Work-relatedness of the presented health problem and sickness absence.

BACKGROUND: Perception by workers of their health problems as work-related is possibly associated with sickness absence (SA). The aim of this study was to to study the relationship between perceived work-relatedness of health problems and SA among workers who visit their GP, taking the influence of other potential determinants into account and to study the influence of these determinants on SA. Design and setting prospective cohort study in 32 Dutch GP practices. METHODS: A secondary analysis of RCT data among workers, aged 18-63 years, who visited their GP. We measured self-reported SA days in 12 months and high SA (>20 days in 12 months) and compared workers who perceived work-relatedness (WR+) with workers who did not (WR-). With multivariable linear and logistic regression models, we analyzed the influence of age, gender, experienced health, chronic illness, prior SA, number of GP consultations and perceived work ability. RESULTS: We analyzed data of 209 workers, 31% perceived work-relatedness. Geometric mean of SA days was 1.6 (95% CI: 0.9-3.0) for WR+- workers and 1.2 (95% CI: 0.8-1.8) for WR- workers (P = 0.42). Incidence of high SA was 21.5 and 13.3%, respectively (odds ratio 1.79; 95% CI: 0.84-3.84). SA was positively associated with chronic illness, prior SA, low perceived work ability and age over 50. CONCLUSIONS: Perceived work-relatedness was not associated with SA. SA was associated with chronic illness, prior SA, low perceived work ability and age over 50.

The role of personal characteristics, work environment and context in working beyond retirement: a mixed-methods study.

OBJECTIVE: To investigate the role of personal characteristics, work environment and context in working beyond retirement. METHODS: In the current study, a mixed-methods design was applied including quantitative survey data and semi-structured telephone interviews. Respondents (N = 568) were selected from the Study on Transitions in Employment, Ability and Motivation (STREAM). Personal characteristics, work characteristics and contextual factors were measured using a questionnaire at baseline. Concurrently, qualitative data of 30 persons aged over 65 years were gathered. Logistic regression analyses were used to identify quantitative associations and thematic analyses were used for qualitative purposes. RESULTS: Quantitative data revealed that being in good physical health (OR = 1.80), developmental proactivity (OR = 1.38), interesting work (OR = 2.02), appreciation (OR = 1.62) and voluntary work (OR = 1.58) were associated with working beyond the statutory retirement age. Additionally, qualitative findings suggested that working beyond retirement was mainly driven by the desire to contribute to society (e.g., mentor younger coworkers), and identified the employers' willingness to hire an older worker despite existing stereotypes as an important precondition. CONCLUSIONS: Working beyond retirement is influenced by physical health and work characteristics, as well as motivational determinants such as the desire to contribute to society. However, to meet the increasing demands for paid jobs by individuals aged over 65 years, the willingness of employers to actually hire them is crucial. Therefore, recognition and utilization of older workers' potentials is of great importance.

Affecting patients with work-related problems by educational training of their GPs: a cost-effectiveness study.

BACKGROUND: Assessing the cost effectiveness of training aimed at increasing general practitioners' (GP) work awareness and patients' work-related self-efficacy and quality of life. METHODS: A cluster randomized controlled trial in twenty-six GP practices in the southeast of the Netherlands with 32 participating GPs. GPs working in an intervention group practice received training and GPs working in a control group practice delivered usual care. The training intervention consisted of lectures and workshops aimed at increasing GPs' work awareness and more proactive counseling for patients with work-related problems (WRP). Subjects were working age patients with paid work for at least 12 h per week, who visited one of the participating GPs during the study period. As outcome measures we used the Return to Work Self Efficacy scale to assess patients' work-related self-efficacy and the Euroquol to assess quality of life. We also measured health care costs and productivity costs. With a 4-item questionnaire we asked patients to assess their GPs' work awareness. Data were collected at baseline, after 6 and 12 months. RESULTS: Data of 280 patients could be analyzed. The patient related outcomes did not improve after GP training. The change in GP work awareness and the overall mean cost difference (of €770) in favor of the intervention group were not significant. CONCLUSIONS: The training intervention presented in this paper was not cost-effective. Training which is further personalized and targeted at high risk groups with respect to WRP, is more likely to be cost effective.

