Presenteeism in a Dutch hand eczema population—a cross‐sectional survey

Background Presenteeism (attending work despite complaints and ill health, which should prompt rest and absence) has been overlooked in the field of hand eczema. Objectives To examine the 1‐year prevalence of presenteeism related to hand eczema in a population of hand eczema patients who visited a tertiary referral centre. Secondary objectives: to identify intrinsic/extrinsic reasons for presenteeism and to evaluate associated factors. Methods This was a cross‐sectional questionnaire study. Presenteeism was defined as “going to work despite feeling you should have taken sick leave because of hand eczema”. Respondents answered questions about socio‐demographic factors, clinical features, occupational characteristics, and hand eczema related to occupational exposure. Results Forty‐one per cent (141/346) of patients who had both worked and had hand eczema during the past 12 months reported presenteeism. The most often reported reasons were: “Because I do not want to give in to my impairment/weakness” (46%) and “Because I enjoy my work” (40%). Presenteeism was associated with: mean hand eczema severity; absenteeism because of hand eczema; improvement of hand eczema when away from work; and high‐risk occupations. Conclusions In this study, presenteeism was common and predominantly observed in patients with more severe hand eczema and occupational exposure. The most frequently reported reasons for presenteeism were of an intrinsic nature.


| INTRODUCTION
Hand eczema is one of the most prevalent occupational skin diseases in Europe. 1,2 In Germany, it is even the most frequently reported occupational disease. 3 Hand eczema can lead to sickness absenteeism and eventually to job loss and change of profession. [4][5][6] From other medical conditions, such as allergic rhinitis and arthritis, it is known that sickness absenteeism is often preceded by a phase in which workers try to continue their working activities, while their disease actually hampers their productivity and recovery. [7][8][9] This phenomenon is called presenteeism: attending work despite complaints and ill health that should prompt rest and absence from work. 10 Presenteeism can be regarded as a positive concept by workers with chronic conditions who are able to keep working. 11 However, in both the medical and economic literature, presenteeism is mostly regarded as a negative and counterproductive phenomenon. Presenteeism received little attention for years, but has been increasingly studied in occupational medicine since the start of the 21st century. A recent review highlighted presenteeism as a risk factor for future sickness absence and decreased self-rated health. 12 Furthermore, it has been shown that presenteeism may be related to more productivity loss and higher costs than sickness absence in the long term. 13,14 Despite the fact that hand eczema is frequently caused or aggravated by occupational exposures, 15 hand eczema-related presenteeism has hitherto not received much attention. Although a review from 2010 showed a significant impact of occupational contact dermatitis on work activities, 16 to date only 1 study among patients with hand eczema has addressed presenteeism. Van der Meer et al studied Dutch healthcare professionals with self-reported hand eczema. They considered presenteeism to be "lost time at work" (in terms of amount and quality of work performed). The 1-year prevalence of hand eczema in the healthcare professionals was relatively low (12%); of those with hand eczema, 3.1% reported presenteeism and 1.7% reported sickness absence because of hand eczema. 17 To date, little is known about presenteeism in patients with more severe hand eczema, working in various occupations. Therefore, the aim of this study was to examine the 1-year prevalence of presenteeism related to hand eczema in a population of hand eczema patients who visited a tertiary referral centre. Secondary objectives were to identify intrinsic or extrinsic reasons for presenteeism, and to evaluate factors associated with the prevalence of presenteeism in hand eczema patients. Patients were identified by searching electronic patient records from visits between January 1, 2011 and December 31, 2015. Identified patients received a postal questionnaire. In parallel, patients who visited our outpatient clinic and were diagnosed with hand eczema were also recruited. These patients completed the questionnaire digitally on-site.
The questionnaire was developed to assess the prevalence of presenteeism, intrinsic or extrinsic reasons for presenteeism, and factors associated with presenteeism prevalence. Before the start of the study, a pilot study was conducted in 5 hand eczema patients to finalize the questionnaire. The study was reviewed and approved by the Medical Ethical Review Board of the University Medical Centre Groningen (reference METc 2016/169).

| Study population and recruitment
Patients of working age, between 20 and 67 years, with hand eczema diagnosed by a dermatologist in the past 5 years were included. The diagnosis was made in accordance with guidelines by Menné et al and Diepgen et al. 18,19 Patients were identified from electronic records by use of the International Classification of Disease (ICD, 10th edition), according to the diagnoses L20 (Atopic dermatitis), L23 (Allergic contact dermatitis), L24 (Irritant contact dermatitis), L25 (Unspecified contact dermatitis), and L30 (Other dermatitis). This yielded a total of 1168 patients. One author (J.O.) manually screened these files and identified a total of 789 patients in whom the diagnosis of hand eczema could be confirmed. The other 379 patients were excluded, mainly because the ICD codes were not specific for hand eczema and the dermatitis occurred on body areas other than the hands in these patients. For a study flow diagram, see Figure 1.
In June 2016, an invitation letter, a questionnaire and a prepaid return envelope were sent to the 789 eligible patients. A reminder was sent after 5 weeks. The recruitment of the on-site patients took place between June 2016 and March 2017. A total of 115 patients were approached to complete the questionnaire. For data entry by participants on-site and data entry of the postal questionnaires, the online survey software QUALTRICS was used (Qualtrics, Provo, Utah; http://www.qualtrics.com). To improve the response rate, 10 gift coupons of €50 were raffled among the participants who responded to the postal questionnaire.

