J Occup Rehabil DOI 10.1007/s10926-013-9439-8
Association Between Illness Perceptions and Return-to-Work Expectations in Workers with Common Mental Health Symptoms Camilla Løvvik • Simon Øverland • Mari Hysing Elizabeth Broadbent • Silje E. Reme
•
Ó Springer Science+Business Media New York 2013
Abstract Purpose Mental health symptoms (MHSs) may affect people’s work capacity and lead to sickness absence and disability. Expectations and perceptions of illness have been shown to influence return to work (RTW) across health conditions, but we know little about illness perceptions and RTW-expectations in MHSs. The aim of this study was to investigate the association between illness perceptions and RTW-expectations in a group struggling with work participation due to MHSs. Methods Crosssectional associations between illness perceptions and return to work expectations at baseline were analyzed for 1,193 participants who reported that MHSs affected their work participation. The study was part of a randomized controlled trial evaluating the effect of job focused Cognitive Behavioral Therapy (CBT) combined with supported employment (IPS). Participants were from a working age population with diverse job status. Results There was a strong and salient relationship between illness perceptions C. Løvvik (&) M. Hysing S. E. Reme Uni Health, Uni Research, Krinkelkroken 1, 5015 Bergen, Norway e-mail:
[email protected] C. Løvvik S. Øverland Department of Health Promotion and Development, University of Bergen, Bergen, Norway S. Øverland Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway E. Broadbent Department of Psychological Medicine, University of Auckland, Auckland, New Zealand S. E. Reme Harvard School of Public Health, Boston, MA, USA
and RTW-expectations. When adjusting for demographic and clinical variables, the components consequences, personal control, identity and illness concern remained significantly associated with uncertain and negative RTWexpectations. Less illness understanding remained significantly associated with uncertain RTW-expectations, while timeline and emotional representations remained significantly associated with negative RTW-expectations. In the fully adjusted model only the consequences component (believing that illness has more severe consequences) remained significantly associated with RTW-expectations. Openly asked, participants reported work, personal relationships and stress as main causes of their illness. Conclusions In people with MHSs who struggle with work participation, perceptions and beliefs about their problems are strongly associated with their expectations to return to work. Keywords Illness perceptions Return to work (RTW) RTW-expectations Common mental health symptoms (MHSs) Anxiety Depression
Introduction Mental health symptoms (MHSs) such as anxiety and depression are common in the general population [1–3], with a lifetime prevalence of approximately 50 % [1]. The consequences of MHSs can be severe and costly for both the individual and the society, involving sickness absence, work disability, loss in functionality and productivity, and reduced quality of life [1, 4–6]. When confronted with a diagnosis or when experiencing symptoms most people will respond with constructing cognitive and emotional representations of illness, known
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as ‘‘illness perceptions’’ [7, 8]. The concept of illness perceptions is based on Leventhal’s theory of Self-regulation [7], stating that experiencing symptoms or receiving a diagnosis will cause people to construct common sense beliefs about their illness in order to cope with health threats [7]. These beliefs are assumed to guide health behaviors and may be characterized as adaptive or maladaptive. Maladaptive illness perceptions would typically involve perceiving illness as having more consequences, being less curable or controllable, lasting for a longer time, causing more emotional distress and difficult to understand. Maladaptive illness perceptions have previously been associated with increased disability, slower recovery rates, and higher health care utilization [8, 9]. Illness perceptions have also been found to accurately predict both recovery and RTW in various patient populations with somatic conditions [10, 11]. However, little is known about the role of illness perceptions in MHSs [12], particularly when it comes to RTW [13]. We would expect several of the illness perceptions to be relevant for RTW-expectations, particularly the timeline component, which concerns the duration of illness, as well as the consequences component, which involves several life domains and causal attributions. The individual’s own expectation