Work Ability, Burnout Complaints, and Work Engagement Among Employees With Chronic Diseases: Job Resources as Targets for Intervention?

Abstract

Purpose
The aim of this study was to investigate the occupational well-being among employees with chronic diseases, and the buffering effect of four job resources, possibly offering targets to enhance occupational well-being.

Method
This cross-sectional study (N = 1951) was carried out among employees in educational and (semi-)governmental organizations in the Netherlands. The dimensions of the survey were chronic diseases (i.e., physical, mental, or both physical and mental), occupational well-being (i.e., work ability, burnout complaints, and work engagement), and job resources (i.e., autonomy, social support by colleagues, supportive leadership style, and open and communicative culture). First, it was analyzed if chronic diseases were associated with occupational well-being. Second, it was analyzed if each of the four job resources would predict better occupational well-being. Third, possible moderation effects between the chronic disease groups and each job resource on occupational well-being were examined. Regression analyses were used, controlling for age.

Results
Each chronic disease group was associated with a lower work ability. However, higher burnout complaints and a lower work engagement were only predicted by the group with mental chronic diseases and by the group with both physical and mental chronic disease(s). Furthermore, all four job resources predicted lower burnout complaints and higher work engagement, while higher work ability was only predicted by autonomy and a supportive leadership style. Some moderation effects were observed. Autonomy buffered the negative relationship between the chronic disease groups with mental conditions (with or without physical conditions) and work ability, and the positive relationship between the group with both physical and mental chronic disease(s) and burnout complaints. Furthermore, a supportive leadership style is of less benefit for occupational well-being among the employees with mental chronic diseases (with or without physical chronic diseases) compared to the group employees without chronic diseases. No buffering was demonstrated for social support of colleagues and an open and communicative organizational culture.

Conclusion
Autonomy offers opportunities to reinforce occupational well-being among employees with mental chronic diseases. A supportive leadership style needs more investigation to clarify why this job resource is less beneficial for employees with mental chronic diseases than for the employees without chronic diseases.

Full text

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 1
ORIGINAL RESEARCH
published: 06 August 2020
doi: 10.3389/fpsyg.2020.01805
Edited by:
Montgomery Anthony,
University of Macedonia, Greece
Reviewed by:
Luigi Isaia Lecca,
University of Cagliari, Italy
Serge Brand,
University Psychiatric Clinic Basel,
Switzerland
*Correspondence:
Ingrid G. Boelhouwer
i.g.boelhouwer@hva.nl
Specialty section:
This article was submitted to
Organizational Psychology,
a section of the journal
Frontiers in Psychology
Received: 08 January 2020
Accepted: 30 June 2020
Published: 06 August 2020
Citation:
Boelhouwer IG, Vermeer W and
van Vuuren T (2020) Work Ability,
Burnout Complaints, and Work
Engagement Among Employees With
Chronic Diseases: Job Resources as
Targets for Intervention?
Front. Psychol. 11:1805.
doi: 10.3389/fpsyg.2020.01805
Work Ability, Burnout Complaints,
and Work Engagement Among
Employees With Chronic Diseases:
Job Resources as Targets for
Intervention?
Ingrid G. Boelhouwer1*, Willemijn Vermeer1and Tinka van Vuuren2,3
1Department of Applied Psychology, Amsterdam University of Applied Sciences, Amsterdam, Netherlands, 2Faculty of
Management, Open University of The Netherlands, Heerlen, Netherlands, 3Loyalis Knowledge & Consult, Heerlen,
Netherlands
Purpose: The aim of this study was to investigate the occupational well-being among
employees with chronic diseases, and the buffering effect of four job resources, possibly
offering targets to enhance occupational well-being.
Method: This cross-sectional study (N= 1951) was carried out among employees in
educational and (semi-)governmental organizations in the Netherlands. The dimensions
of the survey were chronic diseases (i.e., physical, mental, or both physical and
mental), occupational well-being (i.e., work ability, burnout complaints, and work
engagement), and job resources (i.e., autonomy, social support by colleagues,
supportive leadership style, and open and communicative culture). First, it was analyzed
if chronic diseases were associated with occupational well-being. Second, it was
analyzed if each of the four job resources would predict better occupational well-being.
Third, possible moderation effects between the chronic disease groups and each job
resource on occupational well-being were examined. Regression analyses were used,
controlling for age.
Results: Each chronic disease group was associated with a lower work ability. However,
higher burnout complaints and a lower work engagement were only predicted by
the group with mental chronic diseases and by the group with both physical and
mental chronic disease(s). Furthermore, all four job resources predicted lower burnout
complaints and higher work engagement, while higher work ability was only predicted by
autonomy and a supportive leadership style. Some moderation effects were observed.
Autonomy buffered the negative relationship between the chronic disease groups with
mental conditions (with or without physical conditions) and work ability, and the positive
relationship between the group with both physical and mental chronic disease(s) and
burnout complaints. Furthermore, a supportive leadership style is of less benefit for
occupational well-being among the employees with mental chronic diseases (with or
without physical chronic diseases) compared to the group employees without chronic
diseases. No buffering was demonstrated for social support of colleagues and an open
and communicative organizational culture.
Frontiers in Psychology | www.frontiersin.org 1August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 2
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
Conclusion: Autonomy offers opportunities to reinforce occupational well-being among
employees with mental chronic diseases. A supportive leadership style needs more
investigation to clarify why this job resource is less beneficial for employees with mental
chronic diseases than for the employees without chronic diseases.
Keywords: work ability, burnout complaints, work engagement, chronic diseases, multimorbidity, occupational
well-being, job resources
INTRODUCTION
A chronic disease is regarded as a disease with an episode
of treatment that extends over a long period, although the
condition or stage of the disease does not have to be serious
(De Lepeleire and Heyrman, 2003). Examples of chronic
diseases are musculoskeletal diseases, cardiovascular diseases, or
depression. The labor market participation of the population with
chronic diseases is lower than that of the population without
chronic diseases. For the general population at working age
with chronic diseases in the Netherlands, the labor market
participation (for at least 12 h a week) is lower than that of
the population without one or more chronic diseases, namely,
25% and 67%, respectively, in 2010 (Maurits et al., 2013).
Furthermore, the labor market participation of the group with
chronic diseases in the Netherlands is comparable to the mean
figure of the other member countries of the Organization for
Economic Cooperation and Development (SER, 2016).
The need to find strategies and solutions for enhancing
the employment of people with chronic diseases is widely
acknowledged (Nazarov et al., 2019). However, a factor in
the prevalence of chronic diseases among workers is age.
The last decades, the expansion of the aging workforce is an
important factor among others with regard to the preservation of
productivity (Aiyar and Ebeke, 2016), job opportunities, careers,
and social inclusion (Silvaggi et al., 2020). The prevalence of one
or more chronic diseases in the Netherlands in the year 2018
was 20.7% among the group in the age category from 20 to
30 years old, up to 46.4% among the group in the age category
from 55 to 65 years old (CBS, 2019). Furthermore, comorbidity
and multimorbidity of various chronic diseases is expected to
continue to increase (Uijen and van de Lisdonk, 2008;Boyd
and Fortin, 2010). As a consequence, the number of people at
risk of experiencing difficulties with particular work activities
or demands as a result of one or more chronic diseases will be
even more substantial in the future. Therefore, it is increasingly
important to focus on working people with chronic diseases and
indicate possible targets to enhance their occupational well-being.
Occupational well-being can be regarded as a broad
concept, including work ability, burnout complaints, and work
engagement, which are the indicators in the present study. Work
ability, the first indicator, refers to one’s ability to function
well at work or to be able to achieve expected work goals
(Ilmarinen et al., 2005;Ilmarinen, 2007). Work ability is mostly
measured by one or more items of the Work Ability Index
(WAI) questionnaire (Ilmarinen, 2007). The level of work ability
is regarded as a valid indicator for other work outcome measures.
For instance, a moderate or poor work ability is found to be
highly predictive for receiving a disability pension (Alavinia et al.,
2009). Although higher age is associated with more chronic
diseases, studies do report mixed results with regard to the
association between age and work ability. Some studies report a
decreased work ability with older age (van den Berg et al., 2008;
Vangelova et al., 2018); however, also high work ability among
older workers is reported, for instance, in an Australian study
among mature age working women (Austen et al., 2016). Burnout
complaints, the second indicator, are regarded as a prolonged
stress response to chronic stressors at work, which might be
related to the onset of cognitive decline in elderly workers
(Giorgi et al., 2020). Burnout can be defined by three dimensions;
exhaustion, cynicism, and inefficacy (Maslach et al., 2001), which
distinction is in line with the subscales of the Utrecht Burnout
Scale (UBOS) (Schaufeli and van Dierendonck, 2000). Work
engagement, the third indicator, is described as a positive,
fulfilling, affective-motivational state of work-related well-being
that is characterized by vigor, dedication, and absorption, in
line with the subscales of the Utrecht Work Engagement Scale
(UWES) (Bakker et al., 2008).
