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The determinants of sickness presenteeism.


Sickness presenteeism (SP) can be defined as a state in which employees turn up for work in spite of being sick. Although presenteeism is a subject of vivid interest to scholars in occupational medicine, few organizational scholars have extensively worked on the subject. One of the reasons that could have ignited interest in researchers is the growing concern among organizations about how presenteeism leads to lower levels of employee productivity (e.g., Collins et al, 2005) and there are reports of many other hidden costs as well (Goetzel et al, 2004; Hemp, 2004). Ailments commonly associated with SP include headaches, migraines, allergies, depression, gastrointestinal problems and asthma/ breathing difficulties. These are often deemed as benign illnesses that do not force a person to stay away from work, but reduce his/her productivity (Ceniceros, 2001; Goetzel et al, 2004). The present study is aimed at identifying the determinants of SP at work. It retro-flexed some of the existing results relating to SP as well tested new hypotheses that have only been hinted in the literature.

Hypotheses Development

Johns (2009) has traced the first use of the word "presentee". According to the Oxford English Dictionary Online, the word "presentee" was first used by the famous American humorist and author Mark Twain in his famous Book, The American Claimant in 1892. Thereafter though there have been occasional use of the term, however it was not until the early 1990's that the term was used in a defined connotation. Presenteeism in earlier times was only defined as opposite of absenteeism, but gradually more refined forms of definition of presenteeism with defined constructs were available. SP has been defined by Aronsson & Gustafsson (2005) as "the phenomenon that people, despite complaints and ill health that should prompt them to take rest and take sick leave, go to work in any case". They have distinguished between 'work-related demands for presence' and 'personally related demands for presence'. Johansson & Lundberg (2004) have defined presenteeism in the same way as above. According to them, when a person attends to work in spite of being ill or under circumstances which would ideally require leave for e.g. child care. However, we have limited our discussion to cases when employees turn up for work in spite of suffering on health grounds only and does not extent to other reasons like child care. In this study, we categorized determinants of SP broadly into three categories such as work related factors, personal circumstances and personality of the employees. The study also examined the relational influence of the above three categories of factors on SP.

Work Related Factors

There are certain factors which compel the job incumbent to attend work even when sick. Organizational policies for example might not have flexi working hours which might affect an employee's decision to work. Work related factors can be further classified into factors which can be controlled by the employee and some others which are beyond his control. It can be derived that when factors are under the control of an employee, he would have the freedom to choose when to go to work and when not to and hence is expected to report lesser SP than employees who are devoid of sufficient control over tasks.

Irreplaceability can be defined in simple terms as the availability of any other worker to replace the incumbent when the latter is sick. According to Bockerman & Laukkanen (2009), worker's replaceability can be seen from an economic angle. In case a worker can arrange for a replacement when he is absent from work, he would choose to avail of a sick leave when he is ill. On the contrary, if there are no available replacements for a worker and in case of his absence, he has to come back and finish up his pending work, then he would be less likely to take a sick leave. Hence in the second case, the indirect costs of being absent are more for a worker and under such circumstances, he would choose to attend to work when sick. Hence considering the relevance of this context in the current study, we hypothesize that:

H1: Higher the irreplaceability of the job, higher is the SP reported by the incumbent.

Job Demands include physical, cognitive, and social features of a job that necessitate protracted physical and psychological effort (Johns, 2010). Many studies have also labeled it as 'role overload'. Role overload is a concept where a job incumbent is expected to perform more with limited resources and time (Rizzo et al, 1970; DeFrank & Ivancevich, 1998). In his model, Karasek (1979) has pointed out two aspects of job that has maximum effects on employee well being:job demand and control over job. Job demand refers to workload and time pressure. Job control (also termed as decision latitude) refers to the extent to which a person is capable of controlling their tasks and general work activity (Mojzisch et al, 2010). The interplay of these two effects of job demand and job control determines if the job is a "high strain job" or a "low strain job". A high strain job is one, which is high on demand and is low on control whereas a low strain job has lot of job control, but is not much demanding. High strain jobs are most detrimental to the well being of employees and might pose threat to their future health. In the current scenario, where firms focus on profits and rate of return, job demands have become huge. Jobs of the service sector like that of a doctor, nurse or a teacher are considered to be more demanding and might report more presenteeism. Resources have become unlimited, thereby putting much pressure on employees. Employees who lack resources will be reluctant to avail sick leave justifying that they will face a backlog of tasks when they return to work (Aronsson & Gustafsson, 2005). An employee faced with a dilemma of whether to attend work when sick is again an economic decision. Keeping such theoretical framework in mind, we hypothesize:

H2: Higher the pressures associated with a job in terms of scare resources and time, higher will be the reported SP.