Why older workers work beyond the retirement age: a qualitative study.

BACKGROUND: The aims of the present study were to: 1) gain insight into reasons for working beyond the statutory retirement age from older workers' perspectives, and 2) explore how the domains of the research framework Study on Transitions in Employment, Ability and Motivation (STREAM) can be applied to working beyond retirement age. METHODS: A qualitative research design included individual interviews (n = 15) and three focus groups (n = 18 participants) conducted with older workers aged 65 years and older continuing in a paid job or self-employment. Interview participants were recruited from an existing STREAM cohort study. Focus group participants were recruited from companies and employment agencies. The data were subjected to thematic analysis. RESULTS: The most important motives for working beyond retirement age were maintaining daily routines and financial benefit. Good health and flexible work arrangements were mentioned as important preconditions. The themes emerging from the categorization of the motives and preconditions corresponded to the domains of health, work characteristics, skills and knowledge, and social and financial factors from the STREAM research framework. However, our analysis revealed one additional theme-purpose in life. CONCLUSION: This study offers important new insights into the various preconditions and motives that influence working beyond retirement age. In addition, the five domains of the STREAM research framework, including the additional domain of 'purpose in life', seem to be applicable to working beyond retirement age. This knowledge contributes to the development of work-related interventions that enhance older workers' motivation to prolong their working lives.

Productivity at work and quality of life in patients with rheumatoid arthritis.

BACKGROUND: The aim of this study was to determine which combination of personal, disease-related and environmental factors is best associated with at-work productivity loss in patients with rheumatoid arthritis (RA), and to determine whether at-work productivity loss is associated with the quality of life for these patients. METHODS: This study is based on cross-sectional data. Patients completed a questionnaire with personal, disease-related and environmental factors (related to the work environment), and clinical characteristics were obtained from patient medical records. At-work productivity loss was measured with the Work Limitations Questionnaire, and quality of life with the RAND 36. Using linear regression analyses, a multivariate model was built containing the combination of factors best associated with at-work productivity loss. This model was cross-validated internally. We furthermore determined whether at-work productivity loss was associated with quality of life using linear regression analyses. RESULTS: We found that at-work productivity loss was associated with workers who had poorer mental health, more physical role limitations, were ever treated with a biological therapeutic medication, were not satisfied with their work, and had more work instability (R(2) = 0.50 and R(2) following cross-validation was 0.32). We found that at-work productivity loss was negatively associated with health-related quality of life, especially with dimensions of mental health, physical role limitations, and pain. CONCLUSIONS: We found that at-work productivity loss was associated with personal, work-related, and clinical factors. Although our study results should be interpreted with caution, they provide insight into patients with RA who are at risk for at-work productivity loss.

Burden of Sickness Absence Due to Chronic Disease in the Dutch Workforce from 2007 to 2011.

INTRODUCTION: Chronic diseases are associated with productivity loss costs due to sickness absence. It is not always clear, however, which chronic diseases in particular are involved with how many sickness days and associated costs. OBJECTIVE: To determine the prevalence, additional days of sickness absence, and associated costs of chronic diseases among the Dutch working population from 2007 to 2011. METHODS: Prevalence of chronic diseases and additional days of sickness absence were derived from the Netherlands Working Conditions Survey (NWCS) from 2007 to 2011. The cost of each sickness absence day was based on linked personal income data. We used multiple regression analysis to derive the unconfounded additional days of sickness absence due to each chronic disease. RESULTS: Annually, approximately 37 % of the Dutch working population reported some type of chronic physical or psychological disease. No clinically relevant changes in prevalence of specific chronic diseases were observed in the studied period, nor in the number of additional sickness absence days or associated costs. The national financial burden due to sickness absence associated with chronic musculoskeletal disorders amounted to €1.3 billion annually. CONCLUSIONS: Chronic diseases result in substantial productivity loss due to sickness absence. Given the ageing population, the proposed increase in the state pension age and an increase in sedentary lifestyle and obesity, the prevalence of chronic diseases may be expected to rise. Coordinated efforts to maintain and improve the health of the working population are necessary to minimize socioeconomic consequences.

