
for drugs and equipment and 28 per cent reduced co-payments.
For preventive health visits, 43 per cent of health plans waived
co-payments. A 2009 study further confirmed that the health of the
workforce is strongly linked to its productivity and, therefore, to the
health of the company’s bottom line (Smith, 2009).
8.3.6 Total rewards and employee well-being survey:

WorldatWork
A 2011 survey of WorldatWork reports that in the past many employers
implemented wellness programmes, but these programmes usually
provided a reward based on an individual employee’s ability to meet
a specific standard for health promotion or disease prevention (for
example, at-work weight loss, exercise and disease-management
programmes) which brought positive effects to both the employee as
well as the employer. However, the concept of well-being has gone
beyond ‘only health’ but encompasses treating the whole individual
(WorldatWork, 2012).
WorldatWork’s ‘well-being’ approach includes a number of compo-
nents, such as physical health, mental and emotional health, finan-
cial health and spiritual health. This approach encompasses all the
three strategies (that is, primary, secondary and tertiary) advocated
by Loeppke (2008) as shown in Figure 8.2 below.
In 2011, WorldatWork5 conducted a survey of its members to
gather information about current trends in well-being practices in
the survey respondents’ organizations. The employers were asked:
whether they had any strategy for employee well-being; why the
well-being programmes were offered; the degree of support for the
programmes; and extent of utilization of programmes offered and
the like. The quantitative responses to these questions are summa-
rized below:
1. When employers were asked whether they had any strategy for
employees’ well-being, only 54 per cent indicated that they had
such a strategy. Regarding how long the well-being strategy has
been in place, 21 per cent of employers indicated having such
a strategy in place for five or more years, 23 per cent had it for
158 Presenteeism
Physical
health
Spiritual Wellness Mental and

health program emotional
health
Financial
health
Figure 8.2 Components of wellness programme as conceptualized by

WorldatWork
between three and five years and 38 per cent had it between one
and three years (WorldatWork, 2012, p. 11).
2. Among the reasons for offering the programmes, the top responses
included: ‘improve employee health’ (85 per cent), followed by
‘perceived value of employees’ (79 per cent), ‘decrease medical
premiums’ (77 per cent), ‘improve employee productivity’ (73
per cent) and ‘increase employee engagement’ (72 per cent)
(WorldatWork, 2012, p. 12).
3. On the well-being programmes and initiatives offered by the
organizations, 96 per cent of the surveyed organizations indi-
cated offering well-being programmes. Of these organizations, 80
per cent offered EAP (Employee Assistance Programme), followed
by financial education (73 per cent), immunization (73 per cent),
physical fitness (70 per cent) and mental/behavioural health
coverage (69 per cent) (WorldatWork, 2012, p. 9).
4. As for the extent of utilization of the well-being programmes
offered, the top five most-utilized programmes were reported to
be: ‘workplace safety’; ‘HRAs (biometric, physical fitness, etc.)’;
‘flexible schedules’; ‘physical fitness’ and ‘encourage use of vaca-
tion time’ (WorldatWork, 2012, p. 14).
5. The survey results of the communication strategy of the well-being

programme showed that 69 per cent of employers do communi-
cate ‘well-being programmes’ on a frequent and ongoing basis.
The report also provides information on the measured effect
of integrated well-being programme as compared to the tradi-
tional programme. On employee engagement, 88 per cent of the
employers rated ‘integrated well-being’ as having ‘extremely posi-
tive/positive effect’ as compared to 82 per cent for traditional well-
ness programmes. For ‘health-care costs’, integrated well-being
was rated by 74 per cent as having ‘extremely positive/positive
effect’ compared to 48 per cent for the traditional programme.
For productivity, ‘integrated well-being’ had a rating of 79 per
cent as having extremely positive/positive effect’ compared to
71 per cent for the traditional programme. Interestingly, Only
67 per cent of the employers rated having ‘positive’ and ‘extremely
positive’ effects of the integrated program as compared to 81 per
cent for the traditional programme (WorldatWork, 2012, p. 26).
From the above survey results, it is noted that ‘integrated well-being’

programmes have made significant impact on health-care costs as
compared to the other dimensions of the programme outcomes (that
is, employee engagement, productivity). It is also noted that signifi-
cant improvements have been realized in the areas of turnover rates
(that is, 61 per cent for integrated versus 39 per cent for the tradi-
tional, and employee stress levels of 71 per cent for the integrated
programme versus 51 per cent for the traditional one).
8.4 Summary
In this chapter, the strategies that could be adopted to manage pres-

enteeism in the work place have been discussed. It is to be noted that
various authors have focused on different strategies in managing
presenteeism. A few have emphasized having an integrated strategic
framework including all the three levels of strategy – that is, primary,
secondary and tertiary (refer to Figure 8.1). However, some authors
have recommended only a secondary level strategy (Tynan, 2011) and
some only the tertiary one (Paton, 2010; Gurchiek, 2009) to effec-
tively manage presenteeism. Besides the strategies, the chapter has
160 Presenteeism
also presented findings from other studies, surveys and case studies
relating to employee wellness programmes.
It has been noted in this chapter that the researchers in the field
have tried to draw the attention of HR practitioners to focus on the
following issues while dealing with employee wellness:
1. To go beyond the physical health of employees and focus on the

‘whole individual’, adopting an integrated well-being approach.
2. To move away from traditional practices in dealing with pres-
enteeism and develop a proactive partnership approach that
embraces different stakeholder groups (for example, doctors,
insurance companies, employees and other relevant parties; refer
to Box 8.2).
This chapter has also presented a number of specific research

findings to highlight the importance of managing presenteeism
strategically. For example, it was highlighted that businesses that
took a strategic approach to wellness and engagement were more
innovative, more able to retain their staff and more productive
overall (Box 8.3).
Another issue that needs to be highlighted is the cost of imple-
menting comprehensive wellness programmes. For example, Shutler-
Jones and Tideswell (2011) noted that relatively few organizations
have carried out a robust evaluation of the impact and return on
their well-being investments. In this regard the authors have
suggested that those seeking to make a strong case for investing in
the well-being of their staff, a relatively quick approach would be to
use existing research evidence, which highlights both the signifi-
cant risk to organizations if well-being and engagement are not
taken seriously and the benefits that could be realized if managed
properly.
An issue that was barely touched in this chapter is that of the ‘fit
note’. Experts argue that the fit note will lead to more of a focus
debate on adjustments and how they should be made in generating
a better, and earlier, debate about when, where and how to intervene
to keep an employee at work and functioning properly, as well as
getting people back to work from sick leave. Employers need to be
exploring the reasons and any work related triggers that could lead
to sickness presence (Paton, 2010).
Finally, as an evidence of benefits of worksite health-promo-

