Journal of Taibah University Medical Sciences (2022) 17(6), 1051e1059

Taibah University

Journal of Taibah University Medical Sciences

[Link]

Original Article

In the classroom but absent: Evidence of sickness presenteeism among

teachers at four public schools
Carlos Rojas-Roque, MSc a, b, * and Indiana López-Bonilla, PhD c
a
Centro de Investigación en Demografı´a y Salud, CIDS UNAN Leon, Leon Nicaragua
b
Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy
(IECS), Buenos Aires, Argentina
c
Centro de Investigación en Salud, Trabajo y Ambiente (CISTA), Facultad de Ciencias Me´dicas, Universidad Nacional
Autónoma de Nicaragua, UNAN-Leon, Leon, Nicaragua

Received 19 January 2022; revised 26 March 2022; accepted 22 June 2022; Available online 9 July 2022

‫ﺍﻟﻤﻠﺨﺺ‬ ‫ ﻳﻨﺘﺸﺮ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ ﺑﺸﻜﻞ ﻛﺒﻴﺮ ﻧﺴﺒﻴﺎ ﻭﻳﺮﺗﺒﻂ‬،‫ ﺑﻴﻦ ﺍﻟﻤﻌﻠﻤﻴﻦ‬:‫ﺍﻻﺳﺘﻨﺘﺎﺟﺎﺕ‬
‫ ﻫﻨﺎﻙ ﺣﺎﺟﺔ ﺇﻟﻰ ﺗﺪﺧﻼﺕ ﺗﻬﺪﻑ ﺇﻟﻰ ﺗﻌﺰﻳﺰ ﺃﻧﻤﺎﻁ ﺍﻟﺤﻴﺎﺓ‬.‫ﺑﺨﺴﺎﺋﺮ ﺍﻗﺘﺼﺎﺩﻳﺔ ﻋﺎﻟﻴﺔ‬
(‫ ﺍﻷﺩﻟﺔ ﻋﻠﻰ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ )ﺍﻟﺤﻀﻮﺭ ﻟﻠﻌﻤﻞ ﺃﺛﻨﺎﺀ ﺍﻟﻤﺮﺽ‬:‫ﺃﻫﺪﺍﻑ ﺍﻟﺒﺤﺚ‬ .‫ﺍﻟﺼﺤﻴﺔ‬
‫ﻧﺎﺩﺭﺓ ﻧﺴﺒﻴﺎ ﻓﻲ ﺍﻟﺒﻠﺪﺍﻥ ﺍﻟﻤﻨﺨﻔﻀﺔ ﻭﺍﻟﻤﺘﻮﺳﻄﺔ ﺍﻟﺪﺧﻞ ﻭﻓﻲ ﺍﻟﻔﺌﺎﺕ ﺍﻟﻀﻌﻴﻔﺔ ﻣﺜﻞ‬
‫ ﻓﺤﺼﺖ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﻧﺴﺒﺔ ﺍﻧﺘﺸﺎﺭ‬،‫ ﻟﺘﻘﺪﻳﻢ ﺩﻟﻴﻞ ﻋﻠﻰ ﻫﺬﻩ ﺍﻟﻔﺠﻮﺓ ﺍﻟﺒﺤﺜﻴﺔ‬.‫ﺍﻟﻤﻌﻠﻤﻴﻦ‬ ‫ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ؛ ﺍﻟﻤﺪﺭﺳﻮﻥ؛ ﺍﻟﻤﺪﺍﺭﺱ؛ ﺍﻟﺼﺤﺔ؛ ﺍﻟﻌﻮﺍﻣﻞ‬:‫ﺍﻟﻜﻠﻤﺎﺕ ﺍﻟﻤﻔﺘﺎﺣﻴﺔ‬
‫ ﺑﻴﻦ‬،‫ ﻭﻗﺎﻣﺖ ﺑﺘﻘﺪﻳﺮ ﺿﻌﻒ ﺍﻹﻧﺘﺎﺟﻴﺔ ﺍﻟﻨﺎﺗﺞ ﻋﻦ ﺫﻟﻚ‬،‫ﻭﻋﻮﺍﻣﻞ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ‬ ‫ﺍﻟﻤﺘﻌﻠﻘﺔ ﺑﺎﻟﻌﻤﻞ؛ ﻧﻴﻜﺎﺭﺍﻏﻮﺍ‬
.‫ ﻧﻴﻜﺎﺭﺍﻏﻮﺍ‬،‫ﺍﻟﻤﻌﻠﻤﻴﻦ ﻓﻲ ﻟﻴﻮﻥ‬
Abstract
،‫ ﺗﻢ ﺍﺧﺘﻴﺎﺭ ﺃﺭﺑﻊ ﻣﺪﺍﺭﺱ ﻋﺎﻣﺔ ﻓﻲ ﻟﻴﻮﻥ‬،‫ ﻓﻲ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﺍﻟﻤﻘﻄﻌﻴﺔ‬:‫ﻃﺮﻕ ﺍﻟﺒﺤﺚ‬
‫ ﺗﻢ ﺗﺤﺪﻳﺪ‬.‫ ﻣﺪﺭﺳﺎ‬132 ‫ﻧﻴﻜﺎﺭﺍﻏﻮﺍ ﺑﺎﺳﺘﺨﺪﺍﻡ ﻋﻴﻨﺔ ﻣﻼﺋﻤﺔ ﻭﺿﻤﺖ ﺍﻟﻌﻴﻨﺔ ﺍﻟﻨﻬﺎﺋﻴﺔ‬ Objective: Evidence regarding sickness presenteeism (SP)
‫ﺍﻟﻌﻮﺍﻣﻞ ﺍﻟﻤﺤﺪﺩﺓ ﻟﻠﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ ﺑﺎﺳﺘﺨﺪﺍﻡ ﺍﻻﻧﺤﺪﺍﺭ ﺍﻟﻠﻮﺟﺴﺘﻲ ﻣﺘﻌﺪﺩ‬ in low-and middle-income countries and in vulnerable
‫ ﻛﻤﺎ ﺗﻢ ﺍﺳﺘﺨﺪﺍﻡ ﺍﺳﺘﺒﺎﻧﺔ ﺇﻧﺘﺎﺟﻴﺔ ﺍﻟﻌﻤﻞ ﻭﺍﺿﻄﺮﺍﺏ ﺍﻟﻨﺸﺎﻁ ﻟﺘﻘﺪﻳﺮ ﺿﻌﻒ‬.‫ﺍﻟﻤﺘﻐﻴﺮﺍﺕ‬ groups such as teachers is relatively scarce. To provide
.(‫ ﻛﻮﺭﺩﻭﺑﺎ‬31.78 = ‫ ﺩﻭﻻﺭ ﺃﻣﺮﻳﻜﻲ‬1) ‫ﺍﻹﻧﺘﺎﺟﻴﺔ ﺑﺎﻟﺪﻭﻻﺭ ﺍﻷﻣﺮﻳﻜﻲ‬ evidence addressing this research gap, we examined the