to RTW has consistently been shown to predict RTW [14–16] in musculoskeletal disorders [17, 18], as well as in other functional and somatic disorders [19, 20]. For mental disorders, individuals’ expectations of returning to work have been shown to predict actual RTW more accurately than predictions from health care professionals [15]. There are parallels between the concepts of RTW-expectations and self-efficacy. Self-efficacy is central to the initiation and persistence of human behavior [21] and has been defined as ‘‘the belief in one’s abilities to organize and execute the courses of action required to produce given attainments’’ [22]. In the case of RTW-expectations such ‘‘given attainments’’ would be RTW. In order to change or predict specific behaviors, such as those occurring in the RTW-process, measures used need to be tailored to this particular behavior [23]. RTW self-efficacy has recently been developed as an independent and measureable construct [24]. This construct has further been found to predict RTW both in MHSs [23] and other patient populations [24]. It thus appears to be an important intermediate outcome in the study of RTW. Still, it is an outcome we know fairly little about. Since MHSs are a major cause of sickness absence and work disability [4, 25], more knowledge about how their RTW-expectations relate to other significant factors, such as illness perceptions, is highly warranted. Markers of duration and severity such as prior episodes of sick leave due to mental disorders, as well as type and severity of the disorder, are well known risk factors for work disability [15, 26], but the RTW process has also been found to be dynamic and multifactorial and thus not
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dependent on health status alone [27]. The accurate predictions of RTW made by patients themselves could stem from personal expertise about their capability, but could also become ‘‘self-fulfilling prophecies’’ by guiding when or if the person initiates an effort to RTW. The need for more knowledge about RTW-expectations, and eventually how to modify these, has therefore been highlighted [15, 28]. If illness perceptions influence RTW-expectations in MHSs, work participation among people with MPH’s might be modified through changing such negative expectations and illness perceptions. Previous literature on RTW-expectations has primarily focused on either positive or negative expectations. However, qualitative studies of peoples’ experiences with RTW after episodes of sickness absence due to MHSs, have highlighted the experience of uncertainty as crucial in the RTW process [27]. Uncertain RTW-expectations are associated with longer time to RTW than positive RTWexpectations, but less than negative RTW-expectations in injured workers [29], and it may therefore be hypothesized that uncertain RTW-expectations have distinct qualities different from negative and positive RTW-expectations in people with MHSs as well. Research on the interrelationship of illness perceptions and RTW-expectations would shed light on what factors might be related to negative or uncertain expectations and the possible mechanisms through which expectations may influence work disability. This could further help inform interventions aiming to increase work participation for people with MHSs. In MHSs, interventions that integrate a clear focus on work, such as Work-Focused Cognitive Behavioral Therapy (CBT), lead to more rapid RTW than conventional CBT [30]. A probable mechanism of change in these interventions, involve a change in the RTW-expectations. More knowledge about factors associated with RTWexpectations could therefore help inform future treatments to further improve RTW in MHSs. In this paper we investigated the relationship between illness perceptions and RTW-expectations in a study population who reported struggles with work participation due to MHSs. To the best of our knowledge, the associations between illness perceptions and RTW-expectations have not yet been specifically addressed in MHSs, and we therefore aimed to; (i) examine whether illness perceptions are associated with RTW-expectations in a study population of MHSs; (ii) examine the independent associations between illness perceptions and different RTW-expectations (positive, uncertain and negative); and (iii) examine the participants’ own attributions of the most important factors causing their MHSs. We hypothesized that maladaptive illness perceptions would be associated with uncertain or negative expectations to RTW.
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each participant with emphasis on the right to withdraw from the study at any time without any explanation.
