Background: The high levels of sickness absence and disability pensioning experienced during the 1990's and 2000's have become both socially as well as financially burdensome for society. Sickness absence implies a costly loss of production for society and large groups of individuals are risking to become marginalised on the labour market. Sickness absence is both a public health and an economic problem. Thus from both a human approach as well as from an economic perspective it is urgent to increase knowledge about what influences individual behaviour when it comes to sickness absence and return to work. Objectives: The overall aim of the thesis is to elucidate the decisive factors for explaining sickness absence. Three different aspects of sickness absence were considered, i.e. factors leading to sickness absence, factors preventing sickness absence and factors leading back to work ability and work when being sickness absent. This is done using a frame of reference involving broadly defined areas of work, health and social insurance related factors. Material and methods: Study I analyzes the outcome of unemployed sick-listed individuals. A total of 280 individuals from the county of Värmland were followed through register data between the years 2000 to 2001. Linear and logistic regression models were used to analyze the occurrence of short and long term economic incentives. Study II has a longitudinal design and explores determinants of return to work. Sick-listed individuals with a stress-related psychiatric diagnosis from the county of Värmland were analyzed over a period of three years (2000-2003) using logistic regression. The data comprised 911 individuals. Study III is a cross-sectional study using questionnaire data from the county of Värmland from year 2004. A total of 3123 persons either working or being self employed were analyzed on determinants of work presence through logistic regression. Study IV had a cross-sectional design and used questionnaire data from five counties in central Sweden. The data, from 2004, comprised 10536 individuals being employed, i.e. not self-employed, and with self reported physical and mental medical conditions. Logistic regression was mainly used in the analysis and the focus was on risk factors for long term sickness absence. Study V comprises cross-sectional data retrieved at three separate occasions between 1991 and 1994. It includes 8839 individuals from five counties in western Sweden with sickness absence spells over 60 days. The data was analysed through bi-variate probit regression with a focus on effects of vocational rehabilitation on return to work. Results: The results from study I were interpreted as that both short and long term economic incentives matter for the outcome of sickness absence through the interaction of different insurance systems. The principal findings from study II was that age, gender and factors implying less favourable health characteristics and thereby lower work capacity, reduce probabilities of returning to work after long term sickness absence. Considering study III determinants of work presence were found to vary between sexes and whether the determinants were counteracting long or short term sickness absence. Factors interpreted as job control counteracted short term absence. Sense of coherence was found to be an important determinant of work presence for women. In study IV long term sickness absence was found to be related to the level of ill-health. Moreover it was concluded that work environment factors as job strain, job satisfaction, physical work environment were important factors for explaining sickness absence in a population with impaired health. The results from study V indicated that vocational rehabilitation is a potentially effective instrument for improving the individual's work ability and chances of return to work. That no signs of prioritizing selection of rehabilitation participants to those likely to return to work with or without rehabilitation measures, i.e. "managerial creaming", were found was also considered as important results. Conclusions: This thesis shows that we need different models and approaches to improve knowledge about the various aspects of sickness absence as entry into absence, return to work or into disability retirement. It also has the implications that sickness absence behaviour can be influenced. Largely depending on what long term path is chosen for welfare policy at the political level it should be acknowledged that other means, improving working conditions and promoting rehabilitation rather than reducing benefit levels and narrowing the eligibility criteria for the insurance benefits are at hand.

In Sweden, sickness absence due to mental disorder is increasing for both men and women, although more among women. The psychosocial work environment is acknowledged as an important predictor for sickness absence. Employee based work-time control is beneficial for the balance between job stress and recovery and could therefore be of interest when aiming to prevent sickness absence. The aim is to investigate the association between control over daily hours (CoDH) and control over time off (CoT), respectively, and sickness absence. The study also examine whether the association differ by gender and if burnout or depression mediates the associations. Data was derived from two waves of the Swedish Longitudinal Occupational Survey of Health (SLOSH) which is an approximate representation of the Swedish working population (n=8418, of which 4936 were females). Binary logistic regression was used as method of analysis. After adjustment for possible confounders, no association between CoDH and sickness absence was found. Low CoT was significantly associated with sickness absence among men (OR=0.90 [0.84, 0.96]), but not among women. Neither burnout nor depression mediates the associations. CoT is stronger associated with sickness absence than CoDH. CoT with regard to sickness absence is of greater importance for men than women.