prevalence and predictors, and estimated the productivity
56.53 ‫ )ﻓﺘﺮﺓ ﺍﻟﺜﻘﺔ‬%65.2 ‫ ﻛﺎﻥ ﺍﻧﺘﺸﺎﺭ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ‬،‫ ﺑﺸﻜﻞ ﻋﺎﻡ‬:‫ﺍﻟﻨﺘﺎﺋﺞ‬ loss impairment due to SP among teachers in Leon,
.‫ ﻭﻟﻢ ﻳﺘﻢ ﺍﻟﻌﺜﻮﺭ ﻋﻠﻰ ﻓﺮﻭﻕ ﻭﻓﻘﺎ ﻟﻠﺨﺼﺎﺋﺺ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ ﺍﻟﺪﻳﻤﻮﻏﺮﺍﻓﻴﺔ‬،(72.87 - Nicaragua.
.‫ﺃﻇﻬﺮﺕ ﺍﻟﺪﺭﺍﺳﺔ ﻋﻼﻗﺔ ﺳﻠﺒﻴﺔ ﺑﻴﻦ ﺍﻟﺘﺪﺑﻴﺮ ﺍﻟﻤﺒﺎﺷﺮ ﺃﻭ ﺍﻟﺪﻋﻢ ﻭﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ‬
‫ ﻓﺈﻥ ﺍﻟﻤﻌﻠﻤﻴﻦ ﺍﻟﺬﻳﻦ ﻟﻴﺲ ﻟﺪﻳﻬﻢ ﻇﺮﻭﻑ ﻣﻨﺰﻟﻴﺔ ﻣﻨﺎﺳﺒﺔ ﻟﻠﺮﺍﺣﺔ‬،‫ﻋﻼﻭﺓ ﻋﻠﻰ ﺫﻟﻚ‬ Methods: This was a cross-sectional study. Four public
‫ ﻛﺎﻥ ﻣﺘﻮﺳﻂ ﺍﻟﻮﻗﺖ‬.‫ ﻣﺮﺓ‬1.28 ‫ﺗﺰﻳﺪ ﻟﺪﻳﻬﻢ ﺍﺣﺘﻤﺎﻟﻴﺔ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ ﺑﻨﺴﺒﺔ‬ schools in Leon, Nicaragua, were selected, and 132
‫ ﻭﻛﺎﻥ ﻣﺘﻮﺳﻂ ﺍﻟﻨﺴﺒﺔ ﺍﻟﻤﺌﻮﻳﺔ ﻟﺨﺴﺎﺭﺓ‬.٪14.3 ‫ﺍﻟﻀﺎﺋﻊ ﺑﺴﺒﺐ ﺍﻟﻮﺿﻊ ﺍﻟﺼﺤﻲ‬ teachers were included in the final sample. Predictors
‫ ﻛﻤﺎ ﻛﺎﻥ ﻣﺘﻮﺳﻂ ﺗﻜﻠﻔﺔ ﺍﻟﺤﻀﻮﺭ ﺍﻟﻤﺮﺿﻲ ﻟﻠﻔﺮﺩ‬.٪30 ‫ﺍﻹﻧﺘﺎﺟﻴﺔ ﺑﺴﺒﺐ ﺍﻟﺼﺤﺔ‬ influencing SP were identified through multivariable lo-
‫ ﺩﻭﻻﺭﺍ‬1805 ‫ ﻭﺍﻟﺘﻜﻠﻔﺔ ﺍﻹﺟﻤﺎﻟﻴﺔ‬،‫ ﺩﻭﻻﺭﺍ ﺃﻣﺮﻳﻜﻴﺎ‬20 ‫ﺧﻼﻝ ﺍﻷﺳﺒﻮﻉ ﺍﻟﺴﺎﺑﻖ‬ gistic regression. By using the Work Productivity and
.‫ﺃﻣﺮﻳﻜﻴﺎ‬ Activity Impairment Questionnaire, we converted the
productivity loss impairment to 2018 US dollars (1 US
dollar ¼ 31.78 Cordobas).
* Corresponding address: Health Technology Assessment and
Health Economics Department, Institute for Clinical Effectiveness Results: Overall, the prevalence of SP was 65.2% (95%
and Health Policy (IECS), Doctor Emilio Ravignani Buenos Aires, C.I.: 56.53e72.87), and no differences were found in
2024, Argentina.
sociodemographic characteristics. We observed a nega-
E-mail: crojas@[Link] (C. Rojas-Roque)
tive relationship between director/supervisor support and
Peer review under responsibility of Taibah University.
SP (p<0.001). Moreover, teachers without suitable
household conditions for resting had a 1.28 times higher
probability of SP (95% C.I.: 1.03e1.59). The median
Production and hosting by Elsevier percentage time missed for all health reasons was 14.3%.
1658-3612 Ó 2022 The Authors.
Production and hosting by Elsevier Ltd on behalf of Taibah University. This is an open access article under the CC BY-NC-ND license
([Link] [Link]
1052 C. Rojas-Roque and I. López-Bonilla

