• Promoting a Healthier Workforce

    Health and Productivity Management

  • Health and Productivity Management Center

    Health Promotion Programs, Modifiable Health Risks and Employee Absenteeism

    JOEM/January 2001

    Steven G. Aldana, PhD; Nicolaas P. Pronk, PhD

    This literature review demonstrates that the health risks and failure of employees to participate in fitness and health promotion programs are associated with higher rates of employee absenteeism. When determining how to manage absenteeism, employers should carefully consider the impact that health promotion programs can have on rates of absenteeism and other employee-related expenses. (J Occup Environ Med. 2001; 43:36 – 46)

    Over the past 20 years, the number of health promotion programs in workplace settings has continued to grow.1 This growth can be attributed to the increased awareness of the advantages of having quality health promotion programs available for employees. Companies believe that these programs can reduce employee health care costs, disability, and turnover; aid in recruiting new workers; enhance the company image; and improve employee productivity. Skilled employees who are well compensated, have pleasant work environments, and enjoy their work can still have very low productivity when they are absent from work because of poor health. The intent of this literature review is to summarize what is currently known about health promotion programs, modifiable health risks, and employee absenteeism.

    Published works by Woo et al,2  Altchiler and Motta, 3 and CCH Incorporated4 suggest that the causes of absenteeism can be classified into five main categories. The most commonly reported cause is personal illness, followed by family issues, personal needs, entitlement mentality, and stress. The term entitlement mentality describes the attitude that an employer somehow owes an employee the right to be absent from work, which often is expressed by disgruntled or unhappy employees.

    Many of these causes of absenteeism may be initiated by poor employee health. Obviously, personal illness is health-related, but an employee who fails to exercise, gets inadequate sleep, or abuses alcohol may indicate that his or her absenteeism is related to stress even though it was induced by an unhealthy lifestyle. Personal health can also be a mitigating factor in family issues and personal needs. Some employees are absent from work because they are tending children or parents who may be sick from illnesses caused by lifestyle behaviors.

    If employee absenteeism is related to poor health, and if the poor health was caused by a modifiable health risk, then it is logical to conclude that employee health promotion programs may be able to reduce employee absenteeism. This postulate can be possible only if health promotion programs are capable of reducing employee health risks.

    The ability of health promotion programs to affect employee health has been the subject of hundreds of published research manuscripts.5  Health promotion programs are designed to promote health by reducing health risks and actively preventing the onset of disease. They typically include interventions and programs designed to reduce stress; increase physical activity and fitness; reduce high blood pressure and cholesterol; reduce excess body weight; improve nutrition; reduce tobacco, alcohol, and substance use; and even improve seat belt use. Some programs offer cancer screening, health risk appraisals, cooking classes, and a variety of health education activities. Reviews of the effectiveness of many of these interventions have shown mostly promising results.5 In general, health promotion programs are having some success in reducing employee health risks, but changing human lifestyles is indeed a difficult task. If, as the literature suggests, health promotion programs are capable of reducing health risks, a number of questions must be addressed: Are high health risks associated with high rates of absenteeism? Do employees with low health risks have lower rates of absenteeism? Do absenteeism rates decline as health risks are reduced? Can health promotion programs reduce employee absenteeism?

    Literature Review Methodology

    Using literature-searching software developed by Dialog Corporation, a comprehensive search was conducted in the following databases: Medline, Embase, Healthstar, SPORTDiscus, PsycINFO, SciSearch, ERIC, and ABI Inform. The search was conducted using the key words absenteeism, health risks, exercise, physical activity, fitness, stress, obesity, body mass index, hypertension, hypercholesterolemia, illness days, sick days, health promotion, and so forth. To limit the review to studies that are known to have at least an acceptable level of scientific rigor, only those studies published in peer-reviewed journals in the English language were used. The search resulted in 43 studies that evaluated absenteeism and health promotion programs/modifiable health risks. Studies that evaluated the relationship between substance abuse and/or tobacco use and absenteeism were excluded from this search because that literature has a sufficient number of well-designed studies to merit its own review.

