Workplace mistrust and barriers to implementing workplace guidelines for endometriosis and chronic pelvic pain a mixed methods intervention study in an Australian University

in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, 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 e s / b y - n c - n d / 4 . 0 / .

Background Endometriosis and chronic pelvic pain (CPP) substantially affect work participation and productivity, yet workplace interventions remain largely unevaluated. This study piloted Endo@Work, a co-designed workplace guideline to support employees with endometriosis/CPP in an Australian university. Aims To evaluate pre and post implementation experiences of Endo@work among staff with endometriosis and CPP and for managers/supervisors (with and without endo/CPP) in supporting them.

A mixed methods design evaluated a three-month trial of the Endo@Work guidelines, which included a tailored policy, staff and manager/supervisor toolkits, a Chronic Pelvic Pain Coordinator role, and webinar. Online surveys, tailored according to participant group and endo/CPP status, were administered at baseline and at end of trial (n = 58 and n = 36), capturing demographics, endometriosis health-related quality of life (EHP-30), work productivity (WPAI), and factors shaping disclosure and support. Ten semi-structured interviews were analysed using reflexive thematic analysis. Findings Low guideline uptake prevented formal testing of intervention effects, however, the study generated important insights into staff mistrust of internal evaluation processes. Mixed-methods findings suggest impression management response bias, evidenced by underreporting of symptom burden among staff with endometriosis/CPP and high non-response to discrimination items. Interviews contextualised these patterns, showing how academic competition, compounded by university-wide restructure, reinforced stigma, fear of discrimination, and managerial uncertainty about initiating health conversations, sustaining silence and undermining trust in internal surveys. The primary barrier was not policy inadequacy, but entrenched silence around health needs at work. This silence, shaped by cultures of competition and overwork, managerial uncertainty, and limited senior leadership engagement with chronic health, sustained the gap between policy and practice. Page 2 of 32 Howe et al. Discover Public Health (2026) 23:688 1 Introduction Chronic pelvic pain (CPP) is an umbrella term for conditions involving pain attributed to the reproductive organs, urinary tract, bowel, or pelvic floor lasting longer than six months, and are severe enough to impair functioning or require medical care [ 1, 2]. Prevalence rates are high. Global estimates suggest that up to 26.6% of women 1 and those presumed female at birth (PFAB) experience CPP [ 2]. Endometriosis is the most common cause of CPP , affecting an estimated 6–14% of women and PFAB [ 4– 6], indi- cating that endometriosis may be more common than breast cancer, prostate cancer, and diabetes [7, 8]. Estimates indicate that endometriosis underlies between 15.4% and 71.4% of all CPP cases [ 9]. However, ongoing diagnostic delays mean that current prevalence estimates may not fully capture the true burden of the condition [10]. Both endometriosis and CPP can significantly disrupt daily functioning [ 11] with similar symptoms and impacts between both cohorts [ 12]. Pain, including regular pel - vic pain, severe period pain (dysmenorrhea), as well as chronic fatigue, nausea, and gas - trointestinal symptoms are common [ 12– 15]. These symptoms contribute to workplace absenteeism, presenteeism, and substantial productivity losses, with the majority of the economic burden being due to productivity losses [ 12, 16– 22]. Even modest reductions in pain (approximately 20–30%) are strongly correlated with reductions in presenteeism and absenteeism [ 23], suggesting the potential importance of effective symptom man - agement from workplace-based supports in mitigating productivity loss and improving quality of life for workers with endometriosis and CPP . During the COVID-19 pandemic, many Australian workplaces adopted a work from home, or hybrid working approach. These changes in workplace flexibility resulted in more than half of people with endometriosis reporting that their endometriosis symp - toms were much easier to manage, and they were more productive [ 22]. Two key fac - tors identified were the flexibility in time management they had due to working from home, and the ability to use physical aids such as heat packs, comfortable chairs or being able to lie down to manage their symptoms [ 22]. However, in recent years, there has been a move back to working in a centralised office [ 24], with the majority of Australian business indicating that they intend to move back to at least four days per week in the office [25]. Therefore, for women with endometriosis this may again reduce their ability to manage their symptoms and therefore productivity is likely to reduce, as seen in pre- pandemic data [22]. 1 This paper sometimes uses the term "women" to reflect the cohorts of cisgender women most often represented in prior research. However, we recognise that trans and gender-diverse people may also experience menstruation, menopause, and chronic conditions such as endometriosis and chronic pelvic pain; and therefore, should be acknowl- edged and included academic literature. Where possible, we use the term “women and those presumed female at birth (PFAB)” in alignment with research on inclusive language and accurate reporting.[3].

Findings point to the need for external evaluation, visible leadership endorsement, and targeted manager training to meaningfully close this gap. Trial registration: This study was registered with Australian New Zealand Clinical Trial Registry (ANZCTR) on 12 June 2024. The study was registered 25 June 2024, registration number: ACTRN12624000773538p.

Endometriosis, Chronic pelvic pain, Workplace guidelines, Higher education, HR, Evaluation frameworks Page 3 of 32 Howe et al. Discover Public Health (2026) 23:688 While workplaces globally are beginning to adopt reproductive health policies such as paid menstrual and menopause leave, flexible work arrangements, and manager train - ing, no empirical studies have evaluated interventions specifically targeting endome - triosis and/or CPP in the workplace [ 26]. Leaving a critical evidence gap in relation to supporting endometriosis and CPP at work. Existing research has focused on menstrual or menopause-related workplace policies, primarily in the UK and EU [ 27, 28] and some further limited research from Japan [29]. Given the prevalence and burden of these con - ditions, the paucity of codesign and evaluation of endo/CPP workplace-focused inter - ventions is deeply problematic. This study addresses this evidence gap by piloting Endo@Work, a set of co-designed workplace guidelines developed to support employees with endometriosis and CPP in an Australian university. 1.1 Study aims The study evaluated the effectiveness of the codesigned Endo@Work guidelines within an Australian university workplace, focusing on both outcomes and contextual factors influencing their uptake. Specifically, we aimed to: (1) Assess perceived impact of the guidelines in mitigating absenteeism and presenteeism through supporting symptom management for employees with endometriosis and CPP (quantitative). (2) Explore workplace structural and cultural dynamics enabling or impeding guideline implementation or uptake (mixed methods: quantitative and qualitative). (3) Evaluate the guidelines’ perceived quality and practicality, encompassing policies, procedures and education materials (mixed-methods: quantitative and qualitative). 2 Methods 2.1 Study design This mixed methods study evaluated the feasibility and perceived impact of the co- designed Endo@Work guidelines over a three-month intervention period, starting in May 2025. Data collection consisted of two online surveys and follow-up semi-struc - tured interviews. The baseline survey was administered prior to the Endo@Work train - ing webinar, and the second survey was conducted at the end of the three-month trial. Semi-structured interviews were also undertaken at the end of the trial period. The three-month duration was selected in consultation with school 2 and institute 3 leadership as a practical window in which early indicators of engagement and feasibility could be observed, while recognising that sustained cultural and organisational change typically occurs over longer periods. During this time, staff were encouraged to use the guidelines, request reasonable adjustments, and seek support from the designated Chronic Pelvic Pain Coordinators (CPPCs). Integrating survey data with qualitative interviews enabled a comprehensive examina - tion of how the guidelines were received, the extent to which they were used, and the organisational and cultural factors shaping implementation within a university setting. 2 The university consisted of schools employing academic and professional staff responsible for delivering degree pro- grams and conducting research. 3 Research institutes also employed academic and professional staff at the university but focused primarily on research rather than teaching. Page 4 of 32 Howe et al. Discover Public Health (2026) 23:688 Ethical approval for the study was granted by the Western Sydney University Human Research Ethics Committee (H16067—March 2025). 2.2 Development and codesign of the Endo@Work guidelines The Endo@Work guidelines were codesigned through a national survey of Australians living and working with endometriosis [ 30], focus groups with employees managing endometriosis and chronic pelvic pain [ 31], and focus groups with employers, including senior leadership, managers, and human resources (HR) professionals [32]. The Endo@Work intervention includes: 1. A workplace policy document tailored to the higher education (HE) university context. 2. A supervisor toolkit, which provided: 3. Educational content highlighting the impact of endometriosis and CPP on work and career. 4. Lived-experience narratives linked to key educational points. 5. Guidance relevant to employee entitlements within the university context. 6. Procedures for arranging reasonable adjustments. 7. A staff toolkit for employees with endometriosis and CPP , which outlined: 8. Entitlements and reasonable adjustments available and how to access them. 9. Guidance on disclosure emphasising safety and confidentiality. 10. A Chronic Pelvic Pain Coordinator (CPPC) role in each school or institute to practically support guideline uptake. The CPPC was the primary contact for information relating to the Endo@Work pilot. While not providing health information or advice, CPPCs supported staff with procedural queries and directed them to appropriate HR channels for resources, education, and adjustments. 