Aims: This study examined the prospective association between male-female ratio in occupations and levels of effort-reward imbalance, burnout and sickness absence. Specifically, we examined whether levels of effort-reward imbalance, burnout and sickness absence differed by strata of occupational gender composition, and whether effort-reward imbalance explained these differences. Methods: Data from two waves of the Swedish Longitudinal Occupational Survey of Health (SLOSH) was used, forming a sample of 9051 participants. Chi-square test and one-way ANOVA were used to estimate differences in variables between strata of occupational gender composition, and multiple logistic regression analyses were performed to analyse if effort-reward imbalance explained differences in outcomes between five strata of occupational gender composition. The analyses were stratified by gender and level of education. Results: Levels of effort-reward imbalance, burnout and sickness absence varied by strata of occupational gender composition. Effort-reward imbalance was the most consistent predictor, while few significant associations were found between occupational gender composition and the outcomes. Effort-reward imbalance mediated some, but not all of the significant associations between occupational gender composition and the outcomes. Conclusions: There was no strong support for an association between occupational male-female ratio and burnout or sickness absence. Effort-reward imbalance was prospectively associated with all outcomes.

Bakgrund: Sjukfrånvaro, sjukskrivningar och ohälsa är något som kostar både samhället och företagen mycket pengar. En medarbetares personliga hälsa spelar en stor roll när det kommer till både lönsamhet och produktivitet på arbetsplatsen. Motion leder till att en individ blir bättre på att planera arbetsuppgifter, får bättre koncentration och initiativtagande. Många företag investerar i sin personal i form av friskvård, men den förbättrade prestationen varken redovisas eller mäts på ett specifikt konto i redovisningen.  Syfte: Syftet med uppsatsen är att undersöka om och hur företag använder sig av nyckeltal som mäter den ekonomiska resultateffekten av friskvård och andra hälsofrämjande insatser.  Metod: Vi kommer i det här arbetet använda oss av en kvalitativ metod tillsammans med en deduktiv ansats. Datainsamling sker genom semistrukturerade intervjuer eftersom vi då har möjlighet att anpassa våra frågor och följdfrågor. Totalt har 14 respondenter från 13 olika företag intervjuats.  Slutsats: Studien har visat att företag vanligtvis inte mäter den ekonomiska effektiviteten av friskvård och hälsofrämjande insatser, varken generellt eller med hjälp av bestämda nyckeltal. Flertalet upplever att det saknas ett enkelt tillvägagångssätt och många upplever inte sjukfrånvaron som ett problemområde. Samtidigt visade studien att sjukfrånvaron kan vara missvisande eftersom anställda underpresterar på grund av sjuknärvaro. / Background: Absence due to illness, sick leave and ill health is something that costs both society and companies a lot of money. An employee's personal health plays a big role when it comes to both profitability and productivity in the workplace. Exercise leads to an individual becoming better at planning tasks, gaining better concentration and initiative. Many companies invest in their staff in the form of wellness, but the improved performance is neither reported nor measured in a specific account in the accounting. Purpose: The purpose of the essay is to investigate whether and how companies use key performance indicators that measure the financial performance effect of employee welfare benefits and other health-promoting efforts. Method: In this essay we will mainly use a qualitative method together with a deductive approach. Data collection is conducted through semi-structured interviews, since we then have the opportunity to both adapt our questions and follow-up questions. A total of 14 respondents from 13 different companies were interviewed. Conclusion: The study has shown that companies usually do not measure the financial effectiveness of employee welfare benefits and health promotion efforts, neither generally nor with the help of specific key performance indicators. The majority feel that there is no simple approach and many do not experience sickness absence as a problem. At the same time, the study showed that sickness absence can be misleading because employees underperform due to presenteeism.

