Long-term sick leave and work rehabilitation - prognostic factors for return to work

The main objective of this thesis is to examine individual prognostic factors for return to work (RTW) after work rehabilitation, for workers on long-term sick leave with common musculoskeletal and mental health complaints. The process of returning to work after long-term sick leave may be complex, and is often influenced by other factors than health complaints and diagnoses alone. The primary hypothesis in this thesis was that individual’s cognitions about health and illness would be central for returning to work or not, after work rehabilitation. A second hypothesis was that socioeconomic status (SES) through education or occupation would predict RTW after work rehabilitation. A third hypothesis was that the process of returning to work would be complex and differ between subgroups of work rehabilitation participants. Cognitions, such as illness perceptions and fear avoidance beliefs may be a matter of beliefs about cure, control, and expectancies, thus of coping. Coping, as defined in the Cognitive activation theory of stress (CATS), was applied in this thesis. In the CATS, coping is defined as positive response outcome expectancies, in contrast to negative response outcome expectancies (hopelessness) or no response outcome expectancies (helplessness). In Norway, comprehensive inpatient work rehabilitation may be offered to individuals on long-term sick leave. Participants in inpatient work rehabilitation programs typically have sick leave diagnoses related to musculoskeletal and mental health complaints, often characterized by non-specific conditions, mostly subjective health complaints, with few objective medical findings. Individuals with subjective health complaints may believe that their complaints are harmful and may therefore try to avoid activities they believe will harm them, such as work. Experiencing distress and poor functional ability may lead to vicious circles of hopelessness and helplessness, i.e. poor coping. Maladaptive illness perceptions and fear avoidance beliefs about work may contribute to prolonged disability and time out of work. The aim of work rehabilitation is to alter such vicious circles through positive experiences and cognitive processes, and facilitate RTW. This is done by interdisciplinary assessments, education, physical activities, and cognitive behavior modifications offered in a combination of individual and group-based sessions. In addition, collaboration with external stakeholders, such as health care providers, the employer, or the local social insurance office (NAV-office) are important elements during work rehabilitation. In this thesis, individual prognostic factors for RTW after work rehabilitation were investigated in three different samples of work rehabilitation participants. Predictive information was extracted from questionnaires and patient journals while information of work and sick leave were measured by self-reports and official register data of The Norwegian labor and welfare administration (NAV). The primary and secondary hypotheses were investigated in the first paper, where the aim was to examine whether health complaints, illness perceptions, fear avoidance beliefs, coping, and education predicted non-working 3 and 12 months after participating in work rehabilitation, and to assess the relative importance and interrelationship of these factors. Logistic regression analysis was conducted. The results showed that fear avoidance beliefs for work were the most important predictor for non-working both at 3 months, and at 12 months follow-up after participating in work rehabilitation. A multiple regression analysis displayed that almost half of the variance in fear avoidance beliefs for work were explained by the amount of musculoskeletal and pseudoneurological health complaints, i.e. tiredness, sadness/depression, and anxiety, and by illness perceptions and education. For illness perceptions, the components concerning perceived duration, consequences, and personal control of the illness were the most important. Coping did not contribute to explain any variance in fear avoidance beliefs for work. In conclusion, high levels of fear avoidance beliefs for work were a strong predictor for non-working after work rehabilitation. However, the intervening mechanisms between fear avoidance beliefs and subsequent avoidance behavior, in terms of avoiding the workplace when sick, are still poorly understood. The primary and secondary hypotheses were investigated in the second paper, where the aim was to test if fear avoidance beliefs for work would mediate the relationships between musculoskeletal and pseudoneurological complaints, functional ability, level of education, and number of days on sickness benefits during 3-year follow-up after work rehabilitation. Structural equation modeling (SEM) was used to test a predefined mediation model for direct and indirect effects between the hypothesized predictors and days on sickness benefits during follow-up. As hypothesized, fear avoidance beliefs for work mediated the effect of musculoskeletal complaints and education on sick leave during follow-up. There was however, no direct effect of musculoskeletal complaints on fear avoidance beliefs, as this relationship was fully mediated by poor physical function, in terms of moving ability and lifting/carrying ability. Fear avoidance beliefs for work did not mediate the relationship between pseudoneurological complaints or mental function, in terms of coping/interaction ability and sick leave during follow-up. Pseudoneurological complaints had a small direct effect, and length of previous sick leave had a strong independent effect on days on sickness benefits after work rehabilitation. In conclusion, the mechanisms involved in the process of returning to work are complex and involve several intervening factors including health and functional ability, education, previous sick leave, and fear avoidance beliefs for work. The second and third hypotheses were investigated in the third paper. Here the aim was to examine if gender, age, diagnosis, occupation, and length of previous sick leave predicted differences in the process of returning to work, in terms of being at work or registered with sickness benefits, and transitions in and out of work and sickness benefits, during a 4-year follow-up after work rehabilitation. Proportional hazard regression analysis was used to explore the probabilities of being at work, or of receiving sickness benefits, or disability pension, and differences in the transitions between any of these states during follow-up. Regression models based on transition intensities detected differences in the risk factors of entering and leaving a given state. For example among women, the lower probability of being at work than men, could be explained by a lower probability of transitions to work, and not by a higher probability of leaving work. In addition, the probabilities of being at work, and of receiving sickness benefits, and disability pension differed between men and women, age groups, diagnostic category, type of work, and previous history of sick leave. Being a female, having diagnoses other that mental and musculoskeletal, having bluecollar work, and receiving long-term sick leave before entering work rehabilitation, increased the risk of not returning to work and of receiving disability pension during follow-up. The use of novel statistical methods made it possible to understand more of the different patterns in or out of work or of receiving sickness benefits, and how the prognosis differed between groups. The results from this thesis show that the process of returning to work after long-term sick leave and work rehabilitation depends on the interplay between multifaceted prognostic factors related to the history of previous sick leave, age, gender, SES, health, function, and cognitions in terms of illness perceptions and fear avoidance beliefs for work. These findings may have implications for selection criteria into work rehabilitation, for tailoring actions during a work rehabilitation program, and may guide follow-up actions aiming at RTW in collaboration with stakeholders outside the work rehabilitation clinic

