500590 2013

SJP0010.1177/1403494813500590M. Knapstad et al.Short Title

Scandinavian Journal of Public Health, 2014; 42: 96–103

Original Article

Shame among long-term sickness absentees: Correlates and impact on subsequent sickness absence

Marit Knapstad1,2, Simon Øverland1,2, Max Henderson3, Kristina Holmgren4 & Gunnel Hensing4 1Department

of Health Promotion and Development, Faculty of Psychology, University of Bergen, Bergen, Norway, of Public Mental Health, Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway, 3Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, UK, and 4Department of Public Health and Community Medicine, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden 2Department

Abstract Aims: The contribution of general psychological aspects, such as emotions, has received little focus in research on sickness absence. We wanted to study the relationship between shame and sickness absence, which factors that explained differences in levels of shame, and if shame predicted subsequent sickness absence. Methods: We employed a Swedish population-based cohort of current sickness absentees (19–64 years old), responding to a mailed questionnaire in 2008. Data was linked to national registries on sickness absence.Results: The young, those born outside the Nordic countries, those on lower incomes and those with higher level of education reported being more ashamed of their sickness absence. Those with more sickness absence in the past were also more likely to report higher levels of shame. Level of shame was not associated with gender or occupational class. Compared to those absent for a somatic cause, mental or co-morbid illness was associated with higher levels of shame. Those reporting high level of shame were more likely to have prolonged sickness absence the following year. Symptoms of depression at baseline only partly explained these associations. Conclusions: Our results suggest that shame might prolong sickness absence. Increased understanding of the impact of social and emotional aspects around sickness absence could be an important source for improved quality of rehabilitation. Key Words: Emotions, shame, sickness absence, return to work

Introduction Many studies have focussed on how different medical conditions cause and prolong sickness absence. Far fewer have examined the contribution of emotional factors towards this complex behavioural outcome [1,2]. Shame is a fundamental social emotion, and involves negative self-evaluation in relation to important standards for behaviour [for theoretical reviews, see 3,4]. Emotions influence behaviour [5], and feeling ashamed of a current sickness absence could drive return to work as a behavioural response, to conform to social norms [3]. Or, shame may induce psychological disempowerment and disturb rehabilitation and return to work [6]. Previous studies have

linked shame to withdrawal behaviour [3,4], psychopathology [4,7], and destructive coping behaviour [4] – all factors potentially posing obstacles for return to work. Qualitative studies have highlighted the relevance of negative emotions among sickness absentees [8– 11]. Absentees perceive negative reactions from family, colleagues, and rehabilitation personnel as well as changes in interactions in close relationships as shame inducing [10–12]. A recent study among British physicians found fear of negative responses and internalization of others’ negative views as central obstacles for return to work [12]. Absentees have

Correspondence: Marit Knapstad, Department of Health Promotion and Development, Faculty of Psychology, University of Bergen, Christiesgate 13, 5020 Bergen, Norway. E-mail: [email protected] (Accepted 12 July 2013) © 2013 the Nordic Societies of Public Health DOI: 10.1177/1403494813500590

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Shame among long-term sickness absentees   97 described shame for not living up to expectations at work as precursors of long-term sickness absence [9]. Few surveys have examined shame and kindred emotions in relation to sickness absence, none with this as the primary aim. One study found that 30%–50 % of sickness absentees experienced guilt; younger absentees were more affected [13]. Another found an association between feeling bad about staying home while ill and having a high level of sickness absence [14]. In a population with chronic fatigue syndrome, those more embarrassed about symptoms and who exhibited more avoidance behaviour, were more likely to be on long-term sickness absence [15]. Depression is in itself a major cause of sickness absence, and can also prolong absences [1,16]. Shame and symptoms of depression are linked [7], and depression can therefore be involved in the relationship between shame and sickness absence. Similarly, age and history of sickness absence predicts sickness absence [1], and negative emotions towards absence [13,14]. We know little about the experience of shame in employees off work sick, and no study has examined whether feelings of shame among sickness-absentees prolongs sickness absence. Employing a populationbased survey linked to national registries on sickness absence, we aimed to examine: 1) the extent to which current sickness-absentees were ashamed of being sickness-absent, and factors associated with differences in levels of shame; 2) if the experience of shame predicted sickness absence the following year. We also wanted to address the contribution from concurrent symptoms of depression on these associations. Methods Design and study population We employed a cross-sectional design to study differences in level of shame among sickness-absentees, and a longitudinal design to examine the association between level of shame and subsequent prolonged sickness absence. Data from the Swedish “Health Assets Project (HAP)” [described elsewhere; 17] were obtained and linked to the “Longitudinal integrated database for sickness insurance and labour market research, Statistics Sweden (LISA)” records on sickness absence. From the source population in HAP (19–64-yearolds from the Västra Götaland region), all employed individuals sick-listed for at least 15 consecutive days, and registered by the “Social Insurance Agency” (SIA) during the period from 18 February to 15 April 2008, were invited to participate (n = 6140). Data were collected through registers and a postal

