Absenteeism vs. Presenteeism: Measuring the Cost of Working While Unwell

Presenteeism is going to work while ill, the definition Gary Johns used in his 2010 review of the research; absenteeism is staying away because of illness.¹ Both cost working time, but only one leaves a record. A sick day is logged against a name and summed in national statistics. A day worked through a fever, a migraine or a bad back shows up nowhere unless someone asks.

That gap matters because the pressures that keep people off sick lists are not always healthy ones. A 2016 meta-analysismeta-analysis: A study that combines the results of earlier studies on the same question into one overall estimate. Pooling makes the estimate more precise, but it cannot repair the studies it pools: a meta-analysis of surveys is still survey evidence.Full entry in the glossary by Mariella Miraglia and Gary Johns found that strict absence rules, heavy workloads and understaffing go with more working while ill, and the authors advise auditing attendance policies that may cut absence at the cost of more presenteeism.² The working rule follows: read the sick-day count next to one plain question about working while ill, asked the same way every time. Both sit inside the wider dimensions of employee wellbeing, where working conditions come first.

Prefer to watch? The video covers the same ground as this article.

VideoAbsenteeism vs. Presenteeism: The Cost of Working While UnwellWiserHours

Absenteeism vs. presenteeism: two definitions and a missing record

Absenteeism is time missed from work because of illness or injury, and presenteeism, in its most common research sense, is attending work while ill.

Johns reviewed nine distinct definitions, and research has since settled on two: going to work ill, and the productivity lost when people do. The second dominates occupational medicine, but Johns objected that it folds the cost into the definition before anyone asks why people came in.²

Take a support agent who coughs through three days of calls instead of taking two days off. The month’s absence report improves. The agent’s output, recovery and possibly colleagues’ health do not, and the dashboard cannot tell those two stories apart. So treat a drop in sick days as a question rather than a win until you know whether people got healthier or simply stopped staying home.

How absence is counted: the UK and the US as examples

In the UK and the US, for example, official absence figures come from household surveys that ask workers, not from employers’ records. The UK’s Office for National Statistics (ONS) uses its Labour Force Survey.⁵ The US Bureau of Labor Statistics (BLS) uses the Current Population Survey; its 2025 annual figures cover only 11 months, because October went uncollected during the federal government shutdown.⁶

The UK rate works out at about 4.4 days a year per worker, and minor illnesses such as coughs, colds and flu were the most common reason given, in about three of every ten absences. The ONS labels these official statistics in development and advises extra caution with changes involving 2023 and 2024, after quality problems in its survey and changes to its methods.⁵

The same country can produce two very different absence numbers. The CIPD, the UK-based professional body for HR, put the average at roughly double the ONS figure in days in its 2025 survey, which YouGov ran with support from Simplyhealth, a company that sells workplace health plans. Its figure comes from HR professionals reporting on their own organizations, not from a sample of workers.⁷ Neither number is wrong. They count different people in different ways.

Before calling your own absence rate high or low, check that the benchmark was built the same way. An HR team reading days per employee from its own records is closer in method to the CIPD’s employer survey than to the ONS figure, which comes from asking workers about hours.

Why presenteeism is harder to measure than absence

Presenteeism is harder to measure because nobody records it: almost every study relies on what workers say, and the questions differ. Miraglia and Johns found three approaches in the research they pooled: counting days worked while ill, rating how often it happened, and inferring it from people with health problems who took no sick leave.²

A typical question comes from a 2000 Swedish study by Gunnar Aronsson and colleagues, who asked whether, over the past year, people had gone to work despite feeling they should have taken sick leave because of their health.³ Each part of such a question shapes the answer: how far back people must remember, what counts as ill, and who judges.

