Ethical challenges from a problem-solving intervention with workplace involvement: a qualitative study among employees with common mental disorders, first-line managers, and rehabilitation coordinators.

PURPOSE: This study aims to explore ethical challenges potentially arising from a problem-solving intervention with workplace involvement (PSI-WPI) in primary health care (with first-line manager involvement) for employees on sickness absence due to common mental disorders. METHODS: A qualitative design guided by the theoretical framework for systematic identification of ethical aspects of healthcare technologies. Semi-structured interviews were performed with coordinators (n = 6), employees (n = 13), and first-line managers (n = 8). Reflexive thematic analysis was used to analyse and interpret themes. RESULTS: A main theme was identified "the workplace and healthcare hold different organizational value logics" and four sub-themes: "the PSI-WPI challenged the organizational goals and values of the workplace and healthcare", "the PSI-WPI challenged organizational values on fairness", "the PSI-WPI challenged the professional roles of first-line managers and rehabilitation coordinators" and "the PSI-WPI introduced a need for the employee to juggle the employee and patient roles". CONCLUSION: Different organizational value logics, values, and goals can introduce ethical challenges. We advise clarifying stakeholders' roles and preparing employees and managers for the return to work process by providing sufficient information. The ethical challenges and suggested measures to minimize them, should be considered when planning return to work interventions that involve several stakeholders.

The effectiveness of implementing the Guideline for the Prevention of Mental Ill-health Problems at the Workplace on health-outcomes, organizational and social risk factors: a cluster-randomized controlled trial in Swedish schools.

OBJECTIVES: This study aimed to compare the effectiveness of the multifaceted implementation strategy (multifaceted group) versus a discrete implementation strategy (discrete group) for implementing the Swedish Guideline for the Prevention of Mental Ill-health Problems at the Workplace on the primary intervention outcome - exhaustion - and secondary outcomes of stress, health, recovery, psychosocial safety climate, and social and organizational risk factors. Another aim was to examine whether the primary and secondary outcomes differed on the basis of guideline adherence levels, irrespective of the group. METHODS: A cluster-randomized waiting-list controlled trial with 6- and 12-months follow-up was conducted among 19 Swedish public schools. Primary and secondary outcomes as well as guideline adherence were assessed by self-reported questionnaire. Linear mixed modeling was used to compare differences in outcomes between the groups from baseline to 6 and 12 months, and in relation to different adherence levels. RESULTS: The trial comprised 698 employees (83.1%) participated. There were no differences between groups in the primary and secondary outcomes at 6 months, while at 12 months differences were observed for some outcomes to the advantage of the discrete group. Better guideline adherence was associated with improvements in exhaustion at 12 months and the secondary outcomes of psychosocial safety climate, work organization and job content, interpersonal relations and leadership, and recovery over 6 and 12 months. CONCLUSION: The multifaceted implementation strategy was no more effective than the discrete strategy in improving health outcomes or organizational and social work environment. However, higher adherence to the guideline was associated with larger improvements in health outcomes and organizational and social work environment, irrespective of the implementation strategy used.

Experiences of participating in a problem-solving intervention with workplace involvement in Swedish primary health care: a qualitative study from rehabilitation coordinator's, employee's, and manager's perspectives.

