Presenteeism: An overview

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Roxane L. Gervais, Health & Safety Laboratory, UK

Presenteeism: An introduction

Presenteeism as a concept is increasing in importance in the work environment. It occurs when workers go to work when ill and are unable to perform effectively due to their ill health. Due to this loss in productivity, it has been estimated that presenteeism costs organisations more than sickness absence, and as such should be monitored to a greater extent. It impacts on workers’ health, wellbeing and resilience, as well as organisational health. These issues are discussed as are the implications for workplace policies and practices to manage presenteeism.

Presenteeism and workplace policies and good practice

The concept

While presenteeism is influenced by the overall health and wellbeing of employees, there are many work and non-work factors that may cause employees to go to work when ill and when they are not able to produce and perform to the best of their ability. As a rule, individuals who are experiencing ill health should refrain from reporting to work until they are fully recovered. However, for some individuals, depending on their illness, they may either agree with their employer on reduced work hours, less strenuous activities or both, to facilitate return to work after long-term sickness absence. Work generally is good for physical and mental health and overall wellbeing and conversely a lack of work can lead to poorer physical and mental health and overall wellbeing [1]. In this respect, individuals who may have mostly recovered from an illness, but are not 100% fit could engage in certain activities at work[2], and thereby assist further with their full recovery. It must be recognised though that a ‘controlled’ return to work for workers with support from their organisations when on the way to recovery from ill health, would generate different results from those individuals who may feel that they should go to work when they are ill due to the pressures of the work environment.

Presenteeism is a fairly new concept, and with any new concept there are discussions surrounding its definition. Johns (2009) [3] in a review of the concept to date noted that the slightly different interpretations of the term tended to fall into two groups. The first, the European definition, focuses on the management and epidemiology or occupational health aspects of the term and its impact on job insecurity, i.e., workers going to work to ensure that they are ‘seen’ to reduce their chances of being made redundant, with possible consequences of stress and ill health. This is tempered against the North American focus in assessing the impact of ill health, such as experiencing a migraine, on productivity[3]. Johns notes that many of the terms lack scientific integrity such as stating that presenteeism is the opposite of absenteeism and proposed that more research is required to assess the underlying causes of the concept[3].

The causes

As presenteeism involves going to work when ill, it could involve any aspect of ill health. However, it has been shown to be associated with certain health conditions. Schultz and Edington (2007) in a systematic review assessing employee health and presenteeism found that it was linked to allergies, arthritis and health risks which arise from a lack of physical activity and increased body weight[4], thereby supporting the use of workplace health promotion programmes that are developed to address these risk factors[4]. Individuals who suffer from emotional, thyroid or blood pressure concerns are more likely to stay at home to deal with their conditions, while back pain could cause workers to equally choose going on sick leave (absenteeism) or coming to work but not able to work efficiently (presenteeism) to cope with these conditions[5]. Further, higher stress levels are more likely to increase a pattern of presenteeism among individuals[5].

A Swedish study based on a nationally representative sample has shown that sickness absence and presenteeism are influenced by a poor work environment, with poor health and high stress levels further strengthening this relationship[6]. Further, the two concepts positively affect each other, as individuals who are experiencing ill health will manage this illness by alternating between sickness absence and presenteeism, contributing to a further decline in their health[6]. This could lead to future long-term sickness absence, due to poor health[7], allowing for presenteeism to be considered a ‘predictor’ of sickness absence[8]. Therefore, organisations in seeking to manage one of those issues (either absenteeism or presenteeism) should work to manage the other at the same time.

There are several factors that influence presenteeism and absenteeism behaviours and these include[9]:

  • The nature of the health problem itself,
  • The objective and perceived characteristics of work,
  • Organisational policies and procedures,
  • Wider cultural and socio-economic context,
  • Managers’ relationships with employees and their effectiveness in implementing organisational policy.

For example, if managers and supervisors adjust organisational policies and procedures, to allow flexible working; this allows the employees to better manage their ill health[10] and they may not ‘feel’ compelled to report to work. Such an approach would realise better outcomes over the long-term.