The median percentage productivity loss impairment due additional risks to organizations, because of the possibility
to health conditions was 30%. The median per-capita of workplace epidemics, and may affect vulnerable
cost of SP during the prior week was 20 US dollars, populations, including older people and children.14,15 In
and the overall cost was 1805 US dollars. the worst-case scenario, illness can circulate within work-
places and education settings, and SP can contribute to
Conclusion: Among teachers, SP has a relatively high pandemics.16 A recent systematic review has highlighted the
prevalence and is associated with a high economic toll. health consequences of SP on health over time, including
Interventions aimed at promoting healthful lifestyles are worsening mental and physical health; increasing the risk
needed. of hypertension and depression; suppressing the immune
system; and elevating the risk of coronary heart disease.6
Keywords: Health; Nicaragua; School teachers; Sickness Finally, chronic work-associated stress and exhaustion
presenteeism; Work-related factors have been associated with working while ill.6
The costs of SP may be larger than the costs of absen-
Ó 2022 The Authors. teeism from work. A systematic review analyzing the effects
Production and hosting by Elsevier Ltd on behalf of Taibah
of SP observed in cost estimation studies and economic
University. This is an open access article under the CC BY-
NC-ND license ([Link] evaluations has shown that SP costs exceed absenteeism
nd/4.0/). costs.17 In Australia, a study has estimated the productivity
loss due to 12 common medical conditions by applying
data on the prevalence of each condition in the Australian
working population to international estimates of the on-
the-job productivity losses from each condition. The over-
Introduction
all cost of SP to the Australian economy in 2009e2010 was
estimated to be $34.1 billion (nearly four times the cost of
Absenteeism from work has been an indicator used to absenteeism).18
assess the workers’ health within companies or institutions. Increasing awareness regarding the health risks and eco-
The evaluations are made on the basis of the assumption that nomic consequences associated with working while ill sug-
workers in the workplace are fully healthy and productive. gest that SP should be considered a risk-taking behavior, and
However these results provide an imprecise snapshot of should be measured and managed.6 Measuring SP would
overall health status, because workers often attend work provide a clear picture regarding employee health.
while being sick.1 Sickness presenteeism (SP), defined as Moreover, because many factors associated with SP are
going to the workplace while sick,2 has gained research modifiable, their identification is key to developing
interest in recent years, because of its increasing frequency intervention programs that promote healthful lifestyles and
and the consequences on health, public health and labor mitigate negative effects on workers. Therefore, more
productivity impairment among workers.3,4 research evidence regarding the prevalence of SP is needed,
The prevalence of SP, measured as going to work while ill particularly in vulnerable populations for which limited
at least once during a 12-month period, has shown a preva- evidence exists. For instance, Nicaragua lacks information
lence as high as 70%.5 A recent review has indicated that the on SP among teachers. To provide evidence addressing this
prevalence of SP ranges from 23% in countries such as Italy, research gap, this study examined the prevalence of SP,
Portugal and Poland, to more than 50% (in countries such as identified SP predictors and estimated the productivity loss
Montenegro, Malta and Denmark).6 SP has been associated impairment due to SP among teachers in four public
with organizational factors such as organizational schools in the city of Leon, Nicaragua.
commitment;5 the behavior of administrators, supervisors
or directors;7 the support of colleagues and job insecurity;8 Materials and Methods
and work ethic, and bonuses or incentives rewarding good
attendance.9 Personal factors such as family life,5 financial Study design and setting
status10 and circumstances at home that may prevent
proper rest5 have also been associated with SP. Given these This was a cross-sectional study conducted between April
factors, managers, people with unhealthful lifestyle choices, and October of 2018 in four public schools in Leon, a mu-
people with financial problems, “workaholics” and highly nicipality 93 km away from the capital of Nicaragua, in the
skilled white collar workers have been identified as groups northern Nicaraguan Pacific region. Leon has an estimated
vulnerable to SP.11 In addition, workers in education and population of 194,972 inhabitants, of whom 47.7% are
other social sectors have also been found to be vulnerable male.19 This study followed the Reporting of Observational
groups, with a high average frequency (4.1 times a year) Studies in Epidemiology (STROBE) statement for
and duration (11.2 days a year) of SP.12 In line with these reporting of results.20
findings, a study performed in Germany among teachers
working at different types of schools has indicated an SP Participants
prevalence of 57%.13
The frequent practice of SP has been associated with the Study participants comprised teachers of primary and
spread of communicable diseases.14 For example, SP among secondary students at four public schools in Leon. The
people with acute illness such as influenza may pose schools were selected on the basis of convenience, with the
 Sickness presenteeism among teachers 1053

