PurposeFor 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.MethodsThe 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.ResultsOverall, 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.ConclusionThis 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.

BackgroundThe initial responses to the COVID-19 pandemic in Denmark and Sweden differed markedly. Balancing disparate concerns was crucial to generate trust in the COVID-19 restrictions. The aim was to investigate the extent to which there was trust in the handling of the pandemic by the Danish and Swedish governments and public health authorities in each country. A further aim was also to investigate the characteristics of those in Denmark and Sweden who expressed the lowest degree of trust.

MethodsCross-sectional surveys were conducted in 2021, using web panels that are nationally representative of the socio-demographic characteristics. The population consisted of 2619 individuals from Denmark and 2633 from Sweden, representative of the age, sex and region of residence of the populations aged ≥ 18 years. Trust in government and health authorities was captured in two separate trust questions on a 5-point Likert scale and dichotomized into low trusters and non-low trusters for analysis.

ResultsApproximately, 61% of the Danish respondents expressed moderately large or very large trust in the government’s handling of the pandemic. The corresponding proportion for Sweden was 42%. The proportion of low trusters was 11% in Denmark and 34% in Sweden (p < 0.001). Moderately large or very large trust in the public health authority’s handling was expressed by 83% of the Danish respondents and 74% of the Swedish respondents. The proportion of low trusters was 5% in Denmark and 17% in Sweden (p < 0.001). In both countries, trust was lower among men than among women. Age and education were associated with trust but differed between countries (p <  = 0.011).

ConclusionsIn this study, differences in trust between Denmark and Sweden and both overall and within socio-demographic factors were observed. However, given the limitations and bias in the study, it is difficult to determine the cause and true size of these differences. With that in mind, we still believe specific populations and subgroups within those populations have the potential to affect trust in handling of the COVID-19 pandemic, and that these should be kept in mind when developing and communicating responses to pandemics.

The aim of this thesis was to contribute to the development of empirical and theoretical knowledge about the legitimacy and comprehensibility of assessment- and decision-making processes within the sickness insurance system from a client perspective. The focus has been on interactions between clients and other stakeholders within the system, and the extent to which the clients understood and accepted the procedures. In addition, the legitimacy and comprehensibility of the system were studied through the lens of three theoretical concepts: social validity, social insurance literacy (SIL), and moral hazard. For this thesis, a mixed methods approach was adopted, consisting of one quantitative and three qualitative studies, including interviews, files, register data, and a questionnaire. Overall, the findings demonstrates that interactions between clients and other stakeholders were important both for the client’s sick-leave case and for their perceptions of sickness insurance procedures. A continuing dialogue between client and case manager tended to facilitate the client’s understanding and acceptance of the steps taken in the sick-leave process. Furthermore, a client’s perception of the justice of processes in the system was associated with the system’s ability to provide understandable and logical information and procedures. This thesis also demonstrates that assumptions of moral hazard were clearly present and that acts of power and mistrust occurred between stakeholders, as different stakeholders tried to influence the client’s sick-leave process. An acceptable and fair sick-leave process was described by the clients as being one that consisted of relevant procedures, was applicable to the unique client, and was a result of support from other stakeholders. In order to increase the comprehensibility, as well as the legitimacy and fairness, the authorities need to explain and justify a diverse range of steps beyond just the official decisions, so that clients are able to comprehend the what, how, and why of sickness insurance. In terms of SIL, clients’ abilities to obtain, understand, and act on information, did not influence whether they received sickness benefits or their perceived justice. On the other hand, higher scores of perceived justice was associated with high scores of perceived system comprehensibility and being granted sickness benefits. This indicates that what the system does, and what it does not do, influenced clients’ opinions of it, regardless of their own prerequisites.