BACKGROUND: Work-directed interventions that include problem-solving can reduce the number of sickness absence days. The effect of combining a problem-solving intervention with involvement of the employer is currently being tested in primary care in Sweden for employees on sickness absence due to common mental disorders (PROSA trial). The current study is part of the PROSA trial and has a two-fold aim: 1) to explore the experiences of participating in a problem-solving intervention with workplace involvement aimed at reducing sickness absence in employees with common mental disorders, delivered in Swedish primary health care, and 2) to identify facilitators of and barriers to participate in the intervention. Both aims targeted rehabilitation coordinators, employees on sickness absence, and first-line managers. METHODS: Data were collected from semi-structured interviews with participants from the PROSA intervention group; rehabilitation coordinators (n = 8), employees (n = 13), and first-line managers (n = 8). Content analysis was used to analyse the data and the Consolidated Framework for Implementation Research was used to group the data according to four contextual domains. One theme describing the participation experiences was established for each domain. Facilitators and barriers for each domain and stakeholder group were identified. RESULTS: The stakeholders experienced the intervention as supportive in identifying problems and solutions and enabling a dialogue between them. However, the intervention was considered demanding and good relationships between the stakeholders were needed. Facilitating factors were the manual and work sheets which the coordinators were provided with, and the manager being involved early in the return-to-work process. Barriers were the number of on-site meetings, disagreements and conflicts between employees and first-line managers, and symptom severity. CONCLUSIONS: Seeing the workplace as an integral part of the intervention by always conducting a three-part meeting enabled a dialogue that can be used to identify and address disagreements, to explain CMD symptoms, and how these can be handled at the workplace. We suggest allocating time towards developing good relationships, provide RCs with training in handling disagreements, and additional knowledge about factors in the employee's psychosocial work environment that can impair or promote health to increase the RCs ability to support the employee and manager.

Mobile health to promote physical activity in people post stroke or transient ischemic attack - study protocol for a feasibility randomised controlled trial.

BACKGROUND: Physical activity is essential to improve health and reduce the risk of recurrence of stroke or transient ischemic attack (TIA). Still, people post stroke or TIA are often physically inactive and the availability of physical activity promotion services are often limited. This study builds on an existing Australian telehealth-delivered programme (i-REBOUND- Let's get moving) which provides support for home-based physical activity for people post stroke or TIA. The aim of this study is to test the feasibility, acceptability, and preliminary effects of a mobile Health (mHealth) version of the i-REBOUND programme for the promotion of physical activity in people post stroke or TIA living in Sweden. METHODS: One hundred and twenty participants with stroke or TIA will be recruited via advertisement. A parallel-group feasibility randomised controlled trial design with a 1:1 allocation ratio to 1) i-REBOUND programme receiving physical exercise and support for sustained engagement in physical activity through behavioural change techniques, or 2) behavioural change techniques for physical activity. Both interventions will proceed for six months and be delivered digitally through a mobile app. The feasibility outcomes (i.e., reach, adherence, safety and fidelity) will be monitored throughout the study. Acceptability will be assessed using the Telehealth Usability Questionnaire and further explored through qualitative interviews with a subset of both study participants and the physiotherapists delivering the intervention. Clinical outcomes on preliminary effects of the intervention will include blood pressure, engagement in physical activity, self-perceived exercise self-efficacy, fatigue, depression, anxiety, stress and health-related quality of life and will be measured at baseline and at 3, 6 and 12 months after the baseline assessments. DISCUSSION: We hypothesise that the mHealth delivery of the i-REBOUND programme will be feasible and acceptable in people post stroke/TIA living in rural and urban regions of Sweden. The results of this feasibility trial will inform the development of full-scale and appropriately powered trial to test the effects and costs of mHealth delivered physical activity for people after stroke or TIA. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05111951. Registered November 8, 2021.

Ethical aspects of the coordination of return-to-work among employees on sick leave due to common mental disorders: a qualitative study.

PURPOSE: Identify ethical issues that arise in the coordination of return-to-work (RTW) among employees on sick leave due to common mental disorders (CMDs). MATERIAL AND METHODS: 41 semi-structured individual interviews and one focus group interview with stakeholders (n = 46) involved in RTW: employees on sick leave due to CMDs, coordinators and physicians at primary health care centres, managers, representatives of the Swedish social insurance agency and occupational health services. A six-step thematic analysis focused on the ethical values and norms related to autonomy, privacy, resources and organization, and professional values. RESULTS: Five themes were identified: (1) autonomous decision-making versus the risk of taking over, (2) employee rights versus restrictions to self-determination, (3) respect for employee privacy versus stakeholders' interests, (4) risk of unequal inclusion due to insufficient organizational structure and resources, (5) risk of unequal support due to unclear professional roles and responsibilities. CONCLUSION: The main ethical issues are the risks of unequal access to and unequal support for the coordination of RTW. For the fair and equal provision of coordination, it is necessary to be transparent on how to prioritize the coordination of RTW for different patient groups, provide clarity about the coordinator's professional role, and facilitate ongoing boundary work between stakeholders. IMPLICATIONS FOR REHABILITATIONUnfair and arbitrary criteria for inclusion to the coordination of RTW implicate risks of unequal access for the employee on sick leave due to CMDs.Unclear professional roles and responsibilities among stakeholders in the coordination of RTW implicate risks of unequal support for the employee on sick leave due to CMDs.Coordination of RTW should be transparently prioritized on policy and organisational levels to secure fair and equal inclusion.The coordinator's professional role should be clearly defined to facilitate boundary work between stakeholders and improve the competence around the coordination of RTW.