Pro-Social Behaviour in Times of Crisis and Uncertainty : An Empirical Study of Local COVID-19 Restrictions and the Donation Rate in the Norwegian Recycling Lottery

The purpose of this thesis is to investigate the relationship between local COVID-19 restrictions and the donation rate in the Norwegian recycling lottery, employing donations to the lottery as a proxy for pro-social behaviour. The thesis aims to study whether the enforcement of local restrictions has an impact on the donation rate and if separate categories of restrictions impact the donation rate differently. Additionally, the thesis explores whether the effect on the donation rate varies based on the duration of the local restrictions enforcement and whether there is a long-term impact after their termination. The final dataset consists of 461,115 observations that contain data on recycling and the enforcement of local COVID-19 restrictions. The panel dataset also comprises information on municipal affiliation, total transactions, and infection numbers. Regressions on the data are conducted with fixed effects estimation with week and store fixed effects, and total transactions and the infection rate per 100,000 as control variables. The findings reveal a positive effect of local COVID-19 restrictions on the donation rate. The results suggest that the enforcement of local restrictions will increase the donation rate by approximately 0.25 percentage points. Certain categories of restrictions, for instance, those related to travel and the ban on serving alcohol, are also found to have a greater effect than other categories. Furthermore, the thesis reveals that the duration of the local restrictions has a significant and increasing effect from the second week on. There is no evidence that local restrictions have a long-term impact on the donation rate. An additional survey conducted on donation motivation demonstrates that there are diverse motives for contributing to the recycling lottery. Although local restrictions are found to have a positive effect on the donation rate, it remains undetermined whether these restrictions in fact have an impact on pro-social behaviour.nhhma

How do occupational rehabilitation clinicians approach participants on long-term sick leave in order to facilitate return to work? - A focus-group study

Background The objective of this study was to explore occupational rehabilitation clinicians’ experiences on how to approach their participants on long-term sick leave in order to facilitate return to work (RTW). Methods An exploratory qualitative design was used. Four focus groups were conducted with 29 clinicians working on interdisciplinary inpatient and outpatient occupational rehabilitation teams in Norway. The clinicians shared narratives from clinical practice. Transcripts were analysed, and results were reported by use of systematic text condensation. Results The clinicians used several approaches to facilitate RTW among individuals on sick leave. Three themes emerged as especially important in order to succeed: 1) To get a basic understanding of the participant’s life-world through a mapping process; 2) To build a therapeutic alliance through communication characterised by sensitivity to the participants’ needs and emotional concerns; and 3) To initiate processes of change that increase the possibilities for RTW. Four main areas targetable for change were identified, three directed at the individual and one encompassing the participants’ surroundings. These approaches were: a) To increase feelings of confidence and coping; b) To increase the participants’ awareness of their own limits; c) To challenge inefficient and negative attitudes and thoughts related to the sick-role; and d) Close and immediate dialogue with key stakeholders. Conclusions To increase the possibilities for RTW among individuals on long-term sick leave, a thorough mapping process and the construction of a therapeutic alliance are seen as crucial elements in approaches by occupational rehabilitation clinicians. By gaining the participants’ trust and identifying their barriers and possibilities for work, the clinicians can target modifiable factors, especially at the individual level, and obstacles for RTW in their individual surroundings. This study elucidates what occupational rehabilitation clinicians do, say and provide to increase their participants’ abilities and possibilities to RTW.publishedVersio