Furthermore, supporting factors in achieving work goals,
so-called job resources within the Job Demands-Resources
(JD-R) model (Demerouti et al., 2001), might play an important
role. Job resources refer to aspects of the job that are functional
in achieving work goals, or stimulate personal growth, learning
and development or reduce job demands (Schaufeli and Bakker,
2004). In the JD-R model, job demands are regarded as the
aspects of the job that require effort and it is possible that
the effects of a chronic disease result in work demands being
experienced as heavier. In general, the JD-R model and therefore
the beneficial influence of job resources is well established
in several work contexts. In addition, in some studies, job
resources were reported to buffer the impact of job demands
on burnout (Bakker et al., 2005;Xanthopoulou et al., 2007b).
So, job resources can show positive associations with higher
occupational well-being, or job resources might even buffer a
possible association between chronic diseases and occupational
well-being. For that reason, job resources might be of importance
for work functioning among workers with chronic diseases.
Research on associations among the three indicators of
occupational well-being as used in this study is merely focused on
associations between burnout complaints and work engagement.
Studies indicate that these two indicators of occupational
well-being cannot simply be regarded as opposite concepts.
Burnout is mainly predicted by job demands and a lack of job
resources. However, work engagement is specifically predicted
by available job resources (Schaufeli and Bakker, 2004). Studies
on relations between burnout complaints or work engagement
Frontiers in Psychology | www.frontiersin.org 2August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 3
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
on the one hand and work ability on the other hand are scarce.
Nevertheless, there are some results. For instance, in a 6-month
longitudinal study among employees of two manufacturers
Rongen et al. (2014) demonstrated that low work engagement
was related with low work ability beyond known health behaviors
and work-related characteristics. These findings indicate that it
is important to examine all three abovementioned indicators of
occupational well-being within one study.
HYPOTHESES
The aim of the present study is to investigate (1) if chronic
diseases are associated with lower occupational well-being (that
is, lower work ability, higher burnout complaints, or lower
work engagement), (2) the direct effect of four job resources on
occupational well-being, and, most importantly, (3) the possible
moderation of the presumed relationship between chronic
diseases and occupational well-being by job resources. The
approach to combine these concepts in one study is quite unique
and of great relevance in finding possible targets to enhance
occupational well-being among employees with chronic diseases.
Chronic Diseases and Occupational
Well-Being
Chronic diseases are normally categorized as mental or physical.
Different chronic diseases can demonstrate various profiles with
regard to the mean age at which the condition occurs in the
population and the prevalence of the condition between age
groups. Furthermore, a higher prevalence of multimorbidity
is observed with higher age (Banerjee, 2015;Xu et al., 2017).
Therefore, the present study will differentiate between physical
chronic diseases, mental chronic diseases, and comorbidities of
mental and physical chronic diseases, as these groups might differ
with regard to the stage in the course of life and career in which
the members of the group find themselves.
Regarding work ability, several studies have already
investigated the association of chronic diseases with this
indicator of occupational well-being. Workers with different
chronic diseases are reported to be at a higher risk of a lower level
of work ability than workers without these conditions (Koolhaas
et al., 2013;Leijten et al., 2014;van den Berg et al., 2017).
Furthermore, burnout complaints are found to occur more
frequently in certain populations with specific chronic diseases,
such as women with musculoskeletal diseases or men with
cardiovascular diseases (Honkonen et al., 2006), women with
coronary heart disease (Hallman et al., 2003) or women with
depression (Soares et al., 2007). On the other hand, burnout
is also reported to probably influence the development and
course of certain disease processes by several biobehavioral
pathways (Shirom et al., 2006), but this is only studied for some
chronic diseases.
The available studies that assess the association between
chronic diseases and work engagement do not directly present
an unambiguous overview. Schaufeli et al. (2008) reported
significant negative associations between perceived health and
dimensions of work engagement. Furthermore, distress and
depression were both negatively associated with vigor, and
distress was negatively associated with dedication as well.
However, in another study, high work engagement levels were
observed among workers with musculoskeletal symptoms, but
the role of the biomechanical demands of the work tasks of
these workers needed further investigation (Nogueira et al.,
2012). Furthermore, another study among cancer survivors (after
they had returned to work) and their non-cancer referents
(with or without other chronic diseases) demonstrated that
the level of work engagement was high in both study groups,
and only slightly higher among the referents than among the
cancer survivors (Hakanen and Lindbohm, 2008). In general,
vigor is positively related to mental and physical health (Bakker
and Leiter, 2010). Furthermore, vigor is regarded as a physical
indicator of vitality (Ryan and Frederick, 1997), and vitality
is regarded to be related to the absence of chronic diseases
(Strijk et al., 2009).
To summarize, employees with chronic diseases are expected
to have lower work ability, higher burnout complaints, and lower
work engagement than employees without chronic diseases.
Hence, our first set of hypotheses is:
H1a. Workers with chronic diseases (mental and/or physical
chronic diseases) have a lower work ability than workers
without chronic diseases.
H1b. Workers with chronic diseases (mental and/or physical
chronic diseases) have higher burnout complaints than
workers without chronic diseases.
H1c. Workers with chronic diseases (mental and/or physical
chronic diseases) have lower work engagement than workers
without chronic diseases.
Job Resources and Occupational
Well-Being
Assuming that occupational well-being is less favorable in the
case of chronic diseases as we expected, it is important to have
more insight in possible specific ways to improve occupational
well-being by promoting job resources for this population of
workers. In the present study, four job resources are taken into
account: autonomy, social support by colleagues, a supportive
leadership style, and an open and communicative culture. Firstly,
in this section, we will formulate our expectations with regard to
the association of each of the four job resources with occupational
well-being, and then in Section “Moderation by Job Resources,”
we will present our expectations on the moderation by the four
job resources of the presumed relationship between the chronic
disease groups and occupational well-being.
The first job resource, autonomy, refers to the influence on
one’s own work, for instance by autonomous decisions. Several
studies have demonstrated that a lack of autonomy is associated
with poor work ability, as defined by the WAI (van den Berg
et al., 2008). Associations of autonomy and burnout complaints
were found as well, and a lack of autonomy is correlated with
burnout risk (Maslach et al., 2001;Kim et al., 2018). Furthermore,
a meta-analysis by Alarcon (2011) demonstrated that autonomy
is negatively associated with all three burnout subscales. With
regard to work engagement, a cross-national study in different
Frontiers in Psychology | www.frontiersin.org 3August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 4
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
work contexts within eight European countries by Taipale et al.
(2011), demonstrated that autonomy was a strong predictor of the
level of work engagement. Furthermore, job control is associated
with work engagement among Finnish health care personnel in a
longitudinal study by Mauno et al. (2007).Schaufeli et al. (2009)
reported changes in autonomy to be predictive of changes in work
engagement among telecom managers.
With regard to the second job resource, social support
by colleagues, a positive association with work ability is
demonstrated for instance among hospital nurses (Olsen et al.,
2017). Furthermore, among female cancer survivors, co-workers’
support is related to a reduced risk of impaired work ability
(Taskila et al., 2007). Concerning burnout complaints, there is
a consistent and strong body of evidence that a lack of social
support is linked to burnout (Maslach et al., 2001). Also, with
regard to work engagement, a positive association of social
support by work mates with work engagement is for instance
reported in the study in eight European countries in different
work contexts (Taipale et al., 2011).
The third job resource, a supportive leadership style, is studied
in relation to work ability in previous studies, but results vary.
Among IT workers, supervisor support was demonstrated to
predict work ability 1 year later (Sugimura and Thériault, 2010).
However, in a study by Tuomi et al. (2004), an improvement
of supervisory support did not predict an improvement of
work ability, although improvement of supervisory support and
improvement of work ability were significantly associated. In
another study, conducted in several parts of the industrialized
world by McGonagle et al. (2014), supervisor support was
positively related to work ability in the Australian sample only,
and not associated with work ability in the other samples (i.e.,
United States, United Kingdom, Brazil, Poland, and Croatia).
The relation of a supportive leadership style with burnout is
also far from straightforward. Kanste et al. (2007) indicate
that this relationship is complex, as leadership style tends
to be affected by situational factors. However, Maslach et al.
(2001) concluded that a lack of support from supervisors
is especially detrimental in relation to burnout complaints,
even more so than a lack of support from co-workers. With
respect to work engagement, a study demonstrated a higher
contribution of transformational leadership to work engagement
than transactional leadership (Li et al., 2018). As the latter
style focuses on performance within existing boundaries, the
transformational leadership is more change-oriented and might
allow more use of job resources.