    The literature search found articles in the following areas (the number in parentheses is the number of articles for that health risk that were related to worker absenteeism): body mass index/obesity (5), cholesterol (3), stress (7), fitness programs (3), fitness/physical activity (9), hypertension (4), multiple risk factors (3), and health promotion programs (9). As might be expected, each article has its own research hypotheses and research questions. Besides having different purposes, all of the articles have different research designs, statistical approaches, research settings, subject sizes, and time frames. The only common factor among these studies is that some have used similar independent and dependent variables. For example, the literature on fitness and absenteeism uses aerobic capacity, metabolic equivalents, kilocalories of physical activity per day, and physical activity scores as measures of fitness or physical activity. Likewise, the methods of measuring absenteeism can vary from company-maintained records to self-reported, each of which has inherent limitations. Because of these design differences, no attempts were made to compare studies; rather, each study was reviewed and a summary of the collective literature is provided.

    Modifiable Health Risks

    The review is organized around summary tables for each modifiable risk area addressed. Each table contains the following information: primary author; date and reference number; purpose of the evaluation; type of design used as indicated by one of the four main design classifications, preexperimental (PE), experimental (E), quasi-experimental (QE), and correlational (C). In general, preexperimental designs lack a randomized control group and/or a comparison group, and they generally suffer from a wide variety of threats to the validity of the study. Experimental designs all possess a randomized control group and are considered rigorous; quasi-experimental designs are usually conducted in real-world settings and lack randomization, but they often have many subjects and may have either long evaluation periods or be cross-sectional in nature. Correlational studies typically do not evaluate between- and within-group differences; rather, they determine the extent to which variables are associated. Not all studies fit neatly into just one of the four design categories, and only experimental designs have the potential to document causality. Therefore, assignment of a group design is a general designation. Each table also includes information on the number of subjects in each study group, the length of the evaluation period, how absenteeism was measured, and a brief summary of the findings.

    Obesity and Absenteeism

    All of the obesity/absenteeism studies used quasi-experimental designs. Among the five studies shown in Table 1, three different measures of obesity were used: body mass index >28 kg/m2, body weight greater than 20% above ideal, or body fat above 25% for male subjects and 30% for female subjects. Each of the five studies consisted of fairly large sample sizes and used subjects from a variety of cultures and demographics. Despite these differences, all of the studies cited demonstrated one consistent finding: absenteeism rates among obese female subjects are higher than for non-obese female subjects. This strong positive correlation was also well documented among male subjects, with one exception. Burton et al6 found a small, but significant, decrease in absenteeism among obese male subjects, though this finding may have been compromised by the small number of male subjects evaluated (n=179) in that study. The logical explanation for this relationship can be found in reviewing the variety of diseases such as cardiovascular disease, diabetes, and certain cancers, which are firmly linked to the presence of obesity. It may be true that obese individuals have greater rates of disease, which results in higher rates of absenteeism. Nevertheless, without good experimental designs, it is not possible to determine if obesity causes elevated levels of absenteeism, or if high levels of absenteeism are somehow responsible for a high prevalence of obesity, or if an additional variable is somehow confounding the obesity/absenteeism relationship.7-10

    Psychosocial Stress and Absenteeism

    All but one of the seven studies on stress and absenteeism demonstrated similar findings – there is a well-established, independent association between work- and life-related stress and absenteeism (Table 2).Although the other six studies incorporated different research participants and used different methods and stress measures, the remarkably similar findings demonstrated by this body of literature is convincing. The work by Woo et al2 was the only study that did not reveal a significant stress-absenteeism correlation. It is also the only study that was conducted outside of the United States. Undoubtedly, workplace stress is an international issue that affects workers of all nationalities and ethnic origins. Nevertheless, the cultural differences between workers in Singapore and corporate America may be sufficiently different to account for Woo et al's failure to find a significant correlation between work stress and absenteeism. For example, Asian employees may possess greater company loyalty and may not take work absence unless they are truly ill, not just suffering from stress. This explanation is supported by Woo et al's data showing that self-reported minor illness was correlated with absenteeism.

