{"paper_id":"ce893e94-efbc-4a3d-8569-5df6c87cb9b3","body_text":"RESEARCH Open Access\nDiscover Public HealthHowe et al. Discover Public Health          (2026) 23:688 \nhttps://doi.org/10.1186/s12982-026-02018-6\nWorkplace mistrust and barriers \nto implementing workplace guidelines \nfor endometriosis and chronic pelvic pain \na mixed methods intervention study in an \nAustralian University\nDanielle Howe1,2* , Michelle O’Shea1,3, Sarah Duffy3 and Mike Armour1,4,5\n  * C o r r e s p o n d e n c e :  \nDanielle Howe\n22068554@student.westernsydney.\nedu.au\n1NICM Health Research Institute,  \nWestern Sydney University, Sydney, \nAustralia\n2Melbourne Law School, University \nof Melbourne, Melbourne, Australia\n3School of Business, Western \nSydney University, Sydney, Australia\n4Medical Research Institute of New \nZealand (MRINZ), Wellington, New \nZealand\n5School of Medicine, Translational \nResearch Institute (THRI), Western \nSydney University, Sydney, Australia\n© The Author(s) 2026. Open Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International \nLicense, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate \ncredit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. \nYou do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party \nmaterial in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material \nis not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted \nuse, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p :  / / c r e a  t i v e c  o m m o  n s . o r g / l i c e n s \ne s / b y - n c - n d / 4 . 0 /     .    \nAbstract\nBackground Endometriosis and chronic pelvic pain (CPP) substantially affect work \nparticipation and productivity, yet workplace interventions remain largely unevaluated. \nThis study piloted Endo@Work, a co-designed workplace guideline to support \nemployees with endometriosis/CPP in an Australian university.\nAims To evaluate pre and post implementation experiences of Endo@work among \nstaff with endometriosis and CPP and for managers/supervisors (with and without \nendo/CPP) in supporting them.\nMethods A mixed methods design evaluated a three-month trial of the Endo@Work \nguidelines, which included a tailored policy, staff and manager/supervisor toolkits, a \nChronic Pelvic Pain Coordinator role, and webinar. Online surveys, tailored according \nto participant group and endo/CPP status, were administered at baseline and at end of \ntrial (n = 58 and n = 36), capturing demographics, endometriosis health-related quality \nof life (EHP-30), work productivity (WPAI), and factors shaping disclosure and support. \nTen semi-structured interviews were analysed using reflexive thematic analysis.\nFindings Low guideline uptake prevented formal testing of intervention effects, \nhowever, the study generated important insights into staff mistrust of internal \nevaluation processes. Mixed-methods findings suggest impression management \nresponse bias, evidenced by underreporting of symptom burden among staff with \nendometriosis/CPP and high non-response to discrimination items. Interviews \ncontextualised these patterns, showing how academic competition, compounded by \nuniversity-wide restructure, reinforced stigma, fear of discrimination, and managerial \nuncertainty about initiating health conversations, sustaining silence and undermining \ntrust in internal surveys. The primary barrier was not policy inadequacy, but entrenched \nsilence around health needs at work. This silence, shaped by cultures of competition \nand overwork, managerial uncertainty, and limited senior leadership engagement with \nchronic health, sustained the gap between policy and practice.\n\nPage 2 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \n 1 Introduction\nChronic pelvic pain (CPP) is an umbrella term for conditions involving pain attributed \nto the reproductive organs, urinary tract, bowel, or pelvic floor lasting longer than six \nmonths, and are severe enough to impair functioning or require medical care [ 1, 2]. \nPrevalence rates are high. Global estimates suggest that up to 26.6% of women 1 and \nthose presumed female at birth (PFAB) experience CPP [ 2]. Endometriosis is the most \ncommon cause of CPP , affecting an estimated 6–14% of women and PFAB [ 4– 6], indi-\ncating that endometriosis may be more common than breast cancer, prostate cancer, and \ndiabetes [7, 8]. Estimates indicate that endometriosis underlies between 15.4% and 71.4% \nof all CPP cases [ 9]. However, ongoing diagnostic delays mean that current prevalence \nestimates may not fully capture the true burden of the condition [10].\nBoth endometriosis and CPP can significantly disrupt daily functioning [ 11] with \nsimilar symptoms and impacts between both cohorts [ 12]. Pain, including regular pel -\nvic pain, severe period pain (dysmenorrhea), as well as chronic fatigue, nausea, and gas -\ntrointestinal symptoms are common [ 12– 15]. These symptoms contribute to workplace \nabsenteeism, presenteeism, and substantial productivity losses, with the majority of the \neconomic burden being due to productivity losses [ 12, 16– 22]. Even modest reductions \nin pain (approximately 20–30%) are strongly correlated with reductions in presenteeism \nand absenteeism [ 23], suggesting the potential importance of effective symptom man -\nagement from workplace-based supports in mitigating productivity loss and improving \nquality of life for workers with endometriosis and CPP .\nDuring the COVID-19 pandemic, many Australian workplaces adopted a work from \nhome, or hybrid working approach. These changes in workplace flexibility resulted in \nmore than half of people with endometriosis reporting that their endometriosis symp -\ntoms were much easier to manage, and they were more productive [ 22]. Two key fac -\ntors identified were the flexibility in time management they had due to working from \nhome, and the ability to use physical aids such as heat packs, comfortable chairs or being \nable to lie down to manage their symptoms [ 22]. However, in recent years, there has \nbeen a move back to working in a centralised office [ 24], with the majority of Australian \nbusiness indicating that they intend to move back to at least four days per week in the \noffice [25]. Therefore, for women with endometriosis this may again reduce their ability \nto manage their symptoms and therefore productivity is likely to reduce, as seen in pre-\npandemic data [22].\n1 This paper sometimes uses the term \"women\" to reflect the cohorts of cisgender women most often represented \nin prior research. However, we recognise that trans and gender-diverse people may also experience menstruation, \nmenopause, and chronic conditions such as endometriosis and chronic pelvic pain; and therefore, should be acknowl-\nedged and included academic literature. Where possible, we use the term “women and those presumed female at \nbirth (PFAB)” in alignment with research on inclusive language and accurate reporting.[3].\nConclusion Findings point to the need for external evaluation, visible leadership \nendorsement, and targeted manager training to meaningfully close this gap.\nTrial registration: This study was registered with Australian New Zealand Clinical Trial \nRegistry (ANZCTR) on 12 June 2024. The study was registered 25 June 2024, registration \nnumber: ACTRN12624000773538p.\nKeywords Endometriosis, Chronic pelvic pain, Workplace guidelines, Higher \neducation, HR, Evaluation frameworks\n\nPage 3 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nWhile workplaces globally are beginning to adopt reproductive health policies such as \npaid menstrual and menopause leave, flexible work arrangements, and manager train -\ning, no empirical studies have evaluated interventions specifically targeting endome -\ntriosis and/or CPP in the workplace [ 26]. Leaving a critical evidence gap in relation to \nsupporting endometriosis and CPP at work. Existing research has focused on menstrual \nor menopause-related workplace policies, primarily in the UK and EU [ 27, 28] and some \nfurther limited research from Japan [29]. Given the prevalence and burden of these con -\nditions, the paucity of codesign and evaluation of endo/CPP workplace-focused inter -\nventions is deeply problematic.\nThis study addresses this evidence gap by piloting Endo@Work, a set of co-designed \nworkplace guidelines developed to support employees with endometriosis and CPP in \nan Australian university.\n1.1 Study aims\nThe study evaluated the effectiveness of the codesigned Endo@Work guidelines within \nan Australian university workplace, focusing on both outcomes and contextual factors \ninfluencing their uptake. Specifically, we aimed to:\n(1) Assess perceived impact of the guidelines in mitigating absenteeism and presenteeism \nthrough supporting symptom management for employees with endometriosis and \nCPP (quantitative).\n(2) Explore workplace structural and cultural dynamics enabling or impeding guideline \nimplementation or uptake (mixed methods: quantitative and qualitative).\n(3) Evaluate the guidelines’ perceived quality and practicality, encompassing policies, \nprocedures and education materials (mixed-methods: quantitative and qualitative).\n2 Methods\n2.1 Study design\nThis mixed methods study evaluated the feasibility and perceived impact of the co-\ndesigned Endo@Work guidelines over a three-month intervention period, starting in \nMay 2025. Data collection consisted of two online surveys and follow-up semi-struc -\ntured interviews. The baseline survey was administered prior to the Endo@Work train -\ning webinar, and the second survey was conducted at the end of the three-month trial. \nSemi-structured interviews were also undertaken at the end of the trial period.