ORIGINAL ARTICLE
Access to Health Programs at the Workplace and the Reduction of Work Presenteeism A Population-Based Cross-Sectional Study Arnaldo Sanchez Bustillos, MD, MHSc and Oswaldo Ortiz Trigoso, MD
Objective: To examine access to health programs at workplace as a determinant of presenteeism among adults. Methods: Data source was a subsample of the 2009–2010 Canadian Community Health Survey. The outcome was selfreported reduced activities at work (presenteeism). The explanatory variable was self-reported access to a health program at workplace. Logistic regression was used to measure the association between outcome and explanatory variables adjusting for potential confounders. Results: Adjusting for sex, age, education, income, work stress, and chronic conditions, presenteeism was not associated with having access to a health program at workplace (adjusted odds ratio, 1.23; 95% confidence interval, 0.91 to 1.65). The odds of presenteeism were higher in workers who reported high work stress and those with chronic medical conditions. Conclusions: This study found that access to health programs at workplace is not significantly associated with a decline in presenteeism.
W
ork productivity losses are principally measured by absenteeism or days of absence from work because of illness and presenteeism.1 Presenteeism occurs when an employee chooses to be present at work despite feeling ill or when sick leave would have been appropriate. This may cause the employee to work at a reduced capacity with subsequent productivity losses.2 With a posterior decline in health, presenteeism itself is a risk factor that leads to sickness absence (absenteeism).3,4 Various medical conditions as well as different working environments have been associated with presenteeism.5,6 A number of studies have shown that a range of conditions from depression and arthritis to obesity, smoking, and stress is associated with high levels of presenteeism.7–9 Various selfreport instruments have been developed to measure presenteeism for different job types, and thus, the rate of presenteeism as part of lost productivity time may vary.1,10 In a large study, 71% of the healthrelated lost productivity time cost was attributed to presenteeism.11 Although research on presenteeism is relatively new, several strategies to reduce presenteeism and increase work productivity have been studied.12 Worksite-based health promotion and disease management programs have been evaluated in their ability to promote lifestyle changes, improve health, and consequently increase work ability and productivity.13 Workplace health promotion programs aim at smoking cessation, physical activity, healthy nutrition, reduction of obesity, or other interventions that promote healthy lifestyle. Intervention studies have been heterogeneous in From the School of Population and Public Health (Dr Bustillos), University of British Columbia, Vancouver, British Columbia, Canada; and Occupational Medicine Postgraduate Program (Dr Trigoso), Faculty of Medicine, Cayetano Heredia University, Lima, Peru. Dr Bustillos holds an honorary faculty appointment at the School of Medicine of the University of British Columbia. Dr Trigoso is an independent occupational health consultant for Peruvian companies. The authors declare no conflicts of interest. Address correspondence to: Arnaldo Sanchez Bustillos, MD, MHSc, School of Population and Public Health, University of British Columbia, 4th Floor, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada ([email protected]). C 2013 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0b013e3182a299e8
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interventions and study populations, and most of them have reported moderate positive effects.12–14 A workplace-based weight loss program was shown to be effective in reducing presenteeism.15 Similarly, a workplace migraine intervention program focused on prevention and early pharmacologic intervention reported an increase in productivity while at work.16 Programs involving worksite exercise,17 education regarding mental health,18 as well as comprehensive occupational health programs executed by occupational physicians have been shown to be effective.19,20 Nevertheless, studies assessing the effectiveness of health programs that focused on musculoskeletal symptoms such as the prevention of low back pain or reduction of neck and shoulder pain showed negative results.21–23 Most of the studies addressing the effectiveness of workplace health programs on presenteeism have been developed within the setting of one or more companies or industries.12,24 Prospective intervention studies are essential to address the question of a causal relationship between health promotion programs at work and presenteeism; however, population-based studies can add external validity to the conclusions about this association and assess whether it is consistent in a sample representative of various workplaces and geographic locations. Furthermore, it is important to determine whether access to health programs at workplace can reduce presenteeism even when participation in programs is voluntary or not regular.25 Thus, the primary objective of the present study was to assess the effect of access to health promotion programs at work on presenteeism. This study addresses this question by using population-based data from the 2009–2010 Canadian Community Health Survey (CCHS). We examined this association, considering adjustment for several possible confounding variables. Secondarily, we sought to explore the strength of the effect of perceived work stress and chronic diseases and to what extent presenteeism can be attributed to these risk factors.
