Return to work after long-term sick leave : barriers and facilitators

Abstract

Background: Musculoskeletal and psychiatric disorders are the dominating problems and disorders among people on long-term sick leave in all developed countries. From 1997 up to an all time high in 2002, there was a considerable increase in the number of people on long-term sick leave in Sweden.

Aim: The overall aim of this thesis was to investigate people on long-term sick leave in order to find factors that promote or hinder the return to work process.

Specific aims were: to describe the medical reasons for sick leave, the duration of the problems and of the ongoing spell of sickness absence, the rehabilitation support and the individuals’ own expectations of their future return to work (Study I); to investigate whether the predictions of people on long-term sick leave concerning their future RTW had an impact on their return to work (Study II); to describe the frequency of full, partial and no RTW after long-term sick leave, and to investigate the influence of psychosocial work conditions, work ability and health, reported before the onset of sick leave, on full and partial RTW respectively (Study III); to describe the experience of driving and implementing a workplace-based rehabilitation intervention with good access to rehabilitation measures, to find out which people multimodal and/or vocational rehabilitation was advocated for and to find predictors of return to work (Study IV).

Material and methods: All the studies included are sub-studies of the longitudinal HAKuL study (Work and Health in the Public Sector in Sweden), which was launched in 1999. The studies were conducted in four county councils and in local authorities in six municipalities in Sweden. Main occupational groups were registered nurses, assistant nurses, home-based personal care workers in elderly care, employees at childcare centres, administrative personnel, and teachers. The majority, 81%, were women. Study I is a cross-sectional descriptive study with an 18-month follow-up (Study II). Studies III-IV are longitudinal and conducted over a period of three years with a two-year follow-up.

Results - barriers and facilitators of the return to work: The perception of the individuals on long-term sick leave regarding their RTW had a very strong predictive value for real RTW (OR=8.28, 95% CI: 3.31 - 20.69). Other factors found that were predictive of return to work in Study II were: being aged between 45-54 years; having been on the sick list for less than one year; having less pain than those in the quartile with most pain; feeling welcome back to work. In Study III, predictive factors found for full RTW were: low job strain according to the model of Karasek and Theorell (low demands–high decision latitude); good general health before the onset of sick leave; physical and mental demands in balance with the individual’s capacity. Negative consequences of organisational changes gave decreased odds for full RTW. Predictive factors for partial RTW were low job strain and good general health. In the interventional study, Study IV, vocational rehabilitation, being under 45 years of age and low physical demands at work were found to be predictive of RTW.

Other results: Study I. Musculoskeletal and psychological/stress-related problems were, as expected, the most usual causes of long-term sickness absence for 90 days or longer. Combinations of symptoms and disorders were common. The women had experienced their symptoms for six years (median) before the start of their sickness absence and the men for seven years. Twenty-three percent of the women and 24% of the men did not feel welcome back to work. Personal contact and support by the regional social insurance officers were lacking for one third of the sick-listed people. Half of them had no contact with the occupational health service or the trade union. Study III. Two years after the onset of sick leave, 77% had returned to work, 62% full-time, 15% part-time, and 23% were still not working. Part of the full-time returners, 21%, had returned via a period of partial working time, while 41% had returned directly from full-time sick leave to full-time work. The proportion of partial RTW increased with age. Study IV. Problems were encountered at the beginning of the intervention. There were considerable obstacles in adapting the existing computerised personnel administrative systems to give a signal at 28 days of sick leave and the OHS sometimes had lack of resources. To counteract these problems the project organisation sent weekly reminder emails to the supervisors, the OHS were compensated at weak points, and feedback was given to those involved. After a check-up against the salary system, the decision was made to only include people with spells of sick leave of 90 days or more. Vocational rehabilitation was advocated for those with stress-related/psychological problems who were younger than 55 years of age. People with musculoskeletal problems had difficulties resuming work, despite the fact that they often received both multimodal and vocational rehabilitation.

Conclusion: The most important finding in this thesis is the impact of the sick-listed individuals’ own perception of their future RTW. Only one question is required and it is essential to find out if the answer is yes or no in order to tailor rehabilitation measures. Supervisors, OHSs and employers have important roles in detecting psychosocial work conditions at work in order to prevent long-standing work strain and long-term sick leave. It is of great importance that people with musculoskeletal problems are taken seriously early on. When they are finally on long-term sick leave, considerable efforts are needed to help them resume work. Vocational rehabilitation is a favourable treatment for people with stress- related/psychological problems. Part-time sick leave often functions as part of the rehabilitation process and can enhance full RTW. Interventions at workplaces are difficult to accomplish. The structures and efforts must be considered in advance.