With regard to the fourth job resource, an open and
communicative organizational culture, there are some studies
that focus on concepts linked to organizational culture. For
instance, associations with higher work ability were found for
good organizational relationships among personnel of nursing
homes (Kiss et al., 2014) and for a supportive organizational
climate among managers (Feldt et al., 2009). Higher perceptions
of ethical culture demonstrated to be associated with lower
burnout and higher work engagement (Huhtala et al., 2015).
Furthermore, in a review by Wollard and Shuck (2011)
concerning the antecedents of work engagement, not only
results with regard to local microcultures and management,
like psychological climate (Shuck et al., 2011), were reported,
but also antecedents at the organizational level, like corporate
social responsibility (Davies and Crane, 2010). Furthermore, van
Dam et al. (2017) demonstrated that an age-supportive climate is
especially important for older employees’ work engagement and
affective commitment.
To summarize, autonomy, social support by colleagues, a
supportive leadership style, and an open and communicative
culture are expected to be associated with a higher work
ability, lower burnout complaints, and higher work engagement.
Therefore, our second set of hypotheses is:
H2a. Autonomy is associated with higher work ability, lower
burnout complaints, and higher work engagement.
H2b. Social support by colleagues is associated with higher
work ability, lower burnout complaints, and higher work
engagement.
H2c. A supportive leadership style is associated with higher
work ability, lower burnout complaints, and higher work
engagement.
H2d. An open and communicative organizational culture
is associated with higher work ability, lower burnout
complaints, and higher work engagement.
Moderation by Job Resources
The four job resources can be of importance for employees
in the general population, and the focus in this study is on
the possible interaction of the presumed relationship between
the chronic disease groups and occupational well-being. The
JD-R model distinguishes a strain process, related to the level
of the job demands, and a motivational process, influenced by
job resources. Job resources can buffer for demanding work
conditions (Bakker and Demerouti, 2007). As workers with
chronic diseases might experience their work as more demanding
because of these chronic diseases, several job resources might
also buffer the association between the chronic diseases and less
favorable work ability, burnout complaints, or work engagement.
However, to our knowledge, no study has been done to investigate
this among employees with chronic diseases. Among the general
population, studies with a focus on buffering effects of job
resources do not concern work ability, but several studies
concern burnout complaints or work engagement. These studies
demonstrated the importance of job resources interacting with
job demands predicting lower symptoms of burnout (Bakker
et al., 2005;Xanthopoulou et al., 2007a) or higher work
engagement (Bakker et al., 2007). Because of the rationale of
the JD-R model and the above presented results, we expect a
moderating effect for the job resources, and our third set of
hypotheses is:
H3a. Autonomy buffers the presumed relationship of chronic
diseases with lower work ability, higher burnout complaints,
or lower work engagement.
H3b. Social support by colleagues buffers the presumed
relationship of chronic diseases with lower work ability,
higher burnout complaints, or lower work engagement.
Frontiers in Psychology | www.frontiersin.org 4August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 5
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
H3c. A supportive leadership style buffers the presumed
relationship of chronic diseases with lower work ability,
higher burnout complaints, or lower work engagement.
H3d. An open and communicative organizational culture buffers
the presumed relationship of chronic diseases with lower
work ability, higher burnout complaints, or lower work
engagement.
MATERIALS AND METHODS
Participants and Procedure
A cross-sectional employee survey was carried out between
2013 and 2017 in The Netherlands by Loyalis Knowledge
& Consult among employees working in different primary
schools and (semi) governmental organizations (i.e., municipality
and regional water authorities) in accordance with relevant
institutional and national guidelines. The aim was to offer the
employees in the participating organizations information for
improving their sustainable employability. The questionnaires
of the present study included scales for four job resources
(autonomy, social support by colleagues, supportive leadership
style, and open and communicative culture). The questionnaires
were distributed online, accompanied by an e-mail on behalf
of the researchers, stating the relevance and purpose of the
study. The respondents were informed that all data would be
treated confidentially and that the participation was voluntary.
All subjects gave written informed consent in accordance with
the Declaration of Helsinki. The participants were predominantly
female (61.6%) and with a high educational level (73.1%). The
mean age was 46.4 years (SD 11.12).
Measures
Information on chronic diseases was obtained based on the
third question of the WAI questionnaire (Ilmarinen, 2007). This
WAI question consists of a list of actual physical or mental
conditions, for which the respondent can indicate if this is an
actual health condition diagnosed by a physician. The possible
physical conditions may be an injury caused by an accident, a
condition of the musculoskeletal system, cardiovascular disease,
respiratory disease, neurological and sensory disease, digestive
disease, genitourinary disease, skin disease, metabolic disease,
blood diseases, birth defects, or tumors. The possible mental
conditions may be depressive complaints or a depressive disorder,
tension, anxiety, and insomnia or other mental disorders. For
the present study, the condition(s) are classified in three groups
and indicated as chronic diseases. Chronic disease group 1
includes participants with one or more physical condition(s)
(N= 640) which represents 32.8% of the sample. Among these
participants, the most frequently reported chronic diseases are
“medical condition of the musculoskeletal system” with 25.3%
and “cardiovascular disease” with 11.9%. A number of two
physical chronic diseases is reported by 9.8% of the respondents
and 5.3% reported three or more physical chronic diseases.
Chronic disease group 2 includes participants with one or more
mental condition(s) (N= 36), which represents 1.8% of the
sample. Chronic disease group 3 includes participants with one
or more physical conditions and one or more mental conditions
(N= 120). Chronic disease group 3 represents 6.2% of the sample.
The remaining participants in the sample have no physical
chronic disease, or a mental chronic disease (N= 1155, which
represents 59.2% of the sample) (see Tables 1,2).
Work ability was measured by a combination score of the
first two questions from the WAI. The first question of the
WAI indicates the current work ability compared with a person’s
lifetime best on a scale from 0 (completely unable to work) to
10 (work ability at its best). This item is reported to have a very
strong association with the complete WAI (Ahlstrom et al., 2010).
The second question consists of two items: current physical work
ability and current mental work ability in relation to physical and
mental job demands on a scale from 0 (very low) to 5 (very high).
For the present study, the three items were merged into one work
ability scale from 0 (very low) to 5 (very high), whereby the scale
of the first item was adjusted from 0 (completely unable to work)
to 10 (work ability at its best) into a scale from 0 (completely
unable to work) to 5 (work ability at its best) before merging. The
Cronbach’s αof the final work ability scale with three items is 0.74.
TABLE 1 | Groups with chronic diseases and numbers of chronic diseases
(N= 1951).
Chronic diseases Number reported %
Groups
Group 1—physical chronic disease(s) 640 32.8
Group 2—mental chronic disease(s) 36 1.8
Group 3—physical chronic disease(s) and
mental chronic disease(s)
120 6.2
Chronic diseases
Medical condition of the musculoskeletal
system
493 25.3
Cardiovascular disease 232 11.9
Skin disease 189 9.7
Respiratory disease 183 9.4
Neurological and sensory disease 173 8.9
Metabolic disease 118 6.0
Digestive disease 114 5.8
Injury caused by an accident 110 5.6
Genitourinary disease 64 3.3
Tumors 43 2.2
Birth defects 31 1.6
Blood diseases 26 1.3
Other 70 3.6
Mental chronic diseases 156 8.0
TABLE 2 | Numbers of physical chronic diseases.
Number of physical
chronic diseases
Number of
participants
%
1 364 18.7
2 192 9.8
3 81 4.2
4 20 1.0
5 or more 18 0.1
Frontiers in Psychology | www.frontiersin.org 5August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 6
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
Burnout was measured using the UBOS (Schaufeli and van
Dierendonck, 2000), consisting of 15 items on a seven-point
Likert scale from 1 (never) to 7 (always), covering three subscales,
namely, exhaustion, cynicism, and professional inefficacy. In the
present study, the total score of the three subscales was used. The
Cronbach’s α’s for the three subscales were respectively 0.89, 0.82,
and 0.82 and the reliability of the total UBOS scale is 0.89.
Work engagement was measured using the UWES (Bakker
et al., 2008) consisting of nine items on a seven-point Likert scale
from 1 (never) to 7 (always), covering three subscales, namely,
vigor, dedication, and absorption. In the present study, the total
score of the three subscales was used. The Cronbach’s α’s for
these three subscales were respectively 0.90, 0.93, and 0.84 and
the reliability of the total UWES scale is 0.95.
The four job resources (autonomy, social support by
colleagues, a supportive leadership style, and an open and
communicative organizational culture) were measured using
one of the scales by Van Poppel and Kamphuis (2004), which
were developed for the context of primary schools. All four
job resources made use of a five-point scale of 1 (strongly
disagree), 2 (disagree), 3 (not agree, nor disagree), 4 (agree), and 5
(strongly agree). The Cronbach’s α’s were 0.80 for autonomy (four
items), 0.74 for social support by colleagues (five items), 0.89 for
supportive leadership style (four items), and 0.90 for open and
communicative culture (eight items).