aim of capturing the largest student population and teacher educational attainment than teachers, to ensure the clarity
staff among all public schools in Leon. The inclusion and ease of completion of the digital questionnaire during
criteria for participants were working 30 days or more as a the fieldwork.
teacher at the selected school and voluntarily providing The fieldwork occurred in schools. Interviewers
signed informed consent, in accordance with the Helsinki approached each teacher to explain the procedures and read
declaration. the Assent and Informed Consent form, which contained
detailed descriptions of the project and assured the safety,
Data collection procedures confidentiality and privacy of the data collected. Teachers
were surveyed if they had properly digitally signed and
All staff in this research project were trained before the returned the form. Completed digital questionnaires were
data collection. We used the freely available digital platform then reviewed and uploaded to a database.
EpiCollect5 ([Link] to create a digital According to the official registries in the four public
questionnaire, which was exported to tablets. After consul- schools, a total of 184 teachers were eligible to participate in
ting with, and obtaining approval from, the directors of each the study. Of them, 37 teachers could not be contacted
school, we started data collection, which was completed in because they were absent for medical or other personal rea-
August 2018. Before the fieldwork, the study instrument was sons. Therefore, we approached 147 teachers. Three teachers
pilot tested to gather information on the performance of the refused to participate in the study, thus yielding a response
items and the preferred choice of wording, and to assess the rate of 97.9%. After exclusion of 12 observations because of
length and interpretability of the items. For convenience, in missing data, 132 teachers were included in the analysis
the pilot tests, we selected a group of people with lower (Figure 1).

Figure 1: Flowchart of teachers included in the analysis.

