This is the first qualitative study that examines decisions of absence versus attendance when feeling ill among male car mechanics. We found three themes at stake during the decision-making process: 1) Experienced degree of illness, 2) daily life habits, and 3) the importance of the job.
The strength of this study is the use of an open-ended question about decisive themes for absence or attendance at work when feeling ill. Such a question can provide a deeper insight into the process of calling in sick than closed answer surveys can. However, because this question was part of a study with several other questions, the possibility of follow-up questions was limited, and the answers may therefore reflect intuitive responses, rather than thorough reflections. The dilemma of choosing absence or attendance when feeling ill may be a relevant issue for other employees. However, the generalizability is limited, as the absence–attendance culture is probably deeply embedded in organisational practice . The study involved only men, and women might have had other experiences and other areas for consideration than what was found among men, for example due to gendered roles in child care and domestic work. In contrast to studies with similar questions, the informants in the current study were not selected because of their illness or sickness absence [18, 23]. All informants were present at work and reflected on previous experiences of illness and the possible dilemma of attending work or not. Consequently, we do not know their actions, but rather their attitudes to such situations. Of practical reasons, all workers on sickness absence on the day of interview were not included in the study. This is a limitation, as the current sample has to rely on the memory of reporting ill. The present workers may also be selective for those who decide to attend work even if they feel ill. The workers on sickness absence might differ from the present informants regarding decisions of absence versus attendance and therefore might have offered valuable experiences that would have been particularly relevant for the question in our study. Another possible limitation is related to the finding that informants seldom presented negative sides of themselves, such as socially incorrect behaviour . Hence, there might be a bias due to the informants’ desire to make a good impression.
The first theme identified when considering absence or attendance dealt with the experienced degree of illness as perceived by the informants the morning in question. This is in line with the findings in a qualitative study among offshore catering workers , where the participants expressed that the severity of their health conditions, for instance if it was contagious, was decisive for staying away from work. Several informants in our study presented symptoms to illustrate the experienced degree of illness. High fever, vomiting and diarrhoea were considered incompatible with work attendance, thus making a decision of absence versus attendance unnecessary. Decision of work attendance seemed to be based on ability to perform daily life activities at home, which was equated with the ability to work. Therefore, this category may not be specific for car mechanics, but indicate that a norm of legitimate absence is in play. However, the presented illnesses differ from those reported in other studies of presenteeism or absenteeism. The most frequent causes of sickness absence are found to be musculoskeletal pain, fatigue and slight depression . In Norway, causes of absence are dominated by musculoskeletal disorders and mental disorders [25, 26]. Among car mechanics, musculoskeletal problems are found to be associated with absence from work . Surprisingly, our informants focused neither on musculoskeletal nor mental disorders. This observation may indicate that the symptoms described are associated with self-certified sickness absence. Although the causes of self-certified sickness absence in Norway are unknown, they are probably dominated by flu and cold . Symptoms of viral infections have often an acute onset and a short duration and seldom require medical treatment. Musculoskeletal and mental disorders more often require medical advice and sickness certification. By consulting a doctor the workers may transfer the decision and potential dilemma of sickness absence versus sickness attendance to a professional.
Daily life habits were the second theme identified in this study. In nearly all cases the outcome of habits was sickness attendance. According to the push-pull model of motivation developed by Gambetta , daily life habits may be interpreted as a push factor. Behaviour based on norms, traditions or class values is described as non-reflexive and ‘pushes the individual from behind’. Strict work-attendance standards and internalized work-duty norms seem to promote the sickness attendance practice. This phenomenon is also found in other studies of sickness absence and sickness attendance . Workers with conservative attitudes towards absence have been found to prefer sickness attendance . A study describes the father who ‘never took a day off from work due to illness’ as influential in men’s account of common health problems and work . The typical descriptions of habits in the family and during childhood indicate that the daily life habits may be of general relevance and not related to the specific occupation of car mechanics. However, even though not explicitly expressed by the informants, the individual behaviour is also assumed to be constrained by the social influence and the absence culture of the organization .
The third theme, the importance of the job, may be interpreted as a kind of attendance requirement i.e. the work have to be finished if negative consequences for customers and colleagues were to be avoided. According to the push-pull model of Gambetta , this fits well into the pull dimension. ‘Pulled from the front’ assumes that individuals act purposely in accordance with their intentions. Faced with multiple options, they will reflect and choose according to anticipated future rewards. In this case career interests and responsibility for work tasks, colleagues and customers may pull the person towards work despite of him feeling ill. Other models use both ‘attendance incentives’ and ‘attendance requirements’  to label mechanisms that resemble the pull and push concepts employed by Gambetta. In the present study we use pull to signify that individuals are pulled towards work because their attendance is highly required . Sickness presenteeism seems to occur in small firms, where time pressure is prevalent and the replacement of an absent employee is difficult. In such an environment sick leave often has a negative consequence for the absentee, his colleagues or third parties [1, 6]. The context of car mechanic work strongly reflects these characteristics. The study on offshore catering workers  also underscored the importance of specific job situations, for instance if they were onshore or offshore the day of decision. The findings support the general view of the work environment as important for decisions of sickness absence or presence. There is still limited knowledge about the impact of cultures in different occupations, and also possible gender differences. This should be studied further.
Many of the workers that presented themselves as healthy individuals seemed to experience minor illnesses, but did not express a dilemma regarding absence or attendance. It may be that individuals who characterise themselves as healthy hardly ever have health problems, or they may have an unusual high threshold for feeling sick. However, the mean age of 32 years in our study population indicates that these workers represent a healthy group.
The three themes of considerations in the process of choosing absence or attendance when ill are not assumed to be occur separately, even though the informants in our study seemed to have their primary focus on one of the themes. The relationship between “experienced degree of illness” and “the importance of the job” are supposed to be closely related and possibly dependent on the specific job context. Similarly, the “model of illness flexibility” by Johansson & Lundberg  describes the role of work specific factors “adjustment latitude” and “attendance requirement” in combination with “loss of function” in the choice between going to work or not when sick. The statements included in “daily life habits” might be expressions of “attendance requirement” that were not reflected on or made explicit by the informants. This hypothesis has to be followed up by more studies.
A strong motivation for work attendance dominated the decision process in all three areas for consideration in our study. The focus on attendance versus absence in case of sickness may be influenced by low age and a ‘healthy worker effect’ i.e. the phenomenon that unhealthy individuals are excluded from demanding work, whereas healthy individuals remain . However, the sickness absence among car mechanics is about the same as the mean sickness absence among Norwegian men , which does not support the healthy worker effect.