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 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.

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.