Essay 1 (with Oskar Nordström Skans): This paper provides field evidence on the causal impact of past successes on future performances. Since persistence in success or failure is likely to be linked through, potentially time-varying, ability it is intrinsically difficult to identify the causal effect of succeeding on the probability of performing well in the future. We therefore employ a regression discontinuity design on data from professional golf tournaments exploiting that almost equally skilled players are separated into successes and failures half-way into the tournaments (the “cut”). We show that players who (marginally) succeeded in making the cut substantially increased their performance in subsequent tournaments relative to players who (marginally) failed to make the cut. This success-effect is substantially larger when the subsequent (outcome) tournament involves more prize money. The results therefore suggest that past successes provide an important prerequisite when performing high-stakes tasks. Essay 2: Recent experimental evidence suggests that women in general are more discouraged than men by failures which potentially can explain why women, on average, are less likely than men to reach top-positions in firms. This paper provides the first quasi-experimental evidence from the field on this issue using data from all-female and all-male professional golf tournaments to see if this result can be replicated among competitive men and women. These top-performing men and women are active in an environment with multiple rounds of competition and the institutional set-up of the tournaments makes it possible to causally estimate the effect of the result in one tournament on the performance in the next. The results show that both male and female golfers respond negatively to a failure and that their responses are virtually identical. This finding suggests that women’s difficulties in reaching top-positions in firms are caused by external rather than internal barriers. Essay 3: Voting is a fundamental human right. Yet, individuals that are younger than 18 do typically not have this right since they are considered uninformed. However, recent evidence tentatively suggests that the political knowledge of youths is endogenous to the voting age. I test for the existence of such dynamic adjustments utilizing voting age discontinuities caused by Swedish laws. I employ a regression discontinuity strategy on Swedish register data to estimate the causal effect of early age voting right on political knowledge around age 18. The results do not support the existence of positive causal effects of early age voting right on political knowledge. Thus, we should not expect that 16-year-olds respond by acquiring more political knowledge if they are given the right to vote. This finding weakens the case for a lowering of the voting age from 18 to 16. Essay 4 (with Lena Hensvik): We postulate that firms’ production losses  from absence depend on the employees’ internal substitutability, incentivizing firms to keep absence low in positions with few substitutes. Using Swedish employer-employee data we show that absence is substantially lower in such positions even conditional on establishment and occupation fixed effects. The result reflects sorting on both entry and exit margins, with stronger separations responses when it was difficult to predict the absence of the employees beforehand. These findings highlight that internal substitution insures firms against production disruptions caused by absence and that absence costs are important aspects of firms’ hiring and separations decisions.

Which factors best explain the regional variation in sick-listing and early retirement? Data from the Swedish Social Insurance Agency is fitted against variables describing different regional characteristics that have been linked to sickness insurance consumption in the literature. Results, in line with earlier empirical investigation, suggest that particularly the employment rate, the populations‟ age, and its wealth are strong determinants of regional insurance usage. Two further factors, though less discussed in the literature, appear to have some relevance as well: A high share of large workplaces is found to predict higher rates of early retirement, while a large share of foreign-born predict lower sick-listing rates. Both effects have been found before, though the first one perhaps not in Swedish cross section analysis and the latter does not appear to be well understood in the literature. A tentative explanation for it is given here.

<p>Which factors best explain the regional variation in sick-listing and early retirement? Data from the Swedish Social Insurance Agency is fitted against variables describing different regional characteristics that have been linked to sickness insurance consumption in the literature. Results, in line with earlier empirical investigation, suggest that particularly the employment rate, the populations‟ age, and its wealth are strong determinants of regional insurance usage. Two further factors, though less discussed in the literature, appear to have some relevance as well: A high share of large workplaces is found to predict higher rates of early retirement, while a large share of foreign-born predict lower sick-listing rates. Both effects have been found before, though the first one perhaps not in Swedish cross section analysis and the latter does not appear to be well understood in the literature. A tentative explanation for it is given here.</p>

