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

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

Prognostic factors for return to work, sickness benefits, and transitions between these states: A 4-year follow-up after work-related rehabilitation

Purpose The aim of this study was to examine if age, gender, medical diagnosis, occupation, and previous sick leave predicted different probabilities for being at work and for registered sickness benefits, and differences in the transitions between any of these states, for individuals that had participated in an interdisciplinary work-related rehabilitation program. Methods 584 individuals on long-term sickness benefits (mean 9.3 months, SD = 3.4) were followed with official register data over a 4-year period after a rehabilitation program. 66 % were female, and mean age was 44 years (SD = 9.3). The majority had a mental (47 %) or a musculoskeletal (46 %) diagnosis. 7 % had other diagnoses. Proportional hazards regression models were used to analyze prognostic factors for the probability of being on, and the intensity of transitions between, any of the following seven states during follow-up; working, partial sick leave, full sick leave, medical rehabilitation, vocational rehabilitation, partial disability pension (DP), and full DP. Results In a fully adjusted model; women, those with diagnoses other than mental and musculoskeletal, blue-collar workers, and those with previous long-term sick leave, had a lower probability for being at work and a higher probability for full DP during follow-up. DP was also associated with high age. Mental diagnoses gave higher probability for being on full sick leave, but not for transitions to full sick leave. Regression models based on transition intensities showed that risk factors for entering a given state (work or receiving sickness benefits) were slightly different from risk factors for leaving the same state. Conclusions The probabilities for working and for receiving sickness benefits and DP were dependent on gender, diagnoses, type of work and previous history of sick leave, as expected. The use of novel statistical methods to analyze factors predicting transition intensities have improved our understanding of how the processes to and from work, and to and from sickness benefits may differ between groups. Further research is required to understand more about differences in prognosis for return to work after intensive work-related rehabilitation efforts

Prognostic factors associated with return to work following multidisciplinary vocational rehabilitation

OBJECTIVES: The number of people in Western countries on long-term sick-leave and disability pension due to musculoskeletal complaints and psychological health problems is increasing. The main objective of this study was to examine whether fear-avoidance beliefs, illness perceptions, subjective health complaints, and coping are prognostic factors for return to work after multidisciplinary vocational rehabilitation, and to assess the relative importance and inter-relationship of these factors. METHODS: A prospective cohort study with a 1-year follow-up period was performed. A total of 135 individuals on long-term sick-leave (87 women, mean age 45 years) participated in a 4-week inpatient multidisciplinary vocational rehabilitation programme. The participants had been out of work for an average of 10.5 months. RESULTS: Fear-avoidance beliefs about work was the most important risk factor for not returning to work, both at 3 months (odds ratio (OR) 3.8; confidence interval (CI) 1.30–11.32) and 1 year (OR 9.5; CI 2.40–37.53) after the intervention. Forty-eight percent of the variance in fear-avoidance beliefs was explained by subjective health complaints, illness perceptions and education. Coping explained only 1% of the variance. CONCLUSION: These findings indicate that interventions for these patients should target fear of returning to work and illness perceptions about subjective health complaints

Causal inference in multi-state models–sickness absence and work for 1145 participants after work rehabilitation

Background Multi-state models, as an extension of traditional models in survival analysis, have proved to be a flexible framework for analysing the transitions between various states of sickness absence and work over time. In this paper we study a cohort of work rehabilitation participants and analyse their subsequent sickness absence using Norwegian registry data on sickness benefits. Our aim is to study how detailed individual covariate information from questionnaires explain differences in sickness absence and work, and to use methods from causal inference to assess the effect of interventions to reduce sickness absence. Examples of the latter are to evaluate the use of partial versus full time sick leave and to estimate the effect of a cooperation agreement on a more inclusive working life. Methods Covariate adjusted transition intensities are estimated using Cox proportional hazards and Aalen additive hazards models, while the effect of interventions are assessed using methods of inverse probability weighting and G-computation. Results Results from covariate adjusted analyses show great differences in sickness absence and work for patients with assumed high risk and low risk covariate characteristics, for example based on age, type of work, income, health score and type of diagnosis. Causal analyses show small effects of partial versus full time sick leave and a positive effect of having a cooperation agreement, with about 5 percent points higher probability of returning to work. Conclusions Detailed covariate information is important for explaining transitions between different states of sickness absence and work, also for patient specific cohorts. Methods for causal inference can provide the needed tools for going from covariate specific estimates to population average effects in multi-state models, and identify causal parameters with a straightforward interpretation based on interventions