11. One-hour online webinar, hosted by the school/institute and delivered by the research team. Each webinar was tailored to the specific school/institute and introduced endome - triosis and its potential workplace impacts, outlined the workplace policy docu - ment, presented the staff and supervisor toolkits, and introduced the Chronic Pelvic Pain Coordinator (CPPC) role. The webinar also outlined procedures for requesting and arranging endometriosis and CPP related reasonable adjustments. 2.3 Participants, recruitment and study flow The Endo@Work guidelines were piloted across three schools/institutes within an Australian university. The pilot site was selected through the authors’ professional net - work, with three schools/institutes agreeing to participate. Participants were recruited through staff-wide email invitations distributed by administrative liaisons. At baseline and 3-months post-intervention, emails were sent anonymously via institutional mail - ing lists using blind carbon copy (BCC) to all academic, professional, and research staff. The recruitment email included a choice of three links directing recipients to an online Qualtrics survey. Participants were eligible if they were currently employed at the university and cor - responded with one of three groups: (1) staff and managers and supervisors with endo - metriosis and/or CPP , (2) staff without endometriosis or CPP , and (3) managers and supervisors without endometriosis or CPP . Managers and supervisors were defined as Page 5 of 32 Howe et al. Discover Public Health (2026) 23:688 staff with formal responsibility for overseeing, supporting, and managing other under - graduate or postgraduate students and employees, including academic and professional staff. Participants with endometriosis or CPP were grouped together regardless of role to capture shared lived experiences of symptom management and disclosure at work. In contrast, participants without endometriosis or CPP were separated by role to distin - guish between staff experiences and managerial perspectives on supporting employees. While some managers and supervisors may also have had endometriosis or CPP and supervised staff with similar conditions, the grouping approach was designed to priori - tise analytic clarity in comparing lived experience with support roles, rather than to map reporting relationships. The Endo@Work intervention was delivered to all staff; however, survey measures varied by group. Participants with endometriosis or CPP completed condition-specific measures, including health-related quality of life and work productivity, while other staff and managers and supervisors completed measures relating to workplace knowledge, support, and experiences. Interview participants were purposively sampled across all groups to capture a range of perspectives on implementation, support, and workplace dynamics. When the survey was opened, participants accessed the Participant Information Sheet and self-screened for eligibility before providing informed consent and completing the survey, which took approximately 15–30  min. The surveys were hosted on the Qual - trics platform (Qualtrics Ltd). The researchers enabled Qualtrics platform features pre - venting multiple submission from either a single IP address or the same computer. The survey remained open for four weeks, with a reminder email sent midway through the recruitment period to maximise participation. As this was a pilot, a formal target sample size was not predefined. Participation was voluntary, and no financial incentives were provided. At the end of the survey, participants were invited to register interest for a follow-up semi-structured interview. Those who consented were directed to a separate secure form hosted on Qualtrics to provide their contact details, which were stored independently from survey responses maintaining survey anonymity. At the end of the three-month trial, all respondents who expressed interest in an inter- view received a separate Participant Information Sheet by email, outlining the study, interview aims, procedures, and potential risks. Participation was voluntary, and pro - spective participants were encouraged to contact the lead researcher with any questions before providing written consent via digitally signing the consent forms. Participants were given up to two weeks to decide whether to take part. Once consent forms were returned, interview times were arranged at participants’ convenience. The lead author conducted the semi-structured online interviews, hosted via Zoom, which lasted between 45 and 60 min. The interviews explored participants’ perspectives on the implementation, perceived effectiveness, and workplace dynamics (structural and cultural) shaping guideline uptake and effectiveness. 2.4 Cohort continuity This study reports data from baseline (pre-intervention) and post-intervention surveys. The intention was to track the same respondents across both timepoints; however, a Page 6 of 32 Howe et al. Discover Public Health (2026) 23:688 Outcomes Group 1: Staff Group 2: Managers/supervisors Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Demographics Participants reported demographic and workplace characteristics, including age, gender, role type (academic, research, or professional), years employed at the university, self-rated level of seniority, and (for managers/supervisors) the number of staff they supervised. To maintain participant anonymity, school or institute affilia- tion was not recorded Baseline End of trial Baseline End of trial Baseline End of trial Baseline End of trial Baseline End of trial EHP-30 Health-related quality of life (HRQoL) was assessed using the Endometriosis Health Profile-30 (EHP-30), a validated patient-re- ported outcome measure developed specifically for people living with endo- metriosis [33]. The present study incorporated the validated work module to capture HRQoL in the context of employment. Accordingly, the EHP-30 measured six dimensions of HRQoL: pain, control and powerlessness, social support, emotional wellbeing, self-image, and work [34] Baseline End of trial – – Baseline End of trial – Table 1 Outcome measures and schedule of events Page 7 of 32 Howe et al. Discover Public Health (2026) 23:688 Outcomes Group 1: Staff Group 2: Managers/supervisors Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Work productivity and activity impairment: endo/ EndoCost tool For respondents with endometriosis and chronic pelvic pain, work- related productivity was measured using the Work Productivity and Activity Impairment Question- naire—Specific Health Problem (WPAI-SHP) [35]. Consistent with previous studies examining pro- ductivity loss associated with endometriosis [36]), questionnaire items were adapted to refer specifi- cally to endometriosis, for example, replacing “because of your health problem” with “because of problems associated with your endometriosis.” The WPAI-SHP has also been incorporated into the WERF EndoCost tool developed by the World Endometriosis Research Foundation to estimate the economic burden of endometriosis [16] Baseline End of trial – – Baseline End of trial – Work Productivity and Activity Impairment Ques- tionnaire: General Health (WPAI:GH) For ‘Healthy’ cohorts, self-reported absentee- ism and presenteeism was collected using the WPAI-GH (Work Productivity and Activity Impairment—General Health) questionnaire measures the effects of health in general and spe- cific symptoms on work productivity and outside of work. [35] Baseline End of trial Baseline End of trial Baseline End of trial Table 1 (continued) Page 8 of 32 Howe et al. Discover Public Health (2026) 23:688 Outcomes Group 1: Staff Group 2: Managers/supervisors Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Factors influencing ef- fectiveness of Endo@Work guidelines Across the three par- ticipant groups, a series of yes/no questions assessed participants’ comfort discussing health-related needs, available work- place supports, and any modifications to their role or work arrangements. Items were adapted from the research team’s previous national survey examining endometriosis disclosure in workplace contexts [26]. See supple- mentary data file (S1). For staff participants, items fo- cused on their comfort in discussing health needs with supervisors, while for managers and supervi- sors, items assessed their comfort initiating such conversations with employees Baseline End of trial Baseline End of trial Baseline End of trial Baseline End of trial Baseline End of trial Perceived level of knowl- edge around endometriosis and chronic pelvic pain Managers and supervisors were asked a series of questions regarding their perceived level of knowl- edge around endome- triosis and chronic pelvic pain and how it impacts someone at work. They were also asked around their level of knowledge in providing workplace supports for staff with en- dometriosis and chronic pelvic pain. See supple- mentary data file (S2) – – – Baseline End of trial Baseline End of trial Table 1 (continued) Page 9 of 32 Howe et al. Discover Public Health (2026) 23:688 university-wide restructuring during the intervention period and the inclusion of new respondents in the post-survey disrupted continuity. Because surveys were anonymous, it was not possible to identify which participants had completed both surveys. As a result, pre–post comparisons could not be conducted, and findings are reported sepa - rately for each timepoint. Although direct comparisons were not possible, presenting both baseline and post- intervention data expands the overall sample and captures a wider range of perspectives. Reporting both timepoints also highlights consistencies and differences across cohorts, offering key insights that inform the discussion. This limitation also informed the decision to use descriptive statistical analyses only. Due to disruptions in cohort continuity, including organisational restructuring during the intervention period and the inclusion of new respondents at follow-up, participants could not be reliably matched across timepoints. Combined with the anonymous survey design, this precluded pre–post comparisons and inferential analyses. Quantitative data were therefore analysed using descriptive statistics only (e.g. means, standard deviations, and proportions), with findings reported separately for baseline and post-intervention samples. 