Is strain due to household and family work associated with a subjective need for rehabilitation among employees? A cross-sectional study.

BACKGROUND: The gender-specific unequal distribution of paid employment and unpaid household and family work may entail specific implications for women's and men's health and work ability. Medical rehabilitation is provided to maintain or restore work ability and to prevent disability pensioning. However, more than half of the employees who receive disability pension have not utilized any pre-retirement rehabilitation services. The study was conducted to examine associations between strain due to unpaid work and the subjective need for rehabilitation among employees with an increased risk of early retirement due to adverse health conditions. METHODS: Cross-sectional data from the "Third German Sociomedical Panel of Employees" (GSPE-III) were analysed. The sample comprises 1,908 German employees aged between 42 and 56 years. Logistic regression analyses were conducted separately for women and men to explore the association between the strain level and the subjective need for rehabilitation. RESULTS: Overall, women reported a higher strain level compared to men. Strain due to housework was not associated with the subjective need for rehabilitation in men and women. However, after adjustment for socio-demographic, work- and health-related characteristics the odds for a subjective need for rehabilitation were three times higher for women (OR=2.9, p <0.001) and two times higher for men (OR=2.0, p=0.027) with a high level of strain due to family work compared to persons with a low strain level. DISCUSSION: This study analysed the strain of unpaid work in the context of the utilization of medical rehabilitation services. Although women report a gender-specific higher strain due to unpaid work, a high strain level due to family work seems to be an additional and independent factor influencing the subjective need for rehabilitation for both genders equally. CONCLUSION: To prevent disability pensioning, more consideration should be given to the strain factors associated with unpaid family work when designing and organising interventions to promote access to medical rehabilitation services.

[Social Inequalities in Access to and Utilization of Medical Rehabilitation - Results of the Third German Sociomedical Panel of Employees (GSPE-III)]. / Soziale Ungleichheiten im Zugang und in der Inanspruchnahme von medizinischen Rehabilitationsmaßnahmen.

AIM OF THE STUDY: The influence of social status on health is well documented. Preliminary research provides initial evidence for social inequalities in rehabilitation care. Our study examines the role of social inequalities with respect to access and utilisation of medical rehabilitation services by analysing a risk cohort of the German Statutory Pension Insurance Scheme (Deutsche Rentenversicherung Bund). METHODS: Data for the analysis consists of questionnaire data from the first two waves of the Third German Socio-medical Panel of Employees (GSPE-III) and administrative data of participants (2013-2016). This risk cohort comprises 40-54-year-old employees receiving sickness benefits in 2012. Using logistic regression models, the application for medical rehabilitation, its approval and rejection, possible opposition proceedings and its subsequent utilisation were analysed. The social status was measured by an index as well as by the single dimension of education. The analyses were carried out separately by gender. Age, employment status and subjective health status were considered as covariates. RESULTS: A total of 2.376 insured employees, 1.092 men and 1.284 women, were included in the analysis. 639 (26.9%) submitted at least one application for medical rehabilitation. The chance of submitting an application was higher for men with low socioeconomic status (OR=1.8; 95%-CI=1.3-2.5) or lower (OR=1.9; 95%-CI=1.3-2.8) and medium education (OR=1.5; 95%-CI=1.1-2.2) in relation to the high status or education group. For women, low education (OR=1.6; 95%-CI=1.1-2.5) raised the chances of an application. When adjusted for health status and current employment situation, all significant differences disappeared. Regarding approval and utilisation, there were no significant differences between socioeconomic status groups, but women with a medium level of education were significantly more likely to have their application approved on the basis of an opposition proceeding (OR=3.0; 95%-CI=1.1-8.2) than women with a high level of education. CONCLUSION: The analyses provided no evidence of a socially unequal access to or utilization of medical rehabilitation. However, insured persons with a low social status more frequently applied for rehabilitation, especially because of their poorer subjective health. Further research is needed to ensure that this meets the objective needs of this status group.

The Prevalence and Determinants of Being Offered and Accepting Operational Management Services-A Cohort Study.