Some of the other factors that contribute to a ‘presenteeism culture’ in the organisation are low replaceability, low control, conflicting demands, lack of work resources, time pressure, high psychological demands, supervisory status, [[Working Long hours|long work hours, low social support, job insecurity and having a family life that is more demanding than work[9], but not wishing to acknowledge that they have these challenges and thereby reducing work-life balance. In this respect, employees may go to work without addressing some of the challenges that may arise in their home life, thereby selecting ‘work’ over ‘home’, and creating work-life imbalance. It has been found also that parents would go to work when ill to ‘save’ paid sickness absence and vacation leave to care for their children when they in turn fell ill[11]. In addition, individuals with higher performance-based self-esteem (i.e., those whose self-esteem is directly linked to their performance) have been found to go to work when ill[12]. Another factor involves how an organisation’s sick pay provision is allocated, although this may depend on the size of the organisation and the type of work in which the employee is engaged, which have all shown to impact on the return to work practices of employees[13]. Organisational practices, such as a culture of workaholism [14] has been found also to increase presenteeism, as has work-life imbalance due to work interfering with life as workers feel pressured into going to work when ill[15], and thereby not taking care of their health, reducing their ability to deal with both work and home.

Its prevalence

Due to the increase in the volume of research that is being generated about presenteeism, some information is available on its prevalence and the characteristics of the workers more likely to come to work when they are sick. In the United Kingdom, 80% of a group of 1279 doctors had worked while ill[16] over the previous year of the survey. In Sweden out of 3096 employees from various professions/jobs 70% had worked while ill[17] over the past 12 months, whilst in Denmark a similar result (73%) was found from 11, 270 employees from various professions/jobs who were questioned about their leave patterns over the previous year[18]. Other research shows that 60% of 6309 employees in organisations across the United Kingdom and Europe reported working while ill[15]. In addition, a survey of 510 employees of varied professions/jobs from a health insurance company in the United Kingdom showing that when 18% of employees reported sickness absences, a higher rate was found (45%) for employees reporting coming to work when ill[19][20]. Further, those who go to work when ill are more likely to be women and to have a higher level of education, as a study of 2191 participants from various occupational groups in the United States of America (USA) has shown[21].

Recent information from the Fifth European Working Conditions Survey (EWCS) [22] shows that over one-third of the respondents to the survey (39%) reported that they worked while ill (women: 41%, men: 38%). In addition, close to two-thirds (62%) of these noted that they worked while ill for fewer than six days during the previous 12 months, 33% between six and 20 days and 5% more than 20 days. The prevalence of reported presenteeism did not change greatly across the different age groups.

Other information from the survey, as shown in Table 1 and Table 2, reflects the higher rates of presenteeism, when compared against general absenteeism or absenteeism due to an accident at work. The figures reflect that women are more likely than men to present at work when ill, as are managers and those working within education or health.

Table 1. Prevalence of absenteeism and presenteeism by gender and occupation (%)
Absenteeism (>5 days) Absenteeism due to an accident in work Presenteeism
Managers men 13 12 57
women 18 5 56
Professionals men 19 9 46
women 23 10 47
Technicians and associate professionals men 26 12 37
women 26 9 41
Clerical support workers men 31 12 30
women 28 9 38
Service and sales workers men 18 17 34
women 23 12 38
Skilled agricultural workers men 18 27 38
women 15 25 45
Craft and related trade workers men 26 22 31
women 28 11 34
Plant and machine operators men 27 21 37
women 36 11 35
Elementary occupations men 22 21 34
women 22 11 37

Source: Eurofound (2012), p. 117[22]


Table 2. Prevalence of absenteeism and presenteeism by gender and sector of activity (%)
Absenteeism (>5 days) Absenteeism due to an accident in work Presenteeism
Agriculture men 16 25 37
women 15 20 44
Industry men 28 17 35
women 29 7 34
Construction men 23 21 33
women 31 8 42
Wholesale, retail, food and accommodation men 21 16 38
women 21 9 40
Transport men 26 18 38
women 28 18 41
Financial services men 21 14 41
women 28 6 41
Public administration and defence men 28 20 32
women 30 9 45
Education men 22 9 46
women 21 10 45
Health men 22 10 42
women 29 11 43
Other services men 17 14 44
women 20 11 40

