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1.  A Clinically Integrated Post-Graduate Training Programme in Evidence-Based Medicine versus ‘No Intervention’ for Improving Disability Evaluations: A Cluster Randomised Clinical Trial 
PLoS ONE  2013;8(3):e57256.
Background
Although several studies have shown that teaching EBM is effective in improving knowledge, at present, there is no convincing evidence that teaching EBM also changes professional behaviour in practice. Therefore, the primary aim of this study was to evaluate the effectiveness of a clinically integrated post-graduate training programme in EBM on evidence-based disability evaluation.
Methods and Findings
In a cluster randomised controlled trial, fifty-four case-based learning groups consisting of 132 physicians and 1680 patients were randomly assigned to the intervention or control groups. A clinically integrated, post-graduate, 5-day training programme in evidence-based medicine, consisting of (home) assignments, peer teaching, interactive training in searching databases, lectures and brainstorming sessions was provided to the intervention group. The control group received no training. The primary outcome was evidence-based disability evaluation, as indicated by the frequency in use of evidence of sufficient quality in disability evaluation reports. There are no general EBM behaviour outcome measures available. Therefore, we followed general guidelines for constructing performance indicators and defined an a priori cut-off for determination of sufficient quality as recommended for evaluating EB training. Physicians trained in EBM performed more evidence-based disability evaluations compared to physicians in the control group (difference in absolute proportion 9.7%, 95% CI 3.5 to 15.9). The primary outcome differences between groups remained significant after both cluster-adjusted analysis and additional sensitivity analyses accounting for subjects lost to follow-up.
Conclusions
A EBM programme successfully improved the use of evidence in a non-hospital based medical specialty. Our findings support the general recommendations to use multiple educational methods to change physician behaviour. In addition, it appeared important that the professional context of the intervention was very supportive in the sense that searches in databases, using and applying guidelines and other forms of evidence are considered standard practice and are encouraged by colleagues and management.
doi:10.1371/journal.pone.0057256
PMCID: PMC3585805  PMID: 23469188
2.  Revealing barriers and facilitators to use a new genetic test: comparison of three user involvement methods 
Journal of Community Genetics  2012;3(4):237-249.
We compared three common user involvement methods in revealing barriers and facilitators from intended users that might influence their use of a new genetic test. The study was part of the development of a new genetic test on the susceptibility to hand eczema for nurses. Eighty student nurses participated in five focus groups (n = 33), 15 interviews (n = 15) or questionnaires (n = 32). For each method, data were collected until saturation. We compared the mean number of items and relevant remarks that could influence the use of the genetic test obtained per method, divided by the number of participants in that method. Thematic content analysis was performed using MAXQDA software. The focus groups revealed 30 unique items compared to 29 in the interviews and 21 in the questionnaires. The interviews produced more items and relevant remarks per participant (1.9 and 8.4 pp) than focus groups (0.9 and 4.8 pp) or questionnaires (0.7 and 2.3 pp). All three involvement methods revealed relevant barriers and facilitators to use a new genetic test. Focus groups and interviews revealed substantially more items than questionnaires. Furthermore, this study suggests a preference for the use of interviews because the number of items per participant was higher than for focus groups and questionnaires. This conclusion may be valid for other genetic tests as well.
doi:10.1007/s12687-012-0080-6
PMCID: PMC3461230  PMID: 22318407
User involvement; Genetic testing; Public opinion; Attitude; Contact dermatitis; Occupational health
3.  Review on the validity of self-report to assess work-related diseases 
Purpose
Self-report is an efficient and accepted means of assessing population characteristics, risk factors, and diseases. Little is known on the validity of self-reported work-related illness as an indicator of the presence of a work-related disease. This study reviews the evidence on (1) the validity of workers’ self-reported illness and (2) on the validity of workers’ self-assessed work relatedness of an illness.
Methods
A systematic literature search was conducted in four databases (Medline, Embase, PsycINFO and OSH-Update). Two reviewers independently performed the article selection and data extraction. The methodological quality of the studies was evaluated, levels of agreement and predictive values were rated against predefined criteria, and sources of heterogeneity were explored.
Results
In 32 studies, workers’ self-reports of health conditions were compared with the "reference standard" of expert opinion. We found that agreement was mainly low to moderate. Self-assessed work relatedness of a health condition was examined in only four studies, showing low-to-moderate agreement with expert assessment. The health condition, type of questionnaire, and the case definitions for both self-report and reference standards influence the results of validation studies.