In Germany, employers are obliged to offer "operational integration management" (OIM) services to employees returning from long-term sick leave. OIM aims to improve employees' workability and to prevent future sick leave or early retirement. This study examined (i) to what extent OIM services are offered to eligible employees, (ii) to what extent offers are accepted and (iii) the determinants of both outcomes. We used data from a cohort of employees eligible for OIM. Thirty-four potential determinants were assessed in 2013 (i.e., the baseline) using participant reports. In 2015 (i.e., the follow-up), participants were asked (a) whether they had ever been offered OIM services by their employer, and (b) whether they had accepted that offer (i.e., the outcomes). We estimated relative risks by multivariable binomial regression to identify predictors based on backward elimination. In total, 36.0% of the participants were offered OIM services and 77.2% of them accepted that offer. The likelihood of an OIM offer at follow-up was elevated in participants with mental impairment, cancer or long-term absenteeism and increased with organizational justice, neuroticism, and company size. The likelihood of accepting that OIM offer was positively associated with mental impairment and decreased with increasing company size.

Self-reported work ability predicts health-related exit and absence from work, work participation, and death: longitudinal findings from a sample of German employees.

OBJECTIVE: The cohort study examined the performance of the Work Ability Index in predicting health-related exit and absence from work, work participation, and death among a sample of workers previously receiving sickness absence benefits. METHODS: Workers aged 40-54 years who received sickness absence benefits in 2012 completed the Work Ability Index in 2013. Outcomes were extracted from administrative data records covering the period until the end of 2016. RESULTS: Data for 2266 participants were included (mean age: 47.9 years; 54.4% women). Maximum follow-up was 43 months. In terms of work ability, 38.4% had good scores, 38.2% moderate scores, and 23.4% poor scores. Fully adjusted analyses showed an increased risk of a disability pension in workers with poor (HR = 12.98; 95% CI 5.81-28.99) and moderate Work Ability Index scores (HR = 3.17; 95% CI 1.36-7.38) compared to workers with good or excellent scores. The risk of a rehabilitation measure was also significantly increased for workers with poor and moderate scores. In addition, poor scores were prospectively associated with a longer duration of sickness absence and unemployment benefits, and fewer employment days and less income from regular employment. Those with poor Work Ability Index scores also had a significantly increased risk of premature death. CONCLUSIONS: The Work Ability Index is a potential tool to identify individuals with previous long-term sickness absence having an increased risk of health-related exit and absence from work and poor work participation outcomes.

Using Administrative Data to Assess the Risk of Permanent Work Disability: A Cohort Study.

Purpose Unmet rehabilitation needs are common. We therefore developed a risk score using administrative data to assess the risk of permanent work disability. Such a score may support the identification of individuals with a high likelihood of receiving a disability pension. Methods Our sample was a random and stratified 1% sample of individuals aged 18-65 years paying pension contributions. From administrative records, we extracted sociodemographic data and data about employment and welfare benefits covering 2010-2012. Our outcome was a pension due to work disability that was requested between January 2013 and December 2017. We developed a comprehensive logistic regression model and used the model estimates to determine the risk score. Results We included 352,140 individuals and counted 6,360 (1.8%) disability pensions during the 5-year follow-up. The area under the receiver operating curve was 0.839 (95% CI 0.834 to 0.844) for the continuous risk score. Using a threshold of ≥ 50 points (20.2% of all individuals), we correctly classified 80.6% of all individuals (sensitivity: 71.5%; specificity: 80.8%). Using ≥ 60 points (9.9% of all individuals), we correctly classified 90.3% (sensitivity: 54.9%; specificity: 91.0%). Individuals with 50 to < 60 points had a five times higher risk of a disability pension compared to individuals with low scores, individuals with ≥ 60 points a 17 times higher risk. Conclusions The risk score offers an opportunity to screen for people with a high risk of permanent work disability.

