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Respectful encounters and return to work: Empirical study of long-term sicklisted patients' experiences of Swedish healthcare

Authors:
Niels Lynöe at Karolinska Institutet
Niels Lynöe
Maja Wessel at Stockholm County Council
Maja Wessel
Daniel Olsson at Karolinska Institutet
Daniel Olsson
Kristina Alexanderson at Karolinska Institutet
Kristina Alexanderson
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Abstract and Figures

Aims To study long-term sick-listed patients' self-estimated ability to return to work after experiences of healthcare encounters that made them feel either respected or wronged. Methods A cross-sectional and questionnaire-based survey was used to study a sample of long-term sick-listed patients (n=5802 respondents). The survey included questions about positive and negative encounters as well as reactions to these encounters, such as ‘feeling respected’ and ‘feeling wronged’. The questionnaire also included questions about the effects of these encounters on the patients' ability to return to work. Results Among patients who had experienced positive encounters, those who also felt respected (n=3327) demonstrated significantly improved self-estimated ability to return to work compared to those who did not feel respected (n=79) (62% (95% CI 60% to 64%) vs 34% (95% CI 28% to 40%)). Among patients with experiences of negative encounters, those who in addition felt wronged (n=993) claimed to be significantly more impeded from returning to work compared to those who did not feel wronged (n=410) (50% (95% CI 47% to 53%) vs 31% (95% CI 27% to 35%)). Conclusions The study indicates that positive encounters in healthcare combined with feeling respected significantly facilitate sickness absentees' self-estimated ability to return to work, while negative encounters combined with feeling wronged significantly impair it.
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Respectful encounters and return to
work: empirical study of long-term sick-
listed patients’experiences of Swedish
healthcare
Niels Lyno
¨e,
1
Maja Wessel,
1
Daniel Olsson,
2
Kristina Alexanderson,
3
Gert Helgesson
1
ABSTRACT
Aims: To study long-term sick-listed patients’
self-estimated ability to return to work after
experiences of healthcare encounters that made them
feel either respected or wronged.
Methods: A cross-sectional and questionnaire-based
survey was used to study a sample of long-term
sick-listed patients (n¼5802 respondents). The survey
included questions about positive and negative
encounters as well as reactions to these encounters,
such as ‘feeling respected’ and ‘feeling wronged’. The
questionnaire also included questions about the effects
of these encounters on the patients’ ability to return to
work.
Results: Among patients who had experienced
positive encounters, those who also felt respected
(n¼3327) demonstrated significantly improved
self-estimated ability to return to work compared to
those who did not feel respected (n¼79) (62% (95%
CI 60% to 64%) vs 34% (95% CI 28% to 40%)).
Among patients with experiences of negative
encounters, those who in addition felt wronged
(n¼993) claimed to be significantly more impeded
from returning to work compared to those who did not
feel wronged (n¼410) (50% (95% CI 47% to 53%) vs
31% (95% CI 27% to 35%)).
Conclusions: The study indicates that positive
encounters in healthcare combined with feeling
respected significantly facilitate sickness absentees’
self-estimated ability to return to work, while negative
encounters combined with feeling wronged
significantly impair it.
INTRODUCTION
During the last decade, several interventions
have aimed at reducing the high sick-leave
rates in Sweden.
1
The rate of long-term sick-
leave has been particularly high.
2
Different
interventions have sought to improve the
management of sickness certification, but
more knowledge is needed on how return to
work can be promoted among long-term
sickness absentees.
1e4
Some studies indicate that patients’ expe-
riences of healthcare encounters might
influence their chances of returning to
work.
5
Being listened to, having one’s ques-
tions answered and being believed are
among the most common items associated
with positive encounters among long-term
sick-listed patients. Correspondingly, experi-
ences of nonchalance, disrespect and distrust
are commonly associated with negative
encounters.
To cite: Lyno¨e N, Wessel M,
Olsson D, et al. Respectful
encounters and return to
work: empirical study of
long-term sick-listed
patients’ experiences of
Swedish healthcare. BMJ
Open 2011;2:e000246.
doi:10.1136/bmjopen-2011-
000246
<Prepublication history for
this paper is available online.
To view these files please
visit the journal online (http://
bmjopen.bmj.com).
Received 30 June 2011
Accepted 1 September 2011
This final article is available
for use under the terms of
the Creative Commons
Attribution Non-Commercial
2.0 Licence; see
http://bmjopen.bmj.com
1
Stockholm Centre for
Healthcare Ethics (CHE),
Department of Learning,
Informatics, Management
and Ethics, Karolinska
Institutet, Stockholm,
Sweden
2
Unit of Biostatistics,
Division of Epidemiology,
Department of Environmental
Medicine (IMM), Karolinska
Institutet, Stockholm,
Sweden
3
Division of Insurance
Medicine, Department of
Clinical Neuroscience,
Karolinska Institutet,
Stockholm, Sweden
Correspondence to
Dr Niels Lyno¨e;
niels.lynoe@ki.se
ARTICLE SUMMARY
Article focus
-To what extent can positive and perceived
respectful healthcare encounters influence long-
term sick-listed patients’ ability to return to
work?
-To what extent can negative and perceived unfair
healthcare encounters influence long-term sick-
listed patients’ ability to return to work?
Key messages
-Long-term sick-listed patients’ self-estimated
ability to return to work is significantly facilitated
if healthcare encounters are perceived as
respectful.
-Long-term sick-listed patients’ self-estimated
ability to return to work is significantly impeded
if healthcare encounters are perceived as unfair.
-The net effect of feeling respected was highest
among patients with somatic disorders, while the
net effect of feeling wronged was highest among
patients with psychiatric disorders.
Strengths and limitation of this study
-The study sample was large and we obtained
quite a high response rate.
