All 11 OPs who recruited employees participated in the interviews. Of the 15 OPs who did not recruit employees, eight participated in the interviews. Lack of time and personal considerations were reasons given for non-participation. We obtained registered user information for all 24 employees who used the program but only nine were available for an interview. Fifteen employees were unavailable for an interview even after several attempts had been made to reach them. Reasons for non-participation ranged from 'no time' to 'insufficient use of the program' and 'problems with recalling experiences'. The interviewed employee population consisted predominantly of men (67%) between 40 and 50 years suffering from low back pain (75%). Both white and blue collar workers with various levels of education were recruited. Sick leave duration due to back or neck pain including partial absenteeism ranged from seven weeks to six months.
Use of the program by OPs who recruited employees
Use of the program by OPs was low. Three of the 11 OPs never logged in to the website to follow the information or instructions. Five OPs signed in occasionally and only three did so regularly. Six of the 11 OPs tracked the employee's personal diary and read the employee reports based on the questionnaire data at least one time, which included specific recommendations for RTW and referral to secondary care. Only one OP used these recommendations in practice.
Use of the program by employees
Both the registered and actual use of the program was moderate among the employees. Registered data revealed that seven employees, out of 24 employees who used the program, filled in all four questionnaires. Another 12 filled in two or three questionnaires and the remaining five just one questionnaire. Ten employees opened less than 50% of the documents provided. Six employees opened between 50-75% of the documents, four employees opened almost all of them and four employees did indeed open them all. The majority (n = 7) of the nine interviewed employees reported that they read the provided documents sometimes or regularly and performed one or more of the exercises.
Appreciation of the program by OPs
Most OPs believed that the program is useful for employees. Some stressed that it would be most useful for employees who did not know how to cope with pain or were experiencing pain for the first time. Only half of the OPs indicated that the program had added value for themselves. Some OPs mentioned that the program offered additional support for them especially when an employee's recovery was making no progress. About half of the OPs indicated that a website is a good medium for the counselling of employees with back or neck pain. More than half of the OPs were positive about the content (e.g. information, exercises, instructions). It was suggested that the program could be useful as a reference source as it provides a good overview of information for OPs. It also supports the taking of systematic action. Finally, almost all OPs were positive about the user-friendliness and design of the program.
Appreciation of the program by employees
The majority of employees replied affirmatively to 'Did the program add value to the treatment of your back or neck pain?' Overall, employees experienced the program as a supportive tool. The program stimulated them to perform exercises at home, helped them give structure to their daily life and gave them the feeling that they could take an active approach to their pain and RTW process. Furthermore, employees felt their situation was gaining attention. They were positive about the content, user-friendliness and web-based design of the program. They said the information was easy to understand, to the point, and conveniently arranged. About half of the interviewed employees said that the program extended their knowledge of coping with pain and enhanced communication with their OP. A few employees reported that the program helped them to return to work faster.
Of all the available information, the neck and back exercises were appreciated the most. Some employees involved their physiotherapist in the RTW program. One discussed the exercises with his therapist. In contrast, other employees noted that the program was most useful when they received no additional treatment. The program was perceived as useful if employees lacked knowledge, were experiencing pain for the first time or had less severe pain. This outcome was supported by comments from the OPs.
Program usage barriers for OPs
Although about half of the OPs were positive about the added value, content and user-friendliness of the program, all encountered obstacles which limited their use of the program in actual practice. The greatest barrier for OPs was the low number of employees who met the inclusion criteria, especially for those who did not recruit employees. Several OPs mentioned that employees' fast recovery also had an impact on the low numbers involved. Furthermore, many employees were contacted later than the official term, about two weeks after the employee has become absent from work. By this stage employees may already be under treatment by their general practitioner or another therapist. Because of the low number of employees involved, OPs did not get round to using the program with any routine. As one OP said, 'It takes time to get used to the recruitment process and to using the program.' More than half of all OPs did not keep the program in mind during consultations and some had difficulty providing employees with accurate information about the program.