2.5 Outcomes measures and data analysis Respondents were organised by role, separating Staff and Manager responses, and cat - egorised into: ‘Group 1 Staff’ (with three subgroups of staff with endometriosis/CPP , staff with other chronic conditions, and “healthy” staff) and ‘Group 2 Managers and supervisors’ (with two subgroups of supervisors/managers with endometriosis/CPP and ‘Healthy’ Managers and Supervisors). For the purposes of this study, the descriptor ‘Healthy’ refers to respondents who reported no endometriosis diagnosis and/or chronic pelvic pain; and who reported no other chronic health conditions. Table 1 outlines the outcome measures per cohort and collection timepoints captured. Continuous variables are summarised by mean and standard deviation (SD) and cat - egorical variables as counts and proportions expressed as a percentage. Domain scores Outcomes Group 1: Staff Group 2: Managers/supervisors Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Perceptions of Endo@Work Semi-structured interviews explored par- ticipants’ perceptions of the Endo@Work initiative, focusing on organisation- al, cultural, and relational factors that influenced its implementation and outcomes. Interviews also invited feedback on how the Endo@Work materials, including poli- cies and toolkits, could be improved or adapted for broader workplace application End of trial – End of trial End of trial End of trial Table 1 (continued) Page 10 of 32 Howe et al. Discover Public Health (2026) 23:688 for the Endometriosis Health Profile-30 (EHP-30), including the work module, were cal - culated and standardised on a 0–100 scale following published guidelines, with higher scores indicating poorer health-related quality of life. Complementary qualitative data were generated through interviews and analysed using reflexive thematic analysis (RTA), providing contextual insights into the implementation and impact of the guidelines for both employees and managers/supervisors (both groups included those with and with - out endometriosis/CPP). We interpreted the results by combining the strengths of both approaches via triangulation [ 37], the quantitative methods as a means to measure change, while the qualitative methods supported the exploration subjective experiences. All data were de-identified. To protect anonymity, interview participants were assigned a pseudonym. All interviews were recorded, transcribed, and anonymised. Transcripts were anal - ysed using reflexive thematic analyses (RTA) [38], with the primary aim of exploring and contextualising the quantitative findings. Through the explanatory sequential mixed-

design themes were developed through participants lived experiences and the authors’ reflexive engagement with the data to construct themes and provide interpretive insights into the quantitative results. Consistent with RTA, we acknowledged the active role of researchers in shaping the coding process. Rather than applying a prescriptive set of rules, RTA emphasises immersion in the data through repeated reading, reflec - tion, questioning, and iterative engagement with transcripts. Themes were understood not as “discovered” but as constructed through the interaction between researchers and the data [ 39]. Reflexivity was supported through the use of analytic memo writing and reflexive journalling throughout the coding process, enabling the lead author to docu - ment emerging interpretations, assumptions, and analytic decisions. These memos were revisited iteratively to examine how interpretations developed over time and to critically reflect on how researcher perspectives may have shaped the analysis. The lead author (DH) reviewed all transcripts and accompanying interviewer notes. Proceeding this initial review, each transcript was individually read and re read, generat - ing initial codes such as ‘barriers to health disclosures at work’ , ‘contextual factors influ- encing Endo@Work’ , ‘validation and improvements to Endo@Work’ , aligned with the study’s aims and those contextualising the study’s quantitative results. NViVo 15 (release 15.2.1) was used to construct and manage themes, subthemes and supported data organ- isation and analyses. DH regularly discussed the coding process with the wider authorship team, who criti - cally reflected on how their own perspectives influenced interpretation. These discus - sions functioned as a form of reflexive dialogue, where assumptions, interpretations, and potential biases were critically examined and challenged. This collaborative approach ensured analytic rigour through dialogue, reflexive awareness, and consensus-building [39]. The authors’ positionalities include three white cisgender women and one white cisgender man, two of whom live with diagnosed chronic pelvic pain, and all employed within an Australian university; and were considered central to the interpretive process. Recognising these positionalities is important because they shaped how the research team approached and interpreted experiences of gender, health, and workplace culture. Shared lived experience fostered empathy and sensitivity to participants’ narratives, while academic and professional distance supported reflexive awareness of potential biases. This reflexive engagement helped ensure that interpretations remained grounded Page 11 of 32 Howe et al. Discover Public Health (2026) 23:688 in participants’ meanings while acknowledging the researchers’ influence in shaping the analytic process [ 40]. Following these discussions, DH refined and reconstructed the final themes and subthemes to reach a final agreement. The strength and trustworthi - ness of the analysis rested on reflexivity, deep engagement with the data, and iterative collaborative discussions. The analytic approach was aligned with the study’s broader theoretical and method - ological framework, with reflexive thematic analysis supporting an interpretive under - standing of participants’ experiences while complementing the explanatory sequential mixed methods design. 3 Results 3.1 Participants Across the three schools/institutes who took part in Endo@Work employing ~ 300 pro- fessional, technical, academic and research staff, a total of 58 participants completed the baseline survey, and 36 participants completed the post-intervention survey. From the survey sample, ten participants also took part in qualitative interviews con - ducted post-intervention, recruited through the option to engage in interviews at either timepoint (seven from baseline and three from post-intervention). See Fig. 1 for CONSORT adapted participant flow diagram of pre- and post-interven - tion participants for surveys and interviews. 3.2 Quantitative results 3.2.1 Demographics, diagnosis, symptoms and EHP-30 Participant characteristics are summarised in Tables 2 and 3. At baseline, respondents averaged 44 years of age, with most identifying as women (93%), working full-time (91%), and holding academic roles (74%). At post-intervention, the average age was 42 years, with similar proportions identifying as women (89%), employed full-time (81%), and in academic positions (64%). Across both timepoints, 19% (n = 11) at baseline and 28% (n = 10) post-intervention reported living with endometriosis and/or chronic pelvic pain (CPP), with endometriosis being the most frequently reported diagnosis. EHP-30 scores remained consistent across timepoints, with managers reporting greater impacts on quality of life (particularly in the work domain) than staff. See Tables 2 and 3 for full demographic and EHP-30 data. 3.2.2 Uptake of Endo@Work guidelines One staff member with endo/CPP reported accessing supports through the Endo@Work guidelines (See Table 5). Six supervisors stated they were “unsure” whether they or their staff had engaged with the guidelines. 3.2.3 Potential workplace factors influencing Endo@Work Owing to the exceptionally limited uptake of Endo@Work guidelines (n = 1), it was not possible to evaluate intervention effects as initially intended. Instead, the analysis focused on survey and interview data to identify barriers and enablers to Endo@Work. Specifically, we examined (1) workplace structural factors, such as access to flexibility (2) workplace cultural factors, such as disclosure and communication around health; and Page 12 of 32 Howe et al. Discover Public Health (2026) 23:688 (3) feedback on the Endo@Work policy, processes and education materials (reported in qualitative findings). Tables 4 and 5 highlight several workplace factors that may have shaped access to and uptake of the Endo@Work guidelines. Reported sick leave and productivity impacts differed between staff and managers across both timepoints. Managers with endometriosis or chronic pelvic pain (CPP) con - sistently reported higher sick leave and greater productivity loss than staff. At baseline, managers took an average of 1.3 h (SD ± 1.2) of sick leave in the previous week, compared to 0.9 h (SD ± 2.5) among staff. In post-intervention managers reported 12 h (SD ± 21.1) and staff reported 1.2 h (SD ± 2.9) sick leave. Productivity was affected 43% and 40% of the time for managers at baseline and post-intervention, compared with 11% and 22.5% for staff. Disclosure and communication about health needs remained limited, with most managers indicating discomfort or uncertainty in discussing staff wellbeing. Reports Fig. 1 CONSORT adapted participant flow diagram outlining pre- and post-intervention participants for surveys and interviews Page 13 of 32 Howe et al. Discover Public Health (2026) 23:688 Group 1: Staff Group 2: Managers/Supervisors Total Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Total (n) 8 7 20 3 20 58 Age, years Age Average (SD) 40 (± 9) 50 (± 9) 42 (± 10) 41 (± 10) 47 (± 11) 44 (± 10) Gender Woman 8 6 21 3 17 54 (93.1%) Man 0 1 0 0 3 4 (6.9%) Contract Fulltime 6 6 19 3 19 53 (91%) Parttime 2 1 0 0 1 4 (6.9%) Casual 0 0 1 0 0 1 (1.7%) Job type Academic 6 4 19 3 11 43 (74.1%) Research 0 0 0 0 3 3 (5.1%) Professional 2 3 1 0 6 12 (20.7%) Years at University Average, (SD) 6 (± 3) 6 (± 4) 7 (± 7) 11 (± 3) 9 (± 8) 7.7 (± 6.6) Self-reported Level of seniority (0–10 being high) Avg, (SD) 3 ( ±) 2 (± 1) 4 (± 2) 4 (± 2) 6 (± 2) 4.3 (± 2.3) # employees manage Avg, (SD) - - - 6 (± 8) 11 (± 22) 10.7 (± 20.2) # employees that (disclosed) have CPP: Avg, (SD) - - - 1(± 1) 1 (± 2) 0.9 (± 2.2) Causes of CPP*: (n = 11) Endometriosis 5 – – 2 – 7 (63.6%) Adenomyosis 4 1 5 (45.5%) PCOS+ 2 0 2 (18%) IBS 1 1 2 (18%) IBD 1 0 1 (9.0%) CPP symptoms* (n = 11)* Dysmenorrhea 6 - - 3 - 9 (81.8%) HMB 6 2 8 (72.7%) CPP 4 3 7 (63.6%) Bowel symptoms 3 3 6 (54.5%) Bladder symptoms 3 1 4 (36.4%) Table 2 Baseline: Demographics, diagnoses, symptoms and EHP-30 scores Page 14 of 32 Howe et al. Discover Public Health (2026) 23:688 Group 1: Staff Group 2: Managers/Supervisors Total Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Nausea 2 2 4 (36.4%) Backpain 5 3 8 (72.7%) Headache/migraine 3 1 4 (36.4%) Fatigue 6 3 9 (81.8%) Anxiety/depression 1 2 3 (27.3%) Difficulties sleeping 4 2 6 (54.5%) Dyspareunia 3 2 5 (45.5%) Other 2 1 3 (27.3%) Other health cond.