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1.  Associations between partial sickness benefit and disability pensions: initial findings of a Finnish nationwide register study 
BMC Public Health  2010;10:361.
Timely return to work after longterm sickness absence and the increased use of flexible work arrangements together with partial health-related benefits are tools intended to increase participation in work life. Although partial sickness benefit and partial disability pension are used in many countries, prospective studies on their use are largely lacking. Partial sickness benefit was introduced in Finland in 2007. This register study aimed to investigate the use of health-related benefits by subjects with prolonged sickness absence, initially on either partial or full sick leave.
Representative population data (13 375 men and 16 052 women either on partial or full sick leave in 2007) were drawn from national registers and followed over an average of 18 months. The registers provided information on the study outcomes: diagnoses and days of payment for compensated sick leaves, and the occurrence of disability pension. Survival analysis and multinomial regression were carried out using sociodemographic variables and prior sickness absence as covariates.
Approximately 60% of subjects on partial sick leave and 30% of those on full sick leave had at least one recurrent sick leave over the follow up. A larger proportion of those on partial sick leave (16%) compared to those on full sick leave (1%) had their first recurrent sick leave during the first month of follow up. The adjusted risks of the first recurrent sick leave were 1.8 and 1.7 for men and women, respectively, when subjects on partial sick leave were compared with those on full sick leave. There was no increased risk when those with their first recurrent sick leave in the first month were excluded from the analyses. The risks of a full disability pension were smaller and risks of a partial disability pension approximately two-fold among men and women initially on partial sick leave, compared to subjects on full sick leave.
This is the first follow up study of the newly adopted partial sickness benefit in Finland. The results show that compared to full sick leave, partial sick leave - when not followed by lasting return to work - is more typically followed by partial disability pension and less frequently by full disability pension. It is anticipated that the use of partial benefits in connection with part-time participation in work life will have favourable effects on future disability pension rates in Finland.
PMCID: PMC2912806  PMID: 20573207
2.  Work and Health, a Blind Spot in Curative Healthcare? A Pilot Study 
Introduction Most workers with musculoskeletal disorders on sick leave often consult with regular health care before entering a specific work rehabilitation program. However, it remains unclear to what extent regular healthcare contributes to the timely return to work (RTW). Moreover, several studies have indicated that it might postpone RTW. There is a need to establish the influence of regular healthcare on RTW as outcome; “Does visiting a regular healthcare provider influence the duration of sickness absence and recurrent sick leave due to musculoskeletal disorders?”. Methods A cohort of workers on sick leave for 2–6 weeks due to a-specific musculoskeletal disorders was followed for 12 months. The main outcomes for the present analysis were: duration of sickness absence till 100% return to work and recurrent sick leave after initial RTW. Cox regression analyses were conducted with visiting a general health practitioner, physical therapist, or medical specialist during the sick leave period as independent variables. Each regression model was adjusted for variables known to influence health care utilization like age, sex, diagnostic group, pain intensity, functional disability, general health perception, severity of complaints, job control, and physical load at work. Results Patients visiting a medical specialist reported higher pain intensity and more functional limitations and also had a worse health perception at start of the sick leave period compared with those not visiting a specialist. Visiting a medical specialist delayed return to work significantly (HR = 2.10; 95%CI 1.43–3.07). After approximately 8 weeks on sick leave workers visiting a physical therapist returned to work faster than other workers. A recurrent episode of sick leave during the follow up quick was initiated by higher pain intensity and more functional limitations at the moment of fully return to work. Visiting a primary healthcare provider during the sickness absence period did not influence the occurrence of a new sick leave period. Conclusion Despite the adjustment for severity of the musculoskeletal disorder, visiting a medical specialist was associated with a delayed full return to work. More attention to the factor ‘labor’ in the regular healthcare is warranted, especially for those patients experiencing substantial functional limitations due to musculoskeletal disorders.
PMCID: PMC3173611  PMID: 21080214
Return to work; Work disability; Health care services; Musculoskeletal disorders
3.  Promoting work ability in a structured national rehabilitation program in patients with musculoskeletal disorders: outcomes and predictors in a prospective cohort study 
Musculoskeletal disorders (MSDs) are a major reason for impaired work productivity and sick leave. In 2009, a national rehabilitation program was introduced in Sweden to promote work ability, and patients with MSDs were offered multimodal rehabilitation. The aim of this study was to analyse the effect of this program on health related quality of life, function, sick leave and work ability.
We conducted a prospective, observational cohort study including 406 patients with MSDs attending multimodal rehabilitation. Changes over time and differences between groups were analysed concerning function, health related quality of life, work ability and sick leave. Regression analyses were used to study the outcome variables health related quality of life (measured with EQ-5D), and sick leave.
Functional ability and health related quality of life improved after rehabilitation. Patients with no sick leave/disability pension the year before rehabilitation, improved health related quality of life more than patients with sick leave/disability pension the year before rehabilitation (p = 0.044). During a period of −/+ four months from rehabilitation start, patients with EQ-5D ≥ 0.5 at rehabilitation start, reduced their net sick leave days with 0.5 days and patients with EQ-5D <0.5 at rehabilitation start, increased net sick leave days with 1.5 days (p = 0.019). Factors negatively associated with sick leave at follow-up were earlier episodes of sick leave/disability pension, problems with exercise tolerance functions and mobility after rehabilitation. Higher age was associated with not being on sick leave at follow-up and reaching an EQ-5D ≥ 0.5 at follow-up. Severe pain after rehabilitation, problems with exercise tolerance functions, born outside of Sweden and full-time sick leave/disability pension the year before rehabilitation were all associated with an EQ-5D level < 0.5 at follow-up.