tion programmes, Chapman (2005) reported the findings of a
meta-evaluation in which the author reviewed 56 journal articles and
found that such programmes showed an average of 27 per cent reduc-
tion in sick-leave absenteeism, 26 per cent reduction in health costs,
32 per cent reduction in workers’ compensation and disability
management claims costs and an average USD5.81 savings for every
dollar invested.
Three other studies on return on investment in wellness programmes
reported savings of USD3.27 (Baicker et al., 2010) and USD3.85
(Merrill et al., 2011) for each dollar spent on such programmes. In
another study in New Zealand, Tynan (2011) reported that in-house
wellness programmes reduced unplanned staff absence by around
15 per cent in its second year running. Therefore, considering the
substantial potential savings through health promotion/employee
wellness programmes, organizations should consider investing in
such programmes to transform themselves into healthy and produc-
tive entities.
Notes
1. Case management is ‘a collaborative process of assessment, planning,
facilitation, care coordination, evaluation, and advocacy for options and
services to meet an individual’s and family’s comprehensive health needs
through communication and available resources to promote quality cost
effective outcomes’ (American Case Management Association).
2. A ‘fit note’ is the informal name for the statement of fitness for work.
Other names used include medical statement or doctor’s note (www.nhs.
chq/pages/2584.aspx).
3. The National Health Service (NHS) is the publicly funded health-care
system of England. It is the largest and oldest single-payer health-care
system in the world.
4. The Centers for Disease Control and Prevention define an HRA as ‘a
systematic approach to collecting information from individuals that iden-
tifies risk factors, provides individualized feedback, and links the person
with at least one intervention to promote health, sustain function and/or
prevent disease’.
5. WorldatWork is a global association for human resources management
professionals and business leaders focused on attracting, motivating and
retaining employees. WorldatWork promotes the role of human resources
as a profession, offering training and certification in compensation, bene-
fits, work-life and total rewards.
162 Presenteeism
References
(11), 29–31.
K. Baicker, D. Cutler and Z. Zirui (2010) ‘Workplace wellness program can
generate savings’, Health Affairs, XXIX (2), 304–311.
L.S. Chapman (2005) ‘Meta-evaluation of worksite health promotion economic
return studies’, American Journal of Health Promotion, XIX (6), 1–11.
K. Gurchiek (2009) ‘Managers, employees view presenteeism differ-
ently’, HR News, http://www.SHRM.org/Publications/HRNews/Pages/
ViewPresenteeismDifferently.aspx, date accessed 20 March 2013.
J. Hummer, B. Sherman and N. Quinn (2002) ‘Present and unaccounted for’,
Occupational Health and Safety, LXXI (4), 40–44.
R. Loeppke (2008) ‘The value of health and the power of prevention’,
International Journal of Workplace Health Management, I (2), 95–108.
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Underwriter-Life and Health, CIX (29), 16, 24.
R.M. Merrill, B. Hyatt, S.G. Aldana and D. Kinnersley (2011) ‘Lowering
employee health care costs through the lifestyle incentive program’, Journal
of Public Health Management and Practice, XVII, 225–232.
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LII (11), 30–34.
N. O’Reilly (2009) ‘NHS staff health review reveals high levels of sickness
absence’, Occupational Health, LXI (9), 5.
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5.
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(6), 20–22.
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place?’, Employee Benefit Plan Review, LXI (11), 5–7.
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health conditions on presenteeism to employers: a review of the literature’,
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Practitioner, XXIX (1), 39–40, 4.
S. Smith (2009) ‘Health and productivity as a business strategy’, EHS Today,
II (3), 8 pages .
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(February).
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productivity’, Benefits Magazine, LXV (12), 1.
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(8), 54–56, 4.
WELCOA (2006) ‘A platinum well workplace: case study’, Wellness Council of
America, 1–26.
9
Measuring the Costs of
Presenteeism
9.1 Introduction
It has been noted in earlier chapters that presenteeism is an invis-

ible cost to employers. To manage costs of presenteeism, employers
need to have a clear idea about the nature and extent of such behav-
iour and its costs to their respective organizations. In Chapter 8
various strategies adopted by employers to manage presenteeism
were discussed. In the present chapter, a methodology of measuring
presenteeism and monetizing the loss of productivity is presented.
A number of presenteeism measurement instruments could be
adopted to compute the dollar amount related to ‘on the job produc-
tivity loss’ due to presenteeism. Presently, some authors convert the
percentage loss in productivity (captured through one of the produc-
tivity impairment instruments) into number of hours per week/year
that an average individual is unproductive. Then multiply that number
by the average hourly wage and benefits cost for an average employee
and, finally, multiply that by the number of employees with a given
health condition. In the following section a list of absenteeism and
presenteeism measurement questionnaires is presented, with brief
discussions on their reliability and validity. The primary purpose of
this chapter is to present the methodology used in two Singapore
studies and the steps in computation of the cost of presenteeism.
9.2 The work impairment measurement instruments
Presenteeism is measured as the costs associated with reduced

work output, errors on-the-job and failure to meet company
164
Measuring the Costs of Presenteeism 165
production standards. A number of instruments are available for

the use of researchers. For example: (a) Migraine Work Productivity
Loss Questionnaire (MWPLQ); (b) Work Productivity and Activity
Impairment: General Health Questionnaire (WPAI: GH); (c) Work
Limitations Questionnaire (WLQ); (d) World Health Organization’s
Health and Work Performance Questionnaire (HPQ); (e) Stanford
Presenteeism Scale (SPS-6); (f) American Productivity Audit (APA); (g)
Work Productivity Short Inventory (WPSI); (h) Disability Assessment
Questionnaire (WHO-DAS); (i) Health at Work Survey (HWS); (j)
Health Limitation Questionnaire (HLQ).1 Data collected by using
one of these instruments, appropriate for the purpose, could be
converted into dollar amounts reflecting the cost of presenteeism
(Stewart et al., 2003; Goetzel et al., 2004).
In this chapter the works of some of the scholars who have tested
the reliability and validity of some of these measurement instru-
ments are reviewed, after which how to develop a questionnaire to
suit the unique requirements of an organization is discussed. At the
end, a step-by-step process of computing the costs of presenteeism is
presented.
9.2.1 Migraine Work Productivity Loss Questionnaire

The Migraine Work and Productivity Loss Questionnaire (MWPLQ)
was developed by Lerner et al. (1999) at the Health Institute, New
England Medical Center, Boston. This 26-item questionnaire
measures difficulties performing on-the-job work demands due to
migraine (Loeppke et al., 2003).
The objectives of the study were to (a) develop a self-report ques-
tionnaire for measuring the impact of migraine headache on work;
and (b) qualitatively assess aspects of its performance. Data were
collected from two samples of migraine sufferers. The first Migraine
Work and Productivity Loss Questionnaire was assessed through
in-depth interviews, with results indicating that the instrument was
comprehended without difficulty and interpreted consistently by
the subjects. It was also reported that respondents found it easy to
complete.
According to Loeppke et al. (2003), the MWPLQ has ‘face validity’
and high ‘internal consistency’ within each work domain (Cronbach’s
alpha ranges from 0.86–0.95), moderate to strong construct validity,
and it exhibits discriminant validity. The MWPLQ captures employee
166 Presenteeism
absenteeism and presenteeism by asking five questions on the hours of

paid work lost due to migraine and the employees per cent of effective-
ness while working with migraine. These five questions may be used
to calculate the total number of hours of work lost due to migraine
and to assess the time lost from work.
9.2.2 World Health Organization’s Health and Work

Performance Questionnaire
The Health and Work Performance Questionnaire (HPQ) was devel-
oped as an expansion of the work role model in the World Health
Organization (WHO) Disability Assessment Schedule (WHO-DAS),
which is a self-report measure of role functioning that was developed
by WHO for use in community service as well as in intervention
studies. The HPQ2 was administered to four samples and generated
meaningful measures of work performance and absenteeism and
concluded that HPQ could be used to assess the overall effects of
allergies, migraine and other illnesses on overall work performance
in an entire workforce and across different types of occupations
(Kessler et al., 2003)
On the overall evaluation of the HPQ items, Loeppke et al. (2003)
suggested that the overall performance items were likely good indica-
tors and with careful modification, the nine performance measures
could become quite useful tools for a daily or weekly assessment. In
terms of practicality, the HPQ has been translated into more than
20 languages for use by the WHO to assess work role functioning in
different countries. The authors also pointed out that the HPQ was
applicable across many industries and occupations.
9.2.3 Work Productivity and Activity Impairment

Questionnaire
The Work Productivity and Activity Impairment Questionnaire
(WPAI) is a presenteeism instrument developed by Reilly Associates
in partnership with the University of Texas Medical Branch at
Galveston and Marion Merrell Dow (Wahlqvist et al., 2002)3.
The instrument was developed for assessing productivity losses
by measuring the effect of general health and symptom severity on
work productivity. Several versions of the questionnaire are avail-
able, including the WPAI-general health (GH), WPAI-specific health
problem (SHP), combination WPAI (GH-SHP) and WPAI-allergy

specific (AS). The WPAI-GH instrument consists of six questions that
ask the patient the number of hours missed from work activities (that
is, absenteeism) as well as the degree of impairment (that is, presen-
teeism) over the past seven days (Loeppke et al., 2003).
A common feature of these instruments is that they measure the
general notion of productivity loss in the work place as affected by
health (Goetzel et al., 2004). A number of researchers, for example
Kessler et al. (2001), Stewart (2001), Borden et al. (2000),4 Goetzel
et al. (2003) and Burton et al. (1999) have used large-scale survey
methods to quantify financial losses related to several health condi-
tions measured simultaneously (Goetzel et al., 2004). The WPAI
instruments have undergone predictive and concurrent validation.5
The WPAI instrument may be self or interviewer-administered. This
instrument may be self- or interviewer-administered. For construct
validity, the questionnaire measures were correlated with Stanford
SF-36 domains and measures of disease/symptom severity. Loeppke
et al. (2003) argue that the patients’ workplace productivity loss can
be monetized using the WPAI.
9.2.4 The Work Limitations Questionnaire