*: (n = 7) Chronic (body) pain – 4 – – – 4 (57.1%) Chronic myeloid leukemia 1 1 (14.3%) Chronic fatigue 2 2 (28.6%) Degenerative disc disease 1 1 (14.3%) IBS 2 2 (28.6%) Muscle weakness 1 1 (14.3%) Osteoarthritis 1 1 (14.3%) Vertigo 1 1 (14.3%) EHP-30 Score total cohort Avg ± SD Avg ± SD Avg ± SD Pain 34 (± 24) – – 51 (± 13) – 38 (± 22) Control & Powerlessness 39 (± 31) 56 (± 6) 43 (± 28) Emotional wellbeing 19 (± 10) 56 (± 21) 29 (± 21) Social Support 22 (± 26) 38 (± 11) 26 (± 21) Self-Image 41 (± 32) 47 (± 27) 26 (± 23) Work 12 (± 19) 50 (± 30) 42 (± 29) *Indicates answers can add up to more than 100% as respondents could provide more than one answer +Polycystic Ovary Syndrome (PCOS) Table 2 (continued) Page 15 of 32 Howe et al. Discover Public Health (2026) 23:688 Group 1: Staff Group 2: Managers/supervisors Total Staff with endo/CPP With other chronic conditions ‘Healthy’ staff Managers with endo/CPP ‘Healthy’ MANAGERS Total (n) 6 7 14 4 5 36 Age, years Average, (SD) 39 (± 9) 40 (± 20) 41 (± 11) 38 (± 4) 52 (± 9) 42 (± 12) Gender Woman 6 7 12 4 3 32 (88.9%) Man 0 0 2 0 2 4 (11.1%) Contract Fulltime 6 4 10 4 5 29 (80.6%) Parttime 0 2 3 0 0 5 (13.9%) Casual 0 1 1 0 0 2 (5.6%) Job type Academic 1 6 10 3 3 23 (63.9%) Research 2 0 3 0 0 5 (13.9%) Professional 3 1 1 1 2 8 (22.2%) Years at University Average, (SD) 5.1 (± 3) 6 (± 4.1) 6 (± 6.5) 9.5 (± 3.8) 9 (± 6.3) 6.7 (± 5.3) Self-reported level of seniority (0–10 being high) Avg, (SD) 4.3 (± 1.5) 3.1 (± 1.6) 4.4 (± 2.2) 5.3 (± 1.7) 6 (± 1.9) 4.5 (± 2) # employees manage Avg, (SD) – – – 4.5 (± 1.7) 7.6 (± 2.7) 6 (± 2.7) # employees that (disclosed) have CPP: Avg, (SD) – – – 1 (± 0.8) 0.8 (± 1.1) 0.9 (± 0.9) Causes of CPP*: (n = 10) Endometriosis 6 - – 3 – 9 (90%) Adenomyosis 2 2 4 (40%) PCOS 2 1 3 (30%) IBS 0 1 1 (10%) IBD 1 0 1 (10%) CPP symptoms* (n = 10) Dysmenorrhea 3 – – 2 – 5 (50%) HMB 1 3 4 (40%) CPP 4 3 7 (70%) Bowel symptoms 4 2 6 (60%) Bladder Symptoms 1 1 2 (20%) Nausea 2 2 4 (40%) Backpain 2 1 3 (30%) Headache/migraine 3 2 5 (50%) Fatigue 2 1 3 (30%) Anxiety/Depression 1 2 3 (30%) Table 3 Post-intervention: Demographics, diagnoses, symptoms and EHP-30 scores Page 16 of 32 Howe et al. Discover Public Health (2026) 23:688 of discrimination were mixed, with many respondents declining to answer, suggesting ongoing hesitation to disclose or discuss reproductive health needs at work. See Tables 4 and 5 for full results. 3.3 Qualitative findings 3.3.1 Qualitative survey findings Across the baseline and post-surveys, most managers with endo/CPP reported that they did not initiate conversations about health but would engage if raised by staff (66% at baseline; 100% post-intervention). Among “healthy” managers, 70% at baseline reported never discussing staff health, while 60% post-intervention said they would respond only if staff initiated the discussion. These patterns (see Tables 4 and 5) informed the design of the semi-structured interviews, which explored how organisational, cultural, and rela- tional factors influenced disclosure and engagement with the Endo@Work guidelines, as well as ways to improve and adapt the materials. 3.3.2 Interview demographics A total of 10 interviews were conducted across Groups 1 and 2. Table 6 outlines inter- viewee demographics. Group 1: Staff Group 2: Managers/supervisors Total Staff with endo/CPP With other chronic conditions ‘Healthy’ staff Managers with endo/CPP ‘Healthy’ MANAGERS Difficulties sleeping 2 2 4 (40%) Dyspareunia 4 2 6 (60%) Other 0 1 1 (10%) Other health cond.*: (n = 10) Chronic Fatigue – 2 – – – 2 (20%) Chronic Migraine Condition Syndrome 1 1 (10%) Degenerative Disc Disease 1 1 (10%) Inflammatory Arthritis 1 1 (10%) Rheumatoid Arthritis 1 1 (10%) Repetitive Strain Injury 1 1 (10%) Prefer not to say 1 1 (10%) EHP-30 score total cohort Avg ± SD – – Avg ± SD – Avg ± SD Pain 27 (± 26) 44 (± 20) 34 (± 24) Control & Powerlessness 36 (± 33) 52 (± 5) 43 (± 26) Emotional wellbeing 41 (± 17) 35 (± 12) 39 (± 15) Social Support 29 (± 39) 38 (± 18) 33 (± 31) Self-Image 38 (± 25) 50 (± 12) 43 (± 21) Work 18 (± 30) 36 (± 28) 25 (± 29) *Indicates answers can add up to more than 100% as respondents could provide more than one answer Table 3 (continued) Page 17 of 32 Howe et al. Discover Public Health (2026) 23:688 Group 1: Staff Group 2: Managers/Supervisors Total Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Total (n) 8 7 20 3 20 58 Flexibility around timing of breaks (n = 38) Yes 6 6 20 3 35 (92.1%) No 1 1 0 0 – 2 (5.3%) Unsure 1 0 0 0 1 (2.6%) Flexibility to WFH? (n = 38) Yes 6 6 18 3 – 33 (86.8%) No 1 1 1 0 3 (7.9%) Unsure 1 0 1 0 2 (5.3%) How many hours did you miss from work (in past 7 days) Due to CPP Avg (SD) 0.9 (± 2.5) – – 1.3 (± 1.2) – 1 (± 2.1) Due to Other reasons Avg (SD) 3.5 (± 7.5) 0 (± 0) 1.4 (± 3.8) 0.8 (± 1.4) – 1.6 (± 4.4) % time presenteeism* Due to CPP Avg (SD) 11 (± 15.5) – – 43 (± 15.3) – 20 (± 21) Due to ‘Other reasons’ Avg (SD) – 27% (32.5) 23% (18.7) – – 24 (± 22.4) Comfortable rais- ing health issues or concerns with your supervisor (n = 38) Yes 7 4 19 0 – 30 (51.7%) No 1 3 1 3 8 (13.8%) Ever felt judged/ discriminated for accessing additional support modifications? (n = 38) Yes 0 2 1 0 – 3 (7.9%) No 3 4 16 1 24 (63.2%) Unsure 1 1 3 0 5 (13.2%) Table 4 Baseline: Possible Workplace Factors influencing staff access to Endo@Work Page 18 of 32 Howe et al. Discover Public Health (2026) 23:688 3.3.3 Reflexive thematic analyses Analysis of interview transcripts identified three overarching themes and eleven sub - themes (Table 7), capturing structural and cultural dynamics shaping engagement with the Endo@Work guidelines. These themes also provided practical insights for improving implementation, including recommendations for enhancing education, resources, and organisational processes within university settings. 3.4 Theme 1 the flexibility façade: competition and overwork 3.4.1 A restructuring university environment: context of uncertainty and change limiting study participation Participants reported how the university restructure may have limited both staff par - ticipation and the feasibility of introducing new workplace supports. The Endo@Work pilot coincided with a major university restructure and redundancies taking place over a protracted period of time, creating an ongoing climate of uncertainty and precarity. Elena, a mid-career academic supervisor and CPPC with endo, explained that work - place restructuring reflected broader upheaval across the Australian higher education sector. She described how her institution’s approach to staff layoffs had deeply under - mined employees’ “psychological safety” , a concern she noted was echoed nationally as government agencies intervened in several universities in response to widespread men - tal health impacts. Several participants specifically addressed how the university institutional and sec - tor context influenced their engagement with the study. For some, job security reduced Group 1: Staff Group 2: Managers/Supervisors Total Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Blank 4 0 0 2 6 (15.8%) Supervisors: Do you freq. speak to staff about endo/heath needs? (n = 23) Yes – – – 1 3 4 (17.4%) No 1 10 11 (47.8%) Unsure 1 5 6 (26%) Blanks 0 1 1 (4.3%) Supervisors: are you comfortable in conversations providing support (n = 23) Yes – – – 2 20 (87%) No 0 0 0 (0%) Unsure 1 1 2 (8.7%) Blank – 1 1 (4.3%) *Presenteeism values are reported as percentages derived from WPAI scores; all other values represent participant counts Table 4 (continued) Page 19 of 32 Howe et al. Discover Public Health (2026) 23:688 Group 1: Staff Group 2: Managers/Supervisors Total Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Total (n) 6 7 14 4 5 36 Endo@Western: Did you (or any of your staff ) apply for modifications to your role? (n = 15) Yes 1 – – 0 0 1 (6.7%) No 3 3 0 6 (16.7%) Unsure 2 1 5 8 (5.3%) Flexibility around timing of breaks (n = 31) Yes 6 6 14 2 – 28 (90.3%) No 0 1 0 1 2 (6.4%) Unsure 0 0 0 1 1 (3.2%) Flexibility to WFH? (n = 31) Yes 5 6 13 2 – 26 (83.9%) No 0 0 1 1 2 (6.4%) Unsure 1 0 0 1 2 (6.4%) How many hours did you miss from work (in past 7 days) Due to CPP Avg (SD) 1.2 (± 2.9) – – 12 (± 12.1) – 5.5 (± 9.2) Due to other reasons Avg (SD) 2.3 (± 3.6) 1.1 (± 3.0) 0.7 (± 2.9) 0 (± 0) 1.1 (± 2.9) % time presenteeism* Due to CPP Avg % (SD) 22.5 (± 28.2) – – 40 (± 18.3) – 29.5(± 25.2) Due to ‘other reasons’ Avg % (SD) 38.6(± 26.7) 24.7 (± 17.3) – 28.1(± 21.6) Comfortable raising Health issues or con- cerns with your supervisor (n = 31) Yes 5 7 13 2 – 27 (87.1%) No 1 0 1 2 4 (1.3%) Ever felt judged/ discriminated for accessing ad- ditional support modifications? (n = 31) Yes 0 3 1 1 – 5 (16.1%) No 3 4 11 2 20 (64.5%) Unsure 1 0 2 0 3 (9.7%) Blank 2 0 0 1 3 (9.7%) Table 5 Post-intervention: Possible Workplace Factors influencing staff access to Endo@Work) Page 20 of 32 Howe et al. Discover Public Health (2026) 23:688 hesitation. Taylor, a senior academic with CPP , reflected that her secure position made her comfortable to participate: “They’re not going to do anything to me. ” For others, the looming threat of job loss overshadowed the study’s potential impact. Morgan, a senior academic supervisor with CPP , observed: “ About 70 of our specialist staff are going to lose their jobs…so maybe that’s overshadowed [Endo@Work]. ” Elena also noted that the only staff member she was aware of with endometriosis/CPP in her school had been Table 6 Demographics and role of interviewees Staff (n = 3) Manager/ Supervisor (n = 7) Total (N = 10) Diagnosis Endo 1 4 5 (50%) Other cause of CPP 2 – 2 (20%) ‘Healthy’/no CPP diagnosis – 3 3 (30%) Self-reported career stage Early 1 – 1 (10%) Mid – 3 3 (30%) Senior 2 4 6 (60%) Role Academic/Research 3 6 9 (90%) Professional – 1 1 (10%) Did you access Endo@Work guidelines? No 3 7 10 (100%) Did you know of any staff or coworkers who accessed the Endo@Work guidelines? No 3 7 10 (100%) Acted as Chronic Pelvic Pain Coordinator – 3 3 (30%) Time when registered for interview Baseline 2 5 7 (70%) Post-intervention 1 2 3 (30%) Group 1: Staff Group 2: Managers/Supervisors Total Staff with Endo/CPP With other chronic conditions ‘Healthy’ Staff Managers with Endo/CPP ‘Healthy’ Managers Supervisors: Do you freq. speak to staff about endo/heath needs? (n = 9) Yes – – – 2 1 3 (33%) No 0 4 4 (44%) Unsure 2 0 2 (22%) Supervisors: are you comfortable in conversa- tions providing support (n = 9) Yes – – – 2 5 7 (77%) No 0 0 0 (0%) Unsure 2 0 2 (22%) *Presenteeism values are reported as percentages derived from WPAI scores; all other values represent participant counts Table 5 (continued) Page 21 of 32 Howe et al. Discover Public Health (2026) 23:688 made redundant during the Endo@Work study, limiting her ability to support staff accessing the guidelines. 