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The epidemiology of sick leave in an urban population in Malmö, Sweden Agneta Isacsson, Bertil S. Hanson, Lars Janzon and Gunnel Kugelberg Scand J Public Health 1992 20: 234 DOI: 10.1177/140349489202000408 The online version of this article can be found at: http://sjp.sagepub.com/content/20/4/234

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Scand J Soc Med, Vol. 20, No.4

The epidemiology of sick leave in an urban population in Malmo, Sweden Agneta Isacsson', Bertil S. Hanson ', Lars Janzen' and Gunnel KugelbcrgI Department

of Community Health Sciences, Lund University, am/ 2Social Insurance Board. Malmo, Sweden

Tire epidemiology of sick leave in an urban population ill Malmo. Sweden. 'Isacsson, A., 'Hanson, B, S., 'Janzon. L. and 2Kugelberg, G. ('Department of Community Health Sciences. Lund University. and 1Social Insurance Board, Malmo, Sweden Scand J Soc Med 1992.4 (234-239).

The epidemiology of sick leave was studied in the city of Malmo, Sweden, (230000 inhabitants). Every current and completed sick-leave episode during the year of 1985 was collected for 12441 I persons aged 16 to 65, who were registered with the National Health insurance scheme in 1985. Absence rate, absence incidence, absence prevalence and absence duration were analyzed in relation to age, sex, marital status, nationality, income and place of residence. Absence rate (mean value) in the total population was 25.5 days with a median of three days. The absence rate increased by age. High absence rates were seen for females, single people and some immigrant groups. This was even true for residential areas characterized by a higher proportion of single-person households and households on social welfare, of unemployed and people with a low income and a foreign background. The absence rate gives limited information as to the epidemiology of sick leave. Through adding absence incidence, absence prevalence and absence duration it was possible to get a more comprehensive picture of the phenonemon. Sex-differences in absence rate for instance were mainly explained by differences in absence incidence and prevalence, while differences in absence rate regarding nationality were explained by differences in absence duration. This is an important step towards a better understanding of the factors behind sick leave. Key words: sick leave, absence rate, epidemiology, population study.

INTRODUCfION The total cost of the social insurance system in Sweden was in 1988 almost 66 000 million SEK, which corresponds to about one tenth of the GNP. Sickness benefit represents a value of almost half of the total social insurance cost and is the biggest single expense. During the last decade absenteeism owing to illness has increased by over 30%. Between 1983and 1985 there was an increase in the absence rate from

18.4 to 25.3 days. Sick leave was higher for women than for men, 28.4 and 22.0 days respectively (I). A change of one day in the mean number of days of sick leave during one year corresponds to a cost of 1300 million SEK (2). According to the regulations of the social insurance scheme in Sweden, sickness benefit is paid when a person cannot work because of illness. (3). The concept of disease is defined as "every abnormal somatic or mental state that does not belong to the normal process of life" (3). The increase in sick leave in Sweden could bc explained in several ways, for instance changes in the demographic structure of the population and in the panorama of diseases, more women on the labour market, changes in social insurance legislation and praxis and perhaps changes in public attitudes (4). Work-related diseases are increasing and among these musculo-skeletal disorders are in a majority (5, 6). The working environment is of importance for the incidence and prevalence of back and joint disorders. The association between sick leave due to pain in the musculo-skeletal system on the one hand and heavy lifting and monotonous work on the other hand is well documented (7, 8). Hard physical work has decreased in our modern society and been replaced by monotonous low-intensity work. It is, however, not only the workload that is important. Psychosocial factors in the working environment such as work control, job demands and job satisfaction as well as support from managers and colleagues and factors regarding work organisation arc also of importance for neck and back disorders (9, 10). Sick leave can be described in different terms. "Absence rate", synonymous to the mean number of calender days of sick leave per person and year, is the most common measure. However, this measure gives an incomplete picture of sick leave. It does not give any information as to incidence (how often),

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The epidemiology of sick leave in an urban population

Fig. J. Geografic variation of age-adjusted absence rate in

the city of Malmo 1985 (n

= 124411).