1054 C. Rojas-Roque and I. López-Bonilla

Outcomes and measures that assess work stress as low, mild, moderate, severe and
very severe levels (a ¼ 0.67).
The main outcome of the study was the SP, measured by
using the item During the previous 30 days, have you attended Statistical analysis
work despite feeling that you really should have taken sick
leave due to your health (yes/no)? A second main outcome of Statistical analysis was performed in StataÒ v14.2 (Stata
the study was the productivity loss impairment due to SP, Corporation LP, College Station, Texas, USA). A descrip-
measured with the Work Productivity and Activity tive analysis was performed to characterize the teachers
ImpairmenteGeneral Health Questionnaire (WPAI-GH). surveyed. To describe the prevalence of SP among teachers,
We monetized the productivity loss impairment by using we used absolute and relative frequencies. Differences in
teachers’ hourly wages. The WPAI-GH questionnaire was prevalence across subpopulations were assessed with chi-
composed of six items measuring current employment status, square tests. To identify the predictors of SP, we estimated
the number of hours missed because of health problems, the the prevalence ratio (PR), adjusted prevalence ratio (PRa)
number of hours missed for other reasons, the hours actually and their confidence intervals (95% C.I.) through a bivariate
worked, and the degree to which health affected work pro- analysis. For continuous predictors, we estimated the beta
ductivity and regular activities during the prior 7 days. parameters and their 95% C.I. values in the bivariate anal-
Higher scores indicated greater work ability impairment and ysis. PRa, beta parameters and their 95% C.I. values were
lower productivity. The WPAI -GH has been translated into estimated in predictors with p <0.20 in the bivariate analysis.
more than 140 languages, including Spanish, through a All estimates were made with a generalized linear model with
harmonization process consisting of several independent a Poisson distribution and a log link function.24 Because
translations, back translations, expert review of the back frailty and fatigue are associated with age, and sex
translations and local review by users.21 differences may exist, we performed age-stratified and sex-
The predictors of SP included in the study were sex (male/ stratified analysis to consider the effects of these character-
female); age in years (18e34, 35e49 or 50e65); place of istics on SP. The findings are reported in the Electronic
residence (urban/rural); having children under 18 years of age Supplementary Material. To correct residuals potentially
(yes/no); work ethic (yes/no) meant by "ethics labor", distributed differently from the model’s assumption, we
measured with the item Do you perceive/value taking days off calculated all confidence intervals by using 1000
due to health problems as a sign of poor health performance?; bootstrapping replicates with the normal-based method.25
organizational commitment (yes/no), measured with the item For all findings, p <0.05 was considered statistically
Do you perceive/value the perfect job assistance as a sign of significant.
loyalty and institutional commitment?; suitable household To describe the productivity loss impairment, we used the
conditions for resting (yes/no), measured with the item Do you WPAI-GH scoring, which has been well described else-
consider that your household is suitable for rest when you are where.21 To monetize the productivity loss impairment, we
sick?; a financial difficulties measure; a director or supervisor calculated the weekly wage based on the monthly self-
support measure; a coworker and colleague support measure; reported wages, multiplied by the percentage impairment
work satisfaction; and work related stress. The measures for while working in the presence of all health conditions. Costs
financial difficulties, director or supervisor support, and were estimated in Cordobas (C$) and in US dollars by using
coworker and colleague support were based on and adapted the exchange rate as of August 2018 (1 US dollar ¼ 31.78
from a previous study.10 All questionnaires were based on a C$). All costs were inflated and reported by using the latest
scale of 7 points. The financial difficulties questionnaire was monthly consumer price index available from the Nicar-
composed of four items, with scores ranging from 4 to 28 aguan Central Bank, from December 2019.26
points (Cronbach’s alpha a ¼ 0.78). Higher scores indicated
that teachers were struggling financially. The director or
supervisor support questionnaire was composed of ten Results
items, and scores ranged from 7 to 70 points (a ¼ 0.94).
Higher scores indicated that teachers agreed that they Most included teachers were women (69%), with a mean
perceived their director or supervisor positively and age of 43.3  9.11 (mean  standard deviation). On average,
perceived support. The coworker and colleague support teachers earned US 314.4  81.7 per month and had
questionnaire was composed of four items, and had scores 17.8  9.96 years of teaching experience. Additional char-
ranging from 4 to 28 points (a ¼ 0.83). Higher scores acteristics of the participants are reported in Table 1.
indicated that teachers strongly agreed that their coworkers The overall prevalence of SP among teachers was 65.2%
and colleagues were supportive. (95% C.I.: 56.53e72.87), and women reported higher values
To measure work satisfaction, we used the Andrews and than men (69.2% vs 56.1, p ¼ 0.143). Teachers 35e49 years
Withey Job Satisfaction Questionnaire,22 which consists of of age reported higher SP than older and younger teachers.
five questions measuring job motivation and satisfaction No difference in SP was observed according to the teachers’
during the prior 30 days (a ¼ 0.88). Finally, to measure places of residence (68.8% vs. 64.7%, p ¼ 747). Teachers
work-related stress, we used the Work Stress Scale, devel- who had children under 18 years of age had higher SP than
oped by the American Institute of Stress and The Marlin those who did not, although no statistical difference was
Company.23 The questionnaire consists of eight questions indicated (p ¼ 0.156) (see Table 2).
 Sickness presenteeism among teachers 1055