A randomized controlled trial in schools aimed at exploring mechanisms of change of a multifaceted implementation strategy for promoting mental health at the workplace.

BACKGROUND: This study will explore implementation mechanisms through which a single implementation strategy and a multifaceted implementation strategy operate to affect the implementation outcome, which is fidelity to the Guideline For The Prevention of Mental Ill Health within schools. The guideline gives recommendations on how workplaces can prevent mental ill health among their personnel by managing social and organizational risks factors in the work environment. Schools are chosen as the setting for the study due to the high prevalence of mental ill health among teachers and other personnel working in schools. The study builds on our previous research, in which we compared the effectiveness of the two strategies on fidelity to the guideline. Small improvements in guideline adherence were observed for the majority of the indicators in the multifaceted strategy group. This study will focus on exploring the underlying mechanisms of change through which the implementation strategies may operate to affect the implementation outcome. METHODS: We will conduct a cluster-randomized-controlled trial among public schools (n=55 schools) in Sweden. Schools are randomized (1:1 ratio) to receive a multifaceted strategy (implementation teams, educational meeting, ongoing training, Plan-Do-Study-Act cycles) or a single strategy (implementation teams, educational meeting). The implementation outcome is fidelity to the guideline. Hypothesized mediators originate from the COM-B model. A mixed-method design will be employed, entailing a qualitative study of implementation process embedded within the cluster-randomized controlled trail examining implementation mechanisms. The methods will be used in a complementary manner to get a full understanding of the implementation mechanisms. DISCUSSION: This implementation study will provide valuable knowledge on how implementation strategies work (or fail) to affect implementation outcomes. The knowledge gained will aid the selection of effective implementation strategies that fit specific determinants, which is a priority for the field. Despite recent initiatives to advance the understanding of implementation mechanisms, studies testing these mechanisms are still uncommon. TRIAL REGISTRATION: ClinicalTrials.org dr.nr 2020-01214.

Effectiveness of a multifaceted implementation strategy for improving adherence to the guideline for prevention of mental ill-health among school personnel in Sweden: a cluster randomized trial.

BACKGROUND: There is limited research on prevention of mental ill-health of school personnel and the systematic management of school work environments. The aim of this study was to assess the effectiveness of implementing the guideline recommendations for the prevention of mental ill-health in schools, in particular, whether there was a difference in adherence to guideline recommendations between a multifaceted (group 1) and single implementation strategy (group 2) from baseline to 6 and to 12 months. METHOD: We conducted a cluster-randomized controlled trial with a 6- and 12-month follow-up. Data was collected from nearly 700 participants in 19 Swedish schools. Participants were school personnel working under the management of a school principal. The single implementation strategy consisted of one educational meeting, while the multifaceted implementation strategy comprised an educational meeting, an ongoing training in the form of workshops, implementation teams and Plan-Do-Study-Act cycles. Adherence was measured with a self-reported questionnaire. Generalized Linear Mixed Models were used to assess the difference between groups in adherence to the guideline between baseline, 6-, and 12-months follow-up. RESULTS: There were no statistically significant differences between the groups in improvements in adherence to the guideline between baseline, 6-, and 12-months follow-up. However, among those schools that did not undergo any organizational changes during the 12 months of the study significant differences between groups were observed at 12 months for one of the indicators. CONCLUSIONS: The multifaceted strategy was no more effective than the single strategy in improving guideline adherence. There are some limitations to the study, such as the measurement of the implementation outcome measure of adherence. The outcome measure was developed in a systematic manner by the research team, assessing specific target behaviors relevant to the guideline recommendations, however not psychometrically tested, which warrants a careful interpretation of the results. TRIAL REGISTRATION: ClinicalTrials.gov, 150571 . Registered 12 September 2017.

