Y.B. Suijkerbuijk, MD, MSc, L.P. Jansen, MSc, K. Nieuwenhuijsen, PhD, F. Schaafsma, MD, PhD.
My name is Yvonne Suijkerbuijk and I’m living in the Netherlands. In addition to my work as a social insurance physician, I am conducting a research project at the Dutch Research Center for Insurance Medicine (KCVG), based at Amsterdam UMC. My research focuses on work participation among adults with mental health issues who are without (permanent) employment (precarious workers). I find it important to contribute to improving occupational health care for this group, because work resumption can support wellbeing and recovery.
Nearly half of all sick leave is caused by mental health issues. For adults with mental health issues without permanent employment, such as temporary workers and unemployed individuals (referred to as precarious workers), returning to work is particularly challenging. Alongside mental health treatment aimed at symptom relieve, they must also search for a new job during their recovery process before occupational rehabilitation can even begin.
In addition, precarious workers are more likely to face social problems and experience worse health compared to individuals with secure permanent jobs. As a result, their sick leave tends to be longer, and the rate of entry into long-term disability benefits is higher. This is concerning, because a successful return to work can enhance well-being and support recovery for individuals with mental health issues, whereas unemployment and financial insecurity can impede their recovery.
Thus, it is crucial that precarious workers receive occupational health care to facilitate their return to work. However, their access to occupational health is often limited and focused on permanently employed individuals. In addition, specific barriers to returning to work have been identified in this group of workers, including unhelpful perceptions and attitudes toward work resumption. An instrument to identify these barriers to start an intervention that focuses on the reduction of a barrier may lead to improved work capacity and reduced duration of absenteeism.
This project aims to enhance the return-to-work(RTW)-process for sick-listed precarious workers with mental health issues. We will develop an screening tool for occupational health professionals, such as insurance physicians and labor experts, to help them identify RTW-perceptions and attitudes, and other important predictors for sustainable return to work. This tool will support these professionals to implement targeted RTW-interventions for these precarious workers with mental health issues.
We use both qualitative and quantitative research methods for the development and evaluation of a screening tool for the identification of specific barriers for work resumption in sick-listed precarious workers with mental health issues.
Focus group study
First we conduct a focus group study with professionals who are responsible for the occupational health care for precarious workers. We use a thematic analyses to identify the most important themes regarding the RTW-attitudes and perceptions. Furthermore, we will evaluate the professionals’ needs regarding an assessment instrument. Based on these findings we will decide about the type and content of the assessment instrument. Also, we will use the results of a previous Dutch interview study among precarious workers with mental health issues for the content of the instrument.
Vignette study
We will evaluate the inter-rater reliability, content validity, usability and usefulness of the newly developed instrument. Using a vignette study at least 50 occupational health professionals will use the instrument to assess the RTW-attitudes and perceptions of six fictive workers. They will watch video consults of sick-listed precarious workers with mental health issues. After watching and assessing all videos, they will also fill in questions regarding content validity, usability and usefulness. We will use a generalized linear mixed model to analyze inter-rater agreement, inter-item consistency, and the contribution level of each item. Additionally, we calculate the content validity index, system usability scale and usefulness ratings.
Semi-structured interviews
Furthermore we will interview occupational health professionals after using the instrument during 3 real consults with precarious workers and we will interview the workers’ themselves. Themes that emerge from those data will be used for improvement of the instrument.
Secondary regression analyses
We will re-analyze data from three previous Dutch studies to identify specific predictors for the duration of sickness absence and time until return to work. In total, we will include 681 participants and their available baseline characteristics in a Cox regression analysis. Hazard ratios will show us which characteristics are (potentially) impeding factors for work resumption.
Proof-of-concept study
Building on the findings from our previous studies, we will enhance the screenings tool. The updated version will be tested in the Sickness Benefits Act Department at the Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV). The occupational health care professionals will use the instrument to identify specific barriers in sick-listed precarious workers with mental health issues. This enables them to start adequate RTW-interventions if needed. The effectiveness and feasibility of this new approach will be tested in a ‘proof-of-concept’ study. This study includes a process evaluation of the implementation process.
Predictors of duration of sickness absence and time until return to work:
The secondary regression analyses of three previous studies (N= 681 participants) (Suijkerbuijk 2023) showed us that unemployment at the moment of sick-listing (hazard ratio (HR) 0.19, probability index (PI) 84%), loss of employment contract during sickness absence (HR 0.25, PI 80%), and severe psychological symptoms (HR 0.64, PI 61%) are significant predictors of both a longer time until sustainable return to work and prolonged duration of sickness absence among sick-listed precarious workers with common mental disorders. In addition, age above 50 years significantly predicted a longer time until return to work (HR 0.57, PI 65%) and male gender (HR 0.77, PI 56%) a prolonged duration of sickness absence.
Thus, it is important that senior unemployed precarious workers with severe psychological symptoms receive both adequate symptom-focused treatment and occupational rehabilitation support.
Interestingly, RTW-perceptions and attitudes, measured as RTW self-efficacy, did not show a significant association with time until return to work and duration of sickness absence. This contrasts with findings from other studies, which have shown that higher levels of RTW self-efficacy are linked to earlier return to work. One explanation could be that the RTW self-efficacy questionnaires used in the included studies were originally designed for workers with permanent employment. Precarious workers, however, often lack a job to return to and are financially dependent on the social security system, which may cause RTW self-efficacy to function differently for them. Another reason for the lack of association might by that RTW self-efficacy was only assessed at baseline, whereas changes in RTW self-efficacy over time have been found to predict work resumption.