Strategier og tiltak i distriktskommuner og påvirkning på unges etableringsvalg

Dette forprosjektet er utviklet i samarbeid med 3 distriktskommuner Modalen, Hyllestad og Luster med ambisjon om å bidra med kunnskap om hvilke faktorer som er avgjørende for unge menneskers valg om å bosette seg i distriktskommunene, sett fra kommunens og de unges perspektiv. De unge innbyggerne og kommunene vektla begge jobbmuligheter som avgjørende for unge menneskers valg om å bosette seg i distriktskommunene. Andre faktorer knyttet til bostedsattraktivitet var tilgang til bolig, økonomiske tilskuddsordninger og nærhet til naturen. Både konkurransedyktighet og et variert arbeidsmarked påvirker kommunenes attraktivitet. Likeledes kan kommunens eget særpreg løftes frem og avgjøre muligheten for vekst. Det er likevel slik at attraktivitet er en størrelse som stadig er i endring og som varierer med tiltak og utvikling i nærliggende kommuner og byer. Dette krever at kommunene evaluerer tiltak, følger med og evner å tenke nytt om egne virkemidler for å møte nye innbyggeres behov.Strategier og tiltak i distriktskommuner og påvirkning på unges etableringsvalgpublishedVersio

Strategier og tiltak i distriktskommuner og påvirkning på unges etableringsvalg

Dette forprosjektet er utviklet i samarbeid med 3 distriktskommuner Modalen, Hyllestad og Luster med ambisjon om å bidra med kunnskap om hvilke faktorer som er avgjørende for unge menneskers valg om å bosette seg i distriktskommunene, sett fra kommunens og de unges perspektiv. De unge innbyggerne og kommunene vektla begge jobbmuligheter som avgjørende for unge menneskers valg om å bosette seg i distriktskommunene. Andre faktorer knyttet til bostedsattraktivitet var tilgang til bolig, økonomiske tilskuddsordninger og nærhet til naturen. Både konkurransedyktighet og et variert arbeidsmarked påvirker kommunenes attraktivitet. Likeledes kan kommunens eget særpreg løftes frem og avgjøre muligheten for vekst. Det er likevel slik at attraktivitet er en størrelse som stadig er i endring og som varierer med tiltak og utvikling i nærliggende kommuner og byer. Dette krever at kommunene evaluerer tiltak, følger med og evner å tenke nytt om egne virkemidler for å møte nye innbyggeres behov

Multiple transitions in sick leave, disability benefits, and return to work. - A 4-year follow-up of patients participating in a work-related rehabilitation program

<p>Abstract</p> <p>Background</p> <p>Return to work (RTW) after long-term sick leave can be a long-lasting process where the individual may shift between work and receiving different social security benefits, as well as between part-time and full-time work. This is a challenge in the assessment of RTW outcomes after rehabilitation interventions. The aim of this study was to analyse the probability for RTW, and the probabilities of transitions between different benefits during a 4-year follow-up, after participating in a work-related rehabilitation program.</p> <p>Methods</p> <p>The sample consisted of 584 patients (66% females), mean age 44 years (sd = 9.3). Mean duration on various types of sick leave benefits at entry to the rehabilitation program was 9.3 months (sd = 3.4)]. The patients had mental (47%), musculoskeletal (46%), or other diagnoses (7%). Official national register data over a 4-year follow-up period was analysed. Extended statistical tools for multistate models were used to calculate transition probabilities between the following eight states; working, partial sick leave, full-time sick leave, medical rehabilitation, vocational rehabilitation, and disability pension; (partial, permanent and time-limited).</p> <p>Results</p> <p>During the follow-up there was an increased probability for working, a decreased probability for being on sick leave, and an increased probability for being on disability pension. The probability of RTW was not related to the work and benefit status at departure from the rehabilitation clinic. The patients had an average of 3.7 (range 0–18) transitions between work and the different benefits.</p> <p>Conclusions</p> <p>The process of RTW or of receiving disability pension was complex, and may take several years, with multiple transitions between work and different benefits. Access to reliable register data and the use of a multistate RTW model, makes it possible to describe the developmental nature and the different levels of the recovery and disability process.</p

Digital arbeidsrettet rehabilitering: En kvalitativ survey blant rehabiliteringsklinikker i Norge — basert på erfaringer etter korona

Undersøkelsen ble gjennomført i juni 2020 etter full eller delvis nedstenging fra 12. mars. Klinikker som hadde utviklet et digitalt oppfølgingstilbud startet opp igjen med tilpasset drift tidligere enn de som ikke hadde slikt tilbud. Digitale virkemidlet var videokonsultasjoner eller telefonsamtaler, enten som erstatning for eller supplement til fysisk oppmøte ved klinikken. Videomøte ble brukt i en-til-en konsultasjoner og i gruppe. Videomøte og telefonsamtale ble i større grad enn før pandemien brukt som kartlegging i forkant av fysisk rehabiliteringsopphold, for oppfølging av deltakeren samt i trekantsamtaler med eksterne aktører. Erfaringer blant ansatte var generelt positive mens det var blandede tilbakemeldinger fra deltakere. Relasjonsbygging, tillit og allianse var elementer som kunne være utfordrende faktorer digitalt, spesielt for sårbare brukergrupper