Source: Eurofound (2012), p. 117[22]

The consequences and benefits

Presenteeism impacts on both employee and employer. For example, when pressure is put on employees to go to work, this may lower their [[Employee and manager engagement: effects on psychosocial risks|job engagement[23]. Conversely, when organisations support and implement policies that allow the employees to focus on their long-term wellbeing, then both sides benefit in terms of increased productivity, commitment, reduced turnover and retraining costs, enhanced workforce stability, employee loyalty and group cohesiveness[24].

Presenteeism is considered a risk-taking behaviour that is positively associated with job demands and burnout [25].Workers with high job demands may feel compelled to go to work to ensure that the work gets done, but some of the other consequences include exhaustion and depersonalisation[25], depression[26], and depending on the nature of the job, may lead to other health and safety risks to the colleagues of the worker due to him/her being less alert and therefore more accident-prone; thereby adversely affecting both parties by presenting her/himself at work[27].

Recent research from the fifth EWCS found that workers subjected to discrimination, verbal abuse, threats and humiliating behaviour, physical violence, bullying and sexual harassment were more likely to have higher rates of presenteeism. The survey showed also that workers in ‘active’ jobs (i.e., those with high demands and high control and considered most conducive to maintaining wellbeing) present a mixed picture in terms of health outcomes and are associated with the highest level of presenteeism[22].

It must be stressed that going to work when not fully fit does not necessarily lead to presenteeism (i.e. not doing the work as expected). In fact, research has shown that a ‘controlled’ return to work could benefit, both the organisation and the employee, when the employee returns to work while recovering from an illness. A study by Howard et al. (2009) [21] assessed two groups of workers suffering from chronic pain conditions. One group was classified by the authors as ‘presentees’: i.e., those who worked more than 20% of the time post-injury and for more than three months post-injury; or were working at the time of admissions to the treatment. The other group was called ‘absentees’: i.e., those who did not meet the previously listed criteria.

The assessment found that:

  • those workers who were ‘presenting’ themselves at work (i.e., those classified as presentees)
    • were more likely to complete the prescribed functional restorative treatment programme;
    • to return to work either on full-duty or full-time;
    • to retain their work one year post treatment, and
    • not to have a decrease in job demand from pre-injury to post-treatment.

These results suggest that employees and employers benefit if the ill or injured employee stay at work post-injury rather than going on short-term or long-term disability, however, the working conditions must be adjusted to their current abilities[21]. This assessment supports the belief that if employees receive the support from the organisation as part of a staged return to work, then they are more likely to return to work full time after stress related sickness absence and should be one of the return to work strategies to cope with musculoskeletal disorders. The study suggests one of the ways that could be used to encourage employees to work with organisations in managing their ill health and thereby reduce the potential of employees leaving the job due to an acute or short-term health problem. Organisations incur a cost when an employee leaves, with 70% of businesses noting the negative effect on business performance when this happens[28]. Further, it could cost an organisation an estimated €17,251 (2007 rates), which equates to close 40% of the lower end of the average gross pay of an employee to replace said employee[28].

The cost (estimated) and good practice

Costs and impact of presenteeism

Due to the nature of presenteeism, official records do not include individuals who go to work when ill; hence it is difficult to obtain accurate values of its cost to organisations and society. However, more instruments are being developed to measure the concept[29] by assessing the effect of ill health on productivity loss[29]. Despite this, it is argued that a ‘best method’ of measuring presenteeism is yet to be developed or established[4]. Some workplace associations have estimated the cost of presenteeism by examining sickness absence figures, by using international research that shows that in general presenteeism costs could be at least three times higher than absenteeism, with one of these studies suggesting that presenteeism costs were 1.8 times higher when compared to the costs for absenteeism[29].

In 2007, the Sainsbury Centre for Mental Health in assessing the cost of mental ill health estimated that presenteeism costs employers in the United Kingdom €22.3 billion per year[28]. See Table 3.

