POSITIVE EXPERIENCES OF ENCOUNTERS WITH HEALTHCARE AND SOCIAL INSURANCE PROFESSIONALS AMONG PEOPLE ON LONG-TERM SICK LEAVE

Ulrika Müssener, PhD1, Karin Festin, PhD1, Marianne Upmark, PhD2,3 and Kristina Alexanderson, PhD1,2

From the 1Division of Community Medicine, Department of Medicine and Health Sciences, Linköpings University, Linköping, 2Section of Personal Injury Prevention, Department of Clinical Neuroscience and 3Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

OBJECTIVE: To analyse different aspects of positive experiences of people on long-term sick leave with regard to their interactions with healthcare and social insurance professionals.

METHODS: A random population-based questionnaire survey among 10,042 long-term sick-listed people in Sweden. Statements related to positive encounters with the professionals were analysed. Factor analysis and logistic regression was used to identify possible associations with gender, age, marital status, country of birth, level of education, part- or full-time sickness absence, self-rated health, depression during the past year, and reasons for sick leave.

RESULTS: Ninety-two percent of respondents had experienced positive encounters with healthcare and 73% had experienced positive encounters with social insurance. The mean rating was higher for healthcare. The respondents agreed most with the items “treated me with respect”, “listened to me”, and “was nice to me”. Three aspects of interactions were identified: competence, personal attention, and confidence and trust. Women, people born in Sweden, and individuals with good self-rated health experienced the interactions as most positive.

CONCLUSION: The majority of the respondents on long-term sickness absence have had positive interactions with healthcare and social insurance. More research is required to determine the impact that such experiences might have on return to work, and how such interactions might be promoted.

Key words: sickness absence, sick leave, encounters with healthcare and social insurance.

J Rehabil Med 2008; 40: 805–811

Correspondence address: Kristina Alexanderson, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm. E-mail: kristina.alexanderson@ki.se

Submitted January 23, 2007; accepted June 4, 2008

INTRODUCTION

Over the last few decades, long-term sickness absence has increased greatly in Sweden as well as in other countries (1), and the effects of this situation on both individuals and society are highlighted in research, the media and politics. Most investigations of sickness absence have focused on risk factors for sick leave, whereas very little information has been gathered regarding issues that affect return to work (RTW) (2). Interview studies have shown that the way that people on sick leave experience their encounters with healthcare and social insurance professionals might be one factor that influences RTW (3–5). Previous investigations concerning RTW have been conducted mainly from the perspectives of society, healthcare, or employers, while the viewpoint of the person on sick leave has seldom been examined (2). Notwithstanding, it can be argued that if professionals are to succeed in developing interventions that effectively help patients to return to, and remain at, work, it will be highly valuable to explore the experiences of the individuals on sick leave (6).

In one study (7), when people on sick leave were asked what had promoted or hindered RTW, they emphasized how and by whom they had been treated, rather than what type of rehabilitation programmes they had attended. However, earlier investigations about sick-listed persons’ experiences of interactions with professionals were relatively small and/or strongly biased with regard to age, diagnosis and regional area (3, 4, 7–9), or very limited with regard to the number of questions about interactions (8). Hence, further research is needed to provide a greater and more detailed understanding of how persons on long-term sickness absence experience their interactions with social and healthcare professionals. From a health-promoting perspective, it is necessary to examine factors that promote RTW, of which positive encounters with professionals might constitute one. Furthermore, comprehensive information is required about what aspects people in fact perceive as positive interactions. Thus far, studies have explored negative encounters (3, 10). In contrast, the focus of the present investigation was on positive encounters, because we assume that such encounters might promote RTW.

The aim was to analyse different aspects of positive experiences of people on long-term sick leave with regard to their interactions with healthcare and social insurance professionals.

methods

Study population

A cross-sectional population-based questionnaire survey was conducted. The study population consisted of a random sample of 10,042 of the total of 22,158 people in Sweden who on 31 January 2003, were 20–64 years of age, and had an ongoing spell of full- or part-time sick leave that had lasted for 6–8 months, and had not been granted disability pension. The sample was drawn from a register compiled by the National Social Insurance Board (RFV) that included all people on sick leave who fulfilled the mentioned criteria.