| Measurements
All concepts are briefly described below. For a comprehensive overview of the definitions and categorization for the analyses, see Appendix S1. All variables concern the past 12 months unless otherwise indicated.
Presenteeism. Patients were asked whether they had both worked and had hand eczema during the past 12 months. In these patients, presenteeism was assessed with the question: "During the past 12 months, did you go to work despite feeling that you should have taken sick leave because of your hand eczema? Yes/no." The duration of presenteeism was also measured. 20 Reasons for presenteeism. Intrinsic and/or extrinsic reasons for presenteeism were measured with the following question: "You indicated that during the past 12 months you went to work despite feeling that you should have taken sick leave because of your hand eczema. What was the reason for this? (multiple answers possible)." Answer categories were assembled from Johansen et al, 21 Johns et al, 22 and Aronsson et al. 10 Following the pilot study, 2 answer categories were added: "Because I think it is expected of me" and "Because I don't want to give in to my affliction/weakness". Hand eczema related to occupational exposure. Absenteeism because of hand eczema; improvement of hand eczema when away from work; 23 hand eczema related to occupational exposure; 23 and wet work, which was determined according to the German "Technische Regeln für Gefahrstoffe" (TRGS) 401 criteria 34 and work by Behroozy et al. 35 Covariables. Frequency of hand eczema ([nearly] all the time or more than once); 23 months worked; and job loss or early retirement because of hand eczema.

| Statistical analysis
Before the analyses were performed, 3 preparatory steps were taken.
First, to handle missing values, each completed postal questionnaire was screened. When missing values were found, the sender was contacted by telephone or email to obtain an answer. In this way, all missing data were retrieved. The design of the digital questionnaire did not allow for missing data. Second, respondents and non- in a sample with a presenteeism proportion of 0.40, the necessary minimal sample size is N = 300. Odds ratios (ORs) with 95% confidence intervals were calculated. Analyses were performed with IBM SPSS STATIS-TICS for Windows, Version 23.0 (IBM Corp., Armonk, New York). A P value of <.05 was regarded as being statistically significant.
A sensitivity analysis was conducted to examine the influence of income on presenteeism in the multivariable model. Information on income was not provided by all respondents (respondents choosing the options "I don't know" or "I would rather not answer this question"), so, for the analysis, these response options were regarded as missing. As logistic regression analysis only handles complete cases, income was left out of the main multivariable model. In a subgroup analysis, reasons for presenteeism were assessed for the digital questionnaire on-site group to check whether reasons in this group differed from those in the total group. to the digital questionnaire on-site were significantly younger than respondents to the postal questionnaire. Also, during the past 12 months, their hand eczema prevalence was higher, they had more severe hand eczema, they worked during fewer months, and they called in sick more often because of their hand eczema (Table 1).

| Presenteeism prevalence and reasons for presenteeism
In the analyses of presenteeism prevalence, 346 respondents were included because they had both worked and had hand eczema during the past 12 months. A total of 141 (40.8%) respondents reported that they had experienced presenteeism during the past year. No significant difference in presenteeism prevalence was observed between the respondents to the digital and postal questionnaires. Table 2 shows the reported reasons for presenteeism with a differentiation between 5 intrinsic and 11 extrinsic reasons. In total, Appendix S2 for all reported reasons for both groups.

| Factors associated with presenteeism
In a univariable logistic regression analysis (Table 3), significant associations were found between presenteeism and variables from all 4 domains (socio-demographics, clinical features, occupational characteristics, and hand eczema related to occupational exposure). Significant variables were included in the multivariable model. For income, see sensitivity analyses.
In the multivariable regression model (Table 4), more severe hand eczema; absence because of hand eczema in the past 12 months, hand eczema that improved when away from work; and working in a high-risk occupation were significantly associated with presenteeism prevalence.