Table 1: Characteristics of the study population (n [ 132). Table 2: Prevalence of sickness presenteeism among teachers at
Characteristics Absolute 95% C.I. four public schools in Leon, Nicaragua.
frequency (%) Characteristics Prevalence of SP, in p
Sex % (95% C.I.)
Male 41 (31.06) 23.67e39.56 Overall
Female 91 (68.94) 60.43e76.32 65.15 (56.53e72.87) e
Age in years Sex
18e34 23 (17.42) 11.79e24.97 Men 56.09 (40.48e70.58) 0.143
35e49 68 (51.52) 42.91e60.02 Women 69.23 (58.88e77.94)
50e65 41 (31.06) 23.67e39.56 Age in years
Place of residence 18e34 60.87 (39.59e78.68)
Urban 116 (87.88) 81.02e92.48 35e49 72.06 (60.07e81.54) 0.213
Rural 16 (12.12) 7.51e18.97 50e65 56.10 (40.48e70.58)
Children under 18 years of age Place of residence
No 55 (41.67) 33.46e50.32 Urban 68.75 (42.22e86.88) 0.747
Yes 77 (58.33) 49.64e66.53 Rural 64.66 (55.42e72.90)
Workday Children under 18 years of age
Morning 67 (50.76) 42.17e59.29 No 58.18 (44.63e70.59) 0.156
Afternoon 53 (40.15) 32.04e48.83 Yes 70.12 (58.84e79.40)
Othera 12 (9.09) 5.19e15.42 Workday
Grade of students taught Morning 64.18 (51.88e74.85)
Preschool 8 (6.06) 3.03e11.74 Afternoon 60.38 (46.51e72.75) 0.118
Primary 36 (27.27) 20.27e35.60 Othera 91.67 (55.96e98.96)
Secondary 84 (63.64) 54.99e71.48 Grade of students taught
Otherb 4 (3.03) 1.12e7.88 Preschool 87.50 (42.19e98.53) 0.416
Years of teaching experience Primary 69.44 (52.37e82.44)
Mean  standard 17.8  9.96 16.06e19.49 Secondary 61.90 (50.95e71.76)
deviation Otherb 50.00 (9.24e90.75)
Monthly wage in US dollarsc
Notes. 95% C.I.: 95% confidence interval.
Mean  standard 314.4  81.68 300.21e328.67 a
Including teachers with morning and afternoon workdays, as
deviation
well as evening workdays.
Notes. 95% C.I.: 95% confidence interval. b
Including teachers of both preschool and primary students,
a
Including teachers with morning and afternoon workdays, as and primary and secondary students.
well as evening workdays.
b
Including teachers of both preschool and primary students,
and primary and secondary students.
times (adjusted 95% C.I.: 1.03 to 1.59). Similar findings are
c
Exchange rate in August 2018: 1 US dollar ¼ 31.78 Cordobas.
Wages are inflated and reported according to the December 2019 reported in the sex-stratified and age-stratified analysis in
monthly consumer price index available from the Nicaraguan the Electronic Supplementary Material.
Central Bank. The productivity loss impairment due to SP during the
prior week, according to our survey in teachers, is presented
in Table 4. Overall, the median percentage time missed
because of all health conditions was 14.3%: 12.7% for
Table 3 presents the association between SP and men and 16.7% for women. The median percentage
the predictors considered in the study. Overall, in the impairment while working in the presence of all health
bivariate analysis, none of the sociodemographic conditions, corresponding to the median percentage
variables showed an association with SP. SP was most productivity loss impairment due to health conditions, was
strongly associated with having suitable home conditions 30% for both women and men. The median percentage
for resting (non-adjusted p ¼ 0.002), director or overall work impairment due to overall health conditions
supervisor support (non-adjusted p<0.001), coworker and was 2.4%, ranging from 1.9% for men to 2.5% for
colleague support (non-adjusted p ¼ 0.001) and work- women. The median percentage activity impairment
associated stress (non-adjusted p ¼ 0.001). After adjust- because of all health conditions was 20% for men and
ment for the simultaneous effects of predictors that yielded 30% for women.
a non-adjusted p<0.2 in the bivariate analysis, coworker Table 5 presents the costs of SP during the prior week for
and colleague support and work-associated stress lost their teachers. Overall, the median cost of SP was 19.96 US
significant association with SP. Director or supervisor dollars (25th and 75th quartiles: 7.88 and 46.25), ranging
support and suitable conditions for rest were strongly from 16.45 US dollars for men to 21.23 US dollars for
associated with SP. We observed a negative relationship women. We estimated a total loss due to SP during the
between the director support measure and SP (adjusted p prior week of 358.79 US dollars for men and 1446.47 US
<0.001). In addition, a lack of suitable household condi- dollars for women, yielding an overall cost of 1805.27 US
tions for resting increased the probability of SP by 1.28 dollars.
1056 C. Rojas-Roque and I. López-Bonilla