-The outcome measure was the respondents’ self-
estimated ability to return to work, not their
actual ability.
-The findings are based on the views of long-term
sick-listed patients and so generalisation may not
be possible.
Lyno¨e N, Wessel M, Olsson D, et al.BMJ Open 2011;2:e000246. doi:10.1136/bmjopen-2011-000246 1
Open Access Research
The aim of the present study was to examine how, in
the experience of patients on long-term sick leave,
positive and negative encounters in healthcare affect
their self-estimated ability to return to work, and what
difference, if any, it makes if these experiences are
accompanied by feelings of being respected or wronged.
MATERIAL AND METHODS
The present study derives from a population-based and
cross-sectional questionnaire survey conducted among
randomly selected long-term sickness absentees
(n¼10 042) who in 2003 had an ongoing sick-leave spell
that had lasted for 6e8 months. There were 5802
respondents to the survey which was conducted in 2004;
the results of other aspects of the survey have been
previously reported.
6e8
In the present study we have
examined the respondents’ experiences using a ques-
tionnaire asking about positive and negative encounters,
what kinds of encounters they had experienced and how
they reacted in terms of feeling respected or wronged.
The response options were ‘yes’ and ‘no’ to the ques-
tions whether or not they had experiences of positive
and negative encounters in healthcare. To the questions
asking how the participants felt when experiencing
positive and negative encounters, there were several
response options, such as: ‘I felt respected/wronged’,
‘I was happy/disappointed’, ‘I felt satisfied/became
angry’, etc. The participants were asked whether or not
they completely agreed/disagreed or largely agreed/
disagreed with the option. When the results were
analysed, those who completely or largely agreed were
collapsed into one group (agree) as were those who
completely or largely disagreed (do not agree).
The patients were also asked to estimate how these
encounters had affected their ability to return to work,
in terms of being impeded, not being influenced or
being facilitated. Response options were not being
influenced, being impeded, being facilitated very much
or being facilitated to a certain extent. When results
were analysed, the response options were collapsed into
those who were impeded and those who were facilitated.
In addition, the respondents were asked if they were sick-
listed for (a) psychiatric disorders, (b) musculoskeletal
pain, (c) other somatic diseases or (d) more than one of
the previous categories. When presenting the results, we
focus on respondents in categories aec.
The results are presented as proportions (with 95%
CIs) of those who estimated that return to work was
facilitated compared to those who stated that return to
work was not influenced or impeded when experiencing
positive encounters/feeling respected, and of those who
felt impeded compared to those who stated that return
to work was not influenced or facilitated when experi-
encing negative encounters/feeling wronged. Focusing
on the association between respectful/unfair encounters
and return to work, we performed logistic regression
analysis adjusting for different background variables
such as sex, age, educational level and different diag-
noses. However, adjustment made no substantial differ-
ence to the results. Accordingly, we present the crude
proportions with 95% CIs.
The frequency and associations between positive
encounters and feeling respected, and negative
encounters and feeling wronged, are presented as
attributable risks (AR)
9
with a 95% CI, using the R-
package pARtial.
10
Since a majority of all encounters
concerned physicians (70%), we have replaced the
wording ‘healthcare providers including physiothera-
pists and midwives’ in the questionnaire with ‘physicians’
in the text.
The study was approved by the regional research ethics
committee in Linko
¨ping (Dnr 03-261).
RESULTS
The response rate was 58% (n¼5802) of the original
sample. Of the participants who had experienced posi-
tive encounters (n¼3406), 97.7% (95% CI 97.2% to
98.2%) stated that they also felt respected. Among those
who had experienced negative encounters (n¼1403),
70.8% (95% CI 68.4% to 73.2%) declared they also felt
wronged (figure 1).
When comparing patients who had experienced
negative encounters and felt wronged with those who
had experienced negative encounters but not felt
wronged, we found a significantly higher proportion of
patients in the former category who reported that they
were impeded from returning to work (50% (95% CI
47% to 53%) vs 31% (95% CI 27% to 35%)) (table 1).
When adding feeling wronged to negative encounters,
the self-rated hindering effect on return to work was
highest among patients on sickness absence for
Figure 1 The left-hand side of
the figure shows the distribution of
answers regarding experiences of
positive healthcare encounters in
relation to self-estimated influence
on return to work. The sample is
divided into those who
experienced positive encounters
but did not feel respected and
those who experienced positive
encounters and felt respected. The right-hand side of the figure shows the distribution of answers regarding negative encounters in
relation to self-estimated influence on return to work. The sample is divided into those who did not and did feel wronged.
2Lyno¨e N, Wessel M, Olsson D, et al.BMJ Open 2011;2:e000246. doi:10.1136/bmjopen-2011-000246
Medical encounters’ effect on sick-listed patients’ return to work
‘psychiatric disorders’ (38% (95% CI 29% to 37%) vs
59% (95% CI 54% to 64%)) and lowest among
those sick-listed for ‘other somatic conditions’ (28%
(95% CI 19% to 37%) vs 39% (95% CI 32% to 47%))
(table 2).
The patients who stated that they had experienced
positive encounters and felt respected claimed to
a significantly higher degree that return to work was
facilitated by the encounter, compared to those who
experienced positive encounters but did not
feel respected (62% (95% CI 60% to 64%) vs 34% (95%
CI 28% to 40%)) (table 1). When adding feeling
respected to positive encounters, the self-rated facili-
tating effect on return to work was highest among those
sick-listed for ‘other somatic conditions’ (23% (95% CI
5% to 41%) vs 54% (95% CI 51% to 58%)) and lowest
among patients sick-listed for ‘psychiatric disorders’
(53% (95% CI 29% to 77%) vs 76% (95% CI 74% to
79%)) (table 3).
