key: cord-0886055-ypdsozqq authors: Masuda, M.; Ishimaru, T.; Hino, A.; Ando, H.; Tateishi, S.; Nagata, T.; Tsuji, M.; Matsuda, S.; Fujino, Y. title: A cross-sectional study of socioeconomic status and sickness presenteeism in Japanese workers during the COVID-19 pandemic date: 2021-07-25 journal: nan DOI: 10.1101/2021.07.23.21260909 sha: 5c93cbb53bd5982a734314ef98c1cbaac5f5584b doc_id: 886055 cord_uid: ypdsozqq Background: We examined the relationship between socioeconomic and health status, and lifestyle habits and sickness presenteeism among Japanese workers during the COVID-19 epidemic. Methods: A cross-sectional study using Internet monitors was conducted in December, 2020 in Japan. Of 33,302 survey participants, we analysed 27,036 (13,814 males and 13,222 females) who reported experience with sickness presenteeism. Results: The OR of sickness presenteeism associated with unmarried versus married status was 1.15. Respective figures for other variables were 1.11 for manual laboring work compared to desk work; 1.79 and 2.29 for loss of employment at the time the pandemic began and continuation of unemployment compared to maintaining employment during the pandemic; and 3.34 for a feeling of financial instability compared to stability. Conclusion: The issue of sickness presenteeism has been highlighted by COVID-19. Shortly after the initial confirmation of COVID-19 in China, the infection spread 22 globally, and its presence in Japan was confirmed in January 2020. Japan then 23 experienced two peaks of infection, one each in May and August 2020, which were 24 relatively short-lived, and the number of people infected and deaths were considered low 25 on comparison with other countries. The number of infections then increased again in 26 November 2020, which was the so-called third wave, and was considered the peak of the 27 Sickness presenteeism has rapidly attracted attention in occupational health. It has 29 been defined as "the phenomenon of people, despite complaints and ill health that should 30 prompt rest and absence from work, still turning up at their jobs" 1 have been reported in a number of countries 2-6 . It is known that workers with sickness 32 presenteeism are more likely to be aware of suboptimal general health and at increased 33 risk of developing coronary artery disease and depression. 7-9 . Known workplace impacts 34 of sickness presenteeism include increased long-term leave, reduced work capacity, and 35 the spread of infectious diseases [10] [11] [12] . 36 Vulnerable socioeconomic conditions, insecure employment status, as well as 37 individual health views, work attitudes, company leave systems and culture influence 38 workers' experience of sickness presenteeism 13 . Workers who are worried about their job 39 security are reluctant to take time off work for treatment. Workers with insecure 40 employment are more likely to engage in sickness presenteeism because they fear that 41 complaining about their health condition will be detrimental to the status of their 42 employment contract. The shortage of employees and inadequate leave system also lead 43 to an increase in sickness presenteeism 14, 15 . Sick leave rates are low in areas where 44 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260909 doi: medRxiv preprint unemployment rate is high 16 , and it is thought that the fear of losing employment and 45 poverty have led to situations in which people feel they have no choice but to work even 46 if they are in poor physical condition 17 . In addition, worker behaviors, such as a positive 47 job attitude, feelings of strong obligation, and considering absence a less legitimate option, 48 are also known to result in sickness presenteeism 18 . 49 We hypothesized that the COVID-19 epidemic would affect worker experience of 50 sickness presenteeism via an effect on their socioeconomic status and employment 51 instability, as well as on their health behaviors. During a COVID-19 epidemic, workers 52 may be more hesitant to report their health condition to the company when they are not 53 feeling well. Reports worldwide have also noted the interruption of treatment for 54 previously controlled diseases during the COVID-19 outbreak 19,20 , which also acts to 55 increase sickness presenteeism. Furthermore, the management of sickness presenteeism 56 is important in terms of preventing the spread of infection. Among various measures taken 57 to halt the spread of COVID-19 in the workplace, self-reporting of physical condition and 58 restriction of attendance by employees who have fever or other health problems are 59 particularly important -the fact that some employees still come to work despite feeling 60 ill is now an issue. 61 Some studies have considered the assumption that the COVID-19 epidemic affects 62 the experience of workers' sickness presenteeism 21,22 . However, there are few reports on 63 the characteristics of workers experiencing sickness presenteeism during the COVID-19 64 epidemic. We examined the relationship between socioeconomic and health status, and 65 lifestyle habits and sickness presenteeism among Japanese workers during the COVID-66 19 epidemic. 