Control variable is calendar age, as reported by the
respondents. Age is reported to show different relationships with
various chronic diseases and also to be negatively associated with
work ability in other studies (van den Berg et al., 2008).
Analysis
The data were analyzed using SPSS software, version 25 (IBM
Corporation, Armonk, NY, United States) for WindowsR
/Apple
MacR
. Descriptives are reported for age, work ability, burnout
complaints, work engagement, and the four job resources
(autonomy, social support by colleagues, a supportive leadership
style, and an open and communicative organizational culture).
The scores on job resources were standardized by zscores. For
the regression analyses, we used dummies for three categories
of employees with chronic diseases (groups 1, 2, or 3), in order
to establish the relationship with the type of chronic disease. In
doing so, we used employees without chronic diseases (group
4) as the reference category. Hardy (1993) recommends to use a
reference category that serves as a useful comparison to the other
categories, and to use a large group as the reference category.
The reference category is omitted from the regression analyses;
the standardized coefficient (β) shows the extent to which the
other group deviates from the reference group and is regarded
as the indicator of the effect size (Ferguson, 2009). Standardized
coefficients are more easily comparable, because the variables are
standardized to have a mean of 0 and standard deviation of 1.
In line with other common effect indices, a βcoefficient of 0.2
is regarded as a small effect, a βcoefficient of 0.5 is regarded as
a medium effect, and a βcoefficient of 0.8 is regarded as a large
effect (Sullivan and Feinn, 2012).
Three separate multiple regression analyses were used to
investigate the associations between the dummies and each of the
job resources with respectively work ability, burnout complaints,
and work engagement, also including age in each analysis.
Furthermore, possible moderation by autonomy, social support
by colleagues, a supportive leadership style, and an open and
communicative culture were analyzed by interaction terms of
each of the chronic disease groups and each of the four job
resources. The dummies for the interaction terms of employees
without chronic diseases and each of the four job resources
are also omitted.
RESULTS
Descriptives
The mean age of the group with physical chronic disease(s) was
47.9 years (SD 10.81), and significantly higher (p<0.05) than
the mean age of the group with mental chronic disease(s) with
42.1 years (SD 11.35) and also than the group without chronic
diseases with 45.5 years (SD 11.25). The mean age of the group
with physical and mental chronic disease(s) [with both physical
and mental condition(s)] was 47.5 years (SD 10.37) (see Table 3).
Table 3 also shows that the mean level of work ability was
significantly higher in the group without chronic diseases (4.0),
than in the group with physical chronic disease(s) (3.9) (p<0.05),
the group with mental chronic disease(s) (3.6) (p<0.05), and
the group with both physical and mental condition(s) (3.4)
(p<0.05). Furthermore, the level of work ability in the group
with physical chronic disease(s) was significantly higher than in
the group with mental chronic disease(s) (p<0.05) and the group
with both physical and mental condition(s) (p<0.05). The mean
level of burnout complaints was significantly lower in the group
without chronic diseases (2.3) than in the group with physical
chronic disease(s) (2.4) (p<0.05), the group with mental chronic
disease(s) (3.0) (p<0.05), and the group with both physical
and mental condition(s) (3.2) (p<0.05). Moreover, the level of
burnout complaints in the group with physical chronic disease(s)
was significantly lower than in the group with mental chronic
disease(s) (p<0.05) and the group with both physical and mental
condition(s) (p<0.05). The mean level of work engagement was
significantly higher in employees without chronic diseases (5.1),
than in the group with mental chronic disease(s) (4.2) (p<0.05)
and the group with both physical and mental condition(s) (4.3)
(p<0.05), but not different from the group with physical chronic
disease(s) (5.1). Furthermore, the level of work engagement in
the latter group was significantly higher than in the group with
mental chronic disease(s) (p<0.05) and the group with both
physical and mental condition(s) (p<0.05).
The level of each of the four job resources (autonomy, social
support by colleagues, a supportive leadership style, or an open
and communicative culture) in the group with physical chronic
disease(s) and the group with mental chronic disease(s) was at
the same level as in the group without chronic diseases. The level
of each job resource was significantly lower in the group with
physical and mental chronic disease(s) than in the group without
chronic diseases (p<0.05) (see Table 3).
As shown in Table 4, significant correlations (p<0.01)
between work ability, burnout complaints, work engagement,
Frontiers in Psychology | www.frontiersin.org 6August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 7
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
TABLE 3 | Health condition groups: age, work ability, burnout complaints, work engagement, and job resources (autonomy, social support by colleagues, a supportive
leadership style, or an open and communicative culture).
Variable M (SD) Missing Group
1—physical
chronic
disease(s)
Group 2—mental
chronic
disease(s)
Group 3—physical
chronic disease(s)
and mental chronic
disease(s)
Group 4—no
chronic
disease(s)
Complete study
sample
N640 36 120 1155 1951
Age in yearsµ34 47.9 (10.81)#42.1 (11.35) 47.5 (10.37) 45.5 (11.25) 46.4 (11.12)
Work abilityµλ
Five-point scale
– 3.9 (0.51)#3.6 (0.67)#3.4 (0.71)#4.0 (0.50) 3.9 (0.55)
Burnout complaintsµλ
Seven-point scale
– 2.4 (0.72)#3.0 (0.92)#3.2 (0.94)#2.3 (0.69) 2.4 (0.76)
Work engagementµλ
Seven-point scale
– 5.1 (1.05) 4.2 (1.16)#4.3 (1.11)#5.1 (1.11) 5.0 (1.11)
Autonomy
Five-point scale
6 3.6 (0.65) 3.5 (0.70) 3.5 (0.70)#3.7 (0.65) 3.7 (0.65)
Social support by colleaguesλ
Five-point scale
6 4.0 (0.50) 3.9 (0.50) 3.9 (0.61)#4.0 (0.52) 4.0 (0.52)
Supportive leadership styleλψ
Five-point scale
11 3.7 (0.76) 3.8 (0.71) 3.3 (0.93)#3.7 (0.80) 3.7 (0.80)
Open and communicative
cultureλψ
Five-point scale
8 3.4 (0.67) 3.4 (0.58) 3.0 (0.72)#3.4 (0.67) 3.4 (0.68)
M, mean; SD, standard deviation; N, number of participants. µSignificant difference between group 1 and group 2 at the 0.05 level. λSignificant difference between group
1 and group 3 at the 0.05 level. ψSignificant difference between group 2 and group 3 at the 0.05 level. #Significant difference from group 4 at the 0.05 level.
TABLE 4 | Work ability, burnout complaints, work engagement, and job resources (autonomy, social support by colleagues, supportive leadership style, or open and
communicative culture): correlations.
Variables 1 2 3 4 5 6 7
Work ability (0.74)
Burnout complaints −0.579** (0.89)
Work engagement 0.434** −0.781** (0.95)
Autonomy 0.312** −0.362** 0.282** (0.80)
Social support by colleagues 0.161** −0.322** 0.355** 0.171** (0.74)
Supportive leadership style 0.238** −0.352** 0.343** 0.240** 0.351** (0.89)
Open and communicative culture 0.233** −0.385** 0.380** 0.250** 0.356** 0.618** (0.90)
Cronbach’s α’s are in parentheses. **Correlation is significant at the 0.01 level (two-tailed).
and each of the four job resources were observed in the
expected directions.
Hypothesis Testing
The explained variances of the regression models were 22% for
work ability, 32% for burnout complaints, and 27% for work
engagement. Age is a predictor with a small effect size for lower
work ability (β=−0.091, p<0.01) and lower work engagement
(β=−0.040, p<0.05); however, age is no predictor for the level
of burnout complaints (see Table 5).
The first set of hypotheses was partly confirmed. All three
chronic disease groups were associated with lower work ability
(β’s −0.085, −0.092, and −0.235, respectively; p<0.01).
However, groups 2 and 3 (both groups with mental conditions,
with and without physical chronic diseases) were related to
higher burnout complaints (β’s 0.087 and 0.212, respectively;
p<0.01) and to lower work engagement (β’s −0.084 and −0.133,
respectively; p<0.01), but this was not the case for the group
with exclusively physical chronic diseases (see Table 5). In other
words, H1a is completely supported and H1b and H1c are
partly supported.
The analyses of the second set of hypotheses regarding
the four job resources demonstrates that only autonomy and
a supportive leadership style were associated in the expected
directions with work ability, burnout complaints, and work
engagement. Social support by colleagues and an open and
communicative organizational culture were only associated with
burnout complaints and work engagement as expected, but not
associated with work ability (see Table 5). In other words,
H2a and H2c are completely supported and H2b and H2d are
partially supported.