(how many) or the duration of the periods of sick leave. The aim of this study is to investigate how factors like age, sex, marital status, nationality, income and place of residence are related to the four measures of sick leave: the traditional measure "absence rate", as well as "absence incidence", "absence prevalence" and "absence duration". MATERIAL AND METHODS The city of Malmo in the south of Sweden, is well-suited for epidemiological studies. The death rate, cancer morbidity and health-care utilization arc all high (11, 12). The population of approximately 230000 inhabitants in Malmo can be divided up into 18 geographical districts, differing from each other in social, economic, ethnic and cultural aspects. This study covers everyone in the city of Malmo, between 16-65 years of age, entitled to sickness benefit under the Swedish national health scheme. The study population was defined on July 1st 1985. The number of people who moved in and out of the city in 1985 was almost even. Therefore migration could not have affected the results of our study more than marginally. The information about sick leave during 1985 was collected from the register at the Swedish National Health Insurance Board. All sickness benefits paid to people who arc on sick leave are administrated through this register. For this reason the validity of data from the register can be regarded as high.Those who were off work in order to nurse a sick child have not been included in this study. On July 1st 1985 a total of 141317 people between 16and 65 years of age lived in the city of Malmo. With permission from the Swedish Data Inspection Board a record-linkage was made between the population register in Malmo and the sickness absence register at the Swedish National Social Insurance Board. Personal identification code numbers,

235

marital status, nationality and place of residence were collected from the population register of Malmo's county administration board. Information about every current and completed episode of sick leave in 1985was added from the absence register as well as information about income. The population in the city of Malmo was informed about this study in the three daily newspapers. Nine people refused to participate. 124411 people in Malmo between 16 and 65 years of age were insured in the Swedish national social insurance scheme and these constitute the study population. 103914 (84.0%) individuals were Swedish and 20497 had a foreign background (born abroad). Of these 4423 (21.6%) came from Yugoslavia. 2706 (13.2%) from Denmark, 2500 (12.2%) from Poland, 1639 (8.0%) from Finland, 1245 (6.1%) from the former West Germany, 1131 (5.5%) from Hungary, 898 (4.4%) from South America, 441 (2.2%) from Turkey, 476 (2.3%) from Norway, 3321 (16.2%) from the rest of Europe and 1717 (8.4%) came from other parts of the world. In this study the four concepts of sick leave have been defined as follows:

1. Absence rate- the mean number of calender days of sickness benefit paid per person and year.

2. Absence duration - the mean number of days of the absence episodes per year.

3. Absence incidence - the number of new absence episodes per person and year.

4. Absence prevalence - the percentage of the population with at least one absence episode per year. The study population was divided into age groups of five years. Marital status was defined as married, single, divorced or widowed. Immigrants were defined as foreign citizens, Swedish citizens born abroad and young people under the age of 18 with one parent born abroad. The city of Malmo was geographically divided into 18 districts and 132 smaller geographical areas. These districts can be demographically and sociologically characterised by statistical data from the Agency of Administrative Development in Malmo. The statistics are mainly based on data from the population register in Malmo and from national registers at the Swedish Central Bureau of Statistics. The different measures of sick leave have been adjusted for age by the direct method, using the total population as a standard. RESULTS The absence rate in the total population was 25.5 days, with a median of three days. Thirty-three per Scand J Soc Med 20

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A. lsacsson et al.

absence rate

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Fig. 2. Absence rate by age and sex in the city of Malmo