Lerner et al. (2001) developed the Work Limitations Questionnaire
(WLQ) to measure the impact of chronic diseases and treatment
for on-the-job work performance. The WLQ, developed at the New
England Medical Center, consists of four demand scales: time,
physical, mental–interpersonal and output. It is a 25-item instru-
ment that measures the impact on job performance of chronic
health problems or treatment. A version of the instrument for acute
illness is also available. The WLQ questionnaire has undergone
excessive validity and reliability testing (Lerner et al., 2001) and
has been implemented across a variety of conditions, including
rheumatoid arthritis, headache, epilepsy and osteoarthritis (Lerner
et al., 2002).
9.2.5 Health Limitation Questionnaire

The Health Limitation Questionnaire (HLQ) was developed at
Erasmus University, Rotterdam University for Medical Technology,
and is designed to collect data on the relationships among illness,
treatment and work performance (van Roijen et al., 1996). HLQ is a
168 Presenteeism
23-item instrument which has been used on several study popula-

tions, including a representative sample of the general population,
migraine patients, and patients with hip or knee problems (Goetzel
et al., 2004).
9.2.6 The Work Productivity Short Inventory

The Work Productivity Short Inventory (WPSI) was developed to
estimate decrements in employee productivity associated with 15
common disease conditions (Goetzel et al., 2003). Eleven of these
conditions pertain directly to employees, and the other four pertain
to care giving provided by employees to their spouses, dependents or
elders. The 11 employee-specific conditions are: allergies, respiratory
infections, arthritis, asthma, anxiety disorder, depression and bipolar
disorder, stress, diabetes, hypertension, migraine and other major
headaches and coronary heart disease/high cholesterol. The instru-
ment was designed to measure the absence or presence of certain
disease conditions, absence associated with those conditions and
presenteeism losses experienced by employees when suffering from
the health conditions indicated earlier (Goetzel et al., 2004). Three
versions of the instrument were developed, differing according to
the length of recall period: 12 months, three months and two weeks
(Goetzel et al., 2004).
9.2.7 American Productivity Audit

The American Productivity Audit (APA) is a telephone survey of a
random sample of a large number of U.S. workers, designed to quan-
tify the impact of health conditions on work. Using the survey
results, lost productive time (LPT) was measured for personal and
family health reasons and expressed in hours and U.S. dollars). The
APA was completed using the Work and Health Interview (WHI),
a computer-assisted telephone interview designed to quantify lost
productive work time as a result of health conditions, including
time of absence from work and reduced performance while at work
(Stewart et al., 2003).
9.2.8 Stanford Presenteeism Scale

Koopman et al. (2002) developed the Stanford Presenteeism Scale
(SPS-6), San Mateo County, California. First, 175 county health
employees completed the 34-item Stanford Presenteeism Scale

(SPS-34). After analysing the data, the authors then collected six
items from among the 34 items that described presenteeism, and
these six eventually became the Stanford Presenteeism Scale SPS-6.
The authors reported that SPS-6 has excellent psychometric charac-
teristics supporting the feasibility of its use in measuring health and
productivity in relation to presenteeism.
9.2.9 Health at Work Survey

The Health at Work Survey (WHS) was developed by the World Health
Organization (WHO) as part of the WHO Composite International
Diagnostic Interview.
9.3 Designing questionnaires and collecting data
To examine the nature and extent of presenteeism, a comprehen-

sive questionnaire must be designed based on the literature and on
review of the available presenteeism instruments. A sample question-
naire is shown in Appendix 5.1 at the end of this book. This ques-
tionnaire was structured to collect demographic and current work
environment data, including the prevalence of medical conditions
and evidence of presenteeism-related information. A recall period of
12 months, three months or two weeks can be used, depending on
the purpose of the study when the respondents were asked to report
on their health conditions.
9.4 Data analysis
With the available data, reliability and validity of the various

constructs of the questionnaire were carried out. After confirming
the reliability and validity of the constructs, regression analyses and
other statistical tests were carried out to test the hypotheses. It is to
be noted that such statistical tests are not necessary for the users,
whose purpose is only to compute the lost productive hours and the
equivalent costs to the employers.
Next, the per cent of productivity lost due to sickness presenteeism
over the three-month recall period,6 was pro-rated to an annual-
ized number, using the metric employed by Goetzel et al. (2004,
p. 403).
170 Presenteeism
9.5 Computing the costs of presenteeism
A number of steps were followed to arrive at the cost of presenteeism;

these are discussed below:
Step 1: Conversion to monetary value of on-the-job productivity loss

due to presenteeism.
Step 2: Compute the proportion of annual productivity loss using
the metric (suggested by Goetzel et al., 2004, p. 403).
Step 3: Convert the proportion of annual productivity lost
(computed in Step 2) to the equivalent number of hours lost per
year.
Step 4: Compute the average hourly base pay from the self-reported
monthly income of the survey respondents or from the human
resource department.
Step 5: Compute average eligible benefits of the employees in rela-
tion to their base pay.
Note: This information may be sourced from the publications of
National statistics (for example, for the United States, the Bureau
of Labor Statistics; for Singapore, the Year Book of Statistics).
To complete Step 5, details of all wage and non-wage costs rele-

vant for the sample are to be computed (refer to sample Table 9.1).
In summary, compute the average benefits for employees in each
base-pay range, as shown in (a) below, and then the total benefits
(including pension fund/CPF) for each pay range and each age group,
as shown in (b) below:
(a) Average Benefits (for each salary group, excluding CPF7 related
benefits) = AWS8/Bonus + Non-Wage Cost + Annual Leave + Sick
Leave (details shown in Table 9.2 below).
(b) Total Benefits (for each salary range and age group,9 if applicable)
= Average Benefits + Employer’s Central Provident Fund (CPF)
Contribution (details shown in sample Table 9.3).
Step 6: Add the proportionate benefits (that is, benefits as a
percentage of base pay) with the lost base pay and compute the
total cost of productivity lost by an employee who suffered from
the specified health condition or conditions. Alternatively, one
Table 9.1 Sample on annual labour cost per employee, by industry and major
cost component
Wage cost (S$) Non-wage cost ($)
Employer’s
Basic contribu-
wage, tion retire- Medical
overtime ment/ cost and Net
Total and other Bonus Social other training All other
Overall labour regular (variable security health cost (if labour
industry Cost Total payment wage) fund care costs applicable) costs
TOTAL XX XXX XXX XXX XXX XXX XXX XXX
Table 9.2 Sample on average benefits for each salary range (Singapore)
Average
benefits
Bonus Annual Sick leave (variable
Salary range (variable Non-wage leave (to be (to be pay per
(per month) Mid-point wage) cost* computed) computed) year)
< 2,000 1,000 XXX XXX XXX XXX XXX

2,001–4,000 3,000 XXX XXX XXX XXX XXX
> 12,000 13,000 XXX XXX XXX XXX XXX
Note: *From Table 9.1. For a complete example, refer to Tables 5.1–5.3 in Chapter 5.
could also try to get the average hourly wage of all companies,
which should be available from national statistical publica-
tions. In case of the United States, the U.S. Bureau of Labor
Statistics (BLS) is the appropriate source, as used by Goetzel
et al. (2004).
Step 7: Multiply the lost productive hours by the average hourly wage
rates of the organization concerned or the industry average of all
companies as reported in the national statistics (for example, U.S.
Bureau of Labor Statistics).
It is to be noted that costing of lost productive hours due to

presenteeism may vary based on the assumptions made by the
172 Presenteeism
Table 9.3 Sample on cost of sickness presenteeism to organizations
Cost of sickness
presenteeism
Overall Male Female

