Exploring stakeholders' perceived problems associated with the care and support of children and youth with mental ill health in Sweden: a qualitative study.

BACKGROUND: Care and support for children and youth with mental ill health have become more specialized and are provided by an increasing number of stakeholders. As a result, services are often fragmented, inefficient and unco-ordinated, with negative consequences for the service user and their family. Enhanced collaboration could lead to improved care and support but requires a shared understanding and a joint problem formulation between involved stakeholders to commence. The aim of this study was to explore different stakeholders' perceived problems associated with delivering care and support to children and youth with mental ill health and to discuss how the perceived problems relate to collaboration. METHODS: A qualitative descriptive study was conducted, using short statements of perceived problems written by stakeholders involved in the care and support of children and youth with mental ill health during an inter-organizational workshop. The 26 stakeholders represented school and student health, primary health care, specialist care, social services, and different service user organizations. Data were collected during February 2020. Inductive content analysis with a summative approach was used when analysing the data. RESULTS: The perceived problems were summarized in a model consisting of four main categories: Resources and governance; Collaboration and co-ordination; Knowledge and competence; and Stigma and confidence, containing 24 subcategories. These categories and subcategories were distributed over three levels: Societal level, Organizational level and Individual level. The perceived problems were shared on the category level but to some extent varied between stakeholder groups on the subcategory level. The perceived problems were either directly or indirectly related to collaboration. CONCLUSIONS: The perceived problems often acted as barriers to achieving successful collaboration. The problems were distributed on all three levels in the developed model, indicating a complex problem. Even though the perceived problems were shared by stakeholders on an overall level, the findings indicate that the stakeholders did not have a completely shared understanding of the perceived problems, as they tended to focus on aspects most relevant to their own organization or perceptions. The challenge is to find which perceived problems are appropriate for inter-organization problem-solving and which can be solved within individual organizations.

From Threatening Chaos to Temporary Order through a Complex Process of Adaptation: A Grounded Theory Study of the Escalation of Intensive Care during the COVID-19 Pandemic.

To ensure high-quality care, operationalize resilience and fill the knowledge gap regarding how to improve the prerequisites for resilient performance, it is necessary to understand how adaptive capacity unfolds in practice. The main aim of this research was to explain the escalation process of intensive care during the first wave of the pandemic from a microlevel perspective, including expressions of resilient performance, intervening conditions at the micro-meso-macrolevels and short- and long-term consequences. A secondary aim was to provide recommendations regarding how to optimize the prerequisites for resilient performance in intensive care. A grounded theory methodology was used. First-person stories from different healthcare professionals (n70) in two Swedish regions were analyzed using the constant comparative method. This resulted in a novel conceptual model (including 6 main categories and 24 subcategories), and 41 recommendations. The conclusion of these findings is that the escalation of intensive care can be conceptualized as a transition from threatening chaos to temporary order through a complex process of adaptation. To prepare for the future, the components of space, stuff, staff, system and science, with associated continuity plans, must be implemented, anchored and communicated to actors at all levels of the system.

Health Consequences of the COVID-19 Pandemic among Health-Care Workers: A Comparison between Groups Involved and Not Involved in COVID-19 Care.

Health consequences have been reported among health-care workers (HCWs) exposed to COVID-19. Sweden chose to manage the pandemic with a lower and more equal long-lasting work strain and shorter periods of recovery than in other countries. Few studies have examined the health consequences among HCWs working in such conditions. This study compared the health consequences after the first wave of the COVID-19 pandemic between HCWs involved in the care of COVID-19 patients and other HCWs and between occupational groups working in COVID-19 care. Multinomial logistic regression and univariate general linear models were used to identify differences. The levels of depression, emotional and physical fatigue, sleep quality, and general health were measured 6 months after the onset of the pandemic in 3495 HCW employed in Sweden. HCWs directly involved in COVID-19 care reported significantly poorer sleep quality and higher scores on emotional and physical exhaustion than those not involved in such care. Health consequences did not differ significantly between different occupational groups involved in COVID-19 care except for specialist nurses/midwives. HCWs more frequently involved in COVID-19 care reported higher levels of emotional and physical fatigue and poorer sleep but less severe than those reported in more severely affected countries.