Patients with MSDs participating in a national work promoting rehabilitation program significantly improved their health related quality of life and functional ability, especially those with no sick leave. This shows that vocational rehabilitation programs in a primary health care setting are effective. The findings of this study can also be valuable for more appropriate patient selection for rehabilitation programs for MSDs.
PMCID: PMC3626929  PMID: 23384339
Sick leave; Musculoskeletal pain; Multimodal rehabilitation; Health related quality of life; Function
4.  Cost-effectiveness of a workplace intervention for sick-listed employees with common mental disorders: design of a randomized controlled trial 
BMC Public Health  2008;8:12.
Considering the high costs of sick leave and the consequences of sick leave for employees, an early return-to-work of employees with mental disorders is very important. Therefore, a workplace intervention is developed based on a successful return-to-work intervention for employees with low back pain. The objective of this paper is to present the design of a randomized controlled trial evaluating the cost-effectiveness of the workplace intervention compared with usual care for sick-listed employees with common mental disorders.
The study is designed as a randomized controlled trial with a follow-up of one year. Employees eligible for this study are on sick leave for 2 to 8 weeks with common mental disorders. The workplace intervention will be compared with usual care. The workplace intervention is a stepwise approach that aims to reach consensus about a return-to-work plan by active participation and strong commitment of both the sick-listed employee and the supervisor. Outcomes will be assessed at baseline, 3, 6, 9 and 12 months. The primary outcome of this study is lasting return-to-work, which will be acquired from continuous registration systems of the companies after the follow-up. Secondary outcomes are total number of days of sick leave during the follow-up, severity of common mental disorders, coping style, job content, and attitude, social influence, and self-efficacy determinants. Cost-effectiveness will be evaluated from the societal perspective. A process evaluation will also be conducted.
Return-to-work is difficult to discuss in the workplace for sick-listed employees with mental disorders and their supervisors. Therefore, this intervention offers a unique opportunity for the sick-listed employee and the supervisor to discuss barriers for return-to-work. Results of this study will possibly contribute to improvement of disability management for sick-listed employees with common mental disorders. Results will become available in 2009.
Trial registration
PMCID: PMC2254399  PMID: 18194525
5.  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
6.  Protocol for the atWork trial: a randomised controlled trial of a workplace intervention targeting subjective health complaints 
BMC Public Health  2016;16:844.
Subjective health complaints, such as musculoskeletal and mental health complaints, have a high prevalence in the general population, and account for a large proportion of sick leave in Norway. It may be difficult to prevent the occurrence of subjective health complaints, but it may be possible to influence employees’ perception and management of these complaints, which in turn may have impact on sick leave and return to work after sick leave. Long term sick leave has many negative health and social consequences, and it is important to gain knowledge about effective interventions to prevent and reduce long term sick leave.
This study is a cluster randomised controlled trial to evaluate the effect of the modified atWork intervention, targeting non-specific musculoskeletal complaints and mental health complaints. This intervention will be compared to the original atWork intervention targeting only non-specific musculoskeletal complaints. Kindergartens in Norway are invited to participate in the study and will be randomly assigned to one of the two interventions. Estimated sample size is 100 kindergartens, with a total of approximately 1100 employees. Primary outcome is sick leave at unit level, measured using register data from the Norwegian Labour and Welfare Administration. One kindergarten equals one unit, regardless of number of employees. Secondary outcomes will be measured at the individual level and include coping, health, job satisfaction, social support, and workplace inclusion, collected through questionnaires distributed at baseline and at 12 months follow up. All employees in the included kindergartens are eligible for participating in the survey.
The effect evaluation of the modified atWork intervention is a large and comprehensive project, providing evidence-based information on prevention of long-term sick leave, which may be of considerable benefit both from a societal, organisational, and individual perspective.
Trial registration NCT02396797. Registered March 23th, 2015.
PMCID: PMC4992332  PMID: 27542921
Sick leave; Subjective health complaints; Mental health complaints; Musculoskeletal complaints; Back pain; Anxiety; Depression; Coping; Workplace intervention; Randomised controlled trial
7.  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
8.  Determinants for return to work among sickness certified patients in general practice 
BMC Public Health  2012;12:1077.
Long-term sickness absence is one of the main risk factors for permanent exit out of the labour market. Early identification of the condition is essential to facilitate return to work. The aim of this study was to analyse possible determinants of return to work and their relative impact.
All 943 subjects aged 18 to 63 years, sickness certified at a Primary Health Care Centre in Sweden from 1 January until 31 August 2004, were followed up for three years. Baseline information on sex, age, sick leave diagnosis, employment status, extent of sick leave, and sickness absence during the year before baseline was obtained, as was information on all compensated days of sick leave, disability pension and death during follow-up.
Slightly more than half the subjects were women, mean age was 39 years. Half of the study population returned to work within 14 days after baseline, and after three years only 15 subjects were still on sick leave. In multivariate proportional hazards regression analysis the extent of previous sick leave, age, being on part-time sick leave, and having a psychiatric, musculoskeletal, cardiovascular, nervous disease, digestive system, or injury or poisoning diagnosis decreased the return to work rate, while being employed increased it. Marital status, sex, being born in Sweden, citizenship, and annual salary had no influence. In logistic regression analyses across follow-up time these variables altogether explained 88-90% of return to work variation.