questionnaire (15 April–30 June 2008). The questionnaire included items on socio-demographic factors, physical and mental health, sickness absence, work and family conditions, life events, leisure and lifestyle. The response rate was 53.9%. Those off their sickness absence at time of participation were not eligible to respond regarding shame and were excluded (n = 1730). A further 13 cases were excluded due to ambiguous registration in the LISA register. The final sample was n = 1567. Exposure: “Level of shame concerning being sickness absent” Inspired by qualitative studies highlighting shame as important among people on sickness absence [9,11], the following question was included in the questionnaire: “To what extent do you feel shame concerning being sickness absent?” Answers were given across five ordinal categories (very low, low, moderate, high, and very high level of shame). To ensure sufficient observations in each group whilst maintaining the option of dose-response examinations, “very low” was kept as reference group in the analyses, “low” and “moderate” was combined as “moderate”, while “high” and “very high” comprised “high”. Prospective outcome: Sickness absence the subsequent year Information on subsequent sickness-absence was obtained from the LISA register. In the Swedish insurance system, the employer covers the first 14 days of a sickness absence spell (except one qualifying day). Thereafter benefits are granted from SIA. In the LISA register, individuals’ total number of sickness absence days and spells per year covered by SIA are registered. Due to a highly skewed distribution, a categorical variable was constructed based on number of registered absence days during 2009: “No registered sickness absence” (> 14 days) was kept as reference, while those with any registered sickness absence days were split by the median. Covariates Demographic variables. The following demographic factors were extracted from Statistics Sweden: Gender (male, female), age (19–49, 50–64 years), country of birth (Nordic, others), gross income (SEK ≤ 149,000, 150,000–299,000, ≥ 300,000) and occupational class (manual, low to intermediate non-manual, higher non-manual and entrepreneurs). Level of education (elementary, upper secondary, higher) was self-reported.

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98    M. Knapstad et al. Sickness absence cause. The physician assigned cause of sickness absence was self-reported and answered across 12 categories, with an open field for “other illness” subsequently sorted into the listed categories. Multiple answers were allowed. In the current study, conditions were merged into the following three categories: “mental”, “somatic” and “mixed”. The category “mental” included depression, stress, anxiety, schizophrenia or other psychotic disorders, and other mental disorder, while “somatic” included infection, cardiovascular disorder, complaints due to pregnancy, injury/accident, back pain and pain in neck or shoulders. The “mixed” category was operationalized as reporting at least one mental and one somatic cause. History of sickness absence.  We used the mean number of sickness-absence days per year over the previous 7 years (LISA data, 2001–2007) and split the sample into: no registered sickness absence days, and the lower, middle and upper tertiles. Because sickness absence often increases with age, and participants younger than 23 years had 1 or more years ineligible for LISA inclusion, the procedure was done separately for each 10-year stratum. Symptoms of depression. The World Health Organization (Ten) Wellbeing Index was used as an indicator for symptoms of depression [18]. The index has been validated as a screening instrument for depression in a Swedish general population sample [19], and a cut-off at ≤ 12 is previously employed [17]. Analyses Multiple imputation based on all variables reported in this study was done using the multivariate normal model procedure in Stata 12, with 100 cycles of imputation. Imputed values were subsequently rounded to the original scale to enable multinomial regression analyses [20]. Sickness absence cause was imputed following Allison’s [20] recommended procedure for nominal variables with more than two categories. Table I displays sample characteristics from the original dataset, before imputation. Bivariate associations between sample characteristics and level of shame were initially examined using chi-squared test. The associations between level of shame and both cause and history of sickness absence were further analysed in multivariate, multinomial regression models. Here, the multinomial odds ratios for outcome levels moderate and high shame were compared to low level of shame, respectively. We first tested for crude associations before successively

