Social Insurance Literacy Among the Sick-listed-A Study of Clients' Comprehension and Self-Rated System Comprehensibility of the Sickness Insurance System.

INTRODUCTION: Sickness insurance systems and their processes have been studied in terms of transparency, comprehensibility and fairness, highlighting the importance of just procedures that make sense to clients. Related research demonstrates differences between groups of clients, pointing towards a social gradient. The concept of social insurance literacy and the Social Insurance Literacy Questionnaire (SILQ) was recently developed and serves as a measure for client's ability to obtain, understand and act on information in a sickness insurance system, relating to the comprehensibility of the information that the system provides. OBJECTIVE: The purpose of this study was to investigate social insurance literacy among clients on sick leave and its associations with perceived justice, being granted sickness benefits and background factors. METHODS: This was a questionnaire study with clients on sick leave in Sweden. In the selection process 3993 clients were invited, of which 1173 recently had their sickness benefits withdrawn. Those who answered the SILQ (n = 1152) also answered a perceived justice measure and accepted sharing register data from the Swedish Social Insurance Agency. Data were analyzed through regression analysis. RESULTS: The findings demonstrate that clients' perceptions of system comprehensibility and the status of their sick leave case was significantly associated with perceived justice, and being granted sickness benefits, while their individual abilities to obtain, understand, and act on information had lesser influence. CONCLUSIONS: The system's ability to provide understandable information seems more important than clients' abilities to comprehend it. From a client perspective, a just system seems to be related to their experiences of the sick leave process (i,e., whether they had an ongoing or closed case) rather than their skills to obtain the correct information.

Continuous glucose monitoring in older adults with diabetes: Data from the diabetes prospective follow-up (DPV) registry.

AIMS: To analyse predictors for continuous glucose monitoring (CGM) use in people with diabetes aged ≥60 years using insulin therapy and to assess the rates of CGM use during recent years (2019-2021). RESEARCH DESIGN AND METHODS: Prospective study including 6849 individuals with diabetes and insulin therapy (type 2 diabetes: n = 5320; type 1 diabetes: n = 1529) aged ≥60 years. Data from 129 treatment centres were retrieved from the Diabetes Prospective Follow-up Registry (DPV) in March 2023. RESULTS: Sensor use in individuals aged ≥60 years has increased in type 1 (2019: 28%, 2020: 39%, 2021: 45%) and type 2 diabetes (2019: 10%, 2020: 16%, 2021: 18%). Predictors for sensor use in older individuals with type 1 diabetes are younger age and CSII use (p < 0.001). Predictors in older individuals with type 2 diabetes are younger age, longer diabetes duration, higher BMI and CSII use (p < 0.001). CONCLUSIONS: CGM has become more common in older adults with diabetes and will presumably increase further. Age is a predictor for sensor use in older adults with diabetes. Age-related physical barriers and insufficient usability of devices, lack of interest in technologies, but possibly also effects of prejudice on the grounds of age may contribute to this finding.

The Social Insurance Literacy Questionnaire (SILQ): Development and Psychometric Evaluation.

PURPOSE: For clients to understand social insurance decisions and processes, information from authorities needs to be comprehensible, and clients need sufficient individual abilities. These dimensions are captured by the concept social insurance literacy, which has been operationalized into a measure, the Social Insurance Literacy Questionnaire (SILQ). The aim of this study was to describe the development of the SILQ and evaluate its psychometric properties using Rasch measurement theory. METHODS: The development of the SILQ included a Delphi study and cognitive interviews. A preliminary version, divided on four scales corresponding to the domains of the concept (obtaining information, understanding information, acting on information, and system comprehensibility) was psychometrically evaluated according to Rasch measurement theory, in a survey to a stratified random sample of people on sick leave (n = 1151) sent out in the fall of 2020. RESULTS: Overall, the items in the final version of the SILQ demonstrated good fit to the Rasch model, and the response scale worked as intended. Unidimensionality was supported for all scales, but minor problems with local dependency was detected for three items. The person separation was 0.80 for the Obtain scale, 0.82 for the Understand scale, 0.68 for the Act scale, and 0.81 for the System scale. Corresponding ordinal alpha values were 0.91, 0.91, 0.86, and 0.91, respectively. CONCLUSION: This study is a first step toward exploring literacy in the social insurance field. The SILQ covers individual abilities and systems' comprehensibility, and the results show that it has acceptable psychometric properties.

