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Bringing Health to the Bottom Line


A healthy workforce means a healthy business, but it&s been nearly impossible for employers to measure and monetize the impact of ill health and the benefits that treat it. The Stanford Presenteeism Scale offers a surprisingly simple solution.


Bringing Health to the Bottom Line

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Choose article section...How SPS worksUsing the scale

By Kenneth R. Pelletier and Cheryl Koopman

A healthy workforce means a healthy business, but it's been nearly impossible for employers to measure and monetize the impact of ill health and the benefits that treat it. The Stanford Presenteeism Scale offers a surprisingly simple solution.

Worker productivity is a critical factor in the strength and profitability of a company's overall business performance. Absenteeism — the classic drain on individual and total workforce productivity — can be measured through readily available data on short-term disability, continuance days and family medical leave. Beyond the physical presence of employees, however, is their daily performance as compared to their normal level of productivity and work quality.

This less obvious aspect of productivity has given rise to the term "presenteeism." Many observers use the word only in a negative context of reduced performance, but we prefer a more flexible definition. Thus, heightened job performance is increased presenteeism, while diminished presenteeism occurs when employees work less productively or at a poorer quality than usual due to a health or medical problem.

Although this concept is frequently discussed, there has not been a method for actually measuring the nature and level of individual or organizational presenteeism, and the extent to which its variations affect a company's bottom line. Presenteeism is a major missing element in an employer's ability to make decisions about employee health and benefits. It is the data needed to link medical benefits and treatment with productivity. Measuring and quantifying this linkage in both direct medical expenditures and indirect costs is essential in an environment in which increasing emphasis on knowledge workers is accompanied by eruptions of double-digit health insurance premium increases.

To address the need for a reliable, research-based measure of presenteeism, we led a team of researchers at the Stanford University School of Medicine in a study funded by Merck & Co., Inc. At present, the fruit of our work is the Stanford Presenteeism Scale-6, or SPS-6, which assesses the relationship between presenteeism, health problems and productivity for working populations. (Click here to see a copy of SPS-6, instructions for scoring and citation for the initial article on the scale, which appeared in the Journal of Occupational and Environmental Medicine.)

How SPS works

SPS-6 measures a worker's perception of his or her ability to overcome the distraction of current physical and/or psychological problems in order to handle job stress, complete tasks, achieve goals and maintain sufficient focus and energy levels. The scale was designed with physical conditions in mind, but in all three of the developmental studies, the most frequent condition spontaneously written into the responses was, in fact, depression. Clearly, the respondents saw the connection — and our research team acknowledges — that the interfering condition can also be psychological.

Issues of physical and mental well-being are of particular importance among employees in mid- to upper-management. Reflecting the work style of many people in executive and knowledge based positions, applications of this assessment are not limited by the boundaries of official work hours or the formal worksite.

SPS-6 was developed in a series of three studies with employees of Stanford University, the U. S. Postal Service and San Mateo County in California. These studies demonstrated that SPS-6 is a valid and accurate measure of presenteeism. Equally important, our research led us to reduce the scale's initial 32 questions to the final six. SPS-6 is now short enough to be administered online and/or included in any standard Health Risk Appraisal. It can be used as a brief stand-alone measure or an ongoing assessment of improvements or decrements in presenteeism over time.

Both the accuracy of the scale and its sensitivity to change are vital, since an employer can then assign a monetary value to increases or decreases that result from direct health programs targeted to medical issues, environmental and/or managerial changes, and innovative performance incentives. In a nutshell, SPS-6 brings employers significantly closer to the ability to measure and monetize changes in employees' abilities to focus on tasks at work.

Using the scale

Ongoing research at both the domestic and international level will further illustrate the range of applications of SPS-6 in linking health and productivity. One study involves a large U.S. automobile manufacturer that spent over $70 million in direct medical costs — not including disability, replacement workers or decreased productivity — for back pain in 2000. This company and our research team are now undertaking an innovative intervention for managing low back pain using an "integrative medicine" model that includes both conventional and alternative (acupuncture, mind/body interventions and herbal anti-inflammatories). SPS-6 will be one of our major measures linking to clinical and cost effectiveness.

On the international front, the government of Singapore has launched a five-year "Health Promotion Board" initiative to develop and evaluate health promotion and disease management interventions for all local employers, including such U.S.-based companies as IBM and Proctor & Gamble. This initiative has specific annual benchmarks, budgets, deliverables and a number of clinical and cost outcome studies that will use SPS-6. Singapore aims to become the healthiest workforce in the world and to subsequently develop and market proven interventions to other companies and countries internationally.

With this new SPS-6 scale, a human resources or medical director can actually derive both the clinical and monetary impact of health impairment and intervention. Such an ability is critical as increased benefit costs erode corporate margins or are passed along to devour workers' wage increases. By explicitly linking health, productivity and monetary issues, a standardized presenteeism measure can bring order to an increasingly chaotic decision process.

Kenneth R. Pelletier, PhD, MD(hc), is chairman of the American Health Association and a clinical professor of medicine at the University of Maryland School of Medicine and the University of Arizona School of Medicine. Contact him at drkrpelletier@aol.com or http://www.usc.edu/dept/gero/ageworks/alternative_medicine/ . Cheryl Koopman, PhD, is an associate professor of psychiatry at the Stanford University School of Medicine.

The Stanford Presenteeism Scale (SPS-6)

PLEASE NOTE: If you are using Internet Explorer version 6 or higher, after clicking to enlarge the graphic, click the picture icon that appears in the lower right-hand corner of the graphic.

Scoring Instructions:

Each response is assigned a value ranging from 1 to 5 points. Note that the scale periodically reverses high points for "strongly agree" and "strongly disagree." This encourages the user to answer each question accurately rather than breezing down the same column of responses.

Point value for questions

1, 3 and 4
2, 5 and 6
Strongly disagree
Somewhat disagree
Somewhat agree
Strongly agree

Sum these points for the SPS-6 total score, which can range from 6 to 30. Lower scores indicate lower presenteeism and reduced performance. Higher scores indicating increased presenteeism and peak performance.


SPS-6 was first published in Journal of Occupational and Environmental Medicine, 2002; 44(1):14-20. The article, Stanford Presenteeism Scale: Health Status and Employee Productivity, was written by Cheryl Koopman, PhD, Kenneth R. Pelletier, PhD, MD(hc), James F. Murray, PhD, Claire E. Sharda, RN, MBA, MHSA, Marc L. Berger, MD, Robin S. Turpin, PhD, Paul Hackleman, MA, Pamela Gibson, MPH, Danielle M. Holmes, and Talor Bendel, BA.

More Business & Health Articles About This Topic:

Working With Depression, Part I: The Case for Quality Mental Health Services (August 1, 2002)

Depression in the Workforce, Part 1: Seeing its Costs in a Fuller Light (Apr. 1, 2000)

The Real Measure of Productivity (November 1999)

Equating Health and Productivity (September 1997)

Resource Links:


Washington Business Group on Healthhttp://www.wbgh.org/

Health Enhancement Research Organizationhttp://www.the-hero.org/

The Wellness Councils of Americahttp://www.welcoa.org/


Kenneth Pelletier, Cheryl Koopman. Bringing Health to the Bottom Line.

Business and Health

Jun. 15, 2003;21.

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