An education programme to increase general practitioners' awareness of their patients' employment: design of a cluster randomised controlled trial.

BACKGROUND: Work and being able to work are important prerequisites for health and well being. Health problems can have a negative influence on the ability to work and not being able to work can be detrimental for patients' psychosocial well being. Although GPs are aware of this importance they do not always structurally pay attention to patients' work during their daily practice. METHODS/DESIGN: To investigate whether GPs can be trained to increase their awareness of work and improve their skills when dealing with work related problems we designed a cluster randomised controlled trial. The intervention in this trial is a tailored training based on the findings of qualitative research with focus groups of GPs. Gender aspects received specific attention in these focus groups. Primary outcome measures are self efficacy of patients concerning return to work, and GPs' use of ICPC code Z05 (work problems) and registration of patients' occupation. Secondary outcome measures are work awareness of GPs as perceived by patients, quality of life, health, use of care and illness related costs. A process evaluation will be part of our study. DISCUSSION: We investigate a training to increase work awareness among GPs, improve their skills in managing work related problems and structurally register work related data in the EMR. We think this study will make a contribution to better health care for workers by motivating GPs to appreciate their specific needs. It will also add to our knowledge of the complex relationship between gender, work and health.

An intervention program with the aim to improve and maintain work productivity for workers with rheumatoid arthritis: design of a randomized controlled trial and cost-effectiveness study.

BACKGROUND: Workers with rheumatoid arthritis (RA) often experience restrictions in functioning at work and participation in employment. Strategies to maintain work productivity exist, but these interventions do not involve the actual workplace. Therefore the aim of this study is to investigate the (cost)effectiveness of an intervention program at the workplace on work productivity for workers with RA. METHODS/DESIGN: This study is a randomized controlled trial (RCT) in specialized rheumatology treatment centers in or near Amsterdam, the Netherlands. Randomisation to either the control or the intervention group is performed at patient level. Both groups will receive care as usual by the rheumatologist, and patients in the intervention group will also take part in the intervention program. The intervention program consists of two components; integrated care, including a participatory workplace intervention. Integrated care involves a clinical occupational physician, who will act as care manager, to coordinate the care. The care manager has an intermediate role between clinical and occupational care. The participatory workplace intervention will be guided by an occupational therapist, and involves problem solving by the patient and the patients' supervisor. The aim of the workplace intervention is to achieve consensus between patient and supervisor concerning feasible solutions for the obstacles for functioning at work. Data collection will take place at baseline and after 6 and 12 months by means of a questionnaire. The primary outcome measure is work productivity, measured by hours lost from work due to presenteeism. Secondary outcome measures include sick leave, quality of life, pain and fatigue. Cost-effectiveness of the intervention program will be evaluated from the societal perspective. DISCUSSION: Usual care of primary and outpatient health services is not aimed at improving work productivity. Therefore it is desirable to develop interventions aimed at improving functioning at work. If the intervention program will be (cost)effective, substantial improvements in work productivity might be obtained among workers with RA at lower costs. Results are expected in 2015. TRIAL REGISTRATION NUMBER: NTR2886.

The importance of job characteristics in determining medical care-seeking in the Dutch working population, a longitudinal survey study.