Adjustment Latitude describes the opportunities people have to reduce or in other ways change their work-effort when ill (Johansson & Lundberg, 2004). In cases of independent professions like in a private clinic or a teacher, this adjustment latitude might be the most compelling factor leading to presenteeism. This is so because in this profession, the doctor or the teacher can manage the day by altering their load of work by attending to lesser patients or taking a class of lesser duration, in case of a teacher. Again the aspect of cost benefit economics can be brought into picture while explaining it. Hence we hypothesize that:

H3: Higher the adjustment latitude, higher is the occurrence of SP.

Team Work & Support: Employees working closely with a team under strict time schedules on important deliverables restrain from opting for a leave which is a risk to their future health status. Influence of team work and pressure from colleagues is an important factor contributing to SP (Grinyer & Singleton, 2000). Hence we hypothesize that:

H4: Higher the social support in the organization, higher is the SP.

Job Security is the feeling of job security that compels an employee to report to work in spite of being sick. In events of downsizing, an organization structure might change, for example, it might become flatter or the work design might change which might not make it viable for a person to be absent from work. Also since sustaining the job becomes important under such scenarios, promotions, performance appraisals matter. In order to safeguard against being a victim of downsizing, a person chooses to display commitment and performance through his attendance at work. We can hypothesize that:

H5: Higher the job insecurity associated with a job, lower will be SP.

Personal Circumstances

Factors outside work can also have substantial effect on an employee's decision of choosing to work when sick. Personal circumstances can be further broken down into financial condition of family and satisfaction with one's family and personal life.

Personal Financial Situation: The pressure of managing finances of one's household becomes even more pressuring and more a prominent factor for presenteeism when an employee fears a job loss. Financial loss caused by absence is assumed to have a more severe impact on the lowly paid, who have narrow financial margins, than on their better-paid counterparts (Aronsson & Gustafsson, 2005). So people of the lower income group are likely to have a greater inclination towards working while sick. We can hypothesize that:

H6: Higher the financial insecurity, higher will be SP.

Satisfaction with Family Life: Basically, when an employee is hired, he is hired with his family. This leads us to conclude that if taxing responsibilities prevail at home, an employee might look for a support system in the organization he/she works for. Given a stimulating work environment, a worker might choose to evade the family responsibilities and report to work rather than spending time at home. This is more so relevant in the Indian context where joint family system still exists. Family might be a "negative presence factor" in case of presenteeism (Kristensen, 1991). Hence we hypothesize that:

H7: Higher the dissatisfaction with one's family life, higher will be the SP shown by the employee.

Personality Factors

Personality traits are the distinguishing factors which determine the degree of efforts and extent of goal attainment of the employee. In a principal agent model, where two employees have same capabilities, it is the personality factor which determines preferences of the two employees which in turn decides their levels of effort (Bowles et al, 2001).

Self Efficacy can be defined as the inherent faith an individual has in himself and his abilities to complete or execute certain tasks in any domain (Bandura & Locke, 2003; Jackson & Schuler, 1985). Self Efficacy drives an individual's efforts to attain his aims and goals (Bandura & Locke, 2003). Studies (for example Lindberg et al, 2013) have shown how self efficacy levels of an employee's help them to cope with 'role overload', 'role conflict' and 'role ambiguity' in an organization. In this context, if we reflect upon the definition of self efficacy we would realize that a person scoring high on self efficacy will have lesser doubts on himself with respect to performing equally good even when sick. This might be an important predictor of SP. Hence we hypothesize that:

H8: Higher the self-efficacy levels displayed by an employee, higher will be the SP.