Do Attitudes towards Work or Work Motivation Affect Productivity Loss among Academic Employees?

Work motivation and job attitudes are important for productivity levels among academic employees. In situations where employees perceive problems, for example, health-related and work environment-related problems, the ability to perform at work could be affected, which may result in fewer publications, reduced quality and less research funding. Few studies, however, have paid attention to productivity loss among academic employees in order to understand how, or if, the perceived loss is affected by the reported problems, either alone or in combination with work motivation and job attitudes. To evaluate whether attitudes towards work-measured as job satisfaction, organisational commitment and work motivation-are associated with productivity loss in the workplace, a cross-sectional study was conducted. This type of design is required as performance is highly variable and is affected by changes in health and work status. This study includes employees who reported either health-related problems, work environment problems or a combination of both (n = 1475). Linear regression analyses were used to answer the hypotheses. Higher levels of motivation, job satisfaction and organisational commitment were associated with lower levels of productivity loss among employees who experienced either health-related or work environment problems. High work motivation and high commitment were significantly associated with lower levels of productivity loss among employees who experienced a combination of problems. In summary, productivity loss among academic employees is not only affected by health-related problems or problems in the work environment but also by work motivation, job satisfaction and organisational commitment; i.e., these factors seem to buffer, or moderate, the reduction in performance levels for this group of employees.

Resilient performance in healthcare during the COVID-19 pandemic (ResCOV): study protocol for a multilevel grounded theory study on adaptations, working conditions, ethics and patient safety.

INTRODUCTION: Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic's rampage, the processes involved and the consequences on working conditions, ethics and patient safety. METHODS: An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants' first-person stories are complemented with data from the healthcare organisations' internal documents and national and international official documents. ANALYSIS: Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic. ETHICS AND DISSEMINATION: This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.

Cost-Effectiveness of a Problem-Solving Intervention Aimed to Prevent Sickness Absence among Employees with Common Mental Disorders or Occupational Stress.

The cost-benefit and cost-effectiveness of a work-directed intervention implemented by the occupational health service (OHS) for employees with common mental disorders (CMD) or stress related problems at work were investigated. The economic evaluation was conducted in a two-armed clustered RCT. Employees received either a problem-solving based intervention (PSI; n = 41) or care as usual (CAU; n = 59). Both were work-directed interventions. Data regarding sickness absence and production loss at work was gathered during a one-year follow-up. Bootstrap techniques were used to conduct a Cost-Benefit Analysis (CBA) and a Cost-Effectiveness Analysis (CEA) from both an employer and societal perspective. Intervention costs were lower for PSI than CAU. Costs for long-term sickness absence were higher for CAU, whereas costs for short-term sickness absence and production loss at work were higher for PSI. Mainly due to these costs, PSI was not cost-effective from the employer's perspective. However, PSI was cost-beneficial from a societal perspective. CEA showed that a one-day reduction of long-term sickness absence costed on average €101 for PSI, a cost that primarily was borne by the employer. PSI reduced the socio-economic burden compared to CAU and could be recommended to policy makers. However, reduced long-term sickness absence, i.e., increased work attendance, was accompanied by employees perceiving higher levels of production loss at work and thus increased the cost for employers. This partly explains why an effective intervention was not cost-effective from the employer's perspective. Hence, additional adjustments and/or support at the workplace might be needed for reducing the loss of production at work.

Preventing sickness absence among employees with common mental disorders or stress-related symptoms at work: a cluster randomised controlled trial of a problem-solving-based intervention conducted by the Occupational Health Services.

OBJECTIVES: Common mental disorders (CMDs) are among the main causes of sickness absence and can lead to suffering and high costs for individuals, employers and the society. The occupational health service (OHS) can offer work-directed interventions to support employers and employees. The aim of this study was to evaluate the effect on sickness absence and health of a work-directed intervention given by the OHS to employees with CMDs or stress-related symptoms. METHODS: Randomisation was conducted at the OHS consultant level and each consultant was allocated into either giving a brief problem-solving intervention (PSI) or care as usual (CAU). The study group consisted of 100 employees with stress symptoms or CMDs. PSI was highly structured and used a participatory approach, involving both the employee and the employee's manager. CAU was also work-directed but not based on the same theoretical concepts as PSI. Outcomes were assessed at baseline, at 6 and at 12 months. Primary outcome was registered sickness absence during the 1-year follow-up period. Among the secondary outcomes were self-registered sickness absence, return to work (RTW) and mental health. RESULTS: A statistical interaction for group × time was found on the primary outcome (p=0.033) and PSI had almost 15 days less sickness absence during follow-up compared with CAU. Concerning the secondary outcomes, PSI showed an earlier partial RTW and the mental health improved in both groups without significant group differences. CONCLUSION: PSI was effective in reducing sickness absence which was the primary outcome in this study.