Clearly, more knowledge is needed to understand the role of RTW self-efficacy in precarious workers’ RTW and sickness absence. Additionally, there is a need of a suitable assessment instrument tailored to sick-listed precarious workers with common mental disorders.
Return-to-work (RTW)-mode
The focus group study revealed that perceptions and attitudes toward returning to work among sick-listed precarious workers with mental health issues can be categorized into three distinct modes within the recovery and RTW-process: the passive, ambivalent and active RTW-mode.
A passive RTW-mode is characterized by a hesitant attitude, negative perceptions of work ability, and a fear of relapse. While this mode is common early in sickness absence due to severe/impeding symptoms and the initiation of treatment, it may persist or (re-)emerge later as a result of psychological or contextual barriers.
In contrast, the ambivalent RTW-mode involves a desire to return to work, but uncertainty regarding one’s work ability and the steps to take regarding work resumption. This mode often arises as symptoms begin to improve.
Finally, the active RTW-mode is marked by positive perceptions of work ability and the belief that returning to work will be beneficial. Workers in this mode actively seek new employment and are typically close to recovery. However, some workers may demonstrate an unhelpful (over)active RTW-mode driven by anxiety or unrealistic perceptions related to their underlying mental health conditions.
Assessing the RTW-mode will enable professionals to implement targeted interventions that support workers in their RTW-process. Both professionals and workers agree that the RTW mode should be evaluated during each consultation, as perceptions and attitudes can change throughout recovery. The professionals prefer personal contact, supported by a simple tool that allows them to ask specific questions and observe non-verbal signs. They are interested in a simple tool to aid in identifying the RTW mode.
Development and evaluation of RE-MODE: a tool for the assessment of the RTW-mode
Development of RE-MODE 1.0
We developed RE-MODE(REturn-to-work MODe Evaluation) based on the results of focus group interviews with occupational health professionals (Suijkerbuijk 2022) and individual interviews with workers (Audhoe 2018). RE-MODE is an assessment tool designed to help professionals identify the RTW-mode in sick-listed precarious workers with mental health issues. The tool consist of 20 items that assess perceptions and attitudes about work resumption. By identifying the RTW-mode, professionals can implement appropriate occupational health interventions to facilitate RTW.
Quantitative evaluation of RE-MODE
The inter-rater reliability (level of agreement among professionals on the RTW mode), inter-item consistency, content validity, usability and perceived usefulness of RE-MODE are generally good, though there remain areas for improvement. These conclusions are based on a vignette study involving 71 professional, each of whom assessed the same six workers through video. Characteristics of the professionals, including age, educational level, job type, and professional experience significantly influenced both the level of agreement on the RTW mode and the recommendation for RTW-interventions.
Qualitative evaluation of RE-MODE
We also conducted additional semi-structured interviews with both professionals and sick-listed precarious workers with mental health issues. Prior to these interviews, the professionals utilized RE-MODE during three consultations with sick-listed workers experiencing mental health issues. They found RE-MODE easy to use and believe it could enhance communication regarding readiness for RTW-support among professionals.
Clients also expressed positive feedback about RE-MODE. They indicated that they were able to identify themselves with the characteristics of the three RTW-modes during various phases of their recovery process. Understanding the RTW mode could help them prepare for consultations with occupational health professional. Clients feel they could use the tool themselves, once their symptoms are sufficiently stabilized. However, they believe that personal contact with a professional is essential to verify the RTW-mode and initiate appropriate RTW-strategies.
Both clients and professionals suggested improving the terminology used in some items and the names of the return-to-work modes, particularly the term "passive" RTW-mode, which has a negative connotation. We are currently reevaluating the terminology used in the items and RTW-modes to minimize labeling and stigmatization.
Future directions
The results of the vignette study and interviews will soon be submitted for publication in a scientific, peer-reviewed journal. Meanwhile, we will proceed with developing an updated version of the tool. RE-MODE 2.0 will be evaluated in a proof-of-concept study in 2025. Occupational health professional will use RE-MODE and identify other predictors as potential barriers for return to work. Then, they can arrange targeted occupational health care interventions.
Future results and publications will be published on the KCVG-website.
Suijkerbuijk YB, Schaafsma FS, Jansen LP, Audhoe SS, Lammerts L, Anema JR, Nieuwenhuijsen K. Predictors of time until return to work and duration of sickness absence in sick-listed precarious workers with common mental disorders: a secondary data-analysis of two trials and one cohort study. International Journal of Mental Health Systems 2023: 17(1);48.
https://doi.org/10.1186/s13033-023-00613-7
Suijkerbuijk YB, Nieuwenhuijsen K. Identification of the return-to-work mode in unemployed workers with psychological problems: a focus group study among occupational health professionals.WORK: A Journal of Prevention, Assessment & Rehabilitation 2023: 74(3); 891-906.
https://doi.org/10.3233/WOR-210434
Suijkerbuijk YB, Nieuwenhuijsen K, Schaafsma FG, Jansen LP. Predictors for time until return to work and duration of sickness absence in unemployed workers with psychological problems; a secondary data-analysis of two trials and one cohort study. Safety and Health at Work 2022: 13; S274. https://doi.org/10.1016/j.shaw.2021.12.1608
Related publications
Suijkerbuijk YB, Schaafsma FG, van Mechelen JC, Ojajärvi A, Corbière M, Anema JR. Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database of Systematic Reviews, 2017.
https://doi.org/10.1002/14651858.CD011867.pub2
Suijkerbuijk YB, Hoving JH, Schaafsma FG. Interventions for obtaining and maintaining employment in adults with severe mental illness.Tijdschrift voor Bedrijfs-en Verzekeringsgeneeskunde 2018: 26(7), 365-367.
https://doi.org/10.1007/s12498-018-0232-7