Return to work was positively or negatively associated by a number of variables easily accessible in the GP’s office. Track record data in the form of previous sick leave was the most influential variable.
PMCID: PMC3541101  PMID: 23241229
9.  Psychoeducation to facilitate return to work in individuals on sick leave and at risk of having a mental disorder: protocol of a randomised controlled trial 
BMC Public Health  2014;14:1288.
Sickness absence due to poor mental health is a common problem in many Western countries. To facilitate return to work, it may be important to identify individuals on sick leave and at risk of having a mental disorder and subsequently to offer appropriate treatment. Psychoeducation alone has not previously been used as a return to work intervention, but may be a promising tool to facilitate return to work. Therefore, the aim of the study is to evaluate the effectiveness of psychoeducation designed specifically to facilitate return to work for individuals on sick leave and at risk of having a mental disorder. The psychoeducation was a supplement to the various standard offers provided by the job centres.
The study is a randomised controlled trial, in which individuals on sick leave either receive psychoeducation and standard case management or standard case management alone. Participants were individuals with mental health symptoms, who had been on sick leave from part-time or full-time work or unemployment for about 4–8 weeks. The psychoeducational intervention was group-based and the course consisted of 2 hour sessions once a week for 6 weeks. The course was given by psychiatric nurses, a psychologist, a social worker, a physiotherapist and a person who had previously been on sick leave due to mental health problems. The sessions focused on stress and work life, and the purpose was to provide individuals on sick leave the skills to understand and improve their mental functioning.
The primary outcome is the duration of sickness absence measured by register data. Secondary outcomes include psychological symptoms, mental health-related quality of life, and locus of control. These outcomes are measured by questionnaires at the start of the intervention and at 3 and 6 months follow-up.
On the basis of this trial, the effect of psychoeducation for individuals on sick leave and at risk of having a mental disorder will be studied. The results will contribute to the continuing research on sickness absence and mental health. It will primarily show whether psychoeducation can lead to faster and sustainable return to work.
Trial Registration
Clinical NCT01637363. Registered 6 July 2012.
PMCID: PMC4300682  PMID: 25516423
Sickness absence; Psychoeducation; Mental health; Return to work; Psychological symptoms; Mental health-related quality of life; Locus of control
10.  Improving return-to-work after childbirth: design of the Mom@Work study, a randomised controlled trial and cohort study 
BMC Public Health  2007;7:43.
Many women suffer from health problems after giving birth, which can lead to sick leave. About 30% of Dutch workers are on sick leave after maternity leave. Structural contact of supervisors with employees on maternity leave, supported by early medical advice of occupational physicians, may increase the chances of return-to-work after maternity leave. In addition, to understand the process of sick leave and return-to-work after childbirth it is important to gain insight into which factors hinder return-to-work after childbirth, as well, as which prognostic factors lead to the development of postpartum health complaints. In this paper, the design of the Mom@Work study is described.
The Mom@Work study is simultaneously a randomised controlled trial and a cohort study. Pregnant women working for at least 12 hours a week at one of the 15 participating companies are eligible to participate. The supervisors of these pregnant employees are randomised at 35 weeks pregnancy into the intervention group or control group. During maternity leave, supervisors in the intervention group contact their employee six weeks after delivery using a structured interview. When employees do not expect to return to their jobs at the end of their scheduled maternity leave due to health problems, the supervisor offers early support of the occupational physician. Supervisors in the control group have no structural contact with their employees during maternity leave. Measurements take place at 30 weeks pregnancy and at 6, 12, 24 and 52 weeks postpartum. In addition, cost data are collected. For the RCT, primary outcome measures are sick leave and return-to-work, and secondary outcome measures are costs, health, satisfaction with intervention and global feelings of recovery. Outcome measures for the cohort are pregnancy-related pelvic girdle pain, fatigue and depression. Finally, a number of prognostic factors for return-to-work and for the development of complaints will be measured.
The Mom@Work study will provide important information about return-to-work of employees after giving birth. Results will give insight in prognosis of postpartum sick leave and complaints. Also, the role of supervisors and occupational physicians in successful return-to-work after childbirth will be clarified.
PMCID: PMC1851952  PMID: 17394629
11.  Recurrence of Medically Certified Sickness Absence According to Diagnosis: A Sickness Absence Register Study 
Introduction Sickness absence is a major public health problem. Research on sickness absence focuses on interventions aimed at expediting return to work. However, we need to know more about sustaining employees at work after return to work. Therefore, this study investigated the recurrence of sickness absence according to diagnosis. Methods We analyzed the registered sickness absence data of 137,172 employees working for the Dutch Post and Telecom. Episodes of sickness absence were medically certified, according to the ICD-10 classification of diseases, by an occupational physician. The incidence density (ID) and recurrence density (RD) of medically certified absences were calculated per 1,000 person-years in each ICD-10 category. Results Sickness absence due to musculoskeletal disorders had the highest recurrence (RD = 118.7 per 1,000 person-years), followed by recurrence of sickness absence due to mental disorders (RD = 80.4 per 1,000 person-years). The median time to recurrent sickness absence due to musculoskeletal disorders was 409 days after the index episode. Recurrences of sickness absence due to musculoskeletal disorders accounted for 37% of the total number of recurrent sickness absence days. For recurrences of sickness absence due to mental disorders this was 328 days and 21%, respectively. Unskilled employees with a short duration (<5 years) of employment had a higher risk of recurrent sickness absence. Conclusions Interventions to expedite return to work of employees sick-listed due to musculoskeletal or mental disorders should also aim at reducing recurrence of sickness absence in order to sustain employees at work.