1985 (n

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cent of the population in the city of Malmo did not have any days of sick leave during the year. The majority of these people were married men, people with high incomes and people in residential areas with a large number of private homes. Almost 50% of all episodes of sick leave during the year lasted between 1-3 days, 80% lasted up to a week and 3% lasted longer than 90 days. Geographic variation There was a marked difference in absence rate between the 18 districts when adjusted for age (Fig. 1). The highest absence Tate was found in the northeastern, eastern and southern districts in the city of Malmo. The absence rate varied from 15.5 to 38.4 days. This variation was mainly explained by differences in absence duration, and to a lesser extent by differences in absence incidence and prevalence. The absence duration varied by up to a week betwee~ the 18 districts, from 10.7 to 17.7 days. Districts with the highest absence rate had a higher number of single-person households, households on social welfare, more people unemployed and people with a low income and a foreign background (13). Differences in absence rate were seen between small geographical areas within the same district. In the eastern part of Malmo the absence rate was 60.2 in one neighbourhood inhabited by 807 persons and 13.5 in another inhabited by 658 persons within the same district. These two neighbourhoods differed in the same way as the districts regarding socio-economical status.

Age and sex The absence rate increased by age (Fig. 2). In the oldest age group, 55--67 years, the absence Tate was 36 days, 2.5 times higher than it was in the youngest group. This difference was explained by a difference in absence duration, absence incidence and prevalence. Absence duration increased by age from 6.9 days in the youngest group to 27.6 days in the oldest age group. Absence incidence and prevalence decreased. In the youngest age group absence incidence was 0.51 and in the oldest 0.33. The absence rate was higher for women than for men in all age groups due to a higher incidence and prevalence. The absence incidence for women was 0.51 and for men 0,41. The absence prevalence for women and men was 69% and 62%, respectively. Seventyfive per cent of the women between 25-29 years had at least one episode of sick leave during the year and the lowest absence prevalence (50%) was seen for men aged 60--64 years. Marital status

The absent rate differed in the different marital status groups. (Fig. 3). When adjusted for age the absence rate was higher for the divorced and widowed compared to the single and the married. This was explained mainly by a higher incidence and less by differences in prevalence and duration. The incidence for the divorced, widowed, unmarried and married was 0.63, 0,49, 0,47 and 0.41 respectively. The highest absence Tate was seen for divorced years of age, 44.5 days, twice as high women 45~9 absence rate

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Yugoslavia. However, the absence rate for immigrants from Germany, South America and some non-European countries was almost synonymous with that of Swedes. Absence incidence and prevalence did not differ significantly between the nationality groups. There was no uniformity in the pattern regarding sex in the various ethnic groups. Yugoslavian women and Turkish men hade the highest absence rate, 72 and 65 days, respectively. Women from Turkey had episodes of absence lasting three times longer than those of Swedish women. Yugoslavian women also had comparatively longer episodes.

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as for married men of the same age, 22.0 days. Eighty per cent of the divorced women compared to 60% of the married men had at least one spell of absence during the year.

Income There was a marked difference in the absence rate regarding income when adjusted for age. The absence rate increased up to an annual income of Sa70000 SEK. Above 100000 SEK there was a decrease in absence rate by increasing income. An identical pattern was seen for incidence and prevalence. The absence duration however, decreased by increasing income. Women had a higher absence incidence in all income classes when compared to men. Men with the lowest income had an incidence of 0.5 compared to women with an income of 85 00a-101200, who had almost one episode per person and year. A similar pattern was seen for absence prevalence. At a level of 68 000-101200 SEK almost 80% of all women had been off sick at least once during the year compared to 20% of the men in the lowest income bracket group. Nationality When adjusted for age the absence rate varied between the different ethnic groups mainly because of a difference in absence duration (Fig. 6). The longest spells were seen for immigrants from Turkey and

237

In this study of sick leave our main findings were that the absence rate varied by factors like age, sex, marital status, income and nationality and that absence rate as a mean value, only gives limited information about absenteeism due to illness. The higher absence rate in older people was explained by the longer duration. The most reasonable explanation for this is the fact that chronic diseases are more common in older people (6, 14). This is in good agreement with a number of other studies (1518). Younger people had a higher absence incidence and prevalence. This is most likely due to differences in the panorama of diseases and in attitudes regarding the use of the social insurance system (18). The latter have been discussed in a paper by Ander et at. (19), who showed that women with children younger than 16 years of age and working in heavy jobs, absence rale