Methods Study Design
Participants ‘‘At Work and Coping’’ (AWaC) is a multicenter randomized controlled trial evaluating the effectiveness of CBT and an adaptation of Individual Placement and Support (IPS) on RTW for people with common MHSs such as symptoms of anxiety and depression (Trial registration— http://www.clinicaltrials.gov, with registration number NCT01146730). The trial has two arms, and the control condition is Usual Care. Data presented in the current paper comprise cross-sectional data from baseline questionnaires. For participant inclusion and drop-out, see Fig. 1. Ethics The study was approved by The Regional Ethical Committee and the Norwegian Social Science Data Services National Register of Data. All principles in the Helsinki declaration were followed. Informed consent was signed by
Fig. 1 Flowchart showing enrollment of study participants
Inclusion criteria were adults aged between 18 and 60 years old who claimed that MHSs, such as symptoms of anxiety and/or depression, hindered or complicated work participation. Eligibility was not dependent upon actual job status and the study population consisted of persons actively working (n = 334, sick listed (n = 529) or receiving disability benefits (n = 330). Exclusion criteria involved severe mental illness, ongoing substance abuse, ongoing psychological therapy elsewhere, suicide risk, and pregnancy. For the purpose of this study we used a subset consisting of those responding to the RTW-expectations item (n = 1,008). Procedure Participants received information about the study either through their GP or local national insurance offices, but
Enrollment
Sources:
Screened
General Practitioner, case manager, other or self-referral
(n=1416)
Excluded due to exclusion criteria (n=197) Declined to participate (n=17)
Reasons for exclusion (more than one reason noted for 47 participants): Mental health symptoms not main reason for work participation problems (n=76) Cannot start RTWprocess within 4-6 weeks (64)
Randomized (n=1202)
Serious mental illness (n=45) Withdrawn consent (n=9)
Ongoing psychological therapy (n=44) Age (n=13) Pregnancy (n=4)
Final sample (n=1193)
Does not speak Norwegian (n=3) Substance abuse (n=1)
Control/Usual Care (n=564)
Intervention (n=629)
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could also be made aware of the study through web-sites of the Norwegian Labor and Welfare Administration or posters in GP’s offices. All participants went through a screening procedure lasting 30 min where the main focus was to inform about the ongoing trial and to evaluate whether the person vas eligible for the trial according to the inclusion criteria. If eligible, participants would then be asked if they were willing to participate. Willing participants provided their informed consent and filled in the baseline questionnaire, which included measures on demographic data as well as standardized instruments on mental and somatic health complaints. The participants were further followed up with questionnaires after 6 and 12 months. Data on work participation and benefits from national registries were also collected as part of the AWaC study. Only data from the baseline assessment is presented here. A total of nine participants withdrew their consent after inclusion. Expectations to Return to Work The primary outcome of this study was the participants’ RTW-expectations. These were measured by participants’ responses to the following statement: ‘‘I expect to return to work within the next few weeks’’. Responses were given on a five-point Likert scale ranging from ‘‘strongly agree’’ to ‘‘strongly disagree’’. Drawing on existing literature pointing at how uncertainty could be of specific importance in the RTW-process [25, 27], we trichotomized the RTWexpectations variable the following way: Those who strongly agreed or agreed to the statement were categorized as having positive RTW-expectations, those responding ‘‘neither agree nor disagree’’ were categorized as having uncertain RTW-expectations and those responding disagree or strongly disagree were categorized as having negative RTW-expectations. Illness Perceptions Five dimensions concerning the cognitive representations of illness have been identified through previous research. The dimension consequences refers to the expected outcome and severity of the illness that the person holds; timeline refers to the perception of the illness as either more acute or chronic; cure or control describes if the person believes that the illness in question can be cured or controlled by themselves or through treatment; identity refers to the label that a person will use to describe the illness, and also to the symptoms that are perceived to be part of the illness; and cause refers to what the person believes has caused the illness. Later works on illness perceptions have included the emotional responses to illness, such as fear or anger and distress. In this study, illness
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perceptions were measured by the Brief Illness Perceptions Questionnaire (B-IPQ) [31], a nine-item questionnaire that applies a single-item scale to assess each dimension of illness perceptions. The B-IPQ provides a reliable and rapid assessment of illness perceptions [31]. The first eight items of the B-IPQ are rated on a 0-10 response scale, while the ninth item (cause) is open-ended. The five B-IPQ items consequences, timeline, personal control, treatment control and identity measure the cognitive representations of illness while emotional representations are measured by illness concern and emotional response. The item understanding measures coherence or comprehensibility of the illness. In the current paper the 9 items were analyzed and applied as separate components. Confounders Selection of potential confounders was guided by previous research of factors known to influence RTW-expectations. Job-status at baseline was seen as a plausible confounder, as having a job to go back to at all should influence the prospect of return. Job status was measured by asking whether the participants had a job to return to at the moment. It was assumed that those actively working or sick listed for\1 year would be in the group reporting to have a job to go back to. As illness perceptions may partly reflect accurate representations of health status, mental and somatic health measures were included as possible confounders. Mental health symptoms were measured with the Hospital Anxiety and Depression Scale (HADS) [32] while subjective health complaints were measured with the Subjective Health Complaints Inventory (SHC) [33]. Finally, demographic variables such as age, gender and education were also included. Statistical Methods Descriptive statistics, including frequency distributions, were used to assess the distribution of RTW-expectations as well as illness perceptions. ANOVA and cross tabulations were used to describe the distribution of illness perceptions, with F-test and Chi square to test for significant differences between positive, uncertain and negative RTWexpectations. Multinomial regression analysis was used to investigate the association between RTW-expectations and illness perceptions. First, the direct association between the B-IPQ items (1-8) and RTW-expectations was assessed. Second, potential confounders were entered in blocks in the following order: Demographics; job status; mental health symptoms and subjective health complaints. Finally, all B-IPQ items (1–8) as well as all the confounders were entered in the same, fully adjusted model. To assess the association between causal beliefs and RTW-expectations
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the three most frequently occurring categories were individually entered in a multinomial logistic regression model using RTW-expectations as outcome. Only cases with a response on RTW-expectations (n = 1,008) were included in the logistic regression models. SPSS version 19 was used for all analysis.