entering candidate confounders and symptoms of depression as a potential mediator. We only included variables associated with both exposure and outcome (p < 0.05). Results are presented as multinomial odds ratios (ORs) with 95% confidence intervals. In addition, test for trends were performed to examine the overall effects of the exposure variables across the ordered levels of shame. For the prospective analyses, those on disability benefit in 2009 (n = 174) or not working as an employee at baseline (n = 72) were excluded. These reported somewhat lower level of shame than those included in the prospective analyses (χ2 = 5.9, df = 2, p = 0.05). Multinomial regression models (outcome levels “below median” and “above median” versus “no sickness absence”, respectively) and a test for trend were used to predict subsequent sickness absence by level of shame. Stata 12 was used for all analyses. Ethics HAP was approved by the Ethics Committee, University of Gothenburg, Sweden: registration number 039-08. Results Sample characteristics Of the total sample (n = 1567), about two thirds were female and almost half were 50 years of age or older. Median (IQR) self-reported length of the current episode of sickness absence was 47 days (25). High level of shame concerning being sickness absent was reported by 20% (95% CI 18–22), moderate level by 34% (95% CI 31–36) and low level of shame by 46% (95% CI 44–49). Of the sub-sample followed up in registries (n = 1321), 37.8% had sickness absence beyond 14 days during 2009, median (IQR) = 29 (45) days for those with sickness absence below and 242 (213) days for those above the median. Cross-sectional associations between level of shame and characteristics of sickness absentees Table I shows the bivariate distributions of reported levels of shame in the sample. The young, those born outside the Nordic countries, those on lower incomes, and those with higher level of education reported being more ashamed of their sickness absence. Those with more sickness absence in the past and those with symptoms of depression were also more likely to report higher levels of shame. Level of shame was not associated with gender or occupational class (see Table I).

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Shame among long-term sickness absentees   99 Table I.  Sample characteristics and differences over level of shame concerning being sickness-absent.a Variables

N Gender  Males   Females Age (years)  19–49  50–64 Country of birth  Nordic  Others Education   Elementary school or less  Upper secondary school   Higher education   Missing Gross income   0–149,000 SEK   150,000–299,000 SEK   ≥300,000 SEK Working class  Unskilled – skilled manual   Low – intermediate non-manual   Higher non-manual, entrepreneurial   Missing History of sickness absence  No   1st tertile (low)   2nd tertile   3rd tertile (high)   Missing Cause of sickness absence  Somatic   Co-morbid  Mental  Missing Symptoms of depression  No  Yes   Missing

