Academic journal article Scandinavian Journal of Work, Environment & Health

Implementation of the Danish Return-to-Work Program: Process Evaluation of a Trial in 21 Danish Municipalities

Academic journal article Scandinavian Journal of Work, Environment & Health

Implementation of the Danish Return-to-Work Program: Process Evaluation of a Trial in 21 Danish Municipalities

Article excerpt

Returning to work after long-term sickness absence is a multifaceted and dynamic process involving various stakeholders, such as the sick-listed person, the employer, the insurance agency, and the healthcare system (1, 2). Interventions to improve return to work are often complex (3) as they contain a number of interactive components that need to be coordinated. The evaluation of complex interventions requires both a theoretical understanding of how the intervention is supposed to cause change and a thorough process evaluation to identify implementation problems so that weak links in the causal chain can be identified and strengthened (3-5).

In 2008 the Danish government launched an action plan to reduce sickness absence and improve labor market participation, encompassing 39 initiatives including the Danish return-to-work (RTW) program. The Danish National Research Centre for the Working Environment (NRCWE) was appointed to develop the program in accordance with the action plan and previous experiences from national and international intervention studies. The aim was to examine whether it is possible to implement a RTW program within the existing sickness benefit framework in Danish municipalities and whether the program reduces sickness absence and promotes labor market participation (6).

The program contained a stratified cluster controlled trial in 21 municipalities, with a nested randomized controlled trial (RCT) in 3 of these 21 municipalities. In two previous articles about the effect of the intervention in the 3 RCT municipalities, we found large differences between municipalities with regard to effect on the length of sickness absence (7) and time-to-self-support (8). In this article, we examine whether and to what extent it was possible to implement the Danish RTW program in all 21 participating municipalities.


Legislative context

The Danish sickness benefit scheme covers wage earners, self-employed and unemployed Danish residents. The scheme has undergone many changes (9) and continues to do so; the most recent changes came into force in 2014. In the following, we describe the relevant regulations during the time of the study: Employers pay the full wage or partial compensation for a certain period in the beginning of the sickness absence spell. This period, the so-called "employer period", was 21 days when the study started in 2010 and was extended to 30 days in January 2012, which was within the timeframe of the RTW program. After the employer period, employers can claim compensation for a part of the wage from the local municipality.

The municipal sickness benefit offices are responsible for evaluating and monitoring beneficiaries on long-term sickness absence (>30 days) and initiating RTW efforts. Municipal social insurance officers (SIO) assess and classify all sick-listed persons into three categories, distinguishing between beneficiaries who are likely to RTW within three months (category 1), beneficiaries who are not likely to return to work within three months but are able to participate in RTW activities (category 2), and beneficiaries who are not likely to RTW within three months and are not able to participate in RTW activities (category 3).

The first consultation with the SIO about the beneficiaries' situation and possible steps for RTW must be conducted before the end of the 8th week of absence. Follow-up consultations have to take place every 4th week for category 2 beneficiaries and every 8th week for category 1 and 3 beneficiaries. At the end of the first consultation, the municipal SIO has to develop a plan that includes RTW goals and activities, such as work ability training, gradual return to work, and work modifications. However, the sickness benefit regulations do not specify which kind of activities should be available in a municipality. Initiation of RTW activities depends on the SIO's assessment of the beneficiary and available municipal resources, which might vary considerably between municipalities (10, 11). …

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