Total
Age annual (Equivalent of % of eligible
Salary range Mid-point group income work hours lost)
< 2,000 1,000 XXX XXX XXX XXX XXX

researchers and/or the accounting practices of the country

concerned. For example, Stewart et al. (2003) estimated lost produc-
tivity by translating hours of lost productive time into dollars
by using the survey respondents’ self-reported annual salary or
wage information. Lost dollars were calculated by multiplying lost
hours by the hourly wage. However, it is not clear whether the
annual salary included base-pay incentives and benefits. Goetzel
et al. (2004), on the other hand, computed the lost dollars slightly
differently. They multiplied the unproductive hours by the average
hourly wage and benefits of all U.S. companies (as reported by the
U.S. Bureau of Labor Statistics). For a sample questionnaire, refer
to Appendix 5.1.
Total annual income of the employee concerned includes gross
annual income and the total annual benefits received. Using the
respective percentages of the eligible work time lost per annum
(shown in the earlier sections), the cost of sickness presenteeism to
organizations could be computed. Similarly, the per cent of eligible
work time lost per year by male and female employees can also be
computed separately (For a sample template refer to Table 9.3.).
The costs of presenteeism can be computed for the entire organi-
zation by multiplying the number of employees suffering from the
health condition; or, for the nation as a whole, by multiplying by the
proportion of the total national workforce suffering from the health
condition (assuming that the proportion of employees suffering
from the health condition in the sample is the same as that in the
national workforce).
9.6 Computations of ‘on-the-job productivity loss’

due to chronic and acute health conditions
To compute the costs of productivity loss due to chronic and acute

health conditions, data needs be collected for each condition. Once
the data collection is complete, on-the-job productivity lost for each
of the health conditions can be computed following the steps indi-
cated above for chronic health conditions. Also, refer to Chapter 6
(Singapore Study 2) for further information.
9.7 How to customize your own instrument
Step 1: Select the most appropriate ‘Work Impairment Instrument’ or

an instrument that suits the objectives of your study.
Step 2: Design a questionnaire to capture (a) demographic informa-
tion, (b) work-related information, (c) information specified in
the Work Impairment Instrument and (d) any other information
deemed necessary to complete the analysis (for an example, refer
to the sample questionnaire shown in Appendix 5.1).
Step 3: Pilot test the survey questionnaire to get feedback on clarity, ease
of understanding and time required to complete the questionnaire.
Step 4: Have the questionnaire translated into other languages, if
necessary.
Step 5: Select the sample to make sure that you have enough
completed and usable questionnaires from the survey to be able to
carry out necessary statistical analysis to facilitate interpretation
of the results.
Step 6: After receiving feedback from the reviewers, amend the
questionnaire.
Step 7: Launch the survey. This could either be an on-line survey or
a ‘paper and pencil’ survey.
Step 8: Analyse the data and compute the average productive hours
lost due to sickness.
Step 9: Understand why some employees come to work despite being
sick.
Step 10: Compile the average hourly base pay, benefits and incentives
per employee (may be available from the publications on national
labour statistics of the country concerned).
174 Presenteeism
Step 11: Compute the average cost of on-the-job productivity losses

due to specified sickness or the total hours lost per year due to all
the different health conditions added together.
Step 12: Extrapolate the cost of presenteeism for the entire organi-
zation (multiply the dollar equivalent of lost productivity per
employee per year by the number of employees suffering from the
health conditions). For a complete sample questionnaire, refer to
Appendix 2 at the end of the book.
9.8 Discussions
Reviewers of presenteeism instruments have provided more in-depth

analysis of some of the questionnaires, their validity and reliability
and their other features. However, it is to be noted that some instru-
ments are only suitable for use with certain patient groups, such
as those with migraines (that is, Migraine Work Productivity Loss
Questionnaire). Some other instruments are however, applicable to
broader populations that might have a variety of health conditions
(Schultz et al., 2009).
In a study, Burton et al. (2001) gathered objective productivity
measures of telephone customer-service operators and compared
them with health-risk appraisal data. This study is an example
of calculating presenteeism from a direct measure (Schultz et al.,
2009). However, the need for a reliable and valid way to indirectly
measure presenteeism across many types of jobs and organizations
led to the development of several self-report instruments. It is to be
noted that some instruments are only suitable for use with certain
patient groups, such as those with migraines. Others are appli-
cable to broader populations that might have a variety of health
conditions.
An expert panel convened by the American College of Occupational
and Environmental Medicine recommended that presenteeism meas-
ures cover the following aspects of productivity:
(1) time not on task,

(2) quality of work (for example, mistakes, peak performance, injury
rates),
(3) quantity of work and
(4) personal factors (for example, social, mental, physical, emotional)
(Loeppke et al., 2003).
It is, however, recommended that whichever instrument is chosen,

investigators must interpret their results carefully, since different
questionnaires measure different aspects of productivity.
Notes
1. It is to be noted that most of these instruments are proprietary in nature
and not available on-line except for the Work Productivity and Activity
Impairment questionnaire, ‘Migraine Disability Assessment’, and the
questionnaire for Allergic Rhinitis. Source: American Journal of Managed
Care, April 2007, p. 212).
2. The complete text of the HPQ is available at ‘http://www.hcp.med.
harvard.edu/hpq’.
3. Reilly Associates – A research and consulting firm specializing in the
design, implementation and analysis of quality of life and economic
studies for pharmaceutical companies; Marion Merrell Dow – Marion
Merrell Dow was a U.S. pharmaceutical company based in Kansas City,
Missouri from 1950 until 1996.
4. Available at ‘http://www.ehcaccess.org/surveydata.asp’.
5. Little work has been done to show their construct validity.
6. Some other studies have used recall periods of two weeks, three months
or one year (reference, Goetzel et al., 2004).
7. The Central Provident Fund (CPF) is a compulsory comprehensive
savings plan for working Singaporeans and permanent residents, prima-
rily to fund their retirements, health care and housing needs.
8. AWS, or Annual Wage Supplement, is commonly known to employees
as the 13th month bonus that most companies give out. It represents a
single annual payment to employees that is supplementary to the total
amount of annual wages earned.
9. Employers’ CPF contribution varies between predetermined age groups.
10. Available at ‘http://www.ehcaccess.org/surveydata.asp’.
11. American College of Occupational and Environmental Medicine.
References
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Health Coalition of Tampa, Florida, Published by management Care
Communication, Newton, MA.10
W.N. Burton, D.J Conti, C.Y. Chen, A.B. Schultz and D.W. Edington (1999)
‘The role of health risk factors and disease on worker productivity’, Journal
of Occupational and Environmental Medicine, XLI (10), 863–877.
W.N. Burton, D.J. Conti, C.Y. Chen, A.B Schultz, D.W. Edington, J.M. Weiler,
J.R. Bloomfield, G.G. Woolworth et al. (2001) ‘The impact of allergy and
allergy treatment on worker productivity’, Journal of Occupational and
Environmental Medicine, XLIII, 64–71.
176 Presenteeism
R. Goetzel, S.R. Long, R.J. Ozminkowski, K. Hawkins, S. Wang and W.