| Sensitivity and subgroup analyses
A higher income was significantly associated with a lower presenteeism prevalence in the univariable analysis. Eighty-eight respondents chose not to disclose information about their income or could not answer this question. When income was added to the multivariable model in Table 4, it was no longer significantly associated with presenteeism. The effect of having a high-risk occupation attenuated and became non-significant (P = .07, n = 258). The other significant independent variables remained significant; see Appendix S3.
In a subgroup analysis, the distribution of reasons for presenteeism in the digital questionnaire on-site group was assessed. This showed a very similar ranking to that in the whole group. The same 2 intrinsic reasons for presenteeism were most frequently reported: "Because I do not want to give in to my impairment/weakness" (57.7%) and "Because I enjoy my work" (40.9%). See Appendix S3.

| DISCUSSION
In this study, we found a 1-year prevalence of 41% for presenteeism because of hand eczema. Intrinsic reasons for presenteeism were common, and the phenomenon was strongly associated with severity and occupational characteristics.
More than 40% of the study population indicated that they had experienced presenteeism because of hand eczema in the past 12 months. This proportion is strikingly higher than the low percentage (3%) that was found by van der Meer et al in their study in Dutch healthcare workers. 17 The discrepancy could partly be explained by the probably mild hand eczema severity of their homogeneous working population, which might have minimized the interference with work, as compared with our occupationally heterogeneous patient population with much more severe hand eczema. Another explanation could be the different definition of presenteeism that was used.
We focused on whether respondents felt that they should have called in sick although they did not (subjectively), instead of asking for lost time at work in terms of amount and quality of work performed (a somewhat more objective measure). However, the difference is large, indicating that the phenomenon is indeed quite common in our patient population. A comparison with presenteeism in patients with other chronic diseases is difficult, mainly because many studies measure presenteeism as a decline in productivity or TABLE 1 Basic characteristics of the total study population (N = 500) and a comparison between respondents to the postal questionnaire and respondents to the digital questionnaire on-site and wounds), they found rather similar percentages of presenteeism, ranging between 42.3% (back pain) and 52.2% (insomnia). 45 The percentage found in our population is slightly lower. This could be explained by the fact that we did not mark every respondent who worked with hand eczema as having presenteeism. We incorporated an additional aspect in our definition of presenteeism by including the phrase "… despite feeling you should have taken sick leave because of your hand eczema". This could be regarded by respondents as a proxy for expected productivity loss ("I am going to work although I think I will be less productive because of my hand eczema today"). It could also be regarded as resulting from fear that their hands would become much worse if they worked, regardless of whether this was at the expense of their productivity ("I am going to work although I think my hand eczema will get worse due to my working activities today"). These 2 explanations might influence each other greatly and may very often coexist. New and better-validated instruments are needed to assess productivity loss caused by presenteeism. 37,46 Once these reliable and valid instruments become available, future studies should focus on determining whether presenteeism in patients with hand eczema actually causes productivity loss.
A notable finding in our study is the intrinsic nature of the most often reported reasons for presenteeism. This was also found by  The total percentage exceeds 100% because subjects were permitted to choose multiple reasons.
a Other reported reasons were: "I don't 'feel sick'" (6); "I am selfemployed" (2); "other work could (temporarily) replace my normal work" (2); "it never occurred to me to call in sick for hand eczema" (2); "I work with livestock" (2); "I didn't want to get in trouble over calling in sick; I could easily work from home; I can't sit still; I don't have enough insurance and can't afford employees; re-organization at work; I don't consider hand eczema a reason for calling in sick; people don't take eczema seriously so I don't want to be considered a fraud; it doesn't match my character to call in sick".   Methodologically, a possible limitation could be common method variance; we measured the outcome and all associated variables with the same self-report questionnaire. Furthermore, it is possible that nonresponse bias in the postal questionnaire group could have influenced the results of this study. Unfortunately, we only had sex and age of the postal non-respondents available, so it is not possible to draw conclusions about the presence of non-response bias.
Data were collected with 2 different methods (postal and digital).
The postal and digital on-site respondents were combined for analysis. Age, mean severity of hand eczema, absenteeism because of hand eczema and months worked during the past 12 months significantly differed between the postal and digital on-site respondents. This was expected regarding severity and absenteeism, as the digital respondents were all patients who sought care from a dermatologist when completing the questionnaire, whereas the postal respondents had visited the department at some point during the past 5 years. Nevertheless, presenteeism prevalence was not significantly different between the groups. This, along with similarities in several other variables (eg, sex, education, occupational characteristics, and, especially, whether respondents had both worked and had hand eczema during the past 12 months), led us to combine the respondent groups. Also, reasons for presenteeism in the digital respondent group showed a very similar ranking to those of the whole group in the subgroup analysis.
Finally, we did not control for a possible influence of certain lifestyle factors, such as smoking, high body mass index, or alcohol use, which have been identified as possible risk factors for presenteeism. 50 In this study, we have shown that presenteeism is a common phenomenon in patients with more severe hand eczema. The most frequently reported reasons for presenteeism were of an intrinsic nature. Dermatologists and occupational physicians should pay attention to presenteeism to provide more individually targeted care for hand eczema patients.