Questionnaire and respondents

A comprehensive questionnaire concerning perceptions of interactions with healthcare and social insurance professionals was constructed. It included questions on experiences of positive and negative encounters with the professionals, what emotions such interactions evoked in the respondents, and whether the interactions might promote or hinder RTW. The current study was restricted to analysis of the responses to the questions about positive encounters. Respondents were asked not to think of a particular meeting, but were free to choose one meeting in which they felt they experienced a positive encounter. First they were asked simply to answer “yes” or “no” to whether they had been treated in a positive manner by the professionals. Those who answered yes were asked the following question: “To what extent do the following statements describe how you were treated by the social insurance professional?” They were to indicate to what degree they concurred with the 19 statements listed in Table I, by choosing of 4 response options, ranging from “to no extent” to “to a great extent.” The same question was asked regarding interactions with healthcare professionals. The other factors that were considered in the questionnaire were: level of education, part- or full-time sickness absence, self-rated health, depression during the past year, and reasons for sick leave.

Data on gender, age, country of birth, and marital status were obtained from Riksförsäkringsverket registers (Table II). It took approximately 1 h to complete the questionnaire, which was administrated by Statistics Sweden and sent by post in April 2004 to the home addresses of the persons in the selected population. People who had died or emigrated were excluded (n = 58). A first reminder was sent after one week and a second after another 10 days.

In total, 5802 people (58% of the original sample) participated in the study. The response rate was generally higher among females (p < 0.001), people born in Sweden (p < 0.001), those who were married or had a registered partnership (p < 0.001), and older individuals (p < 0.001) (Table II).

Statistical analyses

Cronbach’s alpha was used to determine the reliability of the responses: first considering the questions about interactions with professionals to determine whether all 19 items should be included in further analyses, and secondly examining each of the factors given by the factor analyses. Mean ratings for responses to the 2 questions concerning encounters with healthcare and social insurance professionals, respectively, were calculated for each of the 19 statements. Factor analysis was performed to identify the factors underlying positive experiences of interactions with professionals. Principal component analysis and an oblimin rotation were used. Factor loadings < 0.4 were excluded from the results. Scores were created for each of the (6) factors that were revealed. The scores for each individual were calculated as the mean of the ratings of the items in a factor. Only respondents who replied to all 19 items were included in the factor analyses.

Odds ratios were calculated for being among the approximately 20% of the respondents who gave the lowest ratings for (i.e. agreed least with) the statements included in each of the factors identified by the factor analyses. Univariate and multiple logistic regression was applied to identify possible associations between an individual’s score for each factor and his or her gender, age, marital status, country of birth, level of education, degree of sickness absence (part- or full-time), self-rated health on a 5-point scale (very good to very bad), depression during the last year, and self-reported reason for absence (musculoskeletal, psychiatric, or other condition).

The study was approved by the research ethics committee of the Faculty of Health Sciences of Linköping University.

Results

A majority of the respondents had experienced being encountered in a positive manner; 92% with healthcare and 73% with social insurance. Of the 5335 participants who stated that they had had positive interactions with healthcare professionals, 4169 had responded to all 19 items under the relevant question (Table I). Alpha for the 19 items was 0.93. In all, 2696 had responded to all the items on the question on positive interactions with social insurance professionals and alpha for these items was 0.94. Compared with the study population, those questions were answered to a greater extent by women (p < 0.001), people who were not married (p < 0.001) and people born in Sweden (p < 0.001). The question about social insurance professionals was also answered more frequently by younger persons (p = 0.0013).

Considering all 19 statements, the rating was somewhat more positive for the question on healthcare. The items “treated me with respect,” “listened to me,” “was nice to me” and “believed what I said” received the highest ratings (greatest agreement) from most of the respondents, with respect to both healthcare and social insurance professionals.

Factor analysis identified 3 factors among the items on positive encounters for each of the 2 organizations (Table III). Those 3 did not correspond completely between the 2 organizations, but despite this, they were given the same name. For interactions with healthcare professionals, the first factor was referred to as “competence” and included items 2–5, 9–14 and 16; the second was called “personal attention”, which contained items 8, 15, 18 and 19; and the third comprised items 1, 6 and 7 and was denoted “confidence and trust” (Table III). The first factor, competence, differed somewhat between the 2 groups of professionals. Considering interactions with social insurance professionals, the items “listened to me,” “treated me with respect,” and “believed in what I said” were instead identified in the third factor. Factor 2 was similar for the 2 questions, except regarding the item “encouraged me to find my own solutions,” which shifted to factor 3 in relation to interactions with healthcare professionals (Table III).

