How much sick leave is work-related?

Review article
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    Abstract
    Background.

    Background.

    Sick leave is a topical subject, particularly following the revision of the Agreement on a More Inclusive Working Life (the IA agreement). However, there has been little discussion about the extent to which sick leave may be related to work.

    Material and methods.

    Material and methods.

    The paper is based on a non-systematic literature search using PubMed combined with personal research and experience.

    Results.

    Results.

    Various studies indicate that a significant proportion of all sick leaves may be due to illness caused by working conditions. Heavy physical work, awkward work postures and low job control are particularly important factors. People who suffer from work-related illnesses have a greater need for absence from work than people with similar illnesses caused by factors other than their work. Workplace interventions designed to prevent work-related illness may also prevent sick leave. Sick leaves which are due to an imbalance between an individual’s resources and his/her job demands, may often be prevented or shortened by workplace interventions, irrespective of what causes the imbalance.

    Interpretation.

    Interpretation.

    It is my view that more importance should be attached to primary preventive measures to reduce work-related illness, combined with workplace interventions to accommodate people who carry a higher risk of sick leave. However, this is not given sufficient attention in the current IA agreement.

    Article

    Sick leave is a topical subject in the context of the 2010 revision of the Agreement on a More Inclusive Working Life (the IA agreement) (1, 2). There has been little discussion about the extent to which sick leave may be related to work, although this may be highly important with respect to what measures will be effective in reducing sick leave and expulsion from work. So far, the IA agreement has primarily focused on reducing the level of sick leave through measures designed to help the sick return to work (secondary prevention) rather than on measures designed to prevent people from being sick-listed in the first place (primary prevention) (3). The proposals tabled by the group of experts appointed by the Norwegian Ministry of Labour to assess possible administrative initiatives to reduce sick leave included hardly any primary preventive measures (4).

    This paper provides an overview of the extent to which sick leave may be work-related, i.e. be linked to work or workplace conditions.

    Material and methods

    Material and methods

    The paper is based on a non-systematic literature search using PubMed and a discretionary selection of articles based on personal knowledge of the field and experience gained through my own studies.

    What does «work-related» mean?

    What does «work-related» mean?

    All sick leave may be said to be work-related in the sense that the employee finds it difficult to carry out his/her job due to illness, i.e. «health-related work problems». However, this definition is not particularly useful in terms of workplace prevention. «Work-related health problems» are often defined as health problems (illness or injury) which are partly or entirely caused or aggravated by working conditions (5) – (7). Workplace intervention may prevent or reduce such health problems as well as the resulting sick leave.

    Can we trust self-reporting?

    Can we trust self-reporting?

    Questionnaires are often used to investigate work-related health problems; this is the case for Statistics Norway’s Level of living surveys as well as the European Working Conditions Surveys (24). Many have a sceptical attitude to this kind of self-reporting and hold the opinion that the individuals themselves will tend to over-estimate the correlation with work. The HUBRO study compared self-reporting to physician assessment for 217 people suffering from neck/shoulder or arm pain (25). The doctors used criteria drawn up by a group of European experts to assess whether the pain might be caused by working conditions (26). The sufferers themselves considered their pain to be work-related slightly more often than the physicians: 80 per cent versus 65 per cent for neck/shoulder pain, and 78 per cent versus 72 per cent for arm pain. Consequently, self-reporting appears to give a reasonably good measure of the work-related proportion of health problems, but this may vary with the type of health problem and the criteria for assessing the work-relatedness (25).

    The significance of work environment factors

    The significance of work environment factors

    A number of work-related factors have been studied in relation to sick leave, particularly physical/ergonomic factors such as heavy physical work, awkward work postures and repetitive work, psychosocial working conditions such as psychological job demands, job control and social support in the workplace, and organisational factors such as shift work. A comprehensive study of the causes of sick leave carried out in 2004 (29) found limited scientific evidence that physical working conditions – particularly heavy physical work – have an effect on sick leave, and moderate evidence of a causal connection with low job control (30). However, among people who were sick-listed due to back disorders, it was found that a number of factors had an effect, among them low job satisfaction (moderate documentation), low job control, and work involving heavy lifting or a bent/twisted working position (limited documentation) (31). Despite a great number of studies and well documented statistical associations between working conditions and sick leave, it was nevertheless concluded that the scientific documentation to support a causal relationship was generally limited, especially due to problems with selection or confounding (30). Even if the association between disease and certain working conditions is well documented, most people who suffer from a disease are not on sick leave, a fact which may contribute to the relatively weak documentation (32).