Employees with mental disorders seeking support from the workers compensation system - experiences from Denmark.

BACKGROUND: In Europe it is commonly accepted that psychosocial hazards may influence the mental health of employees. However, mental disorders such as depression are generally not acknowledged as an occupational disease covered by the workers compensation system. Studies indicate that workers compensation claim processes may affect employee's health negatively due to a demanding case process. If filing a workers' compensation claim can harm the employees' health, it is highly relevant to pay attention to employees with mental health claims, as they are most likely vulnerable and face a very low chance of compensation. OBJECTIVE: This study investigates how employees with work-related mental disorders experience the process of seeking workers compensation from the Danish Workers' Compensation System. METHOD: Interview (N = 13) and questionnaire (N = 436) data from claimants were analysed. RESULTS: Analysis showed that even though many employees wished for the claim to influence the conditions at the workplace, there seemed to be a lack of preventive health and safety initiatives in the workplaces. Central stakeholders such as health and safety representatives were often not involved. Management involvement was often experienced negatively, and the Danish Working Environment Authority rarely conducted workplace inspections. Employees experienced inadequate information about the workers' compensation process and experienced a lack of coordination between stakeholders. CONCLUSION: A more supportive and coordinated approach in the Workers' Compensation System is recommendable. The processes in the system could be evaluated using the Social Insurance Literacy concept, to ensure sufficient support of the claimants and reduce potential harmful aspects of the process.

The work disability trap: manifestations, causes and consequences of a policy paradox.

PURPOSE: This article focuses on the risk that work disability policies lock people into work disability rather than promote durable health and return to work. We outline the concept of a work disability trap as a heuristic device to explore this policy paradox inherent in the design of most social insurance systems. MATERIALS AND METHODS: This is a conceptual paper drawing on examples from existing research. RESULTS: We identify three manifestations of the disability trap: not overcoming disability; underperforming; and returning to work prematurely. The causes of these manifestations are identified as structural rather than based on malingering clients, while negative consequences are identified both on client and system levels. CONCLUSION: We emphasize the need for systems built on trust and reasonable expectations, and the need for providing rehabilitation support independently of economic compensation. Universal basic income is introduced as a potential tool to ameliorate some of the consequences of the disability trap.Implications for rehabilitationCompensation systems focusing too prominently on early return to work may have counter-productive effects on rehabilitation.Overly suspicious assessment systems nurture a view of people as malingerers.Rehabilitation professionals need to be attentive to system-generated effects which may prevent overcoming work disability.

The impact of leadership on employee well-being: on-site compared to working from home.

BACKGROUND: The Covid-19 pandemic has brought significant changes to the way people work and there are several reasons to believe that working from home will become more common in the future. Yet more knowledge is needed on whether the effectiveness of leadership differs if the work is performed remotely compared to on-site work. PURPOSE: The aim of this study is to examine the place of work as a moderator for the effectiveness of leadership on employee well-being. METHOD: A survey was answered by 364 white-collar workers, employed by a larger Swedish municipality, who because of the covid-19-pandemic were offered to work from home. RESULTS: The employees working in their regular office perceived having more sufficient work equipment. No other differences were found in the investigated variables. Supportive leadership was associated with all investigated well-being variables in the hypothesised directions. Place of work did not moderate the relationship between Support leadership and the investigated well-being outcomes (Job satisfaction, Stress, General well-being). CONCLUSION: This study shows that there are few differences between employees working from home or working on-site during the Covid-19 pandemic. The supportive leadership of the closest manager seem to be important for well-being regardless of the worksite.

Laws, Policies, and Collective Agreements Protecting Low-wage and Digital Platform Workers During the COVID-19 Pandemic.