The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain-A pragmatic randomized controlled trial.

BACKGROUND: For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP. METHOD: This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18-65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model. RESULTS: Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded. CONCLUSION: MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.

Perceived health and work-environment related problems and associated subjective production loss in an academic population.

BACKGROUND: The aim was to investigate the prevalence of health problems and work environment problems and how these are associated with subjective production loss among women and men at an academic workplace. An additional aim was to investigate whether there were differences between women and men according to age group, years at current workplace, academic rank or managerial position. METHODS: A questionnaire was sent in 2011 to all employees at a Swedish university (n = 5144). Only researchers and teachers were included in the study (n = 3207). Spearman correlations were performed to investigate differences in health and work environment problems. Employees who reported having experienced work environment or health problems in the previous seven days (n = 1475) were included in the analyses in order to investigate differences in subjective production loss. This was done using Student's t-test, One-way Anova and generalized linear models. RESULTS: The response rate was 63% (n = 2022). A total of 819 academic staff (40% of the population) reported experiencing either health problems, work environment problems or both during the previous seven days. The prevalence of health problems only or a combination of work environment and health problems was higher among women than men (p-value ˂0.05). This was especially the case for younger women, those in lower academic positions and those who had worked for fewer years at their current workplace. No difference was found for work environment problems. The majority of the employees who reported problems said that these problems affected their ability to perform at work (84-99%). The average production loss varied between 31 and 42% depending on the type of problem. Production loss due to health-related and work-environment related problems was highest among junior researchers and managers. No significant difference between men and women was found in the level of production loss. CONCLUSION: Subjective production loss in academia can be associated with health and work- environment problems. These losses appear similar for women and men even though younger female academics, women in lower academic ranks and those with fewer years of employment in their current workplace report a higher prevalence of health problems and combined work-environment and health problems than men.

Economic Evaluation of Occupational Safety and Health Interventions From the Employer Perspective: A Systematic Review.

OBJECTIVES: The aim of this systematic review was to evaluate the cost-effectiveness of occupational safety and health interventions from the employer perspective. METHODS: A comprehensive literature search (2005 to 2016) in five electronic databases was conducted. Pre-2005 studies were identified from the reference lists of previous studies and systematic reviews, which have similar objective to those of this search. RESULTS: A total of 19 randomized controlled trials and quasi-experimental studies were included, targeting diverse health problems in a number of settings. Few studies included organizational-level interventions. When viewed in relation to the methodological quality and the sufficiency of economic evidence, five of 11 cost-effective occupational safety and health (OSH) interventions appear to be promising. CONCLUSION: The present systematic review highlights the need for high-quality economic evidence to evaluate the cost-effectiveness of OSH interventions, especially at organizational-level, in all areas of worker health.

Individual preferences for physical exercise as secondary prevention for non-specific low back pain: A discrete choice experiment.

