Sickness presence in the Swedish Police in 2007 and in 2010: Associations with demographic factors,job characteristics,and health

Abstract

BACKGROUND: Sickness presence (SP) is a complex phenomenon that has been shown to predict sickness absence, poor work performance, and suboptimal self-rated health. However, more research is needed to increase the understanding of how SP relates to occupational factors, demographic variables, and self-rated health.

OBJECTIVE: The aims of this study were to investigate (1) the prevalence of SP among the Police employees in Sweden in 2007 and in 2010; (2) the association between demographics, seniority, occupational group (police officer vs civil servant), and self-reported health on the one hand and SP on the other hand for both years separately.

METHODS: Survey data from Swedish Police employees from 2007 (n = 17,512) and 2010 (n = 18,415) were analyzed using logistic regression to assess odds ratios (OR) and 95% confidence intervals (CI).

RESULTS: The prevalence of SP was stable between the years, but the proportion who stated that they had not been ill at all decreased from 2007 to 2010 (28.0% vs. 23.6%), while the proportion stating always having stayed at home when ill did not differ; 45.0% in 2007 to 45.8% in 2010. The ORs of SP were higher among those with suboptimal self-rated health compared to those with optimal self-rated health (4.38 (95% CI 4.02– 4.78) and 4.31 (3.96– 4.70) in 2007 and 2010, respectively) and among police officers compared with civilians (1.26 (1.17–1.36) and 1.19 (1.10–1.28)), whereas no clear patterns were found for age, gender, and seniority.

CONCLUSIONS: The prevalences of SP were about the same in 2007 and 2010 and were slightly lower compared to in previous studies. The strong association between SP and suboptimal self-rated health suggests that high levels of SP may be an early marker of future illness and sickness absence. In future studies of SP it is important to account for having been ill, that is, at risk of SP.

Keywords

Gender differences occupation group sick leave police Sweden

1 Introduction

Sickness presence (SP) is a complex phenomenon and so far not much studied although the research is increasing [1, 2]. Two definitions of SP are predominant in the literature [3, 4]; one, mainly used in North-America, focusing on loss of productivity and one in Scandinavia, which defines SP as attending work despite of illness that would have motivated sickness absence. We used the latter definition in this study.

A few studies show that SP predicts sickness absence (SA) and poor general health [5 –7]. Furthermore, SP shows a strong positive correlation with suboptimal self-rated health, sleep disturbances, upper back/neck pain, fatigue, depression, and stomach complaints [8 –12]. A previous study indicated a stronger association between SP and health/ill-health than between SA and health/ill-health [13]. It is well established that self-rated health is a strong predictor of morbidity, functional capacity, and especially an independent predictor of mortality [14 –18] and one hypothesis is that SP either increase the risk of developing suboptimal health or is a risk indicator of future suboptimal health [6].

Those who report SP also tend to have high levels of SA and low income [8, 9]. A Finnish study concluded that for those who had poor health, only one work-related factor, namely possibilities to combine desired and actual weekly working hours, could reduce both SP and SA [10]. According to a Swedish study, psychosocial work factors such as time pressure, deficient and insufficient resources, and difficulties in staff replacement seem to be associated with SP [9]. A study of employees working in elderly care showed an association between perceived job stress and SP [11]. However, to date there are few studies regarding SP in different occupations or organizations [2, 19]. One such study showed higher prevalence of SP among people working within healthcare, education, and welfare [8]. Another important group of public employees are people working in the police force. The police force has fundamental responsibilities in a society e.g., regarding increasing safety and reduce crime [20], and high SP could have negative consequences such as a reduced awareness or productivity. In 2011, the Swedish Police had about 28,600 employees; 28% as civil servants and the rest as police officers. Of all, 40% were women. Previously, one study of SP among those employed as police officers in 2007 was published, finding an SP rate of 47% [21]. To the best of our knowledge, that is the only study on SP among people in the Police force published so far. In this study, as in most previous studies SP has been measured SP at one time point. More knowledge is needed regarding to what extent the prevalence of SP in an organization is stable or not over time. The few previous studies on SP over time have predominantly followed a cohort of individuals [2, 7] rather than studying the level of SP in an organization, that is, also accounting for possible changes in the composition of the work force.

A systematic review of studies on SA among police officers showed that also about SA there are only few studies and the main finding was a slight tendency for higher SA among women police employees [22]. It has also been shown that sleep problems, fatigue, and other health complaints are common among police officers, which could increase the occurrence of SP [12 , 23].

