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1.  Does feeling respected influence return to work? Cross-sectional study on sick-listed patients’ experiences of encounters with social insurance office staff 
BMC Public Health  2013;13:268.
Previous research shows that how patients perceive encounters with healthcare staff may affect their health and self-estimated ability to return to work. The aim of the present study was to explore long-term sick-listed patients’ encounters with social insurance office staff and the impact of these encounters on self-estimated ability to return to work.
A random sample of long-term sick-listed patients (n = 10,042) received a questionnaire containing questions about their experiences of positive and negative encounters and item lists specifying such experiences. Respondents were also asked whether the encounters made them feel respected or wronged and how they estimated the effect of these encounters on their ability to return to work. Statistical analysis was conducted using 95% confidence intervals (CI) for proportions, and attributable risk (AR) with 95% CI.
The response rate was 58%. Encounter items strongly associated with feeling respected were, among others: listened to me, believed me, and answered my questions. Encounter items strongly associated with feeling wronged were, among others: did not believe me, doubted my condition, and questioned my motivation to work. Positive encounters facilitated patients’ self-estimated ability to return to work [26.9% (CI: 22.1-31.7)]. This effect was significantly increased if the patients also felt respected [49.3% (CI: 47.5-51.1)]. Negative encounters impeded self-estimated ability to return to work [29.1% (CI: 24.6-33.6)]; when also feeling wronged return to work was significantly further impeded [51.3% (CI: 47.1-55.5)].
Long-term sick-listed patients find that their self-reported ability to return to work is affected by positive and negative encounters with social insurance office staff. This effect is further enhanced by feeling respected or wronged, respectively.
PMCID: PMC3623723  PMID: 23522034
Encounters; Ethics; Long-term sickness absentees; Return to work; Social insurance office staff; Sweden
2.  Losing independence – the lived experience of being long-term sick-listed 
BMC Public Health  2013;13:745.
Sickness absence is a multifaceted problem. Much is known about risk factors for being long-term sick-listed, but there is still little known about the various aftermaths and experiences of it. The aim of this qualitative study was to describe, analyze and understand long-term sickness-absent people’s experiences of being sick-listed.
The design was descriptive and had a phenomenological approach. Sixteen long-term sickness-absent individuals were purposively sampled from three municipalities in Sweden in 2011, and data were collected through semi-structured, individual interviews. The interview questions addressed how the participants experienced being sick-listed and how the sick-listing affected their lives. Transcribed interviews were analysed using Giorgi's phenomenological method.
The interviews revealed that the participants’ experiences of being sick-listed was that they lost their independence in the process of stepping out of working society, attending the mandatory steps in the rehabilitation chain and having numerous encounters with professionals. The participants described that their life-worlds were radically changed when they became sick-listed. Their experiences of their changing life-worlds were mostly highly negative, but there were also a few positive experiences. The most conspicuous findings were the fact that stopping working brought with it so many changes, the participants’ feelings of powerlessness in the process, and their experiences of offensive treatment by and/or encounters with professionals.
Sick-listed persons experienced the process of being on long-term sickness absent as very negative. The negative experiences are linked to consequences of stopping to work, consequences of social insurance rules and to negative encounters with professionals handling the sickness absence. The positive experiences of being sick-listed were few in the present study. There is a need to further examine the extent of these negative experiences are and how they affect sick-listed people’s recovery and return to work. Long-term sickness absence; sick leave; experiences; interviews; phenomenology; Sweden.
PMCID: PMC3751439  PMID: 23938128
3.  Expectations for Recovery Important in the Prognosis of Whiplash Injuries 
PLoS Medicine  2008;5(5):e105.
Individuals' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations. The role of expectations in recovery from traumatic neck pain, in particular whiplash-associated disorders (WAD), has not been assessed to date to our knowledge. The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD.
Methods and Findings
We used a prospective cohort study composed of insurance claimants in Sweden. The participants were car occupants who filed a neck injury claim (i.e., for WAD) to one of two insurance companies between 15 January 2004 and 12 January 2005 (n = 1,032). Postal questionnaires were completed shortly (average 23 d) after the collision and then again 6 mo later. Expectations for recovery were measured with a numerical rating scale (NRS) at baseline, where 0 corresponds to “unlikely to make a full recovery” and 10 to “very likely to make a full recovery.” The scale was reverse coded and trichotomised into NRS 0, 1–4, and 5–10. The main outcome measure was self-perceived disability at 6 mo postinjury, measured with the Pain Disability Index, and categorised into no/low, moderate, and high disability. Multivariable polytomous logistic regression was used for the analysis. There was a dose response relationship between recovery expectations and disability. After controlling for severity of physical and mental symptoms, individuals who stated that they were less likely to make a full recovery (NRS 5–10), were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery (odds ratio [OR] 4.2 [95% confidence interval (CI) 2.1 to 8.5]. For the intermediate category (NRS 1–4), the OR was 2.1 (95% CI 1.2 to 3.2). Associations between expectations and disability were also found among individuals with moderate disability.
Individuals' expectations for recovery are important in prognosis, even after controlling for symptom severity. Interventions designed to increase patients' expectations may be beneficial and should be examined further in controlled studies.
Lena Holm and colleagues show that in people who had a whiplash injury after a car crash there was an association between expectation of disability and actual disability six months later.
Editors' Summary
The disability associated with injury is a major source of distress for patients, and can be costly to the health care system and employers when persons fail to recover quickly and are unable to return to work. Finding ways to help people recover quickly and get back to optimal health is important. Some of the most common injuries causing disability and time off work result from whiplash—the sudden hyperextension or “whipping” of the neck, which can occur from a motor vehicle crash. It has long been recognized that psychological factors (such as the ability to cope, how “in control” one feels about one's life) are as important as physical symptoms in how disabling an injury can be. There is now growing evidence that a person's feelings about their ability to recover from injury plays a part in actual recovery. Studies from Europe and North America have shown with conditions like low back pain and minor head injury that a patient's feelings about the possibility of getting better are related to how well they do. Less is known about how important these psychological factors are in recovery from disorders due to whiplash associated disorders.
Why Was This Study Done?
The authors wanted to find out whether there was a relationship between people's expectations for their recovery from whiplash associated disorders and their actual recovery six months later. So, for example, they wondered if a person with whiplash who felt they were very unlikely to recover from their injury, actually did not recover (and vice versa).
What Did the Researchers Do and Find?
The authors had access to an unusual set of health information—insurance claims by people who had been involved in car collisions to two insurance companies in Sweden. They identified about 1,000 adult insurance claimants over one year and mailed them a questionnaire that asked for details about the collision as well as information about the claimant: their demographic profile, health history, and the types of pain and symptoms experienced since the crash. The questionnaire also asked the claimant how likely they thought they were to make a full recovery from their injuries.
For those who said they had whiplash associated disorders, the authors followed up with another questionnaire six months later, which asked for information about any disability, pain, or other symptoms that the claimant was still experiencing because of the injury. Of those who had completed the first questionnaire, 82% were followed up.
Only about a quarter of claimants with whiplash associated disorders said they expected to make a full recovery. Perhaps not surprisingly, those with only mild pain, compared to those with intense pain, were more likely to think so. Persons who said they were less likely to make a full recovery were four times more likely to report high levels of disability six months later. Even for persons (or individuals) people with moderate levels of disability six months after injury, their expectations for recovery were similarly linked to how well they did: the lower the expectations for recovery, the higher the disability. These findings were true even after taking into account how severe signs and symptoms the person had, and how well the person was coping psychologically.