    Mod Table 2


    There is evidence that stress is a leading contributor to a variety of health problems, including coronary heart disease, cancer, diabetes, bacterial and viral infections, and depression.11-13 If stress is a causal factor in these illnesses, it is also plausible that stress could be a cause of absenteeism. Survey data from CCH Incorporated4 suggest that employers believe that stress is the cause of approximately 14% of all cases of absenteeism in the United States, and that, according to the International Labor Organization, American workers are now putting in significantly more hours on the job annually than their counterparts in other industrial countries. Greater increases in work productivity can continue only if employees are able to produce more each day. Whether or not recent increases in labor result in increased stress and absenteeism remains to be seen.14-19

    Physical Fitness/Activity and Absenteeism

    The literature examining the association between cardiovascular fitness and absenteeism is split into two major categories: (1) the effect of fitness program participation on employee-related absence, and (2) the association between fitness/physical activity and absenteeism. From a mechanistic perspective, moderate and high levels of cardiovascular fitness or physical activity could potentially impact absenteeism. The data linking physical activity and fitness to morbidity and mortality are convincing. The presence of cardiovascular disease, diabetes, obesity, hypertension, colon cancer, depression, and psychological functioning have all been shown to be partially caused by sedentary living. The extent to which these diseases cause employee absenteeism is unknown, but they clearly play some role in causing health-related absenteeism.

    The theory that participation in fitness programs can lead to less employee absenteeism depends on the ability of the programs to improve or maintain moderate-to-high levels of fitness. On the basis of the fitness program literature summarized in Table 3,it can be concluded that high levels of fitness program participation tend to be associated with decreased levels of near-term absenteeism (1 year). Although each of these studies suffered from validity threats, and each failed to use a true experimental design, they all demonstrated the same high level of participation response. In an attempt to support the theory, only Cox et al20 demonstrated fitness gains associated with program participation. The issue of self-selection that plagues each of these articles exposes the notion that the association between high program participation and low subsequent absenteeism may also be caused by improved employee morale and increased employer commitment, which may occur during the initial phases of employer-sponsored fitness programs.21,22

    Mod Table 3

    The association between fitness and absenteeism is ambiguous at best (Table 4). The available evidence does not indicate a significant association between fitness and absenteeism, although many questions in this area of research have, to date, been unexplored. 23-28 It seems that moderate and high levels of fitness or physical activity can reduce the incidence of many chronic diseases, but this may or may not translate into lower levels of absenteeism. Further complicating this relationship are the interactions that can occur among various health risks. For example, what is the effect of regular exercise after controlling for hypertension, hypercholesterolemia, obesity, age, and gender? Studies that controlled for multiple covariates and were successful in isolating the unique relationship between fitness and absenteeism have also reported conflicting results. Even if the association between fitness and absenteeism is found to be non-existent, the health benefits associated with regular physical activity are sufficient to require that exercise be a principle component of all health promotion programs.

    Mod Table 4

    Cholesterol and Absenteeism

    Only two studies have evaluated the relationship between cholesterol and employee absenteeism.7,28 Using similar designs, both studies developed regression equations to predict absenteeism rates(Table 5). When cholesterol was included as one of several absenteeism predictors, its ability to predict was mixed. Yen et al28 found that for men of all ages, cholesterol was not a significant predictor of absenteeism; for women, cholesterol actually had a small negative correlation with absenteeism. However, they offered no explanation for this finding. Bertera7 reported that employees with cholesterol levels above 221 mg/dL had 11% more time absent from work. This equaled an increased cost of $369 per employee per year in 1990.

    Mod Table 5-6

    Logic dictates that because hypercholesterolemia is perhaps the single most important predictor of cardiovascular disease, those with elevated cholesterol levels might eventually have a greater prevalence of the disease and associated higher rates of absenteeism research question yet to be addressed. An issue that further complicates this concept is the way cardiovascular disease affects an employee’s ability to work. Employees with cardiovascular disease may receive invasive procedures associated with lengthy hospital stays. When this occurs, employees are sometimes taken off full-time employee status and placed on disability. Self- and company-reported measures of absenteeism do not include information on disability use and may fail to capture employee illness that is related to cholesterol-caused disease. From this literature it seems reasonable to conclude that the association between cholesterol and absenteeism is not well known and needs further study.