Table 3. Overall costs of mental ill health to employers in the United Kingdom (UK)
Cost per average employee Total cost to UK employers Per cent of total
€* € billion %
Absenteeism 496 12.4 32.4
Presenteeism 895 22.3 58.4
Turnover 141 3.5 9.2
Total 1,532 38.2 100.0


Adapted from the Sainsbury Centre for Mental Health, 2007[28]

  • Sterling converted to Euro using rate at 01/01/2007 [30]

Another study showed that costs from an assessment of outpatients suffering from rheumatoid arthritis reflected higher estimated costs per individual per week for presenteeism (€299) than for absenteeism (€120) [31]. As the costs were assessed in respect of their productivity at work, these would reflect cost incurred to the respective organisations. Overall, it is difficult to gain an accurate estimate of how much presenteeism costs an organisation. Despite this, when a worker chooses to go to work when not fully recovered from an illness or is not able to function at his/her optimum, this could have a negative influence on her/his productivity, thereby, incurring a cost to the organisation. More research is required therefore to determine the extent to which such behaviours impact on organisations to allow the development of an evidence-base to positively address this issue.

Workplace policies and good practice

Due to the evidence presented above, the rational for a behavioural-based approach to addressing presenteeism[9] [32] seems to warrant pursuing, rather than one that is based solely on the medical model[32], i.e., only focusing on physical symptoms. It is especially important to know an individual’s beliefs about his/her illness in order to determine how best to manage it[9]. Interventions are increasingly available and are being recommended also to address presenteeism at both the organisational and the individual levels.

The risk assessment process should be used to identify any psychosocial risks that could affect workers’ health. Employers in the European Union (EU) are required to evaluate the risks to the safety and health of workers and to put in place any appropriate action to prevent or control those risks, as outlined in the Framework Directive 89/391/EEC[33]. Presenteeism is a risk factor and would fall under this process,

Some of the useful recommendations that should be considered at the onset when managing risk factors, which may lead to presenteeism practices, are [9] [24] [25] [29]:

  • Provide line manager training in policies and practices to those who supervise others.
  • Monitor absence and support health and wellbeing as these will improve productivity and reduce sickness absence levels.
  • Develop an organisational culture that clearly states that employees should take sick leave when ill.

When workers are part of a supportive culture in which they know that time away from work is acceptable, then they are more likely to ‘detach’ from work to allow sufficient recovery from the work environment. The benefit of detaching from work has been recommended to improve on health and wellbeing[34].

Another solution that may assist in managing presenteeism is to develop checklists or indices that supervisors and managers could use to focus on the specific characteristics of the work environment to assess those that could be changed, inclusive of[35], p. 19:

At the organisational level:

  • Are ‘light duties’ really available, such as those that do not require excessive or strenuous input?
  • If available, are they appropriately used? In that the employee can choose when these can be done, rather than having set times to do certain tasks?
  • How much control can the worker have over the pace and intensity of work?
  • Are other workers available to take on the work if pressure builds up?
  • What is the extent of peer pressure to work ‘as normal’?
  • Can workers engage in meaningful dialogue with supervisors about what they can and cannot do?
  • What impact would work absence have on job security and job promotion opportunities?
  • Are health professionals available to tailor workplace exercise programmes?
  • Have supervisors and managers been trained to consider presenteeism, its impact, and what they can do to support sick workers?
  • What is the attitude of management to workers taking time off work?


At the individual level:

  • What is the attitude of the worker to taking time off work, and especially when s/he is suffering from ill health?
  • What external pressures are there on the worker to go to work when sick?
  • Has the worker experienced episodes of ‘burnout’ and depression in the past? This may indicate that the worker may choose to present at work, rather than managing their ill health through sickness absence.