What Do These Findings Mean?
The findings indicate that those with the lowest expectations for recovery after their whiplash injury will have the poorest recovery, and those with the highest expectations will have the best recovery. They also suggest that a patient's expectations about getting better are as important as his or her physical symptoms. The authors say that the more we can influence patients to believe they will make a full recovery, the better chance they will have to recover completely. This means that it may be beneficial for healthcare providers to give support and/or education to patients with whiplash associated disorders that increases their positive feelings toward recovery. The authors call for more studies into whether these types of targeted interventions would be of benefit.
Additional Information
Please access these Web sites via the online version of this summary at
Information about research on injuries and rehabilitation can be found at the Web sites of organisations devoted to studying the health of workers, such as the Institute for Work and Health in Canada, the Finnish Institute of Occupational Health, and the US National Institute for Occupational Safety and Health
The Wikipedia entry for medical aspects of whiplash describes the four grades of whiplash disorder, but does not cover the debate about the credibility of whiplash disorder (please note that Wikipedia is an online encyclopedia that anyone can edit)
The Sjukvardsradgivningen Web site provides information about whiplash-related disorders, common signs and symptoms, recovery and prognosis, and treatments (in Swedish)
PMCID: PMC2375948  PMID: 18479182
4.  What factors are most relevant to the assessment of work ability of employees on long-term sick leave? The physicians’ perspective 
To reach insurance physician (IPs) consensus on factors that must be taken into account in the assessment of the work ability of employees who are sick-listed for 2 years.
A Delphi study using online questionnaires was conducted from October 2010 to March 2011.
One hundred and two insurance physicians reached a consensus on important factors for return to work (RTW) of employees on long-term sick leave; from those factors, the most relevant for the assessment of work ability was determined. From a total of 22 relevant factors considered for the return to work of long-term sick-listed employees, consensus was reached on nine relevant factors that need to be taken into account in the assessment of the work ability of employees on long-term sick leave. Relevant factors that support return to work are motivation, attitude towards RTW, assessment of cognitions and behaviour, vocational rehabilitation in an early stage and instruction for the sick-listed employee to cope with his disabilities. Relevant factors that hinder RTW are secondary gain from illness, negative perceptions of illness, inefficient coping style and incorrect advice of treating physicians regarding RTW.
Non-medical personal and environmental factors may either hinder or promote RTW and must be considered in the assessment of the work ability of long-term sick-listed employees. Assessment of work ability should start early during the sick leave period. These factors may be used by IPs to improve the quality of the assessment of the work ability of employees on long-term sick leave.
PMCID: PMC3679417  PMID: 22622322
Long-term sick leave; Sick-listed employees; Work ability assessment; Physicians’ perspective; Disability assessment
5.  The return-to-work process of individuals sick-listed because of whiplash-associated disorder: a three-year follow-up study in a Danish cohort of long-term sickness absentees 
BMC Public Health  2014;14:113.
The chronic course of whiplash-associated disorder (WAD) has implications for both the individual and society. It has been shown that up to 50% of patients have not yet returned to work six months after a whiplash injury. We wanted to study the return-to-work (RTW) process in individuals sick-listed for more than eight weeks in six Danish municipalities. RTW in individuals sick-listed due to WAD was compared to that in those sick-listed for other musculoskeletal disorders (MSD).
Information about long-term sick-listed individuals in six Danish municipalities was retrieved from an existing database. Data on public transfer income were collected and the RTW process was followed on a weekly basis. Multivariate logistic regression analysis of RTW was done four times during the first three years after the start of sick-listing.
One hundred and four individuals were sick-listed due to WAD and 3,204 individuals were sick-listed due to other MSDs. After 6 months, the RTW was significantly lower in the WAD group. OR for RTW in the WAD group was 0.29 (0.18–0.49) compared to the MSD group. The RTW process for both groups stabilised after two years of follow-up; 44% returned to work in the WAD group as compared to 58% in the MSD group.
Sick-listed individuals with whiplash-associated disorder are less likely to return to work than individuals who are sick-listed because of other musculoskeletal disorders. In both groups, RTW stabilised after two years of follow-up.
PMCID: PMC3922863  PMID: 24495801
Return to work; Whiplash; Whiplash-associated disorder; Musculoskeletal disorders; Long-term sickness absence; Prognosis; Public transfer income
6.  Prognostic Factors for the Work Participation of Sick-Listed Unemployed and Temporary Agency Workers with Psychological Problems 
Introduction Among the working population, unemployed and temporary agency workers are a particularly vulnerable group, at risk for sickness absence due to psychological problems. Knowledge of prognostic factors for work participation could help identify sick-listed workers with a high-risk for work disability and provide input for sickness absence counseling. The purpose of this study was to identify prognostic factors for the work participation of medium- and long-term sick-listed unemployed and temporary agency workers with psychological problems. Methods A cohort of 932 sick-listed unemployed and temporary agency workers with psychological problems was followed for one and a half years. Data collection was conducted at three time-frames: 10 months, 18 months and 27 months after reporting sick. Univariate and multiple logistic regression analyses were performed. Results Perceived health, full return-to-work (RTW) expectations, age and work status at 18 months were strong prognostic factors for work participation at subsequent time-frames in the univariate analyses. Multiple logistic regression revealed that full RTW expectation was a prognostic factor for future work participation in both the medium- and long-term, whereas moderate-to-good perceived health was a prognostic factor for work participation in the medium-term. Being under 45 years of age and having a positive work status at 18 months were prognostic factors for work participation in the long-term. Conclusions Workers’ self-appraisal of health, age and work status were strong prognostic factors for the future work participation of sick-listed unemployed and temporary agency workers with psychological problems. These findings could help occupational and insurance physicians identify high-risk sick-listed workers for sickness absence counseling.
PMCID: PMC3484312  PMID: 22481379
Unemployment; Participation; Psychological problems; Prognostic factors; Vocational rehabilitation
7.  Work and family: associations with long-term sick-listing in Swedish women – a case-control study 
BMC Public Health  2007;7:287.
The number of Swedish women who are long-term sick-listed is high, and twice as high as for men. Also the periods of sickness absence have on average been longer for women than for men. The objective of this study was to investigate the associations between factors in work- and family life and long-term sick-listing in Swedish women.
This case-control study included 283 women on long-term sick-listing ≥90 days, and 250 female referents, randomly chosen, living in five counties in Sweden. Bivariate and multivariate logistic regression analyses with odds ratios were calculated to estimate the associations between long-term sick-listing and factors related to occupational work and family life.
Long-term sick-listing in women is associated with self-reported lack of competence for work tasks (OR 2.42 1.23–11.21 log reg), workplace dissatisfaction (OR 1.89 1.14–6.62 log reg), physical workload above capacity (1.78 1.50–5.94), too high mental strain in work tasks (1.61 1.08–5.01 log reg), number of employers during work life (OR 1.39 1.35–4.03 log reg), earlier part-time work (OR 1.39 1.18–4.03 log reg), and lack of influence on working hours (OR 1.35 1.47–3.86 log reg). A younger age at first child, number of children, and main responsibility for own children was also found to be associated with long-term sick-listing. Almost all of the sick-listed women (93%) wanted to return to working life, and 54% reported they could work immediately if adjustments at work or part-time work were possible.
