PurposeAt the outbreak of the COVID-19 pandemic, health care was at the centre of the crisis. New demands made existing organizational practices and services obsolete. Primary health care had a great deal of responsibility for COVID-19-related care. The pandemic demanded effective leadership to manage the new difficulties. This paper aims to explore experiences and perceptions of managers in primary health care in relation to their efforts to manage the COVID-19 crisis in their everyday work. Design/methodology/approachThe authors used a qualitative approach based on 14 semi-structured interviews with managers in primary health care from four regions in Sweden. The interviews were conducted during September to December 2020. Data were analysed using conventional qualitative content analysis. FindingsData analysis yielded three categories: lonely in decision-making; stretched to the limit; and proud to have coped. The participants felt lonely in their decision-making, and they were stretched to the limit of their own and the organizations capacity. The psychosocial working conditions in primary care worsened considerably during the pandemic because demands on leaders increased while their ability to control the work situation decreased. However, they also expressed pride that they and their employees had managed the situation by being flexible and having a common focus. Originality/valueLooking ahead and using lessons learnt, and apart from making wise decisions under pressure, an important implication for primary health-care leaders is to not underestimate the power of acknowledging the virtues of humanity and justice during a crisis. Continuing professional education for leaders focusing on crisis leadership could help prepare leaders for future crises.

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.

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.

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.

BAKGRUND: I flera studier påvisas svårigheter i att förstå sjukförsäkringssystemet samt skillnader i olika gruppers tillgång till sjukpenning och rehabilitering. Individer med synliga fysiska nedsättningar ifrågasätts i lägre utsträckning jämfört med de med neurologiska eller psykiska nedsättningar. En svensk rapport visar att de som främst får sin sjukpenning indragen är mellan 60-64 år, lågutbildade och utrikes födda. Utifrån ett tidigare insamlat material finns indikationer på skillnader i hur sjukskrivna argumenterar för sina rättigheter och vilka intyg de skickar in.    

SYFTE: Syftet med studien var att undersöka hur kommunikation med Försäkringskassan skiljer sig åt mellan sjukskrivna och hur de verkar förstå sjukförsäkringssystemet.

METOD: Detta var en aktstudie med trettio sjukskrivnas akter från Försäkringskassan, innefattande korrespondensen mellan sjukskriven och handläggare såväl som medicinska utlåtanden och andra dokument. Studiedeltagarna var mellan 32-64 år, varav tjugo var kvinnor och tio män. Graden av sjukskrivning och arbete varierade och alla hade deltagit i en Aktivitetsförmågeutredning. Data analyserades genom kvalitativ aktanalys.

RESULTAT: Resultatet visar att sjukskrivna kommunicerar på olika sätt med sin handläggare, karaktäriserat av känslomässig kommunikation, saklig kommunikation och/eller informationsutbyte. Vilket förefaller ha varierad framgång i att påverka handläggarens beslut. Det fanns även skillnader i hur information kring den sjukskrivne tolkas av olika professionella.

SLUTSATS: Det förefaller finnas en skillnad avseende i vilken utsträckning sjukskrivna förstår sjukförsäkringssystemet och hur de uttrycker sina behov och förutsättningar, varpå stöttning från professionella är essentiellt. Fortsatt forskning behövs för att undersöka socialförsäkringslitteracitet hos sjukskrivna och de skillnader mellan olika grupper som leder till orättvisor inom systemet.

Within vocational rehabilitation as well as insurance medicine individuals’ work ability are assessed. Usually traditional types of validity and reliability are studied, but social validity is still unusual.The purpose of this paper is to introduce the concept of social validity and to describe the importance of so-cially valid assessments of work ability. Social validity includes whether met-hods are perceived as appropriate, legitimate, understandable and worth the effort. Assessment methods with high social validity facilitates individuals understanding for procedures and can increase their motivation to participa-te, both in the assessment and in subsequent interventions. Social validity is also important to avoid that methods are perceived as irrelevant or insulting.

Bakgrund: I det svenska sjukförsäkringssystemet utförs försäkringsmedicinska utredningar av särskilda enheter inom hälso- och sjukvården på uppdrag av Försäkringskassan. Dessa utredningar ligger sedan till grund för handläggares beslut om sjukskrivnas rätt till sjukpenning. Studier av social validitet är ännu ovanliga inom försäkringsmedicin och folkhälsa men kan bidra med kunskap om vad som främjar eller hindrar att metoder uppfattas som godtagbara, begripliga och betydelsefulla.

Syfte: Att utforska sjukskrivna personers upplevelse av social validitet för försäkringsmedicinska utredningar och påföljande myndighetsbeslut avseende sjukpenning inom sjukförsäkringen.

Metod: Detta var en kvalitativ longitudinell studie baserad på telefonintervjuer med 30 sjukskrivna som varit på en försäkringsmedicinsk utredning, samt delvis deras akter från Försäkringskassan. En deduktiv innehållsanalys användes.

Resultat: Sjukskrivnas förståelse för utredningen var beroende av huruvida de specifika testerna var tydligt relaterade till personernas svårigheter eller ej och vilken information de hade fått. De anser att den standardiserade strukturen inte är relevant för alla och att bristen på individanpassning förvårar möjligheten att få en rättvis bild av deras arbetsförmåga. 