Table 3: Predictors of sickness presenteeism among teachers at four public schools in Leon, Nicaragua.
Predictor Unadjusted model Adjusted modela
b
PR 95% C.I. p PRa 95% C.I.b p
Sex
Men Ref
Women 1.23 0.88e1.72 0.221 e e e
Age in years
18e34 Ref
35e49 1.18 0.80e1.73 0.384 e e e
50e65 0.92 0.59e1.43 0.718 e e e
Place of residence
Urban 0.94 0.64e1.37 0.752 e e e
Rural Ref
Children under 18 years of age
No 0.83 0.63e1.08 0.174 0.93 0.71e1.19 0.560
Yes Ref
Work ethic
No Ref
Yes 1.11 0.82e1.45 0.431 e e e
Organizational commitment
No Ref
Yes 0.98 0.60e1.57 0.918 e e e
Suitable household conditions for resting
No 1.45 1.15e1.82 0.002 1.28 1.03e1.59 0.025
Yes Ref
Financial difficulties
Beta parameter 0.01 0.01e0.02 0.233 e e e
Director/supervisor support measure
Beta parameter 0.01 0.01 to 0.00 <0.000 0.01 0.02 to 0.01 <0.000
Coworker and colleague support measure
Beta parameter 0.03 0.04 to 0.01 0.001 0.01 0.03 to 0.01 0.123
Work satisfaction
Beta parameter 0.01 0.01e0.03 0.254 e e e
Work related stress
Beta parameter 0.04 0.01e0.06 0.001 0.02 0.01e0.04 0.136
PR: unadjusted prevalence rate; PRa: adjusted prevalence rate.
a
Model adjusted for all variables that resulted in a p value <0.2 in the bivariate analysis.
b
95% C.I. calculated by bootstrapping with the normal-based method with 1000 replicates.

Table 4: Productivity loss impairment due to sickness presenteeism in the week prior to the survey.
Indicator Median Q1 Q3
Overall
Percentage work time missed because of all health conditions (n ¼ 37) 14.29 7.41 20.00
Percentage impairment while working in the presence of all health conditions (n ¼ 58) 30.00 10.00 70.00
Percentage overall work impairment because of all health conditions (n ¼ 68) 2.39 0.75 8.33
Percentage activity impairment because of all health conditions (n ¼ 59) 20.00 10.00 50.00
Men
Percentage work time missed because of all health conditions (n ¼ 8) 12.66 8.47 18.33
Percentage impairment while working in the presence of all health conditions (n ¼ 15) 30.00 10.00 40.00
Percentage overall work impairment because of all health conditions (n ¼ 16) 1.89 1.13 9.83
Percentage activity impairment because of all health conditions (n ¼ 17) 20.00 10.00 30.00
Women
Percentage work time missed because of all health conditions (n ¼ 29) 16.67 6.25 22.22
Percentage impairment while working in the presence of all health conditions (n ¼ 43) 30.00 10.00 70.00
Percentage overall work impairment because of all health conditions (n ¼ 52) 2.47 0.62 8.33
Percentage activity impairment because of all health conditions (n ¼ 42) 30.00 10.00 60.00
Q1: percentile 25; Q3: percentile 75.
 Sickness presenteeism among teachers 1057