BACKGROUND: The working population is ageing, which will increase the number of workers with chronic health complaints, and, as a consequence, the number of workers seeking health care. It is very important to understand factors that influence medical care-seeking in order to control the costs. I will investigate which work characteristics independently attribute to later care-seeking in order to find possibilities to prevent unnecessary or inefficient care-seeking. METHODS: Data were collected in a longitudinal two-wave study (n = 2305 workers). The outcome measures were visits (yes/no and frequency) to a general practitioner (GP), a physical therapist, a medical specialist and/or a mental health professional. Multivariate regression analyses were carried out separately for men and women for workers with health complaints. RESULTS: In the Dutch working population, personal, health, and work characteristics, but not sickness absence, were associated with later care-seeking. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. Women experience more health complaints and seek health care more often than men. For women, experiencing a work handicap (health complaints that impede work performance) was the only work characteristic associated with more care-seeking (GP). For men, work characteristics that led to less care-seeking were social support by colleagues (GP frequency), high levels of decision latitude (GP frequency) and high levels of social support by the supervisor (medical specialist). Other work characteristics led to more care-seeking: high levels of engagement (GP), full time work (GP frequency) and experiencing a work handicap (physical therapist). CONCLUSIONS: We can conclude that personal and health characteristics are most important when explaining medical care-seeking in the Dutch working population. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. The association between work characteristics and later medical care-seeking differed between health care providers and between men and women. If we aim at reducing health care costs for workers by preventing unnecessary or inefficient care, it is important to reduce the number of workers that report that health complaints impede their work performance. The supervisor could provide more social support, closely monitor workload in combination with work pressure and decision latitude, and when possible help to adjust working conditions. Health care providers could reduce medical costs by taking the work relatedness of health complaints into account and act accordingly, by decreasing the time to referral and waiting lists, and by providing appropriate care and avoiding unnecessary or harmful care.

Inter-doctor variations in the assessment of functional incapacities by insurance physicians.

BACKGROUND: The aim of this study was to determine the--largely unexplored--extent of systematic variation in the work disability assessment by Dutch insurance physicians (IPs) of employees on long-term sick leave, and to ascertain whether this variation was associated with the individual characteristics and opinions of IPs. METHODS: In March 2008 we conducted a survey among IPs on the basis of the 'Attitude--Social norm--self-Efficacy' (ASE) model. We used the ensuing data to form latent variables for the ASE constructs. We then linked the background variables and the measured constructs for IPs (n = 199) working at regional offices (n = 27) to the work disability assessments of clients (n = 83,755) and their characteristics. These assessments were carried out between July 2003 and April 2008. We performed multilevel regression analysis on three important assessment outcomes: No Sustainable Capacity or Restrictions for Working Hours (binominal), Functional Incapacity Score (scale 0-6) and Maximum Work Disability Class (binominal). We calculated Intra Class Correlations (ICCs) at IP level and office level and explained variances (R2) for the three outcomes. A higher ICC reflects stronger systematic variation. RESULTS: The ICCs at IP level were approximately 6% for No Sustainable Capacity or Restrictions for Working Hours and Maximum Work Disability Class and 12% for Functional Incapacity Score. Background IP variables and the measured ASE constructs for physicians contributed very little to the variation--at most 1%. The ICCs at office level ranged from 0% to around 1%. The R2 was 11% for No Sustainable Capacity or Restrictions for Working Hours, 19% for Functional Incapacity Score and 37% for Maximum Work Disability Class. CONCLUSION: Our study uncovered small to moderate systematic variations in the outcome of disability assessments in the Netherlands. However, the individual characteristics and opinions of insurance physicians have very little impact on these variations. Our findings provided no indications of other reasons for these variations. They may be related to different work routines or to different views on the workload of a 'normal' employee. If so, they could be reduced by well-developed and comprehensively implemented guidelines. Therefore, further research is needed.

The development of instruments to measure the work disability assessment behaviour of insurance physicians.

BACKGROUND: Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude--Social norm--self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants. METHODS: Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items. RESULTS: Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour.The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'. CONCLUSIONS: The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.