Over Commitment: Individual boundarylessness can be defined as an inability among people to define boundaries for themselves when excessive is demanded of them. An employee high on individual boundarylessness has less potential to resist request of others. People while possessing boundarylessness have more tendencies to come to work while sick. The concept of individual boundarylessness is similar to that of over commitment (Hansen & Andersen, 2008). The effort reward imbalance (ERI) model developed by Siegrist (1998) gives an important framework for establishing relationship between job demands and its stress effects on employee well being (Jonge et al, 2000). The "over commitment" concept can be viewed as an extension of the Type A personality concept (Siegrist & Marmot, 2004). Type A personality is marked by high sense of achievement, immense desire for recognition, need for advancement, excessive competitiveness and sense of time urgency. This need to achieve extraordinary feats causes excessive striving which might lead to report to work while being sick.

H9: Higher the level of commitment of an individual, higher is the SP.

Data Collection

Data was collected from IT professionals, doctors, consultants and managers (across functions) employed in heavy industry and manufacturing sector during the period October 2012 to February 2013. The questionnaires were distributed to 300 respondents. The response rate was only 49%. The incomplete questionnaires were rejected and only 129 filled questionnaires were used for the final analysis.

In the sample, about 27.5% professionals belonged to the heavy industry and manufacturing sector, 24.5% were from the health sector who were all doctors, 35% were IT professionals. Samples from the consulting sector constituted around 13% of the total sample size. The average age of the sample was 27 years. Majority of the respondents fell into the category of 26 to 35 years of age. Nearly 81% of them were males and 19% of them were females. 55.7% of the sample were holding Bachelor's Degree and the rest 44.3% of them were having a Master's Degree. The average family income of the sample was in the range of Rs.10-15 lakhs per annum. An interesting phenomenon observed was that a higher percentage i.e. about 50% of the respondents works for more than 48 hours per week. About 36% of the sample reported irregular working time.

Dependent Variable

The act of SP was the dependent variable in the research. The Standard Presenteeism Scale was used to assess the employee health and productivity. The scale served as an excellent yardstick to measure the effects of presenteeism in terms of distractions and hindrances to deliver the work outcomes. The Cronbach alpha was measured to be 0.75. To check the frequency of the act of presenteeism, an additional question was asked to the respondents about the number of times they have reported to work when they were ill, but they could have availed a sick leave.

Independent Variables

Independent variables such as 'job demands' and 'adjustment latitude' were measured drawn on items used by Hansen & Andersen (2008) in their study. 'Team work' and 'social support' was measured by using an item "If you have problems with your work, you can obtain the necessary help and support from your team members?". It was also adapted from Hansen & Andersen (2008). The other items had element of team work like 'The people of this team work closely together' and others which again had 5 possible responses. The cronbach alpha for this scale was found 0.79. A single item scale measured job insecurity. The question was: 'In general, how often do you worry about becoming unemployed?'. The response was recorded in a frequency scale of 5 points ranging from 1- 'Always' to 5- 'Never'. Additionally, the respondents were asked to indicate their status of employment in terms of it being fixed term, probation and permanent. Replaceability was measured using an item: 'If you are absent from work for up to a week what proportion of your tasks must you take up again on your return?', which was constructed on similar lines of study done by Aronsson & Gustafsson (2005). Hansen & Andersen (2008) in their study used two items to measure general satisfaction of respondents with their family life and an item which addressed the Hochschild theory of work place being home. The same question was used to measure satisfaction with their family life. The over commitment variable was measured by using a standard questionnaire developed by Siegrist (1996). The Cronbach alpha for this measure was reported to be 0.78 in the study. To measure self efficacy of the respondents, the standard self efficacy questionnaire developed by Schwarzer & Jerusalem (1995) was used. The Cronbach alpha for this measure was found to be 0.77.

A major concern in the study was the use of self reports for sensitive information like support in the organization and family life of the respondents. Also in a self report questionnaire asking for presenteeism, the respondents might under report sickness absence. Studies (van Poppel et al, 2002) have shown that people do not report accurately their sick leaves availed data. One reason why people might do so is explained by the social desirability thesis (Hansen & Andersen, 2008). This might happen because absenteeism from work is not seen in good light in the organizations. Under such situations, it would lead to over estimation and erroneous data on SP. An other concern was the reporting of health status. Since the questions framed to test the prevalence of presenteeism did not mention the name of specific diseases, it could be possible for respondents to subjectively evaluate their health.