Lynch (2004) ‘Health, absence, disability, and presenteeism cost esti-
mates of certain physical and mental health conditions affecting U.S.
employers’, Journal of Occupational and Environmental Medicine, XLVI (4),
398–412.
R.Z. Goetzel, R.J. Ozminkowski, S.R. Long (2003) ‘Development and relia-
bility analysis of the work productivity short inventory (WPSI) instrument
measuring employee health and productivity’, Journal of Occupational and
Environmental Medicine, XLV, 743–762.
R.C. Kessler, C. Barber, C. Beck, P. Berglund, P.D. Cleary, D. McKenas, N.
Pronk, G. Simon, P. Stang, T.B Ustun and P. Wang (2003) ‘The World Health
Organization Health and work Performance Questionnaire (HPQ)’, Journal
of Occupational and Environmental Medicine, XLV (2), 156–174.
R. C. Kessler, P.E. Greenberg, P.E. Mickelson, D. Kristin, L.M. Meneades and
P.S. Wang (2001) ‘The effects of chronic medical conditions on work loss
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LXIII (3), 218–225.
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presenteeism scale: health status and employee productivity’, Journal of
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Gerth and R.B. Lipton (1999) ‘The migraine work and productivity
loss questionnaire: concepts and designs’, Quality of Life Research, VIII,
699–679.
D. Lerner, B.C. Amick III, W.H. Rogers, S. Malspeis, K. Bungay and D. Cynn
(2001) ‘The work limitations questionnaire’, Medical Care, XXXIX (1),
72–85.
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Medicine, XLV, 349–359.
A.B. Schultz, C.Y. Chen and D.W. Edington (2009) ‘The cost and impact of
health conditions on presenteeism on employers’, PharmacoEconomics,
XVII (5), 365–378.
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the American Productivity Audit’, Journal of Occupational and Environmental
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10
Summary and Discussions
10.1 Introduction
The issues related to presenteeism and its impacts on employees

as well as employers have been discussed. This book also explores
the reasons why employees come to work despite being sick and
the strategies adopted by the employers to manage such behaviour.
Concepts of presenteeism and the consequences of such employee
behaviour have been discussed. In Chapter 1, it is noted that there
are two types of presenteeism: ‘sickness presenteeism’ and ‘non-sick-
ness presenteeism’.
In Chapter 2, the main focus is on ‘sickness presenteeism’ (coming
to work despite illness, injury, anxiety, and so on, often resulting in
reduced productivity) and non-sickness presenteeism (working long
hours at a job without the real need to do so).
Both types of presenteeism result in loss of productive time. Many
authors have reported costs of sickness presenteeism, but the cost
figures are different. This is probably due to a number of factors
(methodology used, number of health conditions included, the
time when the study was conducted, basis of costing, and the like).
However, researchers are convinced that presenteeism is a costly
affair and that management needs to tackle such costs.
In 2007, health care costs for U.S. employers accounted for USD
8,796 per employee per year and the majority of these costs were
being shouldered by the employers. In fact, the Mayo Clinic report
emphasized that presenteeism costs employers two to three times
more than direct medical care costs (Mayo Clinic, 2008).
178
Summary and Discussions 179
In Chapter 3, issues regarding ‘absenteeism’ and ‘presenteeism’

are discussed. It has also been suggested by experts that there is
a possibility that the rise in presenteeism may be due to the fact
that employees might be substituting sickness presence for sickness
absence (MacGregor et al., 2008). Further, the issues of employee race,
diversity and absenteeism (Avery et al., 2007) and the possible link
between national culture and absenteeism (Parbotteeah et al., 2005)
are discussed. In addition to those issues, summary findings on an
absenteeism study, conducted by CIPD and Simplyhealth (2012) in
the United Kingdom, are also presented.
Chapter 4 discusses the issue of ‘why employees’ go to work even
when sick. The study found that some workers were more likely to
go to work ill during economic downturns for job security, finan-
cial reasons, work environment, time pressure, and other reasons.
Presenteeism may also occur when there is a shortage of skilled
labour of specific types in the market.
Chapters 5 through 7 present the excerpts of the findings of the
three studies conducted in Singapore. Chapter 5 presents the find-
ings from the survey on the nature and extent of on-the-job produc-
tive time lost due to sickness presenteeism. In addition, this study
also estimated the extent of productive time lost by male and
female employees. Chapter 6 examines the productive time lost
due to chronic and non-chronic sicknesses of employees, whereas
Chapter 7 examines only one aspect of presenteeism by exploring
why employees in Singapore go to work despite being sick.
Chapter 8 presents the findings on how employees and employers
are coping with presenteeism behaviour and the possible strategies
to manage it in an organization. This chapter also discusses who
should be taking the lead in managing presenteeism. In Chapter 9
the author presents a guideline on how to measure the cost of pres-
enteeism. The concluding Chapter 10 presents the possible outcomes
of the strategies that have been suggested by scholars and practi-
tioners to bring about changes to minimize the productivity lost
through presenteeism.
10.2 Research findings
Health and productivity are closely linked. With increasing medical

costs, health-related productivity losses and limited available
180 Presenteeism
resources, employer groups need to be able to determine the value

or return on investment of health-care interventions that they
purchase for their employees. Potential benefits from employer-
purchased health-care interventions, such as disease management,
disability management, optimal pharmaceutical utilization and
health-promotion programmes, include reduced medical costs and
decreased productivity losses associated with the firm’s workforce
(Mayo Clinic, 2008).
Mayo Clinic Health Solutions (2008) reported that for more than a
decade researchers and health consultants gathered hard data, prac-
tical advice and real-life experiences on how to run an effective, effi-
cient worksite health programme. The sources assert that successful
population health-management programmes are comprehensive
and ongoing. The report also advises that effective programmes
consider the needs of a population and tailor programmes accord-
ingly. The key is to start with a company-wide health risk assess-
ment (HRA) which provides data to management to identify and
analyse risk trends and respond with meaningful need-based health
programmes. According to Mayo Clinic Health Solutions (2008),
the most prevalent health risk factors are poor nutrition, emotional
health, safety and weight. Therefore, these risk factors are good
places for many companies to get started. The report also comments
that your own company-specific results can be combined with
health data to help establish organizational priorities and trends
that need attention.
Three case studies are presented below to highlight the outcome of
the strategies used by some employers.
10.2.1 Case Study 1: Northern Food’s ‘Fit4Life’ campaign

The campaign launched in early 2008 by Northern Foods aimed to
increase productivity, reduce absence and enhance retention rates
among a predominantly manual workforce – part of Northern Foods’
ongoing staff-engagement strategy, called the ‘Fit4Life’ campaign.
The company expected that the scheme would provide a (non-finan-
cial) means of rewarding and motivating employees. For this, occu-
pational health specialist advisers were recruited at each company
site to facilitate the implementation of the ‘Fit4Life’ campaign. Box
10.1 presents brief information on Northern Foods’ implementation
approach (Aston, 2010).
Box 10.1 Northern Foods ‘Fit4Life’ campaign
In Northern’s ‘Fit 4 Life’ campaign, all employees get a personal assess-

ment, with individually tailored health advice, plus access to on-site
physiotherapist, massage and chiropody services. The first 100 employees
to complete a lifestyle questionnaire received a pedometer, and National
Health Services (NHS) trained a number of staff members as workplace
health advisers. Staff are encouraged to walk or cycle to work. The health
checks act as an ‘early warning’ system, giving employees the informa-
tion and support they need to take responsibility for their own health and
well-being. Since the campaign began, absence has fallen across all sites,
resulting in significant savings.
Source: L. Aston (2010) Helping Workers Help Themselves
Loeppke (2008) argues that the return on investment in health

and productivity enhancement surpasses the traditional measures
of medical costs into the metrics of productivity improvement. This
author also emphasizes that improving health not only controls
expenses, but also protects, supports and enhances human capital.
Therefore, workplace health initiatives are uniquely positioned to
leverage coordinated health and productivity-enhancement strate-
gies that can deal with the whole person in an integrated manner
and the whole population across the entire health continuum
(Loeppke, 1995). The author also argues that integrated population
health enhancement can lower health risks, reduce the burden of
illness, improve productivity and lower total health-related costs.
A study at the Milken Institute reported that seven chronic health
conditions (cancer, heart disease, hypertension, mental disorders,
diabetes, pulmonary conditions and stroke) are costing the United
States economy more than USD1 trillion per year, with anticipated
growth rates of the prevalence of those seven conditions to yield an
illness burden of USD4 trillion per year by 2023 (Loeppke, 2008).
However, as compared to this ‘business as usual’ scenario, plau-
sible estimates of potential gains (avoided losses) associated with
reasonable improvements in prevention, detection and treatment
of just those seven health conditions would cut annual treatment
costs in the United States by USD217 billion and reduce health-re-
lated productivity losses by USD905 billion by 2023. Furthermore,
lowering obesity rates alone could lead to productivity gains of
USD254 billion and the avoidance of USD60 billion in treatment
expenditures (DeVol et al., 2007; Loeppke, 2008).
182 Presenteeism
10.2.2 Case Study 2: managing changes at