The background to this thesis is the dramatic increase of the long-term sickness absence that took place in Sweden from the late 1990s. There was also a shift in the diagnostic pattern with rising mental diagnoses. The overall purpose was to describe and try to understand the process leading to long-term sickness absence from the perspective of the sickness absentees, in order to get a better knowledge base for preventive and rehabilitative actions. The thesis comprises four studies (I-IV). Research methods have been both qualitative and quantitative. In study I data from individual interviews with 32 persons on long-term sick leave due to burnout was analyzed using a grounded theory approach. In study II the study population comprised of 2064 employed sick-listed persons, a sub sample derived from the 2002 national Swedish survey on health, working conditions, life situation and sick-listing. It was analyzed if persons with burnout had higher probability of having experienced the steps in the burnout staircase compared to other diagnostic groups in accordance with the previously suggested hypothesis of "the burnout staircase". Study III comprised of 2521 employed persons, a sub sample derived from the same national survey as in study II. It was analyzed if psychosocial work environment and conflicts and losses in private life independently or in combination were more strongly associated to sickness absence with mental diagnoses as compared to a healthy population. In study IV individual interviews with 25 professional rehabilitation actors and 14 unemployed sick-listed persons were conducted. Data were analyzed according to grounded theory method. The process that led to sicknes absence can be described as an emotional deprivation process, illustrated as a flight of stairs (the burnout staircase) describing a sequence of steps toward sickness absence (I). In accordance with the tested hypothesis persons with burnout to a noticeable higher extent reported expereince of being in the different steps in the burnout staircase compared to sickness absentees with other diagnoses. The model seemed to be valid also for persons with other mental diagnoses (II). Reorganization and conflicts at work as well as adding adverse private life events were associated with increased risk for sickness absence with mental diagnosis (III). Three significant factors behind the weak co-operation between local social insurance and employment agencies were identified: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies (IV). In this thesis it has been suggested that the course of events preceding sickness absence might be understood as a process of emotional deprivation, where the individual is gradually emptied of the life-giving emotional energy revealed in joy, commitment, and empathy. This life-giving force finds its nourishment in safe and secure social relations with others and in a social structure that promotes this type of social relations. The profound changes in the Swedish labour market during the 1990s influenced not just the psychosocial work climate but also the rehabilitation efforts for unemployed sick-listed persons. When the political goal of reducing the unemployment level came to the forefront the indistinct regulation and the conflicting goals in addition were factors that impaired co-ordinated rehabilitation. In this process also the physicians were involved. A labour market problem was turned into a medical problem.

This thesis studies how sick leave legitimacy is managed in interaction and develops an empirically driven conceptualization of ‘legitimacy work’. The thesis applies an ethnomethodological framework that draws on conversation analysis, discursive psychology, and membership categorization analysis. Naturally occurring interaction is examined in two settings: (1) multi-party meetings at the Swedish Social Insurance Agency, in which participants assess and discuss the ‘status’ of the sick leave and plan for work rehabilitation; (2) peer-based online text-in-interaction in a Swedish forum thread that gathers people on sick leave. The thesis shows how mental states, activities and alternative categories function as resources for legitimacy work. However, such invocations are no straight-forward matter, but impose additional contingencies. It is thus crucial how they are invoked. By detailed analyses of the interaction, with attention to aspects such as lexicality and delivery, the thesis identifies a range of discursive features that manage sick leave legitimacy. Deployed resources are also subtle enough to be deniable as legitimacy work, that is, they also manage the risk of an utterance being seen as invested or biased. While legitimate sick leave is a core concern for Swedish policy-making, administration, and public debate on sick leave, previous research has for the most part been explanatory in orientation, minding legitimacy rather than studying it in its own right. By providing detailed knowledge about the legitimacy work that people on long-term sick leave do as part of both institutional and mundane encounters, the thesis contributes not only new empirical knowledge, but a new kind of empirical knowledge, shedding light on how the complexities of sick leave play out in real-life situations. Traditional sociological approaches have to a significant extent treated legitimacy as an entity with beginnings and ends that in more or less direct ways relate to external norms and cognitive states, or that focus on institutions, authority or government. By contrast, the herein emerging concept ‘legitimacy work’ understands legitimacy as a locally contingent practicality – a collaborative categorially oriented accomplishment that is integral to the interactional situation.