Socio Demographic Categories

From the data mentioned in Table 1, we can see that respondents in age group of 18-25 years and 26-35 years report more presenteeism. In terms of income levels, about 50% of the respondents from the low income group report higher levels of presenteeism than of high income group (H6). If we compare the levels of presenteeism education wise, proportionately people with Bachelor's Degree report to office more often when sick as compared to people having Master's Degrees.

Various hypotheses regarding antecedents and SP were tested initially using a bi-variate correlation followed by linear regression. Table 2 gives results of bi-variate correlations between SP and its proposed antecedents, and correlations

among the proposed antecedents. The correlations show that most of the hypotheses hold true and are consistent with the literature. The correlation of presenteeism with job demands is strong (.349) and positive. Self efficacy (.396) has the strongest correlation with SP followed by excessive job demands (.349). The next sets of strong correlations with SP are team work and social support (.284), job security (.272), irreplaceability (.257) and family issues (.244). All the above relationships were found to be positive in nature. The bi-variate correlations between SP and irreplaceability, job insecurity and dissatisfaction with families are significant at 0.05 level and with other variables such as job demands, self efficacy and team work, it is significant at 0.01 level. Two antecedents viz. adjustment latitude (.119) and over commitment (.110) were not found to be significantly correlated.

Regression Analysis

To see the effect of each of the variable on the prevalence of SP, a linear regression was performed on the data. The detailed analysis of each of the regression is given in the Table 3. As we see from the R square value that job demands explain 12. 2% variance in SP. The beta coefficient for job demands is strong (.349) and positive. About 6.6% of the variance in SP is explained by irreplaceability. The relationship is positive and significant. This means that the tougher it is to get a replacement for a job incumbent, the higher is his chance of reporting sick to work. Team work and social support mechanisms existing in the organization explain 8% variance in SP. The relationship as hypothesized was found to be positive and significant. Our hypothesis could not be established in the case of adjustment latitude. The results were not found significant as shown in the table. Job insecurity explains about 7. 4% variance in SP.

Team work and social support mechanisms existing in the organization explain 8% variance in SP.

Our hypothesis that dissatisfaction with one's family life leads to high SP is also proved through the above table. Family helps in explaining about 6% variance in SP. About 15.7% of the variance in SP can be explained with the help of self efficacy of individuals. The relationship between over commitment and SP was not found significant. This is contrary to many studies that have been done on presenteeism in other countries.

Table 3 shows relative importance of various category of factors on SP. We can infer that both the F- Statistics and Beta are significant for all the three factors. However, work related factors explain the maximum variance in SP followed by personality factors and personal circumstances of an employee.


The prevalence of SP in the sample was proved as the results were significant. In fact it is as common a phenomenon as absenteeism in India. The support for H1 displays that irreplaceability is an important factor predicting SP. In the context of IT professionals it might be related to the special expertise that they possess. Each of them is a certified professional and hence finding a replacement for them would be a tough job. The peculiarity for the professionals from manufacturing sector is that most of them are employed in shift roles. In such allocation of work timings where shifts are rotated in a weekly or a monthly basis, finding a replacement would be even more difficult. Doctors being in service profession are "on call" and hence report to work at even odd hours when a patient is there to attend. Members of occupational groups whose everyday tasks are to provide care or welfare services, or teach or instruct have a substantially increased risk of being at work when sick. These are occupations where relationships with other persons play an important part in work outcome. This hypothesis is also supported by other studies (Aronsson et al, 2000). H2 is also supported by the results which essentially mean that when a job is endowed with tight schedules and scarce resources which amount to severe workload to the job incumbent, more is the likelihood of SP of the person. One argument for this finding can be that the person puts resource and time availability priority ahead of personal health issues. The current levels of high market competition fueled by customer base and external environment has led the companies to focus on quality, service and productivity which essentially means increased time pressure and intensification of work by employees which might be highly harmful to their health (Landsbergis et al, 1999). Paucity of resources might encourage such behaviors. In client facing roles like consulting, time is very precious and hence trend of SP might be very prevalent. Also irregular working hours might encourage more SP which can be applicable to the professions like doctors and consultants.