In the context of the COVID-19 pandemic, this commentary describes and compares shifting employment and occupational health social protections of low-wage workers, including self-employed digital platform workers. Through a focus on eight advanced economy countries, this paper identifies how employment misclassification and definitions of employees were handled in law and policy. Debates about minimum wage and occupational health and safety standards as they relate to worker well-being are considered. Finally, we discuss promising changes introduced during the COVID-19 pandemic that protect the health of low-wage and self-employed workers. Overall, we describe an ongoing "haves" and a "have not" divide, with on the one extreme, traditional job arrangements with good work-and-health social protections and, on the other extreme, low-wage and self-employed digital platform workers who are mostly left out of schemes. However, during the pandemic small and often temporary gains occurred and are discussed.

Multilevel, risk group-oriented strategies to decrease sickness absence in the public sector: evaluation of interventions in two regions in Sweden.

PURPOSE: Sickness absence has been identified as needing to be addressed through multilevel interventions, but knowledge regarding optimal design and implementation of such interventions is scarce. The aim of this study was to evaluate the implementation and effects of a large-scale multilevel intervention in the public sector in Sweden. METHODS: The overall effect of the intervention was assessed using mixed-effect models. Sickness absence data (before, and 6 or 12 months after the intervention) for 90 intervention groups and 378 reference groups was retrieved from administrative personnel systems from the two participating regional councils. The implementation processes were evaluated using qualitative content analysis of qualitative interviews conducted at two timepoints. RESULTS: The results show that the vast majority of implemented measures were on an individual level and the integration of the intervention differed between the two regions. The reception and perception of the intervention activities seem to have been influenced by the implementation process, and how well the interventions were communicated and integrated, both regarding the integration of the different interventions and their integration into the discrete context and existing routines. No short-term overall effects on sickness absence were found. CONCLUSIONS: The results point to the many challenges in implementing complex interventions, especially where organizational measures are involved-including adequate participation by, and communication between, the involved actors, as well as sufficient resources. The results indicate potential learning effects regarding the awareness of organizational factors in sick leave, after implementing and integrating multilevel strategies.

Swedish managers' experience-based understanding of the Capacity to work in employees with Common Mental Disorders: a Focus Group Study.

PURPOSE: Understanding of the capacity to work among employees with common mental disorders (CMDs) is important, but contemporary knowledge on this issue lacks the managers' perspective. The aim of this study was to explore and describe managers' experience-based understanding of capacity to work in employees with CMD. METHODS: A qualitative focus group study was designed. Managers with experience in supporting employees with CMD were recruited via organizations and networks. Eight focus group interviews with 31 participants took place. RESULTS: The analysis resulted in five categories. (1) Capacity to mentally focus on work tasks decreases or disappears, with negative consequences for work output. (2) Capacity to commit to continuous and coherent task changes, making tasks that span longer periods of time difficult. (3) Capacity to independently adapt to the needs of the situation decreases, and employees need more guidance and instructions than usual. (4) Capacity to keep up professional appearances is reduced, and the employees struggle with the professional role. (5) Ability to interact socially and professionally decreases, which potentially causes conflicts at the workplace. CONCLUSIONS: This study adds managers' perspective to the increasing knowledge on how capacity to work is influenced by CMDs. Managers understand CMDs in employees as changed, reducing the capacities needed for occupational functioning. A deeper understanding of reduced capacity to work is needed to adapt workplaces, and our findings can facilitate work accommodations for employees with CMDs.

Work capacity assessments and efforts to achieve a job match for claimants in a social security setting: an international inventory.