3.4.2 Embedded university flexibility: supporting symptom management while reinforcing concealment Participants described flexibility in start and finish times and the option to work from home, though limitations remained for professional, teaching, and laboratory roles. For many, this flexibility supported symptom management. Maya, an early-career academic with endometriosis, noted: “I can arrive to my lab slightly later in the day or work to later at night [because] I often have trouble sleeping with my pain. ” At the same time, participants highlighted how the output-focused culture of uni - versities led to both autonomy and concealment. Taylor, a senior academic with CPP , reflected: “ As long as you’re producing what the university expects of you, not many questions are asked. ” Yet, by allowing symptoms to be managed privately, it may reduce perceived need, or the opportunity, for disclosure. Siena, a mid-career academic supervi- sor and CPPC with endo, explained: “It’s relatively easy to hide [endometriosis] because a lot of academic work is solo…a lot of the time you do that in silence. ” Thus, while flexi- bility was valued and supported an individual’s symptom management, it also reinforced concealment. Potentially limiting disclosure, perpetuating a culture of silence and reduc- ing engagement with Endo@Work. 3.4.3 A culture of overwork: intensification of endo and CPP symptoms Participants described workplace flexibility as a ‘double-edged sword’ , shaped by a broader culture of overwork and competition. Career advancement and promotions were primarily determined by measurable outputs, which flexibility both enabled by allowing staff to work from home and extend their hours well beyond contractual lim - its. Elena remarked, “It’s maybe just an academic thing, we have a culture of being so hyper-competitive, individualised and siloed” (Elena, Mid-career Academic Supervisor and CPPC, Endo Diagnosis). Several participants with endometriosis or CPP elucidated the dual nature of work - place flexibility. While adjustments such as flexible hours or working from home Table 7 Interview Themes and sub-themes Themes Subthemes Theme 1 The flexibility façade: competi- tion and overwork A restructuring university environment: context of uncertainty and change limiting study participation Embedded university flexibility: supporting symptom management while reinforcing concealment A culture of overwork: intensification of endo and CPP symptoms Theme 2 The health costs of competi- tiveness: silence and apathy “I’d rather be silent than vulnerable.” Competition encourages silence around health needs “We don’t talk about periods, bums or poos.” Stigma as a contributor to silence Overwork and health apathy Exceptions to discussing endometriosis and CPP at work Theme 3 From validation to continuous improvement: strengthening Endo@Work Perceived positive impact Policy feedback—inclusive language Processes feedback Education feedback Page 22 of 32 Howe et al. Discover Public Health (2026) 23:688 supported symptom management, they also reinforced an output-driven culture that intensified workplace pressures, often worsening flare-ups, symptoms and wellbeing. Elena explains: “The obvious adjustments they were fine with, just working from home every now and again…but it’s actually the nature of the work, the culture that they’ve built around this, the pressure to exceed and succeed. All of this was impacting my well - being so severely that I got hospitalised”—Elena, Mid-career Academic Supervisor and CPPC, Endo Diagnosis. For participants with endometriosis or CPP , this culture often meant pushing through painful symptoms to maintain productivity and avoid perceptions of underperformance. Morgan, a senior academic with CPP , explained: “If someone has a chronic condition, your work output might be less if you’re having a particularly hard time. And then you really have to flog yourself…[so] my work outputs are good [and] so I don’t draw atten - tion to myself. ” 3.5 Theme 2 the health costs of competitiveness: silence and apathy 3.5.1 “I’d rather be silent than vulnerable” . Competition encourages silence around health needs Across all interviews, participants (including those without chronic health conditions) described how the competitive, output-driven culture of universities fostered silence around health needs. The combination of performance pressures and flexible working structures created an environment where disclosing vulnerability was perceived as risky. As Kai explained: “When you’re not feeling 100%, you’re more vulnerable, right? And people have diffi- culties talking about vulnerability in a work environment, especially in an academic work environment [because] it’s a competitive environment. You don't want to be the one that has that kind of issue. You're surrounded by high-achieving people, and you don't want to be the underdog. ”—Kai, Senior Academic Supervisor, no diagnosis This silence was evident across both early and senior career staff. Aanya shared: “It feels like there is a big message that you should be able to manage your work - load… I’ve been in Academia a long time and the only time I’ve mentioned to my manager that I had endo was when I had surgery and had to give a reason for being off for two weeks…other than that, I simply don’t talk about it. ”—Aanya, Senior Aca- demic Supervisor and CPPC, Endo diagnosis Even those tasked with championing Endo@Work as Chronic Pelvic Pain Coordinators (CPPC) described discomfort in disclosing their own diagnosis. As Aanya noted, despite her leadership role, she removed a personal disclosure from a staff email draft for Endo@ Work: “There was just this thing I was really uncomfortable to disclose… [because] the underlying message might be that there’s barriers to keeping up with this pace” (Aanya, Senior Academic Supervisor and CPPC with Endo). Page 23 of 32 Howe et al. Discover Public Health (2026) 23:688 3.5.2 “We don’t talk about periods, bums or poos. ” Stigma as a contributor to silence Although participants worked within health-focused schools and institutes, many described endometriosis and chronic pelvic pain as “still too personal” to disclose (Samara, mid-career academic supervisor with endo). Stigma tied to menstruation and pelvic pain (alongside related issues such as IBS) was seen as contributing to silence. One participant recalled a colleague’s decision to disclose endometriosis in a school-wide presentation as “brave” (Siena, mid-career academic supervisor and CPPC, with endo), highlighting the perceived risk of such openness even within a health and research sec - tor. As Morgan, a senior academic with CPP , reflected, “They’re hidden. They’re the ugly things that you don’t talk about. You don’t talk about your periods or lack thereof. You don’t talk about bums and poos. ” Several participants reported that this taboo was compounded by gendered norms. One participant reported that male colleagues appeared more comfortable discussing their pelvic health, while women might perceive disclosure of endometriosis or CPP as “awkward” . Samara (mid-career academic supervisor with endometriosis), elaborates, “I feel it could be awkward to tell people about it [endometriosis], while he just told every - one that he has kidney stones” . Managers also reported tensions between creating supportive workspaces while also acknowledging taboos and the need to respect privacy. Kai (senior academic supervisor, no diagnosis) explained, “I tend to create an environment where people feel like they can come to me…[but] I don’t feel like I have the tools to have those conversations without putting people in a position where they feel that they’re privacy is being invaded. ” Even supervisors with lived experience, such as Siena (a mid-career academic supervisor with CPPC and endometriosis) acknowledged this hesitation, “I’m more than happy for peo - ple to come to me…but I don’t have the desire to do it the other way around” . Participants also highlighted the risks of missteps in navigating these taboos. Samara (a mid-career academic supervisor with endo) recalled a male manager being repri - manded for asking a female colleague about pelvic and cervical cancer screening, later receiving a complaint of sexual harassment despite his best intentions. Such examples underscore how deeply engrained stigma and gendered expectations shape workplace silences around endometriosis and chronic pelvic pain. 3.5.3 Overwork and health apathy Most participants described universities as environments where staff were constantly “overworked and overstretched” (Elena), leaving little time or capacity to engage with others’ health needs. For some, this led to apathy, while for others it reflected the practi- cal impossibility of accommodating every additional need. Siena, a mid-career academic supervisor with endo, captured this dynamic: “Everyone is just so busy, it could just be one of those things that people go, ‘Oh! I’d like to know a little more about that, but I just don’t have time or capacity for it right now” . Supervisors noted how heavy workloads limited their ability to support staff and stu - dents. Samara, a mid-career academic supervisor with endo, explained, “ As a supervisor, I have about 10 students and supposedly I need to have fortnightly meetings with them and each of them for 30 min. Then, if we calculate that’s a couple of hours” . At senior levels, this strain constructed indifference. Morgan, a senior academic with CPP , recalled advocating for colleagues in leadership meetings: “you go to that meeting Page 24 of 32 Howe et al. Discover Public Health (2026) 23:688 and speak on behalf of those people because you’re supposed to be an advocate, and it lands on deaf ears. They go, ‘Oh, people always complain about this’ . ” Elena (mid-career academic supervisor) living with endometriosis, discussed the per - sonal cost organisational indifference can impose on people’s health and wellbeing: “I’m always having to advocate for myself and it’s a fucking strain. Having to con - stantly explain myself, justify my sick leave, or accommodation requests, especially to management, it’s so dismissive and invalidating. And they don’t realise the con - textual factors that can contribute to worsening pain, flare-ups, the inflammation, all of it…no matter how many times I explain that no matter how many times I ask for adjustments, it gets ignored. ”—Elena, Mid-Career Academic Supervisor and CPPC, Endo diagnosis. 