PMCID: PMC2832874  PMID: 20052523
Absenteeism; Sickness absence; Epidemiology; Recurrence of sickness absence
12.  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
13.  Occupational rehabilitation programs for musculoskeletal pain and common mental health disorders: study protocol of a randomized controlled trial 
BMC Public Health  2014;14:368.
Long-term sick leave has considerably negative impact on the individual and society. Hence, the need to identify effective occupational rehabilitation programs is pressing. In Norway, group based occupational rehabilitation programs merging patients with different diagnoses have existed for many years, but no rigorous evaluation has been performed. The described randomized controlled trial aims primarily to compare two structured multicomponent inpatient rehabilitation programs, differing in length and content, with a comparative cognitive intervention. Secondarily the two inpatient programs will be compared with each other, and with a usual care reference group.
The study is designed as a randomized controlled trial with parallel groups. The Social Security Office performs monthly extractions of sick listed individuals aged 18–60 years, on sick leave 2–12 months, with sick leave status 50% - 100% due to musculoskeletal, mental or unspecific disorders. Sick-listed persons are randomized twice: 1) to receive one of two invitations to participate in the study or not receive an invitation, where the latter “untouched” control group will be monitored for future sick leave in the National Social Security Register, and 2) after inclusion, to a Long or Short inpatient multicomponent rehabilitation program (depending on which invitation was sent) or an outpatient cognitive behavioral therapy group comparative program. The Long program consists of 3 ½ weeks with full rehabilitation days. The Short program consists of 4 + 4 full days, separated by two weeks, in which a workplace visit will be performed if desirable. Three areas of rehabilitation are targeted: mental training, physical training and work-related problem solving. The primary outcome is number of sick leave days. Secondary outcomes include time until full sustainable return to work, health related quality of life, health related behavior, functional status, somatic and mental health, and perceptions of work. In addition, health economic evaluation will be performed, and the implementation of the interventions, expectations and experiences of users and service providers will be investigated with different qualitative methods.
Trial registration NCT01926574.
PMCID: PMC3996166  PMID: 24735616
Absenteeism; Occupational health; Rehabilitation; Return to work; Cognitive behavior therapy; Exercise musculoskeletal diseases
14.  Workplace as an origin of health inequalities 
OBJECTIVE: To investigate the effect of the workplace on the socioeconomic gradient of sickness absence. DESIGN: Comparison of the relation between socioeconomic status and employee sickness absence in three different towns. SETTINGS: The towns of Raisio, Valkeakoski, and Nokia in Finland. They are equal in size and regional social deprivation indices, located in the neighbourhood of a larger city, and produce the same services to the inhabitants. SUBJECTS: All permanent local government employees from Raisio (n = 887), Valkeakoski (n = 972), and Nokia (n = 934) on the employer's registers during 1991 to 1993. MAIN OUTCOME MEASURES: Rates of short (1-3 days) and long (> 3 days) spells of sickness absence, irrespective of cause, and separately for infection, musculoskeletal disorder, and trauma. RESULTS: In blue collar male and female workers, compared with the same sex higher grade white collar workers, the age adjusted numbers of long sick leaves were 4.9 (95% CI 4.2, 5.8) and 2.8 (2.6, 3.1) times higher, respectively. The risk varied significantly between the towns, in men in relation to long sick leaves irrespective of cause and resulting from musculoskeletal disorders, and in women in relation to long leaves resulting from infection. The numbers of long sick leaves were 3.9 (95% CI 2.8, 5.4) times higher in blue collar male workers than in higher grade white collar male workers in Raisio, 4.9 (95% CI 3.8, 6.3) times higher in Valkeakoski, and 5.8 (95% CI 4.5, 7.5) times higher in Nokia. Sickness absence of blue collar employees differed most between the towns. The rates of long sick leaves in blue collar men were 1.46 times greater (95% CI 1.25, 1.72) in Valkeakoski and 1.85 times greater (95% CI 1.58, 2.16) in Nokia than in Raisio. In men, no significant differences were found between the towns as regards the numbers of long sick leaves of higher grade white collar male workers. The socioeconomic gradients differed more between the towns in men who had worked for four years or more in the same employment than in men who had worked for shorter periods. No consistent health gradients of socioeconomic status were evident for short sick leaves among either sex. CONCLUSIONS: In men and to a lesser extent in women, the workplace is significantly associated with health inequalities as reflected by medically certified sickness absence and the corresponding socioeconomic gradients of health.
PMCID: PMC1756934  PMID: 10492732
15.  Evaluation of the efficacy of a short-course, personalized self-management and intensive spa therapy intervention as active prevention of musculoskeletal disorders of the upper extremities (Muska): a research protocol for a randomized controlled trial 
Musculoskeletal disorders (MSDs) constitute a major occupational health problem in the working population, substantially impacting the quality of life of employees. They also cause considerable economic cost to the healthcare system, with, notably, the reimbursement of treatments and compensation for lost income. MSDs manifest as localized pain or functional difficulty in one or more anatomical areas, such as the cervical spine, shoulder, elbow, hand, and wrist. Although prevalence varies depending on the region considered and the method of assessment, a prevalence of 30% is found in different epidemiological studies. The disease needs to be prevented, not only for medical and economic reasons, but also for legal reasons, owing to the requirement of assessing occupational risks. The strategy envisaged may thus revolve around active, multimodal prevention that has employees fully involved at the heart of their care. Although physical exercise is widely recommended, few studies with a good level of evidence have enabled us to base a complete, well-constructed intervention on exercise that can be offered as secondary prevention in these disorders.