There was no significant difference between women
and men, but we noticed a tendency for women who felt
respected to reply more often that this had increased
their ability to return to work (63% (95% CI 61% to
64%) for women vs 59% (95% CI 56% to 61%) for men).
Men, on the other hand, tended to be more inclined to
find themselves impeded from returning to work if
feeling wronged (55% (95% CI 48% to 61%) vs 49%
(95% CI 45% to 52%) for women).
DISCUSSION
We found that patients on long-term sick leave experi-
enced positive healthcare encounters as facilitating
return to work, while negative encounters impeded it.
The facilitating effect of positive encounters was signifi-
cantly augmented when combined with the patient
feeling respected, while return to work was significantly
reduced if negative encounters were combined with
feeling wronged. Feeling respected had a greater effect
in relation to positive encounters regarding return to
work than feeling wronged had in relation to negative
encounters (table 1).
Encounters may affect return to work
Insofar as the respondents’ experiences fully or partly
reflect their actual ability to return to work, these find-
ings identify a number of aspects of physicianepatient
interactions that have to be handled properly in order to
facilitate patients’ chances of returning to work. There is
much discussion on how to promote return to work
among long-term sickness absentees, which focuses on
different types of rehabilitation measures.
3 5
The present
study suggests that physicians and other healthcare staff
may also have an impact on patients’ ability to return to
work through the way they interact with patients. This
agrees with the results of an interview study indicating
that such encounters had as great an impact on return to
work as rehabilitation measures.
11
Table 1 Self-estimated effect among long-term sick-listed patients of positive and negative healthcare encounters on return to
work in relation to feeling/not feeling respected and feeling/not feeling wronged
Return to work was
Facilitated Not influenced Impeded
Positive encounters
Not feeling respected (n¼79) 34% (28% to 40%) 63% 3%
Feeling respected (n¼3327) 62% (60% to 64%) 37% 1%
Negative encounters
Not feeling wronged (n¼410) 8% 61% 31% (27% to 35%)
Feeling wronged (n¼993) 4% 46% 50% (47% to 53%)
The results are presented as proportions (95% CIs).
Table 2 Patients who experienced negative healthcare encounters and their self-estimated ability to return to work when
feeling/not feeling wronged, in relation to the reason for sickness absence
Type of medical disorder
Return to work was
Facilitated Not influenced Impeded
Psychiatric disorders
Not feeling wronged (n¼104) 5% 57% 38% (29% to 37%)
Feeling wronged (n¼316) 4% 37% 59% (54% to 64%)
Musculoskeletal disorders
Not feeling wronged (n¼142) 7% 66% 27% (20% to 34%)
Feeling wronged (n¼302) 7% 49% 44% (38% to 49%)
Other somatic disorders
Not feeling wronged (n¼86) 5% 67% 28% (19% to 37%)
Feeling wronged (n¼161) 4% 57% 39% (32% to 47%)
The results are presented as proportions (95% CIs).
Lyno¨e N, Wessel M, Olsson D, et al.BMJ Open 2011;2:e000246. doi:10.1136/bmjopen-2011-000246 3
Medical encounters’ effect on sick-listed patients’ return to work
Patients’ understanding of being respected and being
wronged
It should be noted that the survey does not provide any
details as to what the respondents meant by feeling
respected and feeling wronged. In medicine, respecting
patients usually relates to respecting their right to
autonomous decision-making. Physicians are supposed
to respect patient autonomy and also to enhance it, for
example, by support and encouragement. Showing
respect for patient autonomy might enhance patients’
self-esteem and enable them to accomplish more.
5
It
may thus facilitate their self-estimated as well as their
actual ability to return to work. In practice, showing
respect for patient autonomy might involve basic good
manners such as treating the patient as competent and
showing a genuine interest in what they say.
However, a list of reasonable behaviours towards
patients does not cover all aspects of treating them with
respect. We found that something was added when the
patients felt that they had experienced positive health-
care encounters and also felt respected, as was shown by
their estimations of their ability to return to work. What
this addition more specifically consists of cannot be
determined from our questionnaire survey, but does
deserve to be further examined. For instance, people
might understand ‘being respected’ as being respected
more broadly as a person and not solely as having one’s
autonomy respected.
Similar remarks can be made regarding negative
encounters and feeling wronged. Instead of empowering
patients’ self-esteem, experiences of being wronged
might impair patients and decrease their ability to return
to work. Thus, disrespecting patients is regrettable in
itself and might also have negative consequences for
their wellbeing.
12
Feeling wronged is, however, not necessarily the same
as actually being wronged, and it may be that patients
sometimes provoke the doctor to act in a less appro-
priate way.
13 14
Provoked or not, there may be situations
where patients perceive the doctor as intimidating,
condescending or patronising, while the physician does
not realise until afterwards that the encounter could
have been perceived that way.
14
We find it interesting that patients who were absent
from work due to psychiatric disorders seemed to be
more affected by feeling wronged in their encounters
than those with somatic disorders. Perhaps psychiatric
patients are more sensitive to having their autonomy
questioned. However, when feeling respected was added
to the experience of positive encounters, it had little
influence on patients sick-listed for psychiatric disorders.
In this case, patients with ‘other somatic conditions’
were the most sensitive group. We have no explanation
for this inverse result.
Limitations
Since our data concern a special patient group, the
results may not be generalisable to the general patient
population. Long-term sick listed patients may, for
instance, have faced greater disappointments in their
healthcare contacts than other patient groups. They may
also have had more experience of not being believed.
However, regarding the effect of positive encounters, our
results are supported by other studies. One report points
to a reduction in sick-leave duration for patients with
tonsillitis,
15
while another study identifies improvements
in HbA1c and LDL-cholesterol in patients with
diabetes.