Are self-report of disability pension and long-term sickness absence accurate? Comparisons of self-reported interview data with national register data in a Swedish twin cohort

<p>Abstract</p> <p>Background</p> <p>Self-reported disability pension (DP) and sickness absence are commonly used in epidemiological and other studies as a measure of exposure or even as an outcome. The aims were (1) to compare such self-reports with national register information in order to evaluate the validity of self-reported DP and sickness absence, and (2) to estimate the concordance of reporting behaviour in different twin zygosity groups, also by sex.</p> <p>Methods</p> <p>All Swedish twins born 1933-1958 who participated in the Screening Across the Lifespan Twin study (SALT) 1998-2003, were included (31,122 individuals). The self-reported DP and long-term sickness absence (LTSA) at the time of interview was compared to the corresponding register information retrieved from the National Social Insurance Agency by calculating the proportions of agreements, kappa, sensitivity, specificity, concordance rates, and chi-square test, to evaluate construct validity.</p> <p>Results</p> <p>The proportions of overall agreement were 96% and specificity 99% for both DP and LTSA, while the sensitivity was 70% for DP and 45% for LTSA. Kappa estimates were 0.76 for DP, and 0.58 for LTSA. The proportions of positive agreement were 64% for DP and 42% for LTSA. No difference in response style was found between zygosity groups among complete twin pairs for DP and LTSA. Results were similar for women and men and across age. Kappa estimates for DP differed somewhat depending on years of education, 0.68 (college/university) vs. 0.77 (less than 13 years in school) but not for LTSA.</p> <p>Conclusions</p> <p>Self-reported DP data may be very useful in studies when register information is not available, however, register data is preferred especially for LTSA. The same degree of twin similarity was found for truthful self-report of DP and LTSA in both monozygotic and dizygotic twin pairs. Thus, the response style was not influenced by genetic factors. One consequence of this would be that when estimating the relative importance of genetic and environmental effects from twin models, heritability estimates would not be biased.</p

Treatment Efficacy, Clinical Utility, and Cost-Effectiveness of Multidisciplinary Biopsychosocial Rehabilitation Treatments for Persistent Low Back Pain: A Systematic Review

Study Design: Systematic review. Objectives: To review the current literature on the treatment efficacy, clinical utility, and cost-effectiveness of multidisciplinary biopsychosocial rehabilitation (MBR) for patients suffering from persistent (nonspecific) lower back pain (LBP) in relation to pain intensity, disability, health-related quality of life, and work ability/sick leave. Methods: We carried out a systematic search of Web of Science, Cochrane Library, PubMed Central, EMBASE, and PsycINFO for English- and German-language literature published between January 2010 and July 2017. Study selection consisted of exclusion and inclusion phases. After screening for duplication, studies were excluded on the basis of criteria covering study design, number of participants, language of publication, and provision of information about the intervention. All the remaining articles dealing with the efficacy, utility, or cost-effectiveness of intensive (more than 25 hours per week) MBR encompassing at least 3 health domains and cognitive behavioral therapy–based psychological education were included. Results: The search retrieved 1199 publications of which 1116 were duplicates or met the exclusion criteria. Seventy of the remaining 83 articles did not meet the inclusion criteria; thus 13 studies were reviewed. All studies reporting changes in pain intensity or disability over 12 months after MBR reported moderate effect sizes and/or p-values for both outcomes. The effects on health-related quality of life were mixed, but MBR substantially reduced costs. Overall MBR produced an enduring improvement in work ability despite controversy and variable results. Conclusions: MBR is an effective treatment for nonspecific LBP, but there is room for improvement in cost-effectiveness and impact on sick leave, where the evidence was less compelling

Protocol for the SEED-trial: Supported Employment and preventing Early Disability

Background: Early withdrawal or exclusion from the labor market leads to significant personal and societal costs. In Norway, the increasing numbers of young adults receiving disability pension is a growing problem. While a large body of research demonstrates positive effects of Supported Employment (SE) in patients with severe mental illness, no studies have yet investigated the effectiveness of SE in young adults with a range of social and health conditions who are receiving benefits. Methods/design: The SEED-trial is a randomized controlled trial (RCT) comparing traditional vocational rehabilitation (TVR) to SE in 124 unemployed individuals between the ages of 18-29 who are receiving benefits due to various social- or health-related problems. The primary outcome is labor market participation during the first year after enrollment. Secondary outcomes include physical and mental health, health behaviors, and well-being, collected at baseline, 6, and 12 months. A cost-benefit analysis will also be conducted. Discussion: The SEED-trial is the first RCT to compare SE to TVR in this important and vulnerable group, at risk of being excluded from working life at an early age