METHODS Data Source and Study Sample Participants were respondents to the 2009–2010 CCHS. The CCHS is a national survey of people aged 12 years and older that is conducted by Statistics Canada on an ongoing basis with data released every year.26 The CCHS has a cross-sectional design and collects information by using a complex stratified multistage cluster sampling method. The 2009–2010 CCHS collected responses from people living in private occupied dwellings covering all provinces in Canada. The sampling frame excluded individuals living on Indian reserves, institutional residents, members of the Canadian armed forces, and residents of certain remote regions. Data were collected by using in-person and phone interviews. A detailed description of the survey methodology has been published elsewhere.26 Respondents who were residents of the province of Nova Scotia participated in the optional “Physical Activities and Facilities at Work” module of the 2009–2010 CCHS. Participants were asked questions related to access to facilities that promote healthy activities at work as well as their working status and reduction of activities at work because of health problems.27 The 2009–2010 CCHS provided a total sample of 4712 individuals in the province of Nova JOEM r Volume 55, Number 11, November 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JOEM r Volume 55, Number 11, November 2013
Health Programs at Workplace and Presenteeism
Scotia (overall response rate of 74.6%). From the CCHS database, we extracted an analytical sample consisting of individuals aged between 20 and 69 years who reported having a job in the week before the survey administration and who provided valid responses regarding access to health programs at work and reduced activities at work. Questions related to age, sex, education, income, perceived work stress, and chronic diseases were considered for possible confounding variables. Invalid responses to all of these questions were excluded from the analysis.
Study Variables The primary outcome variable of interest was presenteeism, coded as a binary variable (yes/no). Presenteeism was derived from the question, “Does a long-term physical condition or mental condition or health problem reduce the amount or the kind of activity you can do at work?” with three possible valid responses: “sometimes,” “often,” or “never.” Presenteeism was defined with the answers “sometimes” or “often” reduced activities at work because of long-term physical or mental conditions or health problems. The primary explanatory variable, access to health programs at work, was coded as a binary variable. It was derived from the question, “At or near your place of work, do you have access to programs to improve health, physical fitness, or nutrition?” with “yes” and “no” as possible answers. The type of health program was not specified. Possible confounding variables were selected a priori, choosing conditions possibly associated with presenteeism and access to health programs. Covariables included sex, age (considered in five categories: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years), highest level of education in two categories (secondary and postsecondary education), personal income in Canadian dollars (less than Can$20,000; Can$20,000 to Can$39,999; Can$40,000 to Can$59,999; Can$60,000 or more; and not stated), self-perceived work stress in three categories (low, moderate, and high level of stress), and chronic diseases coded as binary (no chronic disease or at least one chronic condition, including any of the following: hypertension, diabetes mellitus, heart disease, previous stroke, asthma, chronic obstructive pulmonary disease, arthritis, chronic back pain, diagnosed digestive disorder, migraine, cancer, mood disorder, and anxiety disorder). Variables related to working environment or organizational culture at workplace were not included in the analysis.
Statistical Analysis Descriptive statistics of the distribution of covariates with respect to the outcomes were summarized. The rate of presenteeism by categories of access to health program and covariates was calculated. Differences between included and excluded respondents were examined using chi-squared tests. Bivariable logistic regression analyses were used to examine the association between independent variables with presenteeism. Multivariable logistic regression was used to provide adjusted odds ratios (ORs) of the associations with 95% confidence intervals (CIs). To account for the different probabilities that individuals were selected in the CCHS sample, all analyses included rescaled (probability) weights obtained by dividing the sampling frequency weights provided by Statistics Canada by the mean of the weights in the analytical sample.26 All analyses were performed using SAS statistical software version 9.3 (SAS Institute, Inc, Cary, NC).
RESULTS A total of 1615 respondents met our selection criteria and were included in the final analysis. Figure 1 shows the sample selection process. Overall, 13 respondents (0.7%) did not provide valid answers to the questions on education and self-perceived work stress and were excluded from the analysis. Compared with the final sample, excluded respondents were equally likely to report access to a health program at workplace (P = 0.43) and to report presenteeism
FIGURE 1. Flowchart of sample selection.