    On a related note, investigators from Sweden29 investigated the possibility that rates of absenteeism may be greater for employees who were recently informed that they had high levels of cholesterol. In this study, employees who completed on-site cholesterol screenings and had high levels of blood cholesterol were informed that they were hypercholesterolemic and at increased risk for heart attack. When absenteeism rates of employees with low blood cholesterol were compared with those of employees having known elevated cholesterol levels, there was no difference for the 12 months after the screening. The authors concluded that if employees know they are hypercholesterolemic, they are not more likely to perceive themselves as ill and take more illness days.

    Hypertension and Absenteeism

    Three of the four studies (Table 6) that evaluated hypertension reported no difference in rates of absenteeism between normotensive and hypertensive adults.7,28,30 Using the same mechanistic approach as that used to describe how hypercholesterolemic employees might have reduced absenteeism, the theory behind the hypothesis that hypertensive employees have higher rates of absenteeism depends on the decreased prevalence of disease thought to be enjoyed by normotensive individuals. The link between hypertension and various cardiovascular diseases is solid. Nevertheless, it seems that none of the unique variance in employee absenteeism can be accounted for by hypertension alone.31 When hypertension is treated as just one of several employee risk factors, the ability to account for absenteeism is greatly enhanced. This multiple-risk-factor approach will be discussed in the next section.

    Multiple Modifiable Risk Factors and Absenteeism

    Three published studies (Table 7) evaluated the association between the number of risk factors an individual may possess and absenteeism. Burton et al30 and Bertera7 reported on data revealing that absenteeism increased as the number of modifiable risk factors increased. Employees with three or more risk factors had the highest rates of absenteeism. After evaluating similar risk factors, Yen et al28 demonstrated that high stress, obesity, and high blood cholesterol were significant predictors of absenteeism by themselves, but that only stress and smoking were able to contribute unique variance in a regression model. Interestingly, the best single predictor of future absenteeism was past absenteeism.

    Mod Table 7

    Without causal inferences, it is impossible to determine the direction of these associations. The health risk literature provides a clear argument that elevated health risks are associated with increased morbidity, and it is believed that high rates of morbidity cause increased absenteeism. Regardless of how logical this argument seems, there is no way to eliminate the possibility that high levels of absenteeism cause elevated health risks. Until such data become available, these few studies suggest a significant, but small, positive correlation between multiple health risks and absenteeism. It is also interesting that many individual health risks do not seem to have an association with absenteeism, but when they are found in the company of other health risks (a cluster of risks), the cluster is often linked with higher rates of absenteeism.

    Effect of Health Promotion Program Participation on Employee Absenteeism

    In general, the literature evaluating the effect of health promotion program participation on absenteeism has been conducted in real-world settings under less than ideal research conditions. Randomization of employees or worksites into treatment (health promotion programs) or control groups is difficult-to-impossible to do. Because of this design weakness, most studies are quasi-experimental and use some form of time-series or unequal control group. Despite this design limitation, an advantage of this literature has been the generally large sample sizes that were evaluated. The studies summarized in (Table 8) represent program participation and absenteeism data on a combined population of more than 68,812 individuals.32-40

    Mod Table 8

    Because of the differences in health promotion program offerings, evaluation design methods, and absenteeism measures reported by this literature, caution is required in summarizing these findings, especially when there is considerable disagreement among studies. The majority of these studies tend to support the hypothesis that employees who participate in worksite health promotion programs have lower subsequent levels of absenteeism than nonparticipating employees. Although the majority of these differences are significant, the magnitudes of the differences are modest. Those studies reporting significant reductions in absenteeism for program participants found the reductions to be approximately 3% to 16% and, in most cases, the reductions did not appear until near the end of the evaluation periods suggesting that if absenteeism reductions are possible, they are not short-term benefits.