also consistently scored lower on maladaptive illness perception items of B-IPQ except for the item treatment control. In terms of their job status the majority of participants with positive RTW-expectations reported having a job to return to, while the lowest proportion of those who reported having a job to return to was seen in those with uncertain RTW-expectations.
Open-Ended Item The final item in B-IPQ is an open-ended question with the following wording: ‘‘Please list in rank-order the three most important factors that you believe caused your illness’’. This item is designed to register a person’s causal beliefs or attributions concerning origination of the illness in question. A framework for categorization of this openended item was developed through assessing the responses applying a bottom-up approach. An independent researcher initially categorized 200 responses and identified tentative categories that later were refined. The framework was repeatedly evaluated and discussed with two of the authors (MH and CL) to ensure reliability and consistency of the categorization. Responses to this open-ended item could sometimes relate to more than one category. A typical example would be cases where the participant listed ‘‘work/stress’’ as reasons for MHSs. In such cases it was allowed for the response to be placed in more than one category. In cases of disagreement or ambiguous responses, this was resolved through discussion until consensus was reached. A total of 3,060 responses were categorized.
Illness Perceptions and RTW-Expectations Correlations between single items of the B-IPQ (1–8) were initially analyzed to test for potential multicollinearity when entered in the multiple regression model. Correlations varied from 0.016 to 0.624, and multicollinearity was thus not considered a problem. Uncertain RTW-Expectations
Results
The association between illness perceptions and uncertain RTW-expectations were significant for six of the eight components (consequences, personal control, identity, illness concern and emotional response) in the unadjusted analyses (Table 2). When including the demographic variables gender, age and education and further including job status, the same components remained significantly associated with uncertain RTW-expectations. When mental health (HADS) and subjective health complaints (SHC) were further included in the analysis, the component measuring emotional representations was no longer significantly associated with uncertain RTW-expectations (Table 2).
Demographic and Clinical Characteristics of Study Population
Negative RTW-Expectations
An overview of demographic and clinical characteristics of the study population is presented in Table 1. The study population was characterized by more women than men, education at university or postgraduate college levels, and a mean age of 40.2 years. The majority of participants reported having a job to return to. More participants scored above the cut-off for anxiety (77.8 %) than for depression (54.1 %), and 32 % reported positive RTW-expectations while 31 % reported uncertain and 37 % reported negative RTW-expectations. Table 1 also describes the differences in illness perceptions between the positive, uncertain and negative RTW-expectations. There were no significant differences in any of the demographical variables, but participants with positive RTW-expectations reported fewer symptoms of anxiety and depression as well as fewer subjective health complaints. Participants with positive RTW-expectations