Conclusions
Workers’ self-reported illness may provide valuable information on the presence of disease, although the generalizability of the findings is limited primarily to musculoskeletal and skin disorders. For case finding in a population at risk, e.g., an active workers’ health surveillance program, a sensitive symptom questionnaire with a follow-up by a medical examination may be the best choice. Evidence on the validity of self-assessed work relatedness of a health condition is scarce. Adding well-developed questions to a specific medical diagnosis exploring the relationship between symptoms and work may be a good strategy.
doi:10.1007/s00420-011-0662-3
PMCID: PMC3299958  PMID: 21667280
Self-report; Work-related illness; Work-related diseases; Validation; Occupational health
4.  Empowering employees with chronic diseases: process evaluation of an intervention aimed at job retention 
Purpose
Employees with a chronic disease may experience work-related problems that contribute to the risk of job loss. We developed a group-based intervention programme aimed at clarifying problems, making these a subject of discussion at work, and realizing solutions. This process evaluation investigates the intervention’s feasibility and the satisfaction of 64 participants in eight groups.
Methods
Data were collected through process evaluation forms and self-report questionnaires.
Results
The recruitment of participants was time-consuming. Highly educated women working in the service sector were overrepresented. The programme was administered as planned, although components were sometimes only discussed briefly, due to lack of time. Satisfaction with the overall programme among participants was high; it was perceived as effective and there were only three dropouts. In particular, the focus on feelings and thoughts about having a chronic disease was highly valued, as were the exchange of experiences and role-playing directed at more assertive communication.
Conclusions
A vocational rehabilitation programme aimed at job retention is feasible and is perceived to be effective. Such a programme should address psychosocial aspects of working with a chronic disease beside practical problems. The recruitment of participants is time-consuming. Cooperation with outpatient clinics is necessary in order to reach all groups of employees with a chronic disease that might benefit from job retention programmes. Trial registration: ISRCTN77240155
doi:10.1007/s00420-010-0577-4
PMCID: PMC3016203  PMID: 20848126
Process evaluation; Chronic disease; Vocational rehabilitation; Occupational health; Job satisfaction; Job retention
5.  Activities of occupational physicians for occupational health services in small-scale enterprises in Japan and in the Netherlands 
Objectives
Occupational health service (OHS) for small-scale enterprises (SSEs) is still limited in many countries. Both Japan and the Netherlands have universal OHS systems for all employees. The objective of this survey was to examine the activities of occupational physicians (OPs) in the two countries for SSEs and to investigate their proposals for the improvement of service.
Methods
Questionnaires on types and sizes of the industries they serve, allocation of service hours (current and desired), sources of information for occupational health activities etc. were mailed in 2006 to 461 and 335 Japanese and Dutch OPs, respectively, who have served in small- and medium-scale enterprises. In practice, 107 Japanese (23%) and 106 Dutch physicians (32%) replied, respectively.
Results and Conclusions
Total service time per month was longer for OPs in the Netherlands than OPs in Japan. Japanese OPs spent more hours for health and safety meetings, worksite rounds, and prevention of overwork-induced ill health (14–16% each). Dutch OPs used much more hours for the guidance of absent workers (48%). Thus, service conditions were not the same for OPs in the two countries. Nevertheless, both groups of OPs unanimously considered that employers are the key persons for the improvement of OHS especially in SSEs and their education is important for better OHS. The conclusions should be taken as preliminary, however, due to study limitations including low response rates in both groups of physicians.