By definition, only people who are ill can be SP. However, most studies on SP do not include a question about whether people have been ill or not during the studied period, that is, if they were at risk of SP. This hampers the possibility to interpret and compare the SP rates between groups, as rates of people with illness varies between groups.

The aims of this study were to investigate (1) the prevalence of SP among the Police employees in Sweden in 2007 and in 2010; (2) the association between demographics, seniority, occupational group (police officer vs civil servant), and self-reported health on the one hand and SP on the other hand for both years separately.

2 Methods

This study is based on self-reported data from two cross-sectional surveys of the employees of the Swedish Police, in 2007 and 2010, respectively. All employees in the Swedish Police the respective years were invited to participate in the web-based survey, administrated by Statistics Sweden.

The Swedish Police initiated the surveys, which included questions about demographics, work environment, health, SA, and SP. The questions were based on a previous web-based survey administrated in 2005 and we were given the opportunity to modify some of the previously included questions. Respondents were guaranteed complete anonymity in order to get a high response rate. Therefore, no information is available for individuals who did not respond, hence, no detailed drop-out analyses could be performed.

In 2010, the Swedish Police had 28,017 employees of which 72% were police officers and the others were civil servants. In 2010, a total of 18,884 police employees responded (response rate = 75%). The equivalent number in 2007 was 17,892 (response rate = 74%) [24]. The individuals who had responded to the questions about SA and SP were included in the present study; a total of 17,512 individuals in 2007 and 18,415 in 2010. Hence, attrition due to missing responses on the items about SP was 380 individuals in 2007 and 469 individuals in 2010; 2.1 and 2.4%, respectively.

2.1 Outcome variable

Sickness presence (SP) was assessed, using answers to the question “How many times during the past 12 months did you go to work even though you think that you should have been off sick, considering your health status?”. The response options were “I have been ill, but stayed home each time”, “Once”, “2 to 4 times”, “5 to 9 times”, “10 times or more”, and “I have not been ill during the past 12 months”. Those who had been SP at least two times were categorized as having been SP. Those who answered that they had stayed at home each time when ill (been SA) were thus at risk of SP but had not been SP. All who had not been ill had either been SA each time or SP at least once.

2.2 Explanatory variables

The following demographic variables were included in the analyses: gender, age group (<35, 35–54, and >54 years), seniority (supervisors vs. subordinate), and type of employment (civilians vs. police officers). The latter categorization was based on the fact that civilians and police officers often have different work tasks and work environment [20].

Self-rated health (SRH) was based on a well-validated question “How do you perceive your general health?” with five response alternatives: very good, good, neither good nor poor, fairly poor, and very poor [25, 26]. In order to avoid problems with too small cell counts we dichotomized the SRH variable into optimal (very good and good) vs. suboptimal health (neither good nor poor, fairly poor, and very poor). In Sweden, all employees who have work incapacity due to disease or injury can be sickness absent. After a qualifying day, the employer provides sick pay up through day 14 of a sick-leave spell. After that, sickness benefit is paid by the National Social Insurance Agency. The first 7 days can be self-certified, after that a medical certificate is required. Sickness benefits amount up to 80% of lost income, up to a certain level and can be paid for 365 days.

2.3 Statistical analyses

Descriptive statistics were used and SP was cross-tabulated with all variables included in the study, separately for the two surveys. We used chi-square tests, first contrasting “Not ill at all” with all other categories combined, in order to evaluate if the proportion of employees who had not been ill at all in the last 12 months differed between years 2007 and 2010. Secondly, after excluding those who had not been ill at all, that is, those not at risk of SP, to evaluate whether the proportion who stayed home every time (i.e., had no SP) among those employees who had been ill differed between the years.

Logistic regression analyses were performed for having been SP at least twice versus less than twice, in line with previous studies [9, 21], generating odds ratios (OR) with 95% confidence intervals (CI). In the adjusted models, sex, age, seniority, type of employment, and SRH were included simultaneously. All data analyses were performed using IBM^® SPSS^® Statistics, version 20.

The study was approved by the Regional Ethical Review Board, Stockholm, Sweden.