In the unadjusted analyses for associations between individual illness perceptions and negative RTW-expectations, all eight components of the B-IPQ measuring illness perceptions were significantly associated with the outcome (Table 2), and all but understanding remained significantly associated with negative RTW-expectations when adjusting for the demographic variables gender, age and education. When further including job status in the model, the component emotional representations was no longer significant. Further inclusion of variables on mental health (HADS) and subjective health complaints (SHC) lead to the illness perception components treatment control and understanding no longer being significantly associated with negative RTW-expectations. In the fully adjusted model, only the illness perceptions component consequences remained significantly associated with RTW-expectations. This association was significant
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J Occup Rehabil Table 1 Demographic and clinical characteristics of participants Mean (SD)
Return-to-work expectations Positive (n = 326) Mean (SD)
Uncertain (n = 312) Mean (SD)
Negative (n = 370) Mean (SD)
F
40.2 (9.6)
40.2 (9.2)
39.7 (9.9)
40.7 (9.8)
1.0
20.7 (10.6)
19.1 (10.5)
20.2 (10.1)
22.4 (10.9)
8.3*
18.8 (6.9)
16.9 (7.2)
19.6 (6.6)
19.8 (6.7)
17.8*
The brief-illness perception questionnaire (0–10) Consequencesa 7.1 (1.9)
Continuous variables Age Subjective health complaints (SHC) Total score Hospital anxiety and depression scale Total score
6.4 (2.2)
7.3 (1.8)
7.6 (1.6)
37.3*
Timelinea
5.9 (2.4)
5.5 (2.7)
5.8 (2.3)
6.4 (2.2)
11.7*
Personal control
4.1 (2.2)
4.5 (2.2)
3.9 (2.1)
4.0 (2.2)
6.8*
Treatment control
6.9 (2.1)
7.0 (2.1)
7.0 (1.9)
6.7 (2.2)
2.5
Identitya
6.6 (2.1)
6.1 (2.2)
6.7 (2.0)
7.1 (1.8)
20.2*
Illness concerna
6.5 (2.3)
6.0 (2.5)
6.7 (2.1)
6.8 (2.1)
12.5*
Understanding
6.2 (2.4)
6.4 (2.4)
6.0 (2.5)
6.1 (2.4)
3.4*
Emotional responsea
7.7 (2.0)
7.2 (2.3)
7.7 (1.8)
8.0 (1.7)
12.5*
N (%)
N (%)
N (%)
N (%)
v
662 (66.4)
262 (26.3)
172 (17.3)
228 (22.9)
50.7*
681 (67.6)
224 (22.2)
197 (19.5)
260 (25.8)
4.2
615 (61.0)
210 (20.8)
189 (18.8)
216 (21.4)
2.7
Categorical variables Self-reported job status: has job to return to at the moment Gender Female Education University/postgraduate college Mental health status, HADS, (cut off =[8) Anxiety
778 (77.8)
228 (22.8)
251 (25.1)
299 (29.9)
15.5*
Depression
541 (54.1)
139 (13.9)
183 (18.3)
219 (21.9)
24.3*
Numbers are based on a subset of 1,008 participants responding to the RTW-expectations item * Significant at the 0.05 level a
Higher score indicates more maladaptive illness perceptions
for both uncertain and negative RTW-expectations (Table 2). The Pseudo R square values (Cox & Snell, Nagelkerke) indicated that total variance explained by the model was between 16 and 18 %. Results from the Open Ended Item A total of 1,122 participants responded to the ninth and open-ended item asking them what they believed the three main causes of their illness were. The response rate was highest for the first listed cause (n = 1,122) while 1,028 participants listed a second cause, and 910 participants listed a third cause. The complete categorization yielded a total of 31categories, but for the purpose of this paper only the three most frequently occurring categories are
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presented. Perception of work as a primary cause of illness was reported by 22 % (n = 262) of the participants and was the cause that was most frequently reported compared to other causes. Personal relationships was reported by 13 % (n = 160) as a primary cause of MHSs, while stress was reported by 10 % (n = 123). As a second reason for MHSs, 15 % (n = 182) reported work, 11 % (n = 133) reported personal relationships and 5 % (n = 71) reported stress. Further, as a third reason for MHSs 14 % (n = 168) reported work, while personal relationships was reported by 10 % (n = 121) and stress as reason for MHSs by 4 % (n = 54). When individually assessed for association with RTWexpectations, none of these were significantly associated with either of the RTW-expectations (p [ 0.05).