Factors in work and in family life could be important to consider to prevent women from being long-term sick-listed and promote their opportunities to remain in working life. Measures ought to be taken to improve their mobility in work life and control over decisions and actions regarding theirs lives.
PMCID: PMC2151941  PMID: 17931411
8.  Expectations, perceptions, and physiotherapy predict prolonged sick leave in subacute low back pain 
Brief intervention programs for subacute low back pain (LBP) result in significant reduction of sick leave compared to treatment as usual. Although effective, a substantial proportion of the patients do not return to work. This study investigates predictors of return to work in LBP patients participating in a randomized controlled trial comparing a brief intervention program (BI) with BI and physical exercise.
Predictors for not returning to work was examined in 246 patients sick listed 8-12 weeks for low back pain. The patients had participated in a randomized controlled trial, with BI (n = 122) and BI + physical exercise (n = 124). There were no significant differences between the two intervention groups on return to work. The groups were therefore merged in the analyses of predictors. Multiple logistic regression analysis was used to identify predictors for non return to work at 3, 12, and 24 months of follow-up.
At 3 months of follow-up, the strongest predictors for not returning to work were pain intensity while resting (OR = 5.6; CI = 1.7-19), the perception of constant back strain when working (OR = 4.1; CI = 1.5-12), negative expectations for return to work (OR = 4.2; CI = 1.7-10), and having been to a physiotherapist prior to participation in the trial (OR = 3.3; CI = 1.3-8.3). At 12 months, perceived reduced ability to walk far due to the complaints (OR = 2.6; CI = 1.3-5.4), pain during activities (OR = 2.4; CI = 1.1-5.1), and having been to a physiotherapist prior to participation in the trial (OR = 2.1; CI = 1.1-4.3) were the strongest predictors for non return to work. At 24 months age below 41 years (OR = 2.9; CI = 1.4-6.0) was the only significant predictor for non return to work.
It appears that return to work is highly dependant on individual and cognitive factors. Patients not returning to work after the interventions were characterized by negative expectations, perceptions about pain and disability, and previous physiotherapy treatment. This is the first study reporting that previous treatment by physiotherapists is a risk factor for long-term sick leave. This has not been reported before and is an interesting finding that deserves more scrutiny.
PMCID: PMC2780378  PMID: 19912626
9.  A Cluster-Randomised Trial Evaluating an Intervention for Patients with Stress-Related Mental Disorders and Sick Leave in Primary Care 
PLoS Clinical Trials  2007;2(6):e26.
Mental health problems often affect functioning to such an extent that they result in sick leave. The worldwide reported prevalence of mental health problems in the working population is 10%–18%. In developed countries, mental health problems are one of the main grounds for receiving disability benefits. In up to 90% of cases the cause is stress-related, and health-care utilisation is mainly restricted to primary care. The aim of this study was to assess the effectiveness of our Minimal Intervention for Stress-related mental disorders with Sick leave (MISS) in primary care, which is intended to reduce sick leave and prevent chronicity of symptoms.
Cluster-randomised controlled educational trial.
Primary health-care practices in the Amsterdam area, The Netherlands.
A total of 433 patients (MISS n = 227, usual care [UC] n = 206) with sick leave and self-reported elevated level of distress.
Forty-six primary care physicians were randomised to either receive training in the MISS or to provide UC. Eligible patients were screened by mail.
Outcome Measures:
The primary outcome measure was duration of sick leave until lasting full return to work. The secondary outcomes were levels of self-reported distress, depression, anxiety, and somatisation.
No superior effect of the MISS was found on duration of sick leave (hazard ratio 1.06, 95% confidence interval 0.87–1.29) nor on severity of self-reported symptoms.
We found no evidence that the MISS is more effective than UC in our study sample of distressed patients. Continuing research should focus on the potential beneficial effects of the MISS; we need to investigate which elements of the intervention might be useful and which elements should be adjusted to make the MISS effective.
Editorial Commentary
Background: People who take sick leave from work as a result of mental health problems very often report that the cause is stress-related. Although stress-related sick leave imposes a significant burden on individuals and economies, few evidence-based therapies exist to prevent sick leave in people who are experiencing stress-related mental health problems. The researchers carrying out this study wanted to evaluate the effectiveness of an intervention for stress-related mental health disorders amongst people who had been on sick leave for less than three months. The intervention involved short training sessions for primary health-care practitioners, during which the practitioners were taught how to diagnose stress-related problems; how to provide information to patients and encourage their recovery and active return to work; and how to give advice and monitor patients' recovery. The researchers carried out a cluster-randomized trial evaluating this training program, in which 46 primary care practitioners were assigned by chance to receive either the training program or to practice usual care. Over the course of the trial, 433 patients with elevated levels of distress and sick leave were included in the study, 227 of whom were treated by practitioners receiving the training program and 206 of whom received usual care. These patients were followed up for 12 months and the primary outcome studied in the trial was the length of sick leave taken until full return to work. Secondary outcome measures included patients' reports of distress, depression, and other symptoms as recorded using specific questionnaires.
What the trial shows: In the trial, data on the primary outcome measure was available for 87% of the patients treated by practitioners receiving the training intervention and 84% of the patients receiving usual care. When these outcomes were analyzed, there was no evidence of a benefit of the training program on amount of sick leave taken. Over the course of the study, the severity of patients' self-reported symptoms fell in both groups, but there was no significant difference in symptom severity between the two groups of patients. A subgroup analysis suggested that more practitioners in the intervention group recognized patients as having stress-related mental health problems. Among the group of patients who were diagnosed as having stress-related mental health problems, those who were treated by practitioners in the intervention group seemed to return to work slightly more quickly than those in the usual care group. However, it is not easy to interpret the findings of this secondary analysis.
Strengths and limitations: Strengths of this study include the procedures for cluster randomization, in which primary care practitioners were randomized, rather than patients. This process ensures that only patients assigned to the intervention arm receive the benefits of the intervention, and avoids “contamination” between intervention and control groups. A further strength includes the blinding of researchers who were collecting data to the intervention that each practitioner had received. The findings of the study, however, are difficult to interpret. No effect of the training intervention was found on the study's primary outcome measure; it is possible that the training intervention does indeed have some benefit, but the benefit may not have been found in this particular trial because of the inclusion of patients with a very wide range of problems; in addition the practitioners may have not had the time or ability to apply what they learnt in the training program.
Contribution to the evidence: Very little evidence exists regarding the effects of training interventions for improving care of patients with stress-related mental health problems. The findings of this trial support those of another study carried out in a primary care setting, which found that training interventions do not seem to reduce length of sick leave. However, another study carried out in an occupational health-care setting, in which patients included in the trial had been recognised as having stress-related mental disorders, did find some benefit of an intervention program.
PMCID: PMC1885369  PMID: 17549228
10.  Increased Risk of Long-Term Sickness Absence, Lower Rate of Return to Work, and Higher Risk of Unemployment and Disability Pensioning for Thyroid Patients: A Danish Register-Based Cohort Study 
Little is known about how thyroid diseases affect work ability.
The objective of this study was to evaluate the risk of work disability for patients with thyroid disease compared with the general population.