A prospective, multicenter, comparative (intervention arm vs. control arm), randomized (immediate vs. later treatment) study using Zelen’s design. This study falls under active prevention of MSDs of the upper extremities (UE-MSDs). Participants are workers aged between 18 and 65 years with latent or symptomatic MSDS, with any type of job or workstation, with or without an history of sick leave. The primary aim is to show the superiority at 3 months of a combination of spa therapy, exercise, and self-management workshops for 6 days over usual care in the management of MSDs in terms of employee functional capacity in personal and professional daily life. Secondary aims are to assess the benefit of the intervention in terms of pain, quality of life, and accumulated duration of sick leave.
This randomized controlled trial is the first that will aim to evaluate multidisciplinary management of UE-MSDs using nonpharmacological treatment combining exercise, self-management, and spa therapy. The originality of this intervention lies, in its short, intensive format, which is compatible with remaining in work; and in its multidisciplinary approach. This trial has the potential to demonstrate, with a good level of evidence, the benefits of a short course of spa therapy combined with a personalized self-management program on the functional capacity, pain, and quality of life of employees in their daily life.
Trial registration
Clinical NCT02702466 retrospectively registered.
Protocol: Version 4 of 9/10/2015.
Electronic supplementary material
The online version of this article (doi:10.1186/s12891-016-1353-8) contains supplementary material, which is available to authorized users.
PMCID: PMC5148841  PMID: 27938361
Musculoskeletal disorders; Exercise; Spa therapy; Prevention
16.  Cost-effectiveness of 40-hour versus 100-hour vocational rehabilitation on work participation for workers on sick leave due to subacute or chronic musculoskeletal pain: study protocol for a randomized controlled trial 
Trials  2015;16:317.
Although vocational rehabilitation is a widely advocated intervention for workers on sick leave due to subacute or chronic nonspecific musculoskeletal pain, the optimal dosage of effective and cost-effective vocational rehabilitation remains unknown. The objective of this paper is to describe the design of a non-inferiority trial evaluating the effectiveness and cost-effectiveness of 40-h multidisciplinary vocational rehabilitation compared with 100-h multidisciplinary vocational rehabilitation on work participation for workers on sick leave due to subacute or chronic musculoskeletal pain.
A non-inferiority study design will be applied. The study population consists of workers who are on part-time or full-time sick leave due to subacute or chronic nonspecific musculoskeletal pain. Two multidisciplinary vocational rehabilitation programs following the bio-psychosocial approach will be evaluated in this study: 40-h vocational rehabilitation and 100-h vocational rehabilitation, both delivered over a maximum of 15 weeks. The 100-h vocational rehabilitation comprises five modules: work participation coordination, graded activity, cognitive behavioral therapy, group education, and relaxation. The 40-h vocational rehabilitation comprises work participation coordination and a well-reasoned choice from the other four modules. Four rehabilitation centers will participate in this study, each delivering both interventions. Patients will be randomized into one of the interventions, stratified for the duration of sick leave (<6 weeks or ≥6 weeks) and type of sick leave (part-time or full-time). The primary outcome is work participation, measured by self-reported sick leave days, and will be assessed at baseline, mid-term, discharge, and at 2, 4, 6, 8, 10, and 12 months follow-up. Secondary outcomes are work ability, disability, quality of life, and physical functioning and will be assessed at baseline, discharge, and at 6 and 12 months follow-up. Cost outcomes are absenteeism, presenteeism, healthcare usage, and travelling costs. Cost-effectiveness will be evaluated from the societal and employer perspectives.
The results obtained from this study will be useful for vocational rehabilitation practice and will provide stakeholders with relevant insights into two versions of vocational rehabilitation.
Trial registration
Dutch Trial Register identifier: NTR4362 (registered 17 March 2014).
PMCID: PMC4518875  PMID: 26215748
vocational rehabilitation; subacute musculoskeletal pain; chronic musculoskeletal pain; work participation; cost-effectiveness; non-inferiority; randomized controlled trial; multicenter
17.  Sick leave patterns as predictors of disability pension or long-term sick leave: a 6.75-year follow-up study in municipal eldercare workers 
BMJ Open  2014;4(2):e003941.
The aim was to study whether a workplace-registered frequent short-term sick leave spell pattern was an early indicator of future disability pension or future long-term sick leave among municipal eldercare workers.
The municipal healthcare sector in the city of Aarhus, which is the second largest city in Denmark.
All elder care employees who worked the entire year of 2004 in the municipality of Aarhus, Denmark (N=2774). The employees’ sick leave days during 2004 were categorised into: 0–2 and 3–17 short (1–7 days) spells, 2–13 mixed short and long (8+ days) spells and long spells only. Student workers (n=180), employees who were absent due to maternal/paternal leave (n=536) and employees who did not work the entire year of 2004 (n=1218) were not included.
Primary outcome
Disability pension and long-term sick leave (≥8 weeks) were subsequently identified in a National register. The cumulative incidence proportion as a function of follow-up weeks was estimated using the Kaplan-Meier curve. The relative cumulative incidence (RR) of experiencing events within 352 weeks was analysed in a generalised linear regression model using the pseudo values method adjusted for age, occupation, unfavourable work factors and sick leave length.
A frequent short-term and a mixed sick leave pattern showed RRs of being granted a disability pension of 2.08 (95% CI 1.00 to 4.35) and 2.61 (95% CI 1.33 to 5.12) compared with 0–2 short spells. The risk of long-term sick leave was significantly increased for all sick leave patterns compared with 0–2 short spells. Adding sick leave length to the models attenuated all RRs and they became non-significant.