3.5.4 Exceptions to discussing endometriosis and CPP at work While disclosure was often constrained, participants noted exceptions where endo - metriosis or chronic pelvic pain could be discussed more openly. Several participants, including Samara, described how trusted colleagues, particularly where personal rela - tionships existed or where a coworker had a similar diagnosis fostered a sense of shared experience, safety and understanding. “Only one colleague told me she had endometriosis and had experienced severe fer - tility challenges. It was only after we became closer that she shared this with me, when the relationship felt more personal than purely professional. ”—Samara, mid- career academic supervisor, Endo diagnosis. Supervisors researching or conducting work in reproductive health also observed greater disclosure among their staff and students. They attributed disclosures to the vis - ibility of their research in reproductive health, which they suggested might have helped legitimate and normalise conversations about endometriosis and chronic pelvic pain. 3.6 Theme 3 from validation to continuous improvement: strengthening Endo@Work Although none of the participants reported directly accessing the Endo@Work guide - lines, each interviewee offered feedback on the perceived value of the intervention. They described positive impacts from the research team’s involvement, particularly the vis - ibility created through the webinar, and provided constructive suggestions on workplace policies, procedures, and educational materials. 3.6.1 Perceived positive impact Participants viewed implementing the Endo@Work guidelines as an important first step toward raising awareness of endometriosis and chronic pelvic pain. Webinars, toolkits, and promotional emails were perceived as “really valuable” (Noor, Senior Professional Supervisor, no diagnosis), prompting conversations and disclosures that had not previ - ously occurred. As Noor reflected, “Your resources have been really good because I’ve had people come up to me and go, ‘Hey! Thank you just for even getting the word out there. ’ And divulging that they’ve got endo, or they’ve got chronic pelvic pain” . Supervisors also noted subtle cultural shifts linked to the guidelines that are difficult to quantify. Siena (mid-career academic supervisor and CPPC, endo diagnosis) observed: Page 25 of 32 Howe et al. Discover Public Health (2026) 23:688 “In one of our forums one person openly said that she had it [endo] in a presentation and it wasn’t specifically an endometriosis presentation…but she outwardly said it in front of the school…and I wonder whether 12 months ago it would have been the same…so I think it is slowly changing the more that this kind of awareness is raised. ” 3.6.2 Policy feedback—inclusive language Participants provided positive feedback from the workplace policy. Noting how reason - able adjustments and supports outlined through the guideline documents were ones they already used and found effective in managing symptoms. Most feedback, however, centred on the title of the guidelines. While the intervention was promoted as Endo@Work: Endometriosis and Chronic Pelvic Pain Guidelines, reac- tions were mixed surroundings the ‘inclusiveness’ of this title. Participants with endome- triosis reported that explicitly naming the condition was affirming and raised visibility. As one person noted, it signalled clearly that the resource was “for them” and legitimised endometriosis in workplace discussions. In contrast, respondents without an endometri- osis diagnosis interpreted how the title ‘Endo@’ was exclusionary, even with the subtitle referencing chronic pelvic pain. Morgan, a senior academic with CPP , reflected that “it’s not inclusive of a whole range of conditions, ” suggesting the terminology risked narrow- ing the reach of the educational materials. Other respondents felt that the “Endo@” title made the guidelines appear relevant only to people with a formal diagnosis, which risked excluding those who were undiagnosed or unaware they might have endometriosis. Samara (mid-career academic supervisor with endometriosis) noted that it often takes many years to receive an endometriosis diagnosis, observing that some students and staff might not recognise their symptoms as endometriosis. She suggested a broader label such as “pelvic pain” might “cut-through” more effectively, supporting a wider group of workers, and might even encourage earlier pathways to diagnosis. 3.6.3 Processes feedback Participants emphasised the importance of top-down support in promoting Endo@ Work. While school-wide emails promoting Endo@Work were sent from the school’s administrative team with senior-management approval, many participants noted these emails were ineffective amid the volume of staff e-communications. As Noor, a senior professional supervisor, reflected, “the Dean was really keen…but we could have had more input from that higher level…more advertising from that level rather than relying on me and the engagement team. ” All participants noted the importance of top-down promotion of guidelines and materials. Aanya highlighted how meaningful endorse - ment from senior leadership would have greater potential to shift workplace culture and uptake of Endo@Work guidelines: “I’m a supervisor, and I have endo. But, for me to be open about it I need reassur - ance, and the only way you get that is if it is coming from the top of the organisation and for it to feel really genuine…not just directly to staff but also to managers and supervisors around what the expectations are”—Aanya, Senior Academic Supervi - sor and CPPC, Endo Diagnosis. Page 26 of 32 Howe et al. Discover Public Health (2026) 23:688 All participants valued the CPPC role, which provided “a go—to person” (Noor, Senior Professional Supervisor, no diagnosis). However, several participants raised concerns about the role’s placement within schools. Some felt that locating the CPPC within Human Resources (HR) or Work Health and Safety (WHS) portfolio/work areas would provide a stronger organisational mandate and prevent burdening employees espe - cially those with lived experience of the condition(s). As Elena, a mid-career academic and CPPC with endo, explained, assigning the role to staff with lived experience risked “unintentionally burden[ing] someone” rather than embedding responsibility at the structural level. 3.6.4 Education feedback Participants valued the webinar content, particularly the use of lived experiences and case studies, but emphasised that additional education and training resources were needed to sustain awareness over time. Suggestions included posters, repeated/ongoing webinars or training sessions, induction trainings, and brief reminders at staff meetings. While the toolkit was comprehensive, many reported they were “too dense” (Siena, mid- career academic supervisor and CPPC, endo diagnosis) for everyday use. Respondents recommended developing concise, accessible resources such as one-page summaries and infographics that could be displayed in physical spaces across campus and offices to reinforce ongoing education. 4 Discussion The findings highlight the challenges in implementing and evaluating reproductive health interventions in university workplaces, where competitive cultures, structural pressures, ambivalent leadership and entrenched silence around health needs shape workplace experiences. Although it was not possible to compare pre- and post-inter - vention data, survey responses across both timepoints, alongside interview data, pro - vided valuable insights into the challenges of evaluating a workplace-based reproductive health intervention from within the organisation, and the entrenched silence around health needs at work, particularly at the intersection of gender, chronic conditions and reproductive health. 4.1 The challenges of evaluating a workplace-based reproductive health intervention from within the organisation Our findings suggest that reliance on internal evaluation mechanisms may have under - mined staff trust and limited the reliability of the survey, thereby affecting the evalu - ation of the Endo@Work guidelines. Survey responses and EHP-scores indicated that staff with endo/CPP appeared unusually 'healthy’ , reporting fewer symptoms impacts on work than both comparable working populations [ 17, 20, 34] and managers/supervi - sors in our own study. This diverges from previous research, where staff typically report higher levels of endo/CPP related challenges than senior staff [ 30]. It is important to note that ‘healthy’ in this context reflects self-reported survey responses rather than clinically assessed health status and may therefore reflect reporting behaviours rather than true differences in symptom burden. There are two possible factors contributing to this: staff at this university are genuinely healthier than comparable populations, or, more plausibly, they may have underreported their symptoms. Given that interviewees Page 27 of 32 Howe et al. Discover Public Health (2026) 23:688 described ‘suffering through’ pain, concealing symptoms, and fearing job loss during an ongoing restructuring, this suggests that underreporting is more likely the explanation. These discrepancies indicate that internal surveys did not fully capture the extend to health needs, reflecting a broader pattern of silence and under-disclosure within aca - demic workplaces. This aligns with a growing body of literature demonstrating wide - spread non-disclosure of endometriosis and chronic pelvic pain in workplace settings [41– 43], where employees often conceal symptoms due to stigma, fear of discrimination, and concerns about career consequences. Under-disclosure may be partly driven by mistrust in internal evaluation and report - ing mechanisms, which can make staff cautious about sharing health information. Because the evaluation was conducted internally, participants may have feared that their responses could be used against them in performance or role assessments. The literature attributes this to impression management bias, a form of social desirability bias in which workers minimise negative health or safety attributes/experiences when completing internal HR or health and safety surveys, particularly when they anticipate potential dis - crimination or consequences due to their responses [ 44, 45]. Evidence further suggests that many workers distrust internal staff surveys, especially those related to workplace health and safety, and may deliberately withhold information, reflecting a common belief that ‘you do not tell HR’ about health-related vulnerabilities [45, 46]. This interpretation aligns with our quantitative findings, where most respondents with endo/CPP chose not to answer whether they had experienced discrimination when accessing additional supports. Non-responses here are unlikely to reflect an absence of discrimination; rather, it may signal perceived risk. This reading is reinforced by our interviews, where four participants explicitly sought reassurance that their responses would remain confidential and used only for external research purposes. Existing litera - ture similarly shows that workers often avoid disclosing endometriosis or CPP due to fears of stigma, discrimination, and mistrust in managerial support [22, 41, 42]. This con- cern may also explain why the