Adjustment latitude was found to be insignificantly predicting SP in the workplace (H3). Our finding also holds true in the light of other similar studies on the antecedents of presenteeism (Johansson & Lundberg, 2004) where the authors could establish only a weak relationship between adjustment latitude and SP. Many respondents in our sample have reported not to have sufficient control over the way they do their tasks. There might be difference of adjustment latitude between different occupations (Hultin et al, 2010). Our data is composed of people mostly from the IT and manufacturing background. These industries are mostly very process oriented and the outcome of each job is very well defined. Hence there is hardly any scope for people to adjust their work load according to their health conditions.

Team work is found to lead to presenteeism (H4). This holds true for the sample because in IT companies, people work in one team to deliver a project, under these circumstances, a team member might be obliged to others in his team because of various reasons like giving him opportunity to be a part of the project, equipping him with necessary training and the like and might display this obligation through attendance. Employees who receive strong positive support from the organization, in most cases, reciprocate their gratitude through their attitudes and behaviors which are favorable to the organization (Eisenberg et al, 1986). It is seen as a "social exchange perspective" (LaMastro, 1999) where support from the organization and colleagues lead to increased tendency of attendance at work among other things. Another way of looking at it is the pressure from team mates to report to work irrespective of health issues. Team work culture increases dependency of people on each other because collaboration is needed to jointly deliver and execute a project.

The hypothesis relating to job insecurity could also be established (H5). IT this day has become overstaffed so much so that there are more people than projects available. It is said to have a popular "bench" concept where in manpower is shown to the client to get a project. Under such scenarios, people resources are always surplus or are a buffer for the organization. This calls for cut throat competition and survival of the fittest.

We also found support for our hypothesis of family dissatisfaction being a factor in predicting SP(H7). The famous joint family culture in India makes it even a stronger ground than western countries for presence of SP. Under the joint family system which is a huge consumption unit, the liabilities of the bread earners are even more with more number of members in the family. Under such scenarios, staying away from home while sick is expected to be more prevalent. The increased social support network at office could be another factor encouraging staying away from home. Such dissatisfaction with family life might be arising from sick spouse, children, divorce, unsuccessful marriage and others. Our findings are also supported by studies on family life and presenteeism (Hansen & Andersen, 2008; Kristensen, 1991). Hochschild (1997) expounded the concept of work place as an extension of home where creative and stimulating work might make it more interesting for people to work on that doing rigorous work at home (Hansen & Andersen, 2008).

Another major contribution is the finding of personality factors like self efficacy being associated with SP (H8). In dividual boundarylessness or over commitment was not found to be predicting SP (H9). At high levels of over commitment, the SP is expected to be more (Hansen & Andersen, 2008). More fine data analysis methods and exploration in all dimensions of commitment would probably yield better results.


The study undertaken is definitely very relevant in terms of it being a matter of concern for both employees and the organization. Presenteeism is a more sensitive scale to measure employee health than absenteeism (Caverley et al, 2007). It can also be seen in the light of fitness and other wellness programs sponsored by the organization. Educating employees about the occurrence of such a phenomenon is very important. Programs like regular free health checkups, medical campus, newsletters, articles about health in the company magazine and the like can prove to be beneficial. But having said that just educating won't be enough to check the alarming rates of presenteeism. An effective way to curb presenteeism would be providing good medical facilities, adequate number of sick leaves and other benefits to the employees.

Increasing rates of presenteeism is an alarm to the organization. 'When people don't feel good, they simply don't do their best work (Hemp, 2004).These hidden symptoms existing in the workplace can prove to be a great cost factor for organizations. Recognizing the existence of such a phenomenon can be a source of competitive advantage for an organization.

This also has implications for organizations in terms of relooking at their policies which might be in disguise promoting presenteeism. If the organization has a culture where sickness absence is not seen in good light, then employees are likely to report more SP. The culture that availing of a sick leave in normal has to be inculcated and people should be encouraged to stay at home and rest in case of illness. Also, the organizations have to set examples and display that there would be no adverse effect of availing a sick leave when needed on the employees' job.