[Potentials of the Third German Socio-Medical Panel of Employees (GSPE-III) for Research in the Field of Migration and Rehabilitation: The Example of Utilization of Rehabilitative Care]. / Potenziale des Dritten Sozialmedizinischen Panels für Erwerbspersonen (SPE-III) für die Forschung im Bereich Migration und Rehabilitation: Das Beispiel der Inanspruchnahme rehabilitativer Versorgung.

PURPOSE: The majority of previous studies shows that migrants use medical rehabilitation less often than non-migrants. In some cases, opposite results have been reported. Previous research, however, has different limitations. The present study examines the use of rehabilitation among migrants and non-migrants by means of the Third German Socio-medical Panel of Employees (GSPE-III). METHODS: The study is based on the first wave of the GSPE-III, extended by administrative data from the insurance accounts of the respective study participants. The survey was conducted in May 2013 and comprises a risk cohort of insurants of the German Statutory Pension Insurance Scheme (Deutsche Rentenversicherung Bund) who are at risk of reduced social participation and who received sickness benefits in 2012. We compared non-German nationals, German nationals with a migration background and German nationals without a migration background. Based on the Andersen Healthcare Utilization Model, the quality of life, the self-perceived risk of a reduced earning capacity as well as demographic and socio-economic factors were taken into account as covariates using a logistic regression model. RESULTS: Of the 2,413 respondents surveyed, 2.7% were foreign nationals and 4.4% were German nationals with a migration background. As compared to Germans with no migration background, Germans with a migration background and non-German nationals did not significantly differ in their utilization of rehabilitation (adjusted odds ratio=0.78, 95%-CI=0.47-1.30 and adjusted odds ratio=0.99; 95%-CI=0.53-1.88, respectively). CONCLUSION: The GSPE-III allows overcoming some limitations of previous studies by means of detailed data on migration background as well as the possibility to consider confounding factors at different levels and to link survey with routine data. The results contradict the majority of previous studies and show that epidemiological research on the utilization of rehabilitative care among migrants is inconsistent. For the interpretation of the present findings, it is also necessary to take into account the special properties of the GSPE-III and the comparatively small sample size.

Associations between overcommitment, effort-reward imbalance and mental health: findings from a longitudinal study.

PURPOSE: The effort-reward imbalance (ERI) model includes extrinsic and intrinsic aspects of work stress. The single components, ERI and overcommitment (OC), are known to be associated with mental health. The aim of this study was to test whether OC is a mediator of the association between ERI and mental health. METHODS: Longitudinal analyses were conducted using data from the Third German Sociomedical Panel of Employees on German employees aged 40-54 years. The short version of the ERI questionnaire was used to measure ERI and OC at baseline (2013). Outcomes were mental health problems and self-rated mental health (5-Item Mental Health Inventory) in 2015. Multivariate regressions were conducted controlling for sociodemographics, health-related behaviour, job-related aspects, and mental health at baseline. RESULTS: A total of 912 men and 1148 women were included in the final analysis. Baseline OC was positively associated with follow-up mental health problems and negatively with self-rated follow-up mental health. While there was no direct effect of ERI on mental health, ERI affected mental health problems (b = 0.14; 95% CI 0.03 to 0.25) and self-rated mental health (b = - 1.15; 95% CI - 1.79 to - 0.57) indirectly through OC. CONCLUSIONS: OC was associated with reduced mental health. There was no association between ERI and mental health that was independent of OC. OC could therefore be interpreted as a mediator between ERI and mental health. Future studies are needed to test the causality of this association.

Influence of social support among employees on mental health and work ability-a prospective cohort study in 2013-15.

Background: The study examined the association of social support with mental health, subjective work ability and psychological consultation. Methods: The cohort study included 1886 German employees (40-54 years) with sickness absence exceeding six weeks in 2012. Postal surveys were carried out in 2013 and 2015. Results: After adjustment for socio-demographic data, work-related characteristics and personality factors, persons with low social support compared to high social support had poorer mental health (b=-4.96; 95% CI: -7.11 to -2.81) and a lower work ability index (b=-1.10; 95% CI -2.00 to -0.21). Low social support was not associated with increased odds of consulting a psychologist (OR =1.30; 95% CI: 0.86-1.96). Conclusions: Low social support is an independent predictor of poorer mental health and lower work ability. This study highlights the importance of identifying people who have limited access to social support.