3 Results

The total prevalence of having been SP≥2 times in the last 12 months did not differ between the years; the rates were 45.0% (n = 7886) in 2007 and 45.8% (n = 8428) in 2010 (Table 1). However, there was a significant increase between the two time points in rates of participants reporting having been SA every time when ill in the whole study population (11.8% in 2010 compared to 8.5% in 2007), as well as in both genders, all age groups, in both supervisors and subordinates, and in both police officers and civilian employees. In general, the number of individuals who had never been ill in the last 12 months was significantly lower in 2010 (23.6%; n = 4340) compared to 2007 (28.0%; n = 4912). Other characteristics were similar in year 2007 and in year 2010.

Table 2 (left side) shows the results of the logistic regression with crude and adjusted ORs for reporting SP at least twice compared to those with no or one SP, including those who stated they had not been ill at all that the last year, regarding demographic variables and SRH in 2007 and 2010. Men had slightly higher ORs than women of reporting high SP in 2010. Older employees (>54 years of age) had significantly lower risk of high SP than younger (<35 years of age) in the adjusted models for both years, in 2010 also middle-aged employees had lower ORs than the younger employees. Subordinate employees had slightly higher risk of high SP than supervisors in 2010 in the adjusted model. Police officers had higher ORs of high SP in both the crude and the adjusted model, with ORs ranging from 1.26 in 2007 to 1.19 in 2010 in the adjusted model. Respondents reporting suboptimal SRH had significantly higher odds of reporting high SP in both models compared to those with optimal SHR, with adjusted ORs ranging from 4.31 to 4.38. Overall, the associations between the studied variables were similar in 2007 and 2010, with the exception that ORs for SP tended to be lower in 2010 compared to 2007 among people aged 33–54 years.

In Table 2 (right side) only employees who were at risk of SP were included, i.e., only those who reported they had been ill sometime the last 12 months. The levels of the ORs varied substantially. However, essentially the same pattern is observed here as on the left side of Table 2. That is, employees with suboptimal SRH had much higher odds of SP than those with optimal SRH, with an adjusted OR of 3.28 in 2007 and 3.32 in 2010. Police officers had slightly higher odds of SP than civilians with an adjusted OR of 1.33 in 2007 and 1.30 in 2010. Additionally, men had slightly higher odds than women of reporting SP (OR = 1.22) both years.

4 Discussion

In this study of Police employees in Sweden, the prevalence of sickness presence (SP) was similar in both studied years – 2007 and 2010. However, the proportion who in 2010 answered that they had not been ill at all during the last year was lower than in 2007, and the proportion who had taken sickness absence (SA) each time they were ill was higher in 2010. The respondents above 54 years of age reported almost twice as high rates of not having been ill at all in the last 12 months, compared to those in the youngest age group. Suboptimal self-rated health (SRH) was highly and significantly associated with reporting high SP in both years; those with suboptimal SRH had more than three times higher odds of SP compared to those with optimal SRH – and even higher when including those who had not been ill during the last 12 months. Additionally, male gender, being a subordinate, as well as being a Police officer rather than a civilian employee, were factors associated with higher odds of reporting high SP. On the other hand, individuals of older age had lower ORs of being SP compared to younger individuals. The patterns of associations were essentially the same in both 2007 and 2010.

The 45–46% prevalence of SP at least twice per year is substantially lower than the 64% recently reported in a study of a representative sample of the working population in Sweden [6]. Two previous studies showed the highest prevalence of SP among those who work in the welfare, healthcare, or educational sectors [8, 27]. Thus, employees in occupations related to human services and contacts are more frequently going to work despite feeling they should have stayed home due to being ill [28, 29]. A number of explanations for this has been presented, for example, in a random sample of Norwegian physicians (n = 1,476), 80% reported working despite an illness at least once per year, often due to work ethics and workplace culture (e.g., did not want to increase colleagues’ work load) [27, 30]. Other explanations of SP are low job control and relatively low salary [8] and poor management of own health [29]. Aronsson et al. concluded that feelings of responsibility towards patients/clients were the main reason for the high prevalence of SP among health care, education, and welfare workers [8]. Many of these factors are likely to be present also among police employees and especially among police officers. Our results showed that among those who had been ill police officers had higher odds of SP than civilian employees. The decision to go to work might be explained by, for instance, feelings of responsibility towards society and colleagues and desire to solve crimes as the police officers often have place-based work in areas with high crime concentration or a lack of resources in terms of not being able to replace the ill person with someone else may exist. On the other hand, also a positive health selection into police work and regular physical exercise might account for the, in comparison to other studies, lower levels of SP. More studies about this are, however, warranted. A Danish study of 12,935 employees indicated that those with a conservative attitude to SA had more frequent SP [31]. However, the same study found that work-related factors were slightly more important than personal attitudes for decisions to be SP [31].