J Occup Rehabil Table 2 Crude individual and adjusted associations between illness perceptions and return-to-work expectations, OR (95 % CI) Return to work-expectations
Crude individual associations OR (95 % CI)
Adjusted for gender, age and educational level OR (95 % CI)
Adjusted for job status OR (95 % CI)
Adjusted for HADS and SHC total scores OR (95 % CI)
Fully adjusted model OR (95 % CI)
1.25 (1.10–1.42)*
Uncertain return-to-work expectations Illness perceptions Consequences
1.25 (1.15–1.35)*
1.24 (1.15–1.35)*
1.27 (1.17–1.38)*
1.24 (1.12–1.36)*
Timeline
1.05 (0.98–1.12)
1.05 (0.98–1.12)
1.03 (0.96–1.10)
0.99 (0.93–1.07)
0.95 (0.88–1.03)
Personal controla
1.12 (1.04–1.20)*
1.11 (1.03–1.20)*
1.15 (1.06–1.24)*
1.10 (1.02–1.19)*
1.04 (0.95–1.14)
Treatment controla
1.01 (0.94–1.09)
1.00 (0.93–1.08)
1.01 (0.93–1.09)
1.01 (0.92–1.10)
1.01 (0.92–1.10)
Identity
1.14 (1.06–1.23)*
1.14 (1.06–1.23)*
1.15 (1.06–1.24)*
1.10 (1.01–1.20)*
1.03 (0.92–1.15)
Illness concern
1.14 (1.06–1.22)*
1.13 (1.06–1.21)*
1.14 (1.07–1.21)*
1.09 (1.01–1.18)*
1.01 (0.91–1.12)
Understandinga
1.08 (1.01–1.15)*
1.07 (1.01–1.15)*
1.10 (1.03–1.17)*
1.08 (1.01–1.15)*
1.07 (0.99–1.15)
Emotional representations
1.12 (1.03–1.20)*
1.12 (1.03–1.20)*
1.12 (1.03–1.21)*
1.05 (0.96–1.14)
0.94 (0.84–1.05)
Negative return–to-work expectations Illness perceptions Consequences
1.39 (1.28–1.51)*
1.39 (1.28–1.51)*
1.41 (1.29–1.54)*
1.37 (1.24–1.50)*
1.31 (1.15–1.48)*
Timeline Personal controla
1.16 (1.09–1.23)* 1.11 (1.04–1.19)*
1.15 (1.08–1.23)* 1.12 (1.04–1.20)*
1.14 (1.06–1.21)* 1.14 (1.06–1.23)*
1.09 (1.02–1.17)* 1.09 (1.01–1.18)*
1.02 (0.95–1.10) 1.01 (0.93–1.11)
Treatment controla
1.07 (1.00–1.15)*
1.07 (1.00–1.15)*
1.07 (1.00–1.15)*
1.06 (0.98–1.14)
1.06 (0.97–1.15)
Identity
1.26 (1.17–1.36)*
1.26 (1.17–1.36)*
1.27 (1.17–1.37)*
1.20 (1.10–1.31)*
1.10 (0.98–1.23)
Illness concern
1.16 (1.09–1.24)*
1.17 (1.09–1.25)*
1.17 (1.10–1.26)*
1.11 (1.03–1.20)*
0.98 (0.88–1.08)
Understandinga
1.06 (1.00–1.13)*
1.06 (0.99–1.13)
1.08 (1.01–1.15)*
1.05 (0.98–1.12)
1.06 (0.98–1.14)
Emotional representations
1.20 (1.11–1.30)*
1.20 (1.11–1.29)*
1.20 (1.11–1.30)*
1.13 (1.04–1.24)*
0.98 (0.88–1.10)
Reference category 1 (Positive return-to-work expectations) * Significant at the 0.05 level a
Variable has been reversed so that a higher score means more maladaptive illness perceptions
Discussion This study found a strong and salient relationship between illness perceptions and return-to-work (RTW) expectations in people with mental health symptoms. People with uncertain and negative RTW-expectations had more maladaptive illness perceptions than people with positive return to work expectations. There was a stronger relationship between maladaptive illness perceptions and negative RTW-expectations compared to uncertain RTWexpectations, supporting the hypothesis of distinct qualities of the different RTW-expectations. Perceiving more consequences, less personal control, attributing more symptoms to the illness, being more concerned about the illness, less understanding of illness and experiencing more emotional distress was related to uncertain RTW-expectations. In addition to these six components, also believing that the illness would last a long time and believing that the illness would be difficult to cure was associated with negative RTW-expectations. As expected, fewer of those with uncertain and negative RTW-expectations reported having a job to go back to, and also reported more subjective
health complaints and symptoms of depression and anxiety compared to those with positive RTW-expectations. However, even when adjusting for these variables, most of the illness perception components remained significantly associated with the RTW-expectations. When asked what the participants themselves believed the main cause of their illness to be, work was most frequently reported, followed by personal relationships, and stress. When we examined the relation between these causal attributions and RTW-expectations we found that none were significantly associated with neither uncertain nor negative RTWexpectations. Illness Perceptions and Return to Work Expectations The current results support our hypothesis that maladaptive illness perceptions are associated with uncertain and negative RTW-expectations. This is in line with previous research showing that illness perceptions are related to RTW in somatic conditions such as Myocardial Infarction [34] but also for workers on sick leave regardless of diagnosis [35].