16
Another limitation is that the study concerns patients’
self-estimations of the influence of positive and negative
healthcare encounters on their ability to return to work.
Such estimates may be difficult to make, and patients
may over- or underestimate the influence of these
encounters. Further research is needed to establish the
influence of positive and negative healthcare encounters
on the ability to return to work in real life.
A third limitation is the non-response rate, which, as is
so often the case, is somewhat higher among men and
younger patients. Compared to other patient studies, the
response rate was high and the large number of subjects
provides a solid base for conclusions.
Table 3 Patients who experienced positive healthcare encounters and their self-estimated ability to return to work when
feeling/not feeling respected, in relation to the reason for sickness absence
Type of medical disorder
Return to work was
Facilitated Not influenced Impeded
Psychiatric disorders
Not feeling respected (n¼17) 53% (29% to 77%) 47% 0%
Feeling respected (n¼931) 76% (74% to 79%) 23% 1%
Musculoskeletal disorders
Not feeling respected (n¼28) 28% (11% to 45%) 68% 4%
Feeling respected (n¼1018) 53% (50% to 56%) 45% 2%
Other somatic disorders
Not feeling respected (n¼22) 23% (5% to 41%) 73% 4%
Feeling respected (n¼798) 54% (51% to 58%) 45% 1%
The results are presented as proportions (95% CIs).
4Lyno¨e N, Wessel M, Olsson D, et al.BMJ Open 2011;2:e000246. doi:10.1136/bmjopen-2011-000246
Medical encounters’ effect on sick-listed patients’ return to work
CONCLUSION
Our study indicates that feeling respected in healthcare
encounters significantly facilitates long-term sick-listed
patients’ self-estimated ability to return to work, while
feeling wronged significantly impairs it.
Funding This research received no specific grant from any funding agency in
the public, commercial or not-for-profit sectors.
Competing interests None.
Ethics approval The Research Ethics Committee in Linko¨ping approved this
study (Dnr 03-261).
Contributors NL had the original idea for the present study, took the leading
part in its conception and design, conducted the first statistical analysis,
contributed substantially to the interpretation of results, wrote the first draft of
the manuscript and participated in critical revision of later versions. MW and
DO conducted all further statistical analyses, contributed to the interpretation
of results and critically revised the manuscript. KA conceived and designed the
questionnaire and was responsible for data acquisition. She contributed
substantially to the interpretation of results and critically revised the
manuscript. GH contributed substantially to the conception and design of the
study and to the interpretation of results. He had a leading role in the revision
of the manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data available.
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Lyno¨e N, Wessel M, Olsson D, et al.BMJ Open 2011;2:e000246. doi:10.1136/bmjopen-2011-000246 5
Medical encounters’ effect on sick-listed patients’ return to work

Supplementary resources (3)

Reviewer comments
Data
October 2011
Niels Lynöe · Maja Wessel · Daniel Olsson · Kristina Alexanderson · Gert Helgesson
Author's manuscript
Data
October 2011
Niels Lynöe · Maja Wessel · Daniel Olsson · Kristina Alexanderson · Gert Helgesson
Supporting Statement
Data
October 2011
Niels Lynöe · Maja Wessel · Daniel Olsson · Kristina Alexanderson · Gert Helgesson
... Indeed, the literature has offered evidence of complicated procedures, poor communication and a lack of professional expertise among insurers (Black et al., 2019;Dean et al., 2019). Furthermore, insurers often come across as rulers with the power to dismiss claims or force tests, treatments and rehabilitation measures upon claimants without either listening to or respecting their thoughts and wishes (Lynöe et al., 2011;Strunin and Boden, 2004;Thornthwaite and Markey, 2017). Finally, the literature has reported that claimants can suffer from psychological, financial or social consequences because of the failures in the compensation system (Beardwood et al., 2005;Kilgour et al., 2015) [1]. ...
... Although the research has largely targeted the RTW-related roles of insurers within causebased workers' compensation systems (Kosny et al., 2011;Lippel, 2007), some studies have focused on social insurance officers within disability-based insurance systems (Hubertsson et al., 2011;Lynöe et al., 2011;Lynöe et al., 2013;Müssener et al., 2015) [2]. In Finland, disability insurance is part of statutory social security, which means that the contents of the insurance, including covered loss events and compensation amounts, are specified in legislation. ...
... During the analysis, the author prioritized the chain of events and the views of the interviewees on the roles of their insurers. The results that are based on the association between insurer roles and rehabilitation outcomes agree with those of earlier studies, indicating that positive encounters with social insurers can promote RTW among long-term sickness absentees (Lynöe et al., 2011;Olsson et al., 2016;Collie et al., 2019). ...
Facilitator or enforcer, ally or enemy? Claimant’s perceptions of insurers’ roles in occupational rehabilitation
Article
  • May 2022
Purpose This study aims to deepen the understanding of insurers’ role within the return-to-work (RTW) process by uncovering and categorizing the multiple roles assumed by the insurer based on the claimant’s perceptions and identifying the underlying mechanisms that explain the relationship between perceived insurer roles and occupational rehabilitation outcomes. Design/methodology/approach The author used a qualitative approach with theory-guided content analysis to examine 24 semi-structured interviews with occupational rehabilitation claimants who had undergone occupational rehabilitation within the earnings-related pension insurance system in Finland. Findings The author uncovered three perceived insurer roles in relation to other stakeholders in the rehabilitation network: financier, coordinator and leader. These roles have different perceived responsibilities and influences on rehabilitation outcomes. Additionally, the author found four perceived insurer roles in relation to the claimants, which varied according to their democracy and activity levels: ally, facilitator, enforcer or enemy. Based on this study, the author recommends that insurers adopt democratic and participatory actor roles (ally and facilitator) to promote the RTW process in occupational rehabilitation. Originality/value This inaugural study applied role theory to insurers within the RTW process, developing a new framework of insurer profiles. This study reveals the dynamic nature of insurers and enhances the understanding of the connections between perceived insurer roles and rehabilitation outcomes.