(P = 0.39). The distribution of the sample by access to health programs and all covariables varied widely (Table 1). Almost half of the respondents (49.8%) reported having access to a health promotion program at or near workplace. In the sample, 52.5% were men and only 7.4% were in the age group of 60 to 69 years. Respondents with postsecondary education comprised 71.1%, whereas people who did not state income constituted 10.1% of the sample. Respondents classified as having high level of work stress represented 24.8% of the sample, whereas 57.8% reported at least one chronic condition. Table 1 also shows the rate of reported reduced activities at work or presenteeism. The frequency of presenteeism was lower in those who reported access to a health program at work (13.1%) than in those who reported not having access (18.6%). There were some differences in the distribution of presenteeism within the categories of covariables. Frequency of presenteeism by sex did not differ considerably. With respect to age, respondents aged between 20 and 29 years reported the lowest rate of presenteeism (6.7%). Presenteeism was similar in participants with secondary and postsecondary education. The groups with lower income reported higher rates of presenteeism (19.4% for those with less than Can$20,000 income). Presenteeism rate was higher (24.0%) in the group with high levels of work stress than in those with low and moderate stress. Participants who reported at least one chronic condition had a presenteeism rate considerably higher than those who did not report chronic conditions (24.4% vs 4.1%). Table 2 displays the results of the bivariable and multivariable analyses. In the unadjusted analysis, the odds of presenteeism were higher among respondents who did not report access to a health program at work than among those who reported access (OR = 1.51; 95% CI, 1.16 to 1.98). In the multivariable model adjusted for sex, age, education, income, work stress, and chronic conditions, the odds of presenteeism remained elevated but not significant (adjusted OR = 1.23; 95% CI, 0.91 to 1.65). Some of the confounders included in the analysis were associated with presenteeism. There was no significant difference in the odds of presenteeism between men and women. With respect to the age category of 20 to 29 years, age categories between 30 and 59 were all more likely to report reduced activities at work. There was no association of presenteeism and education. Respondents who reported income higher than Can$40,000 had lower odds of presenteeism than those with income less than
C 2013 American College of Occupational and Environmental Medicine
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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JOEM r Volume 55, Number 11, November 2013
Sanchez and Ortiz
TABLE 1. Distribution of the Sample and Rate of Presenteeism by Access to Health Programs and Determinants of Presenteeism (Weighted Analysis)
Distribution of Total Sample (n = 1,615) n Access to health program Yes No Sex Male Female Age, yr 20–29 30–39 40–49 50–59 60–69 Education Secondary Postsecondary Income, Can$
Access to Health Programs at the Workplace and the Reduction of Work Presenteeism A Population-Based Cross-Sectional Study Arnaldo Sanchez Bustillos, MD, MHSc and Oswaldo Ortiz Trigoso, MD
Objective: To examine access to health programs at workplace as a determinant of presenteeism among adults. Methods: Data source was a subsample of the 2009–2010 Canadian Community Health Survey. The outcome was selfreported reduced activities at work (presenteeism). The explanatory variable was self-reported access to a health program at workplace. Logistic regression was used to measure the association between outcome and explanatory variables adjusting for potential confounders. Results: Adjusting for sex, age, education, income, work stress, and chronic conditions, presenteeism was not associated with having access to a health program at workplace (adjusted odds ratio, 1.23; 95% confidence interval, 0.91 to 1.65). The odds of presenteeism were higher in workers who reported high work stress and those with chronic medical conditions. Conclusions: This study found that access to health programs at workplace is not significantly associated with a decline in presenteeism.