Self-Reported Work Ability Predicts Rehabilitation Measures, Disability Pensions, Other Welfare Benefits, and Work Participation: Longitudinal Findings from a Sample of German Employees.

Purpose The study examined the performance of the Work Ability Index in predicting rehabilitation measures and disability pensions, sickness absence and unemployment benefits, and work participation among a sample of workers previously receiving sickness absence benefits. Methods Workers aged 40 to 54 years who received sickness absence benefits in 2012 completed the Work Ability Index in 2013. Outcomes were extracted from administrative data records. Results Data for 2149 participants were included (mean age: 47.8 years; 54.4% women). Mean follow-up was 19 months. Work Ability Index scores were poor (7-27 points) in 21% of the participants, and moderate (28-36 points) in 38.4%. In all, 224 rehabilitation measures and 35 disability pensions were approved. Fully adjusted analyses showed increased risk of rehabilitation measures in workers with poor (HR 4.55; 95% CI 3.14-6.60) and moderate scores (HR 2.08; 95% CI 1.43-3.01) compared to workers with good or excellent scores (37-49 points). The risk of a disability pension increased significantly for workers with poor scores (HR 7.78; 95% CI 2.59-23.35). In addition, poor scores were prospectively associated with a longer duration of sickness absence and employment benefits, and fewer employment days and less income from regular employment. Conclusions The Work Ability Index is a potential tool for following up workers who already have an increased risk of permanent work disability due to previous long-term sickness absence.

Acceptance and barriers to access of occupational e-mental health: cross-sectional findings from a health-risk population of employees.

PURPOSE: Occupational e-mental-health (OEMH) may extend existing instruments for preservation or restoration of health and work ability. As a key precondition to efficient implementation, this study examined acceptance and person-centered barriers to potential uptake of OEMH for work-related distress in employees with an elevated risk of early retirement. METHODS: Within the framework of the "Third German Sociomedical Panel of Employees", 1829 employees with prior sickness absence payments filled out a self-administered questionnaire. Participants had a mean age of 49.93 years (SD = 4.06). 6.2% indicated prior use of eHealth interventions. Potential predictors of acceptance of OEMH were examined based on the "Unified Theory of Acceptance and Use of Technology" (UTAUT) extended by work ability, mental health, eHealth literacy and demographic characteristics. RESULTS: 89.1% (n = 1579) showed low to moderate acceptance (M = 2.20, SD = 1.05, range 1-5). A path analysis revealed significant, positive direct effects of UTAUT predictors on acceptance (performance expectancy: 0.48, SE = 0.02, p < 0.001; effort expectancy: 0.20, SE = 0.02, p < 0.001; social influence: 0.28, SE = 0.02, p < 0.001).Online time and frequency of online health information search were further positive direct predictors of acceptance. Model fit was good [χ 2(7) = 12.91, p = 0.07, RMSEA = 0.02, CFI = 1.00, TLI = 0.99, SRMR = 0.01]. CONCLUSIONS: Attitudes towards OEMH are rather disadvantageous in the studied risk group. Implementation of OEMH, therefore, requires a-priori education including promotion of awareness, favorable attitudes regarding efficacy and usability in a collaborative approach.

Injustice at work affects work ability and role functioning: findings of a cohort study.

OBJECTIVES: The aim was to analyze the longitudinal effects of organizational injustice (OIJ) and effort-reward imbalance (ERI) on work ability, emotional role functioning and physical role functioning. METHODS: Longitudinal data with a two-year follow-up of people previously receiving sickness absence benefits were used for analyses. OIJ and ERI were included separately and mutually in logistic regression models. Effects were tested for additivity. All analyses were additionally performed stratified by sex. All models were adjusted for sociodemographics and neuroticism. RESULTS: 1886 participants (44.5% men, mean age: 48 years) were included. When mutually adjusted, OIJ and ERI affected work ability, and OIJ affected emotional role functioning. In stratified analyses, OIJ affected all outcomes in women, and ERI affected work ability in men. Additive effects of OIJ and ERI were not identified. CONCLUSIONS: OIJ and ERI are important risk factors of limited participation. People with experiences of health-related and work-related impairments are in need of reliable structures and just working conditions.