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... Some studies have explored sickness absentee's experiences of specific types of positive and negative encounters (49)(50)(51), and one study showed that a majority had experienced positive encounters with healthcare professionals, including aspects of being treated with respect and being listened to (6). A minority of sickness absentees had also experienced negative encounters with healthcare professionals, such as disrespectful encounters, being questioned (11,52,53), or being wronged (49,54). The experience of negative encounters might have mental, social, as well as occupational consequences (7). ...
... Sickness absentee's experiences of encounters have in some studies been related to their ability to RTW (6,8,9,11,12,(49)(50)(51)(52)(53)(54)(57)(58)(59). Specific types of positive encounters have been shown to promote the ability to RTW among patients (9-14), e.g., healthcare professionals listening to patients and offering helpful support during the period of recovery (52) or believing in the sickness absentees' work capacity (58). ...
... Specific types of positive encounters have been shown to promote the ability to RTW among patients (9-14), e.g., healthcare professionals listening to patients and offering helpful support during the period of recovery (52) or believing in the sickness absentees' work capacity (58). There are also studies showing that patient's experiences of interactions with healthcare professionals regarding work issues could be a contributing factor promoting RTW for sickness absentees with specific diagnoses, such as, heart failure, musculoskeletal pain, mental disorders, cancer in general, and injuries (10,14,54,57,58,(60)(61)(62)(63). Some previous studies have observed that sickness absent women experienced negative encounters from professionals more often men (53,63). ...
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... Based on research from face-to-face studies, treatment expectations are closely linked to the patient-clinician relationship (Connolly Gibbons et al., 2003;Visla, Constantino, Newkirk, Ogrodniczuk, & Sochting, 2018) where positive clinical encounters have been associated with better treatment outcome (Fluckiger, Del Re, Wampold, Symonds, & Horvath, 2012) higher placebo responses (Kaptchuk et al., 2008) and self-estimated ability to return to work, among sick-listed patients (Lynoe, Wessel, Olsson, Alexanderson, & Helgesson, 2011). Despite fundamental differences in treatment contexts and patient-clinician interactions, the present study found equivalent expectations in online and face-to-face treatment and no significant or clinically meaningful difference in the effect of expectations on the treatment outcome between the two modalities. ...
Association between expectations and clinical outcomes in online v. face-to-face therapy - an individual participant data meta-analysis
Article
Full-text available
  • Apr 2024
  • PSYCHOL MED
Background Online treatments are increasing in number and are currently available for a wide range of clinical problems. To date little is known about the role of treatment expectations and other placebo-like mechanisms in online settings compared to traditional face-to-face treatment. To address this knowledge gap, we analyzed individual participant data from randomized clinical trials that compared online and face-to-face psychological interventions. Methods MEDLINE (Ovid) and PsycINFO (Ovid) were last searched on 2 February 2021. Randomized clinical trials of therapist guided online v. face-to-face psychological interventions for psychiatric or somatic conditions using a randomized controlled design were included. Titles, abstracts, and full texts of studies were independently screened by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Authors of the matching trials were contacted for individual participant data. Ratings from the Credibility and Expectancy Questionnaire and the primary outcome measure from each trial were used to estimate the association between expectation ratings and treatment outcomes in online v. face-to-face interventions, using a mixed-effects model. Results Of 7045 screened studies, 62 full-text articles were retrieved whereof six studies fulfilled the criteria and provided individual participant data ( n = 491). Overall, CEQ ratings predicted clinical outcomes ( β = 0.27) at end of treatment with no moderating effect of treatment modality (online v. face-to-face). Conclusions Online treatment appears to be equally susceptible to expectancy effects as face-to-face therapy. This furthers our understanding of the importance of placebo-like factors in online treatment and may aid the improvement of healthcare in online settings.
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... 25 Research also suggests that patients' perceived ability to return to work increases if they have a positive perception of their physician's communicative attributes (eg, listening skills) and personal qualities (eg, respectfulness). 67,73,101 In a study of sick-listed individuals, Claréus et al. ...
Recovery expectations can be assessed with single-item measures: findings of a systematic review and meta-analysis on the role of recovery expectations on return-to-work outcomes following musculoskeletal pain conditions
Article
Full-text available
  • Sep 2022
  • PAIN
The objective of this systematic review is to quantify the association between recovery expectations and return-to-work outcomes in adults with musculoskeletal pain conditions. In addition, this review has the second objective to compare the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Relevant articles were selected from Embase, PsycINFO, PubMed, Cochrane and manual searches. Studies that assessed recovery expectations as predictors of return-to-work outcomes in adults with musculoskeletal pain conditions were eligible. Data was extracted on study characteristics, recovery expectations, return-to-work outcomes and the quantitative association between recovery expectations and return-to-work outcomes. Risk of bias was assessed using the Effective Public Health Practice Project. Odds ratios were pooled to examine the effects of recovery expectations on return-to-work outcomes. Chi-square analyses compared the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Thirty studies on a total of 28,741 individuals with musculoskeletal pain conditions were included in this review. The odds of being work disabled at follow-up were twice as high in individuals with low recovery expectations (OR = 2.06 (95% CI 1.20-2.92) p < .001). Analyses also revealed no significant differences in the predictive value of validated and non-validated single-item measures of recovery expectations on work disability (χ2 = 1.68, p = 0.19). There is strong evidence that recovery expectations are associated with return-to-work outcomes. The results suggest that single-item measures of recovery expectations can validly be used to predict return-to-work outcomes in individuals with musculoskeletal pain conditions.