Another aspect can be the area of ergonomics. Because of improper work arrangements and work settings, many employees report back and neck pain and other disorders. These small symptoms might go a long way in establishing presenteeism as a norm in the organization. Jobs should be redesigned so that they do not have adverse effect on employee's health (Demerouti et al, 2009). There is also a business case for checking presenteeism. Cost incurred in preventing presenteeism is much lesser than compensating for the ill health of employees through insurances and other means. Thus a more proactive approach is required from the organization's end; a reactive approach to employee health might be detrimental to the bottom line of the organization.

Presenteeism has lot of occupation specific antecedents. Future extensions to this research must look at those aspects. Due to low number of females in our sample, adequate testing of gender effects on sickness presenteeism could not be done. A thorough investigation into this matter can be done. A study of presenteeism in the Indian workforce should include the context of culture and economy in the country. Though, in this study we have tried to include some element of Indian's priority like family issues, but most other variables are inspired from previous studies on Scandinavian workforce. There would be other factors that might prompt presenteeism in the Indian workforce, which needs to be studied. Data analysis was based on a self report questionnaire which itself poses question on the quality of data. Since employees might have a tendency to hide their absenteeism rates in the organization, they might have reported it wrongly. Also it might be possible for a respondent to underestimate or overestimate the level of sickness he possesses. In extreme circumstances, the respondent might not even be aware of an ailment he is suffering from.


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Sasmita Palo is from Centre for Human Resources Management & Labor Relations, Tata Institute of Social Sciences, Mumbai. E-Mail Sneha Pati is from ITC Limited. E- Mail :
Table 1 Presenteeism Prevalence among Socio Demographic
Categories (%)

Socio Demographic Never Once 2-3 4-5 6-10
Variables Times Times Times

 Male 35.38 6.15 10.77 29.23 18.46
 Female 21.43 14.29 28.57 35.71 0
Age Group
 18-25yrs 10.71 10.71 32.14 17.86 28.57
 26-35yrs 8.89 24.44 37.78 6.67 22.22
 36-45yrs 50 0 0 50 0
 46-55yrs 75 0 25 0 0
 Bachelor's Degree 27.27 22.73 27.27 13.64 9.09
 Master's Degree 28.57 11.43 42.86 8.57 8.57
Family Level Income
 High 31.25 12.5 31.25 18.75 6.25
 Low 20 10 10 10 50
 Medium 27.03 24.32 32.43 5.41 10.81

Table 2 The Correlation Matrix

Variables Job Job Team Work
 Insecurity Demands and Social

Job Insecurity 1.00
Job Demands .935 ** 1.00
Team Work and .282 * .288 * 1.00
Social Support
Irreplacea bility .184 0.21 0.27
Family Issues .190 .298 ** .191
Self Efficacy .195 .310 ** .304 **
Adjustment .213 .197 -.103
Overcommittment -.164 -.250 * -.208

Variables Irreplaceability Family Self
 Issues Efficacy

Job Insecurity
Job Demands
Team Work and
Social Support
Irreplacea bility 1.00
Family Issues -.132 1.00
Self Efficacy .405 ** .250 * 1.00
Adjustment -.095 -.003 .014
Overcommittment .059 -.268 * .090

Variables Adjustment Overcommittment

Job Insecurity
Job Demands
Team Work and
Social Support
Irreplacea bility
Family Issues
Self Efficacy
Adjustment 1.00
Overcommittment .014 1.00

** Correlation is significant at the 0.01 level (2-tailed)

* Correlation is significant at the 0.05 level (2-tailed)

Table 3 Linear Regression Analysis Predicting SP on Work, Personal
Circumstances and Personality Related Factors

Name of the Variable R-Square F Statistics Beta (Sig.)

Work Related Factors 0.03 19.213 0.454 **
Personal Circumstances 0.06 4.686 0.244 *
Personality Factors 0.10 8.263 0.315 *

Note: ** Correlation is significant at the 0.01 level (2-tailed)

* Correlation is significant at the 0.05 level (2-tailed)
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Author:Palo, Sasmita; Pati, Sneha
Publication:Indian Journal of Industrial Relations
Geographic Code:9INDI
Date:Oct 1, 2013
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