67 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Treatment status was determined using the following single-item question: "How 83 many days have you worked (including at home) in the last 30 days under conditions in 84 which you would really like to take a day off?" Respondents were asked to respond with 85 the number of days. Those who answered 3 days or more were regarded as a group with 86 sickness presenteeism. 87 88 Survey of subject socioeconomic conditions, health status, and lifestyle factors 89 The questionaire was conducted via the Internet and enquired about the subject's 90 socioeconomic conditions. Specifically, the survey enquired about age, sex, marital status 91 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. With regard to health status and psychological factors, we asked about self-rated 99 health, psychological distress, sense of loneliness, presence of supportive friends, and 100 having a health condition that requires company consideration to allow work. 101 Psychological distress was addressed using the Kessler 6 (K6) test 24 , whose validity in 102 Japanese has been confirmed 25 . Subjects with a K6 score of 5 or higher were considered 103 to have mild psychological distress. Loneliness was examined with the question: "Have 104 you ever felt alone?", with response options of: "never," "a little," "sometimes," "usually," 105 and "always." The presence of a health condition that required the employer's 106 consideration to permit work was surveyed using the question: "Do you require 107 consideration or support from your company to continue working in your current health 108 condition?", with the three response options of: "no;" "yes, but I have not received 109 support;" and "yes, and I have received support." 110 The questionaire also contained a variety of questions on lifestyle and work-related 111 factors, including smoking (never; quit more than one year ago; quit within the past year; 112 started to smoke < 1 year ago; have smoked for > 1 year), alcohol consumption (6-7 113 days/week; 4-5 days/week; 2-3 days/week; < 1 day/week; almost never), exercise habit, 114 breakfast routine, time spent in one-way commuting and number of overtime hours 115 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260909 doi: medRxiv preprint worked/day. With regard to exercise, participants indicated the number of days each week 116 on which they exercised for 30 minutes or more. Regarding breakfast, they indicated the 117 number of days each week on which they had breakfast. 118 119 Age-and sex-adjusted odds ratios (ORs) and multivariate adjusted ORs were 121 analyzed using a multilevel logistic model with nesting by residential prefecture. All 122 analyses included the incidence rate of COVID-19 since declared pandemic status was an 123 area-level variable. In the analyses of socioeconomic conditions, the model included sex, 124 age, marital status, equivalent household income, job type, employment status, 125 educational background, and level of comfort with financial condition. The model for 126 analysis of health-related factors included age, sex, psychological distress, self-rated 127 health, feeling of lonliness, having a friend who can provide support, and having a health 128 condition which requires the employer's support to allow work to occur. The model used 129 to analyse lifestyle and work-related factors incorporated age, sex, alcohol intake, 130 smoking habit, exercise, breakfast routine, overtime hours worked/day and time required 131 for one-way commuting. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The ORs of health status, psychological disteress associated with sickness 150 presenteeism is shown in Table 3 . On multivariate analysis, the OR of sickness 151 presenteeism associated with poor self-rated health was 11.21; experience of 152 psychological distress was 6.11; feeling always alone was 8.30; and the need for company 153 consideration to allow work but not receiving it was 9.57. 154 The ORs of lifestyle and occupational factors associated with sickness 155 presenteeism is shown in Table 4 . Smoking, breakfast routine, commute time, and hours 156 worked overtime were associated with sickness presenteeism. In contrast, we saw no longer than 2 hours in one-way commuting (OR=1.45, 1.18-1.77, p<0.001), or worked 162 more than 2 hours overtime (OR=2.53, 95%CI: 2.53-2.80, p<0.001). 163 164 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This study found that 19% of workers in Japan had experienced sickness 166 presenteeism during the COVID-19 pandemic. Risk of experiencing sickness 167 presenteeism was higher in workers with a lower socioeconomic status and those in poor 168 health. Further, risk was also higher in workers with an unfavorable lifestyle and working 169 conditions. 170 Socioeconomic status is known to be an important factor in a worker's experience 171 of sickness presenteeism 14,26 . Further, emergencies such as disasters impair access to 172 health care for people with a disadvantaged socioeconomic status 27,28 . As a result, 173 opportunities for workers to experience sickness presenteeism can be expected to increase. 174 The present study reveals that socioeconomically disadvantaged workers were more 175 likely to experience sickness presenteeism during the COVID-19 pandemic. In particular, 176 risk of sickness presenteeism was increased in subjects with low income, unemployment 177 experience, and economic insecurity, a finding consistent with previous studies of the 178 impact of COVID-19 on sickness presenteeism. 