The aim of this study was to investigate the associations between factors in working- and family life and long-term sick listing ≥90 days in Swedish women. The hypothesis that there are associations beyond those which are strictly connected to the medical diagnosis that could be associated with long-term sick leave in Swedish women was confirmed. In this study factors connected with occupational work and own children were studied, but the underlying disease or dysfunction was not further investigated. The results provide evidence that factors in working life connected with competence and influence, industrial mobility, dissatisfaction with work tasks, mental and physical strain above capacity, are associated with long-term sick-listing.
Long-term sick listing show associations with number of children, age at birth of first child and having the main responsibility for own children. The picture of a long-term sick-listed woman could be that she had had her first child rather early, and have more than two children, and took the main responsibility for the children over the years. The women in the reference group seemed to be in more equal family conditions. Thus long-term sick-listing in women was found to be associated with traditional family circumstances and inequality. Multiple demands from family and work could probably entail increased negative stress and be a challenge to women's health and well-being, and a determinant for long-term sickness absence. This is supported by studies, which found that those who have multiple roles and demands are more exposed to negative stress, resulting in physical and psychosocial dysfunctions [24–26]. Lundberg and co-workers (2003) found that during the 1990s the domestic workload, mainly connected with own children, increased for men and women, but to a greater extent for women . In a study of personnel in the Swedish Post it was found that women with children and with exposure to domestic work had an increased risk for high sick leave .
Possibly the sick-listed women had experienced high demands, but not enough flexibility and influence at work. There might be an association with low decision latitude at work. Low influence on working hours is used in this study as a proxy for influence at work, and the women were comparable regarding occupations and jobs. The findings are in concordance with earlier studies, which have demonstrated that low job control is associated with sick leave, and a health hazard, especially in women [28, 29]. Low job control and low social support at work has been found to increase the risk for mortality and sickness absence [30, 31]. In recent research control over daily working hours has been found to be a health promoting factor, which might facilitate employees to combine a full-time job with the demands of domestic work .
Present employment status, such as being permanent employed or not, and hours worked per week did not differ between the investigated groups, but regarding part-time work the results differ and are also somewhat contradictory. In the analyses it was found that part-time work could possibly be potential risk factor for later long-term sick-listing, but on the other hand the sick-listed women reported that they could go back to working life if they could work part-time. This could be interpreted in the sense that doing part-time work earlier in life meant not giving wholehearted support to occupational work, leading to reduced opportunities for adapting to increased demands and the higher levels of competence required in working life later on. At present, when the women are on sick leave, part-time work could have a reverse effect and allow the individual to use at least part of her work ability. It has been concluded that it is mainly women with small children who want to decrease working hours ; however, we did not find that this demand was greater among younger women. Dellve et al (2006) found that part-time work was strongly related to long-term work ability among female home care workers. It is suggested that it could be a way of coping with demanding work, for example high workload . A higher probability of illness has been observed in a study of those who had changed from full-time to part-time work although they were probably in a status of deteriorating health . The associations seem to be complex and the causality is still unclear. The influence of part-time work on long-term sick leave probably depends on the time in life at which it appears, and the possibility of selection bias remains to be investigated.
For younger women in jobs within the healthcare and childcare sectors there was found an association with reported bullying at work from superiors or workmates. This could explain a later sickness absence, as bullying is serious and deeply affects the individual. It reflects a poor psychosocial climate at the workplace, as well as insufficient leadership. It has earlier been concluded that not only the victims, but also the observers at the workplace report negative stress due to the existence of bullying . In a Finnish study, exposure to bullying was shown to be a risk factor for later sick-listing in women . The study population was hospital staff, thus in many ways similar to our study population. An extensive Swedish study of health and sickness absence in women in the public sector, as well as a study of female personnel in a large Swedish company, showed associations between bullying at work and later sick-listing [19, 37].
In the logistic model there were associations between dissatisfaction with the workplace and few employers over the years; and in the bi-variate analyses between lack of appreciation at work and an overall dissatisfaction with working life. These findings could be interpreted in different ways: One possible explanation could be that the sick-listed women to a larger extent were not in their most sought-after jobs or occupations, and that reported dissatisfaction therefore could have a negative impact on their work situation. Also, as the sick-listed women had more often been absent from work due to more pregnancies, and probably also for taking care of their children when they were ill, it is possible that they were not able to contribute satisfactorily at work or were not sufficiently updated to fulfil the demands at work. Earlier periods of absence from work due to children and childbirth could explain the sick-listed women's reported lack of competence. Increasing demands at the workplace during the past years probably require a continuous and steady presence to maintain skills and keep up to date. The sick-listed women in our study might not have been able to cope with these increasing demands, which were connected with reorganisations and staff cuts. They found reorganisations more demanding and trying. Being on long-term sick leave could be a strategy for women who are unable to handle the new and increasing demands at work due to downsizing and reorganisations. These findings are in concordance with those from other studies showing that all forms of organisational instability, downsizing or expansion are related to sickness absence and health hazards [3, 18, 40].
The results from this study must be interpreted in relation to the general situation on the labour market and how it has developed, especially during recent years when the number of people on sick leave has gone up. The increase in general job strain could certainly be a health hazard to those who have additional strain from family life. It is thus possible that the potential determinants for long-term sick-listing identified in this study could reflect deficiencies in changing work organisations. There has been increased sex segregation in the Swedish labour market during the 1990s and the beginning of this century. In areas where mostly women work, in the public sector, the conditions have deteriorated further, time pressure has increased, and there has been an increase in mental and physical workload, above all in labour-intensive services and in human services [3, 19, 38]. It has been concluded that organisational downsizing can deteriorate the psychosocial work environment and cause increased rates of sick leave in employees [39–41]. These circumstances can probably explain, at least to a certain extent, the rapid and extensive increase in long-term sick leave in women during the recent years.
The study population was randomly selected from the AFA register and the Swedish populations register. Employees from different sectors of the labour market were thus included, especially those where women predominate. The findings could be generalised to a great deal of these women, especially those in the public sector and in the investigated age groups.
Certain medical diagnoses which have not increased during the past years were excluded in order to concentrate in those diagnoses which stand behind the recent increase in long-term sick-listing . Immigrated women were not included in this study as it has been demonstrated that they differ from the native Swedish women regarding factors connected to sick leave and poor health . There is no simple causal connection which can explain the differences, but it has been suggested that there is a reciprocal influence between health, work, and migration, which is more pronounced for women than for men . This exclusion could cause an underestimation of potential risk for sick-listing in the women living in Sweden.
The data was collected at one occasion and therefore the causality is unclear. The direction of causality is somewhat clearer regarding data on number of children, age at birth of first child, number of employers and earlier jobs, but more unclear regarding reports of other factors in working life. As the study is based on retrospective self-reported data it is possible that the reporting could be dependent on the outcome, which is the sick leave itself, and a decreased health status among the cases. This is a limitation due to the design of this study, and some of the reported retrospective aspects of working life could have been influenced by the present long-term sick-leave. But this was what they reported at the time of our investigation and it reflects the circumstances when reporting. The factors investigated could hardly be estimated in any other way than by self-reports, unless the study would have had a prospective design. Therefore the conclusions should be drawn with care.