doi:10.1007/s00420-010-0514-6
PMCID: PMC2836247  PMID: 20130904
Education; Employer; Occupational physician; Occupational health services; Small-scale enterprises
6.  Facilitating Empowerment in Employees with Chronic Disease: Qualitative Analysis of the Process of Change 
Introduction In the field of healthcare, empowering patients who have a chronic disease is defined as increasing their knowledge and skills, in order to enable them to define their treatment goals and take personal responsibility for their medical treatment. Our goal was to explore the nature of empowerment for employees who have a chronic disease and who experience work-related problems. Methods We used an explorative qualitative approach to document, from a professional perspective, the experiences of patients who participated in an empowerment training program. The researcher and the three instructors identified several themes which appeared to be important to many participants. These themes were fine-tuned and illustrated using brief case histories. Results We identified seven themes and characterized them in terms of employee tasks. These included: (1) developing a realistic understanding of one’s abilities, (2) standing up for oneself in a self-confident way, (3) maintaining social relations based on mutual understanding with supervisors and colleagues, (4) collecting and assimilating knowledge of one’s options, rights and duties, (5) consulting others and negotiating with regard to work accommodations, (6) planning one’s job so as to provide personal satisfaction, and (7) maintaining a social life outside work. Not every employee is faced with all of these tasks, but most have to deal with several. Conclusion Empowerment presupposes that employees with a chronic disease can act to solve problems at the workplace. The experiences during a comprehensive empowerment training illustrate that a process of reflection on personal emotions and a cognitive process of exploration and identification of bottlenecks at work may precede these actions. Our primary contribution is the aforementioned list of seven common tasks that many workers have to perform. Disseminating the list can support employees who have a chronic disease and may also be useful for their managers, HRM staff, occupational health and other healthcare workers.
doi:10.1007/s10926-009-9188-x
PMCID: PMC2775116  PMID: 19582552
Job retention; Chronic disease; Rehabilitation, vocational; Disability management; Work disability; Employment; Workplace; Job satisfaction; Occupational health; Return to work
7.  Information and feedback to improve occupational physicians’ reporting of occupational diseases: a randomised controlled trial 
Purpose
To assess the effectiveness of supplying occupational physicians (OPs) with targeted and stage-matched information or with feedback on reporting occupational diseases to the national registry in the Netherlands.
Methods
In a randomized controlled design, 1076 OPs were divided into three groups based on previous reporting behaviour: precontemplators not considering reporting, contemplators considering reporting and actioners reporting occupational diseases. Precontemplators and contemplators were randomly assigned to receive stage-matched, stage-mismatched or general information. Actioners were randomly assigned to receive personalized or standardized feedback upon notification. Outcome measures were the number of OPs reporting and the number of reported occupational diseases in a 180-day period before and after the intervention.
Results
Precontemplators were significantly more male and self-employed compared to contemplators and actioners. There was no significant effect of stage-matched information versus stage-mismatched or general information on the percentage of reporting OPs and on the mean number of notifications in each group. Receiving any information affected reporting more in contemplators than in precontemplators. The mean number of notifications in actioners increased more after personalized feedback than after standardized feedback, but the difference was not significant.
Conclusions
This study supports the concept that contemplators are more susceptible to receiving information but could not confirm an effect of stage-matching this information on reporting occupational diseases to the national registry.
doi:10.1007/s00420-009-0468-8
PMCID: PMC2836252  PMID: 19830449
Reporting; Occupational diseases; Psychological models; Information dissemination; Occupational health physicians
8.  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.
Background
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?
Methods/design
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.
Discussion
The results will be published in 2009. The strengths and weaknesses of the study protocol are discussed.
Trial registration
ISRCTN72643128
doi:10.1186/1471-2458-9-140
PMCID: PMC2689200  PMID: 19439084
9.  Effect of an EBM course in combination with case method learning sessions: an RCT on professional performance, job satisfaction, and self-efficacy of occupational physicians 
Objective
An intervention existing of an evidence-based medicine (EBM) course in combination with case method learning sessions (CMLSs) was designed to enhance the professional performance, self-efficacy and job satisfaction of occupational physicians.
Methods
A cluster randomized controlled trial was set up and data were collected through questionnaires at baseline (T0), directly after the intervention (T1) and 7 months after baseline (T2). The data of the intervention group [T0 (n = 49), T1 (n = 31), T2 (n = 29)] and control group [T0 (n = 49), T1 (n = 28), T2 (n = 28)] were analysed in mixed model analyses. Mean scores of the perceived value of the CMLS were calculated in the intervention group.
Results
The overall effect of the intervention over time comparing the intervention with the control group was statistically significant for professional performance (p < 0.001). Job satisfaction and self-efficacy changes were small and not statistically significant between the groups. The perceived value of the CMLS to gain new insights and to improve the quality of their performance increased with the number of sessions followed.