W
ork productivity losses are principally measured by absenteeism or days of absence from work because of illness and presenteeism.1 Presenteeism occurs when an employee chooses to be present at work despite feeling ill or when sick leave would have been appropriate. This may cause the employee to work at a reduced capacity with subsequent productivity losses.2 With a posterior decline in health, presenteeism itself is a risk factor that leads to sickness absence (absenteeism).3,4 Various medical conditions as well as different working environments have been associated with presenteeism.5,6 A number of studies have shown that a range of conditions from depression and arthritis to obesity, smoking, and stress is associated with high levels of presenteeism.7–9 Various selfreport instruments have been developed to measure presenteeism for different job types, and thus, the rate of presenteeism as part of lost productivity time may vary.1,10 In a large study, 71% of the healthrelated lost productivity time cost was attributed to presenteeism.11 Although research on presenteeism is relatively new, several strategies to reduce presenteeism and increase work productivity have been studied.12 Worksite-based health promotion and disease management programs have been evaluated in their ability to promote lifestyle changes, improve health, and consequently increase work ability and productivity.13 Workplace health promotion programs aim at smoking cessation, physical activity, healthy nutrition, reduction of obesity, or other interventions that promote healthy lifestyle. Intervention studies have been heterogeneous in From the School of Population and Public Health (Dr Bustillos), University of British Columbia, Vancouver, British Columbia, Canada; and Occupational Medicine Postgraduate Program (Dr Trigoso), Faculty of Medicine, Cayetano Heredia University, Lima, Peru. Dr Bustillos holds an honorary faculty appointment at the School of Medicine of the University of British Columbia. Dr Trigoso is an independent occupational health consultant for Peruvian companies. The authors declare no conflicts of interest. Address correspondence to: Arnaldo Sanchez Bustillos, MD, MHSc, School of Population and Public Health, University of British Columbia, 4th Floor, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada ([email protected]). C 2013 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0b013e3182a299e8
1318
interventions and study populations, and most of them have reported moderate positive effects.12–14 A workplace-based weight loss program was shown to be effective in reducing presenteeism.15 Similarly, a workplace migraine intervention program focused on prevention and early pharmacologic intervention reported an increase in productivity while at work.16 Programs involving worksite exercise,17 education regarding mental health,18 as well as comprehensive occupational health programs executed by occupational physicians have been shown to be effective.19,20 Nevertheless, studies assessing the effectiveness of health programs that focused on musculoskeletal symptoms such as the prevention of low back pain or reduction of neck and shoulder pain showed negative results.21–23 Most of the studies addressing the effectiveness of workplace health programs on presenteeism have been developed within the setting of one or more companies or industries.12,24 Prospective intervention studies are essential to address the question of a causal relationship between health promotion programs at work and presenteeism; however, population-based studies can add external validity to the conclusions about this association and assess whether it is consistent in a sample representative of various workplaces and geographic locations. Furthermore, it is important to determine whether access to health programs at workplace can reduce presenteeism even when participation in programs is voluntary or not regular.25 Thus, the primary objective of the present study was to assess the effect of access to health promotion programs at work on presenteeism. This study addresses this question by using population-based data from the 2009–2010 Canadian Community Health Survey (CCHS). We examined this association, considering adjustment for several possible confounding variables. Secondarily, we sought to explore the strength of the effect of perceived work stress and chronic diseases and to what extent presenteeism can be attributed to these risk factors.
METHODS Data Source and Study Sample Participants were respondents to the 2009–2010 CCHS. The CCHS is a national survey of people aged 12 years and older that is conducted by Statistics Canada on an ongoing basis with data released every year.26 The CCHS has a cross-sectional design and collects information by using a complex stratified multistage cluster sampling method. The 2009–2010 CCHS collected responses from people living in private occupied dwellings covering all provinces in Canada. The sampling frame excluded individuals living on Indian reserves, institutional residents, members of the Canadian armed forces, and residents of certain remote regions. Data were collected by using in-person and phone interviews. A detailed description of the survey methodology has been published elsewhere.26 Respondents who were residents of the province of Nova Scotia participated in the optional “Physical Activities and Facilities at Work” module of the 2009–2010 CCHS. Participants were asked questions related to access to facilities that promote healthy activities at work as well as their working status and reduction of activities at work because of health problems.27 The 2009–2010 CCHS provided a total sample of 4712 individuals in the province of Nova JOEM r Volume 55, Number 11, November 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JOEM r Volume 55, Number 11, November 2013
Health Programs at Workplace and Presenteeism
Scotia (overall response rate of 74.6%). From the CCHS database, we extracted an analytical sample consisting of individuals aged between 20 and 69 years who reported having a job in the week before the survey administration and who provided valid responses regarding access to health programs at work and reduced activities at work. Questions related to age, sex, education, income, perceived work stress, and chronic diseases were considered for possible confounding variables. Invalid responses to all of these questions were excluded from the analysis.
Study Variables The primary outcome variable of interest was presenteeism, coded as a binary variable (yes/no). Presenteeism was derived from the question, “Does a long-term physical condition or mental condition or health problem reduce the amount or the kind of activity you can do at work?” with three possible valid responses: “sometimes,” “often,” or “never.” Presenteeism was defined with the answers “sometimes” or “often” reduced activities at work because of long-term physical or mental conditions or health problems. The primary explanatory variable, access to health programs at work, was coded as a binary variable. It was derived from the question, “At or near your place of work, do you have access to programs to improve health, physical fitness, or nutrition?” with “yes” and “no” as possible answers. The type of health program was not specified. Possible confounding variables were selected a priori, choosing conditions possibly associated with presenteeism and access to health programs. Covariables included sex, age (considered in five categories: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years), highest level of education in two categories (secondary and postsecondary education), personal income in Canadian dollars (less than Can$20,000; Can$20,000 to Can$39,999; Can$40,000 to Can$59,999; Can$60,000 or more; and not stated), self-perceived work stress in three categories (low, moderate, and high level of stress), and chronic diseases coded as binary (no chronic disease or at least one chronic condition, including any of the following: hypertension, diabetes mellitus, heart disease, previous stroke, asthma, chronic obstructive pulmonary disease, arthritis, chronic back pain, diagnosed digestive disorder, migraine, cancer, mood disorder, and anxiety disorder). Variables related to working environment or organizational culture at workplace were not included in the analysis.