The analyses of the third set of hypotheses regarding the
possible moderation by the four job resources of the association
between the chronic disease groups with the three indicators of
occupational well-being resulted in some significant results for
autonomy and for a supportive leadership style. However, no
Frontiers in Psychology | www.frontiersin.org 7August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 8
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
TABLE 5 | Summary of multiple regression analyses for variables predicting work ability, burnout complaints, and work engagement (N= 1951).
Work ability Burnout complaints Work engagement
Variable B SE B βB SE B βB SE B β
Age −0.004 0.001 −0.091** 0.000 0.001 −0.003 −0.004 0.002 −0.040*
Group 1—physical chronic disease(s) −0.097 0.024 −0.085** 0.046 0.031 0.028 0.053 0.048 0.022
Group 2—mental chronic diseases(s) −0.371 0.096 −0.092** 0.489 0.124 0.087** −0.698 0.190 −0.084**
Group 3—physical chronic disease(s)
and mental chronic diseases(s)
−0.535 0.053 −0.235** 0.671 0.069 0.212** −0.621 0.106 −0.133**
Autonomy 0.117 0.015 0.214** −0.157 0.020 −0.207** 0.151 0.031 0.135**
Group 1 ×Autonomy −0.011 0.025 −0.012 −0.050 0.033 −0.038 0.078 0.050 0.040
Group 2 ×Autonomy 0.254 0.098 0.069*−0.212 0.127 −0.041 0.074 0.195 0.010
Group 3 ×Autonomy 0.195 0.047 0.096** −0.150 0.060 −0.053*0.077 0.092 0.018
Social support of colleagues 0.018 0.016 0.034 −0.133 0.021 −0.177** 0.243 0.032 0.218**
Group 1 ×Social support of colleagues −0.027 0.027 −0.027 0.064 0.035 0.047 −0.060 0.053 −0.030
Group 2 ×Social support of colleagues −0.046 0.105 −0.011 −0.128 0.135 −0.021 0.064 0.207 0.007
Group 3 ×Social support of colleagues 0.048 0.047 0.026 −0.091 0.061 −0.035 0.045 0.093 0.012
Supportive leadership style 0.071 0.019 0.130** −0.100 0.025 −0.132** 0.159 0.038 0.143**
Group 1 ×Supportive leadership style −0.023 0.032 −0.023 −0.004 0.041 −0.003 −0.062 0.063 −0.031
Group 2 ×Supportive leadership style −0.319 0.150 −0.070*0.180 0.195 0.028 −0.220 0.298 −0.024
Group 3 ×Supportive leadership style −0.051 0.055 −0.029 0.170 0.071 0.070*−0.312 0.108 −0.087**
Open and communicative culture 0.020 0.020 0.038 −0.115 0.025 −0.152** 0.229 0.039 0.206**
Group 1 ×Open and communicative
culture
0.056 0.031 0.059 −0.027 0.040 −0.020 −0.049 0.061 −0.025
Group 2 ×Open and communicative
culture
0.052 0.130 0.011 −0.181 0.168 −0.028 0.204 0.258 0.021
Group 3 ×Open and communicative
culture
−0.076 0.056 −0.041 −0.006 0.073 −0.002 −0.083 0.111 −0.022
R20.217 0.321 0.267
F26.159 44.535 34.292
*Correlation is significant at the 0.05 level (two-tailed). **Correlation is significant at the 0.01 level (two-tailed).
moderation was found for social support of colleagues, nor for
an open and communicative organizational culture.
Autonomy buffered the negative relationship of both the
group with mental chronic disease(s) (β= 0.069, p<0.05) and the
group with both mental and physical chronic diseases (β= 0.096,
p<0.01) with work ability (see Figures 1,2). Autonomy also
buffered the positive relationship of the group with physical and
mental chronic disease(s) (β=−0.053, p<0.05) with burnout
complaints (see Figure 3).
A supportive leadership style also demonstrates three
significant moderation effects, namely in (1) the negative
relationship between the group with mental chronic disease(s)
with work ability (β=−0.070, p<0.05), (2) the positive
relationship between the group with physical and mental chronic
disease(s) with burnout complaints (β= 0.070, <0.05), and (3) the
negative relationship between the group with physical and mental
chronic disease(s) with work engagement (β=−0.087, <0.01).
The results indicate that a supportive leadership style is less
beneficial for the employees with mental chronic diseases than
for the employees without chronic diseases. In other words, the
group without chronic diseases demonstrates an interaction effect
by a supportive leadership style resulting in a larger increase in
work ability and in work engagement and in a larger decrease
of burnout complaints, than the abovementioned groups with
chronic diseases (see Figures 4–6). See Table 5 for all results.
In short, the results supported H3a and H3c partially, and H3b
and H3d were not supported.
DISCUSSION AND CONCLUSION
The expectation that the presence of one or more chronic diseases
was associated with lower work ability is met. So, employees
with a physical or a mental chronic disease, or both, are at risk
of experiencing a lower work ability. This is in line with other
studies (Koolhaas et al., 2013;Leijten et al., 2014;Kadijk et al.,
2018). The group with mental and physical chronic diseases is
the most vulnerable as the effect size for this group is at the
highest level (between small and medium). Moreover, age is also
negatively associated with work ability as demonstrated in other
studies (van den Berg et al., 2008); however, this association
is small. The expectation that the presence of one or more
chronic diseases was associated with higher burnout complaints
and with a lower work engagement was partly met, as this
was not the case when only physical chronic disease(s) were
involved. In the case that mental chronic diseases are involved,
higher burnout complaints and lower work engagement were
present, as are also reported in other studies. Concerning burnout
complaints, any possible relations with depression, a highly
prevalent mental condition, sharing its etiology with burnout
Frontiers in Psychology | www.frontiersin.org 8August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 9
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
FIGURE 1 | Moderation effect between autonomy and the group with mental chronic diseases versus the group without chronic diseases on work ability. Autonomy
1is≤1 standard deviation below mean. Autonomy 2 is ≥1 standard deviation above mean.
FIGURE 2 | Moderation effect between autonomy and the group with mental and physical chronic diseases versus the group without chronic diseases on work
ability. Autonomy 1 is ≤1 standard deviation below mean. Autonomy 2 is ≥1 standard deviation above mean.
(Shirom et al., 2006), might play a role. This also might clarify that
the group with exclusively physical chronic diseases demonstrates
no association with higher burnout complaints. However, the
latter is not in line with other studies, like in the Finnish
nationwide population studies. Higher burnout was reported
among women with coronary heart disease (Hallman et al.,
2003), and among women with musculoskeletal diseases and men
with cardiovascular diseases (Honkonen et al., 2006). Possibly,
the comparability between studies is affected because the study
samples have different profiles with regard to the combination of
various types of physical chronic diseases and also because the
present study included a specific segment of the labor market.
With regard to the absence of an association of physical chronic
diseases with lower work engagement in the present study, there
are very few studies to make comparisons with. Further, in the
present study, the level of work engagement is a little lower
with higher age, which is in contrast to several studies indicating
workers are more engaged as they age (Kim and Kang, 2017).
Frontiers in Psychology | www.frontiersin.org 9August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 10
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
FIGURE 3 | Moderation effect between autonomy and the group with mental and physical chronic diseases versus the group without chronic diseases on burnout
complaints. Note: Autonomy 1 is ≤1 standard deviation below mean. Autonomy 2 is ≥1 standard deviation above mean.
FIGURE 4 | Moderation effect between supportive leadership style and the group with mental chronic diseases versus the group without chronic diseases on work
ability. Supportive leadership style 1 is ≤1 standard deviation below mean. Supportive leadership style 2 is ≥1 standard deviation above mean.
In short, the results demonstrate that the occupational well-being
of the workers with mental chronic diseases is vulnerable, as
their chronic disease is associated with a higher level of burnout
complaints and a lower level of work engagement.
Not all associations of each of the four job resources with each
of the three measures of occupational well-being are as expected.
The associations of autonomy and a supportive leadership style
with each of the three measures of occupational well-being
are as expected, with the highest effect size for autonomy
predicting higher work ability and lower burnout complaints.
The associations of social support of colleagues and an open
and communicative organizational culture with each of the three
measures of occupational well-being are not as expected, as these
two job resources are not associated with work ability. This is an
Frontiers in Psychology | www.frontiersin.org 10 August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 11
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
FIGURE 5 | Moderation effect between supportive leadership style and the group with mental and physical chronic diseases versus the group without chronic
diseases on burnout complaints. Supportive leadership style 1 is ≤1 standard deviation below mean. Supportive leadership style 2 is ≥1 standard deviation above
mean.