\nThe three-month duration was selected in consultation with school 2 and institute 3 \nleadership as a practical window in which early indicators of engagement and feasibility \ncould be observed, while recognising that sustained cultural and organisational change \ntypically occurs over longer periods. During this time, staff were encouraged to use \nthe guidelines, request reasonable adjustments, and seek support from the designated \nChronic Pelvic Pain Coordinators (CPPCs).\nIntegrating survey data with qualitative interviews enabled a comprehensive examina -\ntion of how the guidelines were received, the extent to which they were used, and the \norganisational and cultural factors shaping implementation within a university setting.\n2 The university consisted of schools employing academic and professional staff responsible for delivering degree pro-\ngrams and conducting research.\n3 Research institutes also employed academic and professional staff at the university but focused primarily on research \nrather than teaching.\n\nPage 4 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nEthical approval for the study was granted by the Western Sydney University Human \nResearch Ethics Committee (H16067—March 2025).\n2.2 Development and codesign of the Endo@Work guidelines\nThe Endo@Work guidelines were codesigned through a national survey of Australians \nliving and working with endometriosis [ 30], focus groups with employees managing \nendometriosis and chronic pelvic pain [ 31], and focus groups with employers, including \nsenior leadership, managers, and human resources (HR) professionals [32].\nThe Endo@Work intervention includes:\n1. A workplace policy document tailored to the higher education (HE) university context.\n2. A supervisor toolkit, which provided:\n3. Educational content highlighting the impact of endometriosis and CPP on work and \ncareer.\n4. Lived-experience narratives linked to key educational points.\n5. Guidance relevant to employee entitlements within the university context.\n6. Procedures for arranging reasonable adjustments.\n7. A staff toolkit for employees with endometriosis and CPP , which outlined:\n8. Entitlements and reasonable adjustments available and how to access them.\n9. Guidance on disclosure emphasising safety and confidentiality.\n10. A Chronic Pelvic Pain Coordinator (CPPC) role in each school or institute to practically \nsupport guideline uptake. The CPPC was the primary contact for information relating \nto the Endo@Work pilot. While not providing health information or advice, CPPCs \nsupported staff with procedural queries and directed them to appropriate HR channels \nfor resources, education, and adjustments.\n11. One-hour online webinar, hosted by the school/institute and delivered by the research \nteam.\nEach webinar was tailored to the specific school/institute and introduced endome -\ntriosis and its potential workplace impacts, outlined the workplace policy docu -\nment, presented the staff and supervisor toolkits, and introduced the Chronic Pelvic \nPain Coordinator (CPPC) role. The webinar also outlined procedures for requesting \nand arranging endometriosis and CPP related reasonable adjustments.\n2.3 Participants, recruitment and study flow\nThe Endo@Work guidelines were piloted across three schools/institutes within an \nAustralian university. The pilot site was selected through the authors’ professional net -\nwork, with three schools/institutes agreeing to participate. Participants were recruited \nthrough staff-wide email invitations distributed by administrative liaisons. At baseline \nand 3-months post-intervention, emails were sent anonymously via institutional mail -\ning lists using blind carbon copy (BCC) to all academic, professional, and research staff. \nThe recruitment email included a choice of three links directing recipients to an online \nQualtrics survey.\nParticipants were eligible if they were currently employed at the university and cor -\nresponded with one of three groups: (1) staff and managers and supervisors with endo -\nmetriosis and/or CPP , (2) staff without endometriosis or CPP , and (3) managers and \nsupervisors without endometriosis or CPP . Managers and supervisors were defined as \n\nPage 5 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nstaff with formal responsibility for overseeing, supporting, and managing other under -\ngraduate or postgraduate students and employees, including academic and professional \nstaff.\nParticipants with endometriosis or CPP were grouped together regardless of role to \ncapture shared lived experiences of symptom management and disclosure at work. In \ncontrast, participants without endometriosis or CPP were separated by role to distin -\nguish between staff experiences and managerial perspectives on supporting employees. \nWhile some managers and supervisors may also have had endometriosis or CPP and \nsupervised staff with similar conditions, the grouping approach was designed to priori -\ntise analytic clarity in comparing lived experience with support roles, rather than to map \nreporting relationships.\nThe Endo@Work intervention was delivered to all staff; however, survey measures \nvaried by group. Participants with endometriosis or CPP completed condition-specific \nmeasures, including health-related quality of life and work productivity, while other staff  \nand managers and supervisors completed measures relating to workplace knowledge, \nsupport, and experiences. Interview participants were purposively sampled across all \ngroups to capture a range of perspectives on implementation, support, and workplace \ndynamics.\nWhen the survey was opened, participants accessed the Participant Information Sheet \nand self-screened for eligibility before providing informed consent and completing the \nsurvey, which took approximately 15–30  min. The surveys were hosted on the Qual -\ntrics platform (Qualtrics Ltd). The researchers enabled Qualtrics platform features pre -\nventing multiple submission from either a single IP address or the same computer. The \nsurvey remained open for four weeks, with a reminder email sent midway through the \nrecruitment period to maximise participation. As this was a pilot, a formal target sample \nsize was not predefined. Participation was voluntary, and no financial incentives were \nprovided.\nAt the end of the survey, participants were invited to register interest for a follow-up \nsemi-structured interview. Those who consented were directed to a separate secure form \nhosted on Qualtrics to provide their contact details, which were stored independently \nfrom survey responses maintaining survey anonymity.\nAt the end of the three-month trial, all respondents who expressed interest in an inter-\nview received a separate Participant Information Sheet by email, outlining the study, \ninterview aims, procedures, and potential risks. Participation was voluntary, and pro -\nspective participants were encouraged to contact the lead researcher with any questions \nbefore providing written consent via digitally signing the consent forms. Participants \nwere given up to two weeks to decide whether to take part. Once consent forms were \nreturned, interview times were arranged at participants’ convenience.\nThe lead author conducted the semi-structured online interviews, hosted via Zoom, \nwhich lasted between 45 and 60 min. The interviews explored participants’ perspectives \non the implementation, perceived effectiveness, and workplace dynamics (structural and \ncultural) shaping guideline uptake and effectiveness.\n2.4 Cohort continuity\nThis study reports data from baseline (pre-intervention) and post-intervention surveys. \nThe intention was to track the same respondents across both timepoints; however, a \n\nPage 6 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nOutcomes Group 1: Staff Group 2: Managers/supervisors\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nDemographics\nParticipants reported \ndemographic and \nworkplace characteristics, \nincluding age, gender, \nrole type (academic, \nresearch, or professional), \nyears employed at the \nuniversity, self-rated \nlevel of seniority, and (for \nmanagers/supervisors) \nthe number of staff they \nsupervised. To maintain \nparticipant anonymity, \nschool or institute affilia-\ntion was not recorded\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nEHP-30\nHealth-related quality of \nlife (HRQoL) was assessed \nusing the Endometriosis \nHealth Profile-30 (EHP-30), \na validated patient-re-\nported outcome measure \ndeveloped specifically for \npeople living with endo-\nmetriosis [33]. The present \nstudy incorporated the \nvalidated work module \nto capture HRQoL in the \ncontext of employment. \nAccordingly, the EHP-30 \nmeasured six dimensions \nof HRQoL: pain, control \nand powerlessness, \nsocial support, emotional \nwellbeing, self-image, and \nwork [34]\nBaseline\nEnd of trial\n– – Baseline\nEnd of trial\n–\nTable 1 Outcome measures and schedule of events\n\nPage 7 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nOutcomes Group 1: Staff Group 2: Managers/supervisors\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nWork productivity and \nactivity impairment: endo/ \nEndoCost tool\nFor respondents with \nendometriosis and \nchronic pelvic pain, work-\nrelated productivity was \nmeasured using the Work \nProductivity and Activity \nImpairment Question-\nnaire—Specific Health \nProblem (WPAI-SHP) [35]. \nConsistent with previous \nstudies examining pro-\nductivity loss associated \nwith endometriosis [36]), \nquestionnaire items were \nadapted to refer specifi-\ncally to endometriosis, for \nexample, replacing \n“because of your health \nproblem” with “because \nof problems associated \nwith your endometriosis.” \nThe WPAI-SHP has also \nbeen incorporated into \nthe WERF EndoCost tool \ndeveloped by the World \nEndometriosis Research \nFoundation to estimate \nthe economic burden of \nendometriosis [16]\nBaseline\nEnd of trial\n– – Baseline\nEnd of trial\n–\nWork Productivity and \nActivity Impairment Ques-\ntionnaire: General Health \n(WPAI:GH)\nFor ‘Healthy’ cohorts, \nself-reported absentee-\nism and presenteeism \nwas collected using \nthe WPAI-GH (Work \nProductivity and Activity \nImpairment—General \nHealth) questionnaire \nmeasures the effects of \nhealth in general and spe-\ncific symptoms on work \nproductivity and outside \nof work. [35]\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nTable 1 (continued) \n\nPage 8 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nOutcomes Group 1: Staff Group 2: Managers/supervisors\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nFactors influencing ef-\nfectiveness of Endo@Work \nguidelines\nAcross the three par-\nticipant groups, a series of \nyes/no questions assessed \nparticipants’ comfort \ndiscussing health-related \nneeds, available work-\nplace supports, and any \nmodifications to their role \nor work arrangements. \nItems were adapted \nfrom the research team’s \nprevious national survey \nexamining endometriosis \ndisclosure in workplace \ncontexts [26]. See supple-\nmentary data file (S1). For \nstaff participants, items fo-\ncused on their comfort in \ndiscussing health needs \nwith supervisors, while for \nmanagers and supervi-\nsors, items assessed \ntheir comfort initiating \nsuch conversations with \nemployees\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nBaseline\nEnd of trial\nPerceived level of knowl-\nedge around endometriosis \nand chronic pelvic pain\nManagers and supervisors \nwere asked a series of \nquestions regarding their \nperceived level of knowl-\nedge around endome-\ntriosis and chronic pelvic \npain and how it impacts \nsomeone at work. They \nwere also asked around \ntheir level of knowledge \nin providing workplace \nsupports for staff with en-\ndometriosis and chronic \npelvic pain. See supple-\nmentary data file (S2)\n– – – Baseline\nEnd of trial\nBaseline\nEnd of trial\nTable 1 (continued) \n\nPage 9 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nuniversity-wide restructuring during the intervention period and the inclusion of new \nrespondents in the post-survey disrupted continuity. Because surveys were anonymous, \nit was not possible to identify which participants had completed both surveys. As a \nresult, pre–post comparisons could not be conducted, and findings are reported sepa -\nrately for each timepoint.\nAlthough direct comparisons were not possible, presenting both baseline and post-\nintervention data expands the overall sample and captures a wider range of perspectives. \nReporting both timepoints also highlights consistencies and differences across cohorts, \noffering key insights that inform the discussion.\nThis limitation also informed the decision to use descriptive statistical analyses only. \nDue to disruptions in cohort continuity, including organisational restructuring during \nthe intervention period and the inclusion of new respondents at follow-up, participants \ncould not be reliably matched across timepoints. Combined with the anonymous survey \ndesign, this precluded pre–post comparisons and inferential analyses. Quantitative data \nwere therefore analysed using descriptive statistics only (e.g. means, standard deviations, \nand proportions), with findings reported separately for baseline and post-intervention \nsamples.\n2.5 Outcomes measures and data analysis\nRespondents were organised by role, separating Staff and Manager responses, and cat -\negorised into: ‘Group 1 Staff’ (with three subgroups of staff with endometriosis/CPP , \nstaff with other chronic conditions, and “healthy” staff) and ‘Group 2 Managers and \nsupervisors’ (with two subgroups of supervisors/managers with endometriosis/CPP \nand ‘Healthy’ Managers and Supervisors). For the purposes of this study, the descriptor \n‘Healthy’ refers to respondents who reported no endometriosis diagnosis and/or chronic \npelvic pain; and who reported no other chronic health conditions.\nTable 1 outlines the outcome measures per cohort and collection timepoints captured.\nContinuous variables are summarised by mean and standard deviation (SD) and cat -\negorical variables as counts and proportions expressed as a percentage. Domain scores \nOutcomes Group 1: Staff Group 2: Managers/supervisors\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nPerceptions of Endo@Work\nSemi-structured \ninterviews explored par-\nticipants’ perceptions of \nthe Endo@Work initiative, \nfocusing on organisation-\nal, cultural, and relational \nfactors that influenced \nits implementation and \noutcomes. Interviews \nalso invited feedback on \nhow the Endo@Work \nmaterials, including poli-\ncies and toolkits, could \nbe improved or adapted \nfor broader workplace \napplication\nEnd of trial – End of trial End of trial End of trial\nTable 1 (continued) \n\nPage 10 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nfor the Endometriosis Health Profile-30 (EHP-30), including the work module, were cal -\nculated and standardised on a 0–100 scale following published guidelines, with higher \nscores indicating poorer health-related quality of life. Complementary qualitative data \nwere generated through interviews and analysed using reflexive thematic analysis (RTA), \nproviding contextual insights into the implementation and impact of the guidelines for \nboth employees and managers/supervisors (both groups included those with and with -\nout endometriosis/CPP). We interpreted the results by combining the strengths of both \napproaches via triangulation [ 37], the quantitative methods as a means to measure \nchange, while the qualitative methods supported the exploration subjective experiences.\nAll data were de-identified. To protect anonymity, interview participants were \nassigned a pseudonym.\nAll interviews were recorded, transcribed, and anonymised. Transcripts were anal -\nysed using reflexive thematic analyses (RTA) [38], with the primary aim of exploring and \ncontextualising the quantitative findings. Through the explanatory sequential mixed-\nmethods design themes were developed through participants lived experiences and the \nauthors’ reflexive engagement with the data to construct themes and provide interpretive \ninsights into the quantitative results. Consistent with RTA, we acknowledged the active \nrole of researchers in shaping the coding process. Rather than applying a prescriptive \nset of rules, RTA emphasises immersion in the data through repeated reading, reflec -\ntion, questioning, and iterative engagement with transcripts. Themes were understood \nnot as “discovered” but as constructed through the interaction between researchers and \nthe data [ 39]. Reflexivity was supported through the use of analytic memo writing and \nreflexive journalling throughout the coding process, enabling the lead author to docu -\nment emerging interpretations, assumptions, and analytic decisions. These memos were \nrevisited iteratively to examine how interpretations developed over time and to critically \nreflect on how researcher perspectives may have shaped the analysis.\nThe lead author (DH) reviewed all transcripts and accompanying interviewer notes. \nProceeding this initial review, each transcript was individually read and re read, generat -\ning initial codes such as ‘barriers to health disclosures at work’ , ‘contextual factors influ-\nencing Endo@Work’ , ‘validation and improvements to Endo@Work’ , aligned with the \nstudy’s aims and those contextualising the study’s quantitative results. NViVo 15 (release \n15.2.1) was used to construct and manage themes, subthemes and supported data organ-\nisation and analyses.\nDH regularly discussed the coding process with the wider authorship team, who criti -\ncally reflected on how their own perspectives influenced interpretation. These discus -\nsions functioned as a form of reflexive dialogue, where assumptions, interpretations, and \npotential biases were critically examined and challenged. This collaborative approach \nensured analytic rigour through dialogue, reflexive awareness, and consensus-building \n[39]. The authors’ positionalities include three white cisgender women and one white \ncisgender man, two of whom live with diagnosed chronic pelvic pain, and all employed \nwithin an Australian university; and were considered central to the interpretive process. \nRecognising these positionalities is important because they shaped how the research \nteam approached and interpreted experiences of gender, health, and workplace culture. \nShared lived experience fostered empathy and sensitivity to participants’ narratives, \nwhile academic and professional distance supported reflexive awareness of potential \nbiases. This reflexive engagement helped ensure that interpretations remained grounded \n\nPage 11 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nin participants’ meanings while acknowledging the researchers’ influence in shaping the \nanalytic process [ 40]. Following these discussions, DH refined and reconstructed the \nfinal themes and subthemes to reach a final agreement. The strength and trustworthi -\nness of the analysis rested on reflexivity, deep engagement with the data, and iterative \ncollaborative discussions.\nThe analytic approach was aligned with the study’s broader theoretical and method -\nological framework, with reflexive thematic analysis supporting an interpretive under -\nstanding of participants’ experiences while complementing the explanatory sequential \nmixed methods design.\n3 Results\n3.1 Participants\nAcross the three schools/institutes who took part in Endo@Work employing ~ 300 pro-\nfessional, technical, academic and research staff, a total of 58 participants completed the \nbaseline survey, and 36 participants completed the post-intervention survey.\nFrom the survey sample, ten participants also took part in qualitative interviews con -\nducted post-intervention, recruited through the option to engage in interviews at either \ntimepoint (seven from baseline and three from post-intervention).\nSee Fig. 1 for CONSORT adapted participant flow diagram of pre- and post-interven -\ntion participants for surveys and interviews.