Leeds University, UK
Shutler-Jones and Tideswell (2011) report that during a period of
significant change, the University of Leeds, in the United Kingdom,
adopted a multi-pronged approach to ensure that its people are
supported as much as possible. An example of this was the devel-
opment of a ‘Road Map for Change’, which provides guidance for
managers on best practice for effective change management, as well
as signposting to support services available for staff. These include
everything from staff counselling, mediation and a dedicated
Citizens Advice Bureau phone line, to career advice for those leaving
the institution. Additional support is also directed into areas going
through major restructure – for example, executive coaching for
senior managers. Workshops were planned to support these areas to
help rebuild teams and increase resilience.
Another important element of change management at Leeds was the
active involvement of the campus trade unions. Working in partner-
ship, an organizational change policy was developed, which included
strategies to avoid compulsory redundancy and ensure staff consulta-
tion as well as to create a framework to allow staff to be redeployed
into other areas of the university (Shutler-Jones and Tideswell (2011).
10.2.3 Case Study 3: Workwell in action – how the

company is working fitter
British Telecom (BT) management put a lot of time and effort into
wellness and engagement, which meant improving communica-
tion across the company. Their old annual staff survey was changed
into a shorter quarterly survey, reducing the administrative burden
and helping the management closely monitor staff attitudes and
engagement levels in order to tackle any issues early on. Their health
services also focused on early intervention and prevention. They
tried to move away from the old ‘command and control’ mindset
to get people first to take responsibility for their own actions and
then get to a point where they would be looking out for each other.
Their code was ‘Never let a colleague fail’, and that applied to all
aspects of business, including safety and health and well-being. They
worked with the unions and other stakeholders to develop an online
programme, called ‘Work Fit’, with simple tools with which people
could take control of their own health. The ‘Work Fit’ programme
drove home the message that improving health and well-being is
very much a collaborative process. ‘Business In The Community’

(BITC) recommends four approaches that employers should take to
enable employees to flourish:
1. Create better physical and psychological health where employees

are engaged to make healthy lifestyle choices.
2. Better work reflects the importance of a happy, engaging work
environment that promotes good work.
3. Better specialist support acknowledges the role of early inter-
vention and proactive management in supporting wellness and
recovery.
4. Better relationships are about good communication and devel-
oping social capital both at work and at home.
Box 10.2 Workwell model and employee well-being
BT’s old annual staff survey was amended into a shorter quarterly survey,
reducing the admin burden and helping us monitor staff attitudes and
engagement levels closely so that they could tackle any issues early on.
BTs health services also focus on early intervention and prevention.
BT’s management tried to move away from the old ‘command and control
mindset’ to get people first to take responsibility for their own actions
and then to a point where they would be looking out for each other.
Source: L. Aston (2010) Helping Workers Help Themselves.
BITC argues that sometimes even the most basic education can go a
long way in preventing workplace illnesses. Flu and colds are among
the top five causes of presenteeism. Employers need to instruct their
employees about simple ways to minimize the spreading of virus,
such as washing hands regularly and avoiding close contact with
sick employees.
10.2.4 Guidelines for managers

Authors suggest that employers should approach presenteeism like
any other health risk, namely with both prevention and mitigation
strategies. To limit the potential impact of presenteeism on produc-
tivity, companies should identify the key worksite risk factors driving
presenteeism and develop strategies to minimize it. Further, experts
argue that job demands and burnout are important (causal) factors
influencing presenteeism. Therefore, a way to reduce presenteeism
is to redesign job demands such that they do not have undesirable
184 Presenteeism
effects on employee health. Another way could be to discourage

employees from continuing to work when not fully fit to do so. This
can be achieved by developing a culture that clearly removes the
ambiguity regarding what employees have to do when they are sick.
Margoshes (2005) suggests that managers and occupational health
professionals should be aware that presenteeism might be good in the
short term but in the long term it will create more problems in terms of
employee sicknesses and enhanced costs. Therefore, employers need
to create a climate in which staying home when sick is not a taboo. On
the work floor, supervisors should encourage sick employees to stay at
home and, as role models, should behave the same way themselves. It
is reasonable to expect that some employees will find it more difficult
to comply with such a culture and supervisor’s interventions, since
employees who find it hard to say ‘No’ to others’ wishes and expecta-
tions (boundarylessness) are inclined to exhibit more presenteeism
than their counterparts (Aronsson and Gustafsson, 2005).
Aston (2010) comments that employers should be encouraged to
foster work environments that are conducive to good mental well-
being and the enhancement of mental capital. It is suggested that
this approach could be very cost-effective due to reductions in the
costs of presenteeism, labour turnover, recruitment and absen-
teeism. This model has been developed by ‘Business for Business’,
and it provides a framework for articulating the business benefits of
a strategic, integrated and holistic approach to wellness and engage-
ment, plus practical toolkits to provide businesses put the approach
into action. It is recommended that employers enable employees
to flourish by creating an environment in which all employees are
encouraged to make healthy lifestyle choices, and the model recom-
mends the following approaches that employers should take:
1. Better work reflects the importance of a happy, engaging work

environment that promotes ‘good work’ that is secure, varied and
puts employees in control (Coats and Lekhi, 2008).
2. Better specialist support acknowledges the role of early inter-
vention and proactive management in supporting wellness and
recovery.
3. Better relationships are about good communication and devel-
oping social capital, both at work and at home.
What the ‘Workwell’ model demonstrates is that conven-

tional health-promotion activities, such as ‘Fruity Fridays’ and
discounted gym memberships are, by themselves, not enough.
Right Management argues that one could be a triathlete, but if
not engaged, this person will not be performing as well as he or
she could. Health interventions can be costly, and organizations
may not see the benefits for years. By taking a holistic approach,
employers start seeing measurable benefits in the short term as
well as in years to come. In fact, the ‘Workwell’ model takes a dual
approach to wellness, encouraging employees to take responsibility
for their own lifestyle choices.
BITC works closely with a number of leading occupational health
providers, who agree that the wellness and engagement agenda is
creating opportunities for them and their clients. Experts in this field
suggest that relatively small changes to working practices could have
a big impact on performance and perception. It is suggested that part-
nerships are key to releasing the potential of occupational health. If
clients position themselves right, this is an opportunity for occupa-
tional health professionals to be at the forefront of a revolution in
the way services are delivered. The ‘Workwell’ model highlights the
benefits of this type of collaborative working. For example, BT has
already put it into practice and sees it as being equally critical to the
business.
It is estimated that if the employee absence in the NHS could be
reduced by one-third across the board, it would save an annual direct
cost of UK £555 million a year. The consultants argue that most
companies still have some way to go in recognizing the potential
of wellness and engagement to improve their business. The consult-
ants comment that the most effective organizations are those that
integrate wellness and engagement into all aspects of their everyday
business from board level down.
10.2.5 Savings from investments in presenteeism