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rig. J. Age-aOJUSICU aosence rate oy nanonauty In the city of Malmo 1985 (n = 124411). Scand J Soc Med 20

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238

A. Isacsson et at.

more often than others were off sick for shorter periods. This was considered to be a rational behavior in order to cope with- a strenous life-situation

(coping-behavior). Sick leave differed by sex because of a higher absence incidence and prevalence among women. The higher incidence and prevalence could have several explanations. Though women live six years longer than men on average, their perceived health is worse (18, 20) and women are higher consumers of health care than men are (18,21). Women also have the main responsibility for the children and the higher incidence could perhaps to some part be explained by coping-behavior (19). Furthermore, compared to men, they have a lower level of education, and an increasing number of women are found in strenuous and monotonous jobs where sick leave is common (22. 23). The differences in absence rate found between the marital status groups, when adjusted for age. could very likely be explained by the fact that health is poorer among those who are widowed, single and divorced compared to those who arc married (24, 25). Differences in lifestyle as well as differences in social network and social support might contribute to this fact (24--26). Absence rate increased by increasing income. Above an income of about 100000 SEK absenteeism due to illness decreased by increasing income. SimiIar results have been found by others (15, 16). Income is here used as a proxy for social class. As morbidity is higher in the lower social classes, sick leave decreased by increasing income as expected. However. in the lowest income group sick leave was lower. This is probably explained by the fact that students and part-time workers arc overrepresented in these lower income groups. They more seldom report themselves sick on days off. Differences in health status (especially musculoskeletal disorders) and sickness absenteeism between different income groups might be due to differences in working tasks and position at work. Physically hard and monotonous work is less well-paid and sick leave is more common in these kind of jobs (23, 27, 28). The higher absence rate seen in some immigrant groups, due to a higher absence duration, could to some part be explained by differences in health status (23). Immigrants more often than Swedes are seen in monotonous and physically hard jobs, where unemployment. chronic diseases, (especially musculoskeletal disorders), and sick leave are more com-

man (23, 29). Not seldom, rehabilitation of persons with musculoskeletal disorders takes quite a long time, resulting in longer spells of absence (18). Problems of communication and cultural differences could be contributing factors as well (29). It is obvious that a person is not sicklisted by chance. The risk is greater for elderly people, women, for those who are divorced, for some people with a foreign background and those with a low income. By adding two epidemiological measures, absence incidence and absence prevalence and a fourth measure, absence duration, we were able to get a more comprehensive picture of sickness absenteeism. The sex-differences in absence rate, were explained by differences in absence incidence and prevalence while the nationality differences were explained by differences in absence duration. Considering the magnitude of the problem this should merit further studies regarding causes and possibilities for prevention and rehabilitation. More knowledge is needed especially of factors of importance for absence incidence as well as factors influencing the duration and course of these episodes of sick leave.

ACKNOWLEDGEMENT This study has been supported by grants from the Swedish National Social Insurance Board.

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3. 4. 5.

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crease". Stockholm: Riksforsakringsvcrket 1989. (Riksforsakringsverkct redovisar 1989: 1). (in Swedish). Riksforsakringsverket, The role of the "doctor of confidence" at the social insurance board. Stockholm: Forsakrings-kasseforbundet, 1990. (Bilaga FKF 93-1 90.03). (in Swedish). Diderichsen F. Sick leave and disability pension vary substantially due to different professions. Lakartidningen 1990; 87: 179-84. (in Swedish). Riksforsakringsverket. Medicine of social insurance. Stockholm: (Forsakringskasseforbundet, 1988). (in Swedish). Riksforsakringsverket. Special reports to the government regarding health and its prevention. Stockholm: Riksforsakringsverket, 1990 (Riksforsakringsverket anser 1990: 5). (in Swedish). Riksforsakringsverket, Sickness benefit by diagnoses. 1983. Stockholm: Riksforsakringsverket, 1987. (Statistical Report 1987: 5). (in Swedish). Hansson T. Back pain and work. Goteborg: Arbetsmiljofonden, 1989. (in Swedish). Hagberg M. The importance of work environment for