Full sample

Low level of shame

Moderate level of shame

High level of shame

n

%

n

%

n

%

n

%

1567

100

725

46.3

527

33.6

315

20.1

530 1037

33.8 66.2

257 468

35.4 64.6

180 347

34.2 65.8

93 222

29.5 70.5

802 765

51.2 48.8

293 432

40.4 59.6

292 235

55.4 44.6

217 98

68.9 31.1

1393 174

88.9 11.1

684 41

94.3 5.7

441 86

83.7 16.3

268 47

85.1 14.9

383 660 504 20

24.4 42.1 32.2 1.3

214 266 235 10

29.5 36.7 32.4 1.4

116 236 166 9

22.0 44.8 31.5 1.7

53 158 103 1

16.8 50.2 32.7 0.3

138 1067 362

8.8 68.1 23.1

46 494 185

6.3 68.1 25.5

51 357 119

9.7 67.7 22.6

41 216 58

13.0 68.6 18.4

832 514 203

53.1 32.8 13.0

382 235 101

52.7 32.4 13.9

285 170 66

54.1 32.3 12.5

165 109 36

52.4 34.6 11.4

18

1.1

7

1.0

6

1.1

5

1.6

463 367 363 373 1

29.5 23.4 23.2 23.8 0.1

235 179 160 151 0

32.4 24.7 22.1 20.8 0.0

156 118 129 123 1

29.6 22.4 24.5 23.3 0.2

72 70 74 99 0

22.9 22.2 23.5 31.4 0.0

1098 138 300 31

70.1 8.8 19.1 2.0

611 32 68 14

84.3 4.4 9.4 1.9

318 60 140 9

60.3 11.4 26.6 1.7

169 46 92 8

53.7 14.6 29.2 2.5

868 545 154

55.4 34.8 9.8

487 174 64

67.2 24.0 8.8

276 195 56

52.4 37.0 10.6

105 176 34

33.3 55.9 10.8

OR (95% CI) a

  χ2 = 3.5, df = 2, p = 0.175     χ2 = 76.9, df = 2, p < .001     χ2 = 41.0, df = 2, p < .001     χ2 = 27.2, df = 4, p < .001         χ2 = 16.7, df = 4, p = 0.002       χ2 = 1.7, df = 4, p = 0.789         χ2 = 18.9, df = 6, p = 0.004           χ2 = 140.0, df = 4, p < .001         χ2 = 112.1, df = 2, p < .001      

OR = Odds Ratio; 95% CI = Confidence Interval. aData from original dataset, before multiple imputation. List-wise deletion employed in the chi-squared tests.

In the multivariate analyses, having a mental illness as sickness absence cause gave 3.9 (95% CI 2.8–5.4) and 4.8 (95% CI 3.4–6.8) times higher odds for reporting moderate and high levels of shame, respectively, compared to those sickness absent with a somatic illness. Adjusting for confounders barely altered these increased odds (see Table II). The association was partly mediated by symptoms of depression, but the odds remained about threefold for both moderate and high level of shame after adjustments (OR = 3.5, 95% CI 2.4–4.9 and OR = 2.9, 95% CI

1.9–4.3, respectively). There were no clear differences between those with mental illness only and those with mixed mental and somatic illness when compared to those only having somatic illness as sickness absence cause (see Table II). The odds for higher levels of shame increased incrementally with the extent of sickness absence history. Only the second and third tertile groups reached conventional significance compared to those without a history of registered sickness absence, and only when comparing high versus low level of shame (see Table III).

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100    M. Knapstad et al. Table II. Level of shame by of sickness absence cause in a multinomial logistic regression analysis, crude and adjusted models.a Cause of Low vs. Moderate level of shame sickness absence  Crude model Model 1b

Somatic Co-morbid Mental

Low vs. High level of shame Model

2c

Crude model

Model 1b

Model 2c

OR

(95% CI)

OR

(95% CI)

OR

(95% CI)

OR

(95% CI)

OR

(95% CI)

OR

(95% CI)

1.0 3.6 3.9

(2.3–5.6) (2.8–5.4)

1.0 3.4 3.8

(2.2–5.4) (2.8–5.3)

1.0 3.2 3.5

(2.0–5.1) (2.4–4.9)

1.0 5.1 4.8

(3.1–8.2) (3.4–6.8)

1.0 4.5 4.4

(2.8–7.4) (3.1–6.4)

1.0 3.3 2.9

  (2.0–5.5) (1.9–4.3)

OR = Multinomial odds ratio; CI = Confidence interval. aLow level of shame contrasted to moderate and high level of shame, respectively. There was an overall effect of cause of sickness absence on level of shame (chi2 = 111.4, df = 4, p < .001, adjusted for confounders). bModel 1: Adjusted for age, education and history of sickness absence. cModel 2: Adjusted for Model 1 + symptoms of depression (WHO wellbeing index ≤ 12).

