Background: Decisions concerning entitlement to sickness benefits have a substantial impact on the lives of individuals and on society. In most countries, such decisions are made by professionals working in public organisations, and there is much debate about the work performed by those experts, hence more knowledge is needed on this subject.
Objectives: The overall aim of the research underlying this thesis was to study, from different perspectives, the practices of actors involved in making decisions regarding the right to both sickness benefits and measures aimed at promoting return to work (RTW).
Materials and methods: Five separate studies were performed using different investigative designs, data, and data analyses. The first two studies (papers I and II) scrutinised scientific publications concerning the sickness certification practices of physicians and the routines of social insurance officers, respectively. The third investigation (paper III) assessed the quality of physician's sickness certificates as a basis for social insurance officers' decisions about sickness benefits. The fourth study (paper IV) examined the experiences of inter-organisational cooperation between public servants working at social insurance and employment offices. The last study (Paper V) analysed the experiences of patients regarding encounters with health care professionals and social insurance officers in this context.
Results: The twenty-six studies of physicians' sickness certification practices that were reviewed (paper I) focused on physicians, and occasionally on physicians and patients, but never on the interaction between them. Most of the studies emanated from Norway and Sweden, and were conducted by researchers in medical science, mainly physicians. Questionnaires were used to collect data in 80% of the studies. It was found that different physicians varied greatly in regard to the length of sickness absence they certified for similar patients.
All but two of the sixteen studies scrutinised in paper 11 were conducted by behavioural scientists using social science theory. In the majority of those investigations, data were obtained through interviews. The studies were done in Norway and Sweden, and dealt with different dimensions of managing clients, although only two of the investigations considered the actual granting of sickness benefits. The majority of the studies focused on coordination of RTW measures, and some of those indicated that gender bias affected the decisions that were made.
In the study presented in paper III, it was found that many of the analysed sickness certificates (n = 2,249) did not contain enough information to allow social insurance officers to determine eligibility for sickness benefits. General practitioners and physicians in training provided more essential data than did other categories of physicians, for example concerning the patients' occupational tasks. Statements about rehabilitation measures aimed at promoting RTW were not included on 60% of the certificates for women, compared to 36% of those issued for men.
As described in paper IV, analyses of fourteen interviews with public servants working together on the same cases in inter-organisational projects identified important areas of the experiences. The daily collaboration on cases enabled development of good relationships and improved what was referred to as cooperative competence. The collaborative nature of the project made it possible to include only those clients who were perceived as being motivated to participate in RTW measures. Close and more frequent interaction with clients proved to be beneficial in that it facilitated mobilisation of the clients. The discrepancy between the rules and regulations of the social insurance, and the unemployment authorities was an obstacle to cooperation.
In the study reported in paper V, eleven sickness benefit recipients were interviewed about how they experienced encounters with rehabilitation professionals. The experiences were assigned to five major categories: being treated with respect, feeling supported, establishing a personal relationship, perceiving demands as well-balanced, and participating in decisions regarding rehabilitation. Several interviewees believed that RTW might be promoted by positive encounters and hindered by negative interactions.
Conclusions: The overall conclusion that can be drawn from the current results is that there is insufficient knowledge concerning the sickness certification practices of physicians and the practices of social insurance officers regarding granting of sickness benefits. Closely related to the granting of sickness benefits, particulary given the work-line strategy in Sweden is the assessment of work capacity, which has, from the perspective of social insurance standards, been studied from a very limited viewpoint. The theoretical framework of research in this area need to be developed to provide better understanding of the mentioned practices and the interactions between the different professionals and between professsionals and clients, from the perspectives of both gender and ethnicity.
Linköping: Linköpings Universitet , 2005. , 85 p.
sickness absence, sickness benefit, practices, client, patients, sickness certification, sick leave, return to work, inter-organisational cooperation, gender, work capacity
2005-06-10, Aulan, Hälsans Hus, Universitetssjukhuset, Linköping, 13:00 (Swedish)