Sick leave length was a better indicator of future workability than spell frequency. Preventive actions should target employees engaged in homecare. The more sick leave days the greater the preventive potential seems, irrespective of spell frequency.
PMCID: PMC3918999  PMID: 24508850
18.  Faster return to work after psychiatric consultation for sicklisted employees with common mental disorders compared to care as usual. A randomized clinical trial 
Return to work (RTW) of employees on sick leave for common mental disorders may require a multidisciplinary approach. This article aims to assess time to RTW after a psychiatric consultation providing treatment advice to the occupational physician (OP) for employees on sick leave for common mental disorders in the occupational health (OH) setting, compared to care as usual (CAU).
Cluster randomized clinical trial evaluating patients of 12 OPs receiving consultation by a psychiatrist, compared to CAU delivered by 12 OPs in the control group. 60 patients suffering from common mental disorders and ≥ six weeks sicklisted were included. Follow up three and six months after inclusion. Primary outcome measure was time to RTW. Intention- to-treat multilevel analysis and a survival analysis were performed to evaluate time to RTW in both groups.
In CAU, referral was the main intervention. Both groups improved in terms of symptom severity and quality of life, but time to RTW was significantly shorter in the psychiatric consultation group. At three months follow up, 58% of the psychiatric consultation group had full RTW versus 44% of the control group, a significant finding (P = 0.0093). Survival analysis showed 68 days earlier RTW after intervention in the psychiatric consultation group (P = 0.078) compared to CAU.
Psychiatric consultation for employees on sick leave in the OH setting improves time to RTW in patients with common mental disorders as compared to CAU. In further research, focus should be on early intervention in patients with common mental disorders on short sick leave duration. Psychiatric consultation might be particularly promising for improvement of RTW in those patients.
Trial registration number
ISRCTN: 86722376
PMCID: PMC2938286  PMID: 20856601
psychiatric consultation; mental disorders; RCT; sickness absence; major depressive disorder; anxiety disorder; somatoform disorder
19.  Prevalence and Causes of Medical Absenteeism Among Staff (Case Study at Mazandaran University of Medical Sciences: 2009-2010) 
Materia Socio-Medica  2013;25(4):233-237.
Work absenteeism is a significant issue and can be observed in terms of human resources management. Given the importance of staff practices, which are anticipated in every organization, the role of each employee in this system and the implications of their absence as well as the importance of recovery time rest in fast recovery of staff and anticipated costs for their lost work days, thus this study is aimed to determine the extent and causes of medical absenteeism (sickness absence) of head staff of Mazandaran University of Medical Sciences.
Methods and Materials:
This descriptive and cross-sectional study was conducted using medical absenteeism (sickness absence) persons happened in 2010. Research population was included all records of staff working in central departments of Mazandaran University of Medical Sciences. There was no sampling due to the importance of the issue. Studied variables were included age, gender, employment status, employees’ education, name of the disease, physician specialty in issuing the medical absence paper, leave issuing reference and department, position of the employee, number of absence days, number of absences, number of annual leave days. Also, data were gathered using a checklist, then were entered into the SPSS software and got analyzed using descriptive statistics. In order to respect the confidentiality, name of the doctors and employees weren’t mentioned publicly.
Based on the results, 1200 employees were leaved the organization due to the sickness issue, which 957 (79.7%) of them were studied. The mean age for those employees was 39±7. Also, total average sick leave days and total sick leave days were 2±1 and 2571, respectively. 40.8 % ( 390 employees) were male and the rest were female. Moreover, 18.3% of sick leaves were issued for singles and the remained were for married employees. Regarding the employees’ education, 2% under diploma, 11.3% diploma, 7.8% upper diploma, 47.6% B.Sc., 14.6% MS.c and 15.85 had doctorate degree. Considering their position, 65%, 30.3%, 2.5% and 1.8% were experts, others, heads, and mangers, respectively. Furthermore, their employment status indicated that 62.3%, 18.1%, 16.8% and 2.8% of employees were employed in form of formal, short-term contract, long-term contract and other forms, respectively. Among the aspiratory diseases, 115 persons had got cold and 97 were infected to flu. The prevalence of other diseases was as follows: neck and back pain among the skeletal diseases (118 persons), fever and headache among the signs (71 persons) and diarrhea and vomiting among the infectious diseases (88 persons).
According to the study results, due to the nature of staff work, physical problems, which are caused by doing mental works as well as low mobility, are rising among the employees. Of course, practicing ergonomic considerations, devoting hours in form of exercise break for staff can be effective in this regard. In order to address other diseases, vaster researches are needed with a concentration on exact reasons of work absenteeism.
PMCID: PMC3914745  PMID: 24511264
Absenteeism; Medical absenteeism; Employees; Sick leave; Disease.
20.  Partial sick leave associated with disability pension: propensity score approach in a register-based cohort study 
BMJ Open  2012;2(6):e001752.
To support sustainability of the welfare society enhanced work retention is needed among those with impaired work ability. Partial health-related benefits have been introduced for this target. The aim was to estimate the effects of partial sick leave on transition to disability pension applying propensity score methods.
Register-based cohort study.
Sample from the national sickness insurance registers representative of the Finnish working population (full-time workers) with long-term sickness absence due to musculoskeletal disorders, mental disorders, traumas or tumours.