Table III. Level of shame by history of sickness absence in a multinomial logistic regression analysis, crude and adjusted models.a History of sickness absence Low vs. Moderate level of shame  

No 1st tertile (low) 2nd tertile 3rd tertile (high)

1b

Low vs. High level of shame

Crude model

Model

Model

OR

(95% CI)

OR

(95% CI)

OR

1.0 1.0 1.2 1.2

(0.7–1.4) (0.9–1.7) (0.9–1.7)

1.0 1.0 1.2 1.3

(0.8–1.4) (0.9–1.7) (0.9–1.7)

1.0 1.1 1.2 1.2

2c

Crude model

Model 1b

Model 2c

(95% CI)

OR

(95% CI)

OR

(95% CI)

OR

(95% CI)

(0.8–1.4) (0.9–1.7) (0.8–1.6)

1.0 1.3 1.5 2.1

(0.9–1.9) (1.0–2.2) (1.5–3.1)

1.0 1.4 1.6 2.3

(1.0–2.1) (1.1–2.4) (1.5–3.3)

1.0 1.4 1.5 1.9

  (1.0–2.2) (1.0–2.3) (1.3–2.8)

OR = Multinomial odds ratio; CI = Confidence interval. level of shame contrasted to moderate and high level of shame, respectively. There was an overall effect of history of sickness absence on level of shame (chi2 = 17.9, df = 6, p = 0.007, adjusted for confounders). bModel 1: Adjusted for education and gross income. cModel 2: Adjusted for Model 1 + symptoms of depression (WHO wellbeing index ≤ 12). aLow

However, there was an overall effect of sickness absence history (χ2 = 17.9, df = 6, p = 0.007, adjusted). These associations were not accounted for by concurrent symptoms of depression (see Table III). The effect of level of shame on sickness absence the following year There was a relationship between high level of shame and having sickness absence the following year, as well as an overall effect of shame (χ2 = 16.9, df = 4, p = 0.002, adjusted) (Table IV). The relationship was stronger for longer periods of sickness absence (OR = 1.5, 95% CI 1.0–2.2 and OR = 2.1, 95% CI 1.5– 3.1 for having sickness absence days below and above the median, respectively). Discussion Main findings First, we found that moderate and high levels of shame concerning being sickness-absent were reported by one third and one fifth of our sample of

sickness absentees. Second, having a mental illness as sickness absence cause was associated with near four- and five-fold increased odds of reporting moderate and high levels of shame, compared to those having a somatic illness as cause. The young, those born outside the Nordic countries, those on lower incomes, higher level of education and a more sickness absence in the past reported being more ashamed of their sickness absence. Third, those reporting high level of shame were more likely to have prolonged sickness absence the following year. Symptoms of depression at baseline partly explained these associations. Strengths and limitations The strengths of the study include its specific design, comprising new cases of current sickness absentees from the general population. The longitudinal design allowed for studying the temporal sequence between exposure and outcome. In addition, the use of register data to measure sickness absence reduces common methodological problems, such as attrition and recall bias.

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Shame among long-term sickness absentees   101 Table IV.  Effect of shame on number of sickness-absence days in 2009, crude and adjusted models, in a multinomial logistic regression analysis.a Level of shame

Sickness absence days below the mediand

Sickness absence days above the median d



Crude model

Crude model

Low level of shame Moderate level of shame High level of shame

Model 1b

Model 2c

OR (95% CI) OR

(95% CI) OR (95% CI)

1.0 1.1 (0.8–1.5) 1.6 (1.1–2.3)

(0.8–1.5) (1.0–2.2)

1.0 1.1 1.5

1.0 1.0 1.4

(0.7–1.5) (0.9–2.0)

Model 1b

Model 2c

OR (95% CI) OR (95% CI) OR (95% CI) 1.0 1.3 (0.9–1.8) 2.0 (1.4–3.0)

1.0 1.3 (1.0–1.9) 2.1 (1.5–3.2)

1.0   1.2 (0.9–1.7) 1.7 (1.2–2.6)

OR = Multinomial odds ratio; CI = Confidence interval. level “no registered sickness absence” versus “below the median” and “above the median”, respectively. There was an overall effect of level of shame on prospective sickness absence (chi2 = 16.9, df = 4, p = 0.002, adjusted for confounders). bModel 1: Adjusted for age and history of sickness absence. cModel 2: Adjusted for Model 1 + symptoms of depression (WHO wellbeing index ≤ 12). dOf those with any days of registered sickness absence in 2009. aOutcome