For the question on interactions with healthcare professionals, the alpha values were 0.92, 0.76 and 0.71 for factors 1, 2 and 3, respectively. The corresponding alpha values for interactions with social insurance professionals were 0.91, 0.83 and 0.85. The lowest value, 0.71, might have been due to the fact that only 3 statements were included in that factor. Together, the 3 factors explained about 62% of the variation in the healthcare interactions and 64% of those with social insurance. Table IV shows statistics of the individual scores for each factor.

Multiple logistic regression was performed to analyse the odds ratio (OR) ratings for the 3 factors covering the positive experiences (Tables V and VI), and the results indicated some significant differences in how groups of respondents scored each of the factors. Regarding interactions with healthcare professionals (Table V), women had higher odds of rating the positive items as more positive. For interactions with both healthcare and social insurance professionals (Table VI), the largest differences in OR values were found for country of birth and self-rated health. Participants born in Sweden and those with good self-rated health who experienced their encounters as positive did so to a greater extent than others.

Discussion

This study of people who were on long-term sick leave and had had positive interactions with healthcare and social insurance professionals identified 3 different dimensions; namely, being treated with competence, personal attention, and confidence and trust. The largest differences in how groups of respondents experienced positive encounters with the professionals were found in relation to country of birth and self-rated health. More precisely, people born in Sweden and those who had good self-rated health rated their positive experiences higher than did participants who were born in other countries or had low self-rated health. Moreover, that vast majority, 92% had experienced positive interactions with healthcare and 73% with social insurance staff.

Methodological considerations

This investigation had several strengths. One of these is the sample size, because, to our knowledge, ours is the largest and most comprehensive study conducted so far to examine the way that people on sick leave experience their interactions with healthcare and social insurance professionals. A second advantage is that the questionnaire used was based on corresponding experiences found in previous such studies conducted in the same area. Another asset is that the sample was based on a population, not biased to specific diagnosis, occupation, geographical area, workplace, or clinic, which are more common study bases. Furthermore, the sample was drawn from a register kept by the National Social Insurance Board, which is an authority with years of experience and very accurate databases. However, the drop-out rate was relatively high (42%), which, unfortunately, is often the case in large questionnaire surveys, especially those investigating people with regard to sick leave. The larger proportion of women in the study population agrees well with the fact that women in Sweden, as in most industrial nations, have a higher rate of sickness absence (11).

The inclusion criterion concerning the ongoing sick leave spell was set to increase the chance that the individuals had also been in contact with social insurance staff, and that there would be variation in their experiences of the interaction. Nevertheless, a relatively large number of the respondents did not answer the questions about experiences of positive encounters with social insurance staff. We do not know whether this was because the interactions had not been positive or because they had not yet been in contact with social insurance staff. The latter might have been the case, even though we used the inclusion criterion of a sick leave spell at least 6 months long to increase the chances that the respondents had met social insurance professionals. The probability of having experienced a positive encounter was greater in relation to healthcare, since most sick-listed people meet this category of professionals more often (e.g. necessary to procure a sickness certificate).

These 2 groups of professionals differ greatly in the ways they interact with people on sick leave: social insurance staff have a gate-keeping role that obliges them to determine whether clients fulfil the requirements for receiving benefits and additional RTW measures (12); the healthcare professionals’ role is to help and treat patients and in some cases also, as medical experts, issue sickness certificates to other stakeholders (2). Differences in expectations and previous experiences might also affect how individuals perceive they are being encountered.

Face validity can be claimed, since the questionnaire was developed by professionals and researchers who had worked for many years with sickness absentees and/or such research. In addition, the construction of the questions was based on previous findings obtained in qualitative (3–5) and quantitative studies (8, 9), and through clinical experiences and theoretical considerations (13). Early versions were tested in small pilot studies. It is difficult to say whether the use of more directed and specific questions is the most suitable method for gaining knowledge about encounters with professionals. We used a query that concerned one meeting where the respondents felt they had been treated positively or negatively by healthcare or social insurance staff, instead of asking how often they had experienced such encounters. Thus, our interest was focused on what the participants actually perceived during such meetings, rather than on how common the positive or negative experiences were. Östlund et al. (9) used 16 statements about perception of interactions with professionals in a comprehensive questionnaire that included both positive and negative items. Their analysis discerned 3 dimensions that they referred to as supportive, distanced, and empowering treatment (9), and these 3 factors could explain 72% of the variation observed in that study, which is somewhat higher than the rate in our investigation. Another questionnaire study (8) included 4 broad items that addressed the matter of how people on sick leave experience their interactions with healthcare, social insurance professionals, and occupational health services.