21,22 Economic deprivation is a direct 179 reason for sickness presenteeism. Workers with unstable employment or a low income 180 have little choice but to work hard for their livelihoods, even if they are not feeling well. 14 181 Conversely, workers with sickness presenteeism are more likely to exacerbate their 182 illness 10 . As a result, sickness presenteeism will work in the direction of lower income 183 and employment instability. Workers with unstable employment may not be entitled to 184 sick leave or may be reluctant to take it 29,30 , rendering them prone to sickness 185 presenteeism. Moreover, experience of sickness presenteeism has also been shown to 186 exacerbate health status, resulting in turn in employment instability as well as economic 187 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Our present results revealed that those with a poor health condition had a greater 189 likelhood of experiencing sickness presenteeism: those whose self-rated health was poor, 190 or with psychological distress, a sense of loneliness, and workplace support were at 191 greater risk of experiencing sickness presenteeism. It is clear from the definition that 192 sickness presenteeism is more likely in poor health 1 . Conversely, workers with sickness 193 presenteeism are known to be more likely to exacerbate their illness 10 . In our present 194 study, we found an association between greater psychological distress and a higher 195 Sickness presenteeism is an major occupational health issue and public health 222 challenge. The COVID-19 pandemic has brought a particular focus to it. Our present 223 study emphasizes that sickness presenteeism is associated with socioeconomic status. 224 Regardless of causation, individuals with a lower socioeconomic or health status were at 225 greater risk of sickness presenteeism. It is therefore critical to recognize not only the 226 clinical importance of COVID-19, but in addition the deterioration in labor productivity 227 and the impact on the lives and health of workers through the socioeconomic environment. 228 It is important to foster the social consensus that workers should take the day off from 229 work when they are feeling unwell. It is known that companies with a leave system that 230 is easy to use when workers are not feeling well have a low incidence of infectious 231 diseases 15 . An easy-to-use leave system is effective not only in reducing sickness 232 presenteeism but also with regard to COVID-19 countermeasures. 233 234 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. we did not investigate the types of illnesses and health problems experienced by people 239 with sickness presenteeism. Third, we did not determined the chronological relationship 240 between sickness presenteeism and socioeconomic status and lifestyle. 241 In this study, we found that around 19% of Japanese workers experienced sickness 242 presenteeism during the period of rapidly spreading COVID-19 infection. Those who 243 were socioeconomically disadvantaged, in poor health, or with unfavorable lifestyle 244 habits were more likely to report sickness presenteeism. Accordingly, the issue of 245 sickness presenteeism has been highlighted by COVID-19. The increase in sickness 246 presenteeism may not only worsen the health status of individuals, but also have long-247 term effects on society, such as reduced productivity and increased social security burden 248 due to employment instability. These findings indicate the need for efforts to decrease 249 sickness presenteeism in workers who need to recuperate at home. 250 251 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 2 . Association between socioeconomic status and sickness presenteeism * The multivariate model was adjusted for sex, age, marital status, job type, equivalent household income, educational background, employment status, perception of financial situation and incidence rate of COVID-19 by prefecture. Age-and sex-adjusted Multivariate* 95%CI All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. Table 3 . Association between health status, psychological distress and sickness presenteeism * The multivariate model was adjusted for sex, age, marital status, job type, equivalent household income, and incidence rate of COVID-19 by prefecture. Age-and sex-adjusted Multivariate* 95%CI 95%CI All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260909 doi: medRxiv preprint Sick but yet at work. An empirical study of Sick at work-a risk factor for long-term sickness 276 absence at a later date? Work attendance among healthcare 279 workers: prevalence, incentives, and long-term consequences for health and 280 performance Physicians who do not take sick leave: hazardous heroes? 282 Presenteeism in the workplace: A review and research agenda Sickness presenteeism: Prevalence, attendance-pressure 286 factors, and an outline of a model for research What makes you work while you are sick? Evidence 289 from a survey of workers Chapter 5. Risk factors for sick leave -general studies No security: a meta-analysis and review of job 293 insecurity and its consequences Going to work ill: A meta-analysis of the correlates of 295 presenteeism and a dual-path model