Design, Setting, and Participants:
In a longitudinal register study, outpatients (n = 862) with nontoxic goiter, hyperthyroidism, Graves' orbitopathy (GO), autoimmune hypothyroidism, or other thyroid diseases and their matched controls (n = 7043) were observed in the years 1994–2011 in Danish national registers of social benefits, health, and work characteristics. Cox regression analyses estimated adjusted hazard ratios (HRs) for the first year after diagnosis and subsequent years.
Main Outcome Measures:
Transitions between work, long-term sickness absence, unemployment, and disability pension were measured.
Patients differed significantly from the general population with regard to sickness absence, disability pension, return from sickness absence, and unemployment. In the first year after diagnosis, higher risks of sickness absence was seen for GO (HR 6.94) and other hyperthyroid patients (HR 2.08), who also had lower probability of returning from sickness absence (HR 0.62) and higher risk of disability pension (HR 4.15). Patients with autoimmune hypothyroidism showed a lower probability of returning from sickness absence (HR 0.62). In subsequent years, GO patients had significantly higher risk of sickness absence (HR 2.08), lower probability of return from sickness absence (HR 0.51), and unemployment (HR 0.52) and a higher risk of disability pension (HR 4.40). Hyperthyroid patients also had difficulties returning from sickness absence (HR 0.71).
Thyroid patients' risk of work disability is most pronounced in the first year after diagnosis and attenuates in subsequent years. GO patients have the highest risk of work disability.
PMCID: PMC4207932  PMID: 24937367
11.  Subacute and chronic, non-specific back and neck pain: cognitive-behavioural rehabilitation versus primary care. A randomized controlled trial 
In the industrial world, non-specific back and neck pain (BNP) is the largest diagnostic group underlying sick-listing. For patients with subacute and chronic (= full-time sick-listed for 43 – 84 and 85 – 730 days, respectively) BNP, cognitive-behavioural rehabilitation was compared with primary care. The specific aim was to answer the question: within an 18-month follow-up, will the outcomes differ in respect of sick-listing and number of health-care visits?
After stratification by age (≤ 44/≥ 45 years) and subacute/chronic BNP, 125 Swedish primary-care patients were randomly allocated to cognitive-behavioural rehabilitation (rehabilitation group) or continued primary care (primary-care group). Outcome measures were Return-to-work share (percentage) and Return-to-work chance (hazard ratios) over 18 months, Net days (crude sick-listing days × degree), and the number of Visits (to physicians, physiotherapists etc.) over 18 months and the three component six-month periods. Descriptive statistics, Cox regression and mixed-linear models were used.
All patients: Return-to-work share and Return-to-work chance were equivalent between the groups. Net days and Visits were equivalent over 18 months but decreased significantly more rapidly for the rehabilitation group over the six-month periods (p < .05). Subacute patients: Return-to-work share was equivalent. Return-to-work chance was significantly greater for the rehabilitation group (hazard ratio 3.5 [95%CI1.001 – 12.2]). Net days were equivalent over 18 months but decreased significantly more rapidly for the rehabilitation group over the six-month periods and there were 31 days fewer in the third period. Visits showed similar though non-significant differences and there were half as many in the third period. Chronic patients: Return-to-work share, Return-to-work chance and Net days were equivalent. Visits were equivalent over 18 months but tended to decrease more rapidly for the rehabilitation group and there were half as many in the third period (non-significant).
The results were equivalent over 18 months. However, there were indications that cognitive-behavioural rehabilitation in the longer run might be superior to primary care. For subacute BNP, it might be superior in terms of sick-listing and health-care visits; for chronic BNP, in terms of health-care visits only. More conclusive results concerning this possible long-term effect might require a longer follow-up.
Trial registration
PMCID: PMC2649916  PMID: 19116007
12.  Early coordinated multidisciplinary intervention to prevent sickness absence and labour market exclusion in patients with low back pain: study protocol of a randomized controlled trial 
Musculoskeletal disorders account for one third of the long-term absenteeism in Denmark and the number of individuals sick listed for more than four weeks is increasing. Compared to other diagnoses, patients with musculoskeletal diseases, including low back pain, are less likely to return to work after a period of sick leave. It seems that a multidisciplinary intervention, including cooperation between the health sector, the social sector and in the work place, has a positive effect on days off work due to musculoskeletal disorders and particularly low back pain. It is a challenge to coordinate this type of intervention, and the implementation of a return-to-work (RTW)-coordinator is suggested as an effective strategy in this process. The purpose of this paper is to describe the study protocol and present a new type of intervention, where the physiotherapist both has the role as RTW-coordinator and treating the patient.
A randomized controlled trial (RCT) is currently on-going. The RCT includes 770 patients with low back pain of minimum four weeks who are referred to an outpatient back centre. The study population consists of patients, who are sick-listed or at risk of sick-leave due to LBP. The control group is treated with usual care in a team of a physiotherapist, a chiropractor, a rheumatologist and a social worker employed at the centre. The Intervention group is treated with usual care and in addition intervention of a psychologist, an occupational physician, an ergonomist, a case manager from the municipal sickness benefit office, who has the authority in the actual case concerning sickness benefit payment and contact to the patients employer/work place. The treating physiotherapist is the RTW-coordinator. Outcome will be reported at the end of treatment as well as 6 and 12 months follow up. The primary outcome is number of days off work. Secondary outcomes are disability, pain, and quality of life. The study will follow the recommendations in CONSORT-statement in designing and reporting RCTs.
This large RCT is testing the effectiveness of a preventive intervention targeting patients on short term sick leave or at risk being sick listed because of low back pain. We have developed a novel multidisciplinary team structure using the treating physiotherapist as the return to work coordinator, and having the case manager from the municipal sickness benefit office participating in team meetings. The study has the potential to contribute to the knowledge about how to target the challenges in the treatment of LBP. The aim is to prevent sickness absence and labour market exclusion - both on the individual level and economic costs at community level. Short term results will be available in 2014.
This study is approved by the Danish Regional Ethics Committee ( H-C-2008-112) and is registered at.
Trial registration NCT01690234
PMCID: PMC3606127  PMID: 23496897
Low back pain (LBP); Return to work (RTW); Sickness absence; Rehabilitation; Prevention; Multidisciplinary intervention; Coordination; Denmark
13.  How do Workers with Common Mental Disorders Experience a Multidisciplinary Return-to-Work Intervention? A Qualitative Study 
Purpose Long-term sick leave due to common mental disorders (CMD) is an increasing problem in many countries. Recent reviews indicate that return to work (RTW) interventions have limited effect on reducing sickness absence among this group of sick-listed. The aims of this study were to investigate how sick-listed persons with CMD experienced participating in an RTW intervention and how workability assessments and RTW activities influenced their RTW-process, and to examine the working mechanisms of the intervention. The gained knowledge can help improve future RTW intervention design and implementation. Methods In-depth interviews were conducted with 17 participants on sick leave due to CMD who participated in an RTW intervention. Interviews were conducted at three time points with each participant. Principles of interpretative phenomenological analyses guided the analysis. Results The workability assessment consultations and RTW activities such as psychoeducative group sessions and individual sessions with psychologist could result in both motivation and frustration depending on the extent to which the RTW professionals practiced what we have termed an individual approach to the sick-listed person. Conclusions The individual approach seems necessary for the realization of the positive potential in the RTW intervention. However, the fact that RTW professionals are both the facilitators and the controllers of the sick-listed persons’ RTW process is an inherent paradox in the intervention, which can impede the necessary establishment of a high-quality relationship between the sick-listed persons and RTW professionals.