Conclusion
An EBM course in combination with case method learning sessions is perceived as valuable and offers evidence to enhance the professional performance of occupational physicians. However, it does not seem to influence their self-efficacy and job satisfaction.
doi:10.1007/s00420-008-0315-3
PMCID: PMC2467503  PMID: 18386046
Evidence-based medicine; Continuing medical education; Knowledge management; Occupational physician; Professionalism
10.  Effectiveness of e-learning in continuing medical education for occupational physicians 
Background Within a clinical context e-learning is comparable to traditional approaches of continuing medical education (CME). However, the occupational health context differs and until now the effect of postgraduate e-learning among occupational physicians (OPs) has not been evaluated.
Aim To evaluate the effect of e-learning on knowledge on mental health issues as compared to lecture-based learning in a CME programme for OPs.
Methods Within the context of a postgraduate meeting for 74 OPs, a randomized controlled trial was conducted. Test assessments of knowledge were made before and immediately after an educational session with either e-learning or lecture-based learning.
Results In both groups, a significant gain in knowledge on mental health care was found (P < 0.05). However, there was no significant difference between the two educational approaches.
Conclusion The effect of e-learning on OPs' mental health care knowledge is comparable to a lecture-based approach. Therefore, e-learning can be beneficial for the CME of OPs.
doi:10.1093/occmed/kqn053
PMCID: PMC2493067  PMID: 18495676
Continuing medical education; e-learning; mental health; occupational medicine; randomized controlled trial
11.  Irrational Beliefs in Employees with an Adjustment, a Depressive, or an Anxiety Disorder: a Prospective Cohort Study 
It remains unclear if patients with different types of common mental disorders, such as adjustment, anxiety and depressive disorders, have the same irrational ideas. The aim of this prospective cohort study (n = 190) is to investigate differences in level and type of irrational beliefs among these groups and to examine whether a change in irrational beliefs is related to symptom recovery. Irrational beliefs (IBI) and symptoms were measured at four points in time: at baseline, after 3, 6 and 12 months. Results showed that diagnostic groups differed in their level of irrational beliefs and this effect remained over time. Highest levels of irrationality were observed in the double diagnosis group, followed by the anxiety disorder group and the depression group. Participants with adjustment disorders showed the lowest levels of irrationality, comparable to a community sample. We did not find differences in the type of irrational beliefs between diagnostic groups. The level of irrationality declined over time for all diagnostic groups. No differences in decrease were observed between diagnostic groups. The magnitude and direction of change in irrational beliefs were related to the magnitude of recovery of depressive, anxiety and stress symptoms over time. These results support the application of general cognitive interventions, especially for patients with a depressive or an anxiety disorder.
doi:10.1007/s10942-007-0075-0
PMCID: PMC2862953  PMID: 20445759
Irrational beliefs; Cognitive therapy; Common mental disorders; Follow-up studies
12.  Coping and sickness absence 
Objectives
The aim of this study is to examine the role of coping styles in sickness absence. In line with findings that contrast the reactive–passive focused strategies, problem-solving strategies are generally associated with positive results in terms of well-being and overall health outcomes; our hypothesis is that such strategies are positively related to a low frequency of sickness absence and with short lengths (total number of days absent) and durations (mean duration per spell).
Methods
Using a prospective design, employees’ (N = 3,628) responses on a self-report coping inventory are used to predict future registered sickness absence (i.e. frequency, length, duration, and median time before the onset of a new sick leave period).
Results and conclusions
In accordance with our hypothesis, and after adjustment for potential confounders, employees with an active problem-solving coping strategy are less likely to drop out because of sickness absence in terms of frequency, length (longer than 14 days), and duration (more than 7 days) of sickness absence. This positive effect is observed in the case of seeking social support only for the duration of sickness absence and in the case of palliative reaction only for the length and frequency of absence. In contrast, an avoidant coping style, representing a reactive–passive strategy, increases the likelihood of frequent absences significantly, as well as the length and duration of sickness absence. Expression of emotions, representing another reactive–passive strategy, has no effect on future sickness absenteeism. The median time before the onset of a new episode of absenteeism is significantly extended for active problem-solving and reduced for avoidance and for a palliative response.
The results of the present study support the notion that problem-solving coping and reactive–passive strategies are inextricably connected to frequency, duration, length and onset of sickness absence. Especially, active problem-solving decreases the chance of future sickness absence.
doi:10.1007/s00420-007-0238-4
PMCID: PMC2175021  PMID: 17701200
Coping; UCL; Sickness absence; Duration; Length; Frequency

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