All recipients of partial or full sickness benefit whose sick leave period had ended between 1 May and 31 December 2007 were included. The sample was limited to four most prevalent diagnostic groups—mental and musculoskeletal disorders, traumas and tumours. The total sample consisted of 1047 subjects on partial sick leave (treatment group) and 28 380 subjects on full sick leave (control group). A subsample (1017 and 25 249 subjects, respectively) was formed to improve the comparability of the two groups.
Outcome measures
A three-category measure and a binary measure for the occurrence of disability pension on the last day of 2008 were computed.
Partial sickness benefit reduced the risk (change in absolute risk) of full disability pension by 6% and increased the risk of partial disability pension by 8% compared with full sick leave. The effects did not differ markedly for the two main diagnostic groups of musculoskeletal and mental disorders. In men, the use of full disability pension was reduced by 10% with a 5% increase in the use of partial disability pension, while in women the effects were close to those of the total sample.
Our findings suggest that combining work with partial sick leave may provide one means to increase work retention at population level. The use of partial sick leave could be encouraged among men.
PMCID: PMC3533026  PMID: 23144260
Epidemiology; Public Health; Population Registers
21.  The role of extended weekends in sickness absenteeism 
OBJECTIVES—Employees are thought to lengthen their weekends by voluntary absenteeism, but the magnitude of such potentially reversible behaviour is not known.
METHODS—A follow up study based on employers' registers on the dates of work contracts and absences in 27 541 permanent full time municipal employees in five towns during 1993-7. The absence rate on each weekday separately for all sick leaves and for 1 day sick leaves was determined.
RESULTS—3.4% of the male employees and 5.0% of the female employees were on sick leave daily. The mean rate of sickness absence was lowest on Mondays, after which it increased towards Wednesday, and remained on the same level for the rest of the week. This pattern applied to both sexes, to each year of the follow up, and across towns, age groups, and income groups. For 1 day sick leaves, representing 4.5% of the total sickness absenteeism, the rates of sick leave for Mondays and Fridays were 1.4 and 1.9 times greater than those for other weekdays. However, these excess rates account for less than 1% of all days lost due to sickness absenteeism. Extended weekend absences were more common in men, in young employees, and in those in a low socioeconomic position, and they varied between towns.
CONCLUSION—Extended weekends seem to contribute only marginally to the days lost due to sickness absenteeism.

Keywords: occupational health; sickness absence; management
PMCID: PMC1740078  PMID: 11706149
22.  Sick-listing adherence: a register study of 1.4 million episodes of sickness benefit 2010–2013 in Sweden 
BMC Public Health  2015;15:380.
This register study aims to increase the knowledge on how common it is that sickness benefit recipients are sick-listed for as long as their physician prescribes in their medical sickness certificate, i.e. sick-listing adherence, or wholly/partly bring return-to-work (RTW) forward, i.e. early RTW.
The unit for analysis was an episode of 100% sickness benefit, commenced between 1 January 2010 and 31 December 2013. Completed episodes of sickness benefit and full or partial early RTW was analysed by comparing the prescribed length of sick leave in medical sickness certificates and benefit days disbursed by the sickness insurance system. Probability for a full and partial early RTW was estimated with hazard ratio (HR) using the Cox proportional hazard model.
In total, about 1.4 million episodes of sickness benefit (60% women) were included in the study. The overall sick-listing adherence was 84% for women and 82% for men during the first year of sick leave. Adherence varied between 82 and 87% among women and between 79 and 86% among men with regard to ICD-10 diagnosis chapter. The probability of an early RTW varied between diagnosis chapters, where mental disorders was associated with a lower probability of a full early RTW among women and men (HR 0.52 and HR 0.47) as well as a partial early RTW (HR 0.51 and HR 0.46). Younger age (16–29 years), high educational level and high income was associated with a higher probability of an early RTW, while older age (≥50 years), not native-born, low educational level, unemployment and parental leave were associated with a lower probability.
The study demonstrates that sick-listing adherence is relatively high. Probability of an early RTW differs with regard to diagnosis chapter, demographic, socioeconomic and labour market characteristics of the sickness benefit recipients. Interventions intended to improve the sick-listing process, and to affect the length and degree of sick leave in certain target groups, should include measures targeted at physicians’ sick-listing practices. Policies and economic incentives aimed at promoting RTW need to focus on individuals’ residual capacity for work.
PMCID: PMC4399111  PMID: 25887477
Sickness certification; Sick-listing; Adherence; Compliance; Sickness benefit; Return-to-work; Social insurance medicine; Gender; Register study; Sweden
23.  Effectiveness of a Blended Web-Based Intervention on Return to Work for Sick-Listed Employees With Common Mental Disorders: Results of a Cluster Randomized Controlled Trial 
Common mental disorders are strongly associated with long-term sickness absence, which has negative consequences for the individual employee’s quality of life and leads to substantial costs for society. It is important to focus on return to work (RTW) during treatment of sick-listed employees with common mental disorders. Factors such as self-efficacy and the intention to resume work despite having symptoms are important in the RTW process. We developed “E-health module embedded in Collaborative Occupational health care” (ECO) as a blended Web-based intervention with 2 parts: an eHealth module (Return@Work) for the employee aimed at changing cognitions of the employee regarding RTW and a decision aid via email supporting the occupational physician with advice regarding treatment and referral options based on monitoring the employee’s progress during treatment.
This study evaluated the effect of a blended eHealth intervention (ECO) versus care as usual on time to RTW of sick-listed employees with common mental disorders.