A second important barrier for OPs was the limited time available for introducing employees to the program and working with it as well. As another OP pointed out, 'We lack the time to do this kind of projects.' Several OPs mentioned that since they were already burdened by many administrative tasks they found the program more of an extra duty than something that offered added value. As well as these major barriers, OPs indicated other aspects which discouraged their use of the program. One OP explained that he was quite capable of managing the RTW process himself and did not need a program for additional support. Many preferred the more familiar therapies (e.g. physiotherapy) for their employees despite the fact that the program can work as a supportive tool. They preferred having personal contact with employees. One OP stated that he did not use the program because he did not believe in 'computer-based treatment' of physical pain. He explained, 'The ability to touch people is an essential element in the treatment of people with back or neck pain.' Some OPs had no affinity with the use of a web-based program in general and therefore preferred not to use this method. Finally, some OPs faced practical obstacles, such as log-in problems or no access to a computer or the internet in their consulting rooms.
Program usage barriers for employees
The greatest barrier for employees against using the program was the availability of other treatment such as physiotherapy, which involves personal contact. Employees perceived the program as less relevant because they were already getting exercises from their physiotherapist. For some employees the exercises suggested by the program conflicted with the exercises given by the physiotherapist. They felt that some exercises would be performed better after consultation with a physiotherapist. In addition, because some of the advice and exercises were not specific enough, they did not apply to the employee's situation. It was remarkable that almost no employees talked about the outcome of the program with their OPs. The program was not a subject of discussion during consultations; no OPs actually referred to the program. One employee said, 'I expected more commitment from my OP". This did not encourage employees to use the program. Only a few employees considered the large amount of information as a barrier. One employee mentioned that the back or neck pain they were suffering from may have prevented them from sitting at a computer. A small number of employees either had 'problems with logging in' into the program or had 'no affinity with computers'.
Improvements for OPs
Although OPs were generally positive about the user-friendliness and design of the program, some felt that further improving user-friendliness (functionality) might enhance its use. For example, it was suggested that it would be useful if the program was able to sort a list of employees in the same way as the OP's company system does. It should also be easier to register employees in the program. A helpdesk or some additional support would be helpful in case the OP had practical questions. Alternative tools, instead of the program, were also suggested. According to one OP, a website with a practical overview of information would be sufficient to satisfy the needs of OPs and employees. Some questioned whether the OP should be involved in the program at all. For example the direct supervisor or the physiotherapist might have a more prominent role in the promotion and use of the program. One OP mentioned the importance of focussing on the prevention of sick leave due to back or neck pain, in addition to focussing on the RTW process. This broader focus should not only be on sick leave prevention but also on how to work with pain. Additional content should be provided for this purpose. OPs also meet employees at an earlier stage, for example during an open consultation or during a general medical assessment. According to one OP, this would be a good starting point for recruiting employees to the program. OPs put forward that the direct supervisors should be more involved in the prevention of sick leave due to back or neck pain since their support is important.
Improvements for employees
A couple of employees mentioned the importance of customizing the advice to an employee's personal needs. Circumstances can change over time; therefore it is important that the advice fits the employee's current situation. Employees mentioned that a feedback function on the program would be helpful, which was also mentioned by OPs. For example, it would give the employee the opportunity to contact a professional by telephone or e-mail. According to one employee, a personal meeting a couple of weeks after the program is finished would be useful for evaluating recovery. It was suggested that combining hands-on treatment by a physiotherapist with the web-based counselling program would provide optimal support. Increasing the involvement of OPs or physiotherapists may stimulate employees to use the program. Employees also suggested other improvements related to the program content and user-friendliness (e.g. shortening the questionnaires and adding illustrations and cartoons). A link on the company website would also enhance use of the program. One employee felt that more attention should be paid to the psychological distress experienced by employees suffering from back or neck pain. He explained, 'I missed information on how to deal with it mentally.' Another employee felt that more attention should be paid to the prevention of sick leave due to back or neck pain. For example, preventive exercises could be made available on the company's website.
The perceived barriers and possible improvements of the program are summarized in table .
Overview of program usage barriers and possible improvements of the program