implementing educational programs in public schools to

Table 5: Cost of sickness presenteeism during the prior week
prevent undiagnosed, late-diagnosed or misdiagnosed ill-
among teachers at four public schools in Leon, Nicaragua.
nesses, and allowing better management of teachers’ health
Median Q1 Q3 Total amount status.
Overall Our findings indicated that a lack suitable household
Cordobas C$ 634.19 250.41 1469.79 57,367.33 conditions for resting was associated with higher rates of
US dollars 19.96 7.88 46.25 1805.27 SP; a similar finding has been reported in previous
Men research.5 Two hypotheses may explain this finding. First,
Cordobas C$ 522.84 262.20 1056.61 11,401.67 teachers may find that staying in their homes while they are
US dollars 16.45 8.25 33.25 358.79 sick is more stressful, because the multiple tasks that they
Women
perform at home prevent satisfactory rest. Thus, teachers
Cordobas C$ 674.61 246.68 1676.65 45,965.67
US dollars 21.23 7.76 52.76 1446.47
may feel that the workplace becomes the home, and the
home becomes the workplace. Second, teachers may find
Exchange rate in August 2018: 1 US dollar ¼ 31.78 Cordobas. All the workplace more challenging and satisfying than their
costs were inflated and reported according to the December 2019
homes. Because teachers may feel very passionate about
monthly consumer price index available from the Nicaraguan
teaching and believe that their work is socially
Central Bank.
Q1: percentile 25; Q3: percentile 75. beneficial,31 they may feel guilty for not attending work
even when they are sick.
In line with previous studies,1,7,11,13 we found that
director or supervisor support was associated with SP. One
Discussion possible interpretation is that teachers may fail to negotiate
days off because of poor communication1 or because they
This study examined the prevalence and predictors of SP, cannot demonstrate their health problems to their director
and estimated the productivity loss impairment associated or supervisor,10 thus driving SP. Another possible
with SP among teachers in four public schools in Leon city, interpretation is that, in public schools, directors or
Nicaragua. SP was a common practice among teachers, supervisors may serve as role models or examples for their
particularly those teaching preschool students, or working subordinates to follow. Because directors or supervisors are
mornings and afternoons or evenings. SP predictors were part of the group vulnerable to SP,11 the high rate of labor
director or supervisor support and having suitable household attendance of directors or supervisors may translate into
conditions for resting. The productivity loss impairment due higher rates of SP among teachers. Regardless of the
to SP and the total costs due to SP were fairly high. explanation for this result, this predictor is important to
The prevalence of teachers who practiced SP (65.2%) design interventions to address SP. An intervention aimed
was higher than that reported in German teachers at enhancing communication from directors or supervisors
(56.0%)13 but in line with the prevalence reported among to subordinates, or identifying signs of illness among
employees in countries such as Montenegro, Malta and teachers, may be useful for the prediction and early
Denmark.6 Clearly, for some individuals with minor detection of SP.
symptoms or mild diseases, the companionship and self- No relationship was found with other factors such as
esteem that comes with the practice of SP can aid in re- work ethic, organizational commitment or work satisfaction.
covery. Nevertheless, our prevalence estimates shed light These findings may be areas for future research in studies
on the overall health status of teachers, and should raise with larger sample sizes. Other drivers such as organizational
public health concerns, because of the growing evidence of policies or organizational culture have been widely
the damaging and harmful consequences of the common researched in other sectors2,10 but are under-researched
practice of SP on employee well-being. For instance, a among teachers. For a more multi-dimensional and
systematic review has found that SP may increase the risk comprehensive overview of SP, future research must address
of future health problems and absence due to long-term the potential relationship between organizational policies or
sickness.3 Other consequences including worsening culture and SP. Finally, analysis using other approaches,
mental and physical health, increasing risk of such as sociological approaches, that can explain SP in
hypertension and depression, a suppressed immune relation to medical conditions as well as the inherent mean-
system, higher risk of coronary heart disease, and ing of the frequent practice of SP among teachers may serve
elevated risk of chronic work-associated stress and work as another path for future research.
exhaustion have also been reported.6 In addition, the risk
to the health and safety of peers and other people due to Limitations
SP has also been recognized. Attending work may
increase the spread of communicable diseases14 and may Some limitations should be noted as the estimates in this
be particularly harmful to vulnerable people, such as article are reviewed. First, the cross-sectional nature of the
school-aged individuals. In the context of pandemics, SP data prevented us from establishing causality between out-
is a potentially dangerous behavior for the workplace; comes and predictors. Second, the measurement of SP was
therefore, SP is a multivariable issue and a public health performed through self-reporting, thus potentially resulting
concern.27 Hence, promoting healthful workplace policies in measurement imprecision because of biases of social desire
and periodical surveillance and evaluation of this or interpersonal differences pertaining to illness concepts.
behavior are crucial, particularly for the subgroups Third, self-reporting might have resulted in possible biases in
reporting higher SP rates. Interventions may include the measurement of productivity loss impairment due to SP.
1058 C. Rojas-Roque and I. López-Bonilla

However, most studies on SP have been based on self- ILB. Validation: CRR and ILB. Writing original draft:
reported measures.2 To decrease bias due to self-reporting, CRR. Writing, review and editing: CRR and ILB.
trained data collection staff gathered the survey observa-
tions during the pilot phase, and this feedback was incor- Acknowledgements
porated into the fieldwork by providing explanations and
removing teachers’ doubts associated with the items in the The authors gratefully acknowledge the contributions of
questionnaire. In addition, four of five questionnaires Maria Gabriela Narváez, Xochilth Montoya Úbeda, Linda
showed good internal reliability (a> 0.75), whereas one Córdoba and Jordan Fiallos Pérez to the fieldwork. Marvin
questionnaire had an alpha below 0.70 (a ¼ 0.67). Fourth, González Quiroz and Christian Toval Ruı́z provided valu-
our approach to monetize the costs of SP followed that used able comments on earlier drafts of the manuscript.
by many studies of converting the percentage decrease in
productivity into several hours per week in which the average Appendix A. Supplementary data
individual is unproductive. However, calculating the cost of
SP is an abstract concept, given the absence of receipts or Supplementary data to this article can be found online at
billing records associated with SP, in contrast to the records [Link]
for health care costs or other workplace outcomes such as
disability or workers’ compensation.32 Finally, the final References
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