Loeppke (2008) comments that the return on investment in health
and productivity enhancement goes beyond the traditional measures
of medical costs into the metrics of productivity improvement. This
author argues that improving health not only controls expenses, but
also protects, supports and enhances human capital. The author also
186 Presenteeism
argues that workplace health initiatives are uniquely positioned to

leverage coordinated health and productivity-enhancement strate-
gies that can deal with the whole person in an integrated manner
and the whole population across the entire health continuum.
Calculating return on investment (ROI) is complex, as the ratio
will vary with the health condition, nature of treatment, age of the
patient and the like. Luce et al. (2006) reported the ROI of health-care
expenditures from 1977 to 2003. The authors reported that each addi-
tional dollar spent on overall health-care services produced health
gains valued at USD1.55 to USD1.94 under the base case assumptions.
The return on health gains associated with treatment of heart attack,
stroke, type 2 diabetes, and breast cancer were USD1.10, USD1.49,
USD1.55 and USD4.80 respectively. The authors also reported ROI of
a few specific treatments, for example, Cretin (1977) reported a gain
of USD10 for every additional dollar spent for a hypothetical cohort
of heart attack patients. Whereas, Goldman et al. (1988) reported
ROI of USD6.49, USD23.44 and USD35.16, respectively, for low-risk,
medium-risk and high-risk patients who were receiving therapy with
beta blockers. Whereas, Karnon and Jones (2003) reported ROI of
USD27.03 to USD36.81 when treating postmenopausal women with
advanced breast cancer.
10.3 Conclusion
In this book we have discussed the newly emerging concept of ‘pres-

enteeism’. Research findings clearly indicate that presenteeism is
an invisible loss of productivity to employers. Studies in the United
States have revealed that the annual cost of presenteeism is at least
USD150 billion (Goetzel et al., 2004). A study in Australia revealed
that sickness presenteeism costs the economy AUD25.7 billion per
year. Other authors have reported the cost to employers through
presenteeism for health conditions. Our studies in Singapore revealed
that on average an employee lost 3.88 per cent of his or her annual
eligible work time. Studies conducted in the United States and other
countries also revealed that cost of sickness presenteeism is preva-
lent, and proper management of such employee behaviour can be
rewarding for both the employers as well as the employees.
Studies have demonstrated that comprehensive and integrated
health-management strategies can lower health risks; improve labour
productivity and lower health-related costs. Therefore, it is logical

for employers to pursue strategies that can help ensure produc-
tive lifestyles of employees and reduce future health-care costs. In
Chapter 8, we highlighted some of the strategies that have shown
tangible benefits for all the stakeholders. The purpose of the book is
to help raise awareness of both employees and employers about the
hidden costs of presenteeism and the need for an integrated approach
to managing such employee behaviour.
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Practitioner, XXI (1), 39–40, 4.
Index
absence-control policies, 152 British Telecom (BT), 182–3, 185

see also attendance policies burnout, 25, 51–2, 183
absenteeism, 1, 15, 19–20, 179 Business in the Community (BITC),
causes of, 37 155–6, 182–3, 185
CIPD studies on, 36–41
costs of, 35–8 case management, 161n1
culture and, 33–4 case studies, 180–3
defined, 31 Central Provident Fund (CPF),
health risks and, 36 110n5
impact of health-promotion Chartered Institute of Personnel
programmes on, 40–1 and Development (CIPD),
job position and, 32 36–41
managing, 38–40 chronic diseases, 39, 91, 107–8
in Nordic countries, 33 colds, 155
obesity and, 34–5 collectivism, 115, 117, 121
organizational culture and, 114 Confucian values, 75
organizational pay policy and, 32 conscientiousness, 119, 120, 121,
productivity losses from, 31 126, 127, 129
race and, 33 contagious disease, 49
rate of, 37–8 cough, 3, 91, 101, 107, 123
reducing, 49 counselling, 4
stress and, 51 counter-productive work
studies on, 31, 35–6 behaviours, 120
substitution with presenteeism, co-workers, discussions with, 20
32–3, 49, 179 culture
wage levels and, 32 national, 33–4
acute diseases, 91 organizational, 3–4, 114, 115, 117,
allergies, 2, 13, 14, 90 121, 127, 153, 184
American Productivity Audit (APA), customers, loss of, 20
11, 165, 168
anxiety, 91, 107 demographics, 67–8, 98, 122
arthritis, 13, 21, 91, 107 depression, 13, 14, 21, 34, 51–2,
asthma, 91, 107 53–4, 107
attendance policies, 115, 121, 152 diabetes, 14, 21, 22, 34, 91, 107,
Australia, 15, 54, 62, 89 156–7
diarrhoea, 91, 101
back pain, 13, 91 Disability Assessment Questionnaire
benefits, 64 (WHO-DAS), 165
breaks, long, 20 disciplinary action, 115
189
190 Index
disease-management programmes, Health and Work Performance

155, 157 Questionnaire (HPQ), 165, 166
diversity, 33 Health and Work Questionnaire
duty, sense of, 49, 50 (HWQ), 67
Health at Work Survey (HWS),
ease of replacement, 117, 121, 165, 169
126, 127 health-awareness programmes, 4,
economic impacts, 64, 89 38, 92, 100, 108–9
emotional exhaustion, 25 health-care expenditures,
employee assistance programmes 178, 186–7
(EAPs), 155 health-care plans, 156–7
employee productivity, see health conditions
productivity losses see also specific conditions
employees associated with sickness
ease of replacement, 117, 121, presenteeism, 2, 3, 10, 12, 35,
126, 127 61–2, 68–9, 74–5, 88–111, 123–4
reasons for going to work sick by, chronic, 39, 91, 107–8
2, 45–57, 62–3, 111–40, 179 effects of, on work
self-awareness, 92, 99, 100 performance, 69
time spent on personal matters work difficulties and, 69–70
by, 19 health impacts
employment conditions, 47–8, 63–4 of long work hours, 56–7
see also work environment resulting from stress, 51
ergonomics, 155 Health Limitation Questionnaire
extreme jobs, 55–6 (HLQ), 165, 167–8
health-promotion programmes,
Family and Medical Leave Act 40–1, 76, 109, 147–8, 154,
(FMLA), 152 161, 180–2
family issues, 21 see also wellness programmes
fast food, 39 health risk appraisals (HRAs),
female employees, 2, 17, 66, 70–1, 75 149–50, 155
fever, 91, 100–1 health screening, 4
Fit4Life campaign, 180–1 heart disease, 21, 53, 107
‘fit note’, 148, 160 high-wage earners, 55–6
flu, see influenza human resource professionals, 152
flu vaccinations, 148 hypertension, 91, 107, 157
France, 54
Indispensable Man Theory, 50
gastroesophageal reflux disease individual boundarylessness, 88–9,
(GERD), 16 114–15, 119–20, 121
gender differences, in sickness individualism, 34
presenteeism, 2, 17, 66, 70–1, 75 influenza, 3, 91, 107, 123, 155
Germany, 16, 54 Integrated Screening Programme
guilt, 64 (ISP), 109
International Truck and Engine
headache, 3, 13, 91, 101, 107, 123 Corporation, 154
Index 191
Iron Man Mentality, 50 National Business Coalition on

Italy, 16 Health, 156–7
national culture, absenteeism
job autonomy, 115–16, 121 and, 33–4
job demands, 2–3, 92, 99, 108, National Health and Nutrition
109–10, 115, 120, 121, Examination Survey (NHANES),
126, 183 22, 27n7
job insecurity, 20, 48–9, National Health Service (NHS), 149
63–4, 108 Nebraska, 144
job position, 32 Netherlands, 54
job-related factors, 115, 121 neuroticism, 119
job satisfaction, 118 New Zealand, 17, 19
job security, 116, 121 non-managerial employees, 3, 92,
junk food, 39 99, 103–4, 108
non-sickness presenteeism,
labour costs, 104, 105–6 19–25, 178–9
labour shortage, 14 Nordic countries, absenteeism in, 33
Leeds University, 182 Northern Foods, 180–1
lifestyle diseases, 147
Lockheed Martin, 10 obesity
long breaks, 20 absenteeism and, 34–5
long work hours, 52–4 health consequences of, 34–5
depression and, 53–4 presenteeism and, 21–2, 25
health effects of, 56–7 Octopus model, 46
heart attack risk and, 53 organizational culture, 3–4, 114,
motives for, 52–3 115, 117, 121, 127, 153, 184
reasons for, 52 organizational pay policy, 32
lost productive time (LPT), organizational support, 118,
11–12, 168 121, 128
low back pain, 13 output
loyalty, 114 quality, 20, 75
LPT, see lost productive time (LPT) quantity, 20, 75
overcommitment, 88–9
male employees, 17, 66, 70–1, 75
management policies, 115, 121 Pakistan, 55
managerial employees, 3, 92, 99, pay policy, 32
103, 107, 108 performance-related pay
managers, guidelines for, 183–5 (PRP), 32
measurement of costs, 164–75 permanency of employment, 116
mental capital, 184 personal business, at work, 19, 20
mental illness, 14, 107 personal factors, 3, 114–15,
migraine/headache, 2, 14, 101, 123 119–21, 127
Migraine Work Productivity Loss personal financial difficulties,
Questionnaire (MWPLQ), 67, 19–21
94, 165–6 personality, 3–4
moderating relationships, 120–1 Peru, 55
192 Index
power distance, 34, 115, 117, 121, reprimands, 115