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... Facilitating rTW can be challenging due to the complexity of work disability, in which several factors can be expected to influence rTW independent of injury and illness. Examples of such factors include gender, age, education, socioeconomic status, self-efficacy and expectations for recovery and rTW, work demands, rTW coordination, multidisciplinary interventions [15], encounters between patients and health/rTW professionals [16][17][18] and roles, beliefs and perceptions of various stakeholders [19]. Being able to work has been emphasised as meaningful by chronically ill people, despite time periods out of the workplace [20]. ...
Promoting labour market inclusion of the chronically ill: a scoping review of Scandinavian countries’ efforts
Article
Full-text available
  • May 2022
Objectives This article is a scoping review of efforts in labour market inclusion of the chronically ill in the Scandinavian countries, a research area that has received much political as well as research attention in recent years. The aim of the review was to identify promising strategies and the need for further research. Methods Six electronic databases were searched for literature published between 2015 and 2020. We included peer-reviewed articles that studied the effect of measures, aimed at the workplace or at the individual, that are intended to increase participation. Our search resulted in 2718 articles; our screening procedures resulted in 47 included articles. Results Among the included studies, musculoskeletal problems (17 articles) and mental health problems (29 articles) were the most frequent chronic conditions. Multimodal occupational rehabilitation programmes directed towards the individual employee were the most frequent interventions (30 articles). Return to work (24 articles) and sickness absence (12 articles) were the most common outcomes. About half (25 articles) of the included studies reported a positive impact of the intervention on work inclusion of the chronically ill. Conclusions Our review found little evidence of how government programmes directed towards the supply side of the labour market succeed in including the chronically ill. Our review further indicated that multidisciplinary workplace interventions have a substantial effect. We also identified a significant lack of research on the effect of various governmental policies and programmes, including local health, work and welfare services, and limited coordination and cooperation between health and work services professions.
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Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: Clinical Practice Guideline Methods
Article
  • Jul 2022
Objective: To present the methods used to develop a clinical practice guideline (CPG) with recommendations endorsed by key stakeholders for assessing, managing, and supporting return to work for adults with rotator cuff disorders. Design: Clinical practice guideline development. Methods: A steering committee composed of the research team of this project led the development of this CPG in five phases, which followed the standards of the NICE and AGREE II collaborations. During the preparation phase (I), a multidisciplinary working committee of experts in managing rotator cuff disorders (n=20) determined the scope and objectives of the CPG. The recommendations development phase (II) included initial knowledge synthesis, development of preliminary recommendations, systematic consultations with a multidisciplinary panel of key stakeholders (n=51) using a modified three-round Delphi approach and drafting of the original CPG. In the external evaluation phase (III), an external committee of experts evaluated the original CPG using the AGREE II tool. In the dissemination phase (IV) the strategy for disseminating the CPG was developed and implemented. During the update phase (V), the CPG was revised based on an update of the initial knowledge synthesis. Results: 73 preliminary recommendations were developed from the initial knowledge synthesis. During the Delphi consultation, all of these recommendations were endorsed, and one new recommendation was proposed by panelists. The original CPG received an overall AGREE II score of 83% from the external evaluators. In 2021, an update of the initial 2017 knowledge synthesis was conducted and 13 recommendations were revised. Conclusions: The 5-phase consensus methods approach guided the development of a high-quality CPG on assessing, managing and supporting return to work for adults with rotator cuff disorders.
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Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline
Article
  • Jul 2022
Objective: To develop a clinical practice guideline (CPG) covering the assessment, management, and return to work of adults with rotator cuff disorders. Design: Clinical practice guideline. Methods: Using systematic reviews, appraisal of the literature and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the Province of Quebec (Canada). Results: Recommendations (n=73) and clinical decision algorithms (n=3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, non-steroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return to work plan should be developed early, and in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. Conclusions: This CPG was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decision-making for diagnosis and treatment, and planning for successful return to work.
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The nature of positive encounters between disabled workers and insurers in the return to work process
Article
  • Sep 2021
  • Work
Background: Previous research regarding interaction between disabled workers and insurers indicates that encounters between these parties are predominantly negative in nature and may result in psychosocial harm for workers. Further research is required to investigate positive interactions to foster return to work after illness or injury. Objective: To explore and conceptualize perceived positive encounters between disabled workers and insurers in order to identify the mechanisms that support successful rehabilitation outcomes. Methods: This qualitative study explored the experiences of twenty-four disabled workers who had undergone an occupational rehabilitation process. Data were collected with in-depth semi-structured interviews, transcribed, coded, and analyzed using inductive content analysis. Results: Four main themes arose from the 24 key concepts relating to the positive encounters: (1) process flow, (2) customer orientation, (3) information and guidance, and (4) service attitude. The results also reveal that perceived positive encounters promote the return to work not only directly, but also indirectly by improving the informants' motivation, which has previously been found to be one of the most significant factors explaining the outcomes of rehabilitation. Conclusions: The positive relationship between disabled workers and insurers during an occupational rehabilitation could be better understood through a conceptualization of perceived positive encounters. Underlining the importance of positive encounters and their ability to improve the rehabilitee's motivation may contribute to better support methods for the return to work.