A 2019 systematic reviewsystematic review: A review that fixes its question and its rules for including studies in advance, then searches out every study that fits and weighs them together. Some systematic reviews pool the results into a meta-analysis; others describe what the studies found without combining the numbers.Full entry in the glossary of working with infectious illness found reported rates from about a third of workers to almost all of them, with recall periods from a couple of months to years. Lack of cover, a culture of attending, fear of discipline and money worries were among the reasons people gave, though many studies were of health-care staff and their quality was relatively poor.⁸

In a 2004 cost study of health conditions affecting US employers, Ron Goetzel and colleagues, most of them at the health-data firm MEDSTAT, combined a large medical and absence database with published productivity surveys and estimated that presenteeism made up between 18 and 60 percent of the total cost of the 10 conditions it covered, more than medical costs in most cases.⁴ It is a model-based estimate, not a measured cost, and the authors urge caution with any single data source. For an employer, the useful reading is that working below par may cost more than the medical bill, by an amount no single model pins down.

1. Absence is counted: employers log sick days, and national labour-force surveys in the UK and US ask workers about hours lost to sickness
2. Presenteeism is asked about: studies almost always rely on the worker’s own answer: whether they went in while ill, or how much their work suffered; putting a money value on the second needs a model

So measure the act and its cost separately. Ask the same plain question each time, with the same recall period: for example, on how many days in the past four weeks did you work while feeling ill enough to stay home? That wording is our suggestion, not a validated instrument. Treat any money figure built on top of the answers as a range.

What pushes people to work while ill

Poor health itself, rules that make absence costly, heavy workloads and short staffing are among the conditions most strongly linked to working while ill, according to Miraglia and Johns’s 2016 meta-analysis. Almost all the studies it pooled were cross-sectionalcross-sectional: Describes a study that measures everyone in its sample at a single point in time. Because the possible cause and the outcome are recorded together, it can show that two things occur together but not which of them came first.Full entry in the glossary surveys relying on self-reportself-report: A measure in which people describe their own behavior, feelings or circumstances, usually by answering a questionnaire. When the same person supplies both of the things being compared, shared habits of answering can make the link between them look stronger than it is.Full entry in the glossary, so they show which conditions travel together, not which came first.²

The study

Moderate evidence

Miraglia and Johns, 2016: 61 studies of going to work ill, pooled (Journal of Occupational Health Psychology)

Working while ill went with poorer general health (a corrected correlation of about −0.31 across 67 samples), stricter absence policies such as disciplinary trigger points or little paid sick leave (about 0.39), heavier workloads (about 0.28), understaffing (about 0.25) and emotional exhaustion (about 0.36). Being easy to replace went with slightly less of it. More satisfied, committed and engaged employees also went in ill slightly more often, which the authors interpret as a second, motivational path alongside declining health.²

Correlations of this size are moderate: clear across thousands of workers, but a weak guide to what any one person will do or how much a single change would help.

Bar chart with 5 bars; the largest is Strict absence policies at about 0.39.

• Strict absence policiesabout 0.39
• Emotional exhaustionabout 0.36
• Poorer general healthabout 0.31
• Heavier workloadabout 0.28
• Understaffingabout 0.25

Work that waits for you pulls the same way. In the Swedish study, people who had to catch up on almost all their own work after a week off were more likely to go in ill than those with little or none to catch up. Rates were highest in care, welfare and teaching jobs, which the authors had expected from ties with patients, clients and pupils.³

In a team of three where nobody covers anyone, a person who wakes with flu knows Monday’s queue will be twice as long. The emotional exhaustion in the Spotlight is close to the exhaustion dimension of burnout as the WHO describes it, and the engaged employees who go in ill are a reminder that employee engagement is not the same as wellbeing.

Start by checking what your rules make people do. Miraglia and Johns suggest auditing attendance policies and keeping demands such as workload, time pressure and overtime in check.² Arranging cover so work does not pile up answers the Swedish finding, though that is our inference and none of these studies tested it.

How to track both in your own organization

Track absence from records, add one repeated question about working while ill, and read the two together. These steps are our synthesis of the evidence above, not a tested protocol.