Diskussion: Social validitet utforskades för försäkringsmedicinska utredningar och myndighetsbeslut i termer av godtagbarhet, begriplighet och betydelse. Utredningarna indikerar en låg social validitet i termer av godtagbarhet på grund av bristen på individanpassning, även om vissa delar är mer socialt valida än andra. Vidare varierade utredningarnas begriplighet beroende på deras applicerbarhet och den erhållna informationen, medan dimensionen betydelse indikerar en högre grad av social validitet. Handläggarens påföljande myndighetsbeslut ansågs däremot orelaterat till utredningens resultat, sakna konkreta argument och ibland motsägande andra aktörers rekommendationer, vilket indikerar en låg social validitet i termer av både godtagbarhet, begriplighet och betydelse. 

Slutsats: Social validitet finns för delar av utredningarna men är låg för det påföljande myndighetsbeslutet.

Background

Professionals need to be able to express what is at stake during the decision-making process and the discrepancy between formal rules and practical rationality need to be bridgeable and transparent for outsiders. Investigations of social validity for work ability assessments are rare. However, the concept can provide valuable information upon the acceptability and comprehensibility of procedures and how professionals can increase clients’ participation.

The purpose of this study was to investigate social validity for work ability evaluations within the sickness insurance system and the official decisions they lead to.

Methods

This was a longitudinal qualitative study using telephone interviews and files from the Swedish Social Insurance Agency. Clients (n = 30) were interviewed after their participation in a work ability evaluation as well as after receiving an official decision upon eligibility for sickness benefits. Data was analyzed using a deductive content analysis.

Results

Preliminary findings show that clients’ comprehensibility of the different tests and their composition were depending on whether the specific tests were perceived as clearly related to the clients’ difficulties and what information they had received. In order to receive a fair description of the client’s work ability, clients state that the work ability evaluation needs to be individually adapted and that the standardized structure is not relevant for all. What is acceptable and fair to one client could be unacceptable to another, depending on what arguments and information case-managers and evaluation professionals provided.

Conclusions

Authorities need to express and motivate the reasons for a diverse range of steps during clients sick-leave process, not only regarding official decisions. Social validity for work ability evaluations is depending on the provided information and the applicability to the clients’ situation.

Key messages

• Social validity is depending on the provided information and the applicability to the clients’ situation.

• Authorities need to communicate clearly with clients through the whole sick-leave process.

Purpose: The Swedish Social Insurance Administration has developed a new assessment tool for sickness insurance. This study is a part of the initial evaluation of the application, called the Assessment of Work Performance, Structured Activities, and focuses on evaluation of the psychometric properties of social validity, content validity, and utility.

Materials and methods: This was a qualitative study using semi-structured telephone interviews with occupational therapists. A convenience sample was used and participants who fulfilled inclusion criteria (n = 15) were interviewed. Data were analyzed using content analysis with a directed approach.

Results: The results indicate that the application provides valuable information and that it is socially valid. Assessors found work tasks suitable for a diverse group of clients and reported that clients accepted the assessments. Improvements were suggested, for example, expanding the application with more work tasks.

Conclusion: The instrument has benefits; however, further development is desired. The use of a constructed environment in assessments may be a necessary option to supplement a real environment. But depending on organizational factors such as time and other resources, the participants had different opportunities to do so. Further evaluations regarding ecological validity are essential to ensure that assessments are fair and realistic when using constructed environments.

• Implications for rehabilitation

• This study indicates that assessment in a constructed environment can provide a secure and protected context for clients being assessed.

• Psychometric evaluations are a never-ending process and this assessment instrument needs further development. However, this initial evaluation provides guidance in development of the instrument but also what studies to give priority to.

• It is important to evaluate social validity in order to ensure that clients and assessors perceive assessment methods fair and meaningful. In this study, participants found the work tasks appropriate and usable when assessing their clients but client’s perspective must also be included in following studies.

• This assessment instrument is the only activity-based assessment instrument within the Swedish Social Security Insurance. Psychometric evaluations are important since it affects so many individuals in Sweden.

INTRODUCTION

Over the last years the Swedish Social Insurance Agency has implemented and evaluated a national assessment tool with the purpose of a secure and equivalent process in assessing work ability within sickness insurance. An application with structured work tasks was created for the observation based instrument the Assessment of Work Performance (AWP). Social validity investigates whether an assessment is acceptable and socially appropriate.

OBJECTIVE

Investigate social validity, content validity and utility of the application of the Assessment of Work Performance (AWP).

METHOD

This was a qualitative study with semi-structured interviews. A convenience sample was conducted and the occupational therapists who agreed to participate applied the application at their work. Those who had used the application (n=15) was interviewed and data was analysed using content analysis.

RESULTS

The results indicate that the application provides valuable information since clients accepted assessments and assessors found work tasks suitable for a diverse group of clients. Improvements were suggested, for example expanding the application with more work tasks to choose from.

CONCLUSION

It appears to exist social validity, content validity and utility for the application. This study investigates social validity, a psychometric property unusual to investigate in vocational rehabilitation. It is important since an assessment with a non-socially valid instrument can be inappropriate and irrelevant for clients. When an assessment is acceptable and relevant for clients, the complexity of assessment results can be reduced. Therefore it is essential that occupational therapists as well as other professionals ensure quality and acceptability when assessing work ability.