only staff member who accessed the guidelines declined to participate in the post-intervention interview, raising questions about whether they experienced or feared negative consequences. Together, these patterns suggest that silence itself is meaningful data, pointing to a broader culture of mistrust and conceal - ment that shapes whether employees feel safe to disclose their health needs. Our qualitative data suggest that internal evaluation processes may limit the accuracy of reporting with staff distrustful of how personal health information might be used. This finding echoes broader evidence that workplace policies on menstruation, men - strual disorders, and menopause are frequently under-evaluated [ 26]. To address this, future evaluations should prioritise external and independent approaches, ensuring staff feel confident that disclosures will remain confidential and not be used against them in the workplace. The sample should also be interpreted within its specific organisational context. Par - ticipants were drawn from a single Australian university and are not intended to be representative of the broader Australian workforce. Compared with Australian Bureau of Statistics workforce data, this sample reflects a highly educated, predominantly pro - fessional workforce, with distinct employment conditions including greater flexibility alongside sector-specific pressures such as restructuring. These contextual factors are likely to shape both disclosure practices and engagement with workplace interventions. Page 28 of 32 Howe et al. Discover Public Health (2026) 23:688 Accordingly, findings should be interpreted as context-specific insights rather than gen - eralisable estimates of prevalence or behaviour. 4.2 The entrenched silence around health-needs at work contributes to the gap between policy and process The Endo@Work guidelines were piloted in a university setting with strong labour-rela - tions and gender-equity frameworks, underpinned by legislative requirements for rea - sonable adjustments [ 47, 48]. Yet what emerged was not the inadequacy of policy but a culture of competitiveness, overwork, managerial uncertainty and senior-leadership indifference to chronic health conditions. This culture fostered silence around health needs and revealed persistent gaps between policy and practice. Participants consistently described stigma and fear of discrimination as barriers to dis- closure. Aligning with wider evidence that decisions to share chronic health conditions at work are often shaped by anticipated negative outcomes such as stigma, rejection, and concerns about job security [ 49]. Our study demonstrates that even within health- focused research settings, disclosure was rare and even described as “brave” (Siena), highlighting the persistent risks staff associate with openness about reproductive and chronic health. This tension between policy and practice has been observed in other Australian uni - versity studies, showing that while reasonable adjustment and anti-discrimination frameworks exist, workers with chronic invisible conditions often struggle to access accommodations [50]. Participants in both studies described senior-level apathy and the “strain” (Elena) of continual self-advocacy, with those who persisted often being seen as “difficult” [50]. Such dynamics reinforce mistrust and negative workplace environments that are proven to discourage workplace disclosure of endometriosis [42], limiting policy access in practice. Managerial/institutional uncertainty further contributed to silence. Consistent with existing research [ 51– 53] managers in our study reported hesitating to initiate health- related conversations because they feared overstepping professional boundaries or felt they were ill-equipped respond appropriately to any health related disclosures. This hesitation persisted even among managers with an endo/CPP diagnosis. A gendered dimension further shaped these dynamics, with women reporting greater discomfort discussing reproductive or pelvic health than male colleagues, reflecting findings from previous studies [ 42, 54]. This persistent gendered dimension to disclosure is concern - ing because it shows that silence is not only driven by stigma but also by uncertainty and lack of confidence among managers. Without clear structures, training, and leadership support, even well-intentioned supervisors may inadvertently reinforce cultures of non- disclosure, limiting the effectiveness of workplace policies and perpetuating inequities in reproductive and chronic health support. Exceptions around disclosures emerged where managers had lived experience or engaged in reproductive health research. Importantly, these managers did not initiate the disclosure, but participants suggested these contexts created a greater openness and safety where disclosure could occur without fear or discrimination. This supports other research demonstrating how lived-experience advocacy from colleagues or senior lead - ers can disrupt cultures of silence around endometriosis and chronic illness at work [55]. Page 29 of 32 Howe et al. Discover Public Health (2026) 23:688 While our findings emphasise structural and cultural barriers to engagement, limited uptake may also reflect varying levels of staff interest or engagement with the interven - tion. In high-pressure academic environments, workplace initiatives may be depriori - tised or perceived as insufficiently relevant, particularly where immediate work demands dominate. Low uptake should therefore be interpreted as multifactorial, shaped by both organisational barriers and broader patterns of engagement with institutional initiatives. These findings may suggest that policy alone is insufficient. Closing the gap between policy and practice requires managerial training and senior-level endorsement to nor - malise health conversations and support staff needs. Future research should focus on identifying best-practice models for manager training and senior leadership engage - ment, particularly in relation to endometriosis, chronic pelvic pain, and reproductive health at work. 5 Limitations This study was limited by its small sample size, which reduced statistical power and prevented reliable comparisons across role types (e.g. academic/research versus profes - sional staff). The pilot also took place during a period of economic uncertainty, when employees may have been less inclined to engage with new workplace initiatives. These factors, combined with the broader stigma and fear of discrimination around health dis - closures, may have further constrained participation and reporting. Reliance on self-reported data also raises the possibility of underreporting, particu - larly given concerns about confidentiality in internal evaluations. This underscores the importance of future research using larger, more diverse samples and external evaluation processes to reduce mistrust and strengthen evidence on how best to support employees with endometriosis, chronic pelvic pain, and other chronic health conditions. 6 Conclusion This mixed-method intervention study highlights the persistent gap between work - place policy and practice when supporting employees with endometriosis and chronic pelvic pain. While the Endo@Work intervention introduced clear policy, education, and resources, uptake was constrained by entrenched workplace cultures of competi - tion, overwork, and silence around health needs. Quantitative findings suggested under - reporting of health concerns and was validated by qualitative insights revealing how stigma, fear of discrimination, and managerial/institutional uncertainty may have lim - ited disclosure and encouraged underreporting of health needs. Together, these findings demonstrate that even within institutions with established labour and gender-equity frameworks, cultural and relational barriers prevent policies from being meaningfully accessed. A key implication of our study is the need to reconsider how workplace reproductive- health interventions are evaluated. Internal evaluations appeared to amplify fears that personal information might be misused. This suggests that external, independent evalu - ations may be essential to foster trust, encourage openness, and generate more accurate assessments of policy impact. Future efforts could combine robust policy infrastructure with visible senior-level endorsement, manager training, and culturally embedded strategies that normalise reproductive and chronic health at work. Only by addressing both the structural and Page 30 of 32 Howe et al. Discover Public Health (2026) 23:688 cultural dimensions (and ensuring evaluations are trusted) can workplaces begin to close the gap between policy and practice. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1186/s12982-026-02018-6. Supplementary Material 1. Supplementary Material 2. Author contributions D.H. is lead contributor to conception, design, data acquisition, analyses, interpretation of data and drafting the article. Authors 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.) contributed to the interpretation of data, the critical revision of article, and provided final approval of the version to be published. Funding This research received no external funding. Data availability The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author. Declarations Ethics approval and consent to participate Ethical approval for this study was granted by the Western Sydney University Human Research Ethics Committee (H16067, approved March 2025). All procedures were conducted in accordance with the National Statement on Ethical Conduct in Human Research. For the survey component, participants accessed a detailed Participant Information Sheet on the survey landing page outlining the study aims, procedures, risks, benefits, confidentiality, and voluntary nature of participation. Participants provided informed consent electronically by proceeding to the survey. For the interview component, participants received a separate Participant Information Sheet and provided written informed consent prior to participation. Interviews were conducted online, audio-recorded with permission, transcribed, and de-identified. Consent for publicaton Participation across all components was voluntary. Data were collected anonymously (survey) or de-identified (interviews), and participants could withdraw at any time without consequence. All participants consented to the use of their de-identified data for research publication. Competing interest The authors declare no competing interests. Received: 30 January 2026 / Accepted: 23 April 2026

