The population examined in this study is willing to pay more for flexibility at the workplace for people with a chronic disease in general than they are prepared to pay for people with diabetes. The difference in WTP was statistically significant for the “Possibility of part-time” and “Customizing job description” attributes, as well as for the overall average. There were also statistically significant differences in WTP between diabetes and chronic disease in general across subgroups, all of which were found to be higher for chronic disease. This was evident for the subgroups: female, 25–49 years, less than 3 years of further education, relatives or friends with diabetes, treated for a chronic disease within the last year, and the employer not being responsible for flexible working conditions. Our results further indicate that people perceive diabetes, in relative terms, to be of least importance when considering the extent to which employers should ensure flexible work conditions for people with chronic diseases. Although certain flexibility attributes and subgroup analyses did not reach statistical significance, possibly due to sample size, the estimated WTP amounts still indicate an empirically relevant WTP in both groups.
The differences in WTP and opinions regarding employer responsibility may be explained by the perceived severity of the diseases in question. Previous studies have shown that diabetes is perceived as the least severe disease in comparison with heart disease, cancer and stroke [23,24,25]. Furthermore, it has been shown that people view diabetes as a relatively controllable disease as compared to cancer for example [23, 24]. Other research reveals that concern about developing diabetes is relatively low for both women, for whom concerns about breast cancer and heart disease figure more prominently, and men, among whom heart disease and prostate cancer give cause for greatest concern . Likewise, it has also been demonstrated that people have a tendency to underestimate their risk of developing type 2 diabetes . Viewed in light of the existing literature, our results suggest that people of working age do not regard diabetes as a disease that requires as much flexibility or accommodation in the workplace as other chronic diseases, at least in terms of their WTP. This is indicative of a prevailing perception about diabetes as a condition which is essentially manageable and thus not requiring the same level of flexibility or accommodation in the context of work as, for instance, cancer and heart disease. This suggests a potential need for dissemination of knowledge on how to support people with diabetes to be able to reconcile diabetes and work life and to enable people with diabetes to stay in the labor market without limitations brought on by their condition.
Our analysis of WTP for diabetes and chronic disease in general across subgroups revealed that female participants were willing to pay significantly more for chronic disease in general compared to diabetes, while no differences were found in the male subgroup. Being in the younger subgroup and being in the subgroup with a lower level of education also yielded significantly higher WTP values for chronic disease in general compared to diabetes. One potential reason for these observations is the relationship between the respective subgroups and their mean income. All three subgroups, at least in Denmark, are known to have a lower income compared to their counterparts (males, older age group, more than 3 years of further education) [27, 28]. Previous research has shown that income is positively correlated with WTP [29,30,31]. As such, the lower WTP for diabetes compared to chronic disease in these subgroups may reflect a certain difference in ability to pay or at least a different prioritization of disposable income. This inference is also supported by the fact that all three subgroups had a lower WTP value for both diabetes and chronic disease compared to their counterparts, except in the case of chronic disease in the less than 3 years of further education subgroup. WTP in different subgroups of the population may also be partly determined by risk of developing a chronic disease, e.g. indicated by the markedly higher WTP for both diabetes and chronic disease in general of the older age group compared to the younger.
The subgroup analysis further showed that people who do not have relatives or friends with diabetes are willing to pay significantly more for chronic disease in general compared to diabetes, whereas for those with a relative or friend with diabetes there was no statistically significant difference. This finding indicates that respondents with first-hand knowledge of diabetes are more inclined to recognize the need for workplace accommodations and less inclined to view diabetes as of less importance than chronic disease in general. However, the WTP value for diabetes in this subgroup was still lower than for respondents without a friend or relative with the condition. The relatively low WTP among this group may initially seem counter-intuitive, suggesting a perception of diabetes as a relatively manageable disease among people who know someone with the condition. At the same time, in the context of the Danish welfare state, it may also reflect the fact that people who are familiar with diabetes feel that workplace accommodations should be covered by existing legislation regarding flexibility at the workplace.
The respondents who had themselves been treated for a chronic disease within the past year reported a significantly higher WTP for chronic disease in general compared to diabetes, while not having been treated resulted in no statistically significant difference. While not a surprising finding, this result indicates that people who have first-hand experience with chronic disease value flexibility at the workplace higher for chronic disease in general than for diabetes and, since this outcome is to be expected, supports the validity of the discrete choice methodology as capable and sensitive enough to ascertain actual, true preferences.
The results we present indicate that diabetes has a relatively modest ranking as a condition for which flexibility and accommodation at work are perceived to be justified. Public perceptions about diabetes in this context do not, therefore, tally well with what is known about the demands and consequences of the condition in the context of work life . Numerous studies have demonstrated that a diagnosis with diabetes impacts negatively on a range of labor market outcomes e.g. early retirement , productivity , absenteeism  and income levels . The findings we present here indicate that the working population is willing to pay for flexible working conditions for people with chronic disease in general as well as for people with diabetes. However, diabetes was across all our results consistently rated as a disease requiring less flexibility at the workplace compared to chronic disease in general, indicating a lack of knowledge and understanding about the actual scale of the problem of having diabetes in the context of work life.
Strengths and limitations
To our knowledge, this is the first study comparing WTP for flexibility at the workplace for people with diabetes and for people with chronic disease in general. Strengths of this study include the large study population and high response efficiency. Furthermore, there were no statistically significant differences in demographic or chronic disease variables between the group asked about diabetes and the group asked about chronic disease in general, limiting bias arising from heterogeneity between groups. A noteworthy strength of the DCEs used in this study is the ability to concretize the rather abstract question of how much one is willing to pay for a hypothetical attribute by obliging the respondent to choose between predefined options. Another strength of the DCE is the balanced and orthogonal design resulting in a perfectly efficient design .
Although the DCE has many advantages, there may be some methodological limitations. DCEs may be cognitively challenging for some people, in part due to possible fatigue from the large number of questions and also due to respondents’ evaluations regarding the hypothetical context of the experiment . Our response efficiency was, however, high with only 36 respondents excluded due to not understanding the DCE scenarios, indicating that the experiments were meaningful to the participants. Respondents with diabetes were excluded in this study. This may have resulted in slightly overestimated WTP values for flexible accommodations for people with diabetes at work as a previous study, surprisingly, showed relatively lower WTP for flexibility accommodations at work for people with diabetes among people with diabetes themselves . Thus, the difference in WTP for people with diabetes and other chronic diseases may be even bigger than this study suggests. Furthermore, there may be issues of generalizability as it may only be a certain selected group of the general population (e.g., blue-collar workers) who participate in online surveys.
We recognize that, in seeking to set perceptions about diabetes into relief, we have compared diabetes to a number of chronic conditions with which it is often comorbid. The relative influence of diabetes specific morbidity and comorbidity in relation to the labor market outcomes of people with diabetes is, however, an important point of focus and one which research has only recently begun to address . In contrast to public perceptions about the relative severity of diabetes in the context of work life, epidemiological evidence indicates a profound problem impacting both individuals and society at large. There is, moreover, the threat that diabetes will become more prevalent in the working population in the future if population ageing and lifestyle trends continue their current course. Now may be the time to take seriously the challenges that people with diabetes face in their work-life context.