\n3.2 Quantitative results\n3.2.1 Demographics, diagnosis, symptoms and EHP-30\nParticipant characteristics are summarised in Tables 2 and 3. At baseline, respondents \naveraged 44 years of age, with most identifying as women (93%), working full-time (91%), \nand holding academic roles (74%). At post-intervention, the average age was 42 years, \nwith similar proportions identifying as women (89%), employed full-time (81%), and \nin academic positions (64%). Across both timepoints, 19% (n = 11) at baseline and 28% \n(n = 10) post-intervention reported living with endometriosis and/or chronic pelvic pain \n(CPP), with endometriosis being the most frequently reported diagnosis. EHP-30 scores \nremained consistent across timepoints, with managers reporting greater impacts on \nquality of life (particularly in the work domain) than staff. See Tables 2 and 3 for full \ndemographic and EHP-30 data.\n3.2.2 Uptake of Endo@Work guidelines\nOne staff member with endo/CPP reported accessing supports through the Endo@Work \nguidelines (See Table 5). Six supervisors stated they were “unsure” whether they or their \nstaff had engaged with the guidelines.\n3.2.3 Potential workplace factors influencing Endo@Work\nOwing to the exceptionally limited uptake of Endo@Work guidelines (n = 1), it was \nnot possible to evaluate intervention effects as initially intended. Instead, the analysis \nfocused on survey and interview data to identify barriers and enablers to Endo@Work. \nSpecifically, we examined (1) workplace structural factors, such as access to flexibility (2) \nworkplace cultural factors, such as disclosure and communication around health; and \n\nPage 12 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \n(3) feedback on the Endo@Work policy, processes and education materials (reported in \nqualitative findings).\nTables 4 and 5 highlight several workplace factors that may have shaped access to and \nuptake of the Endo@Work guidelines.\nReported sick leave and productivity impacts differed between staff and managers \nacross both timepoints. Managers with endometriosis or chronic pelvic pain (CPP) con -\nsistently reported higher sick leave and greater productivity loss than staff. At baseline, \nmanagers took an average of 1.3 h (SD ± 1.2) of sick leave in the previous week, compared \nto 0.9 h (SD ± 2.5) among staff. In post-intervention managers reported 12 h (SD ± 21.1) \nand staff reported 1.2 h (SD ± 2.9) sick leave. Productivity was affected 43% and 40% of \nthe time for managers at baseline and post-intervention, compared with 11% and 22.5% \nfor staff. Disclosure and communication about health needs remained limited, with most \nmanagers indicating discomfort or uncertainty in discussing staff wellbeing. Reports \nFig. 1 CONSORT adapted participant flow diagram outlining pre- and post-intervention participants for surveys \nand interviews\n \n\nPage 13 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nGroup 1: Staff Group 2: Managers/Supervisors Total\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nTotal (n) 8 7 20 3 20 58\nAge, years\nAge\nAverage (SD) 40 (± 9) 50 (± 9) 42 (± 10) 41 (± 10) 47 (± 11) 44 (± 10)\nGender\nWoman 8 6 21 3 17 54 \n(93.1%)\nMan 0 1 0 0 3 4 (6.9%)\nContract\nFulltime 6 6 19 3 19 53 (91%)\nParttime 2 1 0 0 1 4 (6.9%)\nCasual 0 0 1 0 0 1 (1.7%)\nJob type\nAcademic 6 4 19 3 11 43 \n(74.1%)\nResearch 0 0 0 0 3 3 (5.1%)\nProfessional 2 3 1 0 6 12 \n(20.7%)\nYears at University\nAverage, (SD) 6 (± 3) 6 (± 4) 7 (± 7) 11 (± 3) 9 (± 8) 7.7 \n(± 6.6)\nSelf-reported Level of \nseniority (0–10 being \nhigh)\nAvg, (SD) 3 ( ±) 2 (± 1) 4 (± 2) 4 (± 2) 6 (± 2) 4.3 \n(± 2.3)\n# employees manage\nAvg, (SD) - - - 6 (± 8) 11 (± 22) 10.7 \n(± 20.2)\n# employees that \n(disclosed) have CPP:\nAvg, (SD) - - - 1(± 1) 1 (± 2) 0.9 \n(± 2.2)\nCauses of CPP*: (n = 11)\nEndometriosis 5 – – 2 – 7 \n(63.6%)\nAdenomyosis 4 1 5 \n(45.5%)\nPCOS+ 2 0 2 (18%)\nIBS 1 1 2 (18%)\nIBD 1 0 1 (9.0%)\nCPP symptoms* (n = 11)*\nDysmenorrhea 6 - - 3 - 9 \n(81.8%)\nHMB 6 2 8 \n(72.7%)\nCPP 4 3 7 \n(63.6%)\nBowel symptoms 3 3 6 \n(54.5%)\nBladder symptoms 3 1 4 \n(36.4%)\nTable 2 Baseline: Demographics, diagnoses, symptoms and EHP-30 scores\n\nPage 14 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nGroup 1: Staff Group 2: Managers/Supervisors Total\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nNausea 2 2 4 \n(36.4%)\nBackpain 5 3 8 \n(72.7%)\nHeadache/migraine 3 1 4 \n(36.4%)\nFatigue 6 3 9 \n(81.8%)\nAnxiety/depression 1 2 3 \n(27.3%)\nDifficulties sleeping 4 2 6 \n(54.5%)\nDyspareunia 3 2 5 \n(45.5%)\nOther 2 1 3 \n(27.3%)\nOther health cond.*: (n = 7)\nChronic (body) pain – 4 – – – 4 \n(57.1%)\nChronic myeloid \nleukemia\n1 1 \n(14.3%)\nChronic fatigue 2 2 \n(28.6%)\nDegenerative disc \ndisease\n1 1 \n(14.3%)\nIBS 2 2 \n(28.6%)\nMuscle weakness 1 1 \n(14.3%)\nOsteoarthritis 1 1 \n(14.3%)\nVertigo 1 1 \n(14.3%)\nEHP-30 Score total \ncohort\nAvg ± SD Avg ± SD Avg ± SD\nPain 34 (± 24) – – 51 (± 13) – 38 \n(± 22)\nControl & \nPowerlessness\n39 (± 31) 56 (± 6) 43 \n(± 28)\nEmotional wellbeing 19 (± 10) 56 (± 21) 29 \n(± 21)\nSocial Support 22 (± 26) 38 (± 11) 26 \n(± 21)\nSelf-Image 41 (± 32) 47 (± 27) 26 \n(± 23)\nWork 12 (± 19) 50 (± 30) 42 \n(± 29)\n*Indicates answers can add up to more than 100% as respondents could provide more than one answer\n+Polycystic Ovary Syndrome (PCOS)\nTable 2 (continued) \n\nPage 15 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nGroup 1: Staff Group 2: Managers/supervisors Total\nStaff with \nendo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nstaff\nManagers with \nendo/CPP\n‘Healthy’ \nMANAGERS\nTotal (n) 6 7 14 4 5 36\nAge, years\nAverage, (SD) 39 (± 9) 40 (± 20) 41 (± 11) 38 (± 4) 52 (± 9) 42 \n(± 12)\nGender\nWoman 6 7 12 4 3 32 \n(88.9%)\nMan 0 0 2 0 2 4 \n(11.1%)\nContract\nFulltime 6 4 10 4 5 29 \n(80.6%)\nParttime 0 2 3 0 0 5 \n(13.9%)\nCasual 0 1 1 0 0 2 (5.6%)\nJob type\nAcademic 1 6 10 3 3 23 \n(63.9%)\nResearch 2 0 3 0 0 5 \n(13.9%)\nProfessional 3 1 1 1 2 8 \n(22.2%)\nYears at University\nAverage, (SD) 5.1 (± 3) 6 (± 4.1) 6 (± 6.5) 9.5 (± 3.8) 9 (± 6.3) 6.7 \n(± 5.3)\nSelf-reported level of \nseniority (0–10 being \nhigh)\nAvg, (SD) 4.3 (± 1.5) 3.1 (± 1.6) 4.4 (± 2.2) 5.3 (± 1.7) 6 (± 1.9) 4.5 (± 2)\n# employees manage\nAvg, (SD) – – – 4.5 (± 1.7) 7.6 (± 2.7) 6 (± 2.7)\n# employees that \n(disclosed) have CPP:\nAvg, (SD) – – – 1 (± 0.8) 0.8 (± 1.1) 0.9 \n(± 0.9)\nCauses of CPP*: (n = 10)\nEndometriosis 6 - – 3 – 9 (90%)\nAdenomyosis 2 2 4 (40%)\nPCOS 2 1 3 (30%)\nIBS 0 1 1 (10%)\nIBD 1 0 1 (10%)\nCPP symptoms* (n = 10)\nDysmenorrhea 3 – – 2 – 5 (50%)\nHMB 1 3 4 (40%)\nCPP 4 3 7 (70%)\nBowel symptoms 4 2 6 (60%)\nBladder Symptoms 1 1 2 (20%)\nNausea 2 2 4 (40%)\nBackpain 2 1 3 (30%)\nHeadache/migraine 3 2 5 (50%)\nFatigue 2 1 3 (30%)\nAnxiety/Depression 1 2 3 (30%)\nTable 3 Post-intervention: Demographics, diagnoses, symptoms and EHP-30 scores\n\nPage 16 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nof discrimination were mixed, with many respondents declining to answer, suggesting \nongoing hesitation to disclose or discuss reproductive health needs at work. See Tables 4 \nand 5 for full results.\n3.3 Qualitative findings\n3.3.1 Qualitative survey findings\nAcross the baseline and post-surveys, most managers with endo/CPP reported that they \ndid not initiate conversations about health but would engage if raised by staff (66% at \nbaseline; 100% post-intervention). Among “healthy” managers, 70% at baseline reported \nnever discussing staff health, while 60% post-intervention said they would respond only \nif staff initiated the discussion. These patterns (see Tables 4 and 5) informed the design \nof the semi-structured interviews, which explored how organisational, cultural, and rela-\ntional factors influenced disclosure and engagement with the Endo@Work guidelines, as \nwell as ways to improve and adapt the materials.\n3.3.2 Interview demographics\nA total of 10 interviews were conducted across Groups 1 and 2. Table 6 outlines inter-\nviewee demographics.\nGroup 1: Staff Group 2: Managers/supervisors Total\nStaff with \nendo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nstaff\nManagers with \nendo/CPP\n‘Healthy’ \nMANAGERS\nDifficulties sleeping 2 2 4 (40%)\nDyspareunia 4 2 6 (60%)\nOther 0 1 1 (10%)\nOther health cond.*: (n = 10)\nChronic Fatigue – 2 – – – 2 (20%)\nChronic Migraine \nCondition Syndrome\n1 1 (10%)\nDegenerative Disc \nDisease\n1 1 (10%)\nInflammatory \nArthritis\n1 1 (10%)\nRheumatoid Arthritis 1 1 (10%)\nRepetitive Strain \nInjury\n1 1 (10%)\nPrefer not to say 1 1 (10%)\nEHP-30 score total \ncohort\nAvg ± SD – – Avg ± SD – Avg ± SD\nPain 27 (± 26) 44 (± 20) 34 \n(± 24)\nControl & \nPowerlessness\n36 (± 33) 52 (± 5) 43 \n(± 26)\nEmotional wellbeing 41 (± 17) 35 (± 12) 39 \n(± 15)\nSocial Support 29 (± 39) 38 (± 18) 33 \n(± 31)\nSelf-Image 38 (± 25) 50 (± 12) 43 \n(± 21)\nWork 18 (± 30) 36 (± 28) 25 \n(± 29)\n*Indicates answers can add up to more than 100% as respondents could provide more than one answer\nTable 3 (continued) \n\nPage 17 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nGroup 1: Staff Group 2: Managers/Supervisors Total\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nTotal (n) 8 7 20 3 20 58\nFlexibility around \ntiming of breaks\n(n = 38)\nYes 6 6 20 3 35 \n(92.1%)\nNo 1 1 0 0 – 2 \n(5.3%)\nUnsure 1 0 0 0 1 \n(2.6%)\nFlexibility to WFH? (n = 38)\nYes 6 6 18 3 – 33 \n(86.8%)\nNo 1 1 1 0 3 \n(7.9%)\nUnsure 1 0 1 0 2 \n(5.3%)\nHow many hours \ndid you miss from \nwork (in past \n7 days)\nDue to CPP\n Avg (SD) 0.9 (± 2.5) – – 1.3 (± 1.2) – 1 \n(± 2.1)\nDue to Other \nreasons\n Avg (SD) 3.5 (± 7.5) 0 (± 0) 1.4 (± 3.8) 0.8 (± 1.4) – 1.6 \n(± 4.4)\n% time \npresenteeism*\nDue to CPP\n Avg (SD) 11 (± 15.5) – – 43 (± 15.3) – 20 \n(± 21)\nDue to ‘Other \nreasons’\n Avg (SD) – 27% (32.5) 23% \n(18.7)\n– – 24 \n(± 22.4)\nComfortable rais-\ning health issues or \nconcerns with your \nsupervisor\n(n = 38)\nYes 7 4 19 0 – 30 \n(51.7%)\nNo 1 3 1 3 8 \n(13.8%)\nEver felt judged/\ndiscriminated \nfor accessing \nadditional support \nmodifications?