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Published: 1. September 2015
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Work + health = success What is Knowledge Translation?

Since 2008, more than 200 services have been established and offered to sick-listed employees through the Rapid-return-to-work program. In a large national study, 600 experts on sickness absence management share their experiences and opinions on how this work is conducted today. They now emphasize the need for more competencies in the interventions we provide to sick-listed employees. 

Developing methods to address the challenges from long-term sickness absence has been an important political objective for quite some time in Norway. Sine 2001, the efforts for reducing sickness absence have been regulated through the Inclusive Working Life (IW) program, a national intervention program constructed as an agreement between the authorities and the major labour market partners. Under the IW agreement, participating businesses commit to working to reduce sickness absence, reduce the number of disability recipients, and to include the elderly and individuals with disabilities into working life. The companies can choose whether they want to participate in the IW program. The agreement covers approximately 25% of all Norwegian enterprises and 57% of all employees.

The IW program represents a new approach to preventing sickness absence. It includes a closer follow-up in sickness absence cases, and is anchored in the belief that the workplace is the main arena for sickness absence management. Rather than leaving the responsibility for health management to the physicians and patients, a dialogue between the employer and the employee is encouraged, with assistance from the occupational health services.

The Rapid-return-to-work program is a part of the IW cooperation. It was established in 2007, and is the largest effort for promoting return to work in Norway. The program consists of approximately 250 different return-to-work services, aimed at different diagnostic groups. The services include medical and surgical treatment in clinics, rehabilitation in hospitals (somatic), psychiatric treatment and rehabilitation, occupational training and rehabilitation in institutions, in addition to follow-up and clarification of work abilities. Both the specialist health care service and the Norwegian Labour and Welfare Administration are responsible for the organisation and administration of the program. There are few guidelines concerning the content and few requirements regarding the competency in the individual services. Each service has had the opportunity to provide the interventions they regard to be the best for their patients and their patient groups. The services are organized as temporary offers, and every year they are evaluated for continuity.

Now the authorities want to know how these services are organized, and how they have impacted the management of sickness absence. In a large national study, experts on sickness absence management share their experiences and opinions on how sickness absence management is conducted.

In the study, 32 experts participated in a focus group interview where they shared their experiences and opinions on sickness absence management. They expressed the challenges met in today’s practice, and made suggestions on how we can improve the work we do today. The challenges and suggested improvements where then formulated into 81 statements, and sent as a questionnaire to the leading experts on sickness absence management in Norway. The experts were representatives from the Norwegian Labour and Welfare organization, the occupational health services, the specialist health care service, coordinators from the Rapid-return-to-work program, employers and employees. Six hundred and nine participants returned the questionnaire, where they were asked whether they agreed with the statements formulated in the focus group interview. Consensus was met if more than 70% of the participants agreed to a statement. This was the case for only 16 of the 81 statements. Fifty per cent of these were concerned with the competency in the services. These can be summarised into 7 requirements.

The competence requirements were as follows:

Requirement I: Knowledge about the Inclusive Working Life program should to a larger extent be distributed to health service professionals, not only to the workplace. More than 90% of the participants agreed to this statement, only 3% disagreed. Since the IW agreement came in 2001, the Norwegian work life has gone through a substantial knowledge boost regarding sickness absence and inclusion in the workplace. Employers have learned that there is a difference between health and work ability, and that they should focus more on the healthy part of the person, not just the part that is sick. This has made it easier for employers to make adjustments in the workplace, making it possible for the employees to work despite their health issues. We have realized that going to work sometimes can be the best option for our health. The encouragement of presenteeism is well established in everyday routines, and the management knows that they have to engage in this work to reduce the sickness absence rates. The businesses have become better at cooperating with external actors like the Labour and welfare Administration, the occupational health services and general practitioners. Committed IW businesses have reduced their sickness absence with almost fifty per cent. Parts of the business sector have also achieved the goal of a 20% reduction in sickness absence after the agreement was signed.

Now the remaining question is whether the health support system will follow suit with this paradigm shift we have seen in the business world. The Labour and Welfare Administration’s employment centres have done a good job in promoting this shift. Perhaps this is where we should go when it is the health services’ turn?

Requirement II: The Rapid-return-to-work services need access to research on effective return-to-work interventions. Eighty-two per cent of the participants agreed to this statement, only five per cent disagreed. Earlier evaluations of the program have found large geographical differences in access to research. Large variations have also been found between each service. It is a well-known fact that it is easier to get funding for research and scientific publication than for science communication and popular dissemination. Getting funding for knowledge translation, which is concerned with making research results more accessible and usable for society, is even harder. This is a serious concern. It is time to rethink how we use science communication and knowledge translation in order to sustain a better practice. Here, Norway has a lot to gain by looking outside its own boarders.

Requirement III: The best Rapid-return-to-work services should be documented and made permanent. Eighty per cent of the participants agreed to this statement, 11% disagreed. Today, it is possible for a Rapid-return-to-work service to get funding without having to document the effect of the service. To know whether a service is effective, we need to conduct effect-studies with robust research designs. However, conducting good effect-studies of the Rapid-return-to-work program is demanding, as the patient groups differ between the services, and the patients have varying potential for returning to work. Furthermore, a robust effect-study shows what would have happened if the patients did not participate in the program. Having a control group could solve this. However, to deprive patients from treatment they are entitled to, is ethically challenging. Nonetheless, we still have some methods we can use to learn more about the effect of the services. A program with so many different services offered to numerous target groups should be examined individually or through multi-centre trials where the services are as similar as possible. Only then we can know what we are measuring the effect of, and that knowledge can be replicated and used in new settings.

Requirement IV, V and VI were concerned with the use and exchange of knowledge. This statement is rather self-explanatory: There is a need for more knowledge exchange between the providers of each service, the competency in the occupational health services’ should to a larger extent be included in the program, and the patients’ competency should be more emphasised in the planning and management of each service.

Requirement VII is concerned with knowledge about the services’ patient groups: Evidence-based knowledge about employees at risk of long-term sickness absence has to be more actively used in order to decide who needs the services the most. There was a 73% agreement rate to this statement, 8% disagreed. We know a lot about whom the risk groups are, and we know that different diagnostic groups profit from different types of interventions. This knowledge, however, has not systematically been used when planning the services. There is nothing stopping us from using this knowledge.

The Nordic model is best known for the three-party cooperation consisting of the government, employers, and the employees, who work together to ensure the welfare and social security in the workplace. The tripartite cooperation has contributed to increasing the competency and promoting a paradigm shift in the management of sickness absence. A support portal for those who prescribe sickness absence is the last building block in this wall of knowledge. But we are not finished yet. Perhaps we need a five-party cooperation in this knowledge-intensive field? Occupational health professionals can to a larger extent participate with their experience, and researchers can learn to better communicate their knowledge, thereby contributing to more than referring to individual research results.

No matter which solution we choose, we still need to listen to the experts who demand an increase in knowledge in the field of sickness absence management.


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