FIGURE 6 | Moderation effect between supportive leadership style and the group with mental and physical chronic diseases versus the group without chronic
diseases on work engagement. Supportive leadership style 1 is ≤1 standard deviation below mean. Supportive leadership style 2 is ≥1 standard deviation above
mean.
important finding as studies on the association between these two
job resources and work ability are scarce.
Regarding any possible moderation effects, only autonomy
and a supportive leadership style demonstrate significant results
in the associations between the groups that include participants
with mental chronic diseases. However, the results for these
two job resources point in different directions. The buffering
effect of autonomy is in line with several previous studies and
as we expected. So, autonomy is an important job resource to
alleviate the associations of chronic diseases with less favorable
Frontiers in Psychology | www.frontiersin.org 11 August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 12
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
occupational well-being. However, the moderation effects of a
supportive leadership style are surprising, as these indicate a
supportive leadership style to be of less benefit for occupational
well-being among employees with mental chronic diseases (with
or without physical chronic diseases) than among employees
without chronic diseases. A supportive leadership style does
only slightly buffer the negative relationship of a mental chronic
disease with lower work ability, higher burnout complaints,
or lower work engagement. Moreover, the total level of the
experienced supportive leadership style in the group with
physical and mental comorbidities (see Table 3) is significantly
lower than in all the other groups. Because of the cross-sectional
design, we can only guess about the causes, but an explanation
might be that because of their poorer well-being, employees
with more severe mental chronic diseases receive more support
from their supervisor or manager than the employees with
less severe mental chronic diseases. Employees with a mental
disorder especially are faced with stigma (van Vuuren et al.,
2017;Brouwers et al., 2019;Brouwers, 2020), and perhaps more
reluctant to share their chronic disease with their supervisor or
manager. As not all employees tell their supervisor or manager
about their mental chronic disease, it might as well be possible
that for many employees their mental chronic disease is not
known by the manager or supervisor as long it is not severe
enough to interfere noticeably with work functioning. It is also
possible that in the case that a supervisor or manager does
know about the mental chronic disease, he or she keeps more
emotional distance than with the group without mental chronic
diseases. Furthermore, employees with mental chronic diseases
might experience less support from their supervisor or manager
as long as their functioning is acceptable, up to the situation
that problems with occupational well-being are shared with their
supervisor or manager and become visible in the workplace,
generating more support from their supervisor or manager.
The two other job resources, social support of colleagues and
an open and communicative organizational culture, demonstrate
no moderation at all. Unfortunately, studies into this subject are
scarce. Studies among workers past cancer diagnosis reported
the buffering effects of social support of colleagues, as well as
a better social climate at work, with regard to work ability in
the population of workers past cancer diagnosis (Taskila and
Lindbohm, 2007;Taskila et al., 2007). However, this is a specific
group and only concerns work ability.
Although the group with exclusively mental chronic diseases
is relatively small (N= 36, 1.8%), their mean age (42.1 years)
is significantly lower as the group with exclusively physical
chronic diseases (47.9 years). The mean age of the group with
comorbidity of physical and mental chronic diseases is 47.5 years.
This implies that many employees with chronic diseases will have
around two decades of employment ahead. As the level of all
four job resources among this comorbidity group is experienced
significantly lower than among the group without chronic
diseases, the group with physical and mental chronic disease(s)
needs particular attention with respect to the experienced level of
the job resources.
In general, the research field concerning chronic diseases, the
experience of job resources, and the association with work ability,
burnout complaints, and work engagement still seems to be a
niche. Nevertheless, the present results raise concerns with regard
to the occupational well-being of the employees with mental
chronic diseases, with or without physical chronic diseases. In
addition, there might be a potential to increase their occupational
well-being by offering job resources, especially more autonomy.
Limitations
It is important to notice that the population of the present
study, consisted of a specific sub-group of Dutch employees,
namely, employees in educational and (semi) governmental
organizations. These employees might have a specific profile
compared to the Dutch nationwide employed population.
However, a comparison with the general employed population
was not the aim, and the focus was on the associations within
the group of participants. Furthermore, self-reported measures
might be biased, and hence offer an inadequate indication of
the level of the job resources offered in the workplace. However,
one’s own interpretation of the job resources causes the action,
as formulated in the Thomas theorem (Thomas and Thomas,
1928, p. 572): “If men define situations as real, they are real
in their consequences.” In other words, self-reported measures
are necessary to find out how employees experience their own
situation. Additionally, no causal inferences can be made because
of the cross-sectional nature of the study.
Practical Implications
This study demonstrated that autonomy is an important target
for interventions to enhance work ability and work engagement
and to reduce burnout complaints among employees with mental
chronic diseases. As autonomy covers many possibilities in the
context of work and can range from making decisions about one’s
own work breaks, to making decisions on work procedures, this
job resource offers many opportunities. These possibilities should
be elaborated between an employer and the employee as much
as possible. However, this probably also requires a supportive
leadership style, and the results in the present study regarding
this job resource are unexpectedly less favorable. So, to imbed
more autonomy, the experience of a supportive leadership style
also needs attention.
Furthermore, the choice of workers not to disclose chronic
diseases can be understandable (Brouwers et al., 2019;Brouwers,
2020); however, as a consequence, this prevents extra attention
and effort by the supervisor or manager in managing more
autonomy for these employees. Nevertheless, in work situations
where an employee experiences a low level of autonomy,
especially in the case that chronic diseases are disclosed, a very
important question is what possibilities might be present to
enhance the level of autonomy.
Also, supervisors, line managers, and human resource
management should work together in this process, as the
perspectives on the role of specific job resources have
demonstrated to be different between certain positions (Haafkens
et al., 2011) and a collaboration will present a broader perspective
on options in the context of the work situation.
Furthermore, involving the employees in exploring
possibilities can also generate important workable solutions
Frontiers in Psychology | www.frontiersin.org 12 August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 13
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
and will be an opportunity for more autonomy and experiencing
more support in the context of work. It is important to make use
of experiential experts of all the parties involved.
To conclude, interventions focusing on autonomy offer
opportunities to reinforce work ability and work engagement
and to reduce burnout complaints among employees with mental
chronic diseases, with or without physical chronic diseases.
DATA AVAILABILITY STATEMENT
The datasets generated for this study will not be made publicly
available. The data that support the findings are available from
Loyalis Knowledge & Consult but restrictions apply to the
availability of these data, which were used under license for the
current study, and so are not publicly available. The data are
however available from the authors upon reasonable request and
with permission of Loyalis Knowledge & Consult.
ETHICS STATEMENT
Ethical review and approval was not required for the
study on human participants in accordance with the
local legislation and institutional requirements. The
patients/participants provided their written informed consent
to participate in this study.
AUTHOR CONTRIBUTIONS
IB, WV, and TV developed the study design. TV was
responsible for the data collection. The data analysis was
prepared by IB with support from TV and WV. IB wrote
the first draft of the manuscript, and the later drafts
of the manuscript were adjusted by all three authors
in collaboration. All authors read and approved the
submitted version.
REFERENCES
Ahlstrom, L., Grimby-Ekman, A., Hagberg, M., and Dellve, L. (2010). The work
ability index and single-item question: associations with sick leave, symptoms,
and health – a prospective study of women on long-term sick leave. Scand. J.
Work. Environ. Health 36, 404–412. doi: 10.5271/sjweh.2917
Aiyar, S., and Ebeke, C. (2016). The impact of workforce aging on european
productivity. IMF Work. Pap. 16:1. doi: 10.5089/9781475559729.001
Alarcon, G. M. (2011). A meta-analysis of burnout with job demands, resources,
and attitudes. J. Vocat. Behav. 79, 549–562. doi: 10.1016/j.jvb.2011.03.007
Alavinia, S. M., de Boer, A. G. E. M., van Duivenbooden, J. C., Frings-Dresen,
M. H. W., and Burdorf, A. (2009). Determinants of work ability and its
predictive value for disability. Occup. Med. (Chic. Ill). 59, 32–37. doi: 10.1093/
occmed/kqn148
Austen, S., Jefferson, T., Lewin, G., Ong, R., and Sharp, R. (2016). Work ability,
age and intention to leave aged care work. Australas. J. Ageing 35, 18–22.
doi: 10.1111/ajag.12187
Bakker, A. B., and Demerouti, E. (2007). The job demands-resources model: state
of the art. J. Manag. Psychol. 22, 309–328. doi: 10.1108/02683940710733115
Bakker, A. B., Demerouti, E., and Euwema, M. C. (2005). Job resources buffer
the impact of job demands on burnout. J. Occup. Health Psychol. 10, 170–180.
doi: 10.1037/1076-8998.10.2.170
Bakker, A. B., Hakanen, J. J., Demerouti, E., and Xanthopoulou, D. (2007). Job
resources boost work engagement, particularly when job demands are high.