\n(n = 38)\nYes 0 2 1 0 – 3 \n(7.9%)\nNo 3 4 16 1 24 \n(63.2%)\nUnsure 1 1 3 0 5 \n(13.2%)\nTable 4 Baseline: Possible Workplace Factors influencing staff access to Endo@Work\n\nPage 18 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \n3.3.3 Reflexive thematic analyses\nAnalysis of interview transcripts identified three overarching themes and eleven sub -\nthemes (Table 7), capturing structural and cultural dynamics shaping engagement with \nthe Endo@Work guidelines. These themes also provided practical insights for improving \nimplementation, including recommendations for enhancing education, resources, and \norganisational processes within university settings.\n3.4 Theme 1 the flexibility façade: competition and overwork\n3.4.1 A restructuring university environment: context of uncertainty and change limiting \nstudy participation\nParticipants reported how the university restructure may have limited both staff par -\nticipation and the feasibility of introducing new workplace supports. The Endo@Work \npilot coincided with a major university restructure and redundancies taking place over \na protracted period of time, creating an ongoing climate of uncertainty and precarity. \nElena, a mid-career academic supervisor and CPPC with endo, explained that work -\nplace restructuring reflected broader upheaval across the Australian higher education \nsector. She described how her institution’s approach to staff layoffs had deeply under -\nmined employees’ “psychological safety” , a concern she noted was echoed nationally as \ngovernment agencies intervened in several universities in response to widespread men -\ntal health impacts.\nSeveral participants specifically addressed how the university institutional and sec -\ntor context influenced their engagement with the study. For some, job security reduced \nGroup 1: Staff Group 2: Managers/Supervisors Total\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nBlank 4 0 0 2 6 \n(15.8%)\nSupervisors: Do you \nfreq. speak to staff \nabout endo/heath \nneeds?\n(n = 23)\nYes – – – 1 3 4 \n(17.4%)\nNo 1 10 11 \n(47.8%)\nUnsure 1 5 6 (26%)\nBlanks 0 1 1 \n(4.3%)\nSupervisors: are \nyou comfortable \nin conversations \nproviding support\n(n = 23)\nYes – – – 2 20 \n(87%)\nNo 0 0 0 (0%)\nUnsure 1 1 2 \n(8.7%)\nBlank – 1 1 \n(4.3%)\n*Presenteeism values are reported as percentages derived from WPAI scores; all other values represent participant counts\nTable 4 (continued) \n\nPage 19 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nGroup 1: Staff Group 2: Managers/Supervisors Total\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nTotal (n) 6 7 14 4 5 36\nEndo@Western: \nDid you (or \nany of your \nstaff ) apply for \nmodifications to \nyour role?\n(n = 15)\nYes 1 – – 0 0 1 (6.7%)\nNo 3 3 0 6 (16.7%)\nUnsure 2 1 5 8 (5.3%)\nFlexibility around \ntiming of breaks\n(n = 31)\nYes 6 6 14 2 – 28 (90.3%)\nNo 0 1 0 1 2 (6.4%)\nUnsure 0 0 0 1 1 (3.2%)\nFlexibility to \nWFH?\n(n = 31)\nYes 5 6 13 2 – 26 (83.9%)\nNo 0 0 1 1 2 (6.4%)\nUnsure 1 0 0 1 2 (6.4%)\nHow many hours \ndid you miss \nfrom work (in \npast 7 days)\nDue to CPP\n Avg (SD) 1.2 (± 2.9) – – 12 (± 12.1) – 5.5 (± 9.2)\nDue to other \nreasons\n Avg (SD) 2.3 (± 3.6) 1.1 (± 3.0) 0.7 (± 2.9) 0 (± 0) 1.1 (± 2.9)\n% time \npresenteeism*\nDue to CPP\n Avg % (SD) 22.5 \n(± 28.2)\n– – 40 (± 18.3) – 29.5(± 25.2)\nDue to ‘other \nreasons’\n Avg % (SD) 38.6(± 26.7) 24.7 \n(± 17.3)\n– 28.1(± 21.6)\nComfortable \nraising Health \nissues or con-\ncerns with your \nsupervisor\n(n = 31)\nYes 5 7 13 2 – 27 (87.1%)\nNo 1 0 1 2 4 (1.3%)\nEver felt judged/\ndiscriminated \nfor accessing ad-\nditional support \nmodifications?\n(n = 31)\nYes 0 3 1 1 – 5 (16.1%)\nNo 3 4 11 2 20 (64.5%)\nUnsure 1 0 2 0 3 (9.7%)\nBlank 2 0 0 1 3 (9.7%)\nTable 5 Post-intervention: Possible Workplace Factors influencing staff access to Endo@Work)\n\nPage 20 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nhesitation. Taylor, a senior academic with CPP , reflected that her secure position made \nher comfortable to participate: “They’re not going to do anything to me. ” For others, the \nlooming threat of job loss overshadowed the study’s potential impact. Morgan, a senior \nacademic supervisor with CPP , observed: “ About 70 of our specialist staff are going to \nlose their jobs…so maybe that’s overshadowed [Endo@Work]. ” Elena also noted that the \nonly staff member she was aware of with endometriosis/CPP in her school had been \nTable 6 Demographics and role of interviewees\nStaff (n = 3) Manager/ Supervisor \n(n = 7)\nTotal \n(N = 10)\nDiagnosis\nEndo 1 4 5 (50%)\nOther cause of CPP 2 – 2 (20%)\n‘Healthy’/no CPP diagnosis – 3 3 (30%)\nSelf-reported career stage\nEarly 1 – 1 (10%)\nMid – 3 3 (30%)\nSenior 2 4 6 (60%)\nRole\nAcademic/Research 3 6 9 (90%)\nProfessional – 1 1 (10%)\nDid you access Endo@Work guidelines?\n No 3 7 10 \n(100%)\nDid you know of any staff or coworkers who accessed \nthe Endo@Work guidelines?\n No 3 7 10 \n(100%)\nActed as Chronic Pelvic Pain Coordinator – 3 3 (30%)\nTime when registered for interview\n Baseline 2 5 7 (70%)\n Post-intervention 1 2 3 (30%)\nGroup 1: Staff Group 2: Managers/Supervisors Total\nStaff with \nEndo/CPP\nWith other \nchronic \nconditions\n‘Healthy’ \nStaff\nManagers with \nEndo/CPP\n‘Healthy’ \nManagers\nSupervisors: Do \nyou freq. speak \nto staff about \nendo/heath \nneeds?\n(n = 9)\nYes – – – 2 1 3 (33%)\nNo 0 4 4 (44%)\nUnsure 2 0 2 (22%)\nSupervisors: are \nyou comfortable \nin conversa-\ntions providing \nsupport\n(n = 9)\nYes – – – 2 5 7 (77%)\nNo 0 0 0 (0%)\nUnsure 2 0 2 (22%)\n*Presenteeism values are reported as percentages derived from WPAI scores; all other values represent participant counts\nTable 5 (continued) \n\nPage 21 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nmade redundant during the Endo@Work study, limiting her ability to support staff  \naccessing the guidelines.\n3.4.2 Embedded university flexibility: supporting symptom management while reinforcing \nconcealment\nParticipants described flexibility in start and finish times and the option to work from \nhome, though limitations remained for professional, teaching, and laboratory roles. For \nmany, this flexibility supported symptom management. Maya, an early-career academic \nwith endometriosis, noted: “I can arrive to my lab slightly later in the day or work to later \nat night [because] I often have trouble sleeping with my pain. ”\nAt the same time, participants highlighted how the output-focused culture of uni -\nversities led to both autonomy and concealment. Taylor, a senior academic with CPP , \nreflected: “ As long as you’re producing what the university expects of you, not many \nquestions are asked. ” Yet, by allowing symptoms to be managed privately, it may reduce \nperceived need, or the opportunity, for disclosure. Siena, a mid-career academic supervi-\nsor and CPPC with endo, explained: “It’s relatively easy to hide [endometriosis] because \na lot of academic work is solo…a lot of the time you do that in silence. ” Thus, while flexi-\nbility was valued and supported an individual’s symptom management, it also reinforced \nconcealment. Potentially limiting disclosure, perpetuating a culture of silence and reduc-\ning engagement with Endo@Work.\n3.4.3 A culture of overwork: intensification of endo and CPP symptoms\nParticipants described workplace flexibility as a ‘double-edged sword’ , shaped by a \nbroader culture of overwork and competition. Career advancement and promotions \nwere primarily determined by measurable outputs, which flexibility both enabled by \nallowing staff to work from home and extend their hours well beyond contractual lim -\nits. Elena remarked, “It’s maybe just an academic thing, we have a culture of being so \nhyper-competitive, individualised and siloed” (Elena, Mid-career Academic Supervisor \nand CPPC, Endo Diagnosis).\nSeveral participants with endometriosis or CPP elucidated the dual nature of work -\nplace flexibility. While adjustments such as flexible hours or working from home \nTable 7 Interview Themes and sub-themes\nThemes Subthemes\nTheme 1\nThe flexibility façade: competi-\ntion and overwork\nA restructuring university environment: context of uncertainty and change \nlimiting study participation\nEmbedded university flexibility: supporting symptom management while \nreinforcing concealment\nA culture of overwork: intensification of endo and CPP symptoms\nTheme 2\nThe health costs of competi-\ntiveness: silence and apathy\n“I’d rather be silent than vulnerable.” Competition encourages silence around \nhealth needs\n“We don’t talk about periods, bums or poos.” Stigma as a contributor to silence\nOverwork and health apathy\nExceptions to discussing endometriosis and CPP at work\nTheme 3\nFrom validation to continuous \nimprovement: strengthening \nEndo@Work\nPerceived positive impact\nPolicy feedback—inclusive language\nProcesses feedback\nEducation feedback\n\nPage 22 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nsupported symptom management, they also reinforced an output-driven culture that \nintensified workplace pressures, often worsening flare-ups, symptoms and wellbeing. \nElena explains:\n“The obvious adjustments they were fine with, just working from home every now \nand again…but it’s actually the nature of the work, the culture that they’ve built \naround this, the pressure to exceed and succeed. All of this was impacting my well -\nbeing so severely that I got hospitalised”—Elena, Mid-career Academic Supervisor \nand CPPC, Endo Diagnosis.