PURPOSE: Many high-income countries are witnessing a shift of focus on eligibility for disability benefits towards promotion of work reintegration. However, little is known about how countries assess work capacity, and how a job match is then obtained. The current study aims to compare work capacity assessments and available efforts to achieve a job match in eight high-income OECD countries. METHODS: A survey was conducted among key stakeholders concerning organization of work capacity assessments in social security settings, and efforts made to obtain a job, across eight OECD countries: Australia, Denmark, Finland, Iceland, Sweden, the Netherlands, the United Kingdom and the United States. RESULTS: In most countries, work capacity is assessed at several time points, with variations in moments and in information used for job matching. In countries obtaining information on personal and work levels, the search to find a job match usually begins with the persons who have disabilities. CONCLUSION: Although a shift towards a holistic focus in work capacity assessment has been recognized, medical factors still prevail. Limited emphasis is placed on the implications of functional limitations for the possibilities of work. A holistic approach to assessment needs to be coupled with holistic support measures through provision of coordinated and high quality job matching services.IMPLICATIONS FOR REHABILITATIONBesides determining eligibility for benefits the outcome of the work capacity assessment can also be used for other purposes such as reintegration and should not result in a static description of work capacity but also deliver insight in support needs.Involving multiple institutions and disciplines in work capacity assessments may result in a broader overview of the claimants' capacities, however this places high demands on cooperation and data sharing of all those involved.Incorporating the claimants own perspective on work capacity and possibilities to work might improve the legitimacy of the process and reasonably also the achievement of a good and sustainable job match. This can be achieved by using self reported questionnaires and interviews in the assessments.

Exploring Interactions in the Sickness Insurance System in Terms of Power and Trust.

Purpose Activation policies and efforts to reduce sick leave rates has influenced sickness insurance systems in Western countries, which has led to social security being more connected with work and attempts to expose malingering among the sickness absent. The aim of this study was to explore how power and trust are expressed by clients and stakeholders within the Swedish sickness insurance system. Methods This was a longitudinal qualitative study based on semi structured interviews and case files from 31 clients on sick leave in Sweden. Data was analyzed using a thematic analysis. Results The main theme 'Acts of power and distrust' illustrates how stakeholders' express suspicions towards each other, and how clients need to demonstrate desire and efforts to return to work which other stakeholders verified. Conclusions The clients desire to prove themselves able to contribute to society was prominent in this study and power relations need to be acknowledged, in particular between client and the SIA. Further, to preserve citizens trust in the system, the system needs to demonstrate trust also in the clients.

Social validity of work ability evaluations and official decisions within the sickness insurance system: A client perspective.

BACKGROUND: Studies of the social validity of work ability evaluations are rare, although the concept can provide valuable information about the acceptability, comprehensibility and importance of procedures. OBJECTIVE: The aim of this study was to explore clients' perceptions of social validity of work ability evaluations and the following official decisions concerning sickness benefits within the Swedish sickness insurance system. METHODS: This was a longitudinal qualitative study based on interviews with 30 clients on sick leave, analyzed through deductive content analysis. RESULTS: Clients' understanding of the evaluation was dependent on whether the specific tests were perceived as clearly related to the clients' situation and what information they received. For a fair description of their work ability, clients state that the strict structure in the evaluation is not relevant to everyone. CONCLUSION: The work ability evaluations indicate low acceptability due to lack of individual adaptation, the comprehensibility varied depending on the applicability of the evaluation and information provided, while the dimension 'importance' indicated as higher degree of social validity. The official decision about sickness benefits however was considered unrelated to the evaluation results, lacking solid arguments and sometimes contradictory to other stakeholders' recommendations indicating poor social validity.

Predictive validity of general work ability assessments in the context of sickness insurance.

OBJECTIVE: The activity ability assessment is a Swedish method for assessing general work ability, based on self-reports combined with an examination by specially trained physicians, and, if needed, extended assessments by occupational therapists, physiotherapists and/or psychologists. The aim of this study was to analyse the predictive validity of the activity ability assessment in relation to future sick leave. DESIGN: Analysis of assessments in 300 case files, in relation to register data on sick leave. SUBJECTS: People on sick leave (n =300, 32% men, 68% women; mean age 48 years; assessment at mean sick leave day 249). METHODS: Univariate and multivariate statistics. RESULTS: Self-rated work ability was the only factor with predictive value related to future sick leave. Physicians' evaluations lacked predictive value, except where the person had a limitation in vision, hearing or speech that was predictive of future decisions by the Social Insurance Agency. No sex differences were identified. CONCLUSION: The predictive value of the activity ability assessment for future sick leave is limited, and self-rated work ability is more accurate compared with an extensive insurance medical assessment. Self-rated work ability may be more holistic compared with insurance medicine assessments, which may be overly focused on individual factors. A practical implication of this is that the inclusion of contextual factors in assessment procedures needs to be improved.