Several limitations need consideration. First, our measure of shame was crude, and included no option on absence of shame concerning being sicknessabsent which could induce response bias. Such bias would most likely be non-differential, causing an underestimation of the true associations. Further, the use of a non-validated, single-item measure of shame, could threaten the reliability and validity of the findings. Limited space in a comprehensive questionnaire unfortunately constrained the use of a full-scale instrument. We would however argue that the novelty and relevance of the research question, as a first step to bring attention to an under-studied topic, weigh up for limitations regarding the shame measure. Further, shame is commonly measured via selfreport on scenario-based methods [4,21], and the shame question was directed towards the very situation of interest, namely the experience of being sickness-absent. Also, our main objective was to examine associations with levels of shame, and the varied responses on the shame-item helped achieve this. The response rate on this item was high: Of those eligible to answer, only 1.6% failed to do so, which implies recognition of the question in the target group [22]. Second, the participation rate of the baseline questionnaire was just above 50%, with lower representation among younger age groups and particularly young men [17]. This bias might have led to an overestimation of the association between age and shame and shame in our study. However, while nonparticipation bias influences prevalence estimates, associations are less severely affected [23]. To prevent further problem with missing data, we performed missing imputation on missing item-responses. Third, shame is a fundamentally social emotion, and valuation, eliciting situations and behavioural consequences vary across societies. Little is known about how culture influences feelings of shame

regarding sickness absence [for a general discussion, see 24,25]. Nonetheless, the importance of work, absence legitimacy, composition of the work force and the sickness insurance systems vary, and should be kept in mind when generalizing these findings. Fourth, people that did not enter a new period of sickness absence exceeding 14 consecutive days during the sampling period were not eligible. Our results should therefore not be generalized to very shortterm sickness absence. Also, the requirement of a new onset of sickness absence in the sampling period would exclude some with very long ongoing sickness absences, with corresponding generalization issues. Still, there was considerable variation in both length and history of sickness absence, reducing the impact of this limitation. Fifth, sickness absence cause was self-reported, and information bias cannot be ruled out. The option of giving multiple answers to this item could on the other hand increase validity, as medical cause of functional impairment often is complex. The symptoms of depression measure was developed as a wellbeing scale [18], but is validated as a measure of depression [19]. A sensitivity analysis using a single item on depression (“I have felt sad and down the past week”) gave similar results (data not shown). Interpretation of results and implication for further research and practice As the first study to quantify the relationship between shame and sickness absence, direct comparison with previous results is difficult. Our finding of higher levels of shame among younger absentees, and those with more sickness absence in the past, harmonizes with studies on related negative emotions and sickness absence [13,14]. The prospective analysis suggested that shame prolonged sickness absence, which is in line with the theoretical model of Svensson et al. [6],

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102    M. Knapstad et al. suggesting that shame hinders return to work through a process of psychological disempowerment. This result also fits well with studies on behavioural tendencies related to shame in general [4], and the association between symptom embarrassment and long-term sickness absence in chronic fatigue syndrome [15]. A systematic review identified no studies on perpetuating factors for long-term sickness absence, and called for prognostic research concerning non-medical factors [1]. Return to work, especially after longterm sickness absence, requires contact with doctors, social insurance officers, therapists, employers, colleagues, family and so forth. High level of shame, with behavioural responses such as avoidance, isolation, and low self-esteem, may be a serious obstacle in developing productive strategies and relationships that could help with returning to work [12]. We found large differences in level of shame between the different diagnostic groups, suggesting some sickness absence is experienced as more legitimate than other. Mental illness might be regarded as a less legitimate excuse for the “sick role” than many somatic illnesses, such as infections and fractures [10,26]. The observed age difference in shame could be understood via the same framework. Breaching social expectations and desired social identities can induce stereotyped beliefs, prejudiced attitudes and discriminatory behaviour, as outlined in the literature on stigma in mental illness, with observed consequences in terms of access to treatment, help-seeking and work participation [27]. Internalization of and emotional reactions to stigma are argued to be important in understanding its consequences and might contribute explaining the prolonged sickness absence among those with a high level of shame [28,29]. The concepts of stigma and sick roles are related, but both seem relevant to understand the social import of shame in the current study. Our data supported the robust association between shame and symptoms of depression [7]. Nonetheless, symptoms of depression at baseline only partly explained our results. Despite our crude measures of shame and depression, this study might indicate a relevance of addressing negative emotions in their own right in rehabilitation contexts. Common and familiar emotions, such as shame, may be easier to discuss than medical conditions like depression. On the other hand, people might be hesitant to disclose feelings of shame [30], and the issue needs to be handled sensitively. Increased understanding of the impact of social and emotional aspects around sickness absence can ultimately promote quality of rehabilitation, for instance through facilitating positive and constructive encounters with rehabilitation personnel [6,8,11].