Can self-reported disability assessment behaviour of insurance physicians be explained? Applying the ASE model.

BACKGROUND: Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model (Attitude, Social norm, Self-efficacy) to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers. METHODS: This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit. RESULTS: Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process. CONCLUSION: A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments.

Empowerment of disability benefit claimants through an interactive website: design of a randomized controlled trial.

BACKGROUND: Individuals claiming a disability benefit after long-term sickness absence, have to undergo medical disability assessments. These assessments, often carried out by specialized physicians, can be complicated by wrong expectations or defensive attitudes of disability benefit claimants. It is hypothesized that empowerment of these claimants will enhance the physician-patient relationship by shifting claimants from a passive role to a more active and constructive role during disability assessments. Furthermore, empowerment of claimants may lead to a more realistic expectation and acceptance of the assessment outcome among claimants and may lead to a more accurate assessment by the physician. METHODS/DESIGN: In a two-armed randomized controlled trial (RCT), 230 claimants will be randomized to either the intervention or control group. For the intervention group, an interactive website was designed http://www.wiagesprek.nl using an Intervention Mapping procedure. This website was tested during a pilot study among 51 claimants. The final version of the website consists of five interactive modules, in which claimants will be prepared and empowered step-by-step, prior to their upcoming disability assessment. Other website components are a forum, a personal health record, a personal diary, and information on disability assessment procedures, return to work, and coping with disease and work disability. Subjects from the control group will be directed to a website with commonly available information only. Approximately two weeks prior to their disability assessment, disability claimants will be recruited through the Dutch Workers Insurance Authority (UWV). Outcomes will be assessed at five occasions: directly after recruitment (baseline), prior to disability assessment, directly after disability assessment as well as 6 and 16 weeks after the assessment. The study's primary outcome is empowerment, measured with the Vrijbaan questionnaire. Secondary outcomes include claimants' satisfaction, perceived justice, coping strategy, and knowledge. A process evaluation will also be conducted. DISCUSSION: This study evaluates the effectiveness of an interactive website aimed at empowerment of disability claimants. It is hypothesized that by increasing empowerment, the physician-patient relationship may be enhanced and claimants' satisfaction and perceived justice can be improved. Results are expected in 2010. TRIAL REGISTRATION: NTR-1414.

Training GPs to improve their management of work-related problems: results of a cluster randomized controlled trial.

BACKGROUND: Paying attention to their patients' work and recognizing work-related problems is challenging for many general practitioners (GPs). OBJECTIVES: To assess the effect of training designed to improve the care for patients with work-related problems in general practice. METHODS: A cluster randomized controlled trial among 32 Dutch GPs. GPs in the intervention group received five-hour training. GPs in the control group were not trained. Included patients (age 18-63, working ≥12 h per week) completed baseline questionnaires and follow-up questionnaires planned after one year. Primary outcome at patient level was patients' expectations about their ability to work, measured using the return-to-work self-efficacy scale (RTW-SE). Primary outcomes on GP level were their use of ICPC-code Z05 ('work-related problem') per 1000 working-age patients and percentage of the electronic medical files of working-age patients in which information about occupation had been recorded. RESULTS: A total of 640 patients completed the baseline questionnaire and 281 the follow-up questionnaire. We found no statistically significant differences in patients' RTW-SE scores: intervention 4.6 (95%CI: 4.2-5.0); control 4.5 (95%CI: 4.1-4.9). Twenty-nine GPs provided data about the GP-level outcomes, which showed no statistically significant differences: use of ICPC code Z05 11.6 (95%CI: 4.7-18.6) versus 6.0 (95%CI: -1.2 to 13.2) per 1000 working-age patients; recording of occupation 28.8% (95%CI: 25.8-31.7) versus 28.6% (95%CI: 25.6-31.6). CONCLUSION: Training GPs did not improve patients' work-related self-efficacy or GPs' registration of work-related problems and occupation.

