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Working while sick in context of regional unemployment: a Europe-wide cross-sectional study
  1. Marvin Reuter,
  2. Nico Dragano,
  3. Morten Wahrendorf
  1. Institute of Medical Sociology, Centre for Health and Society, Medical Faculty, University of Düsseldorf, Dusseldorf, Germany
  1. Correspondence to Marvin Reuter, Institute of Medical Sociology, Centre for Health and Society, Heinrich Heine University Duesseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; marvin.reuter{at}


Background Research suggests that areas with high unemployment have lower rates of sickness absence, but the underlying mechanisms remain unclear. One assumption is that when unemployment is high people are more likely to work while being sick (discipline hypothesis). Against this background, we investigate the association between regional unemployment and sickness presenteeism. Second, we study interactions with factors of occupational disadvantage.

Methods We combined survey data of 20 974 employees collected 2015 in 232 regions from 35 European countries with data on regional unemployment rates obtained from Eurostat. Presenteeism was assessed by the fraction of days worked while ill among all days with illness (presenteeism propensity). To investigate if unemployment was related to presenteeism, we estimated multi-level models (individuals nested in regions) that were adjusted for socio-demographic and occupational covariates to account for compositional differences of the regions.

Results The mean presenteeism propensity was 34.8 (SD 40.4), indicating that workers chose presenteeism in 1 out of 3 days with sickness. We found that a change in unemployment by +10 percentage points was associated with a change in presenteeism by +5 percentage points (95% CI 1.2 to 8.6). This relationship was more pronounced among workers with low salary, low skill-level, and industrial and healthcare workers.

Conclusion Our results support the assumption that high unemployment elevates presenteeism, and that people in disadvantaged occupations are particularly affected. Policies managing presenteeism should consider the labour market context, particularly during the aftermath of the COVID-19 pandemic.

  • Sickness absence
  • unemployment
  • workplace
  • geography
  • health behaviour

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  • Twitter Marvin Reuter @MarvinReuter3.

  • Contributors MR conceptualised the study, conducted formal analysis and wrote the original draft. MW contributed to methodology and edited the original draft together with MR and ND.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The underlying data are available from Eurostat and the UK Data Service ( European Foundation for the Improvement of Living and Working Conditions. European Working Conditions Survey, 2015. [data collection]. 4th Edition. UK Data Service. SN: 8098; 2017. doi:10.5255/UKDA-SN-8098-4.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.