BACKGROUND: Exercise is effective in improving non-specific low back pain (LBP). Certain components of physical exercise, such as the type, intensity and frequency of exercise, are likely to influence participation among working adults with non-specific LBP, but the value and relative importance of these components remain unknown. The study's aim was to examine such specific components and their influence on individual preferences for exercise for secondary prevention of non-specific LBP among working adults. METHODS: In a discrete choice experiment, working individuals with non-specific LBP answered a web-based questionnaire. Each respondent was given ten pairs of hypothetical exercise programs and asked to choose one option from each pair. The choices comprised six attributes of exercise (i.e., type of training, design, intensity, frequency, proximity and incentives), each with either three or four levels. A conditional logit regression that reflected the random utility model was used to analyze the responses. RESULTS: The final study population consisted of 112 participants. The participants' preferred exercise option was aerobic (i.e., cardiovascular) rather than strength training, group exercise with trainer supervision, rather than individual or unsupervised exercise. They also preferred high intensity exercise performed at least once or twice per week. The most popular types of incentive were exercise during working hours and a wellness allowance rather than coupons for sports goods. The results show that the relative value of some attribute levels differed between young adults (age ≤ 44 years) and older adults (age ≥ 45 years) in terms of the level of trainer supervision required, exercise intensity, travel time to exercise location and financial incentives. For active study participants, exercise frequency (i.e., twice per week, 1.15; CI: 0.25; 2.06) influenced choice of exercise. For individuals with more than one child, travel time (i.e., 20 minutes, -0.55; CI: 0.65; 3.26) was also an influential attribute for choice of exercise, showing that people with children at home preferred to exercise close to home. CONCLUSIONS: This study adds to our knowledge about what types of exercise working adults with back pain are most likely to participate in. The exercise should be a cardiovascular type of training carried out in a group with trainer supervision. It should also be of high intensity and preferably performed twice per week during working hours. Coupons for sports goods do not appear to motivate physical activity among workers with LBP. The findings of the study could have a substantial impact on the planning and development of exercise provision and promotion strategies to improve non-specific LBP. Providers and employers may be able to improve participation in exercise programs for adults with non-specific LBP by focusing on the exercise components which are the most attractive. This in turn would improve satisfaction and adherence to exercise interventions aimed at preventing recurrent non-specific LBP.

Estimating the Effect and Economic Impact of Absenteeism, Presenteeism, and Work Environment-Related Problems on Reductions in Productivity from a Managerial Perspective.

OBJECTIVES: The aim of this study was to propose wage multipliers that can be used to estimate the costs of productivity loss for employers in economic evaluations, using detailed information from managers. METHODS: Data were collected in a survey panel of 758 managers from different sectors of the labor market. Based on assumed scenarios of a period of absenteeism due to sickness, presenteeism and work environment-related problem episodes, and specified job characteristics (i.e., explanatory variables), managers assessed their impact on group productivity and cost (i.e., the dependent variable). In an ordered probit model, the extent of productivity loss resulting from job characteristics is predicted. The predicted values are used to derive wage multipliers based on the cost of productivity estimates provided by the managers. RESULTS: The results indicate that job characteristics (i.e., degree of time sensitivity of output, teamwork, or difficulty in replacing a worker) are linked to productivity loss as a result of health-related and work environment-related problems. The impact of impaired performance on productivity differs among various occupations. The mean wage multiplier is 1.97 for absenteeism, 1.70 for acute presenteeism, 1.54 for chronic presenteeism, and 1.72 for problems related to the work environment. This implies that the costs of health-related and work environment-related problems to organizations can exceed the worker's wage. CONCLUSIONS: The use of wage multipliers is recommended for calculating the cost of health-related and work environment-related productivity loss to properly account for actual costs.

What incentives influence employers to engage in workplace health interventions?

BACKGROUND: To achieve a sustainable working life it is important to know more about what could encourage employers to increase the use of preventive and health promotive interventions. The objective of the study is to explore and describe the employer perspective regarding what incentives influence their use of preventive and health promotive workplace interventions. METHOD: Semi-structured focus group interviews were carried out with 20 representatives from 19 employers across Sweden. The economic sectors represented were municipalities, government agencies, defence, educational, research, and development institutions, health care, manufacturing, agriculture and commercial services. The interviews were transcribed verbatim and the data were analysed using latent content analysis. RESULTS: Various incentives were identified in the analysis, namely: "law and provisions", "consequences for the workplace", "knowledge of worker health and workplace health interventions", "characteristics of the intervention", "communication and collaboration with the provider". The incentives seemed to influence the decision-making in parallel with each other and were not only related to positive incentives for engaging in workplace health interventions, but also to disincentives. CONCLUSIONS: This study suggests that the decision to engage in workplace health interventions was influenced by several incentives. There are those incentives that lead to a desire to engage in a workplace health intervention, others pertain to aspects more related to the intervention use, such as the characteristics of the employer, the provider and the intervention. It is important to take all incentives into consideration when trying to understand the decision-making process for workplace health interventions and to bridge the gap between what is produced through research and what is used in practice.

Absence of low back pain to demarcate an episode: a prospective multicentre study in primary care.