Social insurance literacy: a scoping review on how to define and measure it.

PURPOSE: Sickness insurance and workers' compensation systems decide on peoples' eligibility for benefits, and are commonly based on medical certificates and assessments of work ability. Systems differ in the extent to which they preserve clients' dignity and right to fair assessments. In this article, we define a new concept for studying interactions between individuals and systems: social insurance literacy, which concerns how well people understand the different procedures and regulations in social insurance systems, and how well systems communicate with clients in order to help them understand the system. METHODS: The concept was defined through a scoping literature review of related concepts, a conceptual re-analysis in relation to the social insurance field, and a following workshop. RESULTS: Five related concepts were reviewed for definitions and operationalizations: health literacy, financial/economic literacy, legal capability/ability, social security literacy, and insurance literacy. CONCLUSIONS: Social insurance literacy is defined as the extent to which individuals can obtain, understand and act on information in a social insurance system, related to the comprehensibility of the information provided by the system. This definition is rooted in theories from sociology, social medicine and public health. In the next step, a measure for the concept will be developed based on this review.Implications for rehabilitationSocial insurance literacy is a new concept that is based on theories in sociology, social medicine and public health.It provides conceptual orientation for analyzing factors that may influence different outcomes of peoples' contacts with social insurance systems.The concept is of relevance for rehabilitation professionals since it focuses on how interactions between individuals and systems can influence the rehabilitation process.The study will in the next step develop a measure of social insurance literacy which will have practical applications for rehabilitation professionals.

Work ethics and societal norms influence sick leave and return to work: tales of transformation.

PURPOSE: This study's purpose was to explore how people on sick leave manage societal norms and values related to work, and how these influence their perspectives of themselves throughout the rehabilitation process. MATERIALS AND METHODS: This was a longitudinal interview study with a narrative approach, comprising 38 interviews with 11 individuals on long-term sick leave. Data collection was conducted in two phases and analysed iteratively through content analysis. RESULTS: The results suggest that work ethics and societal norms influence individuals' views of themselves and the sick leave and rehabilitation process. Conforming one's personal values to the work norm can create internal conflicts and cause feelings of shame for not being able to live up to the established norm. The strong work norm may create unrealistic expectations, which in some cases may result in constraining the return to work process. CONCLUSION: To transform a sick leave narrative into a positive one, societal norms and their influence on identity needs to be recognised. Stakeholders involved in the process can contribute to a positive transformation by not only supporting return to work, but also to acknowledge and help people manage their self-image as having a disability that limits their ability to work.IMPLICATIONS FOR REHABILITATIONStakeholders involved in the sick leave and rehabilitation process need to support sick listed individuals by acknowledging and helping people manage their self-image.Full RTW is not always the best option from a quality of life and wellbeing perspective.Treatment and support from stakeholders should be viewed as meaningful and legitimate, even if it does not lead to RTW.

Communication characteristics between clients and stakeholders within the Swedish sickness insurance system - a document analysis of granted and withdrawn sickness benefit claims.

Purpose: The purpose of this study was to investigate how communication within the Swedish sickness insurance system differs between cases of sick leave and how this may affect clients' cases.Materials and methods: This was a document study using 30 client files from the Swedish Social Insurance Agency (SIA). The clients included had been on a work ability evaluation during their sick leave spell and were aged 32-64 years. The material was analyzed using qualitative document analysis.Results: The results show different approaches to communication, characterized by emotional argumentation, matter-of-fact driven argumentation and information exchange, which have diverse success in affecting official decisions. Arguments characterized by emotions such as frustration or desperation are to a larger extent neglected by the authorities compared to those characterized by a matter-of-fact driven approach and referring to regulations and medical certificates.Conclusion: There are differences regarding how clients and stakeholders communicate the clients' needs and pre-requisites, and how this affects official decisions. Further research must be carried out in order to establish social insurance literacy, initially for individuals on sick leave within the sickness insurance system, and whether there are differences between diverse groups that could lead to injustices.Implications for rehabilitationWithin a social insurance context, professionals need to provide clients with adequate and individually adapted information in order for procedures to be perceived as comprehensible and manageable by the clients.The support from stakeholders such as the treating physician and/or employer can affect clients' sick-leave process.Clients' treating medical professionals can contribute to ensuring that clients rights are met by communicating the clients' needs to other stakeholders in a formal way.