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Multivariate correlations between pain, life interference, health-related quality of life and full-time sick leave 1 year after multimodal rehabilitation, focus on gender and age
Article
Full-text available
  • Mar 2021
Background Chronic pain is a major and complex health condition associated with reduced work performance. A multimodal rehabilitation programme (MMRP) is a common intervention for chronic pain conditions, the goal being for the person to maintain or return to work. Aim To investigate the multivariate relationships between health-related quality of life, life interference, pain, physiological factors before MMRP and full-time sick leave 1 year after MMRP. Material and Methods Data were collected from the Swedish Quality Registry for Pain Rehabilitation. The study included 284 participants. Separate analyses were performed for women, men and three age groups. Results There were correlations between sick leave, physical functioning, pain duration, health-related quality of life, and self-assessed importance of work before MMRP and sick leave 1 year after MMRP. The patterns of factors associated with full-time sick leave varied for women, men and age groups. Conclusions These findings indicate that full-time sick leave for patients with chronic pain is affected by a number of interacting factors. Occupational therapy interventions aiming to develop activity skills in relation to work roles and enable patients to develop skills required to manage the physical, psychological and social demands to return to work or maintain work could be valuable to increase the possibility of attaining a sustainable work situation.
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Women's experiences of being in the sick leave process
Article
Full-text available
  • Apr 2020
Background: Being on sick leave is a risky situation, with loss of meaningful activities, exclusion from the labour market and losing the worker role. Although the benefits of the person’s active involvement in the sick leave process have been emphasized, an increase in sickness absence and longer sick leave periods is still seen, especially among women. Further studies are needed to more deeply understand the person’s own view of the situation. Aims/Objectives: To explore the experiences of being on sick leave among a group of women. Methods: An explorative, qualitative design was used. The analysis was based on individual, semi-structured interviews with 13 women, using qualitative content analysis. Results: Three categories emerged that describe the women’s experiences of the situation of being on sick leave: being regarded as an object, being supported and being engaged. The categories appeared as either barriers or enablers during the sick leave process. Conclusions: The sick leave process could be better understood through multiple dimensions, working at the individual, organizational and societal levels. Using occupation based models underlining the importance of the interaction between person, occupation (work activity) and the environment may contribute to elucidating the complexity in supporting options for the return to work.
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Encouraging Encounters
Article
Full-text available
  • Dec 2007
Long-term sickness-absence has increased in many countries and more knowledge is warranted on factors that can promote return-to-work (RTW). Interactions with professionals might be one such factor and especially experiences of positive encounters. The purpose of the study was to identify and analyze sick-listed persons' experiences of positive encounters with professionals within social insurance and healthcare. An inductive and descriptive qualitative approach was used to analyze ttanscripts from 11 semi-structured interviews with persons with experience of long-term sickness absence.The following five categories of qualities of encounters were found to be of importance: being treated with respect, feeling supported, establishing a personal relationship, perceiving demands as well-balanced, and participating in decisions regarding rehabilitation measures. Several interviewees expressed the opinion that positive encounters with professionals can promote RTW.Further research is needed to elucidate the aspects of interactions that enhance empowerment and self-confidence in persons on sick leave, in order to develop professional treatment strategies that facilitate RTW.
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Trends in long-term sickness absence in Sweden 1992-2008: The role of economic conditions, legislation, demography, work environment and alcohol consumption
Article
Full-text available
  • Apr 2011
  • INT J SOC WELF
Lidwall U, Marklund S. Trends in long-term sickness absence in Sweden 1992–2008: the role of economic conditions, legislation, demography, work environment and alcohol consumption Int J Soc Welfare 2011: 20: 167©179 © 2010 The Author(s), International Journal of Social Welfare © 2010 Blackwell Publishing Ltd and the International Journal of Social Welfare. In Sweden, absence from work because of illness or injury has fluctuated considerably over time. This study aimed to identify potentially important factors behind variations in long-term sickness absence. Aggregated data were used to assess factors correlated with the number of ongoing cases of sickness absence lasting more than 59 days. Trends were analysed using statistics from national social insurance records, labour force surveys and other official statistics. Although specific changes in the degree of generosity in the sickness insurance scheme were important in some cases, the results showed no consistent associations for the study period 1992–2008. Men were generally more sensitive to macroeconomic factors than women. Furthermore, compared with earlier findings, workforce composition had less impact on variations in long-term sickness absence. Notably, public health indicators such as alcohol sales and working conditions were clearly related to long-term sick leave during the period under investigation.
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Swedish Council on Technology Assessment in Health Care (SBU). Chapter 12. Future need for research
Article
Full-text available
  • Oct 2004
  • Scand J Publ Health Suppl
Despite the extensive consequences of sickness absence, scientific research is both surprisingly scarce and theoretically and conceptually underdeveloped. There are few longitudinal studies, and even fewer intervention studies. The medical aspects in sickness insurance are seldom addressed, effects of factors at different structural levels are not considered,and the consequences of sick leave have barely been studied. Furthermore, little is known about the employer's role and the layperson's perspectives. Gender and ethnicity factors should be considered further. The concept of work ability needs to be defined, problematized, and operationalized. However, it is not only more, but mainly it is studies of better quality that are needed, e.g. longitudinal studies, international comparative studies, and randomised controlled trials. This would require multidisciplinary research groups, long-term research environments, international commitment, opportunities for good professional development within the field, and reliable basic data, including sick-listing diagnoses.
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Positive experiences of encounters with healthcare and social insurance professionals among people on long-term sick leave
Article
Full-text available
  • Dec 2008
  • J REHABIL MED
To analyse different aspects of positive experiences of people on long-term sick leave with regard to their interactions with healthcare and social insurance professionals. A random population-based questionnaire survey among 10,042 long-term sick-listed people in Sweden. Statements related to positive encounters with the professionals were analysed. Factor analysis and logistic regression was used to identify possible associations with gender, age, marital status, country of birth, level of education, part- or full-time sickness absence, self-rated health, depression during the past year, and reasons for sick leave. Ninety-two percent of respondents had experienced positive encounters with healthcare and 73% had experienced positive encounters with social insurance. The mean rating was higher for healthcare. The respondents agreed most with the items "treated me with respect", "listened to me", and "was nice to me". Three aspects of interactions were identified: competence, personal attention, and confidence and trust. Women, people born in Sweden, and individuals with good self-rated health experienced the inter-actions as most positive. The majority of the respondents on long-term sickness absence have had positive interactions with healthcare and social insurance. More research is required to determine the impact that such experiences might have on return to work, and how such interactions might be promoted.