Statistical Analysis Descriptive statistics of the distribution of covariates with respect to the outcomes were summarized. The rate of presenteeism by categories of access to health program and covariates was calculated. Differences between included and excluded respondents were examined using chi-squared tests. Bivariable logistic regression analyses were used to examine the association between independent variables with presenteeism. Multivariable logistic regression was used to provide adjusted odds ratios (ORs) of the associations with 95% confidence intervals (CIs). To account for the different probabilities that individuals were selected in the CCHS sample, all analyses included rescaled (probability) weights obtained by dividing the sampling frequency weights provided by Statistics Canada by the mean of the weights in the analytical sample.26 All analyses were performed using SAS statistical software version 9.3 (SAS Institute, Inc, Cary, NC).
RESULTS A total of 1615 respondents met our selection criteria and were included in the final analysis. Figure 1 shows the sample selection process. Overall, 13 respondents (0.7%) did not provide valid answers to the questions on education and self-perceived work stress and were excluded from the analysis. Compared with the final sample, excluded respondents were equally likely to report access to a health program at workplace (P = 0.43) and to report presenteeism
FIGURE 1. Flowchart of sample selection.
(P = 0.39). The distribution of the sample by access to health programs and all covariables varied widely (Table 1). Almost half of the respondents (49.8%) reported having access to a health promotion program at or near workplace. In the sample, 52.5% were men and only 7.4% were in the age group of 60 to 69 years. Respondents with postsecondary education comprised 71.1%, whereas people who did not state income constituted 10.1% of the sample. Respondents classified as having high level of work stress represented 24.8% of the sample, whereas 57.8% reported at least one chronic condition. Table 1 also shows the rate of reported reduced activities at work or presenteeism. The frequency of presenteeism was lower in those who reported access to a health program at work (13.1%) than in those who reported not having access (18.6%). There were some differences in the distribution of presenteeism within the categories of covariables. Frequency of presenteeism by sex did not differ considerably. With respect to age, respondents aged between 20 and 29 years reported the lowest rate of presenteeism (6.7%). Presenteeism was similar in participants with secondary and postsecondary education. The groups with lower income reported higher rates of presenteeism (19.4% for those with less than Can$20,000 income). Presenteeism rate was higher (24.0%) in the group with high levels of work stress than in those with low and moderate stress. Participants who reported at least one chronic condition had a presenteeism rate considerably higher than those who did not report chronic conditions (24.4% vs 4.1%). Table 2 displays the results of the bivariable and multivariable analyses. In the unadjusted analysis, the odds of presenteeism were higher among respondents who did not report access to a health program at work than among those who reported access (OR = 1.51; 95% CI, 1.16 to 1.98). In the multivariable model adjusted for sex, age, education, income, work stress, and chronic conditions, the odds of presenteeism remained elevated but not significant (adjusted OR = 1.23; 95% CI, 0.91 to 1.65). Some of the confounders included in the analysis were associated with presenteeism. There was no significant difference in the odds of presenteeism between men and women. With respect to the age category of 20 to 29 years, age categories between 30 and 59 were all more likely to report reduced activities at work. There was no association of presenteeism and education. Respondents who reported income higher than Can$40,000 had lower odds of presenteeism than those with income less than
C 2013 American College of Occupational and Environmental Medicine
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1319
JOEM r Volume 55, Number 11, November 2013
Sanchez and Ortiz
TABLE 1. Distribution of the Sample and Rate of Presenteeism by Access to Health Programs and Determinants of Presenteeism (Weighted Analysis)
Distribution of Total Sample (n = 1,615) n Access to health program Yes No Sex Male Female Age, yr 20–29 30–39 40–49 50–59 60–69 Education Secondary Postsecondary Income, Can$