Associations between organizational injustice and work ability, self-reported disability days, and medical consultations: cross-sectional findings from employees with prior sickness absence payments.

PURPOSE: The aim of the study was to identify associations between organizational injustice and work ability, disability days, and consultations with general practitioners. METHODS: Cross-sectional data of persons previously receiving sickness absence benefits were used for analyses. Organizational injustice was assessed using a German version of the "organizational justice questionnaire". Dependent variables were the Work Ability Index, self-reported disability days, and consultations with general practitioners. Associations were adjusted for sociodemographic characteristics, behavioral health risks, neuroticism, effort-reward imbalance, and overcommitment. RESULTS: The analysis included 2983 employed persons (54.1% women, mean age: 47.9 years). High organizational injustice was associated with poor work ability (OR = 2.04, 95% CI 1.55-2.69). There were also slight associations with frequent self-reported disability days (OR = 1.34, 95% CI 1.06-1.68). The dependent variables were also associated with the effort-reward ratio and overcommitment. CONCLUSION: Organizational injustice is associated with work ability, self-reported disability days, and health-care utilization. Results support the notion of a complementary role of the models of organizational justice and effort-reward imbalance.

[Motivational and Volitional Processes in the Context of Applying for Medical Rehabilitation Services]. / Motivationale und volitionale Prozesse im Kontext der Beantragung einer medizinischen Rehabilitationsleistung.

OBJECTIVES: We analyzed if intention and planning of an application for medical rehabilitation can be described using the health action process approach. MATERIAL AND METHODS: Data were used from the "Third German Sociomedical Panel of Employees". A questionnaire comprising 8 scales was developed. The scales assess outcome expectancies (3 scales), support by family and physicians (2 scales), self-efficacy, intention and action planning (1 scale each). A confirmatory factor analysis was performed to examine the factorial validity of the questionnaire. Structural equation modeling was used to explain intention and planning of an application for medical rehabilitation. RESULTS: 3 294 persons participated in the survey. The average age was 47.9 years (range 40-54 years, SD=4.1). 53% of the participants were women. Further analyses included data of 2 911 (listwise deletion) and 3 288 participants (estimated missing values), respectively. The anticipated 8-factor structure of the questionnaire was confirmed. The model fit of the structural equation model was good. Intention was explained by family-related negative outcome expectancies, self-efficacy, and support by family and physicians. Intention and support by physicians directly affected planning. Additionally, family-related negative outcome expectancies, family and physician support, and self-efficacy were indirectly associated with planning. This indirect effect was mediated by intention. 51% of the variance of intention and 65% of the variance of planning were explained. DISCUSSION: The findings of the structural equation model indicate that the health action process approach is useful to describe the process of applying for medical rehabilitation. A validation of the model needs longitudinal data on actual applications. CONCLUSION: The health action process approach supports our understanding of motivational and volitional determinants of an application for medical rehabilitation. Our results underline the important role that family doctors and occupational physicians have if an application for medical rehabilitation is needed.

A web-based intervention to promote applications for rehabilitation: a study protocol for a randomized controlled trial.