Effectiveness of an integrated care intervention on supervisor support and work functioning of workers with rheumatoid arthritis.

PURPOSE: In this manuscript, we evaluated the effectiveness of an intervention programme consisting of integrated care and a participatory workplace intervention on supervisor support, work instability and at-work productivity after 6 months of follow-up among workers with rheumatoid arthritis (RA). METHODS: We conducted a randomized controlled trial; we compared the intervention programme to usual care. Eligible patients were diagnosed with RA, had a paid job (> 8 h per week) and who experienced, at least, minor difficulties in work functioning. Supervisor support was measured with a subscale of the Job Content Questionnaire, work instability with the Work Instability Scale for RA, and at-work productivity with the Work Limitations Questionnaire. Data were analyzed using linear regression analyses. RESULTS: A beneficial effect of the intervention programme was found on supervisor support among 150 patients. Analyses revealed no effects on work instability and at-work productivity. CONCLUSION: We found a small positive effect of the intervention on supervisor support, but did not find any effects on work instability and at-work productivity loss. Future research should establish whether this significant but small increase in supervisor support leads to improved work functioning in the long run. This study shows clinicians that patients with RA are in need of efforts to support them in their work functioning. Implications for Rehabilitation Rheumatoid arthritis (RA) is a chronic inflammatory disease with a severe impact on work functioning, even when a patient is still working. It is important to involve the workplace when an intervention is put in place to support RA patients in their work participation. Supervisor support influences health outcomes of workers, and it is possible to improve supervisor support by an intervention which involves the workplace and supervisor.

Economic evaluation of an intervention program with the aim to improve at-work productivity for workers with rheumatoid arthritis.

OBJECTIVES: Evaluating the cost effectiveness and cost utility of an integrated care intervention and participatory workplace intervention for workers with rheumatoid arthritis (RA) to improve their work productivity. METHODS: Twelve month follow-up economic evaluation alongside a randomized controlled trial (RCT) within specialized rheumatology treatment centers. Adults diagnosed with RA between 18-64 years, in a paid job for at least eight hours per week, experiencing minor difficulties in work functioning were randomized to the intervention (n = 75) or the care-as-usual (CAU) group (n = 75). Effect outcomes were productivity and quality of life (QALYs). Costs associated with healthcare, patient and family, productivity, and intervention were calculated from a societal perspective. Cost effectiveness and cost utility were assessed to indicate the incremental costs and benefits per additional unit of effect. Subgroup and sensitivity analyses evaluated the robustness of the findings. RESULTS: At-work productivity loss was about 4.6 hours in the intervention group and 3.5 hours in the care as usual (CAU) group per two weeks. Differences in QALY were negligible; 0.77 for the CAU group and 0.74 for the intervention group. In total, average costs after twelve months follow-up were highest in the intervention group (€7,437.76) compared to the CAU group (€5,758.23). The cost-effectiveness and cost-utility analyses show that the intervention was less effective and (often) more expensive when compared to CAU. Sensitivity analyses supported these findings. DISCUSSION: The integrated care intervention and participatory workplace intervention for workers with RA provides gains neither in productivity at the workplace nor in quality of life. These results do not justify the additional costs.

How do Dutch GPs address work-related problems? A focus group study.

BACKGROUND: In the Netherlands, there is a lack of knowledge about general practitioners' (GPs) perception of their role regarding patients' occupation and work related problems (WRP). As work and health are closely related, and patients expect help from their GPs in this area, a better understanding is needed of GPs' motivation to address WRP. OBJECTIVES: To explore GPs' opinions on their role in the area of work and health. METHODS: This is a qualitative study using three focus groups with Dutch GPs from the catchment area of a hospital in the Southeast of the Netherlands. The group was heterogeneous in characteristics such as sex, age, and practice setting. Three focus groups were convened with 18 GPs. The moderator used an interview guide. Two researchers analysed verbatim transcripts using constant comparative analysis. RESULTS: We distinguished three items: (a) work context in a GP's integrated consultation style; (b) counselling about sick leave; (c) cooperation with occupational physicians (OPs). The participants are willing to address the topic and counsel about sick leave. They consider WRP in patients with medically unexplained symptoms (MUS) challenging. They tend to advise these patients to continue working as they think this will ultimately benefit them. CONCLUSION: The participating GPs seemed well aware of the relation between work and health but need more knowledge, communication skills and better cooperation with occupational physicians to manage work-related problems. [Box: see text].