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The pattern of associations between illness perceptions and RTW-expectations was somewhat different for uncertain and negative RTW-expectations. We saw that a longer timeline perception—how long people think their illness will last—was consistently associated with negative RTWexpectations, but not with uncertain RTW-expectations. Experiencing more emotional distress was associated with uncertain and negative RTW-expectations, but for the uncertain RTW-expectations this association was no longer significant after adjusting for measures on mental health (HADS) and subjective health complaints (SHC). This might be due to an overlap between this illness perception component and the experienced symptom levels of MHSs or subjective health complaints. Further, lower beliefs in the ability of treatment to help the illness—treatment control—were also related to negative RTW-expectations but not with uncertain RTW-expectations. A possible explanation for these findings could be that other factors not captured in our assessment influence uncertain RTWexpectations to a larger degree than the negative RTWexpectations, but it could also reflect some of the underlying factors driving the negative RTW-expectations. In previous studies of low back pain patients, both components (timeline and treatment control) were found to predict poor clinical outcomes [36]. Thus, if negative RTWexpectations predict a worse outcome than uncertain RTWexpectations in MHSs as seen elsewhere [29], the two illness perception components associated with only negative RTW-expectations in the current study could be contributing to the poorer prognosis in this group. It seems for instance reasonable to assume that beliefs about the illness lasting a long time and being difficult to cure could influence behavior towards a self-fulfilling prophecy of no RTW in individuals holding these beliefs. Future prospective studies are warranted to investigate this hypothesis further in order to establish the prognostic value of the different RTW-expectations in MHSs, and how this is influenced by different illness perceptions. The only illness perception component that remained significantly associated with both negative and uncertain RTW-expectations in the fully adjusted model was consequences. This is in line with previous findings showing consequences to be significantly associated with work disability in chronic physical diseases [37] and slower recovery and disability following Myocardial Infarction [34]. The consequences component involves how a person perceives the impact of the illness on life domains, such as participation in work and social activities. This could help explain the strong association between consequences and RTW-expectations. The strong and persistent association may be due to an underlying directional relationship between the two. Consequences could be argued from a theoretical point of view to most likely precede RTW-
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expectations where perceptions of consequences inform the individual’s predictions of RTW, but this needs to be tested in future studies. Causal Attributions To the best of our knowledge, this is the first study to investigate causal attributions of MHSs in people struggling with work participation. In our study we found that the most commonly reported causal attribution for the participants’ MHSs was work. This is in line with previous findings showing that worry about work-related factors is associated with an elevated risk of sickness absence [38]. We further found that stress and personal relationships were the two other most frequently reported reasons for MHSs. Finding MHSs to be attributed to stress in a population struggling with work participation is in line with previous findings indicating that there is a causal relationship between work related psychosocial stress and long term sickness absence [39]. Causal attributions have previously been found to influence and contribute to increased anxiety after Myocardial Infarction [40]. The causal attributions held by an individual may thus be of importance for outcomes such as return to work or recovery, but may also be a factor that contributes to perseverance of psychological symptoms. Although causal attributions were not significantly associated with RTW-expectations in this study, there is still need for future studies applying more detailed analysis to look into the possible impact of causal attributions and work-related outcomes in MHSs. The reporting of personal relationships as a cause for MHSs could be related to characteristics of our study population. A majority of our study participants were women, highly educated, and with a mean age just above forty years. Although not addressed in our data, one possible explanation could be that many of our participants are confronted with the double burden of being both caregivers and workers as these are challenges previously reported as risk factors for sickness absence [41].