PMCID: PMC4229648  PMID: 24532340
Sick leave; Mental disorders; Intervention; Rehabilitation; Return to work; Qualitative research
14.  Undetected Common Mental Disorders in Long-Term Sickness Absence 
Background. Undetected Common Mental Disorders (CMDs) amongst people on sick leave complicate rehabilitation and return to work because appropriate treatments are not initiated. Aims. The aim of this study is to estimate (1) the frequencies of CMD, (2) the predictors of undetected CMD, and (3) the rate of return to work among sick listed individuals without a psychiatric disorder, who are registered on long-term sickness absence (LSA). Methods. A total of 2,414 incident individuals on LSA with a response rate of 46.4%, were identified for a two-phase study. The subsample of this study involved individuals registered on LSA who were sick-listed without a psychiatric sick leave diagnosis. In this respect, Phase 1 included 831 individuals, who were screened for mental disorders. In Phase 2, following the screening of Phase 1, 227 individuals were thoroughly examined by a psychiatrist applying Present State Examination. The analyses of the study were carried out based on the 227 individuals from Phase 2 and, subsequently, weighted to be representative of the 831 individuals in Phase 1. Results. The frequencies of undetected mental disorders among all sick-listed individuals were for any psychiatric diagnosis 21%, depression 14%, anxiety 4%, and somatoform disorder 6%. Conclusions. Undetected CMD may delay the initiation of appropriate treatment and complicate the rehabilitation and return to work.
PMCID: PMC3361179  PMID: 22666588
15.  Risk factors for sickness absence due to low back pain and prognostic factors for return to work in a cohort of shipyard workers 
European Spine Journal  2008;17(9):1185-1192.
The purpose of this study was to determine risk factors for the occurrence of sickness absence due to low back pain (LBP) and to evaluate prognostic factors for return to work. A longitudinal study with 1-year follow-up was conducted among 853 shipyard workers. The cohort was drawn around January 2004 among employees in the shipyard industry. Baseline information was obtained by questionnaire on physical and psychosocial work load, need for recovery, perceived general health, musculoskeletal complaints, sickness absence, and health care use during the past year. During the 1-year follow-up for each subject medical certifications were retrieved for information on the frequency and duration of spells of sickness absence and associated diagnoses. Cox regression analyses were conducted on occurrence and on duration of sickness absence with hazard ratios (HR) with 95% confidence interval (95% CI) as measure of association. During the 1-year follow-up period, 14% of the population was on sick leave at least once with LBP while recurrence reached 41%. The main risk factors for sickness absence were previous absence due to a health problem other than LBP (HR 3.07; 95%CI 1.66–5.68) or previous sickness absence due to LBP (HR 6.52; 95%CI 3.16–13.46). Care seeking for LBP and lower educational level also hold significant influences (HR 2.41; 95%CI 1.45–4.01 and HR 2.46; 95%CI 1.19–5.07, respectively). Living with others, night shift and supervising duties were associated with less absenteeism due to LBP. Workers with a history of herniated disc had a significantly decreased rate of returning to work, whereas those who suffered from hand-wrist complaints and LBP returned to work faster. Prior sick leave due to LBP partly captured the effects of work-related physical and psychosocial factors on occurrence of sick leave. Our study showed that individual and job characteristics (living alone, night shift, lower education, sick leave, or care seeking during the last 12 months) influenced the decision to take sick leave due to LBP. An increased awareness of those frequently on sick leave and additional management after return to work may have a beneficial effect on the sickness absence pattern.
PMCID: PMC2527417  PMID: 18649089
Low back pain; Sick leave; Prognosis; Recurrence; Return to work
16.  Efficacy of ‘Tailored Physical Activity’ or ‘Chronic Pain Self-Management Program’ on return to work for sick-listed citizens: design of a randomised controlled trial 
BMC Public Health  2013;13:66.
Pain affects quality of life and can result in absence from work. Treatment and/or prevention strategies for musculoskeletal pain-related long-term sick leave are currently undertaken in several health sectors. Moreover, there are few evidence-based guidelines for such treatment and prevention. The aim of this study is to evaluate the efficacy of ‘Tailored Physical Activity’ or ‘Chronic Pain Self-Management Program’ for sick-listed citizens with pain in the back and/or the upper body.
This protocol describes the design of a parallel randomised controlled trial on the efficacy of ‘Tailored Physical Activity’ or a ‘Chronic Pain Self-management Program’ versus a reference group for sick-listed citizens with complaints of pain in the back or upper body. Participants will have been absent from work due to sick-listing for 3 to 9 weeks at the time of recruitment. All interventions will be performed at the ‘Health Care Center’ in the Sonderborg Municipality, and a minimum of 138 participants will be randomised into one of the three groups.
All participants will receive ‘Health Guidance’, a (1.5-hour) individualised dialogue focusing on improving ways of living, based on assessments of risk behavior, motivation for change, level of self-care and personal resources. In addition, the experimental groups will receive either ‘Tailored Physical Activity’ (three 50-minute sessions/week over 10 weeks) or ‘Chronic Pain Self-Management Program’ (2.5-hours per week over 6 weeks). The reference group will receive only ‘Health Guidance’.
The primary outcome is the participants’ sick-listed status at 3 and 12 months after baseline. The co-primary outcome is the time it takes to return to work. In addition, secondary outcomes include anthropometric measurements, functional capacity and self-reported number of sick days, musculoskeletal symptoms, general health, work ability, physical capacity, kinesiophobia, physical functional status, interpersonal problems and mental disorders.
There are few evidence-based interventions for rehabilitation programmes assisting people with musculoskeletal pain-related work absence. This study will compare outcomes of interventions on return to work in order to increase the knowledge of evidence-based rehabilitation of sick-listed citizens to prevent long-term sick-leave and facilitate return to work.
Trial registration
The trial is registered in the, number NCT01356784.
PMCID: PMC3558350  PMID: 23343386
‘Tailored Physical Activity’; ‘Chronic Pain Self-Management Program’; ‘Return to work’; ‘Musculoskeletal disorders’; Pain
17.  Predictors of stable return-to-work in non-acute, non-specific spinal pain: low total prior sick-listing, high self prediction and young age. A two-year prospective cohort study 
BMC Family Practice  2010;11:53.
Non-specific spinal pain (NSP), comprising back and/or neck pain, is one of the leading disorders in long-term sick-listing. During 2000-2004, 125 Swedish primary-care patients with non-acute NSP, full-time sick-listed 6 weeks-2 years, were included in a randomized controlled trial to compare a cognitive-behavioural programme with traditional primary care. This prospective cohort study is a re-assessment of the data from the randomized trial with the 2 treatment groups considered as a single cohort. The aim was to investigate which baseline variables predict a stable return-to-work during a 2-year period after baseline: objective variables from function tests, socioeconomic, subjective and/or treatment variables. Stable return-to-work was a return-to-work lasting for at least 1 month from the start of follow-up.
Stable return-to-work was the outcome variable, the above-mentioned factors were the predictive variables in multiple-logistic regression models, one per follow-up at 6, 12, 18 and 24 months after baseline. The factors from univariate analyzes with a p-value of at most .10 were included. The non-significant variables were excluded stepwise to yield models comprising only significant factors (p < .05). As the comparatively few cases made it risky to associate certain predictors with certain time-points, we finally considered the predictors which were represented in at least 3 follow-ups. They are presented with odds ratios (OR) and 95% confidence intervals.