Sjukfrånvaron inom de svenska kommunala vård- och omsorgsorganisationerna ökar. Samtidigt har en organiserings- och styrningsförändring skett inom dessa organisationer de senaste decennierna i form av införandet av New Public Management (NPM) och dess reformer. Studien syftade till att genom en kvalitativ fallstudie få en ökad förståelse för hur psykosociala och organisatoriska faktorer tillsammans kunde ha inverkan på en kommunal vård- och omsorgsorganisations sjukfrånvaro för organisationens medarbetare inom kontaktyrken och dess chefer. Detta utifrån att identifiera vad organisationens sjukfrånvaro orsakades av samt för att föreslå åtgärder för att förebygga framtida sjukfrånvaro. För att uppfylla syftet och studiens frågeställningar genomfördes semistrukturerade intervjuer med totalt 19 intervjupersoner som representerade de arbetsgrupper med organisationens högsta och lägsta sjuktal under 2019 samt de chefsgrupper med organisationens högsta och lägsta sjuktal under 2019. Empirin analyserades utifrån den teoretiska referensramen. Denna innefattade tidigare forskning samt teorier gällande NPM, struktureringsteori, psykosociala sjukfrånvarofaktorer, organisatoriska sjukfrånvarofaktorer, psykosociala friskfaktorer, organisatoriska friskfaktorer samt organisationshälsa. Studiens resultat visade på tre framträdande psykosociala sjukfrånvarofaktorer för medarbetare respektive chefer, fyra organisatoriska sjukfrånvarofaktorer för medarbetare respektive chefer, fyra psykosociala friskfaktorer för medarbetare respektive chefer samt fyra organisatoriska friskfaktorer för medarbetare och fem organisatoriska friskfaktorer för chefer. Resultaten visade att de psykosociala och organisatoriska sjukfrånvaro- och friskfaktorerna påverkade varandra, att det fanns ett samband mellan chefers och medarbetares upplevda arbetsmiljö samt att sjukfrånvaron framförallt kunde härledas till strukturer medan frisknärvaron istället kunde härledas till individers handlingar. Tio åtgärder för att minska sjukfrånvaron inom kommunala vård- och omsorgsorganisationer presenterades utifrån studiens resultat och potentiell vidare forskning har föreslagits. / Sickness absence within the Swedish municipal healthcare organizations is increasing. At the same time, there has been a change in organization and governance within these organizations in recent decades in the form of the introduction of New Public Management (NPM) and its reforms. The study aimed to gain a better understanding of how psychosocial and organizational factors together could have an impact on a municipal healthcare organization's sickness absence, regarding employees in the human service profession and its managers, through a qualitative case study. This to identify what was causing the organization's sickness absence and on proposing measures to prevent future sickness absence. To fulfill the purpose and study questions, semi-structured interviews were conducted with a total of 19 informants representing the working groups with the organization's highest and lowest sickness numbers in 2019 and the management groups with the highest and lowest sickness numbers in 2019. The empirical data was analyzed based on the theoretical frame of reference. This included previous research as well as theories of NPM, structuring theory, psychosocial sickness absence factors, organizational sickness absence factors, psychosocial health factors, organizational health factors and organizational health. The study's results showed three prominent psychosocial sickness absence factors for employees and managers, four organizational sickness absence factors for employees and managers, four psychosocial health factors for employees and managers, four organizational health factors for employees and five organizational health factors for managers. The results showed that the psychosocial and organizational sickness absence and health factors affected each other, that there was a connection between managers and employees perceived work environment and that the sickness absence could primarily be attributed to structures, while work attendance instead could be attributed to individuals' actions. Ten measures to reduce sickness absence within municipal healthcare organizations has been presented based on the results of the study, as well as suggestions for further research.