Coordination of return-to-work for employees on sick leave due to common mental disorders: facilitators and barriers.

PURPOSE: To identify facilitators of and barriers to the coordination of return-to-work between the primary care services, the employee, and the employers from the perspective of coordinators and employees on sick leave due to common mental disorders (CMDs). MATERIAL AND METHODS: Descriptive qualitative study. Semi-structured interviews were conducted with eighteen coordinators and nine employees on sick leave due to CMDs. The Consolidated Framework for Implementation Research (CFIR) was used as a starting point for the interview guides and in the thematic analysis of data. RESULTS: The results show facilitators and barriers related to the CFIR domains "intervention characteristics," "outer setting," "inner setting," and "characteristics of individuals." Positive attitudes, an open dialogue in a three-party meeting, and a common ground for the sick leave process at the primary care centre facilitated coordination, while an unclear packaging, conflicts at the employee's workplace, and a lack of team-based work were examples of barriers. CONCLUSION: The results indicate a need for the detailed packaging of coordination; formalization of coordinators' qualifications and levels of training; and acknowledgement of the role of organizational factors in the implementation of coordination. This is important to further develop and evaluate the efficacy of coordination.IMPLICATIONS FOR REHABILITATIONPositive attitudes to coordination, an open dialogue in a three-party meeting, leadership engagement, routines for the return to work (RTW) process at the primary care centre, and collegial alliances were identified as facilitators.An unclear packaging of the intervention, conflicts at the employee's workplace, lack of team-based work, and lack of coordinator training were identified as barriers.A detailed intervention packaging adapted for the specific setting and formalization of coordinators' qualifications and training is necessary for coordination of RTW.Recognizing organizational factors were identified as being important for the implementation of coordination of RTW for persons on sick leave due to CMDs.

IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) - study protocol for a cluster-randomized trial.

BACKGROUND: IMPROVE aims to conduct a hybrid type 3 evaluation design to test the effectiveness of bundled implementation strategies on intervention fidelity of the Healthy School Start (HSS) program, while simultaneously monitoring effects on health outcomes of children and parents. The HSS is a 4-component family support program for children starting school (5-7 years of age) promoting healthy dietary habits and physical activity in the home environment to prevent childhood obesity and parents' risk of developing type 2 diabetes. METHODS: IMPROVE is a cluster-randomized controlled trial with two arms to evaluate and compare the effects of two different bundles of implementation strategies on intervention fidelity expressed as adherence and responsiveness at 12 and 24 months (primary outcomes). Thirty schools in two municipalities will participate in the study reaching about 1400 families per school year. In stakeholder workshops, key implementation determinants were identified according to the domains of the Consolidated Framework for Implementation Research. Through a consensus process with stakeholders, two bundles of implementation strategies were tailored to address context-specific determinants. Schools randomly assigned to group 1 will receive bundle 1 (Basic) and group 2 will receive bundle 1 + 2 (Enhanced). Bundle 2 consists of external facilitation, fidelity monitoring and feedback strategies. Secondary outcomes will include change in acceptability, appropriateness, feasibility, and organisational readiness as perceived by school staff. In addition, child weight status and diet, and parents' feeding practices and risk of type 2 diabetes will be monitored. Linear and ordinal regression analysis will be used to test the effect on the primary and secondary outcomes, taking clustering and covariates into consideration where needed. Process evaluation will be conducted through key stakeholder interviews to investigate experiences of the program and perceptions on sustainability. DISCUSSION: This systematic approach to investigating the effectiveness of two different bundles of implementation strategies tailored to context-specific determinants on the fidelity of the HSS intervention will provide new insight into feasible implementation strategies and external support needed for the HSS to be effective and sustainable. Results will help inform how to bridge the gap between the research on school-based health programs and routine practice in schools. TRIAL REGISTRATION: Registered prospectively at ClinicalTrials.gov ID: NCT04984421 , registered July 30, 2021.