Even though we found a somewhat lower prevalence of SP in the Swedish Police compared to other studies of the general population, 65% of the Police employees in our study reported going to work while being ill at least once in the last 12 months. Since SP has been shown to be a predictor of SA [8, 32], high SP might lead to more SA and ill health, thus limiting the resources available to serve the aims of this institution of immense importance in the modern democratic societies.

Our finding that SRH was associated with SP among the Police employees is in line with results of studies from e.g., Sweden and Finland [10, 33]. A longitudinal Swedish study showed that SP can be a risk factor for future suboptimal SRH and SA [6] and another Swedish study found a higher positive correlation between SP and SRH than between SA and SRH, particularly in individuals with poor economic circumstances [33]. Moreover, two Swedish studies found that those with SP had higher odds for both future SA and poor SRH [2, 7]. Gender differences in SP have been observed in a number of studies [6, 8]. A majority of these studies explored SP without accounting for that some people not are at risk of SP, as they were not ill during the studied period. In such investigations, women reported both somatic complaints and SP to a higher extent than men as, for example, in a study of Belgian middle-aged workers [34]. Contrary to our results, female workers in Belgium had higher rates of SP than the men. However, a higher rate of women than men have various types of morbidity [35, 36] which could be the explanation for these associations. Therefore, it is important to study SP among those that actually are ill, to get a better estimate of SP in different groups. The slightly higher odds of SP for men might be explained by gender-related roles, non-acceptance of illness or a sick role, the gender segregation of the police work, or stronger health selection among female police employees [35].

The strengths of this study are that all employees of the Swedish police, not just a sample, in two different years were invited, the very large study groups, the high response rates, and that both civilians and officers, and both supervisors and subordinate employees were included. It is also a strength that the same methods for data collection and the same questionnaire items were used in both years. Another strength is that the SP items differentiates between not having been ill at all and having stayed at home every time when ill. However, the study also has some limitations, primarily the cross-sectional nature of the data which means that we cannot draw causal conclusions, and that there was no way to analyze the drop out, as the questionnaire was completely anonymous in order to get a higher response rate. All data are self-reported, which could lead to spurious associations due to common method bias. Recall bias is another issue when asking individuals to recall what happened the last 12 months. Regarding SA, several studies have compared self-reported SA with register data on SA and found high validity of self-reported data [37, 38]. Due to the subjective nature of SP, such validity studies are difficult; however, there is no reason to believe that there would be a higher problem of recall bias regarding SP than for SA.

4.1 Recommendations for research and practice

We suggest that future studies of SP also include a question about whether the participant has been ill at some time during the studied period, that is, has been at risk for SP. From our study it was obvious that the rates of people not having been ill varied much between different groups, and failure to take this into account would lead to wrong conclusions. Furthermore, questions about having stayed at home every time when ill should also be included, to be able to gain more knowledge about the prerequisites for and consequences of staying home or being SP when ill, in different work situations. From this study it is obvious that more occupation-specific research is needed in order to better understand aspects of SP and we suggest that more in-depth studies of this for Police employees in Sweden and other counties are conducted. Although the occurrence of SP was comparatively low in the Police force, further studies are warranted since the strong association with SRH indicates that high SP could have substantial health consequences; however, this must be investigated in prospective studies to rule out reverse causality, which is also likely. It could also be argued that any SP in the Police force is problematic given that mistakes made by police officers could have potentially fatal consequences for the police officer him- or herself, for colleagues, as well as for the public.

5 Conclusions

In this study, the prevalence of SP in the Swedish Police did not differ between 2007 and 2010 and levels were lower than those reported for the Swedish labor market as a whole. Furthermore, men had higher risk for going to work while being ill than women and also police officers had higher risk for the same behavior (going to work despite feelings of illness) than civilians. The strong association between SP and suboptimal self-rated health suggests that high levels of SP may be an early marker of future illness and sickness absence. It is important to include questions about not having been ill at all in future studies of SP.

Conflict of interest

None to declare.

Footnotes

Acknowledgments

This study was supported by grants from Swedish Research Council for Health, Working Life and Welfare.

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