As noted, one of the ways to deal with presenteeism is to use workplace health promotion programmes to address the health risks that could lead to an increase in presenteeism behaviours amongst workers[4]. It is useful to implement such interventions as when risk factors change: i.e. improve; this has a positive effect on presenteeism[36]. Other strategies that could work comprise the following[37]:

  1. Including presenteeism questions into Health Risk Assessment (HRA) instruments to allow a more valid assessment of the problem. This allows an understanding of the issue and gains information for any future methods to target and evaluate the issue.
    • A presenteeism question could entail, ‘Over the past 12 months did you work when you were sick?’ Yes or no responses would suffice[38].
  2. Constructing and providing individual self-care guides to each worker based on his/her symptoms and chronic conditions that were identified in the HRA. This identifies the workers at risk and ensures that the appropriate prevention strategies are in place to reduce presenteeism-related productivity losses.
    • The self-care guide could provide any of the following: information and advice on the specific illness of the worker, give techniques that the worker could use in coping with the illness and allow the worker space to record his/her medical history.
  3. Using the presenteeism-related data from the HRA to design appropriate interventions for any work (sub)-groups within the organisation. As with the individual guides, these allow the identification of symptoms and conditions that could then be targeted accordingly to the respective groups.
    • These data could list the types of illness that employees may experience, but choose to work through them.
  4. Including presenteeism issues in health communication actions. This increases the awareness among workers of the most typical conditions that affect productivity and provides information on the different ways that this could be minimised.
    • Any communication should mention also that employees who go to work when ill may take longer to fully recover and may experience other health issues as a consequence.
  5. Including typical presenteeism conditions in information on medical self-care and training. This facilitates learning for workers on the prevalence of the condition and ways to prevent it from occurring.
    • For example, workers may come to work when they have the flu, but information could be given to them suggesting that resting at home with appropriate fluids and medication would result in faster recovery than if they go to work and try to ‘work’ through the illness.
  6. Providing targeted intervention strategies for the most costly conditions. These strategies could consist of educating or providing the worker with information on solutions that are available to alleviate symptoms and onsite occupational health services support.
  7. Providing incentives for preventing presenteeism. Any measure of presenteeism should be included in a wider organisational-wide wellness incentive programme.
    • When consistent data are collected on presenteeism, this would allow employees to understand better the scale of the problem and perhaps be more willing to invest in its improvement (for example finding ways to support a sick colleague to help her/him recover sooner and thereby function at work more efficiently).
  8. Establishing cultural norms that work to prevent presenteeism. These norms could focus on emphasising that sick absence should be used when the worker is ill, ensuring that workers take regular breaks, inclusive of one for lunch and, of course, taking regular vacation leave.
  9. Including measurements of pre and post presenteeism as part of program evaluation. A consistent evaluation of presenteeism at baseline and regular intervals allows any potential programme effects to be more accurately determined.


The interventions listed above would contribute to a healthy organisation, which in turn could assist in managing presenteeism. However, it has been noted that presenteeism could still occur with employees who operate within a supportive organisation, as they may report for work in support of the organisation and to not let it down[35].

Conclusions

As shown, there are strong links between presenteeism and sickness absence, with organisational policies being one of the influencing factors that impact directly on employees alternating their absenteeism with presenteeism to manage their ill health. While employees note that they ‘choose’ to go to work while being unfit for work[15], such choices would be reduced or eliminated if they knew that the required support from the organisations and their managers/supervisors was available in managing not only their workload, but their health and wellbeing.

The measurement of presenteeism remains an issue with a number of diverse instruments in use that may not provide a full realisation of the costs or consequences involved in the behaviour[3] [31] and that may generate different estimated costs [31] or struggle to establish its overall impact. The continuing research for suitable instruments would improve and build on the tools that organisations could use to measure, assess and evaluate and thereby implement suitable interventions for this risk factor.

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Links for further reading

Business in the Community & Centre for Mental Health, Managing presenteeism: a discussion paper, 2011. Available at: [10]

Downey, J. (2012). How occupational health can help to manage presenteeism, Occupational Health. Retrieved on 02 May 2013, from: [11]

Edwards, P. & Greasley, K. (2010). Absence from work - Presenteeism. European Working Conditions Observatory, European Foundation for the Improvement of Living and Working Conditions. Retrieved on 15 January 2013, from: [12]

Juniper, B. (2012). Tackling presenteeism through employee wellbeing, Occupational Health. Retrieved 04 December 2012, from: [13]