Strengths and Limitations One of the inclusion criteria to the trial involved willingness to initiate the RTW-process within 4–6 weeks after joining the project. This could somewhat limit the generalizability of our findings to people with MHSs already motivated for RTW. However, this does not seem to be the case as the majority of the participants (68 %) reported negative or no RTW-expectations. A possible explanation may be that this explicit inclusion criterion may have steered participants towards admitting willingness to RTW
J Occup Rehabil
also in cases where the participant in reality was experiencing uncertain or negative expectations of RTW, simply because they wanted the intervention. Although we have no way of assessing this, it should still be taken into consideration when interpreting the results, particularly with regards to the distribution of RTW-expectations. In this study we used a single item to measure RTWexpectations. Using more extensive measures such as the RTW-SE questionnaire especially adapted for use in MHSs [23] would have generated more detailed information but was not available in Norwegian at the time of the study. However, the single item used in this study has previously shown to be a strong predictor of non-RTW in a population of sick listed low back pain patients [42]. For the assessment of illness perceptions in our study the general term ‘‘illness’’ was not replaced with a more specific term such as ‘‘psychological distress’’ or ‘‘mental health problems’’ on the B-IPQ questionnaire, which could represent a weakness of the study. This is perhaps specifically important as the study population on average scores as much as three times higher on subjective health complaints compared to the general population [43]. This could indicate that the study population suffer from a wide range of symptoms and conditions—and it is possible that the responses to ‘‘your illness’’ are based on the perceptions of these other complaints or be a compound of their total health problems. However, when the self-reported subjective health complaints were compared between the three different RTW-expectations, no statistically significant differences were detected. It is therefore unlikely that this has biased the results. In our study we found that even though as many as 66.4 % of the participants reported that they had a job to return to, only 26.3 % of these reported positive RTWexpectations. Our study population was heterogeneous regarding job status. Inclusion criteria for the randomized controlled trial our data stem from opened up for the possibility of joining regardless of actual job status or work force connection. This entails that participants in the current study could still be working, sick listed or have fallen out of the work force entirely. It may be argued that participants who have not yet fallen out of the work force or even become sick listed cannot have RTW-expectations as they are still working. However, all participants in the study were also included on the criteria of reporting trouble with work participation due to MHSs. The participants still actively participating in work may have been inclined to consider the RTW-questions as irrelevant and not reply. However, there is also a possibility that they had experiences of uncertainty in regard to their own capacity of remaining active workers and may as such also have answered the question on RTW-expectations based on this uncertainty. Another possibility is that those still actively
working may have answered this question based on their previous experiences with MHSs leading to sickness absence. Nevertheless, future studies using registry-based data on job status could help investigate these relations in a more systematic manner. Previous findings show that a longer duration of MHSs is associated with a longer time to RTW [44]. Hence, it could be argued that a longer duration of MHSs would also be associated with RTW-expectations. We did not include duration of MHSs in the current study. However, it seems likely to assume that the timeline component of illness perceptions would capture a persons’ experience with duration of illness. We found that the timeline component was associated with negative RTW-expectations but not with uncertain RTW-expectations. Although the association between the timeline component and negative RTWexpectations remained significant when controlling for demographic and clinical variables, the association was no longer significant in the fully adjusted model.
Implications The key finding from this study was that illness perceptions were significantly associated with RTW-expectations. Further, the perceived consequences of illness seemed to be more strongly related to RTW-expectations than the other components of illness perceptions. The consequences component of illness perceptions includes beliefs concerning the outcome of illness and its expected effects. Previous research findings have shown that applying techniques from CBT can successfully alter illness perceptions [10]. Future interventions aiming to increase work participation in people with MHSs could perhaps draw upon these previous findings by assessing and addressing patients’ maladaptive illness perceptions. The Brief Illness Perception questionnaire offers the benefits of being easy to administer and score, and may be a helpful instrument in a clinical setting [31]. Although illness perceptions share an internal consistent logic, the findings presented here suggest that consequences may be particularly important in the RTW-process. The consequences component includes ‘‘general beliefs about the impact of the illness on the patient’s personal life, family, social relationships and finances’’ [45] as well as how disabling the patient perceives the illness to be. A particular focus on this dimension of illness perceptions could therefore be a way to move forward in RTW-interventions for MHSs. Although study design does not allow for any conclusions with regards to direction of associations they highlight the need for more research focusing on illness perceptions as a potential explanatory factor for RTW-expectations and as possible predictor of RTW in MHSs.
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Based on previously established findings consistently showing that RTW-expectations accurately predict return to work, we believe that the current findings could help inform intervention programmes aiming to increase work participation for people with mental health symptoms. Acknowledgments This research was funded by the Norwegian Labor and Welfare Administration. Ingrid Blø Olsen helped to develop a framework for categorization of the causal item on the Brief Illness Perception Questionnaire and with the categorization of responses to this item.
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