The Judas kiss: On the work and retrenchment cures and the troubles they bring.

This Sounding Board article uses a number of societal stereotypes related to work and welfare to problematize the relationship between work and health, and how this relates to the prevention and management of work disability. It outlines current discourses in policy and research around these issues, and discusses some of the ethical implications of these discourses. The article concludes that the current policies on work disability and sickness insurance takes their point of departure in over-simplified accounts of the relationship between work and health, and that a more critical reading of the evidence is called for. The implications for research are also discussed, where a system-oriented perspective with attention to social gradients and the various working environments is called for.

Fair or square? Experiences of introducing a new method for assessing general work ability in a sickness insurance context.

PURPOSE: To study social validity and perceived fairness of a new method for assessing general work ability in a sickness insurance context. Assessments are based on self-reports, combined with examinations by physicians, and, if needed, occupational therapists, physiotherapists and/or psychologists. MATERIALS AND METHODS: Interviews with 36 insurance officials, 10 physicians, and 36 sick-listed persons, which were analysed through a qualitative content analysis. RESULTS: Insurance officials and physicians considered the method useful and that it facilitated benefit decisions. The experiences of persons who had undergone the assessment differed, where the dialog with insurance officials seemed to have had an influence on experiences of the assessment and the decisions it led to. CONCLUSIONS: The perceived fairness and social validity of the assessment depended on how it was carried out; organisational conditions and priorities; communication skills; and decision outcomes. Professionals have an important pedagogical task in explaining the purpose and procedure of the assessment in order for the sick-listed to perceive it as fair rather than square, i.e., too standardised and not considering individual conditions. If the assessment could be used also for rehabilitative purposes, it could possibly be perceived as more acceptable also in cases where it leads to denied benefits. Implications for rehabilitation The perceived fairness of work ability assessments is dependent on procedures for the assessment, communication with the person, and the outcome. What is considered fair differs between assessing professionals and persons being assessed. Professionals may influence the perceptions of fairness through their way of communication. Assessments need to be coupled with rehabilitation measures in order to perceived as relevant and acceptable.

Employers' views on disability, employability, and labor market inclusion: a phenomenographic study.

Purpose: This study aims to increase our understanding of employers' views on the employability of people with disabilities. Despite employers' significant role in labor market inclusion for people with disabilities, research is scarce on how employers view employability for this group.Methods: This was a qualitative empirical study with a phenomenographic approach using semi-structured interviews with 27 Swedish employers from a variety of settings and with varied experience of working with people with disabilities.Results: The characteristics of employers' views on the employability of people with disabilities can be described as multifaceted. Different understandings of the interplay between underlying individual-, workplace-, and authority-related aspects form three qualitatively different views of employability, namely as constrained by disability, independent of disability, and conditional. These views are also characterized on a meta-level through their association with the cross-cutting themes: trust, contribution, and support.Conclusions: The study presents a framework for understanding employers' different views of employability for people with disabilities as a complex internal relationship between conceived individual-, workplace-, and authority-related aspects. Knowledge of the variation in conceptions of employability for people with disability may facilitate for rehabilitation professionals to tailor their support for building trustful partnerships with employers, which may enhance the inclusion of people with disabilities on the labor market.Implications for rehabilitationEmployers' views on employing people with disabilities vary with respect to individual-, workplace-, and authority-related aspects in relation to trust, contribution and support.Knowledge of the employers' views on the employability of people with disabilities can support professionals in authorities and in vocational rehabilitation.The findings illustrate the importance of analyzing what type of support employers need as a starting point for building trustful partnerships between authority actors and employers.The findings offer a vocabulary that can be used by professionals in authorities and in vocational rehabilitation in tailoring employer-oriented support to increase labor market inclusion of people with disabilities.