Sickness Absence in Sweden Its relation to Work, Health and Social Insurance Factors

Sammanfattning: Background: The high levels of sickness absence and disability pensioning experienced during the 1990's and 2000's have become both socially as well as financially burdensome for society. Sickness absence implies a costly loss of production for society and large groups of individuals are risking to become marginalised on the labour market. Sickness absence is both a public health and an economic problem. Thus from both a human approach as well as from an economic perspective it is urgent to increase knowledge about what influences individual behaviour when it comes to sickness absence and return to work.Objectives: The overall aim of the thesis is to elucidate the decisive factors for explaining sickness absence. Three different aspects of sickness absence were considered, i.e. factors leading to sickness absence, factors preventing sickness absence and factors leading back to work ability and work when being sickness absent. This is done using a frame of reference involving broadly defined areas of work, health and social insurance related factors.Material and methods: Study I analyzes the outcome of unemployed sick-listed individuals. A total of 280 individuals from the county of Värmland were followed through register data between the years 2000 to 2001. Linear and logistic regression models were used to analyze the occurrence of short and long term economic incentives. Study II has a longitudinal design and explores determinants of return to work. Sick-listed individuals with a stress-related psychiatric diagnosis from the county of Värmland were analyzed over a period of three years (2000-2003) using logistic regression. The data comprised 911 individuals. Study III is a cross-sectional study using questionnaire data from the county of Värmland from year 2004. A total of 3123 persons either working or being self employed were analyzed on determinants of work presence through logistic regression. Study IV had a cross-sectional design and used questionnaire data from five counties in central Sweden. The data, from 2004, comprised 10536 individuals being employed, i.e. not self-employed, and with self reported physical and mental medical conditions. Logistic regression was mainly used in the analysis and the focus was on risk factors for long term sickness absence. Study V comprises cross-sectional data retrieved at three separate occasions between 1991 and 1994. It includes 8839 individuals from five counties in western Sweden with sickness absence spells over 60 days. The data was analysed through bi-variate probit regression with a focus on effects of vocational rehabilitation on return to work.Results: The results from study I were interpreted as that both short and long term economic incentives matter for the outcome of sickness absence through the interaction of different insurance systems. The principal findings from study II was that age, gender and factors implying less favourable health characteristics and thereby lower work capacity, reduce probabilities of returning to work after long term sickness absence. Considering study III determinants of work presence were found to vary between sexes and whether the determinants were counteracting long or short term sickness absence. Factors interpreted as job control counteracted short term absence. Sense of coherence was found to be an important determinant of work presence for women. In study IV long term sickness absence was found to be related to the level of ill-health. Moreover it was concluded that work environment factors as job strain, job satisfaction, physical work environment were important factors for explaining sickness absence in a population with impaired health. The results from study V indicated that vocational rehabilitation is a potentially effective instrument for improving the individual's work ability and chances of return to work. That no signs of prioritizing selection of rehabilitation participants to those likely to return to work with or without rehabilitation measures, i.e. "managerial creaming", were found was also considered as important results.Conclusions: This thesis shows that we need different models and approaches to improve knowledge about the various aspects of sickness absence as entry into absence, return to work or into disability retirement. It also has the implications that sickness absence behaviour can be influenced. Largely depending on what long term path is chosen for welfare policy at the political level it should be acknowledged that other means, improving working conditions and promoting rehabilitation rather than reducing benefit levels and narrowing the eligibility criteria for the insurance benefits are at hand.