J. Educ. Psychol. 99, 274–284. doi: 10.1037/0022-0663.99.2.274
Bakker, A. B., and Leiter, M. P. (2010). Work Engagement: A Handbook of
Essential Theory and Research. London: Psychology Press, 1–209. doi: 10.4324/
9780203853047
Bakker, A. B., Schaufeli, W. B., Leiter, M. P., and Taris, T. W. (2008). Work
engagement: an emerging concept in occupational health psychology. Work
Stress 22, 187–200. doi: 10.1080/02678370802393649
Banerjee, S. (2015). Multimorbidity – older adults need health care that can count
past one. Lancet 385, 587–589. doi: 10.1016/S0140-6736(14)61596-8
Boyd, C. M., and Fortin, M. (2010). Future of multimorbidity research: how
should understanding of multimorbidi.: start your search! Public Health Rev.
32, 451–474. doi: 10.1007/BF03391611
Brouwers, E. P. M. (2020). Social stigma is an underestimated contributing factor
to unemployment in people with mental illness or mental health issues: position
paper and future directions. BMC Psychol. 8:36. doi: 10.1186/s40359-020-
00399-0
Brouwers, E. P. M., Joosen, M. C. W., Van Zelst, C., and Van Weeghel, J. (2019).
To disclose or not to disclose: a multi-stakeholder focus group study on mental
health issues in the work environment. J. Occup. Rehabil. 30, 84–92. doi: 10.
1007/s10926-019- 09848-z
CBS (2019). Health and Care use; Personal Characteristics. Statline. Available
online at: https://opendata.cbs.nl/#/CBS/nl/dataset/83005NED/table?ts=
1565615621872 (accessed August 12, 2019).
Davies, I. A., and Crane, A. (2010). Corporate social responsibility in small-
and medium-size enterprises: investigating employee engagement in fair trade
companies. Bus. Ethics A Eur. Rev. 19, 126–139. doi: 10.1111/j.1467-8608.2010.
01586.x
De Lepeleire, J., and Heyrman, J. (2003). Is everyone with a chronic disease also
chronically ill? Arch. Public Heal. 61, 161–176.
Demerouti, E., Bakker, A. B., Nachreiner, F., and Schaufeli, W. B. (2001). The job
demands-resources model of burnout. J. Appl. Psychol. 86, 499–512.
Feldt, T., Hyvönen, K., Mäkikangas, A., Kinnunen, U., and Kokko, K. (2009).
Development trajectories of Finnish managers’ work ability over a 10-year
follow-up period. Scand. J. Work. Environ. Health 35, 37–47. doi: 10.2307/
40967753
Ferguson, C. J. (2009). An effect size primer: a guide for clinicians and researchers.
Prof. Psychol. Res. Pract. 40, 532–538. doi: 10.1037/a0015808
Giorgi, G., Lecca, L. I., Leon-Perez, J. M., Pignata, S., Topa, G., and Mucci, N.
(2020). Emerging issues in occupational disease: mental health in the aging
working population and cognitive impairment – a narrative review. Biomed.
Res. Int. 2020:1742123. doi: 10.1155/2020/1742123
Haafkens, J. A., Kopnina, H., Meerman, M. G. M., and Van Dijk, F. J. H.
(2011). Facilitating job retention for chronically ill employees: perspectives of
line managers and human resource managers. BMC Health Serv. Res. 11:104.
doi: 10.1186/1472-6963- 11-104
Hakanen, J. J., and Lindbohm, M. L. (2008). Work engagement among breast
cancer survivors and the referents: the importance of optimism and social
resources at work. J. Cancer Surviv. 2, 283–295. doi: 10.1007/s11764-008-
0071-0
Hallman, T., Thomsson, H., Burell, G., Lisspers, J., and Setterlind, S. (2003).
Stress, burnout and coping: differences between women with coronary heart
disease and healthy matched women. J. Health Psychol. 8, 433–445. doi: 10.1177/
13591053030084003
Hardy, M. A. (1993). Regression with Dummy Var iables, 93rd Edn. Thousand Oaks,
CA: Sage.
Honkonen, T., Ahola, K., Pertovaara, M., Isometsä, E., Kalimo, R.,
Nykyri, E., et al. (2006). The association between burnout and physical
illness in the general population-results from the Finnish health 2000
study. J. Psychosom. Res. 61, 59–66. doi: 10.1016/j.jpsychores.2005.
10.002
Huhtala, M., Tolvanen, A., Mauno, S., and Feldt, T. (2015). The associations
between ethical organizational culture, burnout, and engagement: a
multilevel study. J. Bus. Psychol. 30, 399–414. doi: 10.1007/s10869-014-
9369-2
Frontiers in Psychology | www.frontiersin.org 13 August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 14
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
Ilmarinen, J. (2007). The work ability index (WAI). Occup. Med. (Chic. Ill). 57,
160–160. doi: 10.1093/occmed/kqm008
Ilmarinen, J., Tuomi, K., and Seitsamo, J. (2005). New dimensions of work ability.
Int. Congr. Ser. 1280, 3–7. doi: 10.1016/j.ics.2005.02.060
Kadijk, E. A., van den Heuvel, S., Ybema, J. F., and Leijten, F. R. M. (2018). The
influence of multi-morbidity on the work ability of ageing employees and the
role of coping style. J. Occup. Rehabil. 29, 503–513. doi: 10.1007/s10926-018-
9811-9
Kanste, O., Kyngäs, H., and Nikkilä, J. (2007). The relationship between
multidimensional leadership and burnout among nursing staff. J. Nurs. Manag.
15, 731–739. doi: 10.1111/j.1365-2934.2006.00741.x
Kim, B. J., Ishikawa, H., Liu, L., Ohwa, M., Sawada, Y., Lim, H. Y., et al.
(2018). The effects of job autonomy and job satisfaction on burnout among
careworkers in long-term care settings: policy and practice implications for
Japan and South Korea. Educ. Gerontol. 44, 289–300. doi: 10.1080/03601277.
2018.1471255
Kim, N., and Kang, S. W. (2017). Older and more engaged: the mediating role of
age-linked resources on work engagement. Hum. Resour. Manage. 56, 731–746.
doi: 10.1002/hrm.21802
Kiss, P., De Meester, M., Kristensen, T. S., and Braeckman, L. (2014). Relationships
of organizational social capital with the presence of “gossip and slander,”
“quarrels and conflicts,” sick leave, and poor work ability in nursing homes. Int.
Arch. Occup. Environ. Health 87, 929–936. doi: 10.1007/s00420-014-0937-6
Koolhaas, W., Van der Klink, J. J. L., de Boer, M. R., Groothoff, J. W., and Brouwer,
S. (2013). Chronic health conditions and work ability in the ageing workforce:
the impact of work conditions, psychosocial factors and perceived health. Int.
Arch. Occup. Environ. Health 87, 433–443. doi: 10.1007/s00420-013-0882-9
Leijten, F. R. M., van den Heuvel, S. G., Ybema, J. F., van der Beek, A. J., Robroek,
S. J. W., and Burdorf, A. A. (2014). The influence of chronic health problems
on work ability and productivity at work: a longitudinal study among older
employees. Scand. J. Work. Environ. Health 40, 473–482. doi: 10.5271/sjweh.
3444
Li, Y., Castaño, G., and Li, Y. (2018). Linking leadership styles to work engagement:
the role of psychological capital among Chinese knowledge workers. Chinese
Manag. Stud. 12, 433–452. doi: 10.1108/CMS-04-2017- 0108
Maslach, C., Schaufeli, W. B., and Leiter, M. P. (2001). Job burnout. Annu. Rev.
Psychol. 52, 397–422. doi: 10.1146/annurev.psych.52.1.397
Mauno, S., Kinnunen, U., and Ruokolainen, M. (2007). Job demands and resources
as antecedents of work engagement: a longitudinal study. J. Vocat. Behav. 70,
149–171. doi: 10.1016/j.jvb.2006.09.002
Maurits, E., Rijken, M., and Friele, R. (2013). Chronically ill and Work Participation
by People with a Chronic Illness or Physical Disability. Available online at:
www.nivel.nl (accessed September 5, 2019).