BACKGROUND: The German welfare system follows the principle "rehabilitation rather than pension," but more than the half of all disability pensioners did not utilize medical rehabilitation before their early retirement. A major barrier is the application procedure. Lack of information about the opportunity to utilize rehabilitation services restricts the chance to improve work ability and to prevent health-related early retirement by rehabilitation programs. The establishment of new access paths to medical rehabilitation services was, therefore, identified as a major challenge for rehabilitation research in a recent expertise. Thus, a web-based information guide was developed to support the application for a medical rehabilitation program. METHODS/DESIGN: For this study, the development of a web-based information guide was based on the health action process approach. Four modules were established. Three modules support forming an intention by strengthening risk perception (module 1), positive outcome expectancies (module 2) and self-efficacy (module 3). A fourth module aims at the realization of actual behavior by offering instructions on how to plan and to push the application process. The study on the effectiveness of the web-based information guide will be performed as a randomized controlled trial. Persons aged 40 to 59 years with prior sick leave benefits during the preceding year will be included. A sample of 16,000 persons will be randomly drawn from the registers of 3 pension insurance agencies. These persons will receive a questionnaire to determine baseline characteristics. Respondents of this first survey will be randomly allocated either to the intervention or the control group. Both study groups will then receive letters with general information about rehabilitation. The intervention group will additionally receive a link to the web-based information guide. After 1 year, a second survey will be conducted. Additionally, administrative data will be used to determine if participants apply for rehabilitation and finally start a rehabilitation program. The primary outcomes are the proportion of applied and utilized medical rehabilitation services. Secondary outcomes are cognitions on rehabilitation, self-rated work ability, health-related quality of life and perceived disability, as well as days with sick leave benefits and days of regular employment. DISCUSSION: The randomized controlled trial will provide highest ranked evidence to clarify whether theory-driven web-based information supports access to rehabilitation services for people with prior sickness benefits. TRIAL REGISTRATION: German Clinical Trials Register (Identifier: DRKS00005658 , 16 January 2014).

Self-Reported Poor Work Ability--An Indicator of Need for Rehabilitation? A Cross-Sectional Study of a Sample of German Employees.

OBJECTIVE: The purpose of this study was to assess associations of self-reported work ability as measured by the Work Ability Index (WAI) with modifiable behavioral and occupational health risks, health service utilization, and intended rehabilitation and pension requests. DESIGN: This is a cross-sectional study of a random sample of German employees aged 40-54 yrs on sickness benefits in 2012 (trial registration: DRKS00004824). RESULTS: In total, 1312 male and 1502 female employees were included in the analyses. Low WAI scores (i.e., <37 points) were associated with a higher prevalence of occupational and behavioral health risks; a higher likelihood of frequent visits to general, somatic, and psychologic specialists as well as hospital stays; and four to six times higher risks of intended rehabilitation and pension requests. A two-item version of the WAI was as strongly associated with intended rehabilitation and pension requests as the total score. CONCLUSIONS: This study indicates that the WAI is a sensitive screening tool to identify workers on sick leave with a probable need for rehabilitation. The WAI could support the assessment of need for rehabilitation by occupational health services in return-to-work strategies, which include the opportunity to access multiprofessional rehabilitation.

Individual prevention courses for occupational skin diseases: changes in and relationships between proximal and distal outcomes.

BACKGROUND: To treat people with occupational contact dermatitis, the German Accident Prevention and Insurance Association in the Health and Welfare Services offers 2-day individual prevention (IP) seminars. OBJECTIVES: We investigated whether there are short-term and medium-term changes in proximal (e.g. behaviour) and distal (e.g. symptoms) outcomes after an IP seminar, whether changes in proximal outcomes are associated with changes in distal outcomes, and whether subgroups can be identified that benefit in particular. PATIENTS/MATERIALS/METHODS: In a prospective study, 502 participants of 85 IP courses completed the health education impact questionnaire (heiQ™) and skin symptom questionnaire (Skindex-29) at the start of the course, immediately thereafter, and after 6 months. Change was assessed according to standardized effect size. Regression techniques were used to analyse associations between proximal and distal outcomes. RESULTS: After 6 months, participants showed improved self-management skills and preventive behaviour, and less fear of job loss, disease-related symptoms, and emotional distress. Significant associations between proximal and distal outcomes were found. Participants who felt more limited by their skin disease showed greater effects. CONCLUSIONS: The results are consistent with the assumption that IP courses provide a range of benefits for people with occupational contact dermatitis. Changes in distal outcomes may be influenced by changes in proximal outcomes.