Workers' opinions on the effect of contact with health care providers on sickness absence duration.

BACKGROUND: Because of the aging working population and the increasing age of retirement the number of workers with chronic illnesses and disabilities is growing. It is important that workers with health complaints receive efficient health care in order to remain fully or at least partly productive. OBJECTIVE: To explore workers' opinions about the effectiveness of contact with health care providers in shortening sickness absence duration. METHODS: Data come from a four-wave study from 2005 to 2008 among Dutch workers (n=1,424). Data were obtained on visits to health care providers, sickness absence and workers' opinions on whether and how their absence could have been shortened. RESULTS: A third of the workers were of the opinion that the health care provider (most often the general practitioner, GP) had played a role in preventing sickness absence and 35% were of the opinion that the health care provider had limited their absence. Most often the physical therapist (71%) and mental health therapist (61%) shortened sickness absence duration, in contrast to the occupational physician (OP, 25%) and GP (32%). The effectiveness of the health care providers' treatment was associated with the cause of sickness absence. Approximately 15% of the workers reported that their sickness absence could have been shortened if health care providers had provided the proper treatment and if waiting times had been reduced. CONCLUSIONS: Health care providers differ in their potential to shorten sickness absence duration. Health care providers can further reduce sickness absence and health care costs by providing the proper treatment and by reducing waiting times.

The double whammy of a work handicap (differential) effects of health on working conditions and outcomes.

OBJECTIVE: To determine the effect of health on working conditions and outcomes. METHODS: Data were collected in the longitudinal Study on Health at Work (n = 1597 employees), using multiple regression analyses and focusing on three groups of employees: 1) healthy, 2) chronic health complaints without a work handicap, and 3) chronic health complaints with a work handicap. RESULTS: 1) Employees with a work handicap experienced less favorable working conditions and outcomes than other employees. 2) Employees with a work handicap experienced less favorable working conditions and outcomes over time. 3) Employees with chronic health complaints were more vulnerable to the influence of working conditions on outcomes, whereas employees with a work handicap, unexpectedly, benefited from high work pressure and low autonomy. CONCLUSION: 1) Employees with a work handicap differ considerably from employees with chronic health complaints. 2) Employees with a work handicap drift into less favorable working conditions and outcomes. 3) Healthy employees, employees with chronic health complaints, and employees with a work handicap, all are vulnerable to different working conditions.

Demography and life history of Thomas langurs (Presbytis thomasi).

Life history data from wild primate populations are necessary to explain variation in primate social systems and explain differences between primates and other mammals. Here we report life history data from a 12.5-year study on wild Thomas langurs. Mean age at first reproduction was 5.4 years and the sex ratio at birth was even. The mean interbirth interval (IBI) after a surviving infant was 26.8 mo, after nonsurviving infants 17.7 mo, and combined 22.0 mo. Mean annual birth rate of adult females was 0.44, while reaching a peak at 6 years of age and showing no decrease with age. Mortality was highest during the first year of life (48.0% for males and 43.0% for females) and consistently higher for males than females. The oldest female observed during the study was estimated to be 20 years of age, whereas the oldest male disappeared at age 13 years, indicating that males die at a much earlier age than females. A Leslie matrix based on these estimates yielded a growth rate of 1.01, which is comparable to the nonsignificant increase in density indicated by our long-term field data. A comparison with life history data for sympatric frugivorous primates suggests that folivory might be associated with faster life history.