The study was a 2-armed cluster randomized controlled trial. Employees sick-listed between 4 and 26 weeks with common mental disorder symptoms were recruited by their occupational health service or employer. The employees were followed up to 12 months. The primary outcome measures were time to first RTW (partial or full) and time to full RTW. Secondary outcomes were response and remission of the common mental disorder symptoms (self-assessed).
A total of 220 employees were included: 131 participants were randomized to the ECO intervention and 89 to care as usual (CAU). The duration until first RTW differed significantly between the groups. The median duration was 77.0 (IQR 29.0-152.3) days in the CAU group and 50.0 (IQR 20.8-99.0) days in the ECO group (hazard ratio [HR] 1.390, 95% CI 1.034-1.870, P=.03). No significant difference was found for duration until full RTW. Treatment response of common mental disorder symptoms did not differ significantly between the groups, but at 9 months after baseline significantly more participants in the ECO group achieved remission than in the CAU group (OR 2.228, 95% CI 1.115-4.453, P=.02).
The results of this study showed that in a group of sick-listed employees with common mental disorders, applying the blended eHealth ECO intervention led to faster first RTW and more remission of common mental disorder symptoms than CAU.
Trial Registration
Netherlands Trial Register NTR2108; (Archived by WebCite at
PMCID: PMC4468600  PMID: 25972279
occupational health; randomized controlled trial; mental health; depression; anxiety; sick leave
24.  Are environmental characteristics in the municipal eldercare, more closely associated with frequent short sick leave spells among employees than with total sick leave: a cross-sectional study 
BMC Public Health  2013;13:578.
It has been suggested that frequent-, short-term sick leave is associated with work environment factors, whereas long-term sick leave is associated mainly with health factors. However, studies of the hypothesis of an association between a poor working environment and frequent short spells of sick leave are few and results are inconsistent. Therefore, we aimed to explore associations between self-reported psychosocial work factors and workplace-registered frequency and length of sick leave in the eldercare sector.
Employees from the municipal eldercare in Aarhus (N = 2,534) were included. In 2005, they responded to a work environment questionnaire. Sick leave records from 2005 were dichotomised into total sick leave days (0–14 and above 14 days) and into spell patterns (0–2 short, 3–9 short, and mixed spells and 1–3 long spells). Logistic regression models were used to analyse associations; adjusted for age, gender, occupation, and number of spells or sick leave length.
The response rate was 76%; 96% of the respondents were women. Unfavourable mean scores in work pace, demands for hiding emotions, poor quality of leadership and bullying were best indicated by more than 14 sick leave days compared with 0–14 sick leave days. For work pace, the best indicator was a long-term sick leave pattern compared with a non-frequent short-term pattern. A frequent short-term sick leave pattern was a better indicator of emotional demands (1.62; 95% CI: 1.1-2.5) and role conflict (1.50; 95% CI: 1.2-1.9) than a short-term non-frequent pattern.
Age (= < 40 / >40 years) statistically significantly modified the association between the 1–3 long-term sick leave spell pattern and commitment to the workplace compared with the 3–9 frequent short-term pattern.
Total sick leave length and a long-term sick leave spell pattern were just as good or even better indicators of unfavourable work factor scores than a frequent short-term sick leave pattern. Scores in commitment to the workplace and quality of leadership varied with sick leave pattern and age. Thus, different sick leave measures seem to be associated with different work environment factors. Further studies on these associations may inform interventions to improve occupational health care.
PMCID: PMC3701566  PMID: 23764253
Cross-sectional; Home care services; Psychology, Social; Sick leave; Working environment
25.  Effectiveness and cost-effectiveness of an exposure-based return-to-work programme for patients on sick leave due to common mental disorders: design of a cluster-randomized controlled trial 
BMC Public Health  2009;9:140.
To reduce the duration of sick leave and loss of productivity due to common mental disorders (CMDs), we developed a return-to-work programme to be provided by occupational physicians (OPs) based on the principles of exposure in vivo (RTW-E programme). This study evaluates this programme's effectiveness and cost-effectiveness by comparing it with care as usual (CAU). The three research questions we have are: 1) Is an RTW-E programme more effective in reducing the sick leave of employees with common mental disorders, compared with care as usual? 2) Is an RTW-E programme more effective in reducing sick leave for employees with anxiety disorders compared with employees with other common mental disorders? 3) From a societal perspective, is an RTW-E programme cost-effective compared with care as usual?
This study was designed as a pragmatic cluster-randomized controlled trial with a one-year follow-up and randomization on the level of OPs. We aimed for 60 OPs in order to include 200 patients. Patients in the intervention group received the RTW-E programme. Patients in the control group received care as usual. Eligible patients had been on sick leave due to common mental disorders for at least two weeks and no longer than eight weeks. As primary outcome measures, we calculated the time until full return to work and the duration of sick leave. Secondary outcome measures were time until partial return to work, prevalence rate of sick leave at 3, 6, 9, and 12 months' follow-up, and scores of symptoms of distress, anxiety, depression, somatization, and fatigue; work capacity; perceived working conditions; self-efficacy for return to work; coping behaviour; avoidance behaviour; patient satisfaction; and work adaptations. As process measures, we used indices of compliance with the intervention in the intervention group and employee-supervisor communication in both groups. Economic costs were calculated from a societal perspective. The total costs consisted of the costs of consuming health care, costs of production loss due to sick leave and reduced productivity, and out-of-pocket costs of patients for travelling to their OP.
The results will be published in 2009. The strengths and weaknesses of the study protocol are discussed.
Trial registration
PMCID: PMC2689200  PMID: 19439084

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