126, 127 return on investment (ROI), 40, 76,
presenteeism 156, 186
concept of, 1, 7–9, 178
costs of, 26, 61–2, 88, 89, self-awareness, 92, 99, 100
164–75, 186–7 sick, reasons for coming to work
defined, 7–8 while, 2, 45–57, 68, 74,
economic impact of, 64, 89 114–40, 179
education about, 152, 153 sick leave, 50, 64, 115, 152
emotional exhaustion and, 25 sickness presenteeism
interrelated factors affecting, 14 awareness of impact of, 92, 99, 100
job-related factors impacting, 2–3 concept of, 178
managing, 76, 144–61, 179 consquences of, 10–19
non-sickness, 19–25, 178 costs of, 1–3, 12, 18, 23–4, 61–2,
obesity and, 21–2, 25 71–4, 89, 100–2, 104–6,
personal financial difficulties 178, 186–7
and, 19–21 defined, 9–10
predictors of, 3 frequency analysis, 124–5
publications on, 8 gender differences in, 66, 70–1, 75
reducing, 76, 183–5 health conditions associated with,
risk factors for, 183 88–111, 123–4
savings from investments in, 40, prevalence of, 2
76, 156, 186 productivity losses from, 64–5,
sickness. see sickness presenteeism 74–5, 107–8, 125, 179
in Singapore, 61–85 psychological factors in, 88–9
as substitution for absenteeism, reasons for, 45–57, 62–3, 68, 74,
49, 179 114–40, 179
types of, 9 reducing, 4, 76, 128–9, 183–5
prevention strategies, 144–61 research findings on, 179–86
preventive health care, 157 in Singapore, 61–85, 88–111
productivity losses studies on, 2–3, 9, 23–4
to absenteeism, 31 substitution of, for absenteeism,
computations of, 173 32–3, 49, 179
to non-sickness presenteeism, work effectiveness and, 66, 70
19–25, 178 work environment and, 45–6,
to sickness presenteeism, 1–2, 9, 62–3, 68, 70, 93–8, 114, 115,
10–19, 61–2, 64–5, 74–5, 107–8, 117–18, 121, 150–1, 184
125, 178, 179 work-related factors in, 65,
in Singapore, 61–2 70, 115–21
psychological factors, 88–9 Singapore, 2
psychological issues, 48, 64 demographics, 67–8, 98, 122
health conditions in, 88–111
quality of output, 20, 75 reasons for sickness presenteeism
quantity of output, 20, 75 in, 114–40
sickness presenteeism in, 16–17,
race, 33 61–85, 88–111, 102–3
Index 193
South Korea, 55 WellnessProposals.Com, 39

Spain, 16 wishful thinking, 50
Stanford Presenteeism Scale (SPS-6), workaholism, 119
165, 168–9 work commitments, 2
stress, 14, 51, 120 work context, 3
supervisory support, 118, 120, 121, work difficulty, 92, 109
127, 128–9, 184 work effectiveness, 66, 70
Switzerland, 15 work environment, 45–6, 62–3, 68,
70, 93–8, 114, 115, 117–18, 121,
task significance, 116, 121, 126 150–1, 184
teamwork ethos, 114 work hours
Temporary Disability Insurance comparisons of, 56
(TDI), 152 in extreme jobs, 55–6
Thailand, 55 long, 52–4
time pressure, 47, 63 trends, 54–5
work-life conflict, 14, 51–2, 150
United Kingdom, 15, 54 Work Limitations Questionnaire
United States (WLQ), 165, 167
common health conditions in, 62 work performance, effects of health
sickness presenteeism in, 10–15 conditions on, 69–70
work hours in, 54 workplace accommodations, 155
unpaid leave, 152 workplace health audit, 147
Work Productivity and Activity
wage levels, 32 Impairment: General Health
WELCOA (Wellness Council of (WPAI: GH), 67, 165, 166–7
America), 154 Work Productivity Short Inventory
well-being, models of (WPSI), 165, 168
employee, 155–6 work-related factors, 65,
wellness, strategic approach 70, 115–21
to, 146–7 Workwell Model, 156,
wellness programmes, 36, 38–41, 183, 185
149–52, 156–61, 182–3 World at Work, 157–9
see also health-promotion World Health Organization,
programmes 165, 166

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Presenteeism

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List of Illustrations xiii

3.2 Chartered Institute of Personnel and Development

5.2.1 Work environment 62

6.1.1 Psychological factors 88

7.2.3 Personal factors 119

8 How Should Presenteeism Behaviour Be Managed? 144

9 Measuring the Costs of Presenteeism 164

9.2 The work impairment measurement instruments 164

1.1 Conceptual framework 3

Sketches by Bulbul Ahmed

2.1 Employee has flu, sneezing and infecting others 8

2.1 Productivity losses due to different health conditions 14

2.3 Summary of consequences of sickness presenteeism

2.1 ‘Presenteeism’ as defined by scholars 7

4.2 Findings from Finnish studies 47

It is very refreshing that Hesan’s book addresses the emerging concept

health conditions. It also examined the productivity losses due to

through reduced productivity losses and lower costs incurred by

Wee Chow Hou (C.H. Wee), PhD, BBM, PPA

I would like to express my gratitude to my beloved wife for her

Absenteeism at work is one of the most-measured indicators to deter-

U.S.-based studies have reported that sickness presenteeism costs

(d) compute the detailed breakdown of costs of sickness presenteeism

Who? Presenteeism Why?

Figure 1.1 Conceptual framework

culture and personality on presenteeism and examined in-depth

customized questionnaire, data was collected from adult employees in

2.1 What is presenteeism?

The term presenteeism was coined by Cary Cooper, professor of

Box 2.1 ‘Presenteeism’ as defined by scholars

• ‘Going to work despite feeling unhealthy’ (Aronsson et al., 2000; Dew

The definition given by Aronsson and Dew and their colleagues

Box 2.2 Selected list of interesting publication titles on presenteeism

• ‘Present in body, absent in spirit’. (Klobucher, 2011)

Sketch 2.1 Employee has flu, sneezing and infecting others

Figure 2.1 Types of presenteeism

As indicated earlier, presenteeism refers to two different types of

2.2 Sickness presenteeism

Studies on the phenomenon of sickness presenteeism have become

and that the majority of them would like to continue working if

Box 2.3 Health conditions commonly included in presenteeism studies

1. Allergies or sinus pain

2.3 Consequences of sickness presenteeism

2.3.1 Consequences of sickness presenteeism in the

Sketch 2.2 Employee returns to work after an accident

Stewart et al. (2003) launched the American Productivity Audit3 to

Sketch 2.3 Employee is too sick to work

that depression was highly associated with work limitations in time

Sketch 2.4 Employee is affected by depression

Ruez argues that presenteeism is driven by several interrelated

Table 2.1 Productivity losses due to different health conditions

Health condition Lost productivity Source

Diabetes USD158 per employee per Goetzel et al. (2004),

2.3.2 Consequences of sickness presenteeism

Sketch 2.5 Employee worries about the sick child at home

Spain, Germany and Italy

time due to presenteeism. This translated into about SGD2,100 per

Table 2.2 Estimated costs of lost productivity due to sickness presenteeism

Study Cost to the nation/

2003 Stewart USA USD225 billion/year For personal

Another 2009 study in New Zealand estimated the annual burden