Three variables qualified, all of them represented in 3 follow-ups: Low total prior sick-listing (including all diagnoses) was the strongest predictor in 2 follow-ups, 18 and 24 months, OR 4.8 [1.9-12.3] and 3.8 [1.6-8.7] respectively, High self prediction (the patients' own belief in return-to-work) was the strongest at 12 months, OR 5.2 [1.5-17.5] and Young age (max 44 years) the second strongest at 18 months, OR 3.5 [1.3-9.1].
In primary-care patients with non-acute NSP, the strong predictors of stable return-to-work were 2 socioeconomic variables, Low total prior sick-listing and Young age, and 1 subjective variable, High self-prediction. Objective variables from function tests and treatment variables were non-predictors. Except for Young age, the predictors have previously been insufficiently studied, and so our study should widen knowledge within clinical practice.
Trial registration
Trial registration number for the original trial NCT00488735.
PMCID: PMC2919451  PMID: 20646286
18.  Quality of life and illness perception in working and sick-listed chronic RSI patients 
To study differences between working and sick-listed chronic repetitive strain injury (RSI) patients in the Netherlands with respect to indices of quality of life and illness perception.
In a cross-sectional design, one questionnaire was sent to all 3,250 members of the national RSI patient association. For descriptive purposes, demographics, work status and complaint-related variables such as severity, type, duration, and extent of complaints were asked for. Indices of quality of life were assessed through seven SF-36 subscales (physical (role) functioning, emotional role functioning, social functioning, pain, mental health and vitality). A work-ability estimate and VAS scales were used to assess complaint-related decrease in quality of life. Illness perception was assessed through the brief illness perception questionnaire (IPQ-B). Working patients and sick-listed patients were identified. Tests between the two independent groups were performed and P-values < 0.01 were considered significant.
Data from 1,121 questionnaires were used. Two-thirds of the respondents worked and one-third were sick-listed. Average duration of complaints was over 5 years in both groups. The sick-listed patients reported significantly more severe and extensive complaints than did the working patients. In addition, sick-listed patients reported significantly poorer mental health, physical (role) functioning, emotional role functioning, pain, vitality, and work-ability. With respect to illness perception, both groups showed the same concerns about their complaints, but sick-listed patients had significantly more distorted perceptions in their emotional response, identity, treatment control, personal control, timeline, and life consequences. Complaint-related decrease in quality of life was 31% in the working patients and 49% in the sick-listed patients.
The study found a greater number and severe complaints among sick-listed chronic RSI patients and a considerably decreased quality of life because of their complaints. These findings may allow for a better treatment focus in the future.
PMCID: PMC2175018  PMID: 17638005
Work-related upper extremity musculoskeletal disorders; Repetitive strain injuries; Quality of life; Illness perception
19.  Work Ability Index, Absenteeism and Depression Among Patients with Burnout Syndrome 
Materia Socio-Medica  2014;26(4):249-252.
The aim of this study is to estimate the association of burnout syndrome and depression; burnout syndrome and sick leave; and burnout syndrome with Work Ability Index in patients who suffer from stress at work.
Material and methods:
The control clinical study was conducted in the Teaching Department for Professional Pathology and Toxicology at the Primary Health Care Center Tuzla in the period from 2009 to 2014. The study included 140 patients exposed to different levels of stress at work. Besides conducted interviews and anamnesis with working anamnesis, physical examination, all patients were subjected to diagnostic package of questionnaires for assessing exposure to stress at work and its effects on health and work ability and Hamilton Rating Scale for screening depression. All patients were referred to the Department with suspected distress and burnout syndrome. For this study we used a questionnaire for measuring intensity of burnout (two categories exclude suffering from burnout syndrome: successfully overcome stress at work and sometimes feel stress at work and the other two reveal the initial and very high burn-out syndrome. Studied group was consisted of patients categorized with burnout syndrome (n=88).
The questionnaire on the Work Ability Index (WAI) estimated characteristics of sick leave and prognostic factors with current work ability index. Lack of support at work with poor personal relations is the most common factor with the mobbing in burnout syndrome. Significantly more patients with the burnout syndrome suffered very severe depression 49%:37%; more use long sick leaves 53%:21%; several of them have poor WAI 51%:31% compared to those who are only exposed to stress at work (p=0.001). We found that the burn-out syndrome is predictor for developing depression (β=0.312, 95% CI, 0.114-0.353, p=0.001); absenteeism (β=0.285, 95% CI, 0.093-0.334, p=0.001); and a decline in working ability (β=0.413, 95% CI, 0.297-0.648). All the patients in whom it is found burnout syndrome is to provide medical and non-medical assistance in order to achieve stabilization of health and positive work orientation, mental rehabilitation and reintegration at work place.
The process involves serious emergency measures in work organization which include improved in working environment, communication and combat against mobbing.
PMCID: PMC4214807  PMID: 25395887
sick leave; stressors as risk factors at work; declining work ability index
20.  Length of sick leave – Why not ask the sick-listed? Sick-listed individuals predict their length of sick leave more accurately than professionals 
BMC Public Health  2004;4:46.
The knowledge of factors accurately predicting the long lasting sick leaves is sparse, but information on medical condition is believed to be necessary to identify persons at risk. Based on the current practice, with identifying sick-listed individuals at risk of long-lasting sick leaves, the objectives of this study were to inquire the diagnostic accuracy of length of sick leaves predicted in the Norwegian National Insurance Offices, and to compare their predictions with the self-predictions of the sick-listed.
Based on medical certificates, two National Insurance medical consultants and two National Insurance officers predicted, at day 14, the length of sick leave in 993 consecutive cases of sick leave, resulting from musculoskeletal or mental disorders, in this 1-year follow-up study. Two months later they reassessed 322 cases based on extended medical certificates. Self-predictions were obtained in 152 sick-listed subjects when their sick leave passed 14 days. Diagnostic accuracy of the predictions was analysed by ROC area, sensitivity, specificity, likelihood ratio, and positive predictive value was included in the analyses of predictive validity.
The sick-listed identified sick leave lasting 12 weeks or longer with an ROC area of 80.9% (95% CI 73.7–86.8), while the corresponding estimates for medical consultants and officers had ROC areas of 55.6% (95% CI 45.6–65.6%) and 56.0% (95% CI 46.6–65.4%), respectively. The predictions of sick-listed males were significantly better than those of female subjects, and older subjects predicted somewhat better than younger subjects. Neither formal medical competence, nor additional medical information, noticeably improved the diagnostic accuracy based on medical certificates.
This study demonstrates that the accuracy of a prognosis based on medical documentation in sickness absence forms, is lower than that of one based on direct communication with the sick-listed themselves.
PMCID: PMC529266  PMID: 15476563
21.  Safe To Walk? Neighborhood Safety and Physical Activity Among Public Housing Residents 
PLoS Medicine  2007;4(10):e306.
Despite its health benefits, physical inactivity is pervasive, particularly among those living in lower-income urban communities. In such settings, neighborhood safety may impact willingness to be regularly physically active. We examined the association of perceived neighborhood safety with pedometer-determined physical activity and physical activity self-efficacy.