McGonagle, A. K., Barnes-Farrell, J. L., Di Milia, L., Fischer, F. M., Hobbs, B. B. B.,
Iskra-Golec, I., et al. (2014). Demands, resources, and work ability: a cross-
national examination of health care workers. Eur. J. Work Organ. Psychol. 23,
830–846. doi: 10.1080/1359432X.2013.819158
Nazarov, S., Manuwald, U., Leonardi, M., Silvaggi, F., Foucaud, J., Lamore, K.,
et al. (2019). Chronic diseases and employment: which interventions support
the maintenance of work and return to work among workers with chronic
illnesses? A systematic review. Int. J. Environ. Res. Public Health 16:1864.
doi: 10.3390/ijerph16101864
Nogueira, H. C., Diniz, A. C. P., Barbieri, D. F., Padula, R. S., Carregaro, R. L.,
and De Oliveira, A. B. (2012). Musculoskeletal Disorders and Psychosocial
Risk Factors among Workers of the Aircraft Maintenance Industry. in
Work. Amsterdam: IOS Press, 4801–4807. doi: 10.3233/WOR-2012-0767-
4801
Olsen, E., Bjaalid, G., and Mikkelsen, A. (2017). Work climate and the mediating
role of workplace bullying related to job performance, job satisfaction, and
work ability: a study among hospital nurses. J. Adv. Nurs. 73, 2709–2719.
doi: 10.1111/jan.13337
Rongen, A., Robroek, S. J. W., Schaufeli, W., and Burdorf, A. (2014). The
contribution of work engagement to self-perceived health, work ability, and
sickness absence beyond health behaviors and work-related factors. J. Occup.
Environ. Med. 56, 892–897. doi: 10.1097/JOM.0000000000000196
Ryan, R. M., and Frederick, C. (1997). On energy, personality, and health:
subjective vitality as a dynamic reflection of well-being. J. Pers. 65, 529–565.
doi: 10.1111/j.1467-6494.1997.tb00326.x
Schaufeli, W., and van Dierendonck, D. (2000). UBOS Utrechtse Burnout
Schaal: Handleiding. Available online at: https://www.pearsonclinical.nl/ubos-
utrechtse-burnout- schaal (accessed December 6, 2018).
Schaufeli, W. B., and Bakker, A. B. (2004). Job demands, job resources, and their
relationship with burnout and engagement: a multi-sample study. J. Organ.
Behav. 25, 293–315. doi: 10.1002/job.248
Schaufeli, W. B., Bakker, A. B., and van Rhenen, W. (2009). How changes in
job demands and resources predict burnout, work engagement, and sickness
absenteeism. J. Organ. Behav. 30, 893–917. doi: 10.1002/job.595
Schaufeli, W. B., Taris, T. W., and Van Rhenen, W. (2008). Workaholism, burnout,
and work engagement: three of a kind or three different kinds of employee
well-being? Appl. psychol. 57, 173–203. doi: 10.1111/j.1464-0597.2007.00285.x
SER (2016). Work: Important for Everyone. Available online at: https://www.ser.nl/
nl/publicaties/werken-chronische- ziekte (accessed July 20, 2020).
Shirom, A., Melamed, S., Toker, S., Berliner, S., and Shapira, I. (2006). “Burnout
and health review: current knowledge and future research directions,” in
International Review of Industrial and Organizational Psychology 2005, eds G. P.
Hodgkinson and J. K. Fordin (Palo Alto, CA: Consulting Psychologists Press).
doi: 10.1002/0470029307.ch7
Shuck, B., Reio, T. G., and Rocco, T. S. (2011). Employee engagement: an
examination of antecedent and outcome variables. Hum. Resour. Dev. Int. 14,
427–445. doi: 10.1080/13678868.2011.601587
Silvaggi, F., Eigenmann, M., Scaratti, C., Guastafierro, E., Toppo, C., Lindstrom,
J., et al. (2020). Employment and chronic diseases: suggested actions for the
implementation of inclusive policies for the participation of people with chronic
diseases in the labour market. Int. J. Environ. Res. Public Health 17:820.
doi: 10.3390/ijerph17030820
Soares, J. J. F., Grossi, G., and Sundin, Ö (2007). Burnout among women:
associations with demographic/socio-economic, work, life-style and health
factors. Arch. Womens. Ment. Health 10, 61–71. doi: 10.1007/s00737-007-
0170-3
Strijk, J. E., Proper, K. I., Van Der Beek, A. J., and Van Mechelen, W. (2009).
The vital@work study. the systematic development of a lifestyle intervention
to improve older workers’ vitality and the design of a randomised controlled
trial evaluating this intervention. BMC Public Health 9:408. doi: 10.1186/1471-
2458-9- 408
Sugimura, H., and Thériault, G. (2010). Impact of supervisor support on work
ability in an IT company. Occup. Med. (Chic. Ill). 60, 451–457. doi: 10.1093/
occmed/kqq053
Sullivan, G. M., and Feinn, R. (2012). Using effect size—or why the P value
is not enough. J. Grad. Med. Educ. 4, 279–282. doi: 10.4300/jgme-d-12-
00156.1
Taipale, S., Selander, K., Anttila, T., and Nätti, J. (2011). Work engagement in
eight European countries: the role of job demands, autonomy, and social
support. Int. J. Sociol. Soc. Policy 31, 486–504. doi: 10.1108/0144333111114
9905
Taskila, T., and Lindbohm, M. L. (2007). Factors affecting cancer survivors’
employment and work ability. Acta Oncol. (Madr). 46, 446–451. doi: 10.1080/
02841860701355048
Taskila, T., Martikainen, R., Hietanen, P., and Lindbohm, M.-L. (2007).
Comparative study of work ability between cancer survivors and their referents.
Eur. J. Cancer 43, 914–920. doi: 10.1016/j.ejca.2007.01.012
Thomas, W. I., and Thomas, D. S. (1928). The Child in America: Behaviour
Problems And Programs, ed. A. A. Knopf (New York, NY: University of
Michigan).
Tuomi, K., Vanhala, S., Nykyri, E., and Janhonen, M. (2004). Organizational
practices, work demands and the well-being of employees: a follow-up study
in the metal industry and retail trade. Occup. Med. (Chic. Ill). 54, 115–121.
doi: 10.1093/occmed/kqh005
Uijen, A., and van de Lisdonk, E. (2008). Multimorbidity in primary care:
prevalence and trend over the last 20 years. Eur. J. Gen. Pract. 14, 28–32.
doi: 10.1080/13814780802436093
van Dam, K., van Vuuren, T., and Kemps, S. (2017). Sustainable employment:
the importance of intrinsically valuable work and an age-supportive climate.
Int. J. Hum. Resour. Manag. 28, 2449–2472. doi: 10.1080/09585192.2015.113
7607
van den Berg, S., Burdorf, A., and Robroek, S. J. W. (2017). Associations between
common diseases and work ability and sick leave among health care workers.
Frontiers in Psychology | www.frontiersin.org 14 August 2020 | Volume 11 | Article 1805

fpsyg-11-01805 August 4, 2020 Time: 15:40 # 15
Boelhouwer et al. Occupational Well-Being and Chronic Diseases
Int. Arch. Occup. Environ. Health 90, 685–693. doi: 10.1007/s00420-017-
1231-1
van den Berg, T. I. J., Elders, L. A. M., De Zwart, B. C. H., and Burdorf, A. (2008).
The effects of work-related and individual factors on the work ability index: a
systematic review. Occup. Environ. Med. 66, 211–220. doi: 10.1136/oem.2008.
039883
Van Poppel, J., and Kamphuis, P. (2004). Manual School’s Health Measure: Research
About Health, Work and Work Conditions in Schools. Tilburg: IVA.
van Vuuren, T., Smit, A., and Verhoeven, D. (2017). Stigmatisering van
werknemers met een psychische aandoening en hoe HR dit tegen kan gaan.
Tijdschr. Voor HRM 4, 1–18.
Vangelova, K., Dimitrova, I., and Tzenova, B. (2018). Work ability of aging teachers
in Bulgaria. Int. J. Occup. Med. Environ. Health 31, 593–602. doi: 10.13075/
ijomeh.1896.01132
Wollard, K. K., and Shuck, B. (2011). Antecedents to employee engagement. Adv.
Dev. Hum. Resour. 13, 429–446. doi: 10.1177/1523422311431220
Xanthopoulou, D., Bakker, A. B., Demerouti, E., and Schaufeli, W. B. (2007a). The
role of personal resources in the job demands-resources model. Int. J. Stress
Manag. 14, 121–141. doi: 10.1037/1072-5245.14.2.121
Xanthopoulou, D., Bakker, A. B., Dollard, M. F., Demerouti, E., Schaufeli, W. B.,
Taris, T. W., et al. (2007b). When do job demands particularly predict
burnout? The moderating role of job resources. J. Manag. Psychol. 22, 766–786.
doi: 10.1108/02683940710837714
Xu, X., Mishra, G. D., and Jones, M. (2017). Evidence on multimorbidity from
definition to intervention: an overview of systematic reviews. Ageing Res. Rev.
37, 53–68. doi: 10.1016/j.arr.2017.05.003
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Boelhouwer, Vermeer and van Vuuren. This is an open-access
article distributed under the terms of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction in other forums is permitted, provided
the original author(s) and the copyright owner(s) are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with
these terms.
Frontiers in Psychology | www.frontiersin.org 15 August 2020 | Volume 11 | Article 1805