Work and Subjective Health Complaints: Exploring the role of knowledge, expectancies and social support
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Subjective health complaints (SHC) are common in the working population, with prevalence rates as high as 90 % during the past month. The intensity of SHC ranges from normal and tolerable complaints to more severe complaints that may affect our ability to function as usual at work, and musculoskeletal and mental health complaints are the most frequent reasons reported for sick leave in Norway. Back pain is the largest single cause, but in the last decade, sick leave due to mild and moderate mental disorders has had a rapid increase. Generally, sick leave periods for mental disorders tend to last longer than for musculoskeletal disorders. Furthermore, mental disorders account for one-third of all disability benefits, with anxiety and depression being the diagnostic groups contributing to most of the lost working years. To be excluded from the workforce seems to have a general negative impact on health, especially on mental health. Preventing workplace exclusion due common health complaints is an important goal, and the workplace is an important arena for prevention. The high prevalence rates of SHC indicate that we should accept these health complaints as a part of our normal life. Our longstanding efforts to prevent the occurrence of SHC have not produced the desired effects. It could be argued that our endeavor to understand and explain these health complaints, mostly within a biomedical perspective, has led to a medicalization of normal health complaints. The course of medicalizing common health complaints may disempower individuals and decontextualize experiences, and further be harmful and costly for both individuals and societies. Thus, there is a need to transfer more knowledge to the public about the normal presence of health complaints in healthy people and focus on interventions aiming to reduce the negative consequences of common health complaints. Reducing the negative consequences of non-specific musculoskeletal complaints, such as uncertainty, negative response outcome expectancies, maladaptive beliefs, and workplace exclusion, was the idea behind atWork. atWork is an intervention using the workplace as an arena to distribute evidence-based information about commonly experienced health complaints. The development of atWork was based on years of research and clinical experience, which indicated that the information given to back pain patients in a clinical intervention based on a non-injury model could be beneficial for people at a much earlier stage. In the first atWork trial, the intervention was effective in reducing sick leave and maladaptive beliefs about back pain. atWork has subsequently been modified also to target mental health complaints, aiming to increase the positive effects. A new trial was designed to explore if the Modified atWork intervention (MAW) could increase the effects on sick leave and other health-related outcomes compared to the Original atWork intervention (OAW). The main purpose of this thesis was to investigate the role of expectancies, beliefs, and social support for health and sick leave. The Cognitive Activation Theory of Stress, which emphasizes the role of individual experiences and expectancies for health outcomes, was used as the main theoretical framework. The thesis comprises three papers, containing quantitative data retrieved from two cluster randomized controlled trials (“The first atWork trial”, clinicaltrial.gov: NCT00741650 and “The second atWork trial”, clinicaltrials.gov: NCT02396797). The first atWork trial was conducted from 2008-2010, in two Norwegian municipalities. Baseline questionnaire data from this trial (n=1722) was used in paper I. The second atWork trial has been the main research project in this thesis and was conducted from 2014-2016. Baseline questionnaire data (n= 957) from this trial was used in paper II. Paper III includes both register data (n=92) and baseline and follow-up questionnaire data (n=637) from the second atWork trial. In paper I, the association between substantial anxiety and/or depression and different work and health variables were examined. Having a high number of substantial SHC and a high degree of no and negative response outcome expectancies (feelings of helplessness and hopelessness) were associated with anxiety and depression among municipal employees. Experiencing a high number of SHC was consistently the factor having the strongest relationship with anxiety and depression. In paper II, the aim was to explore if directive and nondirective social support were associated with different health and work variables. To obtain this aim, the psychometric properties of the Norwegian version of the Social Support Inventory (SSI) were explored. The Principal Component Analysis confirmed that SSI loaded on two factors, representing directive and nondirective social support. This allowed us to explore if this distinction in social support was relevant for health and work variables. Nondirective social support from coworkers was associated with reporting lower scores on musculoskeletal and pseudoneurological complaints, higher job satisfaction, lower job demands, and higher job control. Directive social support from coworkers had the opposite relationship with all outcome variables. However, this relationship was not statistically significant for pseudoneurological complaints. In paper III, the possible difference between the MAW and the OAW on sick leave and other health related outcomes was examined. The MAW did not have a different effect on sick leave compared to the OAW in kindergarten employees. Both groups had a reduction in faulty beliefs about back pain, but compared to the OAW group, the MAW group had a smaller reduction for two of the statements. This was the statements concerning slipped discs and imagining identifying the cause of back pain. Compared to the OAW group, the MAW group had a more positive change for one of the statements concerning depression, where participants in the MAW group believed less in the hereditary nature of depression after the intervention year. Only the MAW group received a workplace session where the topic was mental health complaints, but both groups had some positive changes in beliefs about mental health complaints. However, the OAW group also had some negative changes, moving in the direction of more stigmatizing beliefs. Participants in the OAW group reported receiving more nondirective social support from coworkers after the intervention year. The MAW group also reported receiving more nondirective social support, but the change was not statistically significant. The findings of this thesis demonstrate that expectancies and social support are important for health. It further demonstrates that both versions of the atWork intervention are effective in changing employees’ beliefs about common health complaints. atWork also seems to encourage more nondirective social support of coworkers. However, modifying the intervention to also include mental health complaints did not have a different effect on sick leave and other health related outcomes compared to targeting only musculoskeletal complaints. The two intervention groups had near equal sick leave rates for the year after the intervention was introduced, indicating that targeting mental health complaints at the workplace did not lead to more exclusion from work either. Both versions of the intervention were feasible in the workplace.