Methods and Findings
Participants were 1,180 predominantly racial/ethnic minority adults recruited from 12 urban low-income housing complexes in metropolitan Boston. Participants completed a 5-d pedometer data-collection protocol and self-reported their perceptions of neighborhood safety and self-efficacy (i.e., confidence in the ability to be physically active). Gender-stratified bivariate and multivariable random effects models were estimated to account for within-site clustering. Most participants reported feeling safe during the day, while just over one-third (36%) felt safe at night. We found no association between daytime safety reports and physical activity among both men and women. There was also no association between night-time safety reports and physical activity among men (p = 0.23) but women who reported feeling unsafe (versus safe) at night showed significantly fewer steps per day (4,302 versus 5,178, p = 0.01). Perceiving one's neighborhood as unsafe during the day was associated with significantly lower odds of having high physical activity self-efficacy among both men (OR 0.40, p = 0.01) and women (OR 0.68, p = 0.02).
Residing in a neighborhood that is perceived to be unsafe at night is a barrier to regular physical activity among individuals, especially women, living in urban low-income housing. Feeling unsafe may also diminish confidence in the ability to be more physically active. Both of these factors may limit the effectiveness of physical activity promotion strategies delivered in similar settings.
Garry Bennett and colleagues measured exercise levels and obtained opinions on neighborhood safety. They concluded that residing in a neighborhood perceived to be unsafe at night is a barrier to regular physical activity.
Editors' Summary
Nowadays we are all encouraged to do more physical activity, as it has been shown that inactivity increases the risk of many medical conditions, including obesity, heart attacks, and strokes. Inactive people die younger. Previous research has shown that people on a low income and those from ethnic or racial minorities have the lowest activity levels. There are, however, many barriers to being active. It has been claimed that people who live in neighborhoods that are unsafe face particular difficulties. They might want to walk, cycle, or take other forms of outdoor exercise near their home, but they fear they would be injured as a result of a violent attack. It is usually the poorest members of society who live in unsafe areas. It is also known that those poor people who belong to minority racial or ethnic groups are particularly likely to feel unsafe.
Why Was This Study Done?
The researchers who did this study wanted to find out whether people in a low-income urban area in the US considered themselves to be unsafe in their neighborhood, and how much physical activity they took part in. Their aim was to establish whether there was an association between the perceived safety level and the amount of activity taken, or if the two were unrelated. Other researchers have tried to look for such an association before, but they have usually relied on how much activity people say they remember taking, not on the actual measured amount. The results from such research have been very varied and inconclusive.
What Did the Researchers Do and Find?
Working in one low-income district of one US city (Boston), they found over 1,000 people to participate in their study, most of whom were from ethnic minorities. They asked them the question: “How safe do you feel walking alone in your neighborhood?” Response options included “safe,” “a little unsafe,” and “unsafe.” The same question was asked about walking alone in the daylight and walking alone after dark. The people in the study also agreed to wear a pedometer for five days. This instrument measures the number of steps that the wearer takes. It is thus a much more accurate way of finding out about activity levels than asking people how much activity they think they have engaged in.
Four out of five people said they did feel safe during the day, but there was no association between daytime safety and physical activity. This was the case for both men and women. Two-thirds of the people in the study felt unsafe in the night-time. There was no association between perceived night-time safety and physical activity among men, but women who reported feeling unsafe at night took around 1,000 fewer steps per day than other women. That amounts to around 20% less physical activity.
What Do These Findings Mean?
Even the women who felt safe at night were only taking around 5,000 steps per day, around half of what the US Surgeon General recommends for good health. So all the women in the study would benefit from more physical activity. However, the much lower amount of activity of the women who felt unsafe does suggest that a perceived lack of safety is an important factor, which could increase the risks to their health. It is interesting that the association between perceived safety and activity was not found in men and only applied to night-time safety. However, the authors argue that their findings provide preliminary evidence that perceived low neighborhood safety may serve as a barrier to physical activity in low-income areas. They discuss in the article the need for further research.
Additional Information.
Please access these Web sites via the online version of this summary at
• The UK National Health Service publishes the online NHS Direct Health Encyclopedia, which describes the benefits of exercise and gives recommendations
• Information on exercise may also be found on MedlinePlus, a service of the US National Library of Medicine and the National Institutes of Health
PMCID: PMC2039759  PMID: 17958465
22.  Expectations and illness perceptions as predictors of benefit recipiency among workers with common mental disorders: secondary analysis from a randomised controlled trial 
BMJ Open  2014;4(3):e004321.
Common mental disorders (CMDs) are among the leading causes of sick leave, and more knowledge on factors related to work participation and return-to-work (RTW) in CMDs is needed. The aim of this study was to investigate RTW-expectations and illness perceptions as predictors of benefit recipiency in CMDs.
Study participants were enrolled in a randomised controlled trial and reported CMDs as a main obstacle for work participation. Three prespecified subgroups were included: people at risk of going on sick leave, people on sick leave (>3 weeks) or people on long-term benefits. Baseline questionnaire data and registry data at baseline and 6 months were used to investigate predictors of benefit recipiency at 6-month follow-up. Benefit recipiency included sickness benefits, disability pension, work assessment allowance and unemployment benefits.
In this study, uncertain and negative RTW-expectations were strong predictors of benefit recipiency at 6 months follow-up. Illness perceptions predicted benefit recipiency in the unadjusted model, but not in the fully adjusted model. In the subgroup on sick leave, uncertain and negative RTW-expectations predicted benefit recipiency, while in the subgroup of people at risk of going on sick leave, negative RTW-expectations predicted benefit recipiency. In the subgroup on long-term benefits, only female gender predicted benefit recipiency.
For people with CMDs, uncertain and negative RTW-expectations predict later benefit recipiency, and expectations seem particularly important for those at risk of or on sick leave. For those at risk of sick leave, benefit recipiency at follow-up denoted a transition onto sick leave or long-term benefit, while those on sick leave had remained so or were receiving long-term benefits. Addressing RTW-expectations in occupational healthcare services or vocational rehabilitation might be beneficial in early stages or even prior to a sick leave episode.
Trial registration, NCT01146730.
PMCID: PMC3948454  PMID: 24589824
23.  Toward an Understanding of Disengagement from HIV Treatment and Care in Sub-Saharan Africa: A Qualitative Study 
PLoS Medicine  2013;10(1):e1001369.
Norma Ware and colleagues conducted a large qualitative study among patients in HIV treatment programs in sub-Saharan Africa to investigate reasons for missed visits and provide an explanation for disengagement from care.
The rollout of antiretroviral therapy in sub-Saharan Africa has brought lifesaving treatment to millions of HIV-infected individuals. Treatment is lifelong, however, and to continue to benefit, patients must remain in care. Despite this, systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programs. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programs in Africa.
Methods and Findings
Eight-hundred-ninety patients enrolled in HIV treatment programs in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda who had extended absences from care were tracked for qualitative research interviews. Two-hundred-eighty-seven were located, and 91 took part in the study. Interview data were inductively analyzed to identify reasons for missed visits and to assemble them into a broader explanation of how missed visits may develop into disengagement. Findings reveal unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Disengagement is interpreted as a process through which missed visits and ensuing reluctance to return over time erode patients' subjective sense of connectedness to care.
Missed visits are inevitable over a lifelong course of HIV care. Efforts to prevent missed clinic visits combined with moves to minimize barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.