Implementation of highly challenging balance training for Parkinson's disease in clinical practice: a process evaluation.

BACKGROUND: Process evaluations provide contextual insight into the way in which interventions are delivered. This information is essential when designing strategies to implement programs into wider clinical practice. We performed a process evaluation of the HiBalance effectiveness trial investigating the effects of a 10-week of highly challenging and progressive balance training for mild-moderate Parkinson's disease (PD). Study aims were to investigate i) the quality and quantity of intervention delivery and ii) barriers and facilitators for implementation. METHODS: Process outcomes included; Fidelity; Dose (delivered and received) Recruitment and Reach. Investigation of barriers and facilitators was guided by the Consolidated Framework for Implementation Research. Program delivery was assessed across four neurological rehabilitation sites during a two-year period. Data collection was mixed-methods in nature and quantitative and qualitative data were merged during the analysis phase. RESULTS: Thirteen program trainers delivered the intervention to 12 separate groups during 119 training sessions. Trainer fidelity to program core components was very high in 104 (87%) of the sessions. Participant responsiveness to the core components was generally high, although adherence to the home exercise program was low (50%). No significant context-specific differences were observed across sites in terms of fidelity, dose delivered/ received or participant characteristics, despite varying recruitment methods. Facilitators to program delivery were; PD-specificity, high training frequency and professional autonomy. Perceived barriers included; cognitive impairment, absent reactional balance among participants, as well a heterogeneous group in relation to balance capacity. CONCLUSION: These findings provide corroborating evidence for outcome evaluation results and valuable information for the further adaptation and implementation of this program. Important lessons can also be learned for researchers and clinicians planning to implement challenging exercise training programs for people with mild-moderate PD. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02727478 , registered 30 march, 2016 - Retrospectively registered.

Recruiting in intervention studies: challenges and solutions.

INTRODUCTION: In order for study results to be relevant for practice, the study participants should represent the source population. A common problem is recruitment of sufficient and representative subjects, threatening the external validity of the study and, ultimately, evidence-based practice. The aim was to highlight common challenges and to present possible solutions to recruitment. METHODS: Using four recent randomised controlled trials as examples, common recruitment challenges were highlighted and solutions were proposed. The four studies represented some common and some specific challenges, but they investigated interventions for the prevention of the two major public health challenges of today: musculoskeletal pain and common mental disorders. RESULTS: Identified challenges and suggested solutions were presented as a checklist to be used for future trials in order to aid recruitment and reporting thereof.

Process Evaluation of a Participative Organizational Intervention as a Stress Preventive Intervention for Employees in Swedish Primary Health Care.

This study is a process evaluation of a trial examining the effects of an organizational intervention (Productivity Measurement and Enhancement System or ProMES) on employee stress. The aims were to explore the implementation process and fidelity to the intervention guidelines, examine the influence of contextual factors (hindrances and facilitators) and explore participants' experience of working with ProMES. We used the UK Medical Research Council (MRC) guidance to guide the process evaluation. The recruitment, reach and dose delivered were satisfactory and participation high. The employees felt ProMES clarified priorities, gave control and increased participation in decision-making. However, difficulty in obtaining statistical productivity data from the central administration office (a central feature of the intervention) hindered full implementation and regular feedback meetings. Staffing shortages interfered with the implementation process, while having seven design teams and one consultant prevented all occupational groups from working simultaneously. A detailed examination of access to necessary organizational data should be undertaken before implementing ProMES. We recommend a better introduction for new employees, more work on design and packaging and giving employees more training in how to use the software program. The study contributes to our understanding of process evaluations in research into organizational stress management interventions.