\nFor participants with endometriosis or CPP , this culture often meant pushing through \npainful symptoms to maintain productivity and avoid perceptions of underperformance. \nMorgan, a senior academic with CPP , explained: “If someone has a chronic condition, \nyour work output might be less if you’re having a particularly hard time. And then you \nreally have to flog yourself…[so] my work outputs are good [and] so I don’t draw atten -\ntion to myself. ”\n3.5 Theme 2 the health costs of competitiveness: silence and apathy\n3.5.1 “I’d rather be silent than vulnerable” . Competition encourages silence around health \nneeds\nAcross all interviews, participants (including those without chronic health conditions) \ndescribed how the competitive, output-driven culture of universities fostered silence \naround health needs. The combination of performance pressures and flexible working \nstructures created an environment where disclosing vulnerability was perceived as risky. \nAs Kai explained:\n“When you’re not feeling 100%, you’re more vulnerable, right? And people have diffi-\nculties talking about vulnerability in a work environment, especially in an academic \nwork environment [because] it’s a competitive environment. You don't want to be the \none that has that kind of issue. You're surrounded by high-achieving people, and you \ndon't want to be the underdog. ”—Kai, Senior Academic Supervisor, no diagnosis\nThis silence was evident across both early and senior career staff. Aanya shared:\n“It feels like there is a big message that you should be able to manage your work -\nload… I’ve been in Academia a long time and the only time I’ve mentioned to my \nmanager that I had endo was when I had surgery and had to give a reason for being \noff for two weeks…other than that, I simply don’t talk about it. ”—Aanya, Senior Aca-\ndemic Supervisor and CPPC, Endo diagnosis\nEven those tasked with championing Endo@Work as Chronic Pelvic Pain Coordinators \n(CPPC) described discomfort in disclosing their own diagnosis. As Aanya noted, despite \nher leadership role, she removed a personal disclosure from a staff email draft for Endo@\nWork: “There was just this thing I was really uncomfortable to disclose… [because] the \nunderlying message might be that there’s barriers to keeping up with this pace” (Aanya, \nSenior Academic Supervisor and CPPC with Endo).\n\nPage 23 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \n3.5.2 “We don’t talk about periods, bums or poos. ” Stigma as a contributor to silence\nAlthough participants worked within health-focused schools and institutes, many \ndescribed endometriosis and chronic pelvic pain as “still too personal” to disclose \n(Samara, mid-career academic supervisor with endo). Stigma tied to menstruation and \npelvic pain (alongside related issues such as IBS) was seen as contributing to silence. One \nparticipant recalled a colleague’s decision to disclose endometriosis in a school-wide \npresentation as “brave” (Siena, mid-career academic supervisor and CPPC, with endo), \nhighlighting the perceived risk of such openness even within a health and research sec -\ntor. As Morgan, a senior academic with CPP , reflected, “They’re hidden. They’re the ugly \nthings that you don’t talk about. You don’t talk about your periods or lack thereof. You \ndon’t talk about bums and poos. ”\nSeveral participants reported that this taboo was compounded by gendered norms. \nOne participant reported that male colleagues appeared more comfortable discussing \ntheir pelvic health, while women might perceive disclosure of endometriosis or CPP as \n“awkward” . Samara (mid-career academic supervisor with endometriosis), elaborates, “I \nfeel it could be awkward to tell people about it [endometriosis], while he just told every -\none that he has kidney stones” .\nManagers also reported tensions between creating supportive workspaces while also \nacknowledging taboos and the need to respect privacy. Kai (senior academic supervisor, \nno diagnosis) explained, “I tend to create an environment where people feel like they can \ncome to me…[but] I don’t feel like I have the tools to have those conversations without \nputting people in a position where they feel that they’re privacy is being invaded. ” Even \nsupervisors with lived experience, such as Siena (a mid-career academic supervisor with \nCPPC and endometriosis) acknowledged this hesitation, “I’m more than happy for peo -\nple to come to me…but I don’t have the desire to do it the other way around” .\nParticipants also highlighted the risks of missteps in navigating these taboos. Samara \n(a mid-career academic supervisor with endo) recalled a male manager being repri -\nmanded for asking a female colleague about pelvic and cervical cancer screening, later \nreceiving a complaint of sexual harassment despite his best intentions. Such examples \nunderscore how deeply engrained stigma and gendered expectations shape workplace \nsilences around endometriosis and chronic pelvic pain.\n3.5.3 Overwork and health apathy\nMost participants described universities as environments where staff were constantly \n“overworked and overstretched” (Elena), leaving little time or capacity to engage with \nothers’ health needs. For some, this led to apathy, while for others it reflected the practi-\ncal impossibility of accommodating every additional need. Siena, a mid-career academic \nsupervisor with endo, captured this dynamic: “Everyone is just so busy, it could just be \none of those things that people go, ‘Oh! I’d like to know a little more about that, but I just \ndon’t have time or capacity for it right now” .\nSupervisors noted how heavy workloads limited their ability to support staff and stu -\ndents. Samara, a mid-career academic supervisor with endo, explained, “ As a supervisor, \nI have about 10 students and supposedly I need to have fortnightly meetings with them \nand each of them for 30 min. Then, if we calculate that’s a couple of hours” .\nAt senior levels, this strain constructed indifference. Morgan, a senior academic with \nCPP , recalled advocating for colleagues in leadership meetings: “you go to that meeting \n\nPage 24 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nand speak on behalf of those people because you’re supposed to be an advocate, and it \nlands on deaf ears. They go, ‘Oh, people always complain about this’ . ”\nElena (mid-career academic supervisor) living with endometriosis, discussed the per -\nsonal cost organisational indifference can impose on people’s health and wellbeing:\n“I’m always having to advocate for myself and it’s a fucking strain. Having to con -\nstantly explain myself, justify my sick leave, or accommodation requests, especially \nto management, it’s so dismissive and invalidating. And they don’t realise the con -\ntextual factors that can contribute to worsening pain, flare-ups, the inflammation, \nall of it…no matter how many times I explain that no matter how many times I \nask for adjustments, it gets ignored. ”—Elena, Mid-Career Academic Supervisor and \nCPPC, Endo diagnosis.\n3.5.4 Exceptions to discussing endometriosis and CPP at work\nWhile disclosure was often constrained, participants noted exceptions where endo -\nmetriosis or chronic pelvic pain could be discussed more openly. Several participants, \nincluding Samara, described how trusted colleagues, particularly where personal rela -\ntionships existed or where a coworker had a similar diagnosis fostered a sense of shared \nexperience, safety and understanding.\n“Only one colleague told me she had endometriosis and had experienced severe fer -\ntility challenges. It was only after we became closer that she shared this with me, \nwhen the relationship felt more personal than purely professional. ”—Samara, mid-\ncareer academic supervisor, Endo diagnosis.\nSupervisors researching or conducting work in reproductive health also observed \ngreater disclosure among their staff and students. They attributed disclosures to the vis -\nibility of their research in reproductive health, which they suggested might have helped \nlegitimate and normalise conversations about endometriosis and chronic pelvic pain.\n3.6 Theme 3 from validation to continuous improvement: strengthening Endo@Work\nAlthough none of the participants reported directly accessing the Endo@Work guide -\nlines, each interviewee offered feedback on the perceived value of the intervention. They \ndescribed positive impacts from the research team’s involvement, particularly the vis -\nibility created through the webinar, and provided constructive suggestions on workplace \npolicies, procedures, and educational materials.\n3.6.1 Perceived positive impact\nParticipants viewed implementing the Endo@Work guidelines as an important first step \ntoward raising awareness of endometriosis and chronic pelvic pain. Webinars, toolkits, \nand promotional emails were perceived as “really valuable” (Noor, Senior Professional \nSupervisor, no diagnosis), prompting conversations and disclosures that had not previ -\nously occurred. As Noor reflected, “Your resources have been really good because I’ve \nhad people come up to me and go, ‘Hey! Thank you just for even getting the word out \nthere. ’ And divulging that they’ve got endo, or they’ve got chronic pelvic pain” .\nSupervisors also noted subtle cultural shifts linked to the guidelines that are difficult to \nquantify. Siena (mid-career academic supervisor and CPPC, endo diagnosis) observed:\n\nPage 25 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \n“In one of our forums one person openly said that she had it [endo] in a presentation \nand it wasn’t specifically an endometriosis presentation…but she outwardly said it \nin front of the school…and I wonder whether 12 months ago it would have been the \nsame…so I think it is slowly changing the more that this kind of awareness is raised. ”\n3.6.2 Policy feedback—inclusive language\nParticipants provided positive feedback from the workplace policy. Noting how reason -\nable adjustments and supports outlined through the guideline documents were ones \nthey already used and found effective in managing symptoms.