1. Write down how your absence figure is measured (per employee or per hour, which absences count) so later comparisons are like with like.
2. Add one question about the act of working while ill to a regular anonymous pulse survey, with a fixed recall period, and report it only in aggregate. Never ask for diagnoses.
3. Read the two figures side by side, never one alone.
4. Check the pressures behind any rise: attendance triggers, missing cover, workload and overtime.
5. Treat any money estimate as a range and say which model produced it.

An invented example of step 3: an office tightens its sickness triggers, and next quarter recorded sick days fall while more people say they worked ill at least once. The report looks better, but some sickness may simply have moved from home to the office, the trade-off the meta-analysis warns about.

Is working while ill always a mistake? Contagious versus long-term illness

Whether working while ill is a mistake depends on the illness. For flu, the World Health Organization advises people with mild symptoms to stay home to avoid infecting others,⁹ and US and English guidance on respiratory infections agrees; for a long-term condition that is neither contagious nor disabling that day, some work can be reasonable. Elsewhere, check your own health authority’s advice.

The US Centers for Disease Control and Prevention (CDC) 2025 guidance says to stay home and away from others with respiratory virus symptoms not better explained by another cause. People can go back to normal activities once symptoms have been improving overall and they have had no fever, without fever-reducing medicine, for at least 24 hours, then take extra precautions for 5 days. The CDC also asks organizations to advise sick people to stay home and to offer paid time off and flexible leave and telework policies.¹⁰

Guidance for England from the UK Health Security Agency is similar: with a high temperature, or when too unwell to work, try to stay at home and avoid contact, work from home if you can, and talk to your employer if you cannot.¹¹

Long-term conditions are different. Some productivity is better than none when an illness is neither debilitating nor contagious, Miraglia and Johns note, and going to work may be self-affirming for some people with chronic conditions such as migraine or depression.² Over time, though, the pattern leans negative: a 2016 systematic review of 12 long-term studies found that most linked working while ill to more sickness absence and poorer self-rated health later, while results for specific physical and mental health outcomes were not yet consistent.¹²

A colleague with a fever who comes in to show willing risks passing the infection to people nearby. A colleague with migraine who works a shorter day with the screen dimmed is making another kind of trade, one that changes to hours or setting might support.

The second half is our suggestion.

When to see a doctor or get urgent help

In an emergency, call your local emergency number. The US and UK routes below are examples from the CDC, the NHS and the National Institute of Mental Health (NIMH); we sorted them by urgency.

• Now: the CDC advises seeking emergency medical care immediately for warning signs such as trouble breathing or chest pain.¹⁰ NIMH’s US advice is to call 911 or go to an emergency room when a life is threatened, and to use 988, by call or text, for emotional distress or suicidal thoughts.¹³ In the UK, emergencies go to 999 or A&E, according to the NHS 111 service.¹⁴ For a mental health crisis, the NHS says to use 999 or A&E if someone’s life is at risk or you cannot keep yourself or someone else safe; Samaritans answers free on 116 123.¹⁵ Elsewhere, use your local emergency number and crisis services.
• Soon: the WHO advises people with flu to seek medical care if symptoms get worse, or from the start if they have severe symptoms or other medical conditions.⁹ In the UK, NHS 111 (by phone or online) is the route when you think medical help is needed now.¹⁴ For mental health concerns in the US, NIMH suggests a primary care provider as the starting point, since one can do a first screening and a referral.¹³ Elsewhere, a family doctor or local health service is a sensible first call.
• Routine: raise a long-term condition that keeps you working below par at your next regular appointment and, if you choose, with occupational health or HR, to ask whether the work can be adjusted.

The bottom line

Absence is the part of sickness an organization can count; presenteeism is the part it has to ask about. Read them together, because strict attendance rules, heavy workloads and thin cover are linked to more working while ill. With a contagious illness, staying away from colleagues is what the WHO and US and English public-health guidance advise.