Promoting Evidence-Based Practice for Improved Occupational Safety and Health at Workplaces in Sweden. Report on a Practice-Based Research Network Approach.

Despite the rapid growth in research and R&D expenditures, the translation of research into practice is limited. One approach to increase the translation and utilization of research is practice based research networks. With the aim of strengthening evidence-based practice (EBP) within occupational health services in Sweden (OH-Services), a practice-based research network (PBRN-OSH) was developed. The PBRN-OSH includes researchers and representatives from end-users. This paper reports on the development, outputs and lessons learned in the PBRN-OSH. The PBRN-OSH resulted in several practice-based research projects as well as different measures to ensure EBP in OSH such as the governmentally sanctioned national guidelines for the OH-services. Moreover, results show that the competence in EBP increased among practitioners at the OH-services. Conducting research in a PBRN is more resource demanding; however, this does not imply that it is less cost effective. To succeed in increasing the utility of research findings via PBRN, resources must be invested into an infrastructure that supports collaboration in the PBRN, including costs for a variety of means of dissemination. Further, translation activities need to be included in academic career paths and reward systems if a major improvement in the impact and return of investments from research is to be expected.

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.

Evaluation and Dissemination of a Checklist to Improve Implementation of Work Environment Initiatives in the Eldercare Sector: Protocol for a Prospective Observational Study.

BACKGROUND: To measure sustainable improvements in the work environment, a flexible and highly responsive tool is needed that will give important focus to the implementation process. A digital checklist was developed in collaboration with key stakeholders to document the implementation of changes in eldercare sector workplaces. OBJECTIVE: This paper describes the study protocol of a dissemination study that aims to examine when, why, and how the digital checklist is spread to the Danish eldercare sector following a national campaign particularly targeting nursing homes and home care. METHODS: This prospective observational study will use quantitative data from Google Analytics describing use of the checklist as documented website engagement, a survey among members in the largest union in the sector, information from a central business register, and monitoring of campaign activities. The evaluation will be guided by the five elements of the RE-AIM framework: reach, effectiveness, adoption, implementation, and maintenance. RESULTS: The study was approved in June 2016 and began in October 2018. The campaign that is the foundation for the evaluation began in 2017 and ended in 2018. However, the webpage where we collect data is still running. Results are expected in 2020. CONCLUSIONS: This protocol provides a working example of how to evaluate dissemination of a checklist to improve implementation of work environment initiatives in the eldercare sector in Denmark. To our knowledge, implementation in a nationwide Danish work environment has not been previously undertaken. Given that the checklist is sector-specific for work environment initiatives and developed through systematic collaboration between research and practice, it is likely to have high utility and impact; however, the proposed evaluation will determine this. This study will advance dissemination research and, in particular, the evaluation of the impact of these types of studies. Finally, this study advances the field through digital tools that can be used for evaluation of dissemination efforts (eg, Google Analytics associated with website) in the context of a rigorous research design activity. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16039.

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.

Experience of Stress Assessed by Text Messages and Its Association with Objective Workload-A Longitudinal Study.

Exploring stress trajectories in detail and over a long time may give valuable information in terms of both understanding and practice. We followed a group of primary health care employees in a randomized controlled trial. The objective was to describe their experience of stress, explore the intra-individual variability and examine the association between the experience of stress and the objective workload. Weekly text messages with a single item stress question were distributed in two time series: 12 weeks at the beginning of the trial and 26 weeks after the 6-month follow up. Aggregated objective data about workload were collected from their administration office and related to stress levels. There was a seasonal variation, with higher stress during the fall than in spring and summer. The analysis comparing high and low stress subgroups showed that the stress trajectory of a high-stress subgroup was different from that of a low-stress subgroup. Individuals with high exhaustion scores had higher odds of belonging to a subgroup of individuals with high intra-individual variability in stress experience. The objective workload was measured in two ways and was strongly associated with the stress experience. We found that the lower the productivity, the higher the feeling of stress.

Nationwide implementation of a national policy for evidence-based rehabilitation with focus on facilitating return to work: a survey of perceived use, facilitators, and barriers.