\nMost feedback, however, centred on the title of the guidelines. While the intervention \nwas promoted as Endo@Work: Endometriosis and Chronic Pelvic Pain Guidelines, reac-\ntions were mixed surroundings the ‘inclusiveness’ of this title. Participants with endome-\ntriosis reported that explicitly naming the condition was affirming and raised visibility. \nAs one person noted, it signalled clearly that the resource was “for them” and legitimised \nendometriosis in workplace discussions. In contrast, respondents without an endometri-\nosis diagnosis interpreted how the title ‘Endo@’ was exclusionary, even with the subtitle \nreferencing chronic pelvic pain. Morgan, a senior academic with CPP , reflected that “it’s \nnot inclusive of a whole range of conditions, ” suggesting the terminology risked narrow-\ning the reach of the educational materials.\nOther respondents felt that the “Endo@” title made the guidelines appear relevant only \nto people with a formal diagnosis, which risked excluding those who were undiagnosed \nor unaware they might have endometriosis. Samara (mid-career academic supervisor \nwith endometriosis) noted that it often takes many years to receive an endometriosis \ndiagnosis, observing that some students and staff might not recognise their symptoms as \nendometriosis. She suggested a broader label such as “pelvic pain” might “cut-through” \nmore effectively, supporting a wider group of workers, and might even encourage earlier \npathways to diagnosis.\n3.6.3 Processes feedback\nParticipants emphasised the importance of top-down support in promoting Endo@\nWork. While school-wide emails promoting Endo@Work were sent from the school’s \nadministrative team with senior-management approval, many participants noted these \nemails were ineffective amid the volume of staff e-communications. As Noor, a senior \nprofessional supervisor, reflected, “the Dean was really keen…but we could have had \nmore input from that higher level…more advertising from that level rather than relying \non me and the engagement team. ” All participants noted the importance of top-down \npromotion of guidelines and materials. Aanya highlighted how meaningful endorse -\nment from senior leadership would have greater potential to shift workplace culture and \nuptake of Endo@Work guidelines:\n“I’m a supervisor, and I have endo. But, for me to be open about it I need reassur -\nance, and the only way you get that is if it is coming from the top of the organisation \nand for it to feel really genuine…not just directly to staff but also to managers and \nsupervisors around what the expectations are”—Aanya, Senior Academic Supervi -\nsor and CPPC, Endo Diagnosis.\n\nPage 26 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nAll participants valued the CPPC role, which provided “a go—to person” (Noor, Senior \nProfessional Supervisor, no diagnosis). However, several participants raised concerns \nabout the role’s placement within schools. Some felt that locating the CPPC within \nHuman Resources (HR) or Work Health and Safety (WHS) portfolio/work areas would \nprovide a stronger organisational mandate and prevent burdening employees espe -\ncially those with lived experience of the condition(s). As Elena, a mid-career academic \nand CPPC with endo, explained, assigning the role to staff with lived experience risked \n“unintentionally burden[ing] someone” rather than embedding responsibility at the \nstructural level.\n3.6.4 Education feedback\nParticipants valued the webinar content, particularly the use of lived experiences and \ncase studies, but emphasised that additional education and training resources were \nneeded to sustain awareness over time. Suggestions included posters, repeated/ongoing \nwebinars or training sessions, induction trainings, and brief reminders at staff meetings. \nWhile the toolkit was comprehensive, many reported they were “too dense” (Siena, mid-\ncareer academic supervisor and CPPC, endo diagnosis) for everyday use. Respondents \nrecommended developing concise, accessible resources such as one-page summaries \nand infographics that could be displayed in physical spaces across campus and offices to \nreinforce ongoing education.\n4 Discussion\nThe findings highlight the challenges in implementing and evaluating reproductive \nhealth interventions in university workplaces, where competitive cultures, structural \npressures, ambivalent leadership and entrenched silence around health needs shape \nworkplace experiences. Although it was not possible to compare pre- and post-inter -\nvention data, survey responses across both timepoints, alongside interview data, pro -\nvided valuable insights into the challenges of evaluating a workplace-based reproductive \nhealth intervention from within the organisation, and the entrenched silence around \nhealth needs at work, particularly at the intersection of gender, chronic conditions and \nreproductive health.\n4.1 The challenges of evaluating a workplace-based reproductive health intervention from \nwithin the organisation\nOur findings suggest that reliance on internal evaluation mechanisms may have under -\nmined staff trust and limited the reliability of the survey, thereby affecting the evalu -\nation of the Endo@Work guidelines. Survey responses and EHP-scores indicated that \nstaff with endo/CPP appeared unusually 'healthy’ , reporting fewer symptoms impacts \non work than both comparable working populations [ 17, 20, 34] and managers/supervi -\nsors in our own study. This diverges from previous research, where staff typically report \nhigher levels of endo/CPP related challenges than senior staff [ 30]. It is important to \nnote that ‘healthy’ in this context reflects self-reported survey responses rather than \nclinically assessed health status and may therefore reflect reporting behaviours rather \nthan true differences in symptom burden. There are two possible factors contributing \nto this: staff at this university are genuinely healthier than comparable populations, or, \nmore plausibly, they may have underreported their symptoms. Given that interviewees \n\nPage 27 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \ndescribed ‘suffering through’ pain, concealing symptoms, and fearing job loss during an \nongoing restructuring, this suggests that underreporting is more likely the explanation. \nThese discrepancies indicate that internal surveys did not fully capture the extend to \nhealth needs, reflecting a broader pattern of silence and under-disclosure within aca -\ndemic workplaces. This aligns with a growing body of literature demonstrating wide -\nspread non-disclosure of endometriosis and chronic pelvic pain in workplace settings \n[41– 43], where employees often conceal symptoms due to stigma, fear of discrimination, \nand concerns about career consequences.\nUnder-disclosure may be partly driven by mistrust in internal evaluation and report -\ning mechanisms, which can make staff cautious about sharing health information. \nBecause the evaluation was conducted internally, participants may have feared that their \nresponses could be used against them in performance or role assessments. The literature \nattributes this to impression management bias, a form of social desirability bias in which \nworkers minimise negative health or safety attributes/experiences when completing \ninternal HR or health and safety surveys, particularly when they anticipate potential dis -\ncrimination or consequences due to their responses [ 44, 45]. Evidence further suggests \nthat many workers distrust internal staff surveys, especially those related to workplace \nhealth and safety, and may deliberately withhold information, reflecting a common belief \nthat ‘you do not tell HR’ about health-related vulnerabilities [45, 46].\nThis interpretation aligns with our quantitative findings, where most respondents \nwith endo/CPP chose not to answer whether they had experienced discrimination when \naccessing additional supports. Non-responses here are unlikely to reflect an absence \nof discrimination; rather, it may signal perceived risk. This reading is reinforced by our \ninterviews, where four participants explicitly sought reassurance that their responses \nwould remain confidential and used only for external research purposes. Existing litera -\nture similarly shows that workers often avoid disclosing endometriosis or CPP due to \nfears of stigma, discrimination, and mistrust in managerial support [22, 41, 42]. This con-\ncern may also explain why the only staff member who accessed the guidelines declined \nto participate in the post-intervention interview, raising questions about whether they \nexperienced or feared negative consequences. Together, these patterns suggest that \nsilence itself is meaningful data, pointing to a broader culture of mistrust and conceal -\nment that shapes whether employees feel safe to disclose their health needs.\nOur qualitative data suggest that internal evaluation processes may limit the accuracy \nof reporting with staff distrustful of how personal health information might be used. \nThis finding echoes broader evidence that workplace policies on menstruation, men -\nstrual disorders, and menopause are frequently under-evaluated [ 26]. To address this, \nfuture evaluations should prioritise external and independent approaches, ensuring staff  \nfeel confident that disclosures will remain confidential and not be used against them in \nthe workplace.\nThe sample should also be interpreted within its specific organisational context. Par -\nticipants were drawn from a single Australian university and are not intended to be \nrepresentative of the broader Australian workforce. Compared with Australian Bureau \nof Statistics workforce data, this sample reflects a highly educated, predominantly pro -\nfessional workforce, with distinct employment conditions including greater flexibility \nalongside sector-specific pressures such as restructuring. These contextual factors are \nlikely to shape both disclosure practices and engagement with workplace interventions. \n\nPage 28 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nAccordingly, findings should be interpreted as context-specific insights rather than gen -\neralisable estimates of prevalence or behaviour.