    Several studies found that rates of absenteeism decreased for only some segments of the employee workforce.32-34 In these studies, decreases were reported for hourly but not salaried personnel, for employees with three or more health risks, and for only the last month of a 2-year evaluation period. These efforts to “torture the data until it confesses” demonstrate significance in one small subset of the evaluation population and send the message that the absenteeism-reducing effects of worksite health promotion programs are not universal and may not be as strong as anticipated. This failure to demonstrate universally significant and meaningful reductions may be a function of several factors, including the quality of the health promotion efforts. A poorly designed program may not reduce the absenteeism and risk factors of employees. Only Blair et al,35 Wood et al,36 and Bertera33 were able to demonstrate health risk reduction and reduced absenteeism in a limited way. Because this body of literature does not share a consensus, it would be wise to conclude that participation in worksite health promotion programs may result in modest reductions in employee absenteeism for some employees.


    Table 9 provides a summary of the associations reviewed in this article. Individual associations range from moderate-to-none. High stress and excessive body weight have the strongest associations with elevated levels of absenteeism. Other health risks and failure to participate in fitness or health promotion programs seem to be only marginally associated with high rates of absenteeism.

    Mod Table 9

    Of the 43 studies reported and summarized here, two used experimental designs, one used a preexperimental design, and the rest used either quasi-experimental or correlational designs. Most of these studies were conducted in the real-world setting, meaning that the researchers had to make the best of difficult research conditions. Most studies used nonrandom control groups or they statistically controlled for confounding variables and used large sample sizes. Without the use of experimental designs, this literature provides little information on causality. Nevertheless, researchers have demonstrated some clear associations, especially in the areas of stress, obesity, fitness and health promotion program participation, and multiple risk factors.

    Another limitation to this work is the validity and reliability of absenteeism measures that were used. Not all measures of absenteeism were the same; some included disability absence, others did not discriminate between personal-illness absences and other absences. In some cases, illness of a family member was part of employee-related absence. Some have implied that self-reported absenteeism may be a relatively weak measure. A recently gathered but unpublished work by Aldana et al (SG Aldana and M Normal, from the Department of Physical Education, Brigham Young University, personal communication, September 1997 revealed that self-reported absenteeism correlated very well with company-reported absenteeism (r = 0.86), which supports the continued use of self-reported absenteeism data. Further complicating absenteeism measures is the commonly held belief that many employees often go to work when ill or stay home when not ill, which would greatly dilute most absenteeism measures. Future absenteeism research will need to refine the outcomes that attempt to assess illness-related absenteeism.

    When considering both modifiable and unmodifiable risk factors, this literature review revealed that approximately 15% to 23% of the variance in absenteeism can be explained. This means that even the most effective health promotion programs can affect only a portion, perhaps 0 to 20%, of all absenteeism. Although 20% seems small, the economic benefit associated with a such a reduction in absenteeism would be substantial, more than enough to pay for the costs associated with health promotion programs.

    Small reductions in absenteeism would save enough to pay for most health promotion programs many times over, and the benefits of health promotion are not confined to employee absenteeism. Employers could also benefit from reduced employee turnover, lower medical care costs, less disability, and improved employee productivity. Thus, an investment in health promotion strategies could provide a company with a variety of benefits in addition to reduced absenteeism.

    If 15% to 23% of absenteeism is associated with health risks, then the rest of the absenteeism variance (77% to 85%) must be associated with other factors, such as unavoidable health issues, entitlement mentality, family issues, morale, corporate policy, salary, benefits, corporate climate, and work environment. According to the CCH Unscheduled Absence Survey,4 companies seem to be focusing absenteeism control efforts on factors other than health. In 1999, companies depended on traditional absenteeism control programs such as paid-time-off programs, buy-back programs, disciplinary action, no-fault systems, bonuses, yearly reviews, and personal recognition to reduce high levels of employee absenteeism. Corporate health promotion or wellness programs are rarely used as a strategy to control absenteeism. In many high-tech industries, health promotion programs are established for one reason: employee recruitment and retention. In these companies, the ability of health promotion efforts to reduce employee health risk is limited and thus may have a very limited impact on absenteeism.


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