Conclusion This is the first study to examine how feelings of shame among current sickness absentees affect future absence. Our results indicate that high levels of shame can maintain sickness absence. Thoughtful consideration and theoretical contextualization are needed when studying the psychological aspects of sickness absence. Conflict of interest None declared. Funding The data collection was financed by the Swedish Social Insurance Agency. References [1] Dekkers-Sanchez PM, Hoving JL, Sluiter JK, et al. Factors associated with long-term sick leave in sick-listed employees: a systematic review. Occup Environ Med 2008;65:153–7. [2] Allebeck P and Mastekaasa A.Chapter 5. Risk factors for sick leave – general studies. Scand J Public Healt 2004;32(63 Suppl):49–108. [3] Scheff TJ. Shame and conformity: The deference-emotion system. Am Sociol Rev 1988;53:395–406. [4] Tangney JP, Stuewig J and Mashek DJ. Moral emotions and moral behavior. Ann Rev Psychol 2007;58:345–72. [5] Loewenstein G. Out of control: visceral influences on behavior. Organ Behav Hum Dec 1996;65:272–92. [6] Svensson T, Mussener U and Alexanderson K. Pride, empowerment, and return to work: on the significance of promoting positive social emotions among sickness absentees. Work 2006;27:57–65. [7] Kim S, Thibodeau R and Jorgensen RS. Shame, guilt, and depressive symptoms: a meta-analytic review. Psychol Bull 2011;137:68–96. [8] Ahrberg Y, Landstad BJ, Bergroth A, et al. Desire, longing and vanity: emotions behind successful return to work for women on long-term sick leave. Work 2010;37:167–77. [9] Eriksson UB, Starrin B and Janson S. Long-term sickness absence due to burnout: absentees’ experiences. Qual Health Res 2008;18:620–32. [10] Svensson T, Mussener U and Alexanderson K. Sickness absence, social relations, and self-esteem: a qualitative study of the importance of relationships with family, workmates, and friends among persons initially long-term sickness absent due to back diagnoses. Work 2010;37:187–97. [11] Svensson T, Karlsson A, Alexanderson K, et al. Shameinducing encounters. Negative emotional aspects of sickness-absentees’ interactions with rehabilitation professionals. J Occup Rehabil 2003;13:183–95. [12] Henderson M, Brooks SK, del Busso L, et al. Shame! Selfstigmatisation as an obstacle to sick doctors returning to work: a qualitative study. BMJ Open 2012;2:e001776. [13] Floderus B, Goransson S, Alexanderson K, et al. Self-estimated life situation in patients on long-term sick leave. J Rehabil Med 2005;37:291–9. [14] Tveito TH, Halvorsen A, Lauvålien JV, et al. Room for everyone in working life? 10% of the employees – 82% of the sickness leave. Norsk Epidemiologi 2002;12:63–8. [15] Knudsen AK, Henderson M, Harvey SB, et al. Long-term sickness absence among patients with chronic fatigue syndrome. British J Psychiat 2011;199:430–1.

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Shame among long-term sickness absentees: correlates and impact on subsequent sickness absence.

The contribution of general psychological aspects, such as emotions, has received little focus in research on sickness absence. We wanted to study the...
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