Purpose This study explores the concept social insurance literacy (SIL) and corresponding questionnaire (SILQ) among workers receiving disability benefits and the comprehensibility of the social security institute (SSI), and examines associations with socio-economic characteristics. Methods 1753 panel members of the Dutch SSI were approached to complete the SILQ-NL37. This measure was based on the original SILQ. The SILQ-NL37 contains domains for obtaining, understanding and acting upon information for both individual SIL and system comprehensibility. A higher score means better SIL or comprehensibility. Data on age, gender, education, living situation, Dutch skills and time receiving disability benefits were also collected. With k-means clustering, groups with adequate and limited SIL were created. Associations with socio-economic characteristics were examined with independent t-tests and linear regression analyses for both the total scores and within domain scores. Cronbach alpha and Spearman rhos indicated measurement properties were good to acceptable for the SILQ-NL37. Results Thirty-five percent of the 567 participants were in the group with limited SIL. Higher individual SILQ-NL37 scores were associated with having a partner (p = 0.018) and northeastern living region (p = 0.031). Higher scores for obtaining (p = 0.041) and understanding (p = 0.049) information were associated with female sex, and for acting on information with younger age (p = 0.020). People with limited Dutch skills (p = 0.063) and a partner (p = 0.085) rated system comprehensibility higher. Conclusions According to the SILQ-NL37 scores, about 35% of the panel members have limited ability to obtain, understand and act upon social insurance systems information. Limited SIL is associated with several socio-economic factors. Future researches should study the concept in a more representative sample, and in different countries and social insurance contexts.

Bakgrund: Aktiveringspolicy och teorier om moral hazard har influerat utformningen av sjukförsäkringssystem i flera delar av västvärlden. Detta har lett till att sjukpenning blivit allt svårare att erhålla, mer kopplat till arbete och aktivitet, samt insatser för att genomskåda fusk bland sjukskrivna.

Syftet med studien var att utforska hur makt och arbetsmoral uttrycks av sjukskrivna och andra aktörer i sjukförsäkringssystemet.

Metod: Detta var en kvalitativ longitudinell studie baserad på intervjuer och akter från 31 sjukskrivna som varit på en försäkringsmedicinsk utredning. Data analyserades genom tematisk analys.

Resultat: Resultatet visar hur olika aktörer misstänkliggör varandras agendor och kompetens, samt hur olika maktmedel används för att rättfärdiga deras slutsatser. Det framkom även vissa allianser mellan aktörer där dessa präglas av samsyn och samarbete mot gemensamma mål i sjukskrivningsprocessen. Primärt ses dessa allianser mellan sjukskriven och sjukskrivande läkare, men även i enstaka fall mellan handläggare och sjukskrivande läkare i de fall läkaren förespråkar aktivering. De sjukskrivna personerna uttryckte en stark vilja och försök mot arbete eller aktivitet, och deras arbetsmoral verifierades ofta av andra aktörer.  

Slutsats: Maktspel förekommer på olika sätt inom sjukförsäkringssystemet och de medel som användes i den här studien gavs olika betydelse beroende på vilken aktör som använde dem (exempelvis tolkningen av en försäkringsmedicinsk utredning). Den här studien kan ifrågasätta vissa antaganden om moral hazard och simulering bland sjukskrivna då personerna ofta presterade över sin förmåga under en försäkringsmedicinsk utredning i förhoppningen om att i någon mån visa sig förmögen att bidra till samhället, vilket även verifierades av andra aktörer.

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.

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.

MATERIALS AND 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.

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 rehabilitation

• Within 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.

INTRODUCTION: Previous studies show differences regarding which clients receive sickness benefits as well as which clients are questioned or not within the sickness insurance system. There are indications that the characteristics of communication can have an impact on the sick leave process, which motivates this study with the following purpose.

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 the clients’ case.

MATERIALS AND METHODS: This was a document study using thirty client files including the correspondence between clients, their case-manager at the Swedish Social Insurance Agency (SIA) as well as other stakeholders. The clients included had been on a work capacity evaluation during their sick leave spell and were aged 32-64 years. There were twenty women and ten men in this study, with a variety of the degree of sickness absence, disability pension and part time work. The material was analyzed using qualitative document analysis.

RESULTS: The results show different approaches in communication, characterized by emotional communication, matter-of-fact driven communication and information exchange, which have diverse success in affecting authority decisions. Arguments characterized by emotions such as frustration or desperation are to a larger extent neglected compared to those characterized by a matter-of-fact driven approach and referring to regulations and medical certificates. There are also differences in how information about the client is interpreted by different professionals.

CONCLUSION: There are differences regarding how clients and stakeholders communicate the clients’ needs and prerequisites, and how this affect the SIA. Further research must be carried out in order to establish social insurance literacy, initially for individuals on sick leave within the sickness insurance, and whether there are differences between diverse groups that could lead to injustice in the system.