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neck and shoulder pain. Stockholm: Arbctsrniljofonden, 1988. (in Swedish). Battic Me. The reliability of physical factors as predictors of the occurrence of back pain reports. A prospcctivc study within industry, 1989.Goteborg. (Thesis). Bigos S, Battie MC, Spengler D, Fisher L, Fordyce W, Hansson T et al. A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine 1991; 16: 1-6. Statistiska ccntralbyran, Living conditions and local variations in standards of living, 1975/76. Stockholm: Statistiska centralbyriin. (Report no 19). (in Swedish). Statistics on cause of death as a basis for planning. Stockholm: SPRI 1983. (Spri report nr 122). (in Swedish). Descriptions of residential areas in the city of Malmo, 1986. Malmo: Statistikbyran, Stadskontorct 1988. (in Swedish). Statistiska ccntralbyran. Bad health and healthcarc, Living conditions 1975-83. Stockholm: Statistiska centralbyran, 1985_ (Report no 42). (in Swedish). Lokandcr S. Sick absence in a Swedish company. A sociomedical study. Lund: Acta Med Scand, 1962. Chevalier A, Luce D. Blanc C, Goldberg M. Sickness absence at the French national electric and gas company. Br J Ind Med 1987; 44: 101-10. Taylor P J, Burridge J. Trends in death, disablement and sickness absence in the British post office since 1891. Br J Ind Mcd 1982; 39: 1: 1-10. Tellnes G. Sickness certification in general practice: A review. Fam Pract 1989; 6: 58-65. Ander S, Edgren B. What kind of strain causes coping behaviour? Institutet fOr Arbctsvctenskap. Stockholm: Kungliga Tckniska Hogskolan, 1988. (in Swedish). Socialstyrelsen. Report on people's health. Stockholm: Socialstyrclscn, 1987. (Socialstyrelsen rcdovisar 1987: 15). (in Swedish). Vogel J, Andersson L-G, Davidsson U, Hall L. The

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lack of equity in Sweden. Living conditions 1975-85. Stockholm: Statistiska ccntralbyran 1987. (Report nr 51). (in Swedish). Bjurulf P, Johansson. G. Ljungdahl L, Persson H, Levin J-E, Astrand G. Sick leave.. according to diagnosis and profession. 1985-87 i Ostergotland. Linkoping: Sarnhallsrnedicinska institutionen, 1990. (in Swedish). Statistiska centralbyriin. Living conditions among im~ migrants. Stockholm: Statistiska ccntralbyran, 1977. (Report nr 9). (in Swedish). Mellstrorn D, Nilsson A, Oden A, Rundgren A, Svanborg A. Mortality among the widowed in Sweden. Scand J Soc Med 1982; 10: 33--41. Berkson J. Mortality and marital status. Am J Public Health 1962; 52: 1318-29. Hanson BS. Social network, social support and health in elderly men. A population study. Dept of Community Health Sciences, Lund University, Malmo: Lund: Studcntlittcratur, 1988 (Thesis). Riksforsakringsvcrkct. Long-term sick leave in different working conditions. Stockholm: Riksforsakringsvcrket 1990. (Riksforsakringsvcrkct redovisar 1990: 14). (in Swedish). Kristensen, TS. Sickness absence and work strain among Danish slaughterhouse workers: An analysis of absence from work regarded as coping behaviour. Soc Sci Med 1991; 32: 15-27. Statistiska ccntralbyran. Living conditions. Immigrants. Stockholm: Statistiska ccntralbyran, 1991. (Report nr 69). (in Swedish). .

Correspondence 10: Agneta Isacsson Department of Community Health Sciences Malmo General Hospital 5-21401 Malmo, Sweden

Scand J Soc Med 20

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The epidemiology of sick leave in an urban population in Malmö, Sweden.

The epidemiology of sick leave was studied in the city of Malmö, Sweden, (230,000 inhabitants). Every current and completed sick-leave episode during ...
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