BACKGROUND: It has been proposed that an episode of low back pain (LBP) be defined as: "a period of pain in the lower back lasting for more than 24 h preceded and followed by a period of at least 1 month without LBP". Previous studies have tested the definition in the general population and in secondary care populations with distinctly different results. The objectives of this study (in a primary care population) were to investigate the prevalence of 1) the number of consecutive weeks free from bothersome LBP, 2) the prevalence of at least four consecutive weeks free from bothersome LBP at any time during the study period, and 3) the prevalence of at least four consecutive weeks free from bothersome LBP at any time during the study period among subgroups that reported >30 days or ≤30 days of LBP the preceding year. METHOD: In this prospective multicentre study subjects with LBP (n = 262) were consecutively recruited from chiropractic primary care clinics in Sweden. The number of days with bothersome LBP was collected through weekly automated text messages. The maximum number of weeks in a row without bothersome LBP and the number of periods of at least four consecutive weeks free from bothersome LBP was counted for each individual and analysed as proportions. RESULTS: Data from 222 recruited subjects were analysed, of which 59 % reported at least one period of four consecutive weeks free from bothersome LBP. The number of consecutive pain free weeks ranged from 82 (at least one) to 31 % (9 or more). In subjects with a total duration of LBP of ≤ 30 days the previous year, 75 % reported a period of 4 consecutive weeks free from bothersome LBP during the study period whereas this was reported by only 48 % of subjects with a total duration of LBP of >30 days the previous year. CONCLUSION: Prevalence of four consecutive pain free weeks is found in the majority of subjects in this population logically reflects duration of LBP within the sample and may be applied on patients in primary care to demarcate a LBP episode.

Validation of a measure of health-related production loss: construct validity and responsiveness - a cohort study.

BACKGROUND: The aim of this study is to evaluate the construct validity and responsiveness of a Swedish measure of health-related production loss as well as to investigate if there is a difference in the level of production loss within a population suffering from persistent back/neck pain and CMDs. METHODS: The sample was drawn from a study that assessed employees' health and working capacity in 74 health care units before and after intervention. The study included 692 patients who reported working the previous six months at baseline measurement, and who were also asked to answer questions related to health-related production loss. Health-related measures were general health derived from Short Form-12, health-related quality of life derived from EQ-5D, and work ability derived from the Work Ability Index (WAI). Convergent validity and external responsiveness were assessed using Spearman's Rank Correlation Coefficient and a linear regression model, respectively. RESULTS: The different measures of health showed a moderate-to-strong correlation with the measure of health-related production loss and fulfilled the criteria for construct validity. Changes in health and work ability led to significant changes in health-related production loss, which demonstrates external responsiveness. This result is valid for both the total population and for the two different subgroups that were evaluated. CONCLUSIONS: The present study shows that this measure of health-related production loss is a valid measure for capturing production loss due to illness, and that work ability is more strongly correlated with health-related production loss than people's general health is. The result shows an average of about 50 % reduced production due to illness, with back pain being the most costly.

Production loss among employees perceiving work environment problems.

OBJECTIVES: The overall aim of this explorative study was to investigate the relationship between factors in the psychosocial work environment and work environment-related production loss. METHODS: Employees at a Swedish university were invited to answer a workplace questionnaire and were selected for this study if they reported having experienced work environment-related problems in the past 7 days (n = 302). A stepwise logistic regression and a modified Poisson regression were used to identify psychosocial work factors associated with work environment-related production loss as well as to identify at what level those factors are associated with production loss. RESULTS: Employees who reported having experienced work environment problems but also fair leadership, good social climate, role clarity and control of decision had significantly lower levels of production loss, whereas employees who reported inequality and high decision demands reported significantly higher levels of production loss. Never or seldom experiencing fair leadership, role clarity, equality, decision demands and good social climate increase the risk of production loss due to work environment problems, compared to those who experience these circumstances frequently, always or most of the time. CONCLUSIONS: Several psychosocial work factors are identified as factors associated with a reduced risk of production losses among employees despite the nature of the work environment problem. Knowledge of these factors may be important not only to reduce employee ill-health and the corresponding health-related production loss, but also reduce immediate production loss due to work environment-related problems.

