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

Sykmeldtes jobbforventninger som prediktor for retur til jobb – en kunnskapsoppsummering med overføringsverdi til NAV

Denne rapporten er en kunnskapsoppsummering som omhandler jobbforventninger blant sykmeldte arbeidstakere. Vi har kartlagt og sammenstilt fagfellevurdert litteratur, publisert i perioden 2008–2024. Hensikten er å gjennomføre en systematisk gjennomgang av litteratur som omhandler sykmeldtes jobbforventninger. Overordnet undersøker vi om en persons jobbforventninger er en god prediktor for sykefraværets varighet og/eller personens retur til arbeid. Sekundært undersøker vi hvorvidt sykmeldtes jobbforventninger brukes inn i tiltak og i oppfølgingen av den sykmeldte. Den identifiserte litteraturen blir syntetisert og sammenstilt på en måte som gjør at kunnskapen har overføringsverdi til det utviklingsarbeidet som foregår i NAV knyttet til jobbforventninger. Dette perspektivet hensyntas både i hvordan resultatene sammenstilles og i drøftingen avslutningsvis.Sykmeldtes jobbforventninger som prediktor for retur til jobb – en kunnskapsoppsummering med overføringsverdi til NAVpublishedVersio

Workplace Inclusion of People With Health Issues, Immigrants, and Unemployed Youths—A Qualitative Study of Norwegian Leaders’ Experiences

Aim: To explore leaders’ perceptions and experiences of facilitators and barriers for successful workplace inclusion of immigrants, unemployed youths, and people who are outside the labor market due to health issues. Methods: Semi-structured individual interviews with 16 leaders who actively engaged in inclusion work, representing different occupations, were conducted. Systematic Text Condensation was used to structure the analysis. Results: The participating leaders emphasized that job match, including their perception of workers’ motivation, respect for workplace policies, and the availability of appropriate accommodation at the workplace, facilitated work inclusion. An active public support system providing professional and financial support to workers and leaders was also an important facilitating factor. The leaders emphasized that their perception of workers’ lack of motivation for the job was the most important barrier in their own hiring and inclusion engagement. Successful inclusion depended on all workers acknowledging responsibility for and contributing to an inclusive work environment. Being open and willing to discuss challenges was an important part of making the inclusion work. In addition, leadership qualities, such as empathy, patience, and a non-judgmental attitude, appeared as a hallmark among these leaders who actively engaged in inclusion work. Conclusion: Workplace inclusion of this population of marginalized people was facilitated by job match, mutual respect, commitment, and trust, as well as financial and practical support from the public support system. Leaders’ inclusion practices were furthermore affected by personal attitudes and perceptions of social responsibility. Even so, successful workplace inclusion was presented as a two-way street. Leaders have the main responsibility in initiating a respectful and trusting relationship, but both the worker and the leader needs to contribute to make the relationship thrive.Workplace Inclusion of People With Health Issues, Immigrants, and Unemployed Youths—A Qualitative Study of Norwegian Leaders’ ExperiencespublishedVersio

Fravær og nærvær blant bussjåfører – et forskningsprosjekt ut fra anbudsområder i Tide buss

Det overordnede målet med prosjektet er å få innsikt i sykefraværet i Tide Buss, for å gi de et utgangspunkt for å finne frem til gode tiltak for å redusere sykefraværet. Det ble gjennomført individuelle intervjuer med 22 sjåfører og fokusgruppeintervjuer med til sammen 23 ledere, tillitsvalgte og verneombud og representanter for BHT / HMS /HR. Studien viser at fravær og nærvær oppstår i et dynamisk samspill mellom rammebetingelsene satt av oppdragsgiver, organisasjon, ledelse og sjåførenes hverdag og erfaringer. Det var omforente forståelser av hva som bidrar til fravær og nærvær på tvers av informantgrupper, inklusive sjåfører og deres ledere. Funnene utfordrer vår forståelse av hvordan og på hvilket nivå sykefravær skal forebygges i denne bransjen.Fravær og nærvær blant bussjåfører – et forskningsprosjekt ut fra anbudsområder i Tide busspublishedVersio

Kartlegging av arbeidsmiljøarbeid i 74 barnehager

Formålet med dette kartleggingsprosjektet var å besvare følgende problemstilling: Hvordan har tiltakene i bransjeprogrammet bidratt til IA-avtalens mål om å bedre arbeidsmiljø, redusere sykefravær og hindre frafall på kort og lengre sikt? For å svare på dette benyttet vi en trianguleringsmetode der vi gjennomførte en spørreundersøkelse, intervjuet styrere og representanter fra partsgruppen, samt innhentet registerdata om sykefravær. Et overordnet funn er at bransjeprogrammet har medvirket til en bevisstgjøringsprosess der arbeidsmiljø, partssamarbeid og medarbeiderskap er blitt satt på dagsorden. Barnehagene har jobbet systematisk med prosesser knyttet til rolleavklaring, samarbeid, kulturbygging og holdningsarbeid i hele organisasjonen. De har fått tilgang til konkrete verktøy og metoder og det var spesielt motiverende å delta på erfaringskonferanse der de kunne få kunnskapspåfyll ved å lære av andres erfaringer.Kartlegging av arbeidsmiljøarbeid i 74 barnehagerpublishedVersio

Kunnskapsproduksjon med relevans for IA-avtalen 2019–2024 – en systematisering og oppsummering

Rapporten besvarer et oppdrag gitt av Arbeids- og velferdsdirektoratet med formål å oppsummere og systematisere kunnskapsproduksjon med relevans for inneværende IAavtaleperiode (2019–2024). Rapporten oppsummerer og sammenstiller 101 publikasjoner (56 fagfellevurderte artikler og 45 rapporter) som ble identifisert gjennom søk og screening etter fagfellevurdert litteratur og grå litteratur. Sammenstillingen viser at det i perioden er generert mye kunnskap om risikofaktorer. På samfunnsnivå synliggjør rapporten at IA-avtalen gjennom de ulike bransjeprogrammene har bidratt til å bedre forutsetningene for forebyggende arbeidsmiljøarbeid i de involverte virksomhetene. Innen rehabilitering / tilbakeføring er det fortsatt mye å hente i form av samhandling mellom de ulike aktørene og kvaliteten av denne samhandlingen. Sammenstillingen kan ikke si noe overordnet om hvorvidt den samlede aktiviteten i inneværende IA-periode har bidratt til redusert sykefravær og frafall. Til dette er tidsperspektivet for kort og det totale tallgrunnlaget i de inkluderte studiene for tynt.Kunnskapsproduksjon med relevans for IA-avtalen 2019–2024 – en systematisering og oppsummeringpublishedVersio

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