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A review of adjusted estimators of attributable risk
Article
  • Jun 2001
This paper reviews adjusted methods of estimation of attributable risk (AR), that is methods that allow one to obtain estimates of AR while controlling for other factors. Estimability and basic principles of AR estimation are first considered and the rationale for adjusted AR estimators is discussed. Then, adjusted AR estimators are reviewed focusing on cross-sectional, cohort and case-control studies. Two inconsistent adjusted estimators are briefly commented upon. Next, adjusted estimators based on stratification, namely the weighted-sum and Mantel-Haenszel (MH) approaches, are reviewed and contrasted. It appears that the weighted-sum approach, which allows for full interaction between exposure and adjustment factors, can be affected by small-sample bias. By contrast, the MH approach, which rests on the assumption of no interaction between exposure and adjustment factors may be misleading if interaction between exposure and adjustment factors is present. Model-based adjusted estimators represent a more general and flexible approach that includes both stratification approaches as special cases and offers intermediate options. Bruzzi et al.’s and Greenland and Drescher’s estimators are reviewed and contrasted. Finally, special problems of adjusted estimation are considered, namely estimation from case-cohort data, estimation for risk factors with multiple levels, for multiple risk factors, for recurrent events, estimation of the prevented and preventable fractions, and estimation of the generalized impact fraction. Comments on future directions are presented.
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Physicians' Empathy and Clinical Outcomes for Diabetic Patients
Article
  • Mar 2011
To test the hypothesis that physicians' empathy is associated with positive clinical outcomes for diabetic patients. A correlational study design was used in a university-affiliated outpatient setting. Participants were 891 diabetic patients, treated between July 2006 and June 2009, by 29 family physicians. Results of the most recent hemoglobin A1c and LDL-C tests were extracted from the patients' electronic records. The results of hemoglobin A1c tests were categorized into good control (<7.0%) and poor control (>9.0%). Similarly, the results of the LDL-C tests were grouped into good control (<100) and poor control (>130). The physicians, who completed the Jefferson Scale of Empathy in 2009, were grouped into high, moderate, and low empathy scorers. Associations between physicians' level of empathy scores and patient outcomes were examined. Patients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%, P < .001). Similarly, the proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than physicians with low scores (44%, P < .001). Logistic regression analyses indicated that physicians' empathy had a unique contribution to the prediction of optimal clinical outcomes after controlling for physicians' and patients' gender and age, and patients' health insurance. The hypothesis of a positive relationship between physicians' empathy and patients' clinical outcomes was confirmed, suggesting that physicians' empathy is an important factor associated with clinical competence and patient outcomes.
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Getting the pain you expect: Mechanisms of placebo, nocebo and reappraisal effects in humans
Article
  • Nov 2010
  • NAT MED
The perception of pain is subject to powerful influences. Understanding how these are mediated at a neuroanatomical and neurobiological level provides us with valuable information that has a direct impact on our ability to harness positive and minimize negative effects therapeutically, as well as optimize clinical trial designs when developing new analgesics. This is particularly relevant for placebo and nocebo effects. New research findings have directly contributed to an increased understanding of how placebo and nocebo effects are produced and what biological and psychological factors influence variances in the magnitude of the effect. The findings have relevance for chronic pain states and other disorders, where abnormal functioning of crucial brain regions might affect analgesic outcome even in the normal therapeutic setting.
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Effect of Patients' Expectations on Recovery from Acute Tonsillitis
Article
  • Oct 1989
To investigate whether the personal attention paid to a patient can affect his or her subjective recovery from acute tonsillitis, a controlled study was performed on 100 patients consulting a doctor for this disease. At the consultation a randomly assigned experimental group (n = 50) was given more detailed information about the diagnosis, treatment and prognosis and also a more extensive physical examination than a control group (n = 50). At a follow-up interview two days later significantly more of the experimental group felt that their symptoms had improved (P less than 0.005) than the control group, significantly more felt that the treatment had helped them (P less than 0.005) and significantly more felt they had received sufficient information about their illness and treatment (P less than 0.001). A deliberate attempt to maximize the expectation effect was thus shown to influence the clinical course of acute tonsillitis, recorded as the degree of subjective improvement.
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A Review of Adjusted Estimators of Attributable Risk
Article
  • Jul 2001
This paper reviews adjusted methods of estimation of attributable risk (AR), that is methods that allow one to obtain estimates of AR while controlling for other factors. Estimability and basic principles of AR estimation are first considered and the rationale for adjusted AR estimators is discussed. Then, adjusted AR estimators are reviewed focusing on cross-sectional, cohort and case-control studies. Two inconsistent adjusted estimators are briefly commented upon. Next, adjusted estimators based on stratification, namely the weighted-sum and Mantel-Haenszel (MH) approaches, are reviewed and contrasted. It appears that the weighted-sum approach, which allows for full interaction between exposure and adjustment factors, can be affected by small-sample bias. By contrast, the MH approach, which rests on the assumption of no interaction between exposure and adjustment factors may be misleading if interaction between exposure and adjustment factors is present. Model-based adjusted estimators represent a more general and flexible approach that includes both stratification approaches as special cases and offers intermediate options. Bruzzi et al.'s and Greenland and Drescher's estimators are reviewed and contrasted. Finally, special problems of adjusted estimation are considered, namely estimation from case-cohort data, estimation for risk factors with multiple levels, for multiple risk factors, for recurrent events, estimation of the prevented and preventable fractions, and estimation of the generalized impact fraction. Comments on future directions are presented.
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