Please see later in the article for the Editors' Summary
Editors' Summary
The human immunodeficiency virus (HIV) infects cells of the immune system, destroying or impairing their function. As the infection progresses, the immune system becomes weaker, and the affected person becomes more susceptible to life-threatening infections. Over the past three decades, 25 million people have died from HIV, and according to the World Health Organization, in 2011, there were roughly 34.2 million people living with HIV, over 60% of whom lived in sub-Saharan Africa. Although HIV cannot be cured, the virus can be suppressed by combination antiretroviral therapy (ART) consisting of three or more antiretroviral drugs. ART controls viral replication and strengthens the immune system, allowing the affected person to fight off infections. With ART, HIV can be managed as a chronic disease: people living with HIV can live healthy lives as long as they take antiretroviral drugs regularly for the rest of their lives.
Why Was This Study Done?
Unfortunately, poor retention in HIV programs is a huge problem: a large proportion—30%–60% in some settings in sub-Saharan Africa—of people starting ART, are lost to follow-up and stop taking treatment. Few studies have looked in depth at the reasons why people with HIV in sub-Saharan Africa miss clinic appointments or even stop coming altogether. So in this study in Tanzania, Uganda, and Nigeria, the researchers did a qualitative analysis from the patients' perspective on the reasons for missing clinic visits. Qualitative research can use information-gathering techniques, such as open-ended interviews, to develop an in-depth understanding of human behavior and the reasons behind such behavior.
What Did the Researchers Do and Find?
The researchers indentified people to interview by using “tracking lists” from HIV/AIDS care clinics in the three countries—patient tracking by clinical trackers is increasingly used as a way to contact patients who have missed clinic appointments. The researchers included people in the study who had been tracked and contacted by clinic trackers, had been absent from the clinic for three months or more, and gave consent to be re-contacted by the researchers. The researchers interviewed participants, using their local language, on several topics, including their experiences of care at the clinic and of tracking, and the circumstances of missed appointments. The detailed accounts were transcribed, and then the researchers categorized the reasons for missing appointments into intentional and unintentional reasons.
Eight-hundred-ninety patients in the three countries were tracked during the study period, but only 287 were located, of whom 91 participated in the study. Of the 91 participants, 76 were being prescribed ART, and 15 had not started treatment. The main unintentional reason for missing clinic visits was a conflicting demand on the patients' time, which was often unexpected and for complex reasons, such as caring for a dying relative, going to a funeral, or traveling to work. These reasons were often transient and changed over time. Intentional reasons were often related to dissatisfaction with the care received at the clinic, especially “the harsh treatment” they received from health workers, which typically referred to behavior perceived by patients to be rude. For example, participants reported being spoken to “roughly” or feeling that the clinic staff “didn't care.” Such behavior made patients feel hurt, humiliated, and angry, and reluctant to return to the clinic. The researchers found that, overall, disengagement from care appeared to be a process through which missed visits and subsequent reluctance to return over time eroded patients' sense of connectedness to care.
What Do These Findings Mean?
Absences from care will be inevitable over a lifetime course of treatment for HIV/AIDS. These findings indicate that absences may be unintentional as well as intentional, and that the reasons are complex and can change over time. Initial reasons for missing may disappear, leaving patients free, but reluctant, to return to care. Reasons for reluctance include shame at having been absent and the anticipation of a negative response to return from care providers. Patient education for ART initiation in sub-Saharan Africa often includes stern warnings about the lifelong commitment beginning ART represents. Paradoxically, educational efforts intended to maximize the benefits of ART for patients may be driving some away from care. Therefore, efforts to prevent missed clinic visits coupled with strategies to minimize any obstacles to coming back to care are necessary to keep patients' missed visits from turning into long-term disengagement from treatment.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Edward Mills
The World Health Organization has the latest data on access to ART
The US National Institute of Allergy and Infectious Diseases has more information on types of ART, and also on adherence to treatment
The US Centers for Disease Control and Prevention has some information about interventions to help improve adherence
PMCID: PMC3541407  PMID: 23341753
24.  Predicting Return to Work in Employees Sick-Listed Due to Minor Mental Disorders 
Objective To investigate which factors predict return to work (RTW) after 3 and 6 months in employees sick-listed due to minor mental disorders. Methods Seventy GPs recruited 194 subjects at the start of sick leave due to minor mental disorders. At baseline (T0), 3 and 6 months later (T1 and T2, respectively), subjects received a questionnaire and were interviewed by telephone. Using multivariate logistic regression analyses, we developed three prediction models to predict RTW at T1 and T2. Results The RTW rates were 38% after 3 months (T1) and 61% after 6 months (T2). The main negative predictors of RTW at T1 were: (a) a duration of the problems of more than 3 months before sick leave; and (b) somatisation. The main negative predictors of RTW at T2 were: (a) a duration of the problems of more than 3 months before sick leave; (b) more than 3 weeks of sick leave before inclusion in the study; and (c) anxiety. The main negative predictors of RTW at T2 for those who had not resumed work at T1 were: (a) more than 3 weeks of sick leave before inclusion in the study; and (b) depression at T1. The predictive power of the models was moderate with AUC-values between 0.695 and 0.763. Conclusions The main predictors of RTW were associated with the severity of the problems. A long duration of the problems before the occurrence of sick leave and a long duration of sick leave before seeking help predict a relatively small probability to RTW within 3–6 months. High baseline somatisation and anxiety, and high depression after 3 months make the prospect even worse. Since these predictors are readily assessable with just a few questions and a symptom questionnaire, this opens the opportunity to select high-risk employees for a targeted intervention to prevent long-term absenteeism.
PMCID: PMC2775114  PMID: 19760489
Sick leave; Mental disorders; Prediction; RTW; Primary care; Emotional distress
25.  Dealing with sickness certification – a survey of problems and strategies among general practitioners and orthopaedic surgeons 
BMC Public Health  2007;7:273.
In order to get sickness benefit a sick-listed person need a medical certificate issued by a physician; in Sweden after one week of self-certification. Physicians experience sick-listing tasks as problematic and conflicts may arise when patients regard themselves unable to work due to complaints that are hard to objectively verify for the physician. Most GPs and orthopaedic surgeons (OS) deal regularly with sick-listing issues in their daily practice. The aim of this study was to explore perceived problems and coping strategies related to tasks of sickness certification among general practitioners (GP) and orthopaedic surgeons (OS).
A cross-sectional study about sickness certification in two Swedish counties, with 673 participating GPs and 149 OSs, who answered a comprehensive questionnaire. Frequencies together with crude and adjusted (gender and working years) Odds ratios were calculated.
A majority of the GPs and OSs experienced problems in sickness certification every week. To assess the patient's work ability, to handle situations when they and the patient had different opinions about the need for sickness absence, and to issue prolongation certificates when the previous was issued by another physician were reported as problematic by a majority in both groups. Both GPs and OSs prolonged sickness certifications due to waiting times in health care or at Social Insurance Office (SIO). To handle experienced problems they used different strategies; OSs issued sickness certificates without personal appointment more often than the GPs, who on the other hand reported having contact with SIO more often than the OSs. A higher rate of GPs experienced support from management and had a common strategy for handling sickness certification at the clinic than the OSs.
Most GPs and OSs handled sickness certification weekly and reported a variety of problems in relation to this task, generally GPs to a higher extent, and they used different coping strategies to handle the problems.
PMCID: PMC2089078  PMID: 17910746

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