Multiple logistic regression analysis was applied to all the items in each factor to compare the participants who gave the highest ratings for (i.e. agreed most with) the statements with those who gave lowest ratings (i.e. agreed least). This was done due to the positive skew distribution of the responses to the analysed questions (for many items, a majority reported that they agreed completely).

Discussion of the results

Previous studies of the interactions between patients/clients and professionals have primarily concerned the communication between patients and physicians (14–16). Patient satisfaction has often been used as an outcome and has in many cases been measured soon after the interactions took place. In the present study focus was also on sickness absentees’ own experiences of positive encounters with other types of professionals who they met during their sick leave, which covered a period of at least 6–8 months. It is not always possible to compare results concerning patient–physician interactions with the more limited data available on interactions between individuals on sick leave and other groups of professionals. People’s previous experiences, expectations, and perceptions, together with other circumstances, might influence how the individuals feel they are being encountered. However, the purpose of the present study was to illustrate the personal accounts of positive encounters experienced by people who were on sick leave, not to identify or discuss the reasons for those perceptions, or whether the individuals were satisfied with how they were treated.

The respondents who had had positive experiences indicated the highest degree of agreement with 3 of the 19 items: “treated me with respect,” “listened to me,” and “was nice to me.” The importance of professionals listening to their clients/patients and treating them with respect has also been found to be of importance in other studies (4, 17, 18). Factor analysis identified 3 different dimensions of positive experiences of interactions: competence, personal attention, and confidence and trust (Table III). The first factor, competence, might include aspects related to professionalism, a quality that has to do with being competent, listening, giving correct information, and showing interest in the individual’s situation. The second factor, personal attention, comprises aspects of being treated in a more personal manner, above what might be expected, for instance that professionals show that they like their clients or talk about themselves. The third factor, confidence and trust, refers to professionals believing in their clients/patients with regard to their ability to work and to take responsibility for their own situation.

In a previous study (4), focus group interviews were used to analyse positive encounters with rehabilitation staff described by people who had been absent from work due to back, neck, or shoulder ailments. The positive encounters that were identified in that investigation were assigned to 2 major categories, which were referred to as respectful treatment and supportive treatment. When using more directed questions about experiences of such interactions (5), it seemed that the most important qualities were as follows: being treated with respect, feeling supported, establishing a personal relationship, perceiving demands as well balanced, and participating in decisions regarding rehabilitation. The interviewees in the studies mentioned were few in number.

In our previous questionnaire study of sickness absentees’ experiences of encounters with professionals (8), the respondents perceived their encounters with healthcare professionals as most positive, followed by social insurance staff and personnel at occupational health services. The interactions were rated as more positive by women, people born in Sweden, older individuals, and those with a higher education. Such comparisons could not be performed in our current study, because it included only people who stated they had had positive encounters. Nevertheless, in our study population, we did notice that the odds for rating interactions as very positive and the mean ratings of statements were higher for women in relation to healthcare professionals and, to a lesser extent, regarding one of the factors concerning interactions with social insurance staff.

Östlund et al. (9) found that women who had been on sick leave perceived their interactions with both social insurance staff and healthcare professionals as more supportive than did men. However, Ahlgren & Hammarström (19) observed quite the reverse: when people on sick leave were asked about their experiences of rehabilitation, it was found that women more often felt that they were distrusted than did men. By comparison, Bäckström (20) studied rehabilitation among people on sick leave and noted that women more frequently experienced being ignored, whereas men felt that they were offered relevant treatment. Notwithstanding, it is not really possible to compare the cited gender-related results with the findings of the present study, chiefly because we limited our analysis to individuals who had had positive interactions, in other words, we did not compare them with those who had not had such experiences.

In conclusion, the majority of the respondents on long-term sickness absence have had positive interactions with healthcare and social insurance; however, to a lesser degree for the latter. Regarding such positive interactions, 3 factors seem to be essential: being treated with competence, personal attention, and confidence/trust. In general, women, people born in Sweden, and individuals with good self-rated health who experienced positive encounters did so to a greater extent than did men, people born in other countries, and those with low self-rated health. Further research is needed to find ways to enhance such positive interactions between patients/clients and healthcare and social insurance professionals.

acknowledgements

Financial support was provided by the Swedish Council for Working Life and Social Research and the Swedish National Social Insurance Board.

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