Cost-effectiveness of a one-year coaching program for healthy physical activity in early rheumatoid arthritis.

PURPOSE: To describe cost-effectiveness of the Physical Activity in Rheumatoid Arthritis (PARA) study intervention. METHOD: Costs were collected and estimated retrospectively. Cost-effectiveness was calculated based on the intervention cost per patient with respect to change in health status (EuroQol global visual analog scale--EQ-VAS and EuroQol--EQ-5D) and activity limitation (Health assessment questionnaire - HAQ) using cost-effectiveness- and cost-minimization analyses. RESULTS: Total cost of the one-year intervention program was estimated to be €67 317 or €716 per participant. Estimated difference in total societal cost between the intervention (IG) and control (CG) was €580 per participant. Incremental cost-effectiveness ratio (ICER) for one point (1/100) of improvement in EQ-VAS was estimated to be €116. By offering the intervention to more affected participants in the IG compared to less affected participants, 15.5 extra points of improvement in EQ-VAS and 0.13 points of improvement on HAQ were gained at the same cost. "Ordinary physiotherapy" was most cost-effective with regard to EQ-5D. CONCLUSIONS: The intervention resulted in improved effect in health status for the IG with a cost of €116 per extra point in VAS. The intervention was cost-effective if targeted towards a subgroup of more affected patients when evaluating the effect using VAS and HAQ. IMPLICATIONS FOR REHABILITATION: The physical activity coaching intervention resulted in an improved effect on VAS for the intervention group, to a higher cost. In order to maximize cost-effectiveness, this type of physical activity coaching intervention should be targeted towards patients largely affected by their RA. The intervention is cost-effective from the patients' point of view, but not from that of the general population.

Prevention of low back pain: effect, cost-effectiveness, and cost-utility of maintenance care - study protocol for a randomized clinical trial.

BACKGROUND: Low back pain (LBP) is a prevalent condition and a socioeconomic problem in many countries. Due to its recurrent nature, the prevention of further episodes (secondary prevention), seems logical. Furthermore, when the condition is persistent, the minimization of symptoms and prevention of deterioration (tertiary prevention), is equally important. Research has largely focused on treatment methods for symptomatic episodes, and little is known about preventive treatment strategies. METHODS/DESIGN: This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden. The primary outcome is the number of days with bothersome pain over 12 months. Secondary measures are self-rated health (EQ-5D), function (the Roland Morris Disability Questionnaire), psychological profile (the Multidimensional Pain Inventory), pain intensity (the Numeric Rating Scale), and work absence.The primary utility measure of the study is quality-adjusted life years and will be calculated using the EQ-5D questionnaire. Direct medical costs as well as indirect costs will be considered.Subjects are randomly allocated into two treatment arms: 1) Symptom-guided treatment (patient controlled), receiving care when patients feel a need. 2) Preventive treatment (clinician controlled), receiving care on a regular basis. Eligibility screening takes place in two phases: first, when assessing the primary inclusion/exclusion criteria, and then to only include fast responders, i.e., subjects who respond well to initial treatment. Data are collected at baseline and at follow-up as well as weekly, using SMS text messages. DISCUSSION: This study investigates a manual strategy (chiropractic maintenance care) for recurrent and persistent LBP and aims to answer questions regarding the effect and cost-effectiveness of this preventive approach. Strict inclusion criteria should ensure a suitable target group and the use of frequent data collection should provide an accurate outcome measurement. The study utilizes normal clinical procedures, which should aid the transferability of the results. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863, February 22, 2012. The first patient was randomized into the study on April 13th 2012.

Hierarchies of health: health and work-related stress of managers in municipalities and county councils in Sweden.

OBJECTIVE: The aim of this study was to investigate the risk of poor health and stress among male and female managers working at different levels in the public sector. METHODS: A cross-sectional study using register data. A modified Poisson regression approach was used to examine the risk of stress and illness in relation to management level and sex; 1088 managers participated and were categorized into different management levels and sexes. RESULTS: The results showed a clear hierarchy of health in relation to managerial level and sex with several significant statistical differences. Women with lower-level management positions suffered to a greater extent from poor health and stress. CONCLUSIONS: Organizations should focus not only on developing individuals in their managerial roles but also on improving the conditions that allow managers to remain healthy and less stressed.