Aim: The aim is to assess whether the national policy for evidence-based rehabilitation with a focus on facilitating return-to-work is being implemented in health-care units in Sweden and which factors influence its implementation.Methods: A survey design was used to investigate the implementation. Data were collected at county council management level (process leaders) and clinical level (clinicians in primary and secondary care) using web surveys. Data were analyzed using SPSS, presented as descriptive statistics.Results: The response rate among the process leaders was 88% (n = 30). Twenty-eight percent reported that they had already introduced workplace interventions. A majority of the county councils' process leaders responded that the national policy was not clearly defined. The response rate among clinicians was 72% (n = 580). Few clinicians working with patients with common mental disorders or musculoskeletal disorders responded that they were in contact with a patient's employer, the occupational health services or the employment office (9-18%). Nearly, all clinicians responded that they often/always discuss work-related problems with their patients.Conclusions: The policy had been implemented or was to be implemented before the end of 2015. Lack of clearly stated goals, training, and guidelines were, however, barriers to implementation. Implications for rehabilitationClinicians' positive attitudes and willingness to discuss workplace interventions with their patients were important facilitators related to the implementation of a nationwide policy for workplace interventions/rehabilitation.A lack of clearly stated goals, training, and guidelines were barriers related to the implementation.The development of evidence-based policies regarding rehabilitation and its implementation has to rely on very structured and clear descriptions of what to do, preferably with the help of practice guidelines.Nationwide implementation of rehabilitation policies has to allow time for preparation including communication of goals and competence assurance in a close collaboration with the end users, namely clinicians and patients. AbbreviationsCBTCognitive behavioral therapyCFIRConsolidated framework for implementation researchCMDCommon mental disordersIPTInterpersonal psychotherapyMMRMultimodal rehabilitationRGRehabilitation guaranteeRTWReturn to workSPSSStatistical package for the social sciences.

Implementation of the Swedish Guideline for Prevention of Mental ill-health at the Workplace: study protocol of a cluster randomized controlled trial, using multifaceted implementation strategies in schools.

BACKGROUND: Given today's high prevalence of common mental disorders and related sick leave among teachers, an urgent need exists for a more systematic approach to the management of social and organizational risk factors within schools. In 2015, we launched the first Swedish occupational health guideline to support a structured prevention of these risks at the workplace. The existence of guidelines does however not guarantee their usage, as studies show that guidelines are often underused. Knowledge is therefore needed on effective implementation strategies that can facilitate the translation of guidelines into practice. The primary aim of the randomized waiting list-controlled trial described in this study protocol is to compare the effectiveness of a multifaceted implementation strategy versus a single implementation strategy for implementing the Guideline for the prevention of mental ill-health at the workplace within schools. The effectiveness will be compared regarding the extent to which the recommendations are implemented (implementation effectiveness) and with regard to social and organisational risk factors for mental ill-health, absenteeism and presenteeism (intervention effectiveness). METHODS: The trial is conducted among primary schools of two municipalities in Sweden. The single implementation strategy is an educational strategy (an educational meeting). The multifaceted strategy consists of the educational meeting, an implementation team and a series of workshops. The outcome measure of implementation effectiveness is guideline adherence. The primary outcome of intervention effectiveness is exhaustion. Secondary outcomes include demands at work, work organization and job contents, interpersonal relations and leadership, presenteeism, work performance, recovery, work-life balance, work-engagement, self-reported stress, self-perceived health, sickness absence and psychosocial safety climate. Process outcomes as well as barriers and facilitators influencing the implementation process are assessed. Data will be collected at baseline, 6, 12, 18 and 24 months by mixed methods (i.e. survey, focus-group interviews, observation). DISCUSSION: The study described in this protocol will provide valuable knowledge on the effectiveness of implementation strategies for implementing a guideline for the prevention of common mental disorders within schools. We hypothesize that successful implementation will result in reductions in school personnel's perceived social and organizational risk factors, mental ill-health and sick-leave. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03322839 (trial registration: 09/19/2017).