    In Denmark a number of longitudinal studies have been conducted in which attempts have been made to reduce the weaknesses of earlier research (33). These studies have combined the use of data from questionnaires and records, and they have studied factors that impact on different stages of the sick leave process (34).

    They estimated that the number of people taking more than six sick days per year could have been 40 per cent lower if everyone’s physical and psychosocial work environment had matched the standard of that enjoyed by the 10 per cent with lowest exposures (35). Other studies from Denmark have shown similar figures (36). Heavy physical work such as heavy lifting/carrying or pushing/pulling, and awkward work postures such as standing up/squatting or a bent /twisted neck/back, appear to be particularly important (37). Many psychosocial job factors appear to be important, such as job control (work autonomy), social support from supervisors, psychological job demands, predictability and role conflicts (33, 38). The results vary somewhat from study to study and between women and men, particularly with respect to psychosocial factors (33). The attributable proportion of sick leave was found to be higher for work-related factors than for life style factors such as smoking (26 per cent among women and 17 per cent among men) (39).

    Social inequalities in health are well documented and working conditions have been shown to influence these differences (40). A Danish study found that physical and psychosocial working conditions could explain as much as 40 – 50 per cent of long-term sick leave differences between the highest and the lowest social classes (managers/academics and skilled/unskilled workers respectively), adjusted for life style and other factors (41).

    The significance of structural working conditions

    The significance of structural working conditions

    Many studies have shown that structural conditions, such as re-organisation and workforce downsizing, can bring higher rates of sick leave, disability retirement and mortality in the following years (42) – (46). This is the case for people who are directly affected (42, 43) but also for people who remain in the company after it has been downsized (43, 46). Tougher job demands, lower job control and higher job insecurity in connection with the downsizing are all factors shown to have an impact on health and sick leave (47). A project entitled «The new state» found that the increase in sick leave in the Norwegian Postal Service and the Public Roads Administration/Mesta after the workforce was downsized in the mid 1990s, could largely be explained by longer periods of sick leave (44). However, other studies have indicated unaltered or lower rates of sick leave after downsizing operations (48, 49). This is interpreted as «sickness presenteeism», i.e. that people attend work even if they are ill, particularly people in time restricted employment or with lower job security (46, 48).

    Discussion

    Discussion

    This literature review shows that sick leave is often work-related, either in a narrow sense, when the absence from work is caused by work-related illness or injury, or in a wider sense, when the absence is caused by an imbalance between individual resources and job demands. In both cases workplace interventions may prevent or shorten the period of sick leave.

    Many resources are expended on initiatives designed to help the sick return to work, by doctors, employers and the Norwegian Labour and Welfare Administration (NAV). However, more importance should be attached to primary preventive measures designed to reduce work-related illness and workplace interventions designed to accommodate people who carry a higher risk of absence, before they get sick-listed. For many, it will take a long time before they are capable of resuming work.

    Employers have an obvious responsibility, but often fail to see the need to take action before the employee falls seriously ill or has taken sick leave. Medical practitioners may see the need, but are often insufficiently briefed on work-related matters and have no contact with employers. The occupational health service possesses knowledge about the relationship between work and health and also has a route of contact with the employer. The occupational health service should play a central part in this context, but its role remains obscure within the current IA agreement. The service is probably underused by everyone ranging from the treating physicians to the employers, the employees and the Norwegian Labour and Welfare Administration.

    The IA agreement has three objectives, but so far most of the focus has been on reducing sick leave. Measures that help us succeed in including the elderly and those with reduced work capacity will enable these people to remain in employment, albeit with a somewhat higher rate of absence. This may however be a low price to pay for keeping as many as possible in employment?

    I would like to thank Helge Kjuus at the National Institute of Occupational Health for providing his comments on my manuscript.

    Conflicting interests listed:

    None

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