\n4.2 The entrenched silence around health-needs at work contributes to the gap between \npolicy and process\nThe Endo@Work guidelines were piloted in a university setting with strong labour-rela -\ntions and gender-equity frameworks, underpinned by legislative requirements for rea -\nsonable adjustments [ 47, 48]. Yet what emerged was not the inadequacy of policy but \na culture of competitiveness, overwork, managerial uncertainty and senior-leadership \nindifference to chronic health conditions. This culture fostered silence around health \nneeds and revealed persistent gaps between policy and practice.\nParticipants consistently described stigma and fear of discrimination as barriers to dis-\nclosure. Aligning with wider evidence that decisions to share chronic health conditions \nat work are often shaped by anticipated negative outcomes such as stigma, rejection, \nand concerns about job security [ 49]. Our study demonstrates that even within health-\nfocused research settings, disclosure was rare and even described as “brave” (Siena), \nhighlighting the persistent risks staff associate with openness about reproductive and \nchronic health.\nThis tension between policy and practice has been observed in other Australian uni -\nversity studies, showing that while reasonable adjustment and anti-discrimination \nframeworks exist, workers with chronic invisible conditions often struggle to access \naccommodations [50]. Participants in both studies described senior-level apathy and the \n“strain” (Elena) of continual self-advocacy, with those who persisted often being seen as \n“difficult” [50]. Such dynamics reinforce mistrust and negative workplace environments \nthat are proven to discourage workplace disclosure of endometriosis [42], limiting policy \naccess in practice.\nManagerial/institutional uncertainty further contributed to silence. Consistent with \nexisting research [ 51– 53] managers in our study reported hesitating to initiate health-\nrelated conversations because they feared overstepping professional boundaries or felt \nthey were ill-equipped respond appropriately to any health related disclosures. This \nhesitation persisted even among managers with an endo/CPP diagnosis. A gendered \ndimension further shaped these dynamics, with women reporting greater discomfort \ndiscussing reproductive or pelvic health than male colleagues, reflecting findings from \nprevious studies [ 42, 54]. This persistent gendered dimension to disclosure is concern -\ning because it shows that silence is not only driven by stigma but also by uncertainty and \nlack of confidence among managers. Without clear structures, training, and leadership \nsupport, even well-intentioned supervisors may inadvertently reinforce cultures of non-\ndisclosure, limiting the effectiveness of workplace policies and perpetuating inequities in \nreproductive and chronic health support.\nExceptions around disclosures emerged where managers had lived experience or \nengaged in reproductive health research. Importantly, these managers did not initiate \nthe disclosure, but participants suggested these contexts created a greater openness and \nsafety where disclosure could occur without fear or discrimination. This supports other \nresearch demonstrating how lived-experience advocacy from colleagues or senior lead -\ners can disrupt cultures of silence around endometriosis and chronic illness at work [55].\n\nPage 29 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \nWhile our findings emphasise structural and cultural barriers to engagement, limited \nuptake may also reflect varying levels of staff interest or engagement with the interven -\ntion. In high-pressure academic environments, workplace initiatives may be depriori -\ntised or perceived as insufficiently relevant, particularly where immediate work demands \ndominate. Low uptake should therefore be interpreted as multifactorial, shaped by both \norganisational barriers and broader patterns of engagement with institutional initiatives.\nThese findings may suggest that policy alone is insufficient. Closing the gap between \npolicy and practice requires managerial training and senior-level endorsement to nor -\nmalise health conversations and support staff needs. Future research should focus on \nidentifying best-practice models for manager training and senior leadership engage -\nment, particularly in relation to endometriosis, chronic pelvic pain, and reproductive \nhealth at work.\n5 Limitations\nThis study was limited by its small sample size, which reduced statistical power and \nprevented reliable comparisons across role types (e.g. academic/research versus profes -\nsional staff). The pilot also took place during a period of economic uncertainty, when \nemployees may have been less inclined to engage with new workplace initiatives. These \nfactors, combined with the broader stigma and fear of discrimination around health dis -\nclosures, may have further constrained participation and reporting.\nReliance on self-reported data also raises the possibility of underreporting, particu -\nlarly given concerns about confidentiality in internal evaluations. This underscores the \nimportance of future research using larger, more diverse samples and external evaluation \nprocesses to reduce mistrust and strengthen evidence on how best to support employees \nwith endometriosis, chronic pelvic pain, and other chronic health conditions.\n6 Conclusion\nThis mixed-method intervention study highlights the persistent gap between work -\nplace policy and practice when supporting employees with endometriosis and chronic \npelvic pain. While the Endo@Work intervention introduced clear policy, education, \nand resources, uptake was constrained by entrenched workplace cultures of competi -\ntion, overwork, and silence around health needs. Quantitative findings suggested under -\nreporting of health concerns and was validated by qualitative insights revealing how \nstigma, fear of discrimination, and managerial/institutional uncertainty may have lim -\nited disclosure and encouraged underreporting of health needs. Together, these findings \ndemonstrate that even within institutions with established labour and gender-equity \nframeworks, cultural and relational barriers prevent policies from being meaningfully \naccessed.\nA key implication of our study is the need to reconsider how workplace reproductive-\nhealth interventions are evaluated. Internal evaluations appeared to amplify fears that \npersonal information might be misused. This suggests that external, independent evalu -\nations may be essential to foster trust, encourage openness, and generate more accurate \nassessments of policy impact.\nFuture efforts could combine robust policy infrastructure with visible senior-level \nendorsement, manager training, and culturally embedded strategies that normalise \nreproductive and chronic health at work. Only by addressing both the structural and \n\nPage 30 of 32\nHowe et al. Discover Public Health          (2026) 23:688 \ncultural dimensions (and ensuring evaluations are trusted) can workplaces begin to close \nthe gap between policy and practice.\nSupplementary Information\nThe online version contains supplementary material available at https://doi.org/10.1186/s12982-026-02018-6.\nSupplementary Material 1.\nSupplementary Material 2.\nAuthor contributions\nD.H. is lead contributor to conception, design, data acquisition, analyses, interpretation of data and drafting the article. \nAuthors M.A., M.O. and S.D. contributed to conception, design and data acquisition. All authors (D.H., M.O., S.D., and M.A.) \ncontributed to the interpretation of data, the critical revision of article, and provided final approval of the version to be \npublished.\nFunding\nThis research received no external funding.\nData availability\nThe original contributions presented in this study are included in the article. Further inquiries can be directed to the \ncorresponding author.\nDeclarations\nEthics approval and consent to participate \nEthical approval for this study was granted by the Western Sydney University Human Research Ethics Committee \n(H16067, approved March 2025). All procedures were conducted in accordance with the National Statement on Ethical \nConduct in Human Research. For the survey component, participants accessed a detailed Participant Information Sheet \non the survey landing page outlining the study aims, procedures, risks, benefits, confidentiality, and voluntary nature \nof participation. Participants provided informed consent electronically by proceeding to the survey. For the interview \ncomponent, participants received a separate Participant Information Sheet and provided written informed consent prior \nto participation. Interviews were conducted online, audio-recorded with permission, transcribed, and de-identified.\nConsent for publicaton\nParticipation across all components was voluntary. Data were collected anonymously (survey) or de-identified \n(interviews), and participants could withdraw at any time without consequence. All participants consented to the use of \ntheir de-identified data for research publication.\nCompeting interest\nThe authors declare no competing interests.\nReceived: 30 January 2026 / Accepted: 23 April 2026\nReferences\n1. Mardon AK, Leake HB, Szeto K, et al. Recommendations for patient education in the management of persistent pelvic \npain: a systematic review of clinical practice guidelines. Pain. 2024;165:1207–16.  h t t p s  : / / d o i  . o r g /  1 0 . 1  0 9 7 / j . p a i n . 0 0 0 0 0 0 0 0 0 0 \n0 0 3 1 3 7     .   \n2. Lamvu G, Carrillo J, Ouyang C, et al. Chronic pelvic pain in women: a review. 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