1. Mardon AK, Leake HB, Szeto K, et al. Recommendations for patient education in the management of persistent pelvic pain: 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 0 0 3 1 3 7 . 2. Lamvu G, Carrillo J, Ouyang C, et al. Chronic pelvic pain in women: a review. JAMA. 2021;325:2381–91. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 1 / j a m a . 2 0 2 1 . 2 6 3 1 . 3. Adler H, Jeffrey S, Ashton LM, et al. The language of endometriosis prevalence: how can gender inclusivity and accuracy coexist? Women’s Reprod Health. 2024;12:266–83. https://doi .org/10.108 0/23293691. 2024.239 6312. 4. Eisenberg VH, Weil C, Chodick G, et al. Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. BJOG. 2018;125:55–62. https://doi.org/10.1111/1471-0528.14711. 5. Mishra GD, Gete DG, Baneshi MR, et al. Patterns of health service use before and after diagnosis of endometriosis: a data linkage prospective cohort study. Hum Reprod. 2025;40:612–22. https://doi.org/10.1093/humrep/deaf026. 6. Rowlands IJ, Abbott JA, Montgomery GW, et al. Prevalence and incidence of endometriosis in Australian women: a data linkage cohort study. BJOG. 2021;128:657–65. https://doi.org/10.1111/1471-0528.16447. 7. Simoens S, Dunselman G, Dirksen C, et al. The burden of endometriosis: costs and quality of life of women with endome- triosis and treated in referral centres. Hum Reprod. 2014;29:2073–2073. https://doi.org/10.1093/humrep/deu112. 8. Treloar SA, Do K-A, O’Connor VM, et al. Predictors of hysterectomy: an Australian study. Am J Obstet Gynecol. 1999;180:945–54. https://doi.org/10.1016/S0002-9378(99)70666-6. 9. Ghiasi M, Kulkarni MT, Missmer SA. Is endometriosis more common and more severe than it was 30 years ago? J Minim Invasive Gynecol. 2020;27:452–61. 10. de Kok L, Boersen Z, Coppus S, et al. Diagnostic delay in endometriosis: is there any progress? Reprod Biomed Online. 2025;105405. Page 31 of 32 Howe et al. Discover Public Health (2026) 23:688 11. Fourquet JMPH, Gao XPD, Zavala DPD, et al. Patients’ report on how endometriosis affects health, work, and daily life. Fertil Steril. 2010;93:2424–8. https://doi .org/10.101 6/j.fertnst ert.2009 .09.017. 12. Armour M, Sinclair J, Ng CHM, et al. Endometriosis and chronic pelvic pain have similar impact on women, but time to diagnosis is decreasing: an Australian survey. Sci Rep. 2020;10:16253–16253. https://doi.org/10.1038/s41598-020-73389-2. 13. Horne AW, Missmer SA. Pathophysiology, diagnosis, and management of endometriosis. BMJ. 2022. h t t p s : / / d o i . o r g / 1 0 . 1 1 3 6 / b m j - 2 0 2 2 - 0 7 0 7 5 0 . 14. Hunsche E, Gauthier M, Witherspoon B, et al. Endometriosis symptoms and their impacts on the daily lives of US women:

from an interview study. Int J Women’s Health. 2023. https://doi.org/10.2147/IJWH.S409733. 15. Armour M, Middleton A, Lim S, et al. Dietary practices of women with endometriosis: a cross-sectional survey. J Altern Complement Med. 2021;27:771–7. https://doi.org/10.1089/acm.2021.0068. 16. Armour M, Lawson K, Wood A, et al. The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: a national online survey. PLoS ONE. 2019;14:e0223316. https://doi.org/10.1371/journal.pone.0223316. 17. Fourquet J, Báez L, Figueroa M, et al. Quantification of the impact of endometriosis symptoms on health-related quality of life and work productivity. Fertil Steril. 2011;96(1):107–12. https://doi .org/10.101 6/j.fertnst ert.2011 .04.095. 18. Røssell E-L, Plana-Ripoll O, Josiasen M, et al. Association between endometriosis and working life among Danish women. Hum Reprod. 2025. https://doi.org/10.1093/humrep/deae298. 19. Nnoaham KEMD, Hummelshoj L, Webster PMD, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril. 2011;96:366-373.e368. https://doi .org/10.101 6/j.fertnst ert.2011 .05.090. 20. Hansen KE, Kesmodel US, Baldursson EB, et al. The influence of endometriosis-related symptoms on work life and work ability: a study of Danish endometriosis patients in employment. Eur J Obstet Gynecol Reprod Biol. 2013;169:331–9. https://doi.org/10.1016/j.ejogrb.2013.03.008. 21. Soliman AM, Coyne KS, Gries KS, et al. The effect of endometriosis symptoms on absenteeism and presenteeism in the workplace and at home. J Manag Care Spec Pharm. 2017;23:745–54. https://doi.org/10.18553/jmcp.2017.23.7.745. 22. Armour M, Ciccia D, Stoikos C, et al. Endometriosis and the workplace: lessons from Australia’s response to COVID-19. Aust N Z J Obstet Gynaecol. 2022;62:164–7. https://doi.org/10.1111/ajo.13458. 23. Armour M, Sinclair J, Chalmers KJ, et al. Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC Complement Altern Med. 2019;19:17. https://doi.org/10.1186/s12906-019-2431-x. 24. ABS ABoS. Working Arrangements. 2025. ABS website. 25. HCA. Almost all Australian businesses have mandatory return-to-office policies, h t t p s : / / w w w . h c a m a g . c o m / a u / s p e c i a l i s a t i o n / b e n e fi t s / a l m o s t - a l l - a u s t r a l i a n - b u s i n e s s e s - h a v e - m a n d a t o r y - r e t u r n - t o - o ffi c e - p o l i c i e s / 4 5 6 0 5 8 . 2023. Accessed 29 Jan 2026. 26. Howe D, Duffy S, O’Shea M, et al. Policies, guidelines, and practices supporting women’s menstruation, menstrual disor- ders and menopause at work: a critical global scoping review. Healthcare (Basel). 2023;11(1–25):20231110. h t t p s : / / d o i . o r g / 1 0 . 3 3 9 0 / h e a l t h c a r e 1 1 2 2 2 9 4 5 . 27. Owen L. Menstruation and humanistic management at work: the development and implementation of a menstrual workplace policy. J Assoc Manag Educ Dev. 2018;25:23–31. 28. Hardy C, Griffiths A, Hunter MS. Development and evaluation of online menopause awareness training for line managers in UK organizations. Maturitas. 2019;120:83–9. https://doi .org/10.101 6/j.maturit as.2018. 12.001. 29. Ariyoshi H. Evaluation of menopausal interventions at a Japanese company. AAOHN J. 2009;57:106–11. h t t p s : / / d o i . o r g / 1 0 . 3 9 2 8 / 0 8 9 1 0 1 6 2 - 2 0 0 9 0 3 0 1 - 0 1 . 30. Howe D, O'Shea M, Duffy S, et al. Endometriosis and workplace inequities: exploring the factors influencing workplace absenteeism and presenteeism. 2025. https://doi.org/10.21203/rs.3.rs-5363991/v1. 31. Howe D, O'Shea M, Duffy S, et al. “Suck it up and push through!” Exploring the experiences of women with endometriosis at work. 2024. https://doi.org/10.21203/rs.3.rs-5480104/v1. 32. Howe D, O’Shea M, Duffy S, et al. From insight into action: understanding how employer perspectives shape endometrio- sis-inclusive workplace policies. Healthc (Amst). 2025;13:930. 33. Jones G, Kennedy S, Barnard A, et al. Development of an endometriosis quality-of-life instrument: the endometriosis health profile-30. Obstet Gynecol. 2001;98:258–64. https://doi.org/10.1016/s0029-7844(01)01433-8. 34. Jones GL, Budds K, Taylor F, et al. A systematic review to determine use of the endometriosis health profiles to measure quality of life outcomes in women with endometriosis. Hum Reprod Update. 2024;30:186–214. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / h u m u p d / d m a d 0 2 9 . 35. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instru- ment. Pharmacoeconomics. 1993;4:353–65. https://doi .org/10.216 5/00019053- 19930405 0-00006. 36. Soliman AM, Rahal Y, Robert C, et al. Impact of endometriosis on fatigue and productivity impairment in a cross-sectional survey of Canadian women. J Obstet Gynaecol Can. 2021;43:10–8. https://doi.org/10.1016/j.jogc.2020.06.022. 37. Carr LT. The strengths and weaknesses of quantitative and qualitative research: what method for nursing? J Adv Nurs. 1994;20:716–21. https://doi.org/10.1046/j.1365-2648.1994. 20 040716 .x. 38. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11:589–97. h t t p s : / / d o i . o r g / 1 0 . 1 0 8 0 / 2 1 5 9 6 7 6 X . 2 0 1 9 . 1 6 2 8 8 0 6 . 39. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18:328–52. 40. Olmos-Vega FM, Stalmeijer RE, Varpio L, et al. A practical guide to reflexivity in qualitative research: AMEE guide No. 149. Med Teach. 2023;45:241–51. https://doi .org/10.108 0/0142159X. 2022.205 7287. 41. Williams V. Experiences of working with endometriosis and the influence of menstrual policy. 2024. 42. Krsmanovic A, Dean M. How women suffering from endometriosis disclose about their disorder at work. Health Commun. 2022. https: //d oi. or g/10 .1080/10 4102 36.20 21.1880053. 43. Hvala T, Hammarberg K. The impact of reproductive health needs on women’s employment: a qualitative insight into managing endometriosis and work. BMC Womens Health. 2025;25:216. https://doi.org/10.1186/s12905-025-03726-y. 44. Joinson A. Social desirability, anonymity, and internet-based questionnaires. Behav Res Methods Instrum Comput. 1999;31:433–8. https://doi.org/10.3758/BF03200723. 45. Keiser NL, Payne SC. Are employee surveys biased? Impression management as a response bias in workplace safety constructs. Saf Sci. 2019;118:453–65. https://doi.org/10.1016/j.ssci.2019.05.051. Page 32 of 32 Howe et al. Discover Public Health (2026) 23:688 46. Gonzales S. The hidden truth affecting productivity: nearly half of employees say they withhold honest feedback. Visier Online: Visier. 2025. 47. Disability-Discrimination-Act. disability discrimination act 1992. In: Australia Po, (ed.). Federal Register of Legislation. 1992. 48. Australian Government FRoL. Fair Work Act In: Legislation FRo, (ed.). 2009. 49. Gignac MAM, Jetha A, Ginis KAM, et al. Does it matter what your reasons are when deciding to disclose (or not disclose) a disability at work? The association of workers’ approach and avoidance goals with perceived positive and negative workplace outcomes. J Occup Rehabil. 2021;31:638–51. https://doi.org/10.1007/s10926-020-09956-1. 50. Humphrys E, Rodgers J, Asquith NL, et al. ‘To prove I’m not incapable, I overcompensate’: disability, ideal workers, the academy. Econ Labour Relat Rev ELRR. 2022;33:698–714. https://doi.org/10.1177/10353046221125642. 51. Coppens E, Hogg B, Greiner BA, et al. Promoting employee wellbeing and preventing non-clinical mental health problems in the workplace: a preparatory consultation survey. J Occup Med Toxicol. 2023;18(1):17. h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 9 5 - 0 2 3 - 0 0 3 7 8 - 2 . 52. Wu A, Roemer EC, Kent KB, et al. Organizational best practices supporting mental health in the workplace. J Occup Envi- ron Med. 2021;63:e925–31. https://doi.org/10.1097/jom.0000000000002407. 53. King C, Edlington T, Williams B. Avoiding difficult conversations in the Australian health sector. SAGE Open Nurs. 2020;6:2377960820941978. https://doi.org/10.1177/2377960820941978. 54. Hawkey A, Chalmers KJ, Micheal S, et al. “A day-to-day struggle”: a comparative qualitative study on experiences of women with endometriosis and chronic pelvic pain. Fem Psychol. 2022;32:482–500. https://doi.org/10.1177/09593535221083846. 55. König A, Zu Biesen CM. “Activism was a survival strategy”: Chronic illness and the power of endometriosis activism as work. Anthropol Work Rev. 2025;n/a:e70005. https://doi.org/10.1111/awr.70005. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.