Addressing Key Knowledge Gaps

1. Common indicators are lacking

Studies of return to and retention in work use different outcome measures, define interventions in different ways and calculate costs differently. This makes it difficult to compare studies, combine findings in systematic reviews and conduct health economic evaluations. Researchers have therefore called for a shared set of core indicators.

In Work Package 1.1, the Center will develop a consensus-based set of core indicators for outcomes and interventions. The indicators will be suitable for both research and follow-up across different sectors.

2. Reliable tools for predicting outcomes are lacking

There is knowledge about individual prognostic factors, including clinical, sociodemographic, lifestyle-related and work-related factors. However, existing prediction tools vary in their psychometric properties and may be unreliable. One key limitation is that they rarely account for how factors at the individual, workplace, healthcare and societal levels interact.

Family-related factors, such as heredity and a shared upbringing, are also rarely included, despite their influence on outcomes after a period of sick leave. Prediction models are seldom combined with analyses of which treatments are effective, such as medication, surgery, psychotherapy or physiotherapy. This makes it harder to provide person-centred care and may contribute to unnecessarily long periods of sick leave.

In Work Package 1.2, the Centre will develop prediction tools and analytical strategies using large, high-quality register data. The tools will be tailored to diagnosis and occupation.

3. Employers lack support

Workplace adjustments can improve the chances of returning to work, and Swedish employers are required to have procedures for making such adjustments. Yet data from the Swedish Work Environment Authority indicate that 60 per cent of employers do not comply with the regulations. Many employers are unsure how to support employees. Barriers may include conflicts with production targets, increased workloads for colleagues and ethical concerns about health information.

Employers also lack knowledge about how different conditions affect work capacity and rarely receive this information from the doctor who certifies sick leave. Evidence for workplace interventions is limited, and it remains unclear which components are effective.

In Work Package 2.1, the Center will examine how employers understand and fulfil their responsibilities, and what helps or hinders workplace adjustments. The findings will inform recommendations, practical tools and training.

4. Preventive measures are not widely implemented

Work-related mental ill health can be prevented by addressing organisational and social risks in the workplace. Guidelines are available, but they are not widely used. The World Health Organization has called for more knowledge about how these guidelines can be implemented in practice.

In two cluster-randomised studies involving 74 schools, the research group showed that a multifaceted implementation strategy improved adherence to the guidelines. Better adherence was associated with less exhaustion and a better work environment. The next step is to test the strategy beyond the school sector. To do this, it needs to be adapted to local needs, and the Center needs to identify which structures can support the work over time, such as human resources departments and occupational health services.

In Work Package 2.2, the Center will test an adaptable strategy in which workplaces already using evidence-based approaches receive less support, while those with greater needs receive more. The aim is to improve cost-effectiveness and support more sustainable implementation.

5. Primary care lacks equitable structures and evidence-based interventions

Primary care issues a large proportion of medical certificates for sick leave, but has no formal link to workplaces. Occupational health services can work directly with employers, but reach only around 60 per cent of employed people.

Support in primary care is often fragmented and unequal. The roles of psychologists, physiotherapists and occupational therapists in insurance medicine are unclear, and the Swedish National Board of Health and Welfare’s guidance on insurance medicine provides limited direction. Complex cases, such as those involving multiple conditions or common mental health problems, are often associated with long periods of sick leave and poor coordination. Sick leave is also often treated as the obvious solution.

Several Swedish studies of employer contact and interventions in primary care have found no effect, possibly because of shortcomings in implementation and collaboration. There is also a lack of knowledge about health economic effects, women’s return to work, and the influence of socioeconomic and ethnic background.

In Work Packages 3.1 and 3.2, the Center will evaluate two new intervention models in primary care through controlled studies. The work will also examine how interprofessional collaboration, professional roles and assessments of work capacity affect equitable return to work in complex cases, and what conditions are needed at national level.

6. Policy, services and workplaces are poorly coordinated

Several government inquiries have described unclear roles and missed opportunities within the social insurance system. Many doctors also find the system difficult to navigate.

Two examples are preventive sickness benefit and rehabilitation compensation. The Swedish Social Insurance Inspectorate (ISF) has highlighted that preventive sickness benefit is used to a limited extent and that there is no strategy for raising awareness of it. Rehabilitation compensation is also used infrequently, its use has declined, and it is often granted late in a period of sick leave. The rules are unclear and relatively unfamiliar to professionals.

In Work Package 4, the Center will identify measures in the current regulations that are underused and evaluate their effects. The work will also aim to clarify responsibilities and improve coordination between employers, primary care, occupational health services, the Swedish Social Insurance Agency and the Swedish Public Employment Service.

7. Promote user-centred innovation

Digital tools for return to work are available, but they often fit poorly into practice and lack support from the people expected to use them. Evidence is rarely combined with systematic involvement of end users, which can reduce the relevance, feasibility and sustainability of solutions.

In Work Package 5, the Center will develop and evaluate user-centred solutions using the Discover, Design/Build, Test framework. This approach is based on co-creation and iterative development. Work in this package will expand towards the end of the Centre’s first period.

8. Knowledge and training are lacking

Employers and healthcare services make too little use of available knowledge, and structures for continuous learning are largely lacking. Primary care doctors often receive little training on the return-to-work process, contributing to variation in the support patients receive.

In Work Package 6, the Center will establish a national training hub for academia, government agencies, occupational health services, primary care and employers. The hub will share the Centre’s methods and findings and will operate throughout the Centre’s lifetime.